TOPIC 2 Flashcards
when is disruptive mood dysregulation disorder (DMDD) diagnoed?
ONLY diagnosed in childhood (onset is before age 10)
risk of suicide is especially high in what age group
older adults (>65)
biopsychosocial model includes…
*Biological factors
*Psychological factors
*Social factors
that either lead to promoting health or causing disease
The Stress-Diathesis Model of Depression
diathesis (predisposition or vulnerability to developing a given disorder) + stress (precipitation cause or triggerinc circumstance) = disorder
learned helplessness
people are used to being helped out they may not even try on their own
Cognitive Theory -
Beck’s Cognitive Triad
Negative view of self
+.
Pessimistic view of the world
+.
Belief that negative reinforcement will continue
Clinical Manifestations of Depression
*Mood of sadness, despair, emptiness
*Negative, pessimistic thinking
*Anhedonia
*Anergia
*Avolition
*Low self esteem
*Apathy
*Social withdrawal
*Excessive emotional sensitivity
*Irritability**
*Low frustration level
*Insomnia or hypersomnia
*Disruption in concentration and decision-making ability
*Excessive guilt
*Indecisiveness
what is the most common presentation of depressive symptoms in children
irritability
Assessing for depression: standardized scales
*Hamilton Depression Scale
*SAD PERSONS Scale
Assessing suicide risk
*SAD PERSONAS Scale
*SAFE-T
Suicidal ideation
process of thinking about killing oneself
Suicidal gesture
action that indicates a person may be about ready to carry out a plan for suicide
Suicide attempt
all willful, self-inflicted, life threatening attempts that have not led to death
Completed suicide
the act of intentionally ending ones life
what me done for a client who is at high risk for attempting suicide
-1:1 continuous monitoring at ARMS LENGTH from client
-documentation every 15 minutes and observation continuously (includes bathroom and shower)
Major Depressive Disorder (MDD) symptoms
-Depressed mood most of the day
-Feelings of worthlessness or excessive or inappropriate guilt
-Significant unintentional weight loss or gain
-Insomnia or hypersomnia
-Diminished interest or pleasure
-Diminished ability to think or concentrate
-loss of energy
-Recurrent thoughts of death, recurrent suicidal ideation
Persistent depressive disorder (PDD)
depression symptoms are less severe than in MDD, and they symptoms must have persisted for at least 2 years and often clients with PDD are able to function in life roles with less disruption than seen in MDD.
Disruptive mood dysregulation disorder (DMDD) onset
Onset before age 10 (diagnosis can be carried to adulthood if symptoms persist)
Disruptive mood dysregulation disorder (DMDD) symptoms
-Severe, recurrent temper outbursts (verbal and/or behavioral)
-Inconsistent developmental level
-Persistent irritability or anger for most of the day (regardless of setting)
treatment for isruptive mood dysregulation disorder (DMDD)
-Family supportive therapy
-Behavior modification therapy
-Medications (e.g., stimulants, antidepressants, mood stabilizers may be used)
Anergia
reduction in or lack of energy
Anhedonia
an inability to find meaning or pleasure in existence
apathy
a lack of feeling, emotion, or interest
insomnia
recurring problems in falling or staying asleep
hypersomnia
increased amount of sleep
Psychomotor agitation
a tension relieving activity (pace, nail-biting, smoke, tap their fingers)
Psychomotor retardation
feelings of fatigue can result in slowed movements
Vegetative signs of depression
include somatic changes and alterations in those activities necessary to support physical life and growth such as eating, sleeping, elimination and sex
Mindfulness-based cognitive behavioral therapy (MCBT)
a combination of CBT and mindfulness based stress reduction techniques.
Electroconvulsive therapy (ECT)
Usually, ECT is done when medications (pharmacologic methods) do not work. It is a procedure done under general anesthesia in which small electric currents are passed though the brain, intentionally triggering a brief seizure. ECT seems to change the brain chemistry that can quickly reverse the symptoms of certain mental illnesses
Vagus nerve stimulation (VNS)
An invasive procedure, performed by a neurosurgeon requiring the implantation of electrodes and a pulse generator that stimulates the vagus nerve; affects blood flow to specific parts of the brain and affects NTs including serotonin and norepinephrine
Rapid (or Repetitive) Transcranial magnetic stimulation (rTMS)
a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression
Deep brain stimulation
electrodes must be surgically implanted into several areas of the brain affected by depression, am insulated wire is connected to an impulse generator that generates stimulations to specific areas of the brain
Bright light therapy
particularly helpful for clients experiencing Seasonal Affective Disorder (SAD).
non-invasive brain stimulation therapies
*Transcranial magnetic stimulation (TMS) & rapid TMS (rTMS)
*Electroconvulsive Therapy (ECT)
invasive brain stimulaton therapies
*Vagus nerve stimulation (VNS)
*Deep brain stimulation
Indications for Electroconvulsive Therapy (ECT)
-Patient is suicidal or homicidal
-Extreme agitation or stupor
-Life-threatening illness as a result of the refusal of foods or fluids
-History of poor antidepressant drug response or a good ECT response (i.e., standard medical treatment has been ineffective)
first line antidepressant classes
-SSRIs
-SNRIs
-Atypical antidepressants
-TCAs
second line antidepressants classes
MAOIs
CAMs (st. johns wort)
Atypical Antidepressants
-mirtazapine
-bupropion
-ketamine & esketamine
Black Box Warning on antidepressant medications
on ALL antidepressant medications; indicates that there is an increased risk of suicidal thinking, feeling and behavior.
SAD PERSONAS Scale
· S: Sex (1 if male)
· A: Age (1 id <19 or >45)
· D: Depression or hopelessness (2)
· P: Previous attempts or psychiatric care (1)
· E: Excessive alcohol or drug use (1)
· R: Rational thinking loss (psychotic or organic illness) (1)
· S: Separated, widowed, divorced (1)
· O: Organized plan or serious attempt (2)
· N: No social support (1)
· A: Availability of lethal plan
· S: Stated future intent (1)
SAFE-T: The 5 steps are as follows…
· Identify risk factors
· Identify protective factors
· Conduct suicide inquiry (note suicidal thoughts, plans, behavior, intent
· Determine risk level intervention (determine risk and choose appropriate intervention to address and reduce risk)
· Document (assessment of risk, rationale, intervention and follow up)
6-8 on SAD PERSONAS Scale
probably requires psychiatric consultation
> 8 on SAD PERSONAS Scale
probably requires hospital admission, voluntary or involuntary
0-5 on SAD PERSONAS Scale
may be safe to discharge (depending on circumstance). If sent home, have follow-up appointment arranged and discharge patient with family or friend
Selective Serotonin Reuptake Inhibitors (SSRIs) action
*Inhibit the reuptake of active serotonin in the brain, effectively increasing the serotonin level
onset of effectiveness for SSRIs
1-2 weeks
full effectiveness for SSRIs
2-4 weeks
common side effects of SSRIs
*Headache, nausea (usually resolve within a few days)
*Sexual problems (often dose-related)
Potential toxic effects of SSRIs and SNRIs
serotonin syndrome
Client Teaching for SSRIs
*Allow time for symptom relief
*Report intolerable side effects or worsening depression
*Monitor for suicidality
*Risk for suicide is greatest during the first 1-4 weeks of antidepressant therapy
Fluoxetine half life
5 weeks
what is important if changing from fluoxetine to an MAOI
*the client must wait 5 weeks to begin the MAOI to avoid serotonin syndrome
when changing from an SSRI to and MAOI how long must the client wait between meds
2 weeks
clinical presentation of serotonin syndrome
*Hyperactivity or restlessness
*Tachycardia à cardiovascular shock, irregular heartbeat
*Fever à hyperpyrexia
*Elevated blood pressure
*Irrationality, mood swings, hostility
*Altered mental status (e.g., delirium)
*Seizures (status epilepticus)
*Myoclonus, incoordination, tonic rigidity
*Abdominal pain, diarrhea, bloating
*Apnea (may lead to death)
Serotonin Syndrome
occurs when medications that work to release serotonin, cause high levels of the chemical serotonin to accumulate in the body; Excess serotonin causes symptoms that can range from mild (shivering and diarrhea) to severe (muscle rigidity, fever and seizures).
what is the first thing to do when treating serotonin syndrome
discontinue offending agents
how to treat symptoms of serotonin syndrome
*Administer serotonin receptor blockade (cyproheptadine, methysergide, propranolol)
*Cooling blankets, chlorpromazine (for hyperthermia)
*Dantrolene, diazepam (for muscle rigidity or rigors)
*Anticonvulsants
*Artificial ventilation
*Induced paralysis
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) action
*Inhibit the reuptake of active serotonin and norepinephrine in the brain
onset of full effectiveness for SNRI
2-4 weeks
common side effects of SNRIs
*Nausea, dizziness, nervousness, anticholinergic effects
*Increase in blood pressure
*Titrate on/ taper off and use extended release to decrease side effects, do not discontinue abruptly
Client Teaching for SNRIs
*Allow time for symptom relief
*Report intolerable side effects, or worsening depression
*Titration of drug dose
*Monitor for suicidality
*Don’t stop taking abruptly (Withdrawal effects are often significant)
contraindications for SNRIs
HTN
glaucoma
tetracyclic antidepressant example
mirtazapine
what group is mirtazapine good for
good for elderly & those with severe depression
what is the advantage of mirtazapine
has less insomia SE and less sexual dusfunction SE
what are the common side effects of mirtazapine
significant weight gain and sedation
norepinephrine dopamine reuptake inhibitor [NDRI] and nicotinic receptor antagonist example
bupropion
what are the advantages of bupropion
little effect on weight or sexual function
what is bupropion also marketed for
smoking cessation
what are the common side effects of bupropion
*Energizing (possible increased anxiety, insomnia; risk for mania induction in clients with undiagnosed bipolar disorder)
NMDA antagonists
ketamine and esketamine
what is the difference between the administration ROUTE of ketamine and esketamine
-ketamine: Injection
-esketamine: nasal spray
where is ketamine/esketamine given?
Administered 1-2 times weekly in provider’s office; MUST STAY IN THE DOCTORS OFFICE FOR 2 HOURS AFTER ADMINISTRATION (not for at home use)
what is the action of ketamine
acts on glutamate rather than the monoamine neurotransmitters; Reserved for severe, treatment-resistant depression
what are the common side effects of ketamine
Immediate, temporary disorientation or confusion (must stay in doctor’s office for 2 hours after administration)
what is required for the use of TCAs?
dose titration (“start low, go slow”)
what is the onset of effectiveness for TCAs
10-14 days
how long does it take for TCAs to reach full effectiveness
4-8 weeks
what are the common side effects of TCAs
*Postural hypotension, tachycardia (usually resolve within 1-2 weeks)
*Anticholinergic effects: Urinary retention, severe constipation = seek immediate medical attention
anticholinergic SE
dry mouth, constipation, blurred vision, esophageal reflux, tachycardia.
what are the potential toxic effects of TCAs
*Cardiovascular (dysrhythmias, tachycardia à MI, heart block)
*Serotonin syndrome
what is the most important thing to remember about TCA dosages
TCA dosages should always be low initially, and gradually increased, especially in older adults with slower drug metabolism due to aging and/or disease processes.
what drugs are in the TCA class
amitriptyline, doxepin, imipramine, and nortriptyline.
client teaching for TCAs
-take dose at bedtime
-fall precautions until orthostatic hypotension SE resolve (1-2 weeks)
-DO NOT stop taking abruptly
what will the patient experience if they stop taking TCA abruptly
*2-4 days later, client will develop nausea, altered heartbeat, nightmares, cold sweats
contraindications for TCAs
*MANY drug-drug interactions!
*Recent MI
*Narrow-angle glaucoma
*History of seizures
*Pregnant women
common SE fro MAOIs
*Hypotension
*Muscle cramps
*Sedation, weakness, fatigue OR insomnia
*Anorgasmia or sexual impotence
*Weight gain
*Anticholinergic effects
what are the potential toxic effects of MAOIs
*Hypertensive Crisis
*Serotonin Syndrome
What foods must be avoided with MAOIs?
Tyramine foods:
-wine
-beer
-cheeses
-ages foods
-smoked meets
**can cause hypertensive crisis
what are the drug-drug interactions for MAOIs
*OTC cold/cough meds; other antidepressants; narcotics; general anesthetics; stimulants; sedatives
when is a 2 week medication break neesed when taking MAOIS
*Between taking MAOI and ingesting any food, drink, or product containing tyramine
*When switching from an MAOI to a different antidepressant
*When switching to an MAOI from another antidepressant (Exception: 5 weeks needed when switching from fluoxetine to an MAOI)
what are the symptoms of hypertensive crisis
*Severe headache
*Stiff, sore neck
*Flushing; cold, clammy skin
*Tachycardia
*Severe nosebleeds, dilated pupils
*Chest pain, stroke, coma, death
*Nausea and vomiting
what should the client do if they are in hypertensive client
*Client should go to emergency department immediately
*Blood pressure (BP) must be evaluated!!
what can be given to lower the clients BP in a hypertensive crisis?
*IV phentolamine (alpha-1 blocker)
*oral chlorpromazine (typical antipsychotic)
*Sublingual nifedipine (calcium channel blocker)
