Transcript Chapter 013
Depressive Disorders
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Major Depressive Disorder
History of one or more major depressive episodes
No history of manic or hypomanic episodes
Symptoms interfere with social or occupational
functioning
May include psychotic features
Affects twice as many women as men
Onset usually occurs in the person’s mid-30’s
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Major Depressive Disorder
Subtypes
Psychotic features
Melancholic features
Atypical features
Catatonic features
Postpartum onset
Seasonal features – seasonal affective disorder (SAD)
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Proposed Subtypes
Premenstrual dysphoric disorder
Mixed anxiety-depression
Recurrent brief depression
Minor depression
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Dysthymic Disorder
Chronic depression for the majority of most
days for at least 2 years
Symptoms are less severe than major
depression with fewer physiologic symptoms
Predispose people to develop major depression
Often occur in childhood and adolescence
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Epidemiology
Leading cause of disability in the United States
Children and adolescents
Older adults
Comorbidity
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Etiology
Biological factors
Genetic
Biochemical
Alterations in hormonal regulation
• Diathesis-stress model
Psychological factors
Cognitive theory
Learned helplessness
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Nursing Process
Assessment
Self-assessment
Unrealistic expectations of self
Feeling what the patient is feeling
Assessment tools
Assessment of suicide potential
Key assessment findings
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Assessment
Subjective Data:
Suicidal ideation
Feelings of sadness
Fatigue
Lack of interest
Feelings of worthlessness
Impaired concentration and decision-making
ability
Sleep disturbance (insomnia or hypersomnia)
Appetite changes (weight gain or weight loss)
Somatic concerns
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Assessment
Objective Data:
Females under the age of 40
Prior episodes of depression
Family history of mood disorder
History of recent stressful event
Lack of social support
Psychomotor agitation or retardation
Pattern of social withdrawal
Lack of social participation
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Nursing Process
Continued
Areas to assess
Affect
Thought processes
Mood
Feelings
Physical behavior
Communication
Religious beliefs and spirituality
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A Mnemonic for Symptoms of
MDD “SIGECAPS”
Sleep changes
Interest (lost of)
Guilt (worthlessness, hopelessness, regret)
Energy loss of fatigue
Concentration difficulties
Appetite changes (low or increased appetite, weight loss or
gain)
Psychomotor retardation or agitation
Suicidality
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Which question would be a priority when assessing
for symptoms of major depression?
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a. “Tell me about any special powers you believe you
have.”
b. “You look really sad. Have you ever thought of
harming yourself?”
c. “Your family says you never stop. How much sleep
do you get?”
d. “Do you ever find that you don’t remember where
you’ve been or what you’ve done?”
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Nursing Process
Continued
Nursing Diagnosis
Risk for suicide – safety is the highest priority
Hopelessness
Ineffective coping
Social isolation
Spiritual distress
Self-care deficit
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Nursing Process
Continued
Outcomes Identification
Recovery model
Focus on patient’s strengths
Treatment goals mutually developed
Based on patient’s personal needs and values
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Nursing Process
Continued
Planning
Geared towards
Patient’s phase of depression
Particular symptoms
Patient’s personal goals
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Nursing Process
Continued
Implementation
Three phases
Acute phase (6 to 12 weeks)
Continuation phase (4 to 9 months)
Maintenance phase (1 year or more)
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Nursing Process
Continued
Basic Level Interventions
Counseling and communication
Health teaching and health promotion
Promotion of self-care activities
Milieu therapy
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Nursing Process
Continued
Identify the patient’s potential for suicide
Create a safe environment
Formulate verbal contract with patient to notify staff
members when feelings begin to get out of control
Encourage patient to express anger in acceptable
ways
Assists patient in recognizing strengths and
accomplishments
Assist patient in performing activities of daily living
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Nursing Process
Continued
Assess for suicide risk by direct questioning about
suicidal thinking, history of suicide attempts, and
whether the client has a specific suicide plan
The more organized the plan is, the more concern it
generated as safety is a priority
Suicidal clients should be placed under suicide
precautions
Close staff supervision
Remove items such as sharps, belts, shoe laces, mirror
etc.
No-suicide contract
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Nursing Process
Continued
Advanced Practice Interventions
Psychotherapy
Cognitive behavioral therapy (CBT)
Interpersonal therapy (IT)
Time-limited focused psychotherapy
Behavior therapy
Group therapy
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Psychopharmacology
Tricyclic antidepressants (TCAs)
Neurotransmitter effects (5HT, NE)
FDA Indications: MDD, Childhood Enuresis
Contraindications: mitral valve disease, heart
blocks increased heart rate and fatal
arrhythmias
Overdose Effects: Delirium, hyperthermia,
convulsion, coma, respiratory failure and
death.
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Side Effects of TCA
Anticholinergic (dry mouth, dry eyes, blurred vision,
constipation, palpitations, and urinary retention)
Tremors, Twitching
Orthostatic hypotension
Paresthesias
Ataxia
Increased suicidal thoughts
Sexual Dysfunction
Weight gain 10 – 20 lbs
Dizziness
Sedation
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Tricylic Antidepressant
Amitriptyline - Elavil® (25 - 300 mg/d)
Amoxapine - Asendin® (25 - 600 mg/d)
Clomipramine - Anafranil® (25 - 250 mg/d)
Desipramine - Norpramin® (10 - 300 mg/d)
Doxepin - Sinequan® (10 - 300 mg/d)
Imipramine - Tofranil® (10 - 300 mg/d)
Maprotiline - Ludiomil® (25 - 225 mg/d)
Nortriptyline - Pamelor® (50 - 150 mg/d)
Protriptyline - Vivactil® (5 - 60 mg/d)
Trimipramine - Surmontil® (25 - 200 mg/d)
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Psychopharmacology
Continued
Monoamine oxidase inhibitors (MAOIs)
Neurotransmitter effects
Indications: useful in atypical depression
(increased sleep, increased appetite, anxiety,
rejection
Adverse/toxic effects: hypertensive crisis
Interactions
Drug: Sympathomimetics, SSRIs, SNRIs, TCA
Food: Foods containing tyramine
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Monoamine Oxidase
Inhibitors (MAOI)
Phenelzine - Nardil (7.5 - 90 mg/d)
Tranylcypromine - Parnate (10 - 60 mg/d)
Isocarboxazid - Marplan (20 - 60 mg/d
Selegiline - Emsam (Patch) 6mg - 12mg/d
Moclobemide – Manerix (Canada)
St. John’s Wort
Side effects: Dizziness, headache, stiff neck, N/V,
restlessness, insomnia, dry mouth, sexual
dysfunction, weight gain and Hepatic necrosis
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The BIG Deal with MAOI
Food interaction: pickled, fermented, smoked,
or aged foods, such as red wine, preserved food,
aged stinky cheese, which leads to hypertensive
crises resulting in intracranial bleed.
Drug Interaction
Other antidepressants
OTC cold and flu medications
Demerol
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Psychopharmacology
Antidepressants
Selective serotonin reuptake inhibitors
(SSRIs)
First-line therapy
Indications
Adverse reactions
Potential toxic effects
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Selective Serotonin Reuptake
Inhibitor (SSRI)
Citalopram - Celexa® (20-60 mg/d) 1998
Escitalopram - Lexapro® (10-20 mg/d) Isomer of
Citalopram
Fluoxetine - Prozac® (20-80 mg/d) 1987
Prozac Weekly (90 mg enteric-coated delayed release
capusule)
Sarafem® (20 - 60 mg/d for PMS)
Fluvoxamine - Luvox® (50 - 300 mg/d)
Paroxetine - Paxil® (20 - 50 mg/d)
Paxil CR (12.5 - 62.5 mg/d) enteric coated
Sertraline - Zoloft® (50 - 200 mg/d) 1992
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Possible Side Effects SSRI
Nausea and Vomiting
Nervousness
Sleep disturbance
Somnolence
Constipation
Sexual dysfunction: libido and orgasm
GI upset
Tremors
Weight gain
Cognitive problems: word finding
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Issues With SSRIs
Discontinuation Symptoms
Dizziness
Nausea
Pins and needles
Zappers
(Prozac does not cause discontinuation symptoms =
16 weeks half life)
Loss of efficacy = poop out
Partial response
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Serotonin Norepinephrine
Reuptake Inhibitor SNRI
Venlafaxine - Effexor®, (75 - 225 mg/d)
Effexor XR® (75 - 225 mg/d)
Desvenlafaxine – Pristiq® (50 – 400 mg/d)
Duloxetine – Cymbalta® (20-60 mg/d for depression
60 - 120 mg/d for diabetic peripheral neuropathy)
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Other Antidepressants
Bupropion - Wellbutrin®, Wellbutrin SR®,
Wellbutrin XL®, Zyban® - (75-450 mg/d)
Enhances release of norepinephrine and dopamine (NDRI)
Be careful in people with history of seizure disorder, head
trauma and eating disorders.
Side effects: anxiety, agitation, insomnia, nausea, tremor and
weight loss
Mirtazapine - Remeron® (15 - 45 mg/d) SN
Nefazodone - Serzone® (200 - 600 mg/d)
Trazadone - Desyrel® (200 - 600 mg/d)
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Serotonin Syndrome
Mild in most people, recovery within 24 - 72 hours, although
it can cause death under circumstances
Seen in people taking two or more medications that increase
levels of serotonin in the CNS
Symptoms: 3 of the following must be present
Mental status changes
Agitation
Myoclonus
Shivering
Hyperreflexia
Ataxia
Diaphoresis
hyperpyrexia
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Management and Prevention
of Serotonin Syndrome
Supportive measures
Discontinue medication
Provide benzodiazepine
Anti-serotonergic agents: Periactin, Sansert,
Inderal
Dantrium for relieving muscle rigidity and
hyperthermia
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Other Treatments
for Depression
Electroconvulsive therapy (ECT)
Transcranial magnetic stimulation
Vagus nerve stimulation
Light therapy
St. John’s wort
Exercise
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Electroconvulsive Therapy (ECT)
Treatment procedure during which an electric
current is passed through the brain. Unilateral or
bilateral
Indication: severe depression, acute mania,
psychotic symptoms, acutely suicidal
Treatment is 3 times a week until the course of 12
treatments is completed
Causes generalized seizure (tonic-clonic)
Contraindication: ICP and recent MI
Side effects: transient short-term memory loss
Not a cure
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Working with Clients Receiving ECT
Consent forms completed
Keep pt NPO for at least 4 hours
Ask the patient to void and remove contact
lenses, jewelry, hairpins, and dentures prior to
treatment
Assess vital signs
Medications: Robinul®, Brevital®, Anectine®
Recovery: lateral recumbent position, orient to
time, place and situation
Offer food
Offer medication for Headache
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Complimentary and
Alternative Medicine
St John’s Wort (Hypericum perforatum) (1,200mg –
1,800mg)
SAM-e (s-adenosylmethionine) (800mg/d)
Omega 3 FFA (1 – 2 grams/d)
Folic Acid (0.3mg/d)
Nature Made
Jarrow
Life Extension
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Complimentary and Alternative
Medicine
Meditation: help with stress, mood disturbance,
anxiety, depression, pain of chronic illness, other
conditions
Pressure point therapies (acupuncture,
acupressure): healing, pain relief, physical and
emotional well-being
Touch therapies, including massage: reduced
pain and anxiety, relaxation and healing; help for
depression, addiction, dementia, anxiety
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Nursing Process
Continued
Evaluation
Short-term indicators and outcome criteria
Reassess and reformulate care plan as necessary
Future of treatment
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