Depressive and Anxiety Disorders

Depressive and anxiety disorders

• Depression is one of the most frequently diagnosed psychiatric illnesses
• Transient symptoms are normal, healthy responses to everyday disappointments
• Pathological depression occurs when adaptation 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 is characterized by depressed mood, loss of interest or pleasure in usual activities and symptoms present for at least 2 weeks.
  • It occurs with no history of manic behavior and cannot be attributed to use of substances or another medical condition
• Persistent depressive disorder (dysthymia), is characterized by sadness, no evidence of psychotic symptoms with a chronically depressed mood for most of the day, more days than not.
  • Manifested for at least 2 years
• Premenstrual dysphoric disorder includes depressed mood, anxiety, mood swings, decreased interest in activities with symptoms that begin during the week prior to menses.
  • Symptoms start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses
• Substance/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 attributable to the direct physiological effects of a general medical condition

Predisposing factors of depression

• Biological theories theorize a hereditary factor may be involved
• Biochemical influences theorize deficiency of:
  • Norepinephrine
  • Serotonin
  • Dopamine

Developmental Implications of Depression

• Childhood symptoms prior to age 3 include:
  • Feeding problems -Tantrums
  • A lack of playfulness
  • Emotional expressiveness
• Symptoms between ages 3 to 5 include:
  • Accident proneness
  • Phobias
  • Excessive self-reproach
• Symptoms between ages 6 to 8 include:
  • Physical complaints
  • Aggressive behavior
  • Clinging behavior
• Symptoms between ages 9 to 12 include:
  • Morbid thoughts
  • Excessive worrying
• Adolescence:
  • Includes anger, aggressiveness, running away, delinquency, social withdrawal, sexual acting out, substance abuse, restlessness, apathy
• Senescence factors:
  • Bereavement overload
  • High percentage of suicides among elderly
  • Symptoms of depression often confused with symptoms of neurocognitive disorder
  • Requires antidepressant medication, electroconvulsive therapy and psychotherapies treatments
• Postpartum depression may last for a few weeks to several months
  • Associated with hormonal changes, tryptophan metabolism, or cell alterations
  • Treatments include antidepressants and psychosocial therapies

Treatment Modalities for Depression

• Individual psychotherapy
• Group therapy
• Family therapy
• Cognitive therapy
• Electroconvulsive therapy
  • Increases levels of biogenic amines
  • Temporary memory loss and confusion
  • Risks: Mortality, permanent memory loss, brain damage
    • Requires pretreatment medication, muscle relaxant, and short-acting anesthetic
• 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
• Pharmacological goal is to increase the synaptic level by one or both
• Black box warning due to increased suicidality, especially in teens and young adults during initial weeks of therapy
• Tricyclic antidepressants (TCAs) are no longer first-line treatment due to side effects and lethality in overdose
  • Block reuptake of norepinephrine and cause anticholinergic side effects, sedation, drowsiness
    • Nortriptyline (Pamelor)
    • Imipramine (Tofranil)
• Monoamine oxidase inhibitors (MAOIs)
  • MAO is the enzyme that destroys monoamines (dopamine, norepinephrine, serotonin, histamine) and MAOIs inhibit the action of MAO to prevent this destruction
  • This increases the synaptic level of neurotransmitters resulting in the antidepressant effects
  • The liver uses MAO to break down tyramine, found in aged/pickled meats and cheeses, and wine and one 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
  • May cause decreased libido, nausea, or vomiting
    • Fluoxetine (Prozac)
    • Sertraline (Zoloft)
    • Paroxetine (Paxil)
    • Fluvoxamine (Luvox)
    • Escitalopram (Lexapro)
    • Citalopram (Celexa)
• Serotonin norepinephrine reuptake inhibitors (SNRIs):
  • Increase both serotonin and norepinephrine which at high doses may lead to hypertension due to stimulation of sympathetic nervous system by norepinephrine and may also help with neuropathic pain
    • Venlafaxine (Effexor)
    • Duloxetine (Cymbalta)
    • Desvenlafaxine (Pristiq)
• 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)
• Patient teaching for antidepressants:
  • Take medication for full 4 weeks
  • Do not discontinue 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 like aged cheese, wine, beer, chocolate, colas, coffee, tea, sour cream, yogurt, smoked and processed meats, beef or chicken liver, canned figs
• Between 30 and 50% of patients do not respond to the first antidepressant prescription
  • Studies are needed to identify the benefits of routine testing, cost effectiveness, and ability to provide timely results

Suicide

• It 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
• Suicide is:
  • Americans 10 to 34 years of age it is the second-leading cause of death
  • Americans 35 to 54 years of age, the fourth-leading cause of death
  • Americans 55 to 64 years of age, the eighth-leading cause of death
  • Overall, the tenth-leading cause of death
• Risk Factors:
  • Suicide rate for single persons is twice that of married persons
  • Women attempt Suicide more often, but more men succeed, generally using more lethal methods
  • Risk of suicide increases with age, especially among men; white men older than 80 years are at the greatest risk of all age, gender, and race groups
  • Affiliation with a religious group decreases risk of suicide
    • Catholics have lower rates than do Protestants or Jewish people
  • 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, followed by Native Americans, African Americans, Hispanic Americans, and Asian Americans
  • Mood and substance use disorders are the most common psychiatric illnesses that precede suicide
  • Schizophrenia, personality disorders, anxiety disorders, severe insomnia, use of alcohol and barbiturates, psychosis with command hallucinations, affliction with a chronic, painful, or disabling illness, family history and being a LGBTQ+ individual
  • Previous suicide attempts increase the risk of a subsequent attempt
  • Loss of a loved one through death or separation, and bullying
• Nursing Process: Assessment:
  • Demographics include looking into age, gender, race, marital status, socioeconomic status/occupation, lethality/Availibility of method, religion, family history of suicide, and/or military history

Suicide intention

• Presenting symptoms/medical-pschiatric diagnosis
• Suicidal ideas and/or acts
• Interpersonal support system
• Seriousness of intent
• Plan
• Means
• Verbal and behavioural clues
• Analysis of the suicidal crisis includes precipitating stressors, relevant history, and life-stage issues
• Additional factors to assess: past medical history, coping strategies, and presenting symptoms

Information for Family and Friends of Suicidal Clients

• Take any hint of suicide seriously and do not keep secrets
• Be a good listener and express feelings of personal worth to the client, and be aware of suicide intervention resources
• Restrict access to firearms or other means of self-harm, acknowledge and accept the person's feelings, and provide a feeling of hopefulness
• Do not leave them him or her alone, show love and encouragement, seek professional help, remove children from the home with no judgement or provocation of guilt

Anxiety Disorders: Introduction

• It is an emotional response to anticipation of danger, the source of which is largely unknown or unrecognized.
• Anxiety is a necessary force for survival, which is not the same as stress.
• Anxiety disorders are the most common of all psychiatric illnesses, more common in women than in men and can be caused by a familial predisposition

Too much anxiety

• When anxiety is out of proportion to the situation that is creating it and 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
• Involves Environmental, Physical condition related with psychological biochemical and social factors

Panic disorder: Assessment

• Panic attacks, the onset of which are unpredictable
• Includes intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort
• Can potentially be accompanied by agoraphobia
• Symptoms of panic attack are:
  • 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
• Interventions for anxiety include:
  • Calm, quiet approach/environment
  • Encourage to identify, describe, and discuss feelings
  • Help identify source of feelings
  • Listen and assess hopelessness and
  • Helpfulness
  • Assess suicidal risk plan and intent directly and involve in activities as tolerated

Problem Solving for Anxiety

• Discuss present and previous coping strategies and discuss meaning and priorities of problems and conflicts
• Use supportive confrontation and teaching, assist with strategies to explore alternative solutions and behaviors, and encourage testing of new coping strategies
• Teach relaxation exercises and promote hobbies and recreation according to patient's preferences and abilities

Panic Attack: Interventions

• Stay with patient and acknowledge discomfort, maintaining a calm demeanour while using short and simple sentences
• Give one direction at a time
• Provide a brown paper bag for hyperventilation to focus on breathing
• Allowing to cry and/or pace helps release/reduce anxiety
• Remind them they're safe
• Communicate/reassure that you are in control, and will not let anything happen to patient
• Move or direct patient to a quieter & less stimulating environment which encourages healthy discussion of perceptions and fears

Obsessive-Compulsive Disorder (OCD)

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

Anxiety treatment

• 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.
• Leads to membrane hyperpolarization.
• Reduces cellular excitation, producing a calming effect found in Alprazolam (Xanax), Lorazepam (Ativan), Diazepam (Valium), Clonazepam (Klonopin)