Week 5 Flashcards
Clinical manifestation of depression according to DSM-4 TR
Depressive disorders are diagnosed when at least five of the nine criteria listed below
are present more than once & for a period longer than a fortnight:
- Depressed mood most of the day, nearly every day.
- Markedly diminished interest or pleasure in all, or most activities, most of the day, nearly every day.
- Significant weight changes [loss or gain] when not dieting.
- Insomnia or Hypersomnia nearly every day.
- Psychomotor agitation or retardation, nearly every day.
- Physical fatigue or loss of energy every day.
- Feelings of worthlessness, excessive or inappropriate guilt nearly every day.
- Diminished ability to concentrate or give enough attention, ambivalence or indecision nearly every
day.
- Recurrent thoughts of death or suicidal ideation
clinical manifestations of mania according to DSM-4 TR
Diagnostic criteria of a manic episode include: elevated, expansive, labile or irritable mood,
abnormal / incongruent and persistent, lasting minimum of one week with three or more of
the following;
-Grandiosity or inflated self
esteem.
-Decreased need for sleep [feels sufficiently rested after a couple of hours of sleep]
-Talkative (or marked pressure of speech)
-Flight of ideas.
-Easily distracted.
-Increase in goal directed activity or
Psychomotor agitation.
-Excessive involvement in pleasurable activities that have a high potential for painful
consequences.
In severe cases, hallucinations &/or delusions may be present. Delusions of
grandeur, Paranoid delusions or both may be present.
Nursing care of the depressed client?
- Comprehensive psychiatric assessment
- Rule out organic causes of illnes (physical conditions can mimic depression)
- Current medical treatments (some treatments can result in depression type symptoms)
- MSE
- Develop therapeutic relationship
- Education of condition and management
- Perform a risk assessment (suicide risk, self harm, aggression to others, neglect of adl’s, substance abuse, compliance)
- Risk managment (identify risks, inhance protective mechanisms, evaluate the clients state of mind - thought, plan, intent, level of risk, Document the assessment, risk and plan of action.
- maintain physical presence
- Encouragement
- Monitor for evidence of ETOC/substance abuse
Nursing care of the bipolar client?
- Comprehensive psychiatric assessment
- MSE
- Exclude physical conditions
- Ensure medical treatments are not producing signs and symptoms of bipolar
- Nursed in a low stimulus environment
- Monitor ADL’s
- Promote rest, sleep, nutrition, hydration
- Attitude of nurse is cruicial eg. approachable, tolerant, patient.
- Limit setting must occur
- Limit visitors and length of stays of visitors
- Psychoeducation - illness, treatment and early warning signs
- Risk assessment (suicide, self harm, aggression to others, risk of harm to others, neglect, compliance, vulnerability
- Risk Management - identify risks, protective mechanisms, clients thoughts, intent, plan, past history; level of risk, Document risk assessment, and plan of action.
- encourage client
- Monitor or ETOH/substance abuse
- develop a relapse plan
How do anti-depressants work?
The perceived action of antidepressants is based on the belief they have an effect on
neurotransmitters in the brain. The reduction or absence of these correlate in cases of depression
What are the 3 neurotransmitters involved in depression?
The 3 neurotransmitters involved are;
- Serotonin
- Noradrenaline (Norepinephrine)
- & Dopamine
Do all clients need anti-depresents?
Not all clients with depression benefit from antidepressant therapy & someone who has experienced
a depressed mood after a stressful event over a brief period, usually recovers without needing
medications.
When is depression more likely to warrent treatment with anti-depression medication?
Additionally, chronic mild cases of depression may be warranted with antidepressant therapy when
other interventions are exhausted.
Family history of depression & recurrent depressive episodes are more likely to warrant
antidepressant therapy.
What are the anti-depressant medication families?
- Tricyclic Antidepressants [TCA‟s] Mono -Amine Oxidase Inhibitors [MAOI‟s] Reversible Mono -Amine Oxidase Inhibitor [RIMA] Selective Serotonin Reuptake Inhibitors [SSRI‟s] Serotonin -Noradrenaline Reuptake Inhibitors [SNRI‟s]
How do Tricyclic Antidepressants (TCA’s) work?
The first of the current range of antidepressants used with Imipramine in 1956.
Generally seen as more effective in treating depression, however more potent side effects & lethal in overdosage
-Usually administered at night due to sedative properties.
Amitryptyline,Dothiepin & Doxepin are commonly used in pain disorders given their propensity to bind to nociceptors
[pain receptors] and enhance efficacy of analgesia. Imipramine commonly used on children with enuresis >5 years
What are the generic names of Tricyclic Antidepresents (TCA’s)
Generic Name
- Clomipramine hydrochloride
- Dothiepin hydrochloride
- Doxepin hydrochloride
- Imipramine
- Nortriptyline hydrochloride
- Trimipramine
What are the tetracyclic anti-depressants
- Mianserin
- Mirtazapine
What are the MonoAmine Oxidase Inhibitors (MAOI’s)?
- Phenelzine sulfate
- Tranylcypromine sulfate
Precautions with MonoAmine Oxidase Inhibitors (MAOI’s)?
Fermented foods / beverages, pickled foods, aged & cured meats, Banana skins,
Avacado, broad bean pods. Stock cubes & packet soups, Soy sauce & sour cream
What are the reversable MonaAmine Oxidase Inhibitors (MAOI’s)?
- Moclobemide
What are the pharmacological interventions for Serotonin Selective Reuptake inhibitors (SSRI’s)?
- Most commonly used Antidepressants currently used since introduction in 1987.
- Very effective in treating depression with a better side effect profile and less toxic in overdose.
- Also effective with social phobias & anxiety disorders.
- Broad usage to the extent of prescription for erectile dysfunction [Fluoxetine]
- Fluoxetine was marketed under the trade name ~ PROZAC until removal of that trade name in many countries.
- Common side effects are; Dry mouth, headache, drowsiness, dizziness, tremors, diarrhoea, loss of appetite.
- SSRI‟s are less sedating than earlier antidepressants.
- Sertraline & Venlafaxine [SNRI] is believed to have an impact on adolescent suicide rates in UK with subsequent bans enforced. Worldwide controversy surrounding its use exists presently with Australia discouraging its use with adolescents.
What are the Selective Seratonin Re-uptake Inhibitors (SSRI’s)?
Generic name:
- Citalopram
- Escitalopram
- Fluoxetine
- Fluvoxamine
- Paroxetine
- Sertraline
What are the Selective Serotonin Noradrenaline reuptake inhitators?
- Desvenlafaxine
- Duloxetine
- Venlafaxine
- Reboxetine [Selective Noradrenaline Reuptake Inhibitor]
What are the mania/hypomania mood stabalizers?
- Lithium Carbonate [LiCO³]
- Sodium Valproate [Na+Val]
- Carbamazepine
- Lamotrigine
- Topiramate
What are the therapeutic ranges for Lithium Carbonate (LiCO3)?
- 5-1.2 mmol/L - Maintenance
- 5 mmol/L - Acute mania
- 0 mmol/L - Toxic levels
Medication considerations for Anti-Depressants
These medications are not addictive.
Antidepressants do not change personality.
When changing antidepressants, Cross titration is of a shorter period since the newer antidepressants require less time to washout”.
Antidepressants are utilised for a variety of general & psychiatric disorders. Fibromyalgia, pain disorders, premature ejaculation, migraines, neuropathy, nocturnal
eneurisis
Medical considerations for Mood Stabalisers
These medications are also used for neuralgic pain & to manage epilepsy. [not
LiCo3] Lithium can cause an upset stomach & affected clients are advised to take dose with milk . Serum levels are taken >12 hours post dosage. The advantage of serum levels is the monitoring of compliance. Lithium is most recommended mood stabiliser for clients having ECT. Two different mood stabilisers can be administered at the same time & antidepressants can be
added during depressive phases.
LiCO3 toxicity usually results in clients requiring dialysis treatment as the majority of the drug is excreted via kidneys.
What is Electro-Convulsive Treatment?
s a treatment for depression and there is a strict protocol governing its use in accordance with the relevant M.H.A.
What are the advantages of Electro-Convulsive Therapy (ECT)?
[1] If a depressed client refuses to eat or drink, ECT works more rapidly than conventional treatments.
[2] Their safety is compromised due to a poor response to medications or due to intense suicidal ideation, ECT has a high success rate.
[3] More appropriate for clients with long standing, treatment resistant depression & catatonic presentations (Schizophrenia or Depression), Schizo-affective Disorder (S.A.D).
[4] Can be used in affective disorders when other treatments are of minimal or no effect.
[5] Electrical current administered (Uni
or Bi-Laterally) and titrated according to response.
[6] Regular Consultant psychiatrist reviews in accordance with relevant MHA.
What are the adverse effects of Electro-Convulsive Therapy (ECT)?
[1] Poor public perception of the use of ECT.
[2] Brief period of headache
[3] Cognitive impairment–Poor STM, impaired attention & concentration, brief disorientation. (This can be exacerbated by depressive state with the client)
[4] Potential for complications consistent with use of IV anaesthetic agents & considered an
invasive procedure.
psychotherapies for treating mood disorders?
Are a non-invasive treatment for mood disorders that are effective and
increasing in popularity. They aid in the prognosis of clients with mood disorders and can be used over the short or long term.
CBT therapy in treating mood disorders?
Useful for all mood & anxiety disorders as a primary or secondary form of treatment.
The aim is to challenge negative or irrational thought patterns. Extreme thoughts = extreme emotions. CBT aims to reduce the intensity of these emotions Feelings result from attitudes, thoughts & beliefs, not the external situations Harmony between thoughts, emotions and behaviour is the desired result
