Mood Disorders - Depression Flashcards
Depression is a __________ rather than one disease
syndrome
Syndrome is
collection of s/s frequently appear together, but without a specific cause.
Depressive disorders represent
group of syndromes that share some common symptoms but with different etiologies, courses and treatments
MDD affects
how you feel, think and behave causing persistent feelings of sadness and loss of interest in previously enjoyed activities.
What depressive disorder is the most common expression
MDD
PDD
person experiences depression without ever experiencing an excessive elevated mood or mania
MDD stands for
Major DEpressive Disorder
PDD stands for
Persistent Depressive Disorder
Unipolar means
no maic episodes
PDD is usually there for how long before it is considered PDD and chronic
2 years
In older adults depression is expressed by
feeling tired and have trouble sleeping
Seem grumpy or irritable
Confusion or attention problems appears to be brain
disorders
- can lead to self-medication
Risk Fcators of Depression
Hx - episodes of depression
Family history of depressive disorder,
especially in first-degree relatives
History of suicide attempts or family history of suicide
Member of the (LGBTQ) community
Female gender
Age 40 years or younger
Postpartum period
Chronic medical illness
Absence of social support
Negative, stressful life events, particularly
early trauma
Active alcohol or substance use disorder
History of sexual abuse
Gentic Fcators for depression
if parent(s) have it even in adopted families
first-degree family member with depression are 2-4 times more likely to become depressed
must interact with environment and neurobiological preconditions for depression to develop.
earlier age of onset, comorbidities, occurence
Depression Changes in receptor-neurotransmitter relationships in the following areas of the brain
Limbic system
Hypothalamus
Prefrontal cortex
Hippocampus
Amygdala
In depression, the neurotransmitters do
Decreased levels of serotonin
Decreased levels of norepinephrine
Decreased levels of dopamine
Decreased glutamate
Decreased GABA (y-aminobutyric acid)
Decreased acetylcholine
Stress-Diathesis Model of Depression
environment, interpersonal, and life events
- predisposition
Stress - ACEs can cause neurophysiological and neurochemical changes in the brain.
- neurotransmitters to over work and causes permanent damage leading to depressive states
Cognitive Theory in DEpression by Beck
predispoition though ealry experiences
- negative thought processes activate in stress
Triad of Cognitive Theory in Depression
– automatic negative thoughts
A negative, self depreciating view of self
A pessimistic view of the world
The belief that negative reinforcement will continue.
Goal of cognitive behavior theory (CBT) is to change the way a patient thinks reducing negative thoughts
Identify the distortion and challenge the distortion by reframing
way a patient thinks reducing negative thoughts
- Identify the distortion and challenge the distortion by reframing
Filtering
Taking negative details and magnifying them while filtering out all positive aspects of a situation.
Personalization
A distorted belief that everything others do or say is somehow about us.
Control falicies
We see ourselves as helpless, a victim of fate, having no control, or we assume total responsibility for the pain and happiness of everyone around us (overcontrol).
Global labeling
We generalize one or two qualities into a negative global judgment. For example, “I’m a loser” verses “In one situation, I failed.”
According to Seligman, Depression is a ______________ helplessness
learned
- initially anxiety replaced with depression
- no control and the situation their fault
MDD S/S mnemonic
SIG E CAPS
MDD S/S
Sleep disturbance (TOO MUCH OR TOO LITTLE)
Interest diminished in pleasurable activities (guilt, worthless) - anhedonia
Guilt feeling; feelings of worthlessness (no self-esteem)
Energy decreased or fatigue and Esteem loss - anegia
Concentration diminished and indecisiveness
Appetite changes
Psychomotor retardation or agitation
Suicidal thoughts and behaviors and thoughts of death
Anhedonia
inability to experience pleaure from past things
Anegia
loss of energy
With MDD, it needs to have what to dx someone with MDD
5+ SYMPTOMS IN A 2+ WEEKS
PDD compared to MDD is
less severe but present for 2+ years
PDD is sometimes taken as the person’s
normal behavior
PDD does not require
hospitalization
PDD age of onset
adolescence or with severe stress can manifest in adulthood
PDD s/s
Daytime fatigue
Functions at work and in social settings but not optimally
Chronic low-level depressed/irritable mood
Eating too much or too little
Usually has trouble falling asleep and once asleep, hypersomnia (sleep too much)
Loss of energy, chronic tiredness
Decreased ability to experience pleasure, enthusiasm or motivation
Irritability
Negative, pessimistic thinking
Low self esteem
HE’S 2 SAD
MDD psychotic ft
hallucinations
delusions
MDD catatonic ft
Nonresponsive, psychomotor retardation, withdrawal
MDD peripartum ft
: During pregnancy and following delivery. May include psychotic features and risk to infant
MDD SAD ft
fall or winter, remits in spring. Includes overeating, anergia, hypersomnia
- ABSENT OF VITAMIN D
Disruptive mood dysregulation disorder
Children
Chronic, severe, persistent irritability with outbursts
Premenstrual dysphoric disorder
Depressive symptoms are present in the week before the onset of menses and gradually improve after onset of menses
Substance medication induced depressive disorder
during or soon after exposure to a substance or medication
Premenstrual dysphoric disorder occurs in the
luteal phase of cycle
Premenstrual dysphoric disorder s/s
emotional labile
anger/irriatble
depressed
- no energy, overeating, sleep disturbance, pshycial symptoms
(PMS)
Baby Blues
Feels depressed, anxious. Cries for no reason, sleep problems
Occurs in 70-80% of new moms.
Improvement within 1-2 weeks without treatment
Postpartum Depression
Strong feelings of sadness, anxiety, despair, guilt, difficult coping.
Symptoms DO NOT subside.
May have thoughts of self-harm or harm to baby
Occurs in about 10% of new moms, within 1-3 weeks PP.
May occur up to a year after birth.
Nursing Interventions for PP Women
Routine PPD screening of mothers for at least 2 years after delivery
Pay close attention to younger, low-income, limited educated moms and those with more than 1 child
PP Psychosis
extremely high with each subsequent delivery with more severe episodes
Onset fairy rapid, within 3 days to one week after delivery
Agitated, anxious, disorganized behavior
Delusions are baby focused
Nurisng Assessment tools for depression
Beck Depression Inventory
Hamilton Depression Scale
Geriatric Depression Scale
Zung’s Self-Rating Depression Scale
The Patient Health Questionnaire (PHQ-9) for the primary care setting
The Edinburgh Post Natal Depression Scale
In mood disorders and depression the nurse should assess for
homicide and suicide potential
medical and neuro exam
triggering events
support systems
psychosocial assessment
Detailed mood-affect assessment shows
Feelings of worthlessness
Guilt
Helplessness
Hopelessness – negative expectations for the future
Anger and irritability
Anxiety – 60-90% of depressed patients has anxiety as well
Affect
Physcial changes to assess in depression
Poor posture
Appears older than they are
Sees world through gray colored glasses (negative)
Facial expression conveys sadness and dejection
Frequent bouts of weeping
Anergia 97% (psychomotor retardation)
Psychomotor agitation
Grooming and hygiene neglected
Vegetative signs of depression: physical (somatic) is lazy
Pain 50-75%
Cognitive and Though Content assessment for a depressed person consists of
Thinking is slow
Memory and ability to concentrate may be affected
Ruminate: think deeply about something (event – breakup or death)
Decrease in problem solving
Poor judgment
Indecisiveness
Delusional thinking with psychotic features
Ruminate
think deeply about something (event – breakup or death)
Nursing Process for Depression
Risk of harm
Mood regulation/stability
Withdrawn behavior leading to social isolation
Lack of motivation leading to self care deficits
Loss of appetite can lead to impaired nutrition
Disturbance of sleep
Impairment in self esteem reducing quality of life
Expected Outcomes for Tx working on depresion
wt gain
sleep 6-8 hours
identify relapse symptoms
normal bowels
daily showers
Interventions in communication for depression
Offering self aka “presence”
Use simple concrete words
Allow time for response
Listen for covert (hidden) messages
Avoid false reassurance or minimizing feelings
Health promotion for pts and family about depression
explain all s/s
teach suicidual ideation and precautionary measures
med teaching
relapse prevention
nutrition
sleeo
exercise
self-help
elimination
Milieu Therapy Interventions
supportive
safety
consistency
validation
involvement
encourage
- rapport before
Psychotherapy Interventions for Depression
CBT - Psychotherapy, talk therapy, group therapy, peer support
Interpersonal psychotherapy (IPT) – structured addressing social issues
Problem solving therapy (PST)
- Define problem
- Develop multiple solutions
- Identify best one and implement
- Assess effectiveness
CBT-1 addresses insomnia
Social skills training
Behavioral activation
Psychodynamic therapy (PT) - Freud
Mindfulness Based Cognitive Therapy
recurrence for MDD
combination of CBT and MBCT
- PRESENT AND ORIENTATED TO THE PRESENT
- NONJUDGEMENTAL
Group Therapy Interventions
support/peer group
medication groups - teach bout meds and adherence to take correctly
Antidepressants target what depression s/s
Sleep disturbance
Appetite disturbance
Fatigue
Decreased sex drive
Psychomotor retardation or agitation
Impaired concentration/forgetfulness
Anhedonia
May take 1-3 weeks
Black Box Warning for Depression medications
- children, adolescents and young adults may experience suicidal ideation with selective serotonin reuptake inhibitors (SSRIs)
Elderly antidepressants should be given
low and slow
Considerations for Antidepressants
Previous response to antidepressants
Ease of administration
Safety and medical comorbidities
Neurotransmitter specificity
Family history of response
Cost
Antidepressants medication
Monoamine oxidase inhibitor (MAOI)
Tricyclic antidepressants (TCA)
Selective serotonin reuptake inhibitor (SSRI)
Atypical antidepressants
MAOIs
- not first line -
inhibits breakdown of norepinephrine, serotonin, doapmine, and tyramine AND increases neurotransmitters
MAOIs are not first line due to
food interactions and drug interactions from elevated tyramine may lead to HBP, hypertensive crisis, CVA, and death
- no bananas, salmai, citrus fruits, beer or wine
MAOIs side effects
Muscle cramps
Weight gain
Sexual dysfunction
Anticholinergic effects (dries up everything- dry mouth, dry eyes, urination decrease)
Serious food/drug interactions (tyramine)
- Aged cheeses/meats
- Foods with yeast
- Soy
- Beer/Wine
- Avocados and bananas
MAOIs medication names
phenelzine (Nardil)
tranylcypromine (Parnate)
isocarboxazid (Marplan)
selegiline (EnSam) *patch
TCAs
effective - noncompliance due to anticholinergic effects
- effective at 4-8 weeks
LETHAL OVERDOSE
TCA medication names
amitriptyline (Elavil)
amoxipine (Asendin)
doxepin (Sinequan)
imipramine (Tofranil)
desipramine (Norpramine)
nortriptyline (Pamelor)
TCA side effects
sedation
mydrasis (pupil dilation)
wt gain
sweating
toxocity
sex dysfunction
decreased seizure threshold
orthostatic hypotension
anticholinergic effects
SSRIs effective with
fewer adverse effects and lower lethality
SSRI potential for
serotonin syndrome
SSRI medication names
fluoxetine (Prozac)
sertraline (Zoloft)
paroxetine (Paxil)
citalopram (Celexa)
escitalopram (Lexapro)
fluvoxamine (Luvox)
vilazodone (Viibryd)
Serotonin syndrome s/s
Shivering
Hyperreflexia
Increased temperature
Vital signs changes
Encephalopathy
Restlessness
Sweating
What increase the chance of serotonin syndrome?
illivit drugs (LSD, cocaine, meth, fentanyl, methamphetamines) nad meletonin and tryptophan
Serotonin syndrome interventions
D/C
muscle relaxant with benzo and/or dantrolene
serotonin blocking agents
O2 and Cool IV fluids
control pulse and BP
if hypotension = phenylephrine or epinephrine
cooling blankets
SSRI side effects
Tremors
Nausea
Headache
Insomnia/drowsiness
Sexual dysfunction
Bruxism
Anxiety/agitation
Dry Mouth
Diarrhea
Hyponatremia
Bruxism
person grinds, clenches, or gnashes his or her teeth
Atypical antidepressants
venlafaxine (Effexor) SNRI
duloxetine (Cymbalta) SNRI
desvenlafaxine (Pristiq) SNRI
bupropion (Wellbutrin) NDRI
trazodone (Desyrel) TSA related
mirtazapine (Remeron) NASSA
What procedure is used for severe depression when medications do not work?
electroconvulsive therapy
ECT is used for
depression when meds fail
psychosis
schizophrenia
marked agitation
vehetative s/s
catatonia
Is ECT safe during pregnancy?
yes
What is the course of ECT tx?
6-12 tx 2-3 times a week
ECT works by
producing a generalized (tonic-clonic) seizure masked by muscle relaxant
- ECT enhances effects of neurotransmitters & increases hippocampal & amygdala volume
ECT seizures last
30-60 sec
Before ECT
NPO for 6 hours
informed consent
remove jewelry, aids, glasses, contact, dentures
VS and mental
Atrophine 30 minutes before
IV
EEG
During ECT
Short acting anesthetic agent: methohexital or propofol IV bolus
Muscle relaxant: succinylcholine
vs, ekg, o2 sat
**Administer 100% O2 through procedure
IV and EEG
After ECT
reversal of anestetic
support stability
Lateral , recumbent postition
Shuld be alert in 15 minutes
IV until full recovery
Vagus Nerve Stim (VNS)
Surgical implant of device in left chest wall with wire threaded around vagus nerve in neck that delivers electrical impulses. Requires informed consent
- INCREASE NEUROTRANSMITTERS
VNS side effects
voice chnages
neck pain
cough
dysphagia
dyspnea
Rapid Transcranial Magneti Stim
- tx resistant depression
- noninvasive
impulse stimulate focal areas of cerebral cortex, may feel tapping or knocking
rTMS side effects
HA
light-head
scalp tingling
DBS
Surgical implant of pacemaker-like device implanted in sub-clavicle region, sending electric currents through a wire to electrodes implanted in the brain.
DBS side effects
HA
visual
sleep distrubances
anxiety
Light Therapy
Influences melatonin, exposed to light source 30-60 minutes daily
SAMe:
OTC dietary supplement used as adjunct tx.
St John’s Wort:
Improves mild depression, not regulated by FDA, not approved for those who have MDD, who are pregnant, or children
Exercise:
↑ serotonin level
Nursing self-care
Unrealistic expectations of self – occurs from setting unrealistic goals for the treatment of the patient.
Becoming depressed
Subconsciously when we over identify and can result in withdraw from the patient
Consultation with a more experienced nurse or clinician can help to deal with any feelings that can interfere with providing optimal care.
Males are more _____________ at suicide than women
successful
Women are _____________ attempts at suicde than men
more
Suicide Myths
asking about it gives them ideas
just attention seeking
behavior will go away if you ignore the warnings
people who talk about it never do it
Risk Factors of Suicide
Previous suicide attempt
Financial problems
End of relationship
New diagnosis or worsening health condition
Refugees
Indigenous people
Lesbian, gay, bisexual, transgender people
Prisoners
Someone who knew someone who committed suicide
Childhood trauma
Access to means (guns, poison…)
Neurobiology of Suicide
low serotonin
overactive noradrenergic (fight or flight)
HPA axis
Prevalance of Youth having more suicides is due to
Aggression
Disruptive behavior
Depression
Social isolation
Episodes of running away
Expressions of rage
Family loss or instability
Frequent problems with parents
Withdraw from friends and family
Talk of death or afterlife when sad or bored
Dealing with sexual orientation
Unplanned pregnancy
Perception of school, work or social culture
Older adults risk factors of suicide
Social Isolation
Solitary living
Widowhood
Lack of financial resources
Poor health
Feelings of hopelessness
Cultural considerations with suicides
Roman Catholics often have lower rates
Reincarnation religions believe suicide is an honorable solution
What is the CPR for suicide prevention
Question
Persuade
Refer
- do not leave alone
remove vicinity of weapons
take to emergency or 911
signs of an acute suicidal crisis
friend or loved one is threatening, talking about or making plans for suicide
What assessment tool do you use for suicdal patients
Modified SAD PERSONS scale – not for seasonal
Suicide Assessment Five-Step Evaluation and Triage (SAFE-T)
Overt verbal cues for suicide
“I can’t take it anymore”
“Life isn’t worth living anymore”
“I wish I were dead”
“Everyone would be better off if I were dead”
COvert verbal cues for suicide
“It’s ok now everything will be ok”
“Things will never work out”
“I won’t be a problem much longer”
“Nothing feels good to me anymore, and probably never will”
“How can I give my body to medical science”
-IF THEY HAVE A ELEVATED MOOD THIS IS A BAD SIGN
Modified SAD Persons Scale CATEGORIES
Sex male
Age <19 or >45
Depression or hopelessness
Previous attempts or psych care
Excessive ETHOL or drug
Rational thinking loss (psych tr organic illness)
Separated, widowed, or divorce
Organized plan or attempt
No social
Stated future intent (repeat or ambivalence)
Suicide Risk Screening
Do you want to hurt yourself?
Not a great question… What does “hurt” mean?
Be direct, ask what you want to know
Ask “Are you wanting to commit suicide?”
Do you have thoughts (ideas) of taking your own life?
Have you made plans to take your life?
Do you have access to tools or situation? (How lethal is the proposed method?)
Have you tried (history) to take your life before?
Bahvioral Cues of Suicide
Giving away prized possessions
Writing farewell notes
Making out a will
Putting personal affairs in order
Having global insomnia
Exhibiting a sudden and unexpected improvement in mood after being depressed or withdrawn
Neglecting personal hygiene
If the suicidal patient is not admitted,
assess support systems, significant others knowledge of the signs of potential suicide ideation and provision of safety resources
The nursing dx for a suicidal pt should include
risk for suicide
imapired fsmily process
lack of support
negative self-image
self-destructie behavior risk
Effective Outcomes for a suicidial pt
Patient will remain safe
Family will stay overnight with patient
Follow-up appointment with counselor or therapist
Phone numbers of hotlines, self-help groups
Is engaged in treatment
States feelings of isolation and loneliness are fewer and less severe
Increase problem solving skills
Safety interventions for suicidal patient
Suicide precautions (continuous observation)
Remove unsafe items
Ongoing risk assessment: As depression lifts, assess for signs of suicide
Suicide Precautions
1:1 Precautions: Continual observation at arm’s length for actively suicidal
15 min precautions: Observe every 15 minutes and document affect/behavior/location
implement and get orders from HCP
Environmental Guidelines for SI pateint
coninuous observation
plastic eating utensils
keep door open no privacy
close to nurse station
swallows all PO meds
Minimize self-harm objects - cords, carts, glass, windows, razors, matches,locked unit
Search
check visitors
Policy and procedures
Communication to a suicidal pt
The crisis is temporary
Unbearable pain can be survived
Help is available
The patient is not alone
The nurse remains nonjudgmental and listens attentively
Management for poisoning or overdose
stabilize
Activated charcoal (prevent absorption)
Antidotes from ID toxin
If a pateint overdoses on Acetaminophen what do you give
Mucomyst
If a pateint overdoses on Benzodiazepines what do you give
: Flumazenil (Romazicon)
If a pateint overdoses on Opioids what do you give
Naloxone (Narcan)
Postvention after a successful suicide
Survivors are stigmatized and isolated
Complicated and painful
Mourning without normal social supports
Five stages of grief
5 stages of grief
denial
anger
bargaining
depression
acceptance
Post-traumatic stress reactions
Irritability
Sleep disturbances
Anxiety
Exaggerated startle reaction
Nausea and headache
Difficulty concentrating
Fear
Guilt
Withdrawal
Reactive depression
Postvention for Nurses
self care for yourself
closely monitor other SI patients
Postmortem assessment (all team members to show why it was allowed to happen)
legal counsel
ensure documentation is complete and accurate
