Module 5 - Mood Disorders - Bipolar/Depression Flashcards
Depressive Disorders
Disturbance in psychological, physiological and social functioning
Has a wide range of symptoms with disturbances in daily patterns
Depressive Disorder Symptoms
Sleep, Appetite, ADL problems, weight, attention, memory, libido
Impulse control, suicidal ideation, social withdraw
physical symptoms like H/A, stomachache, muscle tension
Symptoms present differently between patients
Physical Symptoms are common in depression and are often called ___ symptoms
somatic
Levels of Depression
Transient Depression
Depressive Disorder
Transient Depression Level
A normal reaction to loss
everyone experiences this at some point
sadness directly attributable to a situation or disappointment - “reactive or secondary depression!”
Depressive Disorder Level
sad mood can be related to external events or not
symptoms range from dissatisfaction with life to sudden and abrupt changes in function that suppress or take away the will to live
The most common illness of any medical or psychiatric illness is?
Major Depression / Major Depressive Disorder
Depression affects who?
all ages and backgrounds
Depression is the current leading cause of __ in the US in ages 15-44, and is predicted to be the 2nd leading cause in all ages by 2020
disability
Average Age of Depression disorder
32 yo
How much of the Us population has major depression?
14.8 million people aged 18 yo or older
that is 6.7% of the population
15% of those with depressive disorder will….
die via suicide
very prevalent in older people
Comorbidities that frequently accompany other psychiatric disorders like depression?
Schizophrenia
Substance Abuse
Eating Disorders
Anxiety Disorders
Personality disorders
Risk Factors for Depression
Higher in women than men
Past episodes of depression
Family history
Stressful life event
Current substance use
Medical illness
Limited social supports
know the persons PMH and the whole picture
Etiology for Depression
Exact cause is Unknown!! but.. there is a combination of Interactions Between:
- Genetics (increased risk if first degree relative has it, NT deficiency in Dopamine, NEP and Serotonin)
- Environment
- Individual life history
- Development
- Neurobiological
- Irregularities in the thyroid as especially important in relation to major depressive disorder
Regions of the Brain affected by depression
Thalamus
Cingulate Gyrus
Amygdala
Prefrontal Cortex
Thalamus
Assoc with changes in emotion and stimulates the amygdala
In depression there is INCREASED levels of activity
Amygdala
responsible for negative feelings
In depression there is INCREASED levels of activity / overactivity
Cingulate Gryus
Helps associate smells and sights with pleasant memories of past emotions and takes part in emotional reaction to pain and regulation of aggression
In depression there is INCREASED activity
Prefrontal Cortex
helps regulate emotions
In depression there is DECREASED activity
Primary Depressive Disorders
Major Depressive Disorder
Persistent Depressive Disorder (Dysthymia)
Post Partum Depression
Major Depressive Disorder
Potential for pain and suffering in all aspects of life
Affects kids, teens, adults, elderly, everyone
it is a depressed mood or inability to feel pleasure from previously enjoyed activity - this is the key thing!
What is needed for diagnosis of Major Depressive Disorder
- 4 out of 7 Symptoms (Suicidal Ideation, Sleep disruptions, Appetite disruptions/weight issues, disruption in concentration, disruption in energy level, psychomotor agitation/retardation, or excessive guilt/feelings of worthlessness)
- Must occur over a MINIMUM OF 2 WEEKS
What features may major depressive disorder symptoms include?
Psychotic Features
Catatonic Features
Melancholic Features
Dysthymia
Persistent Depressive Disorder
It is a chronic depressed mood with symptoms of poor appetite or over eating, insomnia or excessive sleep, low energy, fatigue, low self esteem, poor concentration, difficulties making decisions and feelings of hopelessness
Less severe than MDD but presents as a LIFE LONG struggle against depression, chronic negativity and irritability
How long must Dysthymia occur for diagnosis?
> 1 year for children and adolescents
> 2 years for adults and the elderly
What are the must have symptoms for MDD diagnosis?
- Depressed Mood
2. Loss of Interest
What is the average length of MDD?
4-12 months
What is the average length of Dysthymia?
averages more days than not with s/s for at least 2 years
Post Partum Depression
more serious and persistent
Lasting weeks of months after a pregnancy
can emerge any time during the 1st year after childbirth
What leads to a higher incidence of post partum depression
previous psych history
Untreated post partum depression…
can become dangerous for the family and affected individual
*if they have HCP they need to be screened and treated
How obvious is Post Partum depression
Obvious in some women where other clients may not be as ready to share their feelings - so make sure to watch non verbal’s
Assessment Tools for Depression
Beck Depression inventory
Hamilton Depression scale
Geriatric Depression scale
Zung Depression scale
When it comes to psych what always comes first?
Safety (for your and patient)
It is important to always assess for what with depression patients
suicidal risk, ideation, and intent
Key Symptoms of Depression seen in an Assessment
Depressed Mood
Anhedonia
Anxiety
Psychomotor Agitation or Retardation
Somatic Complaints
Vegetative State - Physical and Mental inactivity
Anhedonia
inability to have pleasure/feel pleasure
Areas to Assess in Depression patients
Mood
Affect
Thought Processes
Feelings
Physical Behaviors
Communication
Assessment of Mood in Depression
subjective report of clients emotional state that impacts current life situation
Assessment of Affect in Depression
emotional tone the client projects - physical appearance, posture, mood, eye contact, speech, withdrawn, blunted and flat
Assessment of Thought Processes in Depression
insight and judgment, decision making, memory and concentration and delusions
Assessment of Feelings in Depression
anxiety, hopeless, helpless, guilt, anger and listless
Assessment of Physical Behaviors in Depression
hygiene and grooming, sleep patterns, appetite, bowel habits, libido and anorexia
Assessment of Communication in Depression
maybe soft spoken, mute, cadence, rate, response time
Potential Depression Related Nursing Diagnoses
Risk for Suicide
Hopelessness
Powerlessness
Disturbed Thought Process
Ineffective Coping
Risk for Violence
Ineffective Health Maintenance
Impaired Social Interaction
Therapeutic Communication
Involves:
- Counseling and encouraging engagement in treatment
- encouraging self care activities
- maintain therapeutic milieu
- health teaching
- administering meds per physician/advanced practice nurse
- assess effects of medications and treatments
- educate on coping skills and medications
What always bubbles to the top of psychiatric (and in general) nursing in regard to treatment ?
Therapeutic Communication
Define Communication
conveying info through verbal and nonverbal behaviors.
sending and receiving messages
Define Therapeutic Communication
nurse demonstrates empathy, effective communication skills, and responds to clients thoughts, needs, and concerns
Define Nontherapeutic Communication
nurse responds in ways that cause defensive feelings, misunderstood, controlled, minimized, alienated, discouraged from expressing self, thoughts, and feelings
Examples of Therapeutic Communication Techniques
Giving Broad Openings
Paraphrasing
Offering General Leads
Reflecting Feelings
Voicing Doubts
Clarifying
Placing Events in time Sequence
Giving Information
Encouraging formulation of Plan
Testing Discrepancies
Examples of Non Therapeutic Communication Techniques
Social Responding
Asking Closed Ended Questions
Changing the Subject
Belittling
Making Stereotyped comments
Offering False Reassurance
Moralizing
Interpreting
Advising
Challenging
Defending
___ is a highly important behavior for Therapeutic communication
Listening (Actively)
Active listening involved focus on…
ALL behaviors that the client express, non verbal’s and verbal’s
What is required to actively listen
energy, concentration, specific skills to ask the right questions
What does active listening allow the client to do?
determine content and level of information disclosure
Active Listening involves:
maintaining eye contact
close proximity
projecting a relaxed environment
focus on what the client says, interpret interactions and respond objectively
remember to use non verbal’s when communicating with a client
What is the skill of “Confronting and Setting Limits”
Skill of pointing out in a caring way discrepancies between what the client does and says
It can describe behavior that is inconsistent or confusion
When confronting and setting limits what should you do?
Give at least two possible interpretations of the behavior (choices)
ask for feedback
How does Self Disclosure play into Therapeutic Communication?
It is a technique that should not be used - you should not be disclosing sensitive topics about yourself that are heavy and you have not fully mastered them
Personal information can however help a client open up, not meet your needs, so it can be used if you have total control and keep it brief
Use self disclosure to … not…
to help the client open up not meet your needs
Rules for Self Disclosure
keep it brief
do not imply your situation is the same as the client
only disclose situations you have mastered
do not use to discuss painful situations
curb your talk about yourself
needs to be appropriate and comfortable
nonverbals should be monitored during it to check if the client is receptive
Treatments for Depression
Safety Always comes first!!!!!!!!!!!!!
Psychotherapy and Meds
Group therapy and counseling
family therapy and family involvement
Electroconvulsive therapy
social skills training and milieu therapy
cognitive behavioral therapy
What is the most effective combination to treat depressive disorders?
Psychotherapy and Medications
ECT is used as a treatment when…
other treatments and meds don’t work
It is important to do what during depression treatment other than just treat symptomatically?
get to the root cause
SSRIs
Selective Serotonin Reuptake Inhibitors (Prozac, Zoloft, etc)
1st Generation serotonergic agents which are considered FIRST LINE DRUGS for depression, unless patients medical history or condition warrants use of a different medication
How do SSRI antidepressants compare to other antidepressants?
They generally have fewer side effects than others, but do cause things like nausea, headache, and loss of libido
They have minimal anticholinergic or cardiotoxic side effects
What is a possible lethal reaction to SSRIs?
Serotonin Syndrome
Serotonin Syndrome typically follows use of what kinds of drugs?
SSRIs
TCAs
Tryptophan
Dextromethorphan
Meperidine alone, or with MAOIs
St Johns Wart
What are the first line antidepressants?
SSRIs (also SARIs and SNRIs)
How long does it take to see a good response from most antidepressants?
2-6 weeks
Serotonin Syndrome
Potentially lethal reaction to SSRI and other antidepressant use
S/S of Serotonin Syndrome
Confusion and Disorientation
Mania and Restlessness
Rigidity
Diaphoresis
Tremors
Coma, even could rarely lead to death
Treatment for Serotonin Syndrome
stop all serotonergic drugs, give anticonvulsants if ordered or possibly a serotonin antagonist
Atypical Antidepressants
Second line antidepressants
considered safer than TCAs or MAOIs
ex: Remeron or Trazodone
Tricyclic Antidepressants (TCA)
These are an older kind of antidepressant (first gen) used before SSRIs and Atypical Antidepressants
They used to be the first line drugs against depression (ex: Elavil)
Why are TCAs not used anymore?
- Cardiotoxic Effects
2. Narrow Therapeutic Window
What kind of patients never get TCAs?
Suicidal Patients
What are some current uses for TCAs?
- Patients have been unsuccessful on SSRIs or Atypical antidepressants or have documented past success with TCAs
- Used for patients who also have certain GI disorders such as peptic ulcer disease
Monoamine Oxidase Inhibitors (MAOIs)
Another older antidepressant, not used much anymore since the development of SSRIs
ex: Nardil
Increases tyramine levels
When may MAOIs be used nowadays?
To treat atypical depression or for patients not showing responses to other antidepressants
MAOIs and Tyramine?
Tyramine is a compound in the body that increases with MAOI use
Patients need to be careful about eating high tyramine food because high levels lead to hypertensive crisis!!!
Foods high in tyramine?
yogurt, aged cheeses, beef or chicken liver, canned meats, fish, sausage, avocado, eggplant, alcoholic beverages, chocolate and meat tenderizer.
Things to do during Counseling
Help client ID and question cognitive distortions
Encourage activities that improve self esteem
encourage exercise
encourage supportive relationships
provide referrals for spiritual interventions when needed
Family Therapy
An assessment, intervention and evaluation of family functional and dysfunctional patterns of behavior
Need to examine interactions between parents and children
Goal is to help family members identify and change behaviors that maintain depression and dependence among family members
Electroconvulsive Therapy (ECT)
A therapy that is used if psychopharmacy and all other tx’s are ineffective
It produces a seizure thought to modify neurotransmissions
Short acting anesthesia and muscle paralyzing agents are used
What are some ECT side effects?
Few long term side effects
Can cause memory loss or confusion lasting a few weeks or months after series is complete
Contraindications for ECT?
no absolute contraindications, but some conditions pose a risk:
Recent MI
CVA
Intercranial Mass
ECT is not usually used for clients unless…
need is compelling and all else fails
What is needed in addition to normal procedure to do ECT?
additional high risk consent
skill required
Why may ECT be good for a pregnant woman?
There are no harmful risks to the fetus but antipsychotic drugs can be harmful
Cases where ECT may be useful?
Major Depression and Bipolar Disorders - especially when psychotic features are present
Depression with psychomotor retardation or stupor
Rapid cycling bipolar disorder
Schizophrenia (especially catatonic)
Schizoaffective Syndromes
Pregnant psychotic patients
Parkinson’s Disease patients
Nursing Care for ECT
Routine pre and post anesthesia care
May need to orient client after awakening
Provide supportive care for memory loss (may last for a few weeks; occasionally does not recover)
Inform that this is not a permanent cure
Watch for falls
After ECT, patients are at high risk for…
falls
Cognitive Behavioral Therapy
Therapy attempting to help clients identify and correct distorted, negative and catastrophic thinking, therefore relieving symptoms - change the way they think
It is done in a group OR individual setting
Hope is to work actively with clients to change faulty thought pattersn
Cognitive Behavioral Therapy is a common treatment for …
depressive disorders
What sort of things can Milieu Therapy do for a person?
supportive group activities
protection from suicide intent
assertiveness training
assistance with grooming and hygiene
brief and frequent interpersonal contacts
ensure adequate nutrition
prevent constipation
discourage daytime sleep
How should a nurse assess themselves when working with depressed clients?
Know unrealistic expectations for outcomes
Understand depression is a systemic illness with a complex interaction of causes and IS treatable
Know depressed clients can cause feelings of depression, frustration, anger, and hopelessness
Nurses need to care for themselves as well as the client!
What are some aspects of proper health teaching for depression?
Teach client and family that depression is a legitimate illness
Teach S/S
Review medications
Relaxation techniques
Appropriate humor can be used
What are some good outcome criteria for depression patients?
Remains safe
Reports hope for future
Stabilize to prevent decompensation
Reports improved mood
Plans strategies to reduce effects of precursors of depression
Bipolar Disorder
It is a recurrent mood disorder featuring at least one episode of mania or hypomania
What is the big difference between depression and bipolar?
Depression is marked by mood disturbance where the person feels sad/down
Bipolar disorders are also marked with this but the main difference is these clients will experience mood swings from significant depression to extreme euphoria (manic)
What is the Incidence and Prevalence of Bipolar Disorders like in the US
2.6% of the population have it
average age of first manic episode is 25
estimated 25-50% of clients with bipolar disease attempt suicide at least once in their life with 15% completing it
Earlier onset of bipolar disorder is associated with what?
worse outcomes, including rapid cycling in adulthood
Common Comorbidities with Bipolar Disorders
Substance Abuse
Personality Disorders
Anxiety Disorders
Psychosis
Increased risk of morbidity and mortality
Why are rates of morbidity and mortality in bipolar depression so high and what is this associated with?
It is high because of suicide rates and also because in the manic state the body can become exhausted
This exhaustion is associated with cardiovascular, cerebrovascular, and respiratory diseases and other psychiatric illnesses and substance use disorders
Types of Mood Episodes in Bipolarism
Mania
Hypomania
Depression
Mania
Episode of abnormal and persistent elevated, expansive, or irritable mood
It involves extreme mood swings, sudden outburst, sleep disturbances (sometimes days or weeks), feeling full of energy, grandiosity, distracted, restlessness, exaggerated self esteem, “flight of ideas”, pressured speech, sexual promiscuity, and flamboyant dress
Manic Episodes are severe enough to cause __ __
marked impairment
People undergoing a manic episode need to be what?
hospitalized in order to prevent harm to self or others!
Symptoms of Mania are…
NOT due to other causes like substance abuse, physical disease, etc
Hypomania
A more mild mania without the marked impairment and with judgment still remaining intact
There is no need for hospitalization to prevent harm to others or self
Symptoms are still not due to other causes
There are no psychotic features
Bipolar I Disorder
One or more manic episodes alternative with major depressive episodes
Depressive symptoms here are far less responsive to conventional therapies than manic symptoms
Can undergo mixed state
Mixed State
State or episode where the individual has rapidly alternating moods between depression and mania
Bipolar II Disorder
A major depressive episode and at least one hypomanic episode
No history of a manic episode or mixed episode can exist
It is more long term presentations of symptoms but they function better and may not need hospitalization
Why can Bipolar II Disorder be hard to diagnose?
It can be hard because it looks like depression and it can be even harder if its the persons first depressive episode
Cyclothymia
Bipolar disorder
Clients experience repeated periods of nonpsychotic depression and hypomania for at least 2 YEARS (1 year for kids and adolescents)
A very long term battle
When is the only time Cyclothymia is diagnosed?
if a client’s symptoms have never met the criteria for a MAJOR depressive or manic episode
Rapid Cycling
Bipolar Disorder
Clients have 4 or more manic episodes for at least 2 weeks in a single year
Patients do not respond to classic therapy often and may need ECT
What are rapid cycling episodes marked by?
either partial or full remission for at least 2 months or a switch to an episode of the opposite type
Rapid Cycling is associated with what?
High risk for recurrence and resistance to conventional drug treatments and classic therapy, may need ECT
Rapid cycling has greater severity of…
illness and prominent depressive symptoms
Early Detection of Bipolar Disorders can prevent…
suicide
accidents
substance abuse
marital or work problems
medical comorbidity
legal problems
financial problems
Mood Characteristics of Mania
hypomanic to manic
sociality and euphoria all the way to hostility, irritability, and paranoia
Behavior Characteristics of Mania
hyperactivity
bizarre and colorful dress
highly distractible
impulsive
Thought Process Characteristics of Mania
flight of ideas
grandiosity
poor judgment
auditory hallucinations and delusional thinking (psychosis)
Cognitive Function Characteristics of Mania
significant and persistent problems
difficulties in psychosocial areas (difficulty socializing)
Things the nurse should be aware of with manic patients?
Manipulative
Cause Splitting
Aggressively Demanding (need a team approach to fix this)
Splitting
Staff Splitting
Need consistency with manic patients because they can cause fighting between shifts.
Important Staff Member Actions for Manic Patients
Set limits consistently
frequent staff meetings to deal with patient behavior and staff response is needed.
What things may indicate danger to self or others in a Manic patient?
Assess for suicidal thoughts or plans
May exhaust themselves to the point of needing emergency medical interventions
May not eat or sleep for days at a time
Poor impulse control - is that present?
Nursing Diagnoses for Bipolar Disorders?
Risk for Violence Self / Others
Ineffective Health Maintenance
Impaired social interaction
Ineffective Coping
Disturbed Thought Processes
Situational Low Self – Esteem
Ineffective Therapeutic Regimen Management
Things to Plan for in the Acute Phase of Bipolar Disorders
Maintaining safety (hospitalization, self care to stay alive, medicine)
Medication stabilization
Self care
Things to Plan in the Continuation phase of bipolar disorders
Maintain medication compliance (meds even when better and education is important)
Psycho education teaching
Counseling
Things to plan in the maintenance phase of bipolar disorders
prevent relapse (make sure they have supports and are taking meds to prevent return to the hospital)
What techniques need to be implemented in the Acute Phase of bipolar disorders
communication (therapeutic) (very important with staff and patient)
structure in a safe milieu (they need a structured task to work on)
physiological safety
self care needs
How to properly communicate with a manic patient?
Use firm, calm approach!!
Use short and concise explanations
remain neutral: avoid power struggles
be consistent in approach and expectations
firmly redirect energy into more appropriate areas
Common Psychotherapy Modalities to use in bipolar disorders?
Psychotherapy is used for bipolar disorders extensively and used in combination with meds:
psycho education
cognitive behavioral therapy
family focused treatment
interpersonal therapy
milieu therapy
intensive outpatient program
What is the first line treatment drugs for bipolar disorders?
Mood Stabilizer Drugs
What are 2 properties that define Mood Stabilizers?
- Provide relief from acute episodes of mania or depression
2. They do not worsen depression or mania or lead to increases in cycling
Most common and first line Mood Stabilizer for Bipolar disorder?
Lithium
What does Lithium do as a mood stabilizer?
Prevention and treatment of mania
Affects the clock cycle to restore daily rhythms
May also be used to reduce suicidal tendencies in Bipolar clients
Anticonvulsants (As a mood stabilizer)
Sometimes prescribed instead of Lithium when clients don’t experience a response from Lithium or have intolerable side effects to lithium
Examples: Depakote, Tegretl, Lamictal, Equetro
How long does it take for Lithium to reach therapeutic levels in the blood?
7 to 14 days
What is the therapeutic blood level of lithium and what is the maintenance blood level?
Therapeutic: 0.8 to 1.4 mEq/L
Maintenance: 0.4 to 1.3 mEq/L
Major Long term risks of Lithium?
You have to monitor lithium closely cause it has substantial side effects:
- Hypothyroidism
- Impairment of kidneys ability to concentrate urine
What are some Lithium contraindications?
Cardiovascular disease
Brain damage
Renal disease
Thyroid disease
Myasthenia gravis
Pregnancy
Breastfeeding mothers
Children younger than 12 years
What may be done for initial treatment of acute mania after administering lithium?
As lithium can take several days to take effect in an acute situation, other treatments are used while the patient is in the acute phase
What can antipsychotics do for initial treatment of acute mania?
While waiting for lithium to work:
- It can slow thought processes and slow down speech
- Inhibit aggression
- Decrease psychomotor activity
What can antipsychotics or Benzodiazepine be used to prevent in initial treatment of acute bipolar disorder?
While waiting for lithium to work it can prevent:
- Exhaustion
- Coronary Collapse
- Death
ex: Klonopin and Ativan
Things to teach the client and family about lithium therapy? (very important!)
Effects of treatment
Need to monitor lithium blood levels
side effects at therapeutic levels
effects of food and over the counter medications
when to call the provider
Potential Lithium side effects at Therapeutic Levels
fine hand tremors
GI upset
thirst
muscle weakness
Potential Lithium adverse effects at Toxic Levels
persistent GI upset
coarse hand tremors
confusion
hyperirritability of muscles
sedation
ECG changes
Why is consistent sodium intake important with lithium?
decreased sodium intake can decrease excretion of lithium leading to toxic levels
When is Electroconvulsive therapy used for a bipolar patient?
- Used if pharmacologic interventions fail or symptoms require immediate relief
- severe manic behavior
- rapid cycling
- paranoid, destructive features
- acutely suicidal behavior
When is Milieu Therapy - Seclusion Room or Restraints used in an emergency for clients with bipolar disorder?
- Clear risk of harm to client or others
- Clients behavior has continued despite use of less restrictive methods to keep client and others safe
* However always use the least restrictive type first*
What are some of the associated issues with Seclusion or Restraints?
Therapeutic behaviors (may not help much)
Ethics
State and federal laws
Hospital protocols
You need specific documentation when doing it
