Depressive Disorders Flashcards
Epidemiology of depressive disorders
2x more women, more white, worse in AfAm, SAD, dec SES
Etiology of depressive dx incl per age group
- diathesis stress
- psych - cog predis, neg and/or unrealistic expectations and perceptions (learned helplessness)
- teens - role confusion, conf w/ ind and maturation
- older - societal attitude, self-esteem, hopeless, major life changes
- genetic
- inflam process
Biochemical rf for depressive dx
- NT - Dp, 5-HT, Nor, ACh, glut
- cortisol
- hormones
- electros
Which body system is r/t depression
Thyroid (hypo)
MDD
- 5+ in 2W pd of wt loss, appetite change, sleep disturbance, fatigue, psychomotor agitation or retardation, worthless or guilt, less conc, recurrent thoughts of death
- PLUS dep mood or anhedonia
- marked impair in soc or occup fxn
- may/not have psychotic sx
- can be chronic over 2Y (recur often esp in 1st year, sx distress and impair, not attrib to psychio fx, absence manic/hypomanic episode)
Criteria for MDD in kids and teens
- 3 of following (sig wt or appetite dec, insomnia or hypersomnia, psych agit or retard, feel guilt/worthless, dec conc or indecision, recurrent death/suicide)
- PLUS irritable AND anhedonia
- other sx, vague phys complaints, freq miss school, poor performance, “bored”, sub use, inc anger/hostility, reckless
- sx must cause sig distress or impaired fxn
What is considered sig wt loss?
5+ lbs in a month
What is considered insomnia
under 6h per night
Depressive sx up to age 3
- FTT
- feed prob
- lack playfulness
- lack emo expression
- dec speech and motor dev
Depressive sx age 3-5
- prone to accidents
- phobias
- aggressiveness
- excessive self-reproach for minor infracs
Depressive sx age 6-8
- vague phys complaints
- agg bx
- clingy
- avoid ppl and challenge
- behind social/academic performance
Depressive sx age 9-12
- morbid thoughts
- excess worry
- lack social interest
- think they have disappointed parents
Disruptive mood dysreg dx
- age 6-18y, onset before age 10
- sx anger and constant, severe, irritability present btwn outbursts
** temper tantrum w/ verbal and bx attributes 3x/w for 1y in at least 2 settings - comorb with ODD, ADHD, MDD
Persistent depressive disorder aka dysthymia
- low level dep felt thru most of the day for majority days
- sx for at least 2y in adults
- at least 1y in kids and adults
- 2+ of the following - dec appetite or overeating, insomnia, hypersomnia, low energy, poor self-esteem, difficulty thinking, hopelessness
Tx for persistent dep dx
Antideps, often MAOIs and SSRIs
Premenstrual dysphoria dx
- Sx clustered in last week prior to period incl mood swing, lability, irritability, dep/anx, feel overwhelm, diff conc
- other phys sx like dec energy, overeat, insomnia, breast tenderness, ache, bloat, wt gain
- sx dec sig or disappear w/ onset of menstruation
- usually get SSRIs just for premenstrual period
Sub-induced dep dx
- person does not experience dep sx in absence of drug/alc use or w/d
Dep dx assoc with another medical condx
- cause by kid fail, Parks, Alz
- sx result from ind dx or certain meds not considered MDD
- look at hx, sx, labs
primary care screen for dep
- pt don’t go to PCP for dep
- most present w/ somatic complaints - insom, fatigue, wt loss
- need for consistent dep screen for all pt every visit
psychomotor retardation
- visibly slow PA like mvt and speech
- slow talk, pause before speech, slow chew, long time to cross room
- assoc with severe dep
Psychomotor agitation
- inc activity from mental tension
- restless, pace, tap ft/fingers, abrupt start/stop talk, meanlessly move objects
- assoc with agitation dep
Nursing problems for dep
risk suicide, hopeless, ineff coping, lack support, social iso, self-care deficit
Recovery model
Healing possible and attainable
- focus on pt strength to improve health and reach full potential
- tx goal mutually dev
- based on pt’s personal needs and values
- measured
How to prioritize hypothesis
rank probs by urgency, complexity, time
Tx for dep
- therapeutic comm
- edu CBT
- give meds
- safety
- ID supports
- est sleep routine
- group therapy
Considerations for antidepressants
- improve in 4-6w
- physio sx improve before psych ones (danger of SI w/ inc energy)
- see inc sleep, dec fatigue and crying, inc frustration tolerance
- don’t drink alc
- supp with exercise to inc sleep
- not addictive
How to handle SE of antideps?
dose adjustment or switch to diff med in class
How to stop antideps?
d/c meds 6-9M past sx relief; take up to 12-24M
- if stop meds when feel better, relapse
What happens if you stop antideps abruptly?
Can get w/d sx like nausea, anx, flu, insomnia
Which antideps work best?
Similar across the board but diff SE
- all inc avail of NTs
Order of pharm antidep therapy
- SSRIs first (most tolerable)
- SNRIs next
- TCAs
- MAOIs last resort bc food restrictions
What are SSRIs good for
OCD, psychomotor agit
- first line
- fewer SE
SSRI names
escitalopram, sertraline, citalopram, fluoxetine, paroxetine, vortioxetine, vilazodone
SNaRIs names
venlafaxine, duloxetine
SNRI names
desvenlafaxine
- metabolite of venlafaxine
SRI SE
- Most common: dry mouth, sex prob, HA, blur vis
- drowsy, insomnia, diarrhea, nerves, agit, dizzy
SRI NC
- take 4-8w to work
- SE dec in 4-6w
- monitor for SI, extreme agit, fever, inc BP, manic sx
- sleep hygiene
- teach relax techs
Serotonin syndrome sx
- mental chx like agit, conf, restless, leth, delirium, irritable, dizzy, halluc
- ANS - diaphoresis, flush, tachy, mydriasis
- neuromusc myoclonus (twitch/jerk), hyperreflexia, tremor
- N/V/D
What happens if serotonin syndrome goes untreated
worse myoclonus, HTN, rigor, acidosis, resp fail, rhabdo
When do Sr Sx sx appear
often w/i 6h of first dose of new med, dose chx, intentional OD
What causes death in Sr sx
hyperpyrexia, CV shock
tx for Sr sx
- remove med (dec sx w/i 24h but can take weeks for full recovery)
- BDZ for agit, sz, muscle stiff
- O2
- IVF for fever and hydration
- other sx and supportive care
- drugs for HR and BP
- Sr-prod blocking agents
Which drugs are given for tachy/HR control with sr sx
esmolol or nitroprusside
which drugs are given for hypo in sr sx
phenylephrine or epi
Sr-prod blocking agents
- last resort for sr sx
- meds like cyproheptadine HCl
- dose in 4mg tab; wt-based after 2y old (usually 12-16mg)
TCAs
- older, generic, less $
- block Sr and Nor reuptake
- imipramine, despramine, doxepin, amitriptyline
- take 10-14d for fx, full fx 4-8w
- start low and gradually inc bc meds resemble antipsychotics and SE
- often give at night bc sedative
SE of TCAs
antichol - hot, dry, blur, red, conf, delirium, dry, dilate pupils, ortho hypo, tachy
***FALLS
Big risk of TCAs
OD
- fatal CNS dep esp with other dep like alc
What to check before starting TCA?
- ECG for cardiac bc can cause MI, tachy, dysrhythmia
- Check hx sz
- hx preg, glaucoma
Early tx sx of TCAs
early morning wake up, feel worse in am, some worry and anx
Sx tx for TCAs
- sugar free gum/candy for dry mouth
- take with foods for GI
- freq small meal for diarr
- inc fiber/fluids in diet/exercise for constipate
- sleep measure, give in am/pm based on sx
- hydrate, get up slow for orthostasis
- ED meds for sex
- run water, check void amt for urinary hesitancy
MAOI patho
block monoamine oxidase which metabolizes Sr, Nor, Dp, tyramine (causes inc in NTs)
Names of MAOIS
isocarboxazid, phenelzine, tranylcypramine, selegiline patch
Benefit of selegiline patch
dec intx and food restriction
What are MAOis good for
unconventional dep (arms and legs feel heavy), anx, panic, bulimia, social phobia
Common SE of MAOIs
dry, n, diarr/c, HA, drowsy, insomnia, dizzy, skin rxn patch site
less common SE of MAOIs
muscle jerk/cramp, dec BP, dec sex drive, wt gain, prob start urine flow, prickle/tingle (parasthesia)
Why to watch what you eat with MAOIs? and NC
- often inc bp
- watch for HTN crisis, intercranial hemorrhage, coma, death
- watch for 1st 6w esp
- often occurs w/i 15-90 min of ingesting subs
subs that cause BP
aged cheese, meat, overripe fruit/veg, fermented, marinated, beans, condiments, ALC (even non-alc beer), Demerol, OTC cold meds, SSRIs!
Other MAOI NC
- rarely given with SSRI bc risk of Sr sx
- avoid high amt of caff
- avoid choc and avocado
HTN crisis sx
- occipital HA, palpits, N/V, HTN but ortho hypo, AMS, blur vis, dyspnea/SOA, sweat, neck stiff/sore, big pupils, photophobias, tachy/brady, chest pain, disturbed cardiac r/r, coma, death
Tx for HTN crisis
- phentolamine (regitine) - alpha-adrenergic blocker
- vasodil SL nifedipine (Ca ch blocker) aka Procardia
- supp/sx care
Bupropion (NDRI)
- c/i in eating dx and hx sz
- dec sex SE
- use with smoke cessation
- considered “energizing”
Trazadone
- given at hs for sedative as adjunct with other AD
- chemically sim to TCAs
Mirtazapine
good for sleep
- NaSSAs
SSRIs for kids and teens
- BLACK BOX inc risk SI
- fluoxetine first line
- Venlafaxine, SSNRI off label
- both low SE; mild N, HA, stomachache
- inc 1/2W, 12W for full fx; pt feel chx in 4-8w
- give for 6-24M
TCAs in kids
- more SE; potential dysrhythmia
- potential lethal in OD
- kids impulsive so we avoid
Other tx for dep
- photo
- ECT
- VNS
- TMS
- DBS (rare)
- exercise
- relax (med, guided imagery, massages)
Supplements
John’s wort, SAMe, omega 3
Advanced practice tech for dep
psychotherapy like CBT, IPT (interpersonal), time limited psycho, bx, group therapy
Parts of PHQ-9
- little interest or pleasure
- feeling down, dep, hopeless
- trouble sleep
- poor appetite or overeat
- feeling bad about self
- trouble conc on things
- psychomotor agit or retard
- thoughts you would be better off dead
Early signs of HTN crisis
flush, sweat, anx, irritability, severe HA
SRI w/d sx
- abrupt d/c mild or severe sx (electric surge, brain shiver, pins and needles, black out, short term mem loss, syncope)
What sub to avoid when anx w/ SRIs?
Caffeine
