Depressive Disorders/Suicide Flashcards
what is depression?
alteration in mood that is expressed by feelings of sadness, despair, pessimism
loss of intent in usual activities
somatic symptoms
changes in appetite and sleep- eating too much or too little; sleeping too much or too little
what are the different types of mood disorders?
persistent depressive disorder
premenstrual dysphoric disorder
substance/medication-induced depressive disorder
depressive disorder due to another medical condition
major depressive disorder
seasonal affective disorder (SAD)
how long does a person with persistent depressive disorder having feelings of low level depression?
most of the day
majority of days- for at least 2 years
what are the symptoms of persistent depressive disorder?
in order to be diagnosed a person needs to have 2 of the following
poor appetite or overeating
insomnia or hypersomnia
low energy or fatigue
low self-esteem
poor conentration or difficulty making decisions
feelings of hopelessness
NOT severe enough for hospitalization
what are the essential features of premenstrual dysphroic disorder (PMDD)?
at least 5 symptoms appear in last week prior to menses, start to improve at menses onset
mood swings
marked irritability or anger or increased conflict
marked depressed mood, feeling of hopelessness or slef-deprecation
marked anxiety, tension, feeling of being keyed up or on edge
decreased interest in usual activities
difficulty concentrating
lethargy, easy fatigue marked lack of energy
marked change in appetite
hypersomnia or insomnia
breast tenderness, aching, bloating, weight gain
what is the major depressive disorder?
symptoms cause significant distress in employment, social or other areas of functioning
not attributed to other medical conditions or substance abuse
what are the diagnostic criteria for major depressive disorder?
5 or more must be present for two weeks with a change from previous functioning
depressed mood most of the days or nearly every day
anhedonia- unable to experience pleasure
weight/appetite loss of gain
insomnia/hyersomnia
psychomotor agitation or retardation
anergia/fatigue
feel worthless, inappropriate guilt
trouble thinking, concentrating, indecisiveness
recurrent thoughts of death, suicide thoughts, and plans
what are the major depressive disorder episode specifiers in the DSM-IV?
single episode or recurrent episode
mild, moderate, or severe
with or without psychotic features
with catatonic features
with postpartum onset
with seasonal pattern
what are biological risk factors for depression?
genetic
biochemical- deficiency of serotonin, norepinephrine, glutamate, GABA, dopamine, and acetylcholine
hormonal
chronic inflammation
what are psychological risk factors for depression?
cognitive theory- views primary disturbance in depression as cognitive rather than affective
depression is product of negative thinking; to improve mood, need to change the way a person thinks
what are three cognitive distortions that serve as the basis for depression?
- negative expectations of the environment
- negative expectations of the self
- negative expectations of the future
what needs to be observed in the assessment for depression?
affect
mood/anhedonia
thought process- indecisive; trouble making decisions
feelings- hopeless/despair/worthless/inappropriate guilt
cognitive changes- trouble learning and concetrating
physical behavior- anergia, pscyhomotor agitation or retardation. vegetative/catatonic signs of depression
what should the patient/family education include?
nature of illness
management of the illness
support service
what are treatments and interventions for depression?
therapeutic communication
group therapy
family therapy
cognitive therapy
pharmacology
ECT= electroconvulsive therapy, where this utilized inthose note repsonding to treatment or in a severe catatonic state
brain stimulation therapy
what are examples of antidepressant medications?
monoamine oxidase inhibitors (MAOIs)
tricyclic
selective serotonin reuptake inhibitors (SSRI)
serotonin-norepinephrine reuptake inhibitors (SNRI)
serotonin antagonist and reuptake inhibitors (SARI)
norepinephrine-dopamine reuptake inhibitors (NDRI)
noradrenergic and specific serotonergic antidepressants (NaSSAs)
serotonin partial agonist reuptake inhibitors (SPARI)
serotoin modulators
what was the first medications specialized to treat depression?
monoamine oxidase inhibitors (MAOIs)
what are examples of MAOIs?
selegiline transdermal (Emsam)
phenelzine (Nardil)
tranylcypromine (Parnate)
isocarboxazid (Marplan)
what are the foods that needed to be avoided when taking MAOIs?
avoid tyramine containing foods, such as:
aged cheeses
raisins, fava beans, flat Italian beans
red wines
smoked or processed meats/caviar
soy sauce/soy products/fermented foods
what are the foods that needed to be limited when taking MAOIs?
limit amount of:
gouda cheese, American cheese, mozzarella cheese
yogurt, sour cream
avocados
bananas or any over ripe fruit
beer, white wine, coffee, colas, teas, hot chocolate
chocolate
meat extracts= monsodium glutamate, meat tenderizers
what happens when tyramine containing foods and MAOIs are combined?
it causes a hypertensive crisis
what are the signs and symptoms of a hypertensive crisis?
headache
N/V
tachycarida
fever
diaphoresis
epistaxis
chest pain
SOB
vision changes
what is the treatment for hypertensive crisis?
gastric lavage/activated charcoal
IV vasodilators- nitroprusside sodium (Nipride)
what are the drug-to-drug interactions with MAOIs?
any other antidepressant (fatal)
sympathomimetics- cold and congestion tx
stimulants- amphetamines, cocaine
antihypertensive- methyldopa, reserpine
meperidine and opioid narctoics- morphine, codeine
antiparkinsonian agents- levodopa
how many days should someone be discontinued or potentially be starting on MAOIs before/after starting a different antidepressant?
14 days
what are examples of tricyclic antidepressants?
amitriptyline
doxepin (Silenor)
clomipramine (Anafranil)
desipramine (Norpramin)
nortriptyline (Pamelor)
imipramine (Tofranil)
what happens if a patient either taking an MAOIs or tricyclic antidepressant, if there is an overdose?
both can cause cardiac arrhythmias, such as V Tach and V Fib
what are examples of SSRIs?
fluoxetine (Prozac)
sertraline (Zoloft)
paroxetine (Paxil)
citalopram (Celexa)
escitalopram (Lexapro)
fluvoxamine (Luvox)
what are the side effects of SSRIs?
most common is sexual dysfunction (except Lexapro)- can add Buspar/Wellbutrin to help
insomnia
fatigue
headache
N/V/D
agitation
dizzy
dry mouth
hyponatremiaw
what is the discontinuation syndrome from SSRIs?
dizzy
insomnia
nervous
irritable
nausea
agitation
what is serotonin syndrome?
it is rare; occurs most often when more than one drug is used that increases serotonin levels or when high doses are used
what are the symptoms of serotonin syndrome?
abdominal pain/diarrhea
sweating/fever/shivering
tachycardia/HTN/arrhythmia
AMS- delirium
myclonus- muscle spasms and rigid
increased motor activity
hyperactivity- restless
irritability/mood swings
what can serotonin syndrome progress to?
seizures, coma, death if not recognized and drug withheld
what is the treatment for serotonin syndrome?
stop the medication
supportive care- adjunctant medications and IV fluids
what is the mechanism of action of SNRI?
increases norepinephrine and serotonin levels
what are examples of SNRI?
duloxetijne (Cymbalta)- also used in chronic pain and cognitive symptoms
venlafaxine (Effexor)
desvnlafaxine (Pristiq)- also used for menopause
levomilnacipran (Fetizma)
what is an example of SPARI?
vilazodone (Viibryd)
what are some aspects about vilazodone?
start at low dose
needs to be taken with food d/t causing nausea
the maximum dose is 40 mg
need to be within the therapeutic dose to understand if it is working
causes vivid dreams/nightmares
what is an example of a serotonin modulator?
vortioxetine (Trintellix)
what are some aspects about vortioxetine?
decreases aggression
increases sex drive
increase cognition
what is the onset of vortioxetine?
2-4 weeks, so it is faster than some other antidepressants
what are the side effects of vortioxetine?
nausea, where it usually passes within 3-4 weeks
what is an example of SARI?
trazadone (Desyrel)
what are the aspects of trazadone?
helps with insomnia
most common anti-depressant prescribed
what is an example of NDRI?
bupropion (Wellbutrin)
what are some aspects about buproprion?
uses as adjunctive therapy
can help with sexual dysfunction and apathy from SSRI
cannot take if hx of seizures
can make anxiety worse
decrease appetite
good for helping to quit smoking
what is an example of an NaSSAs?
mirtazapine (Remeron)
what are some aspects with mirtazapine?
give before meals
sedates
stimulates appetite and weight gain
utilized in elderly patients, especially in Alzhemier’s disease
what is the antidepressant black box warning?
antidepressants increased the risk compared to placebo of suicidal thinking and behavior in children, adolescents, and young adults in short-term studies of MDD and other psychiatric disorders.
what are some new therapies for treatment resistant depression?
esketamine intranasal (Spravato)
association of testosterone treatment with alleviation of depressive symptom in men, especially older men
what is an example of an NMDA antagonist?
esketamine intranasal (Spravato)
what are some aspects of esketamine?
it can be very addictive
administer nasal corticosteroid or decongestant 1 hour before
watch BP d/t causing HTN
N/V
given in healthcare setting
what are patient teachings for antidepressant medications?
continue to take the meds even if symptoms don’t seem to be getting better. can take up 4-6 weeks to see improvement
do not discontinue drug abruptly
avoid alcohol while taking antidepressants- can worsen the symptoms
avoid smoking
get up slowly d/t orthostatic hypotension
photosensitivity
notify phsycian with any symptoms of side effects
what is the medication plan for depression?
give each med a 3 month trial
stay on medications for 6-9 months after signs and symptoms stop
3rd recurrence- lifelong therapy recommended
what is electroconvulsive therapy (ECT)?
the induction of grand mal (general) seizure through the application of electrical current to brain
what are the methods for ECT?
anesthesia must be present
electrodes placed bilaterally in frontotemporal region
dose of stimulation is individualized based on client’s seizures threshold
seizures should last 25 seconds-1 minute
movements are minimal d/t muscle relaxer or anti-anxiety
give 6-12 treatments 2-3 times a week for 4-6 weeks
what are the indications for ECT?
severe depression
vegetative symptoms with depression- psychomotor retardation, disturbances in sleep, eating, and energy
psychotic symptoms with depression
mania
schizophrenia
anxiety disorders like OCD and personality disorder
what are contraindications for ECT?
increased intracranial pressure- the only absolute contraindication
recent MI within the past 3 months
recent CVA
severe osetoporosis
acute and chronic pulmonary disorders
high-risk or complicated pregnancy
what are the pre-op nursing roles for ECT?
assessment- ensure screening for those conditions that make ECT contraindicated
keep client NPO for 6-8 hours before procedure- decrease risk for aspiration
monitor vital signs with telemetry
check blood sugar if diabetic
may give oral alkalinizing agents, such as sodium bicarbonate and IV anti-reflux meds, such as reglan
remove dentures, glasses, hairpins, jewelry, change into gown
have patient void, start IV with LR
administer medications as ordered atropine or Robinul iM
stay with client to help decrease anxiety
what are the nursing roles during the ECT?
assist in connecting to monitoring devices
ensure patency or airway; provide suctioning if needed
assist anesthesiologist with oxygenation- will need to be prepared to intubated if needed
observe readouts on monitors- VS, pulse ox, and cardiac functioning
provide support to client’s extremities during seizure
observe and record type and amount of movement induced by seizure
what are the nursing roles after the ECT?
monitor pulse, respirations, blood pressure q15 minutes for first hour- client should remain in bed
position client to prevent aspiration
orient client
describe what occurred
provide reassurances that any memory loss is temporary
allow clietn to verbalize fears
stay with client till fully awake, oriented, and able to perform self-care activities
what are other brain stimulation therapies?
transcranial magnetic stimulation (TMS)
vagus nerve stimulation
deep brain stimulation
what is transcranial magnetic stimulation?
use of burst of magnetic energy applied to brain; works like ECT usually without seizure activity; may take more treatments; can be done outpatient
what is vagus nerve stimulation?
implant electrode onto vagus nerve and send electrical impulses to vagus nerve and thus to brain; all implanted surgically; very invasive= higher risk for infection
what is deep brain stimulation?
implanted electrodes in brain and generators subcutaneously: electrical impulses are continuously generated and sent to the brain
used first in Parkinson’s
shows some promise for depression and OCD treatment
what are some other recommendations for those with depression?
exercise
greenspace
nutrition
light therapy
melatonin
St. John’s Wort
B vitamins/folic acid/SAM-e/magnesium/omega 3 fatty acids/vitamin D 5000 units per day/probiotics/zinc
what are the leading cause of death among suicide victims?
gunshots
what are some theories of suicide?
anger turned inward
hopelessness
desperation/guilt
history of aggression/violence
shame/humiliation
developmental stressors
biological link- someone else in their families had an attempt or died from suicide
copy cat suicide
psychological
environmental
culture
society
what are some protective factors from suicide?
effective and appropriate clinical care for mental, physical, and substance abuse disorders- support for ongoing medical/mental health care relationships
easy access to a variety of clinical interventions and support
restricted access to highly lethal methods of suicide
family and community support- marriage
learned skills in problem solving, conflict resolution, and nonviolent handling of disputes
cultural and religious beliefs hat discourage suicide- support self-preservation instincts
what are the risk factors for suicide?
male gender
increasing age
race (85-90% caucasians)
alcohol or substance use disorders
psychiatric disorder
chronic illness/chronic pain
LGBTQ+ youth
family history of suicide
previous attempt
loss of loved one
lack of employment
what is the assessment for suicide involve?
presenting symptoms/medical psychiatric diagnosis
suicidal idea or acts- seriousness of intent, plan, means, and verbal and behavioral clues
analysis of suicidal crisis- the precipitating stressor, relevant history, and life-stage issues
coping strategies- interpersonal support system
what are nursing interventions for depression/suicide?
ask client directly if there are thoughts of suicide or a plan
create a safe environment
ask for short term contract/safety plan
may need a sitter
secure promise that client will seek out staff
close observation q15 minutes
observe medication administration
identify something worth living for
what is non suicidal self-injury?
risk for self mutilation
what are some common self-injury behaviors?
scratching, cutting, or pinching the skin to the point of bleeding, using fingernails or a sharp object
carving words or symbols into arms, wrists, legs, breasts, torso, or other body areas
biting oneself to the point of bleeding or leaving marks on the skin
burning the skin
intentionally preventing wounds from healing
imbedding objects into the skin
ingesting harmful non-nutritive substances with intention to self-injure
