depressive disorders Flashcards
depression
treatable, freq, accompany other psych issues -> anx
PET scan -> less brain activity
depression epidemiology
F,
white = more prevalent, black = more severe
seasonally worse with less sun
ses -> lower (which came first?
depression etiology: bio
l/t tm methods
genetic
biochem abn: NT (serotonin, norepi, others), electrolytes, cortisol (higher), hormonal (estrogen: progesterone, thyroid - hypo)
inflam
diathesis - stress: predisposition to dep and stress can bring it out
depression etiology: psych
cog theory: thoughts lead to env, psychological predisposition, “-“ and/or unrealistic expectations and perceptions about future and env
learning theory: learned helplessness once repeatedly exposed to stressors and nothing helps
depression: contributing factors - child
need secure attachment
diathesis stress model: detachment of primary caregiver (emotional or phys), parental separation/divorce, death of loved one, pet, relocation, academic failure, phys illness
depression: contributing factors - teens
adults and child theories approach
conflict with independence and maturation, role confusion, grief/loss (death/breakup)
depression: contributing factors - OA
societal attitudes -> give less value to OA (money v wisdom)
self esteem, helpless, hopeless
major stressors: financial problems, life changes (job end, retire, relocate, lose connections to others), phys illness, grief /loss (bereavement overload), decreased functional ability
types
share s/s sadness, empty, irritable, somatic concerns, thinking impairment, all impact ability to function
major dep, disruptive mood dysreg, persistent dep (dysthymia), premenstrual dysphoric, substance/med induced, dep disorder d/t another med condition
major dep disorder: s/s
5+ daily in 2 wk period
must cause marked impairment in social/occupational functioning, cant be caused by substance/med condition
weight loss, appetite change, sleep disturbance, fatigue, psychomotor agitation or retardation, worthlessness or guilt, loss of ability to [], recurrent thoughts of death
+ at least 1 s/s is also either: dep mood or loss of interest of pleasure in almost all activities (anhedonia)
may or may not have psychotic s/s
major dep disorder: course
can be chronic (> 2yr)
recurrent episodes common (usually w/n 1st year), s/s cause distress or impaired functioning, episode not attributed to physiological effects, absence of mani or hypomanic episode
major dep disorder: children and teens - dx
look at behaviors (parents and school) and statements (may not have vocab to express)
5+ s/s in 2 wk: dep, irritable, cranky AND anhedonia
+ any 3: significant weight loss (<5% in 1 mo, dont meet expected gains), decrease in appetite, insomnia (<6hr) or hypersomnia, psychomotor agitation or retardation, fatigue, lack of E, worthless, guilt (no one cares), decreased [], indecisiveness (trouble with homework), recurrent thoughts of death or suicide
major dep disorder: children and teens - other s/s
cause significant distress or impairment in function
freq vague non specific phys complaints (tummy hurts), freq absence from school or poor performance (sick, wont get out of bed), bored, OH/substance abuse, increased anger or hostility, reckless behavior
major dep disorder: children and teens - s/s <3
FTT, feeding issues, lack of playfulness, lack of emotional expression, delay in speech/motor dev
major dep disorder: children and teens - 3-5 s/s
prone to accidents, phobias, aggressive, excessive self reproach for minor infractions
major dep disorder: children and teens - 6-8 s/s
vague phys complaints, aggressive, cling to parents, avoid new people and challenges, behind in social skills/academic performance
major dep disorder: children and teens - 9-12
morbid thoughts, excessive worry, lack of interest socially, think they have disappointed parents
disruptive mood dysregulation disorder
6 - 18 yo, onset must occur <10
decrease dx of bipolar
more common in males and children > adolescents
chronic, severe, persistent irritability
disruptive mood dysregulation disorder - s/s
chronic, persistent irritable/angry mood btw temper outbursts
s/s include anger and constant severe irritability
temper tantrums with verbal and behavioral outbursts at least 3x weekly
display temper tantrums in at least 2 settings: home, school, peers
comorbidities: oppositional defiant, ADHD, MDD
persistent depressive (dysthymia)
low level underlying dep feelings through most of each day, for majority of days
most respond favorably to antidep -> MAOI, SSRI
persistent depressive (dysthymia): s/s
s/s for at least 2 years in adults, 1 yr in children and adolescents
must have 2 of following: decreased appetite or over eating, insomnia or hypersomnia, decreased energy, poor self esteem, difficulty thinking, hopelessness, poor []/difficulty making decisions
premenstrual dysphoric disorders
s/s cluster in last wk prior to onset of a woman’s period
mood swing, irritable, dep, anx, overwhelmed, difficulty []
lack of E, overeating, hypersomnia, insomnia, breast tenderness, aching, bloating, weight gain
s/s decrease significantly or disappear with onset of menstruation
dont need constant meds, just during premenstrual period -> SSRI
substance induced dep dissorder
dont experience dep s/s in absensc of drug or OH use or withdrawal
only with substance use
dep disorder associated with another med condition
KF, PD, AD
from med dx or meds, not considered MDD
look at hx, labs, dx, etc
screening
many different tools
primary care: dont often go to pcp for dep, most present with somatic complaints - insomnia, fatigue, weight loss, etc. - need for conssitent dep screening for all pts every visit -> early tm = better outcomes
assess
affect, mood, thought process/content, SI, judgement/insight, communication (fast/slow, thought blocking), phys behavioral/activities
assess - psychomotor retardation
v severe dep
visible slowing of phys activity -> movements and speech
slow talking, long pauses btw speaking, long time to cross room, slow food chew, wait longer than usual btw bites
assess - psychomotor agitation
increase in activity brought on by mental tension
restless, pacing, tapping fingers or feet, abruptly starting and stopping tasks, meaninglessly moving objects around
associated with agitated dep
nursing problems
r/o suicide, safety, hopeless (self harm), ineffective coping, social isolation, self care deficit
solutions
recovery model: healing is possible and attainable
focus on strengths to improve health and reach full potential
tm goals mutually dev -> SMART
based on pt personal needs and values, measurable
nc
therapeutic com, educate and assist with cog distortion and restructuring techniques, challenge thinking, meds and educate, support (3 + things, people to call), sleep hygiene, participation group
general antidep med edu
combo, effective, alter brain chm
4-6 wk improve, phys s/s improve before psych s/s with more energy = danger of SI bc they can act on it
look for better sleep, less daytime fatigue and crying, increasing frustration tolerance
SE usually handled with dosge adjust or switch to med in same class
d/c as soon as feeling better may result in relapse (educate): 6-9 mo past s/s relief -> up to 12 - 24 mo (taper)
not addictive
abrupt stopping of meds will result in withdrawal: n, anx, insomnia, flu like, brain zaps
non med strategies to feel better -> exercise, decrease caffeine and OH to increase sleep
med types
also for anx sometimes, all increase avail of NT, similar efficacy
SSRI: 1st line, rare r/o serotonin s
SNRI: SSRI’s may be tolerate better bc SE
tricyclic: antichol, careful
MAOI: effective for unconventional dep, tyramine restrictions, tm resistant dep
SRI’s
increase serotonin in synaptic cleft, decrease antichol effects
SSRI
SNaRI
SNRI
SSRI
block reuptake of serotonin, increase serotonin in synaptic cleft
1st line: less SE, dep with anx or psychomotor agitation
rare r/o serotonin s: fluoxetine, paroxetine, sertraline, citalopram, escitalopram
SNaRI
serotonin and noradrenergic
venafaxine
duloxetine
SNRI
desvenlafazine -> vanlafaxine’s metabolits
SE of SRIs
drowsy (take at night)
n (with food, at night)
xerostomia: fluids, gum
insomnia (morning)
d (fiber)
nervous, agitation, restless, dizzy, sexual (no erection, organism, decreased desire)
problems
HA
blurred vision
SRI nc
effective in 4-8 wk, SE decrease in 4-6 wk
monitor for SI, extreme agitation, fever, htn, manic s
sleep hygiene, avoid caffeine if anx, teach relaxation
abrupt d/c may be mild/severe: electric surges, brain shivers, pins and needles (skin), black out, short term mem loss, feeling like on verge of unconsciousness
serotonin s: cm - mental status change
agitation, confusion, restless, lathergy, delirium, irritable, dizzy, hallucinations
serotonin s: cm - ANS
diaphoresis, flush, fever, tachy, mydriasis (pupils dilate)
serotonin s: cm - NM
myclonus (muscle twitch or jerks), hyperreflexia, tremors
serotonin s: cm - GI
n/v/d
serotonin s: cm
if serotonergic med not stopped, may progress
worsening myclonus, htn, rigor, acidosis, respo fail, rhabdo
60% dev s/s w/n 6 hrs of 1st dose, dose change, intentional OD
can be fatal -> hyperpyrexia, CV shock, death
r/t over activation of central serotenergic receptors
serotonin s: tm
slop and decrease med depending on severity
benzo to control agitation seizure, muscle stiff
o2 prn
IV fluids -> dehydration and fever
other symptomatic and supportive care
s/s usually resolve w/n 24 hrs but could take several wks to go away completely
serotonin s: tm - drugs to control HR and BP
tachy/htn: emolol, nitroprusside
hypoT: phenyephrin/epi
serotonin s: tm - serotonin production blocking agents
if other methods dont work
cyproheptadine HCl
weight based dosing
block serotonin production
tca
imipramine, doxepin, amitriptaline
less expensive, making a comeback, older
inhibit reuptake of norepi and serotonin
some results in 10-14 days, full effect in 4-8 wk
take at night -> sedating,
work well with lethargic and fatigues
tca: elevated risks
increased danger of death by OD
increased an potentially fatal CNS dep with OH and other CNS depressants
tca: dosing
initial dose low and slow -> chm structure similar to antipsych, therefore antichol SE: alpha adrenergic blockage can cause postural hypoT and tachy -> dizzy and fall with OA
tca: nc
check ecg and hx seizures
dysR, tachy, MI, heart block
CI in CV issues, narrow angle glaucoma, seizures, preg
initial early tm s/s may include early morning awakening, feeling worse in AM, some worry and anx
tca: SE
antichol and sedatoin, weight gain
dry mouth: hard candy/gum
GI upset: with food
d = freq small meals
c = increase fiber/fluids, diet and exercise
insomnia = sleep hygiene/change dosing time -> AM
orthostasis = hydrated, get up slow
sexual SE = ED meds
urinary retention = run water, monitor amount
MAOIs
phenelzine, tanylcypromine
selegiline: transdermal patch, less interactions and diet restricitons
MAOI: action
block enzyme monoamine oxidase which is used to metabolize monoamines SE, NE, and dopamine and tyramine, increase mood elevating NT
usually 3rd line for dep, anx (panic), bulimia, social phobias
good for unconventional dep -> can lift with positive news/events, arms/legs heavy, oversleep/eat
MAOI: SE
common: dry mouth, n, d, c, HA, drowsy, insomnia, dizzy, lightheaded, skin rxn (patch)
less common: invol muscle jerks, hypoT, decreased sexual desire or difficulty reaching orgasm, weight gain, difficulty starting urine flow, muscle cramp, prickling/tingling (paresthesia)
MAOIs: diet restrict
avoid tryamine to prevent htn crisis: intracranial hemorrhage, convulsions, coma, death; 15 - 90 min after CI substance
monitor bp esp in first 6 wks
aged and processed meats: pepperoni, bologna, salami, pickled herring, liver, frankfurters, bacon, ham
aged cheese
beans
condiments: soy sauce, bouillon, meat tenderizers
beer/ale/liquors/redwine/ non alc wine + beer
no otc cold meds
dont use with SSRI
avoid lots of caffeine
MAOIs: htn crisis - s/s
early: irritable, anx, flush, sweat, severe HA
occipital HA, palpitations, n/v, htn but also orthohypoT, dyspnea, SOA, mental status change, blurred vision, sweat, neck stiff/sore, dilated pupils, photophobia, tachy/brady, chest pain, disturbed heart rate/rhythm
MAOIs: htn crisis - tm
phenotolamine: alpha adrenergic blocker, vasodilate
nifedipine: ccb, relax heart muscle
symptomatic and supportive
other antidep: buproprion
NDRI
CI in ED, seizure hx
good with fatigue
less sexual SE, considered energizing, used in smoking cessation
other antidep: trazadine
chm similar to tca
sedative effect as adjunct with another antidep
at bedtime
mirtazapine
noradrenergic specific seritonergic antidep
good for sleep at bed time
meds for dep in children and teens: SSRI
black box: increased r/o SI, fluoxentine = 1st line, velafaxine = SSNRI used off label, both have low SE, mild n, HA, stomach ache
improve in 1-2wk, 12 wk full effect, gradually feel better, given 6-24 mo
meds for dep in children and teens: tca
more SE -> dysR
potentially lethal OD -> more impulsive
other treatments
phototherapy, ect, vagal nerve stim, transcranial magnetic stim , deep brain stil, st johns wort, same, omega 3, exercise relaxation (mediation, guided imagery, massage), decrease OH
advanced practice treatment
psychotherapy: CBT, interpersonal, time limited focused psychotherapy, behavior
group therapy
