w4 Flashcards
assessment/screening tools for __________
- zung ________ scale
- patient health questionnaire
- Hamilton _______ rating scale
- geriatric _________ scale
- beck ___________ inventory
- Edinburgh postnatal __________ scale
Primary care screening
- Patients usually seek care from PCP for depression?
- Most seek care from somatic complaints associated with depression?
- Need for consistent depression screening for every patient every visit?
depression
Primary care screening
- Patients usually don’t seek care from PCP for depression
- Most seek care from somatic complaints associated with depression
- Need for consistent depression screening for every patient every visit
complication of SRIs: ___________
- can develop within 6 hours of first dose, change in dose, or intentional overdose
- can be fatal
serotonin syndrome
Bipolar 2 disorder
- At least 1 major depressive episode
- At least 1 hypomanic episode (no psychosis)
- Impaired functioning in at least 1 area???
- No history of ______ episode!!
Bipolar 2 disorder
- At least 1 major depressive episode
- At least 1 hypomanic episode (no psychosis)
- Impaired functioning in at least 1 area???
- No history of manic episode!!
depression: Epidemiology
- _______ more common
- Race
- Seasons
- Socio-economic status
Epidemiology
- Women more common
- Race
- Seasons
- Socio-economic status
hypomania vs mania
_______
- lasts 1 week
- severe mood disturbance causes marked impairment
- psychotic features present
_______
- lasts 4 consecutive days
- mood disturbances not severe enough to cause marked impairment
- no psychotic features present
mania
hypomania
drug: ____________
indications
- acute mania
- maintenance treatment
- bipolar disorder
contraindications
- CV disease
- Renal disease
- Brain damage
- Thyroid disease
- Pregnant or breastfeeding mothers
lithium carbonate
Lamotrigine
anticonvulsant mood stabilizer
- For rapid cycling and depressed phase of bipolar illness
- _______ may be life threatening
- Used as add on therapy in refractory mood disorders
Lamotrigine
anticonvulsant mood stabilizer
- For rapid cycling and depressed phase of bipolar illness
- Rash may be life threatening
- Used as add on therapy in refractory mood disorder
expected side effects of all SRIs or serotonin syndrome?
- Dry mouth
- Sex problems
- Tension h/a
- Blurred vision
- Drowsy
- Nausea
- Diarrhea
- Insomnia
- Nervous, agitation, restless
- Dizzy
side effects of all SRIs
- Dry mouth*
- Sex problems *
- Tension h/a*
- Blurred vision *
- Drowsy
- Nausea
- Diarrhea
- Insomnia
- Nervous, agitation, restless
- Dizzy
antidepressants:_________
- May not be as well tolerated compared to SSRIs
- desvenlafaxine
SNRIs – selective serotonin/norepinephrine reuptake inhibitors
Persistent depressive disorder
- AKA dysthymia
- Low level depressive feelings most of the day and majority of the days
- Symptoms last at least 2 years in adults
Must have 2 or more symptoms:
- decreased appetite or overeating
- insomnia or hypersomnia
- low energy
- poor self-esteem
- difficulty thinking
- hopelessness
dont focus on it for exam
Meds for depression: children and teens
SSRIs
- Black box warning – increased risk of ___
- Fluoxetine – ___ line treatment
- Venlafaxine (SNaRIs – serotonin noradrenergic reuptake inhibitors) – used off label
- Both have low s/e – h/a, nausea, GI upset
- Improvement in 1-2 weeks, full effect up to 12 weeks
TCAs
- More s/e
- Risk for dysrhythmias
- Risk for lethal ______
Meds for depression: children and teens
SSRIs
- Black box warning – increased risk of SI
- Fluoxetine – 1st line treatment
- Venlafaxine (SNaRIs – serotonin noradrenergic reuptake inhibitors) – used off label
- Both have low s/e – h/a, nausea, GI upset
- Improvement in 1-2 weeks, full effect up to 12 weeks
TCAs
- More s/e
- Risk for dysrhythmias and lethal OD
serotonin syndrome treatment:
- stop or reduce meds
- __________ – can help control agitation, seizures, muscle stiffness
- oxygen
- IV fluids – dehydration and fever
- Symptomatic and supportive care
- drugs to treat tachycardia and HTN – esmolol, nitroprusside
- drugs to treat hypotension – phenylephrine and epinephrine
- drugs that block serotonin production (not first line) – serotonin production blocking agents
- Symptoms resolves w/in 24 hours – several weeks
treatment:
- stop or reduce meds
- benzodiazepines (diazepam, lorazepam) – can help control agitation, seizures, muscle stiffness
- oxygen
- IV fluids – dehydration and fever
- Symptomatic and supportive care
- drugs to treat tachycardia and HTN – esmolol, nitroprusside
- drugs to treat hypotension – phenylephrine and epinephrine
- drugs that block serotonin production (not first line) – serotonin production blocking agents
- Symptoms resolves w/in 24 hours – several weeks
Lability
Rapid cycling
__________: Rapid shifts or fluctuations in mood state, emotions, or affect.
_________: The occurrence of four or more mood episodes (mania, hypomania, depression) within a 12-month period in bipolar disorder.
lability: Rapid shifts or fluctuations in mood state, emotions, or affect.
Rapid cycling: The occurrence of four or more mood episodes (mania, hypomania, depression) within a 12-month period in bipolar disorder.
Depression symptoms in children by age:
0-3
- FTT
- _________ problems
- Lack of playfulness
- Lack of emotional expression
- Delay in speech or motor development
3-5
- Accidents
- Phobias
- Aggressive
- Excessive self-reproach for minor infractions – ______
6-8
- Vague physical complaints
- Aggressive behavior
- Cling to parents
- Avoid new people/challenges
- ________ in social/academic performance
9-12
- Morbid thoughts
- Excessive worrying
- Lack of interest socially
- Believes parents are ________
Depression symptoms in children by age:
0-3
- FTT
- Feeding problems
- Lack of playfulness
- Lack of emotional expression
- Delay in speech or motor development
3-5
- Accidents
- Phobias
- Aggressive
- Excessive self-reproach for minor infractions – blaming self, guilt
6-8
- Vague physical complaints
- Aggressive behavior
- Cling to parents
- Avoid new people/challenges
- Behind in social/academic performance
9-12
- Morbid thoughts
- Excessive worrying
- Lack of interest socially
- Believes parents are disappointed
bipolar disorders: medications
benzodiazepines
anticonvulsant mood stabilizers
combination med
antipsychotics
other
__________
- sodium valproate/divalproex sodium/valproic acid
- carbamazepine
- lamotrigine
- gabapentin
________
- lithium carbonate
__________
- symbax (olanzapine: antipsychotic + fluoxetine: SSRI)
_________
- olanzapine
- risperidone
- aripiprazole
- quetiapine
___________
- diazepam
- lorazepam
anticonvulsant mood stabilizers
- sodium valproate/divalproex sodium/valproic acid
- carbamazepine
- lamotrigine
- gabapentin
other
- lithium carbonate
combination med
- symbax (olanzapine: antipsychotic + fluoxetine: SSRI)
antipsychotics
- olanzapine
- risperidone
- aripiprazole
- quetiapine
benzodiazepines
- diazepam
- lorazepam
__________ PD (cluster C)
- High need to be taken care of
- Clinging behavior
- Fears of separation and abandonment
- Manipulating others to take responsibilities
- Submissiveness
- Intense anxiety when left alone
Dependent
Nursing care: Dependent PD (cluster C)
- Address current stressors
- Set limits
- Be aware of strong countertransference
- Use therapeutic relationship for assertiveness training
- Encourage independence and self-efficacy
worm tail from HP
antidepressant: _________ s/e
Common
- Dry mouth
- n/d
- constipation
- h/a
- drowsy
- insomnia
- dizzy/lightheaded
- skin reaction at patch site
less common
- involuntary muscle jerks
- low BP
- reduced sex function
- weight gain
- urine hesitancy
- muscle cramps
- tingling skin – paresthesia
MAOIs
Patient/family Teaching: acute mania
- Chronic and episodic nature of bipolar disorder
- Treatment requires 1+ mood stabilizing agents taken for long time
- s/e and toxic s/e
- relapse s/s
- alcohol, drugs, caffeine, and OTC meds can cause ________
- good sleep hygiene is critical for stability – lack of sleep can be r/t manic episode, sleep meds can avert a manic episode
- coping strategies
- therapy
- Chronic and episodic nature of bipolar disorder
- Treatment requires 1+ mood stabilizing agents taken for long time
- s/e and toxic s/e
- relapse s/s
- alcohol, drugs, caffeine, and OTC meds can cause relapse
- good sleep hygiene is critical for stability – lack of sleep can be r/t manic episode, sleep meds can avert a manic episode
- coping strategies
- therapy
Mania
D –
I –
G –
F –
A –
S –
T –
Mania
D – distractibility
I – indiscretion, impulsive, impaired judgement
G – grandiosity delusions
F – flight of ideas
A – activity increase
S – sleep deficit
T – talkativeness
__________ PD (cluster A)
- Severe social and interpersonal deficits
- Rambles
- Paranoid, suspicious, distrust
- Anxiety
- Odd and eccentric
- Hallucinations/delusions
- Can be made aware of their odd beliefs and magical thinking
Schizotypal
Nursing care: Schizotypal PD (cluster A)
- Respect need for social isolation
- Intervene appropriately with pts suspiciousness
- Reinforce social appropriate behavior and dress
- Assess for symptoms that may need intervention – SI
Luna Lovegood from HP
Psychomotor ______ation – visible slowing of physical activity (such as movement or speech), associated with severe depression
- Slow talking
- Long pauses before beginning to talk
- Taking long time to cross room
- Slow food chewing
- Waiting longer than usual between bites
Psychomotor _____ation – increase in activity brought on by mental tension, associated with agitated depression
- Restlessness
- Pacing
- Tapping
- Abruptly starting and stopping tasks
- Meaninglessly moving objects around
Psychomotor retardation – visible slowing of physical activity (such as movement or speech), associated with severe depression
- Slow talking
- Long pauses before beginning to talk
- Taking long time to cross room
- Slow food chewing
- Waiting longer than usual between bites
Psychomotor agitation – increase in activity brought on by mental tension, associated with agitated depression
- Restlessness
- Pacing
- Tapping
- Abruptly starting and stopping tasks
- Meaninglessly moving objects around
lithium carbonate
Labs –
- Initially 1-2 times per week
- Monitor creatinine, thyroid, CBC q 6 months
Teaching
- Risk of ____ when lithium is d/c – assess for s/s of _____
- Do not restrict _______
- Hydration
- If sweating hydrate more
- If illness causes loss of fluids – contact MD
- Intermittent blood tests required
Labs –
- Initially 1-2 times per week
- Monitor creatinine, thyroid, CBC q 6 months
Teaching
- Risk of SI when lithium is d/c – assess for s/s of depression
- Do not restrict sodium
- Hydration
- If sweating hydrate more
- If illness causes loss of fluids – contact MD
- Intermittent blood tests required
Disruptive mood dysregulation disorder (DMDD)
- Onset must occur before age 10
- More common in males and children
Symptoms –
- Anger
- constant and severe irritability
- verbal/behavioral outbursts at least 3x/week
- temper tantrums in at least 2 settings (home, school, etc.)
dont focus on it for exam
meds for mania: bipolar d/o
mood stabilizers regimen:
- lithium (______) + antipsychotic
- sodium valproate/divalproex sodium/valproic acid (_______________) + antipsychotic
___________
- olanzapine
- risperidone
- aripiprazole (older than 10 y/o)
- quetiapine
- ziprasidone
____________ – severe agitation, short term use
- diazepam
- lorazepam
- clonazepam
meds for mania: bipolar d/o
mood stabilizers regimen:
- lithium (other) + antipsychotic
- sodium valproate/divalproex sodium/valproic acid (anticonvulsant mood stabilizers) + antipsychotic
antipsychotics
- olanzapine
- risperidone
- aripiprazole (older than 10 y/o)
- quetiapine
- ziprasidone
benzodiazepines – severe agitation, short term use
- diazepam
- lorazepam
- clonazepam
substance induced depressive disorder - person only experiences depressive symptoms when using drugs, alcohol, or in withdrawal
depressive disorder associated with another medical condition - depressive symptoms result from medical diagnoses or certain medications
- not considered major depressive disorder
- can be caused by kidney failure, Parkinson’s disease, Alzheimer’s disease
dont focus on it for exam
Premenstrual dysphoric disorders
- Symptoms appear the week prior to menstruation and decrease significantly/disappear with the onset of menstruation
- No meds taken continuously, just for the week of symptom onset
Symptoms:
- mood swings
- irritability
- depression
- anxiety
- feeling overwhelmed
- difficulty concentrating
- lack of energy
- over eating
- hypersomnia or insomnia
- breast tenderness
- aching
- bloating
- weight gain
dont focus on it for exam
meds for mood stabilization: bipolar disorder
_____________
- sodium valproate/divalproex sodium/valproic acid
- carbamazepine
- topiramate
- lamotrigine
- gabapentin
________
- lithium carbonate
___________
- symbax (olanzapine: antipsychotic + fluoxetine: SSRI)
____________
- olanzapine
- risperidone
- aripiprazole
- quetiapine
- lurasidone
- ziprasidone
meds for mood stabilization: bipolar disorder
anticonvulsant mood stabilizers
- sodium valproate/divalproex sodium/valproic acid
- carbamazepine
- topiramate
- lamotrigine
- gabapentin
other
- lithium carbonate
combination med
- symbax (olanzapine: antipsychotic + fluoxetine: SSRI)
antipsychotics
- olanzapine
- risperidone
- aripiprazole
- quetiapine
- lurasidone
- ziprasidone
Personality disorder: Cluster ___ – odd, eccentric
- Paranoid PD – delusional
- Schizoid PD – social withdrawal
- Schizotypal PD – unusual, distorted reality
Personality disorder: Cluster __ – anxious, fearful
- Avoidant
- Dependent
- Obsessive-compulsive
Personality disorder: Cluster ___ – erratic, dramatic
- Borderline
- Narcissistic
- Histrionic
- Antisocial
Personality disorder: Cluster A – odd, eccentric
- Paranoid PD – delusional
- Schizoid PD – social withdrawal
- Schizotypal PD – unusual, distorted reality
*pAss
Personality disorder: Cluster C – anxious, fearful
- Avoidant
- Dependent
- Obsessive-compulsive
*C-DOA
Personality disorder: Cluster B – erratic, dramatic
- Borderline
- Narcissistic
- Histrionic
- Antisocial
*B-BAHN
Types
Bipolar 1 disorder
- Most severe form
- Highest mortality rate
- Involves atleast 1 _______ episode
Bipolar 2 disorder
- Atleast 1 ______ episode
- At least 1 _______ episode
major depressive
manic
hypomanic
Types
Bipolar 1 disorder
- Most severe form
- Highest mortality rate
- Involves atleast 1 manic episode
Bipolar 2 disorder
- Atleast 1 hypomanic episode
- At least 1 major depressive episode
Bipolar 1 disorder
- Involves at least 1 _______ episode!!
- Symptoms of alternating manic and depressive episodes and/or hypomanic episodes
- Psychotic episodes (delusions/hallucinations) or depressive episodes common
- The more manic episodes that occur = the more intense episodes are (why medication adherence is important)
- The manic highs mirror lows in intensity
Bipolar 1 disorder
- Involves at least 1 manic episode!!
- Symptoms of alternating manic and depressive episodes and/or hypomanic episodes
- Psychotic episodes (delusions/hallucinations) or depressive episodes common
- The more manic episodes that occur = the more intense episodes are (why medication adherence is important)
- The manic highs mirror lows in intensity
Hypomania vs Mania
_________: A period of intense mood disturbance with persistent elevation, expansiveness, irritability, and extreme goal-directed activity or energy lasting at least 1 week. Symptoms are severe enough to cause marked impairment.
_________: A low-level, less dramatic mania. Increased activity and energy for at least 4 days with at least 3 manic symptoms, but no psychosis and less impairment than full mania.
Mania: A period of intense mood disturbance with persistent elevation, expansiveness, irritability, and extreme goal-directed activity or energy lasting at least 1 week. Symptoms are severe enough to cause marked impairment.
Hypomania: A low-level, less dramatic mania. Increased activity and energy for at least 4 days with at least 3 manic symptoms, but no psychosis and less impairment than full mania.
Bipolar ___ disorder
- Involves at least 1 manic episode!!
- Symptoms of alternating manic and depressive episodes and/or hypomanic episodes
- Psychotic episodes (delusions/hallucinations) or depressive episodes common
- The more manic episodes that occur = the more intense episodes are (why medication adherence is important)
- The manic highs mirror lows in intensity
Bipolar ___ disorder
- At least 1 major depressive episode (may have psychosis)
- At least 1 hypomanic episode (no psychosis)
- Impaired functioning in at least 1 area???
- No history of manic episode!!
Bipolar 1 disorder
- Involves at least 1 manic episode!!
- Symptoms of alternating manic and depressive episodes and/or hypomanic episodes
- Psychotic episodes (delusions/hallucinations) or depressive episodes common
- The more manic episodes that occur = the more intense episodes are (why medication adherence is important)
- The manic highs mirror lows in intensity
Bipolar 2 disorder
- At least 1 major depressive episode (may have psychosis)
- At least 1 hypomanic episode (no psychosis)
- Impaired functioning in at least 1 area???
- No history of manic episode!!
Treatment for anticholinergic s/e associated with what antidepressants?
- Dry mouth – sugar free candy/gum
- GI upset – take with food
- Diarrhea – small frequent meals
- Constipation – increase fiber, fluids and exercise
- Insomnia – sleep hygiene, change admin time of med
- Orthostasis – hydration, get up slow
- Sexual s/e – meds
- Urinary hesitancy – running water, measure amount
antidepressants: Tricyclic antidepressants
- Imipramine
- Doxepin
- Amitriptyline
depression: Medications
________
- Fluoxetine
- Paroxetine
- Sertraline
- Citalopram
- Escitalopram
_______
- Venlafaxine
- Duloxetine
_______
- Imipramine
- Doxepin
- Amitriptyline
________
- Phenelzine
- Tranylcypromine
- Selegiline
________
- Desvenlafaxine (SNRI)
- Trazodone
- Bupropion (NDRI)
- Mirtazapine (NaSSA)
Medications
SSRIs – selective serotonin reuptake inhibitors
- Fluoxetine
- Paroxetine
- Sertraline
- Citalopram
- Escitalopram
SNaRIs – serotonin noradrenergic reuptake inhibitors
- Venlafaxine
- Duloxetine
Tricyclic antidepressants (TCA)
- Imipramine
- Doxepin
- Amitriptyline
Monoamine oxidase inhibitors (MAOIs)
- Phenelzine
- Tranylcypromine
- Selegiline
Others
- Desvenlafaxine (SNRI)
- Trazodone
- Bupropion (NDRI)
- Mirtazapine (NaSSA)
antidepressants: _____________
- Phenelzine
- Tranylcypromine
- Selegiline
- 3rd line treatment for depression
- Also treats anxiety d/o, panic d/o and bulimia
- Effective for unconventional depression
- Tyramine restrictions
Monoamine oxidase inhibitors - MAOIs
SRIs expected s/e vs symptoms of serotonin syndrome?
__________
- agitation
- confusion
- restless
- lethargy
- delirium
- irritability
- dizzy
- hallucinations
- diaphoresis
- flushing
- fever
- tachycardia
- mydriasis – pupils dilate
- myoclonus – muscle twitch
- hyperreflexia
- tremors
- n/v/d
__________
- Dry mouth*
- Sex problems *
- Tension h/a*
- Blurred vision *
- Drowsy
- Nausea
- Diarrhea
- Insomnia
- Nervous, agitation, restless
- Dizzy
serotonin syndrome
- agitation
- confusion
- restless
- lethargy
- delirium
- irritability
- dizzy
- hallucinations
- diaphoresis
- flushing
- fever
- tachycardia
- mydriasis – pupils dilate
- myoclonus – muscle twitch
- hyperreflexia
- tremors
- n/v/d
side effects of all SRIs
- Dry mouth*
- Sex problems *
- Tension h/a*
- Blurred vision *
- Drowsy
- Nausea
- Diarrhea
- Insomnia
- Nervous, agitation, restless
- Dizzy
Personality disorder: Cluster C
Anxious, fearful
1.
2.
3.
Personality disorder: Cluster C
Anxious, fearful
1. Avoidant
2. Dependent
3. Obsessive-compulsive
__________ PD (cluster C)
- Low self esteem
- Shyness increases with age
- Inferiority
- Reluctant to engage with others
- Depression, anxiety, anger
- Obsessed with rejection, humiliation, failure
Avoidant
Nursing care: Avoidant PD (cluster C)
- Friendly, accepting, reassuring
- Accept pt fears
- Enhance new social skills
- Exercises to prevent failure
- Assertiveness training
charlie brown
general Personality disorder: symptoms
- Dysfunctions in cognition, impulse control, interpersonal relationships, and _______
PD: General treatment
- Psychopharmacology
- Indiv. And group Therapy
- DBT
- Family Education and therapy
- Social skills education
PD: prognosis
- Treatable
- Depends on degree of impairment and person’s motivation
Etiology/Risk factors
- Genetics
- Neurobiology
- Psychosocial and environmental
- Diathesis stress model
general Personality disorder: symptoms
- Dysfunctions in cognition, impulse control, interpersonal relationships, and affect
PD: General treatment
- Psychopharmacology
- Indiv. And group Therapy
- DBT
- Family Education and therapy
- Social skills education
PD: prognosis
- Treatable
- Depends on degree of impairment and person’s motivation
Etiology/Risk factors
- Genetics
- Neurobiology
- Psychosocial and environmental
- Diathesis stress model
Nursing care: depression
- _______ highest priority
Recovery model
- Focuses on patients _______ to improve health and reach full potential
- ________ developed treatment goals
- Unique to ________ personal values and needs
- Measurable
Nursing care: depression
- Safety highest priority
Recovery model
- Focuses on patients strengths to improve health and reach full potential
- Mutually developed treatment goals
- Unique to patient’s personal values and needs
- Measurable
which antidepressant? SRIs, TCA, MAOI
s/e in early treatment
- Early morning awakening
- Feeling worse in AM
- Worry and anxiety
Anticholinergic s/e
- Hot as a hare – fever
- Dry as a bone – dry. Mouth and eyes, urinary retention, constipation
- Blind as a bat – dilated pupils, blurred vision
- Mad as a hatter – confusion, delirium
- Sedation
- Weight gain
antidepressants: Tricyclic antidepressants
antidepressants: Tricyclic antidepressants
Nursing implications
- Before giving check:
- what organ?
- hx of what problem?
Nursing implications
- Before giving check:
- ECG for cardiac d/o
- For hx of seizure d/o
lithium carbonate
expected side effects or early, advanced, or severe signs of toxicity?
- Ataxia
- Giddiness
- Serious Electroencephalographic changes
- Blurred vision
- Clonic movements
- Large output of diluted urine
- Seizures
- Stupor
- Severe HTN
- Coma
- Death 2ndary to pulmonary complications
Advanced signs of toxicity:
- Ataxia
- Giddiness
- Serious Electroencephalographic changes
- Blurred vision
- Clonic movements
- Large output of diluted urine
- Seizures
- Stupor
- Severe HTN
- Coma
- Death 2ndary to pulmonary complications
sodium valproate/divalproex sodium/valproic acid
anticonvulsant mood stabilizer
- Example of Anticonvulsant med that might be prescribed for ___________
- Check serum levels
- Broad spectrum of efficacy
- Longer periods of mood stabilization
sodium valproate/divalproex sodium/valproic acid
anticonvulsant mood stabilizer
- Example of Anticonvulsant med that might be prescribed for bipolar disorder
- Check serum levels
- Broad spectrum of efficacy
- Longer periods of mood stabilization
depression: Etiology
Biological
- Genetic
- imbalances – Hormonal, Electrolyte, Cortisol, and neurotransmitters
- inflammatory process
psychological factors
- cognitive theory psychological predisposition - negative and/or unrealistic expectations or environment, self, future
- learning theory – learned helplessness
_______: diathesis stress model
- detachment of primary caregiver
- parental separation or divorce
- death of loved one, pet
- relocation
- academic failure
- physical illness
_______:
- conflicts with independence and maturation
- role confusion
- grief/loss – break up, death
__________:
- societal attitudes
- major stressors – money, life changes, physical illness, grief/loss, decreased function
Etiology
Biological
- Genetic
- imbalances – Hormonal, Electrolyte, Cortisol, Neurotransmitters
- inflammatory process
psychological factors
- cognitive theory psychological predisposition - negative and/or unrealistic expectations or environment, self, future
- learning theory – learned helplessness
child: diathesis stress model
- detachment of primary caregiver
- parental separation or divorce
- death of loved one, pet
- relocation
- academic failure
- physical illness
teens:
- conflicts with independence and maturation
- role confusion
- grief/loss – break up, death
older adults:
- societal attitudes
- major stressors – money, life changes, physical illness, grief/loss, decreased function
antidepressants:_________
- Fluoxetine
- Paroxetine
- Sertraline
- Citalopram
- Escitalopram
- Vortioxetine
- vilazodone
- 1st line
- Rare risk of serotonin syndrome
SSRIs – selective serotonin reuptake inhibitors
Other treatment: _________
- Used to subdue severe manic behavior
- Useful with treatment resistant mania and rapid cycling
- More effective than drugs for treatment resistant bipolar depression
- Depressive episodes – severe, catatonic, treatment resistant depression
Other treatment: ECT
Electroconvulsive therapy
- Used to subdue severe manic behavior
- Useful with treatment resistant mania and rapid cycling
- More effective than drugs for treatment resistant bipolar depression
- Depressive episodes – severe, catatonic, treatment resistant depression
Nursing care: _______
- Initial plan of care focuses on exhaustion and nutrition
- Managing medications
- Decreasing physical activity – walking with nurse ok
- Increasing food/fluid intake
- Ensure minimum 4-6 hours of sleep per night
- Intervene for self-care needs and setting limits on behavior
- Injury prevention
- Establish quiet environment
- Best diet considerations – finger foods high in protein (bananas and peanut butter sandwich)
acute mania
bipolar d/o With ________
- 4 or more manic episodes for at least 2 weeks in 12 months
- Partial/full remission for 2 months at a time or switch to opposite episode
- High risk of recurrence
- Resistant to drug therapy
- Greater severity of illness
- Depressive symptoms predominate
With rapid cycling
- 4 or more manic episodes for at least 2 weeks in 12 months
- Partial/full remission for 2 months at a time or switch to opposite episode
- High risk of recurrence
- Resistant to drug therapy
- Greater severity of illness
- Depressive symptoms predominate
nursing implications for MAOIs
- dietary restrictions – avoid ________ rich foods to prevent ______ crisis
o aged _____ and ______
o overripe ______
o alcohol
o beans
o condiments
- avoid using Demerol – OTC cold meds
- rarely used with SSRIs – risk of serotonin syndrome
- avoid high consumption of _______ – risk of high BP
nursing implications
- dietary restrictions – avoid tyramine rich foods to prevent HTN crisis
o ages meats and cheese
o overripe fruits/veg
o alcohol
o beans
o condiments
- avoid using Demerol – OTC cold meds
- rarely used with SSRIs – risk of serotonin syndrome
- avoid high consumption of caffeine – risk of high BP
bipolar d/o With Mixed features – symptoms of both ______ and ______ occur at the same time
bipolar d/o With Mixed features – symptoms of both depression and mania occur at the same time
Antidepressant meds: general education
- ___-___ weeks for symptom improvement
- _____logical symptoms improve before _____logical symptoms (increased energy = danger for ___)
- Signs of improved sleep – less daytime fatigue and crying, increased frustration tolerance
- s/e handled by adjusting ____ or switching meds in same class
- d/c meds as soon as you feel better may cause ______
- meds usually needed for 6-9 months past symptom relief and up to 12-24 months
- antidepressants are addictive?
- abruptly stopping meds will results in _______ – nausea, anxiety, insomnia, flu like symptoms
- do not drink ______
Antidepressant meds: general education
- 4-6 weeks for symptom improvement
- Physiological symptoms improve before psychological symptoms (increased energy = danger for SI)
- Signs of improved sleep – less daytime fatigue and crying, increased frustration tolerance
- s/e handled by adjusting dose or switching meds in same class
- d/c meds as soon as you feel better may cause relapse
- meds usually needed for 6-9 months past symptom relief and up to 12-24 months
- antidepressants are not addictive
- abruptly stopping meds will results in withdrawal – nausea, anxiety, insomnia, flu like symptoms
- do not drink alcohol
Hypomania
- changes in functioning uncharacteristic for the individual and noticeable by others?
- Episode is severe enough to cause a marked impairment in social or occupational functioning or hospitalization?
- psychotic features?
- Mood is elevated, expansive, or irritable for at least 4 days?
Hypomania
- Episode r/t definite noticeable by others change in functioning uncharacteristic for the individual
- Episode is not severe enough to cause a marked impairment in social or occupational functioning or hospitalization
- No psychotic features
- Mood is elevated, expansive, or irritable for at least 4 days
_________ PD (cluster A)
- Distrust and suspicion
- Reluctant to confide in others
- Anxious
- Jealous
- Controlling as an adult
- Unwilling to forgive
- Vindictive
- Hypervigilant
- Quick to anger
- Provokes others
paranoid PD (cluster A)
Nursing care: paranoid PD (cluster A)
- Counteract mistrust
- Adhere to schedules and boundaries
- Avoid being overly friendly, project neutral and kind affect
- Acknowledge feelings
- Use simple, direct language
Willy Wonka
_________ PD (cluster B)
- Antagonistic behaviors – manipulative, disagreeable
- Disinhibited behaviors – impulsive
- Lack of empathy, remorse, guilt - “not my fault”
- Violates others rights
- Conduct disorder (onset before age 15)
- Needs to prove superiority
- Center of the universe
- Irritable
- Aggressive
- Superficially charming but deceitful
- ex: begins cursing when confronted about drug seeking behavior
antisocial
Nursing care: antisocial PD (cluster B)
- Therapeutic relationship
- Identify dysfunctional thinking and develop new problem solving behaviors
- Self responsibility
- Anger control
- Help build new support system
- Self awareness
walter white from breaking bad
lithium carbonate
expected side effects or toxicity?
- n/v, diarrhea
- thirst
- polyuria
- lethargy, sedation
- fine hand tremor
- risk for renal toxicity/damage – long term use
- risk for thyroid disfunction - goiter and hypothyroidism – monitor for dry skin, hair loss, constipation, bradycardia, cold intolerance
expected side effects or toxicity?
- GI upset
- Coarse hand tremor
- Confusion, sedation, incoordination
- Hyperirritability of muscles
- Electroencephalographic changes
expected side effects or toxicity?
- Ataxia
- Giddiness
- Serious Electroencephalographic changes
- Blurred vision
- Clonic movements
- Large output of diluted urine
- Seizures
- Stupor
- Severe HTN
- Coma
- Death 2ndary to pulmonary complications
expected side effects or toxicity?
- Convulsions
- Oliguria
- Death
expected side effects:
- n/v, diarrhea
- thirst
- polyuria
- lethargy, sedation
- fine hand tremor
- risk for renal toxicity/damage – long term use
- risk for thyroid disfunction - goiter and hypothyroidism – monitor for dry skin, hair loss, constipation, bradycardia, cold intolerance
early signs of toxicity:
- GI upset
- Coarse hand tremor
- Confusion, sedation, incoordination
- Hyperirritability of muscles
- Electroencephalographic changes
Advanced signs of toxicity:
- Ataxia
- Giddiness
- Serious Electroencephalographic changes
- Blurred vision
- Clonic movements
- Large output of diluted urine
- Seizures
- Stupor
- Severe HTN
- Coma
- Death 2ndary to pulmonary complications
Severe toxicity:
- Convulsions
- Oliguria
- Death
bipolar d/o: risk factors
biological factors
- _________!!
- Neurotransmitters (norepinephrine, dopamine, serotonin) - __crease depression/__crease mania
- Neurobiological – changes in prefrontal cortex, hippocampus and amygdala
- Neuroendocrine – HPTA axis
Environmental factors
- Stressful family life
- Adverse events
risk factors
biological factors
- genetics!!
- Neurotransmitters (norepinephrine, dopamine, serotonin) - decrease depression/increase mania
- Neurobiological – changes in prefrontal cortex, hippocampus and amygdala
- Neuroendocrine – HPTA axis
Environmental factors
- Stressful family life
- Adverse events
__________ PD (cluster C)
- Rigid, inflexible standards – interefere with project completion
- Excessive goal seeking that is self or relationship defeating – workaholic
- Unhealthy focus on perfection
- Does not interfere greatly with daily functioning
Obsessive-compulsive
Nursing care: Obsessive-compulsive PD (cluster C)
- Guard against power struggle
- Difficulty with unexpected changes
- Provide structure
- Allow time to complete habitual behaviors
- Promote calm, supportive environment
Sheldon from big bang theory
which anticonvulsant mood stabilizers?
- sodium valproate/divalproex sodium/valproic acid
- carbamazepine
- topiramate
- lamotrigine
- gabapentin
Indicated for acute mania, mood stabilization, rapid cycling
gabapentin
complications r/t antidepressant: ________
HTN crisis symptoms
- h/a
- palpitations
- n/v
- HTN
- Orthostatic hypotension possible
- Dyspnea/SOA
- Mental status changes
- Blurred vision
- Sweating
- Neck stiff/sore
- Dilated pupils
- Photophobia
- Tachycardia or bradycardia
- Chest pain
- Disturbed cardiac rate/rhythm
HTN crisis: treatment
- Phentolamine – alpha-adrenergic blocker, vasodilator
- Sublingual nifedipine – CCB, relaxes cardiac muscles
- Symptomatic and supportive
MAOIs
antidepressants:_________
- Venlafaxine
- Duloxetine
SNaRIs – serotonin noradrenergic reuptake inhibitors
__________ – characteristics and behaviors that comprise a persons unique adjustment to life, including major traits, interests, drives, abilities, values, self-concept, and emotional patterns
- Helps determine _______
Personality – characteristics and behaviors that comprise a persons unique adjustment to life, including major traits, interests, drives, abilities, values, self-concept, and emotional patterns
- Helps determine behavior
Other depression medications
Antidepressants: Desvenlafaxine (SNRI)
Antidepressants: Trazodone
- Chemically similar to TCAs
- Often give at bedtime for sedative effect as adjunct with another AD
Antidepressants: Bupropion (NDRI)
- Contraindicated in ____ d/o and hx of seziures
- Less sexual s/e
- Energizing
- Used in smoking cessation
Antidepressants: Mirtazapine (NaSSA)
- Good for sleep
Others
Antidepressants: Desvenlafaxine (SNRI)
Antidepressants: Trazodone
- Chemically similar to TCAs
- Often give at bedtime for sedative effect as adjunct with another AD
Antidepressants: Bupropion (NDRI)
- Contraindicated in ED and hx of seziures
- Less sexual s/e
- Energizing
- Used in smoking cessation
Antidepressants: Mirtazapine (NaSSA)
- Good for sleep
________ PD (Cluster A)
- Loner
- Poor academic performance
- Disordered family life
- Avoids close relationships
- Depersonalization, detachment, cold, distant
Schizoid
Nursing care: Schizoid PD (Cluster A)
- Avoid being overly friendly
- Don’t try to increase socialization
- Assess for symptoms, patient reluctant to discuss
- Protect from group ridicule
- Respect personal space
lithium carbonate
expected side effects or early, advanced, or severe signs of toxicity?
- n/v, diarrhea
- thirst
- polyuria
- lethargy, sedation
- fine hand tremor
- risk for renal toxicity/damage – long term use
- risk for thyroid disfunction - goiter and hypothyroidism – monitor for dry skin, hair loss, constipation, bradycardia, cold intolerance
expected side effects
Nursing implications: all SRIs
- Effective in __-__ weeks
- s/e diminish in 4-6 weeks
- monitor SI, extreme agitation, fever, increased blood pressure, manic symptoms
- sleep hygiene
- avoid caffeine if anxious
- teach relaxation
- abrupt d/c may be mild or severe- electrical surges, _____ shivers, pins and needles, blackouts, short term memory loss, unconsciousness
Nursing implications:
- Effective in 4-8 weeks
- s/e diminish in 4-6 weeks
- monitor SI, extreme agitation, fever, increased blood pressure, manic symptoms
- sleep hygiene
- avoid caffeine if anxious
- teach relaxation
- abrupt d/c may be mild or severe- electrical surges, brain shivers, pins and needles, blackouts, short term memory loss, unconsciousness
s/s mania
- __________ – extreme, rapid mood swings, irritability or sudden outburst of misplaced rage
- Quick to _______
- Feels misunderstood
- Low or high frustration tolerance?
- Pacing
- Dramatic mannerisms
- Uses jokes, puns
- __________ dress
s/s mania
- Mood liability – extreme, rapid mood swings, irritability or sudden outburst of misplaced rage
- Quick to anger
- Feels misunderstood
- Low frustration tolerance
- Pacing
- Dramatic mannerisms
- Uses jokes, puns
- Flamboyant or sexual dress
Personality disorder: Cluster B
Erratic, dramatic
1.
2.
3.
4.
Personality disorder: Cluster B
Erratic, dramatic
1. Borderline
2. Narcissistic
3. Histrionic
4. Antisocial
____________
A specific notable pattern of thinking, feeling and behaving that is:
- Persistent, inflexible
- Pervasive – across a broad range of situations
- Involves inner experience and externa behavior
- Differs significantly from individual’s culture
- Involves 2 or more areas of functioning – thinking, feeling, interpersonal functioning, impulse control
- Leads to significant distress/impairment – social, legal, work, money, safety, etc.
- Not better accounted for by another mental health condition, direct effect of a substance, or medical condition
Personality disorder
Personality disorder: Cluster A
odd/eccentric
1.
2.
3.
Personality disorder: Cluster A
odd/eccentric
1. Paranoid PD – delusional
2. Schizoid PD – avoid, social withdrawal
3. Schizotypal PD – unusual, distorted reality
major depressive disorder (MDD)
- persistent and/or chronic?
- recurrent episodes common?
- causes distress and/or impaired function?
- episodes attributed to physiological function?
- manic or hypomanic episode present?
major depressive disorder (MDD)
- can be persistent and chronic
- recurrent episodes common
- causes distress or impaired function
- episodes not attributed to physiological function
- NO manic or hypomanic episode
life threatening rash associated with which 2
anticonvulsant mood stabilizers?
- sodium valproate/divalproex sodium/valproic acid
- carbamazepine
- topiramate
- lamotrigine
- gabapentin
treatment for rash: __________
o Is an allergic reaction
o Can advance to toxic epidermal necrosis
o Can advance to steven johnson syndrome (w/in first few weeks)
o Flu like symptoms – sore throat, fever, chills, blisters, burning eyes
- carbamazepine
- lamotrigine
treatment for rash: Stop meds immediately
o Is an allergic reaction
o Can advance to toxic epidermal necrosis
o Can advance to steven johnson syndrome (w/in first few weeks)
o Flu like symptoms – sore throat, fever, chills, blisters, burning eyes
SRIs expected s/e or symptoms of serotonin syndrome?
- agitation
- confusion
- restless
- lethargy
- delirium
- irritability
- dizzy
- hallucinations
- diaphoresis
- flushing
- fever
- tachycardia
- mydriasis – pupils dilate
- myoclonus – muscle twitch
- hyperreflexia
- tremors
- n/v/d
serotonin syndrome symptoms
If med is not d/c symptoms may progress to:
- worsening myoclonus
- HTN
- Rigor
- Acidosis
- Respiratory failure
- Rhabdomyolysis
________ disorder
symptoms
5 or more are present daily in a 2 week period:
- wight and appetite changes
- sleep disturbances
- fatigue
- psychomotor agitation or retardation
- worthlessness or guilt
- loss of ability to concentrate
- recurrent thoughts of death
+ 1 of these must occur:
- depressed mood
- anhedonia – loss of interest/pleasure
major depressive disorder (MDD)
carbamazepine
anticonvulsant mood stabilizer
- Risk of low ______ – check serum levels
- Check ______ and ________ function
- Effective in pts who have no response to lithium or with 2ndary mania
- _______ may be life threatening
carbamazepine
anticonvulsant mood stabilizer
- Risk of low WBC – check serum levels
- Check hepatic and renal function
- Effective in pts who have no response to lithium or with 2ndary mania
- Rash may be life threatening
_________ PD (cluster B)
- Suicidal behavior or self-mutilating behavior
- Affective instability
- Mood swings
- Identity disturbance
- Intense anger, uncontrollable
- Paranoid
- Severe dissociation
- Feeling empty, dysphoria, bored
- Avoids abandonment (real or imagined)
- Unstable interpersonal relationships
- Impulsivity – spending, sex, substance use
- Views self as victim
- Splitting – defense mechanism, unable to accept both positive and negative feelings, people/self/life are either all good or all bad
Borderline
Nursing care: Borderline PD (cluster B)
- Assessment – risks and emotional triggers
- Build trust, therapeutic relationship
- Teach coping strategies for emotional regulation
- Set boundaries and conflict resolution
- Safety
Rebecca Bunch (Crazy Ex-Girlfriend)
_________ PD (cluster B)
- Excitable, dramatic, excessive emotions, smothering
- High functioning
- Bold, provocative, attention seeking
- Self centered
- Low frustration level
- Limited relationships
- Considers relationships more intimate than they are
histrionic
Nursing care: histrionic PD (cluster B)
- Seductive behavior is a response to stress
- Ignore flirtations
- Keep interactions professional, set boundaries
- Help pt clarify feelings
- Teach role model assertiveness
- Assess for SI
the kardashians
Mania vs hypomania vs both?
- characterized by elevated mood and increased energy levels
- more severe, with symptoms lasting at least one week and causing significant impairment in daily functioning.
- It often involves psychotic features like delusions or hallucinations.
- less extreme and does not lead to marked impairment, though others may notice changes in behavior.
- episodes are shorter, lasting at least four days.
- associated with Bipolar I Disorder
- seen in Bipolar II Disorder
- requires immediate intervention due to its acute nature and potential for harmful consequences.
Mania vs hypomania
- both characterized by elevated mood and increased energy levels
- Mania is more severe, with symptoms lasting at least one week and causing significant impairment in daily functioning.
- mania often involves psychotic features like delusions or hallucinations.
- Hypomania, on the other hand, is less extreme and does not lead to marked impairment, though others may notice changes in behavior.
- Hypomanic episodes are shorter, lasting at least four days.
- Mania is associated with Bipolar I Disorder
- hypomania is seen in Bipolar II Disorder
- mania requires immediate intervention due to its acute nature and potential for harmful consequences.
________ PD (cluster B)
- Entitlement, self importance
- Lack of empathy
- Exploits others
- Low self esteem
- Hypersensitivity
- Constant need for admiration
“I don’t care about your problems”
“I deserve to get my way b/c I am better than other people”
“If I flatter my boss, even though he is incompetent, I will get a promotion”
Narcissistic
Nursing care: Narcissistic PD (cluster B)
- Remain neutral
- Promote strong pt self-identity
- Avoid power struggles or becoming defensive
- Role model empathy
voldemort from HP
lithium carbonate
expected side effects or early, advanced, or severe signs of toxicity?
- GI upset
- Coarse hand tremor
- Confusion, sedation, incoordination
- Hyperirritability of muscles
- Electroencephalographic changes
early signs of toxicity:
- GI upset
- Coarse hand tremor
- Confusion, sedation, incoordination
- Hyperirritability of muscles
- Electroencephalographic changes
antidepressants: ___________
- Imipramine
- Doxepin
- Amitriptyline
- 2nd line treatment for depression
- Increased danger of death by OD
- Anticholinergic adverse reactions
- Increased potentially fatal CNS depression with ETOH and other CNS antidepressants
- TCAs less expensive
TCA
antidepressants: Tricyclic antidepressants
other symptoms of MDD in children/teens:
- frequent, ________ physical complaints
- frequent absence or poor school performance
- boredom
- SUD
- Anger or hostility
- Reckless
other symptoms of MDD iin children/teens:
- frequent, vague physical complaints
- frequent absence or poor school performance
- boredom
- SUD
- Anger or hostility
- Reckless
epidemiology
- ___________ and undiagnosed bipolar disorder may occur together
- can begin at any age
- bipolar 1 – more common in males
- bipolar 2 – more common in females
- cyclothymia – onset common in adolescence or early adulthood
epidemiology
- depression and undiagnosed bipolar disorder may occur together
- can begin at any age
- bipolar 1 – more common in males
- bipolar 2 – more common in females
- cyclothymia – onset common in adolescence or early adulthood
key concepts with meds
bipolar d/o:
lithium = (2)
carbamazepine = (1)
lamotrigine = (1)
depression:
SRIs = (1)
SRIs for kids = (1)
TCA = (1)
TCAs for kids = (2)
MAOIs = (2)
key concepts with meds
bipolar d/o:
lithium = toxicity, don’t restrict sodium
carbamazepine = life threatening rash
lamotrigine = life threatening rash
depression:
SRIs = serotonin syndrome, treat with beznos
SRIs for kids = Black box warning – increased risk of SI
TCA = anticholinergic s/e
TCAs for kids = Risk for dysrhythmias and lethal OD
MAOIs = avoid tyramine (aged meat/cheese/fruit/veg, alcohol, etc), risk for HTN crisis
lithium carbonate
expected side effects or early, advanced, or severe signs of toxicity?
- Convulsions
- Oliguria
- Death
Severe toxicity:
- Convulsions
- Oliguria
- Death
