Bipolar II and SSRIs Overview

Characterized by hypomania alternating with major depressive episodes
Personality disturbance, impulse difficulties, mood instability, and recurrent depression
Criteria similar to manic episodes, but duration is at least 4 days (not 1 week)
No marked impairment in social or occupational functioning
Psychosis is NOT present
Milder than Bipolar I

### Mood Disorder: Depressive Disorders

SSRIs (Selective serotonin reuptake inhibitors)
- Examples: Lexapro, Prozac, Zoloft, Paxil, Celexa
- Fewer side effects
- Safer in overdose
- Side effects: GI issues, sexual dysfunction, weight gain (in some)
- Serotonin syndrome: potentially serious side effect caused by drug-induced excess of serotonin
  - Most often reported in patients taking two or more medications that increase CNS serotonin levels
  - Can cause death, but is usually mild and resolves with supportive care
  - Develops within hours or days after initiating or increasing the dose
  - Symptoms include: AMS, autonomic dysfunction, neuromuscular abnormalities
SNRIs (Serotonin norepinephrine reuptake inhibitors)
- Examples: Effexor, Serzone, Cymbalta
- Second-generation drugs
- Newer, fewer side effects
- Safer in overdose
- Side effects: GI issues, sexual dysfunction, weight gain (in some), serotonin syndrome

First-generation drugs
Examples: Nardil and Parnate
Reserved for patients whose depression fails to respond to other antidepressants or who cannot tolerate typical antidepressants
Not used frequently due to side effects
Can precipitate hypertensive crisis
Food cautions:
- Tyramine-containing foods (aged cheese, draft beer, smoked salmon, soy sauce, red wine) can trigger hypertensive crisis, which can be life-threatening
- Symptoms: sudden, severe pounding headache, racing pulse, flushing, stiff neck, chest pain, nausea, vomiting, profuse sweating
More lethal in overdose than newer antidepressants
Prescribed cautiously in patients with elevated suicide potential
Generally given in divided doses to minimize side effects
Used cautiously in suicidal patients

### Electroconvulsive Therapy (ECT)

Effective treatment for severe depression
Reserved for patients with medication-resistant or medication-intolerant depression, or who are so severely ill that rapid treatment is required
Examples of severe illnesses requiring rapid treatment: malnutrition, catatonia, or suicidality

"Have you thought about killing yourself?"
"Do you have a plan?"
"Are the means to carry out this plan available to the patient?"
Assess the plan for lethality: the more planned out, the more likely
Contract for safety (showing support)
Elopement risk
Attempt history: If a patient has attempted suicide before, it's more probable they'll try again
Indicators:
- Giving stuff away
- Making lists

Antianxiety agents (Benzos)
- Lorazepam (Ativan)
- Alprazolam (Xanax)
- Diazepam (Valium)
First generation antipsychotics:
- Haloperidol (Haldol)
- Perphenazine
- Chlorpromazine (Thorazine)
- Loxapine (Adasuve)
Second generation antipsychotics:
- Risperidone (Risperdal)
- Olanzapine (Zyprexa)
- Ziprasidone (Geodon)
Combinations (B52):
- Haloperidol (Haldol)
- Lorazepam (Ativan)
- Diphenhydramine (Benadryl)

Failure to provide for the older adult's basic needs or to protect them from harm
Family members, custodians, and care facility personnel may inflict physical abuse and sexual abuse
Financial abuse:
- Caretakers may steal cash or credit cards or coerce the older person to transfer property or accounts
- Victims also lose personal belongings, medications, and food stamps.

Delirium: sudden decline from a previous level of functioning
- Medical emergency
- Reversible if treated quickly
- 25% of patients do not survive
- Caused by general medical conditions (UTI) or substance-induced (intoxication or withdrawal)
Results in disturbances in:
- Consciousness (key criteria)
- Attention
- Cognition (try giving directions)
- Perception (hallucinations)
- Motor abilities
Cognitive changes/problems with:
- Memory
- Orientation
- Language
- Attention
- Perception
Common in the older adult population but can happen in any age group
Risk factors:
- Pre-existing cognitive impairments
- Elderly
- Male (over 65 with alcohol)
- Alcohol abuse
- Lower levels of education attainment
- Fractures
- Depression
- Impaired vision
- Post-op (anesthesia use)
Etiology:
- Post-op
- Drug intoxications/withdrawal
- Infections
- Metabolic disorders (diabetes/thyroid issues)
- Medications
- Neurological diseases (MS, Parkinson's)
- Tumors (in brain)
- Psychosocial stressors
Interventions for delirium:
- Elimination/correction of underlying cause
- Symptomatic/supportive measures:
  - COMFORT
  - Rest and fluid/electrolyte maintenance
  - Injury protection
- Hallucinations/disorientations:
  - Promote relaxation
  - Gentle reorientation
  - Safety
  - Resolve underlying stressor
  - Reassurance