Depression and Anxiety Disorders

• Depression and anxiety disorders are explored in this presentation.
• Annie Smith, RN-BC, MSN, presents the material.

Objectives

• Identify depression symptomatology for patient assessment.
• Understand nursing interventions for depression-related behaviors.
• Distinguish facts from myths about suicide.
• Apply the nursing process to individuals showing suicidal behavior.
• Recognize types of anxiety, obsessive-compulsive, and related disorders, including their symptoms.
• Learn appropriate nursing interventions for anxiety, obsessive-compulsive, and related disorders.

Introduction to Depression

• Depression is a frequently diagnosed psychiatric illness.
• Transient depressive symptoms can be a normal response to life's disappointments.
• Pathological depression involves impaired adaptation and functioning.
• Depression is characterized by feelings of 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 should be present for at least 2 weeks.
  • No history of manic behavior is present.
  • Origin cannot be attributed to substance use or another medical condition.
• Persistent Depressive Disorder (Dysthymia):
  • Involves a sad or "down in the dumps" mood.
  • No psychotic symptoms are present.
  • Key feature is a chronically depressed mood lasting most of the day, more days than not, for at least 2 years.
• Premenstrual Dysphoric Disorder:
  • Involves depressed mood, anxiety, and mood swings.
  • Experience decreased interest in activities.
  • Symptoms start the week before menses, improve within days after menses onset, and are minimal or absent postmenses.
• Substance- or medication-induced depressive disorder is considered a direct result of physiological effects of a substance.
• Depressive disorder associated with another medical condition is attributed to direct physiological effects of the medical condition.

Predisposing Factors to Depression

• Biological Theories:
  • Genetics: Hereditary factors may play a role.
  • Biochemical Influences: Deficiencies in norepinephrine, serotonin, and dopamine could be implicated.

Developmental implications of Depression

• Childhood Depression:
  • Under Age 3: Feeding problems, tantrums, lack of playfulness and emotional expressiveness can occur.<
  • Ages 3 to 5: Accident proneness, phobias, and self-reproach manifest.
  • Ages 6 to 8: Physical complaints, aggressive/clinging behaviors appear during this time.
  • Ages 9 to 12: Morbid thoughts and excessive worrying can occur.
• Adolescence:
  • Symptoms include anger, aggressiveness, running away, delinquency and/or social withdrawal.
  • Also includes sexual acting out, substance abuse, and/or restlessness and apathy.
• Senescence:
  • Can involve bereavement overload and there is a higher percentage of suicides among elderly.
  • Can exhibit symptoms of depression being confused with neurocognitive disorder symptoms.
  • Possible Treatments: antidepressant medication, electroconvulsive therapy, and/or psychotherapies.
• Postpartum Depression:
  • Can last for a few weeks to several months.
  • Associated with hormonal changes, tryptophan metabolism, or cell alterations.
  • Treatments: antidepressants and psychosocial therapies.

Treatment Modalities for Depression

• Psychotherapy:
  • Individual psychotherapy
  • Group therapy
  • Family therapy
  • Cognitive therapy
• Electroconvulsive Therapy (ECT):
  • Mechanism is thought to increase biogenic amine levels.
  • Side effects: Can cause temporary memory loss and confusion.
  • Mortality, permanent memory loss, and brain damage are risks.
  • Involves pretreatment medication, muscle relaxants, and short-acting anesthetics.
• Psychopharmacology:
  • Tricyclics
  • Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Monoamine Oxidase Inhibitors (MAOIs)
  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Antidepressants

• Norepinephrine and serotonin impact mood regulation.
• The goal is to increase synaptic levels of norepinephrine and serotonin, and/or both with medication.
• Black box warning exists for increased suicidality, especially in teens and young adults, during therapy’s initial weeks.
• Tricyclic Antidepressants (TCAs):
  • Are no longer first-line treatment due to side effects and overdose lethality.
  • Block norepinephrine reuptake.
  • Anticholinergic side effects, sedation, and drowsiness may occur.
  • Examples: Nortriptyline (Pamelor) and Imipramine (Tofranil).
• Monoamine Oxidase Inhibitors (MAOIs):
  • MAO enzyme destroys monoamines (dopamine, norepinephrine, serotonin, histamine).
  • MAOIs prevent MAO from destroying monoamines.
  • These increase synaptic neurotransmitter levels, resulting in antidepressant effects.
  • Liver uses MAO to break down tyramine and tyramine must be restricted in the diet while taking MAOIs, due to risk of hypertensive crisis.
  • isocarboxazid (Marplan), Phenelzine (Nardil), Selegiline (EMSAM), and Tranylcypromine (Parnate), are all examples.. Selective Serotonin Reuptake Inhibitors (SSRIs):
  • Block serotonin reuptake, making it more available.
  • May cause nausea, decreased libido, 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.
  • High doses may lead to hypertension due to stimulating the sympathetic nervous system.
  • May help with neuropathic pain.
  • Examples: Venlafaxine (Effexor), Duloxetine (Cymbalta), and Desvenlafaxine (Pristiq).
• Other Antidepressant Agents include:
  • Mirtazapine (Remeron)- is a norepinephrine and serotonin specific antidepressant (NaSSA).
  • Buproprion (Wellbutrin)- is a norepinephrine dopamine reuptake inhibitor (NDRI), also used for smoking cessation.
  • Brexpiprazole (Rexulti) & Trazodone (Desyrel)- are serotonin antagonist and reuptake inhibitors (SARI).
  • Vortioxetine (Trintellix) -is a serotonin modulator and stimulator.
  • Vilazodone (Viibryd) is a serotonin partial agonist and reuptake inhibitor (SPARI).

Serotonin Syndrome

• Results from excess serotonin.
• Symptoms:
  • Neuromuscular excitation
  • Altered mental status
  • Autonomic dysfunction (diaphoresis, hypertension, hyperthermia).

Client/Family Education Related to Antidepressants

• Continue medication for 4 weeks.
• Do not discontinue medication abruptly.
• Report symptoms like sore throat, fever, yellow skin, bleeding, bruising, persistent gastrointestinal upset, severe headaches, and any chest pain to physician.
• Avoid foods/medications with high tyramine content if taking MAOIs, which includes aged cheese, wine, beer and/or chocolate and colas.
• Consume coffee/tea and sour cream/yogurt in moderation.

Pharmacogenomics

• Between 30 and 50% of patients do not respond to first antidepressant prescription.
• There is need for studies that identify benefits of routine testing, cost effectiveness, and ability to provide timely results.

Question 2: Tricyclic Antidepressants

• Question:
  • When teaching about tricyclic antidepressant medications, what information should the nurse include?
• Correct Answer: The full therapeutic potential of tricyclics may not be reached for 4 weeks.
  • Clients should be advised that tricyclic medications may take several weeks to reach their full therapeutic effect.

Question 3: Paroxetine (Paxil)

• Question:
  • A client is diagnosed with major depression and prescribed paroxetine (Paxil). What medication information should the nurse include in discharge teaching?
• Correct Answer: The medication should not be discontinued abruptly.
  • Can result in dizziness, lethargy, headache, and nausea if abruptly terminated.

Introduction to Suicide

• Suicide is a behavior, and not a diagnosis or disorder.
• The majority of suicides are committed by individuals with a diagnosed mental disorder.
• Suicide is the second-leading cause of death among Americans aged 10-34.
• For Individuals ages 35-54 it is the fourth-leading cause, and for ages 55-64 it is the eighth leading cause.
• Suicide is the tenth-leading cause of death overall.

Risk Factors for Suicide

• Marital Status: The suicide rate for single persons is twice that of married persons.
• Gender: Women attempt suicide more often, but men are more successful.
• Method: Men often choose more lethal methods than women.
• Age: Suicide risk increases with age, particularly among men.
• White men over 80 are at highest risk of all age/gender/race groups.
• Religion: Affiliation with religious group reduces suicide risk.
• Catholics have lower rates than Protestants or Jewish people.
• Socioeconomic Status: Highest and lowest social classes have higher suicide rates than the middle class.
• Ethnicity: Whites have the highest risk, followed by Native, African, Hispanic, and Asian Americans.
• Psychiatric illness: Mood and substance use disorders are the most common, also schizophrenia, personality and anxiety disorders.
• Severe insomnia is associated with added suicide risk.
• Use of alcohol and barbiturates.
• Other factors that Increase risk are: Psychosis with command hallucinations, chronic painful or disabling illness family history, LGBTQ+ status.
• A history of prior attempts, loss of loved one, and/or bullying are all major risk factors.
• Factors to consider when assessing suicide risk include demographics, age, gender, ethnicity/race and/or Marital status.
• Socioeconomic status, occupation, lethality and access to method, religion and/or family and military history are also important to consider.
• Also assess seriousness of intent, plans, means and/or presence of verbal and behavioral clues, as well as interpersonal support system.
• When you're analysing suicidal crisis, it's important to look into precipitating stressor, relevant history and/or life-stage issues.

Information for Family and Friends of Suicidal Clients

• There are many important tips, including that you need to take any hint of suicide seriously.
• Important for families to not keep suicide a secret, be a good listener, express feelings or personal worth to the client and/or be aware of suicide intervention resources can help. Keep access to firearms and other means of self-harm extremely limited.
• Key actions for family and friends of suicidal individuals include:
• Acknowledge and accept the person’s feelings.
• Provide a feeling of hopefulness, not leave them alone, show love, encourage, and/or seek professional help.
• Ensure you remove children from the home and don't judge or show anger toward the person/provoke guilt, as these can make the situation worse.

Anxiety Disorders

• Anxiety is an emotional response to anticipating danger, from a source largely unknown/unrecognized and it is necessary for survival and is not stress.
• Characterized as the most common of all psychiatric illnesses
• Typically more common in women than in men
• Evidence supports the existence of a familial predisposition
• "Too much" Anxiety is when it's out of proportion and interfering important areas of functioning.

Generalized Anxiety Disorder (GAD)

• GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.

Panic Disorder

• Involves recurrent panic attacks.
• Onset is unpredictable and involves intense apprehension, fear, or terror associated with feelings of intense physical discomfort
• Agoraphobia may or may not be an accompanying factor.
• Symptoms of a panic attack:
  • Sweating
  • Trembling
  • Shaking, shortness of breath, chest pain, or discomfort, nausea, abdominal distress
  • Light-headedness, chills, hot flashes, numbness or tingling, depersonalization
• Dread, fear of losing control/dying

Anxiety Interventions

• Provide a calm, quiet environment.
• Encourage them to identify, describe, and discuss feelings with one another.
• Identify the source of feelings.
• Listen and assess hopelessness and helplessness.
• Directly assess their intent and plan for suicide.
• Involve them in activities as tolerated.
• Problem-solving:
  • Help them to discuss current and past coping strategies.
  • Support discussion related to meaning/priorities of conflict.
  • Encourage them to use supportive confrontation/teaching.
  • Assist with strategies to explore alternative solutions or behaviors.
  • Teach and/or encourage testing new coping strategies and/or relaxation exercises.
  • Promote meaningful hobbies and recreation according to patient's preferences and abilities.

Panic Attack Interventions

• One should stay with patient and acknowledge patient discomfort.
• Maintain a calm style and demeanor with short and simple sentences/directions.
• treat hyper-ventilation and have patient focus on breathing with the patient.
• Allow to cry and pace (these are anxiety-reducing behaviors).
• The responder also needs to communicate control over the situation while communicating their own safety of the patient.
• Facilitate move to a quieter and less stimulating environment and encourage discussion their concerns or fears.

Obsessive-Compulsive Disorder (OCD)

• OCD presents with Recurrent obsessions or compulsions. These issues are severe enough to be time-consuming, severe enough to be time-consuming, or to cause marked anxiety or significant compromise.
• Characteristics of Obsessions:
  • Recurring intrusive and unwanted thoughts, urges, or images the person cannot get rid of using logic or reasoning
• Characteristics of Compulsions:
  • Recurrent actions or thoughts whose intention is to prevent or lessen anxiety or to prevent dreaded the circumstances.

Question #3 (Panic Attack)

• Question:
• When you're caring for a client experiencing a panic attack, which nursing actions should be implemented?
• Correct Answer: D Communicate with simple words and brief messages.
• When talking to a patient struggling with panic attack, it is important to use concise and simple words. If you're getting loud, you are increasing anxiety.

Anxiety Treatment Modalities: Psychopharmacology

• Examples of anti-anxiety agents
  • Hydroxyzine (Vistaril)
  • Alprazolam (Xanax)
  • Clonazepam (Klonopin)
  • Diazepam (Valium)
  • Lorazepam (Ativan)

Benzodiazepines

• Benzodiazepines act by increasing GABA activity by tying specific receptors, in turn increasing membrane hyperpolarization.
• Reduce cellular excitation producing a calming effect (same mechanism as alcohol), used at low doses to treat anxiety
  • Alprazolam (Xanax)
  • Lorazepam (Ativan)
  • Diazepam (Valium)
  • Clonazepam (Klonopin)