Depressive and Anxiety Disorders

• Depressive and Anxiety Disorders are covered

Objectives

• Identify depression symptomatology for patient assessment use
• Describe appropriate nursing interventions for depression associated behaviors
• Differentiate suicide facts from myths
• Apply the nursing process to individuals who exhibit suicidal behavior
• Describe various types of anxiety, obsessive-compulsive, and related disorders, identifying their symptomatology.
• Describe appropriate behavioral nursing interventions for anxiety, obsessive-compulsive, and related disorders.

Introduction

• Depression is the oldest and one of the most frequently diagnosed psychiatric illnesses
• Transient symptoms are normal, healthy responses to everyday disappointments in life
• Pathological depression occurs when adaption is ineffective and functioning is impaired.
• Depression is an alteration in mood that is expressed 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 have to be present for at least 2 weeks
• Must have no history of manic behavior
• Can not be attributed to substance use or another medical condition
• Persistent Depressive Disorder (dysthymia) : Sad or down in the dumps with no evidence of psychotic symptoms
• Essential feature is a chronically depressed mood for most of the day, more days than not for at least 2 years
• Premenstrual Dysphoric Disorder: Depressed mood, anxiety, mood swings, and decreased interest in activities.
• Symptoms begin during 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.
• Substance- or medication-induced depressive disorder: Considered to be the direct result of physiological effects of a substance
• Depressive disorder associated with another medical condition: Attributable to the direct physiological effects of a general medical condition

Predisposing Factors to Depression

• Biological theories Genetics: A hereditary factor may be involved
• Biochemical influences: Deficiency of norepinephrine, serotonin, and dopamine has been implicated.

Development Implications

• Childhood depression
• Symptoms among young children include feeding problems, tantrums, lack of playfulness and emotional expressiveness
• Symptoms for ages 3 to 5 include accident proneness, phobias, excessive self-reproach
• Physical complaints, aggressive behavior, clinging behavior for ages 6-8
• Morbid thoughts and excessive worrying happens between ages 9-12
• Adolescence Symptoms include anger, aggressiveness, running away, delinquency, social withdrawal, sexual acting out, substance abuse, restlessness, apathy
• Senescence: Bereavement overload, Suicide rates are high among elderly
• Symptoms of depression confused with symptoms of neurocognitive disorder
• Treatment: Antidepressant medication, Electroconvulsive therapy, Psychotherapies
• Postpartum depression: May last for a few weeks to several months and is Associated with hormonal changes, tryptophan metabolism, or ceil alterations.
• Treatments: Antidepressants and psychosocial therapies

Treatment Modalities

• Individual psychotherapy
• Group therapy
• Family therapy
• Cognitive therapy
• Electroconvulsive therapy
• Thought to increase levels of biogenic amines
• Side effects: Temporary memory loss and confusion
• Risks: Mortality; permanent memory loss; brain damage
• Medications: Pretreatment medication; muscle relaxant; short acting aesthetic
• Psychopharmacology
• Tricyclics
• Selective serotonin reuptake inhibitors
• Monoamine oxidase inhibitors (M A O I's)
• Serotonin norepinephrine reuptake inhibitors

Antidepressants

• Norepinephrine and serotonin play roles in regulating mood.
• Pharmacological goal to increase synaptic level of one or both
• Black box warning due to increased suicidality during initial weeks of therapy for teens and young adults.
• Tricyclic Antidepressants (TCAs): No longer first-line treatment because of side effects and lethality in overdose
• Block reuptake of norepinephrine, may cause Anticholinergic side effects, 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, increases the synaptic level of neurotransmitters resulting in the antidepressant effects
• Liver uses MAO to break down tyramine, found in aged/pickled meats and cheeses, and wine.
• You must restrict tyramine from diet if taking MAOI due to risk of hypertensive crisis, Isocarboxazid (Marplan), Phenelzine (Nardil), Selegiline (EMSAM, Tranylcypromine (Parnate)
• Selective Serotonin Reuptake Inhibitors (SSRIs): Block the reuptake of serotonin, therefore making it more available.
• May cause decreased libido, nausea, or vomiting
• Examples: Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), Fluvoxamine (Luvox), Escitalopram (Lexapro), Citalopram (Celexa)
• Serotonin Norepinephrine Reuptake Inhibitors (SNRIs): increase both serotonin and norepinephrine
• At high doses may to hypertension due to stimulation of sympathetic nervous system by norepinephrine
• Can help with neuropathic pain, Venlafaxine (Effexor), Duloxetine (Cymbalta), 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 to take 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 with high tyramine when taking MAOIs , aged cheese, wine, beer, chocolate, colas, coffee, tea, sour cream, Yogurt, smoked/processed meats, beef or chicken liver, and canned figs
• Between 30 and 50% of patients do not respond to first antidepressant prescription and A study is needed to identify benefits of routine testing, cost effectiveness, and ability to provide timely results.

Introduction Chapter 11 on Suicide.

• Suicide is not a diagnosis or disorder, it is a behavior
• Over 90% of suicides are by individuals with a diagnosed mental disorder, that is a contributing factor for their suicide

Epidemiological Factors

• Suicide is the second-leading cause of death among Americans ages 10-34
• The fourth-leading cause of death for ages 35 to 54
• Eighth-leading cause of death for ages 55-64
• Suicide is the tenth-leading cause of death overall.

Risk Factors of Suicide

• The suicide rate for single people is twice that of married persons.
• Women attempt suicide more often, but more men succeed.
• Men commonly choose more lethal methods than do women.
• The risk of suicide increases with age, particularly among men
• White men older than 80 years are at the greatest risk
• Affiliation with religion decreases the risk of suicide, Catholics have lower rates than do protestants and Jewish people
• Individuals in the very highest and lowest social classes have higher suicide rates compared to the middle class
• Whites are at the highest for suicide, followed by Native Americans, African Americans, Hispanic Americans, and Asian Americans.
• Psychiatric illness: Mood and substance use disorders are the most common psychiatric illnesses that precede suicide, Schizophrenia, Personality disorders, and Anxiety disorders.
• Other Risk Factors: Severe insomnia, alcohol or barbiturates, Psychosis with command hallucinations, chronic/ painful/ disabling illness, family history, LGBTQ+ individuals, having attempted previously, loss of loved one, and bullying

Nursing Process: Assessment

• Demographics: age and gender
• Ethnicity/race and marital Status
• Socioeconomic status / occupation
• Lethality and Availability of Method
• Religion, Family history of suicide, and Military history
• Seriousness of intent, plan, and means
• Interpersonal support system
• Analysis of the suicidal crisis by looking for precipitating stressor, relevant history, life-stage issues, family history
• Evaluate psychiatric / medical / family history, coping strategies and presenting symptoms

Information for Family and Friends of the Suicidal Client

• Take any hint of suicide seriously
• Don’t 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 self-harm

More Information for Family and Friends of the Suicidal Client

• Acknowledge and accept the persons 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 in him or her.

Anxiety Disorders- Introduction

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

Epidemiological Statistics

• Anxiety disorders are the most common of all psychiatric illnesses
• More common in women than in men, a familial predisposition probably exists.
• Anxiety is too much when it is out of proportion to the situation creating it or when anxiety interferes with social, occupational, or other important areas of functioning.

Application of Nursing Process

• Generalized anxiety disorder (GAD): is characterized by chronic, unrealistic, and excessive anxiety and worry
• Panic Disorder: Recurring panic attacks characterized by the unpredictable onset of intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort.
• May or may not be accompanied by agoraphobia
• Symptoms of panic attack include sweating, trembling, shaking, shortness of breath, chest pain, or discomfort
• Other Symptoms of panic attack: 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
• Problem Solving includes discussing present and previous coping strategies
• Discuss meaning and priorities of problems and conflicts
• Use supportive confrontation and teaching
• Encourage testing of new coping strategies
• Teach relaxation exercises
• Promote hobbies and recreation according to patient’s preferences and abilities.
• Anxiety / Panic Attack Interventions includes a calm/environment, encouraging description of feelings, identify sources of feelings and assess plans and intents

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 (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 less stimulating environment.
• Encourage discussion of perceptions and fears.
• Obsessive-Compulsive Disorder (OCD)
• Assessment data: Recurrent obsessions or compulsions that is time-consuming/ cause impairment
• Obsessions: Recurring thoughts, impulses, or images that are intrusive and stressful, and unable to be expunged by logic or reasoning
• Compulsions: Repetitive ritualistic behavior or thoughts, the purpose of which is to prevent or reduce distress or to prevent some dreaded even or situation

Treatment Modalities: Psychopharmacology

• Agents include Hydroxyzine (Vistaril), Alprazolam (Xanax), Clonazepam (Klonopin), Diazepam( Valium), and Lorazepam (Ativan)
• Benzodiazepines: Promote the activity of GABA by binding to a specific receptor on the GABA receptor complex leading to to Membrane hyperpolarization
• Reduces cellular excitation to produce a calm effect at low doses to treat anxiety
• Alprazolam (Xanax), Lorazepam (Ativan), Diazepam (Valium), Clonazepam (Klonopin) are examples of anti-anxiety medication