Depression and Anxiety Disorders

• Depressive and anxiety disorders are the focus of the presentation.

Objectives

• Identify depression symptomatology for patient assessment.
• Describe appropriate nursing interventions for depression-associated behaviors.
• Differentiate between facts and myths about suicide.
• Apply the nursing process to individuals exhibiting suicidal behavior.
• Describe various types of anxiety, obsessive-compulsive, and related disorders, then identify the symptomatology of each.
• Describe appropriate nursing interventions for behaviors associated with anxiety, obsessive-compulsive, and related disorders.

Introduction to Depression

• Depression is a frequently diagnosed psychiatric illness, and is in fact the oldest.
• Transient symptoms are normal.
• Pathological depression involves ineffective adaptation and impaired functioning.
• Depression is an alteration in mood that manifests as sadness, despair, and pessimism.

Types of Depressive Disorders: Major Depressive Disorder

• Characterized by depressed mood and loss of interest or pleasure in usual activities.
• Symptoms are present for at least 2 weeks.
• There is no history of manic behavior.
• The condition cannot be attributed to substance use or another medical condition.

Types of Depressive Disorders: Persistent Depressive Disorder (Dysthymia)

• Characterized by being sad or "down in the dumps."
• There is no evidence of psychotic symptoms.
• The essential feature is a chronically depressed mood for most of the day, more days than not, for at least 2 years.

Types of Depressive Disorders: Premenstrual Dysphoric Disorder

• Characterized by depressed mood, anxiety, and mood swings.
• Also characterized by decreased interest in activities.
• Symptoms begin the week prior to menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.

Types of Depressive Disorders: Substance/Medication-Induced & Associated with Medical Condition

• Substance- or medication-induced depressive disorder is considered to be the direct result of physiological effects of a substance.
• Depressive disorder associated with another medical condition is attributed to the direct physiological effects of a general medical condition.

Predisposing Factors to Depression: Biological Theories

• Genetics: Hereditary factors may be involved.
• Biochemical influences: Deficiency of norepinephrine, serotonin, and dopamine has been implicated.

Developmental Implications: Childhood Depression Symptoms

• Under age 3: Feeding problems, tantrums, lack of playfulness and emotional expressiveness.
• Ages 3 to 5: Accident proneness, phobias, excessive self-reproach.
• Ages 6 to 8: Physical complaints, aggressive behavior, clinging behavior.
• Ages 9 to 12: Morbid thoughts and excessive worrying.

Developmental Implications: Adolescence Depression Symptoms

• Anger, aggressiveness.
• Running away.
• Delinquency.
• Social withdrawal.
• Sexual acting out.
• Substance abuse.
• Restlessness, apathy.

Developmental Implications: Senescence Depression Symptoms

• Bereavement overload.
• High percentage of suicides among the elderly.
• Symptoms of depression are often confused with symptoms of neurocognitive disorder.
• Treatments include antidepressant medication, electroconvulsive therapy, and psychotherapies.

Developmental Implications: Postpartum Depression

• May last for a few weeks or several months.
• Associated with hormonal changes, tryptophan metabolism, or cell alterations.
• Treatments include antidepressants and psychosocial therapies.

Treatment Modalities

• Individual psychotherapy.
• Group therapy.
• Family therapy.
• Cognitive therapy.

Treatment Modalities: Electroconvulsive Therapy

• Thought to increase levels of biogenic amines.
• Side effects include temporary memory loss and confusion.
• Risks include mortality, permanent memory loss, and brain damage.
• Uses pretreatment medication, muscle relaxant, and a short-acting anesthetic.

Treatment Modalities: Psychopharmacology

• Tricyclics.
• Selective serotonin reuptake inhibitors.
• Monoamine oxidase inhibitors (MAOIs).
• Serotonin-norepinephrine reuptake inhibitors.

Antidepressants

• Norepinephrine and serotonin play a major role in regulating mood.
• The pharmacological goal is to increase the synaptic level of one or both.
• A black box warning is due to increased suicidality (especially in teens and young adults) during initial weeks of therapy.

Tricyclic Antidepressants (TCAs)

• No longer first-line treatment due to side effects and lethality in overdose.
• Block reuptake of norepinephrine.
• Side effects: Anticholinergic, sedation, drowsiness.
• Nortriptyline (Pamelor) and Imipramine (Tofranil) are examples.

Monoamine Oxidase Inhibitors (MAOIs)

• MAO is the enzyme that destroys monoamines (dopamine, norepinephrine, serotonin, histamine).
• MAOIs inhibit the action of MAO to prevent destruction of monoamines.
• This action increases the synaptic level of neurotransmitters.
• Tyramine is found in aged/pickled meats and cheeses, and wine.
• The liver uses MAO to break down tyramine.
• A tyramine-restricted diet must be followed if taking MAOIs due to risk of hypertensive crisis.
• Isocarboxazid (Marplan), Phenelzine (Nardil), Selegiline (EMSAM), and Tranylcypromine (Parnate) are examples.

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Block the reuptake of serotonin, making it more available.
• May cause decreased libido, nausea, or vomiting.
• Examples: Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), Fluvoxamine (Luvox), Escitalopram (Lexapro), and Citalopram (Celexa).

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

• Increase both serotonin and norepinephrine
• At high doses may lead to hypertension due to stimulation of sympathetic nervous system by norepinephrine.
• May also help with neuropathic pain.
• Examples: Venlafaxine (Effexor), Duloxetine (Cymbalta), and Desvenlafaxine (Pristiq).

Other Antidepressant Agents

• Mirtazapine (Remeron): Norepinephrine and serotonin specific antidepressant (NaSSA).
• Buproprion (Wellbutrin): Norepinephrine dopamine reuptake inhibitor (NDRI), also used for smoking cessation.
• Brexpiprazole (Rexulti) & Trazodone (Desyrel): Serotonin antagonist and reuptake inhibitors (SARI).
• Vortioxetine (Trintellix): Serotonin modulator and stimulator.
• Vilazodone (Viibryd): Serotonin partial agonist and reuptake inhibitor (SPARI).

Serotonin Syndrome

• Results from excess serotonin.
• Symptoms include neuromuscular excitation, altered mental status, and autonomic dysfunction (diaphoresis, hypertension, hyperthermia).

Client/Family Education Related to Antidepressants

• Continue taking medication for 4 weeks.
• Do not discontinue medication abruptly.
• Report sore throat, fever, malaise, yellow skin, bleeding, bruising, persistent vomiting or headaches, rapid heart rate, seizures, stiff neck, and chest pain to physician.
• Avoid foods and medications high in tyramine when taking MAO I's, including aged cheese, wine and beer, chocolate and colas, coffee and tea, sour cream and yogurt, smoked and processed meats, beef or chicken liver, and canned figs.

Pharmacogenomics

• Between 30% and 50% of patients do not respond to first antidepressant prescription.
• A study is needed to identify the benefits of routine testing, cost effectiveness, and ability to provide timely results.

Question/Answer: Tricyclic Antidepressants

• The full therapeutic potential of tricyclics may not be reached for 4 weeks.

Question/Answer: Major Depression Medication

• The medication should not be discontinued abruptly.

Introduction to Suicide

• Suicide is not a diagnosis or a disorder; it is a behavior.
• More than 90% of suicides are by individuals who have a diagnosed mental disorder.

Epidemiological Factors: Suicide Ranking

• The second-leading cause of death among Americans 10 to 34 years of age.
• The fourth-leading cause of death for ages 35 to 54.
• The eighth-leading cause of death for ages 55 to 64.
• The tenth-leading cause of death overall.

Risk Factors: Marital Status and Gender Differences

• The suicide rate for single persons is twice that of married persons.
• Women attempt suicide more often, but more men succeed.
• Men commonly choose more lethal methods than do women.

Risk Factors: Age and Religion

• Risk of suicide increases with age, particularly among men.
• White men older than 80 years are at the greatest risk.
• Affiliation with a religious group decreases the risk of suicide; Catholics have lower rates than do Protestants or Jewish people.

Risk Factors: Socioeconomic Status and Ethnicity

• Individuals in the very highest and lowest social classes have higher suicide rates than those in the middle class.
• Whites are at the highest risk for suicide, followed by Native Americans, African Americans, Hispanic Americans, and Asian Americans.

Risk Factors: Psychiatric Illness and Insomnia

• Mood and substance use disorders are the most common psychiatric illnesses that precede suicide.
• Other psychiatric disorders that account for suicidal behavior include schizophrenia, personality disorders, and anxiety disorders.
• Severe insomnia is associated with increased risk of suicide.

Risk Factors: Other Influences

• Use of alcohol and barbiturates.
• Psychosis with command hallucinations.
• Affliction with a chronic, painful, or disabling illness.
• Family history of suicide.
• LGBTQ+ individuals have a higher risk of suicide than do their heterosexual counterparts.
• Having attempted suicide previously increases the risk of a subsequent attempt; about half of those who ultimately commit suicide have a history of a previous attempt.
• Loss of a loved one through death or separation.
• Bullying.

Nursing Process: Assessment - Demographics

• Age
• Gender
• Ethnicity/race
• Marital status
• Socioeconomic status / Occupation
• Lethality and availability of method
• Religion
• Family history of suicide
• Military history

Nursing Process: Assessment - Intent

• Seriousness of intent.
• Suicidal ideas or acts.
• Interpersonal support system.
• Plans.
• Means.
• Verbal and behavioral clues.

Nursing Process: Assessment - Other

• Analysis of the suicidal crisis, including precipitating stressors, relevant history, and life-stage issues.
• Psychiatric/medical/family history.
• Coping strategies.
• Presenting symptoms.

Information for Family and Friends of the Suicidal Client

• Take any hint of suicide seriously.
• Do not keep secrets.
• Be a good listener.
• Express feelings of personal worth to the client.
• Know about suicide intervention resources.
• Restrict access to firearms or other means of self-harm.
• Acknowledge and accept the person's feelings.
• Provide a feeling of hopefulness.
• Do not leave him or her alone.
• Show love and encouragement.
• Seek professional help.
• Remove children from the home.
• Do not judge or show anger toward the person or provoke guilt in him or her.

Anxiety Disorders: Introduction

• Anxiety is an emotional response to anticipation of danger, the source of which is largely unknown or unrecognized.
• Anxiety is a necessary force for survival, and is not the same as stress.

Anxiety Disorders: Epidemiological Statistics

• Most common of all psychiatric illnesses.
• More common in women than in men.
• A familial predisposition probably exists.

Anxiety Disorders: Definition of Too Much

• When anxiety is out of proportion to the situation that is creating it.
• When anxiety interferes with social, occupational, or other important areas of functioning.

Generalized Anxiety Disorder (GAD)

• Characterized by chronic, unrealistic, and excessive anxiety and worry.

Anxiety Pathway

• Stress leads to anxiety.
• Anxiety leads to:
  • Relief Behavior which gives Effective Mediation and less anxiety.
  • A situation where there is ineffective mediation which then increases anxiety and more negative effects.

Panic Disorder: Assessment

• Characterized by recurrent panic attacks, the onset of which are unpredictable.
• Manifested by intense apprehension, fear, or terror, associated with feelings of impending doom and accompanied by intense physical discomfort.
• May or may not be accompanied by agoraphobia.

Panic Attack: Symptoms

• Sweating, trembling, shaking.
• Shortness of breath, chest pain, or discomfort.
• Nausea or abdominal distress.
• Dizziness, chills, or hot flashes.
• Numbness or tingling sensations.
• Derealization or depersonalization.
• Fear of losing control or "going crazy”.
• Fear of dying.

Anxiety: Interventions

• Calm, quiet approach/environment.
• Encourage to identify, describe, and discuss feelings.
• Help identify the source of feelings.
• Listen and assess hopelessness and helplessness.
• Assess suicidal risk plan and intent directly.
• Involve in activities as tolerated.

Problem Solving

• Discuss present and previous coping strategies.
• Discuss meaning and priorities of problems and conflicts.
• Use supportive confrontation and teaching.
• Assist with strategies to explore alternative solutions and behaviors.
• Encourage testing of new coping strategies.
• Teach relaxation exercises.
• Promote hobbies and recreation according to patient's preferences and abilities.

Panic Attack: Interventions

• Stay with patient and acknowledge discomfort.
• Maintain a calm style and demeanor.
• Speak in short, simple sentences.
• Give one direction at a time.
• Treat hyperventilation, provide a brown paper bag, and focus on breathing with the patient.
• Allow to cry and pace (these are anxiety-reducing behaviors).
• Communicate that you are in control and will not let anything happen to patient.
• Communicate that patient is safe.
• Move or direct patient to a quieter, less stimulating environment.
• Encourage discussion of perceptions and fears.

Obsessive-Compulsive Disorder (OCD): Assessment Data

• Recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or significant impairment.
• Obsessions are recurrent thoughts, impulses, or images experienced as intrusive and stressful, and unable to be expunged by logic or reasoning.
• Compulsions are repetitive ritualistic behaviors or thoughts, the purpose of which is to prevent or reduce distress or to prevent some dreaded event or situation.

Question/Answer: Client Experiencing Panic Attack

• Communicate with simple words and brief messages.

Treatment Modalities: Psychopharmacology - Anti-Anxiety Agents

• Hydroxyzine (Vistaril).
• Alprazolam (Xanax).
• Clonazepam (Klonopin).
• Diazepam (Valium).
• Lorazepam (Ativan).

Benzodiazepines

• Promote the activity of GABA by binding to a specific receptor on the GABA receptor complex, leading to membrane hyperpolarization.
• Reduces cellular excitation producing a calming effect, which which is the same mechanism as alcohol.
• Used at low doses to treat anxiety.
• Examples: Alprazolam (Xanax), Lorazepam (Ativan), Diazepam (Valium), and Clonazepam (Klonopin).