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
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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
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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)
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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

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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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