TOPIC 4 - depressive disorders Flashcards
comorbidity and risk factors
prior history ox depression or family history
member of vulnerable groups
female
age 40 or under
active substance use
history of sexual abuse
postpartum period
stressful life events
history of other chronic mental or medical illness
DMDD is only diagnosed …
in childhood (before age 10)
percent of children less than 3 who have depression
15% (often under diagnosed and has a high recurrence rate)
percent of older adults with depression
20%
manifestations of depression
sadness, despair, empty, negative, pessimistic, anhedonia, anergia, avolition, low self esteem, apathy, social with-drawl, excessive emotional sensitivity, low frustration, irritable, insomnia, disrupted concentration, excessive guilt, indecisiveness
avolition
anhedonia
anergia
most common presentation of depressive symptoms in children
irritable (less likely to be sad or withdrawn)
assessing for depression
MSE
psychosocial assessment
physical assessment
standardized scales (Hamilton or SAD PERSONS)
assessing suicide risk
SADPERSONAS scale
SAFE-T
different types of suicidality
suicidal ideation, suicide attempt, completed suicide, parasuicidal behavior
monitoring and documentation guidelines for suicidal risk
1:1 continuous monitoring
document every 15 minutes (observations, statements, activities, behaviors)
biopsychosocial model
social / biological / psychological factors are all interlinked and important for regarding and promoting health
mind and body are not separate
biological factors
endocrine, immune, and neurosystem functioning
stress diathesis model
diathesis - predisposing cause or underlying vulnerability
stress - precipitating cause or triggering circumstance
= disorder
accounts for relationship between early life trauma and later development of vulnerability
cognitive theory triad
negative view of self + pessimistic view of world + belief that negative reinforcement will continue
people acquire a psychological disposition to depression from early life experiences
learned helplessness
condition of a human or animal that has learned to behave helplessly, failing to respond even though there are opportunities for help
(initial response to event is anxiety but then is replaced by depression- believed they are at fault)
depressive disorders
major depressive disorder
persistent depressive disorder
disruptive mood dysregulation disorder
major depressive disorder
depressed most of the day, most days of the week
significant distress or impairment in functioning due to symptoms
not attributable to substance use or other medical condition
persistent depressive disorder
chronic depression
less severe symptoms than in MDD
symptoms must have persisted for at least 2 years
able to function in life roles greater than those with MDD
DMDD (disruptive mood dysregulation disorder)
onset before age 10
s/s : severe temper outburst, inconsistent developmental level persistent irritability or anger
treatment: family supportive therapy, behavioral modification therapy, meds (stimulant, antidepressant, mood stabilizer)
therapy models
CBT, MBCT, ITP, bright light
MBCT
combination of CBT and mindfulness based stress reduction
bright light therapy
helpful for those experiencing seasonal affect disorder
light substitutes for lack of daylight in the winter months = less sleepy, more energy
vagus nerve simulation
invasive procedure - implant electrodes and pulse generator that stimulates vagus nerve
approved for people with chronic or recurrent TRD who have failed to respond to four or more adequate treatments
rapid transcranial magnetic stimulation
noninvasive - magnetic fields stimulate nerve cells in the brain to improve symptoms of depression
deep brain stimulation
for movement disorders such as tremors, parkinsons, or OCD
noninvasive modes of brain stimulation vs invasive
non invasive = TMS or rTMS and ECT
invasive = VNS, deep brain stimulation
indications for ECT
patient is suicidal or homicidal, extreme agitation, life threatening illness as a result of the refusal of nutrition, history of poor antidepressant drug response
side effects of ECT
nausea, dizzy, short term memory loss, weakness (procedure elicits a seizure)
first line antidepressants
SSRI
SNRI
atypical antidepressants
TCAs
atypical antidepressants
mirtazapine
bupropion
ketamine & esketamine
second line antidepressants
MAOIs
CAMs
FDA requires what on all antidepressant meds
black box warning
SSRI meds
fluoxetine
fluvoxamine
paroxetine
citalopram
escitalopram
sertraline
side effects of SSRI
headache, nausea, sexual problems
serotonin syndrome
onset and effectiveness of SSRI
Onset of effectiveness: 1-2 weeks (varies by drug)
Full effectiveness: 2-4 weeks (varies by drug)
decrease dose if …
side effects are intolerable but the medication has been effective for lessening symptoms
client teaching for SSRIs
allow time for symptom relief
report intolerable side effects or worsening depression
risk for suicide in first 1-4 weeks
half life of fluoxetine
5 weeks
how long to wait between fluoxetine and starting other meds
If changing from fluoxetine to an MAOI, the client must wait 5 weeks to begin the MAOI to avoid serotonin syndrome
If changing from a different SSRI to an MAOI, the wait between meds must be 2 weeks; also 2 weeks if switching from an MAOI to an SSRI (including fluoxetine)
clinical presentation of serotonin syndrome
Hyperactivity or restlessness
Tachycardia _ cardiovascular shock, irregular heartbeat
Fever _ 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)
treatment 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
labs to assess evaluation of serotonin syndrome
- complete blood count (CBC)
- blood culture
- thyroid function tests
- drug screens
- kidney function tests
- liver function tests
onset of effectiveness for SNRIs
2-4 weeks
side effects of SNRI
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
serotonin syndrome
client teaching for SNRI
allow time for symptom relief, report intolerable side effects, titration of drug dose, monitor for suicidality, DON’T STOP ABRUPTLY
contraindications for SNRI
HTN and glaucoma
mirtazapine (tetracyclic antidepressant)
Good for elderly & those with severe depression
Less insomnia SE, less sexual dysfunction SE
COMMON SIDE EFFECTS (SE):
Significant weight gain
Sedation
bupropion (NE dopamine reuptake inhibitor)
Little effect on weight or sexual function
Also marketed for smoking cessation (discussed further in Topic 10)
COMMON SIDE EFFECTS (SE):
Energizing (possible increased anxiety, insomnia; risk for mania induction in clients with undiagnosed bipolar disorder)
NMDA antagonists
ketamine and esketamine
for severe treatment of resistant depression
admin of NMDA antagonists
nasal spray - esketamine
inject - ketamine
admin 1-2 times a week in the providers office
TCAs
dose titration
onset of effectiveness : 10-14 days
full effectiveness : 4-8 weeks
side effects : postural hypotension, tachycardia. urinary retention, constipation, serotonin syndrome
TCA dosages
start low go slow
client teaching for TCAs
take at bedtime
fall precautions
do not stop abruptly
contraindications for TCAs
MANY drug-drug interactions!
Recent MI
Narrow-angle glaucoma
History of seizures
Pregnant women
MAOI side effects
Hypotension
Muscle cramps
Sedation, weakness, fatigue OR insomnia
Anorgasmia or sexual impotence
Weight gain
Anticholinergic effects
Hypertensive crisis
avoid which foods and drugs while on MAOIs
tyramine foods
OTC meds, other antidepressants, narcotics, general anesthetics, stimulants, sedatives
2 week med break needed for MAOIs when …
between taking MAOI and ingesting any food, drink, or product containing tyramine
when switching from MAOI to or from another antidepressant
5 weeks needed for switches between fluoxetine and MAOIs
hypertensive crisis
excessive tyramine = can lead to CVA
s/s : headache, stiff neck, tachycardia, severe nosebleeds, dilated pupils, chest pain, stroke, N/V/D
ER admin of meds for hypertensive crisis
if BP elevated
IV phentolamine
oral chlorpromazine
sublingual nifedipine
