Depressive Disorder, Ch 16
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Questions and Answers

Which nursing diagnosis most accurately describes an individual who has not been able to work since the death of a parent, cannot look at any of the parent's belongings, and cries daily for hours at a time?

  • Post-trauma syndrome related to parent’s death
  • Anxiety (severe) related to parent’s death
  • Coping, ineffective related to parent’s death
  • Grieving, complicated related to parent’s death (correct)

    • What assessment questions would we ask the child?

    Self-harm, suicide; have you been diagnosed with depression, have you had treatment for depression?

    When teaching about the tricyclic group of antidepressant medications, which information should the nurse include?

  • The full therapeutic potential of tricyclics may not be reached for 4 weeks. (correct)
  • Long-term use may result in physical dependence.
  • Tricyclics should not be given with antianxiety agents.
  • Strong or aged cheese should not be eaten while taking this group of medications.

    • Which of the following medication information should the nurse include in discharge teaching for a client diagnosed with major depression prescribed Paroxetine (Paxil)?

    <p>The medication should not be discontinued abruptly.</p> Signup and view all the answers

    What is mood?

    <p>A pervasive and sustained emotion.</p> Signup and view all the answers

    What is affect?

    <p>The external, observable emotional reaction.</p> Signup and view all the answers

    What characterizes Major Depressive Disorder?

    <p>Symptoms present for at least 2 weeks and affect the patient's ability to function.</p> Signup and view all the answers

    Which of the following is a symptom of Major Depressive Disorder? (Select all that apply)

    <p>Psychomotor agitation</p> Signup and view all the answers

    Pathological depression occurs when adaptation is ineffective.

    <p>True</p> Signup and view all the answers

    What must individuals experience to be diagnosed with Persistent Depressive Disorder?

    <p>A chronically depressed mood for more days than not for at least 2 years for adults.</p> Signup and view all the answers

    When do symptoms of Premenstrual Dysphoric Disorder typically begin?

    <p>During the week prior to menses.</p> Signup and view all the answers

    Which of the following can lead to Substance or Medication-Induced Depressive Disorder? (Select all that apply)

    <p>Alcohol intoxication</p> Signup and view all the answers

    Gender prevalence shows that females are diagnosed with depressive disorders more often than males.

    <p>True</p> Signup and view all the answers

    The essential feature of Persistent Depressive Disorder is a chronically _____ mood.

    <p>depressed</p> Signup and view all the answers

    What is a key symptom of postpartum depression?

    <p>Fatigue/Irritability</p> Signup and view all the answers

    What are some common treatments for depression?

    <p>Antidepressants, psychotherapy, and lifestyle changes.</p> Signup and view all the answers

    Which of the following are common symptoms of mild depression? (Select all that apply)

    <p>Tearfulness</p> Signup and view all the answers

    What is a common side effect of SSRIs? (Select all that apply)

    <p>Suicidal ideation</p> Signup and view all the answers

    What is a common sign of serotonin syndrome?

    <p>Muscle spasms</p> Signup and view all the answers

    What intervention can help manage anticholinergic side effects of tricyclic antidepressants?

    <p>Offer sugar-free hard candy</p> Signup and view all the answers

    Which dietary restriction is essential for a patient taking MAOIs?

    <p>Avoiding tyramine-rich foods</p> Signup and view all the answers

    Which symptom is NOT associated with withdrawal from antidepressants?

    <p>Numbness in extremities</p> Signup and view all the answers

    What is the primary treatment approach for serotonin syndrome?

    <p>Discontinue the offending medication</p> Signup and view all the answers

    Which outcome indicates effective management of orthostatic hypotension?

    <p>The patient gradually dangles legs before standing</p> Signup and view all the answers

    What is a potential complication of mixing St. John's wort with SSRIs?

    <p>Serotonin syndrome</p> Signup and view all the answers

    What is a key indicator of a hypertensive crisis?

    <p>Elevated blood pressure</p> Signup and view all the answers

    What is a common physiological symptom associated with severe depression?

    <p>General slow-down of the entire body</p> Signup and view all the answers

    Which symptom is NOT typically associated with mild depression?

    <p>Flat affect</p> Signup and view all the answers

    What intervention is recommended for clients at risk for suicide?

    <p>Maintaining close observation</p> Signup and view all the answers

    What characteristic best describes the affective symptoms of moderate depression?

    <p>Feelings of helplessness and powerlessness</p> Signup and view all the answers

    Which therapeutic approach is effective in managing social isolation?

    <p>Support groups and group activities</p> Signup and view all the answers

    What should be prioritized when planning care for a client with complicated grieving?

    <p>Developing a trusting relationship with the client</p> Signup and view all the answers

    Which symptom is commonly seen in transient depression?

    <p>Some crying and sadness</p> Signup and view all the answers

    What psychological effect is indicated by a client who exhibits regression and tearfulness after a loss?

    <p>Mild depression</p> Signup and view all the answers

    What is the primary reason for the black-box warning on antidepressants for younger populations?

    <p>Increased risk of suicidality</p> Signup and view all the answers

    Which nursing intervention is appropriate for enhancing a client's self-esteem?

    <p>Encouraging independence in activities of daily living</p> Signup and view all the answers

    What is a common side effect of SNRIs?

    <p>Increased anxiety</p> Signup and view all the answers

    Which of the following medications is classified as an atypical antidepressant?

    <p>Bupropion</p> Signup and view all the answers

    What is the primary action of SSRIs?

    <p>Inhibit serotonin reuptake</p> Signup and view all the answers

    What should clients be advised regarding the discontinuation of MAOIs?

    <p>A washout period is necessary to avoid hypertensive crisis.</p> Signup and view all the answers

    Which treatment method is typically used for treatment-resistant depression?

    <p>Electroconvulsive therapy (ECT)</p> Signup and view all the answers

    What major risk is associated with all antidepressants according to the black-box warning?

    <p>Increased risk of suicidality</p> Signup and view all the answers

    Which medication must be avoided when a patient is taking an SSRI?

    <p>Monoamine oxidase inhibitors (MAOIs)</p> Signup and view all the answers

    What is a recommended intervention for managing dry mouth caused by tricyclic antidepressants?

    <p>Suck on sugar-free candies</p> Signup and view all the answers

    Which of the following treatments involves invasive procedures and is generally considered a last resort?

    <p>Vagal nerve stimulation</p> Signup and view all the answers

    What is a key dietary restriction for patients taking MAOIs?

    <p>Avoiding tyramine-rich foods</p> Signup and view all the answers

    What is a characteristic of Major Depressive Disorder?

    <p>Symptoms must be present for at least 2 weeks.</p> Signup and view all the answers

    Which of the following symptoms is NOT associated with Persistent Depressive Disorder?

    <p>Extreme psychomotor agitation</p> Signup and view all the answers

    What is the essential feature of Premenstrual Dysphoric Disorder?

    <p>Symptoms begin in the week prior to menses.</p> Signup and view all the answers

    Which demographic factor is associated with a higher prevalence of depressive disorders?

    <p>Marital status</p> Signup and view all the answers

    Which condition is likely to lead to Substance or Medication-Induced Depressive Disorder?

    <p>Intoxication from opioids</p> Signup and view all the answers

    Which of the following best describes the difference between mood and affect?

    <p>Mood is fixed, while affect is changeable.</p> Signup and view all the answers

    What symptom is characteristic of the cognitive theory of depression?

    <p>Faulty thinking patterns</p> Signup and view all the answers

    Which of these is a major risk factor for developing Postpartum Depression?

    <p>Hx of depression</p> Signup and view all the answers

    Which statement about childhood depression is true?

    <p>Children under age 3 may show physical complaints.</p> Signup and view all the answers

    Which of the following describes a predisposing factor to depression from a biological perspective?

    <p>Genetic predisposition and neurotransmitter deficiency</p> Signup and view all the answers

    What can premature and prolonged grief in older adults be classified as?

    <p>Bereavement overload</p> Signup and view all the answers

    Which of these types of depressive disorders is the least severe?

    <p>Persistent Depressive Disorder</p> Signup and view all the answers

    Which of the following treatments is commonly administered to manage postpartum depression?

    <p>SSRIs and psychosocial therapies</p> Signup and view all the answers

    What is a common side effect associated with SSRIs?

    <p>Suicidal ideation</p> Signup and view all the answers

    Which of the following interventions can help manage dry mouth caused by tricyclic antidepressants?

    <p>Sucking on sugar-free candy</p> Signup and view all the answers

    What is a key characteristic of Monoamine Oxidase Inhibitors (MAOIs)?

    <p>They are rarely prescribed due to their side effects.</p> Signup and view all the answers

    Which medication is typically used for treatment-resistant depression?

    <p>Electroconvulsive therapy (ECT)</p> Signup and view all the answers

    What should clients be advised regarding the discontinuation of antidepressants?

    <p>They should taper off medication to avoid withdrawal effects.</p> Signup and view all the answers

    Which of the following treatments is specific to postpartum depression?

    <p>Zulresso (Brexanolone)</p> Signup and view all the answers

    Which interaction is important to avoid when taking an SSRI?

    <p>Use of a monoamine oxidase inhibitor (MAOI)</p> Signup and view all the answers

    What is the primary function of SNRIs?

    <p>They inhibit the reuptake of norepinephrine and serotonin.</p> Signup and view all the answers

    What is a significant risk associated with stopping MAOIs abruptly?

    <p>Hypertensive crisis</p> Signup and view all the answers

    What is a key sign of serotonin syndrome?

    <p>High temperature</p> Signup and view all the answers

    Which intervention is most effective in managing anticholinergic side effects of tricyclic antidepressants?

    <p>Frequent sips of water</p> Signup and view all the answers

    What should be avoided to prevent a hypertensive crisis in patients taking MAOIs?

    <p>Tyramine-containing foods</p> Signup and view all the answers

    Which symptom is NOT associated with serotonin syndrome?

    <p>Severe anxiety</p> Signup and view all the answers

    What is the primary treatment approach for managing serotonin syndrome?

    <p>Discontinuation of the offending medication</p> Signup and view all the answers

    What is the recommended action to prevent orthostatic hypotension in patients taking tricyclics?

    <p>Gradually rise from bed and dangle the legs</p> Signup and view all the answers

    Which symptom indicates a potential overdose of tricyclic antidepressants?

    <p>Increased heart rate</p> Signup and view all the answers

    What should patients taking SSRIs be warned about concerning St. John's wort?

    <p>It increases the risk of serotonin syndrome</p> Signup and view all the answers

    Which symptom is NOT associated with severe depression?

    <p>Feeling tired and listless</p> Signup and view all the answers

    What is a common physiological symptom seen in moderate depression?

    <p>Sleep disturbance</p> Signup and view all the answers

    What is an appropriate intervention for a client at risk for suicide?

    <p>Maintain close observation and a safe environment</p> Signup and view all the answers

    Which nursing diagnosis focuses on a client’s inability to carry out daily living activities?

    <p>Low self-esteem/self-care deficit</p> Signup and view all the answers

    What treatment can begin along with therapy for someone experiencing severe depression?

    <p>Medications, which may take time to work</p> Signup and view all the answers

    What is a key characteristic of mild depression?

    <p>Tearfulness and regression</p> Signup and view all the answers

    Which of the following is a common affective symptom of moderate depression?

    <p>Powerlessness</p> Signup and view all the answers

    What is a recommended approach for dealing with complicated grieving in clients?

    <p>Building a trusting relationship</p> Signup and view all the answers

    How are attempts to handle grief in a therapeutic context typically approached?

    <p>Expressing and identifying emotions is encouraged</p> Signup and view all the answers

    Which type of depression includes symptoms like profound worthlessness and confusion?

    <p>Severe depression</p> Signup and view all the answers

    What is the minimum duration of symptoms for Major Depressive Disorder to be diagnosed?

    <p>At least 2 weeks</p> Signup and view all the answers

    Which type of depressive disorder is characterized by a chronically depressed mood lasting for at least 2 years in adults?

    <p>Persistent Depressive Disorder</p> Signup and view all the answers

    What is the essential feature of Premenstrual Dysphoric Disorder (PMDD)?

    <p>Severe symptoms that improve after menstruation begins</p> Signup and view all the answers

    What are common symptoms contributing to Persistent Depressive Disorder?

    <p>Low self-esteem and feelings of hopelessness</p> Signup and view all the answers

    Which mechanism is considered a psychosocial theory related to depression?

    <p>Cognitive distortions</p> Signup and view all the answers

    How does the epidemiology of depression generally affect women compared to men?

    <p>Women tend to be diagnosed more often than men.</p> Signup and view all the answers

    What distinguishes Substance or Medication-Induced Depressive Disorder from other types of depression?

    <p>It is evident solely during intoxication or withdrawal from substances.</p> Signup and view all the answers

    Which of the following symptoms is NOT usually associated with Major Depressive Disorder?

    <p>Increased energy levels</p> Signup and view all the answers

    What is a possible consequence of Persistent Depressive Disorder if it remains untreated?

    <p>Increased risk of developing Major Depressive Disorder</p> Signup and view all the answers

    What kind of adaptation issue leads to the classification of pathological or clinical depression?

    <p>Ineffective adaptation to daily stresses</p> Signup and view all the answers

    What physiological factor is related to depression and may worsen symptoms?

    <p>Hypothyroidism</p> Signup and view all the answers

    What symptom might children under age 3 exhibit when experiencing depression?

    <p>Feeding problems and changes in eating</p> Signup and view all the answers

    What is one treatment commonly used for Postpartum Depression?

    <p>Brexaolone (Zulresso)</p> Signup and view all the answers

    Study Notes

    Mood vs. Affect

    • Mood is a pervasive and sustained emotion
    • Affect is the outward, observable emotional reaction

    Types of Depressive Disorders

    • Major Depressive Disorder (MDD): Most severe type
      • Symptoms present for at least 2 weeks, most of the day
      • Interferes with patient's ability to function
      • Characterized by depressed mood
      • Loss of interest or pleasure (Anhedonia)
      • No history of manic behavior
      • Not attributable to substance use or medical condition

    Persistent Depressive Disorder (Dysthymia)

    • Less severe than MDD
    • Characterized by a chronically depressed mood for most days of the week
      • At least 2 years for adults, 1 year for children and adolescents.
    • Must have two or more of the following: poor appetite, insomnia/hypersomnia, low energy, low self-esteem, concentration issues, and feelings of hopelessness.
    • Can lead to MDD later in life.

    Premenstrual Dysphoric Disorder (PMDD)

    • Symptoms begin during the week prior to menses and improve within a few days after menses start.
    • Symptoms include: depressed mood, anxiety, mood swings, decreased interest in activities.
    • Can interfere with social, work, or school functioning.
    • Treatment includes: exercise, diet, and relaxation therapy.

    Substance/Medication-Induced Depressive Disorder

    • Direct result of physiological effects of a substance (ex: beta-blockers, birth control, anticonvulsants, drugs of abuse, or toxins)
    • Depressed mood associated with intoxication or withdrawal from substances or medications.

    Depressive Disorder Associated with Another Medical Condition

    • Attributable to the direct physiological effects of a general medical condition (ex: strokes, amputations, thyroid dysfunction, MI, traumatic brain injuries, Cushing's, Huntington's, Parkinson's, and MS)
    • Important to check thyroid levels

    Predisposing Factors to Depression

    • Genetics
    • Deficiency of neurotransmitters: serotonin, norepinephrine, and dopamine.
    • Possible failure within the HPA (hypothalamic-pituitary-adrenocortical) axis.
    • Secondary Depression related to:
      • Medication side effects
      • Neurological disorders (ex: CVA/Stroke)
      • Hormonal disturbances (ex: hypothyroidism/hyperthyroidism)
      • Electrolyte disturbances (ex: hypercalcemia, hyponatremia, hyperkalemia)
      • Nutritional deficiencies (ex: low protein, carbs, vitamin B1, B9, B12, zinc, iron, etc.)
      • Other physiological conditions (ex: SLE, congestive HF, MI, DM, infectious disorders)
      • Inflammation

    Predisposing Factors: Psychosocial Theories

    • Psychoanalytic Theory: Loss is internalized and directed against the ego.
    • Learning Theory: Learned helplessness (numerous failures lead to giving up).
    • Object Loss Theory: Abandonment or separation from a significant other during the first 6 months of life.
    • Cognitive Theory: Views primary disturbance as cognitive rather than affective. Cognitive distortions serve as the basis for depression, including:
      • Negative expectations about the environment, self, and future.

    Developmental Implications

    • Childhood Depression:

      • < Age 3: Feeding problems, tantrums, lack of playfulness
      • Ages 3-5: Accident proneness, phobias, excessive self-reproach
      • Ages 6-8: Many physical complaints, aggressive behavior, clinging behavior
      • Ages 9-12: Morbid thoughts, excessive worrying

    • Adolescent Depression:

      • Anger, irritability, aggressiveness, acting out, running away, delinquency, social withdrawal, sexual acting out, substance abuse restlessness, apathy.
      • Differentiate depression from typical adolescent behavior based on timeframe and progression
      • A visible manifestation of behavioral change lasting several weeks is the best clue for a mood disorder.

    • Senescence: Bereavement overload (many losses experienced, unable to resolve one grief before another).

      • High percentage of suicides in elderly.
      • May be mistaken for pseudodementia.
      • Symptoms of depression can be confused with symptoms of neurocognitive disorder. .
      • Treatment: Antidepressants (SSRIs), psychotherapies (group, peer support), ECT.

    • Postpartum Depression (PPD):

      • Can last from a few weeks to several months.
      • Associated with hormonal changes, metabolic and psychosocial influences, and tryptophan metabolism (tryptophan is a precursor to serotonin).
      • Risk factors: history of depression, family history of psychiatric disorder.
      • Symptoms: Fatigue/Irritability, Loss of appetite, Sleep disturbances, Loss of libido, Concern about inability to care for infant
      • Treatment Antidepressants (SSRIs), psychosocial therapies.
      • Brexanolone (Zulresso): Administered IV and is only available through restricted distribution program.
      • Zurzuvae (Zuranolone): Treats PPD and may affect the CNS, so educate about not driving.

    Treatment

    • Inpatient vs. Outpatient Treatment:

      • Inpatient: Harm to self or others
      • Outpatient: Therapy, medication management

    • Supportive Psychosocial Interventions:

    • Parental and Family Therapy

    • Medication: May take 4 weeks to see full effects and side effects.

      • Black Box Warning: All antidepressants have a Black Box warning about increased risk of suicidality in children, adolescents, and young adults.

    Nursing Process/Assessment

    • Differentiate between transient and pathological depression.

    • Transient Depression: Symptoms are not dysfunctional.

      • Mood: Feeling "blue", sadness
      • Behavior: Some crying
      • Cognitive: Difficulty getting mind off of disappointment
      • Physiological: Feeling tired and listless.

    • Mild Depression: Symptoms are identified with normal grieving.

      • Mood: Anger, anxiety
      • Behavior: Tearful, regression
      • Cognitive: Preoccupied with loss, self-blame, ambivalence
      • Physiological: Anorexia, insomnia, headache, backache, chest pain.

    • Moderate Depression: Symptoms associated with dysthymic disorder.

      • Mood: Helpless, powerless
      • Behavior: Slowed, slumped posture, limited verbalization
      • Cognitive: Slowed thinking, difficulty concentrating.
      • Physiological: Anorexia or overeating, sleep disturbances, headaches.

    • Severe Depression: Symptoms of major depressive disorder and bipolar depression.

      • Mood: Feelings of total despair, worthlessness, flat affect
      • Behavior: Psychomotor retardation, curled-up position, absence of communication
      • Cognitive: Prevalent delusional thinking, confusion, suicidal thoughts
      • Physiological: General slow-down of the body.

    Diagnosis + Planning/Implementation

    • Risk for Suicide:

      • Be direct: "Are you having thoughts about harming yourself?"
      • Maintain close observation.
      • Maintain a safe milieu/environment: Minimize dangerous objects.
      • Encourage verbalizations of honest feelings.

    • Complicated Grieving:

      • Develop a trusting relationship with the client.
      • Encourage the client to express and identify emotions.
      • Communicate that crying is acceptable.

    • Low Self-Esteem/Self-Care Deficit:

      • Be accepting of the client.
      • Encourage the client to recognize areas of change.
      • Encourage independence in performing ADLs.

    • Powerlessness:

      • Encourage the client to take responsibility.
      • Help the client set goals.
      • Help the client identify areas they can and cannot control.

    • Social Isolation:

      • Support groups
      • Group activities

    Client/Family Education

    • Nature of the Illness:

      • Education about symptoms of depression.
      • Education on how to respond to emergency situations and available support services.

    • Management of the Illness:

      • Medication management.
      • Help with physical aspects: Adequate nutrition, optimal rest periods, winding down periods, group activities, dark sleep environment, constipation management, self-care deficits (create a schedule).
      • Techniques: Assertiveness, stress-management, coping skills.
      • Ways to increase self-esteem.
      • Therapy: Individual, group, family.
      • Bright light therapy, ECT, Transcranial magnetic stimulation, Vagal nerve and deep brain stimulation.

    Treatment Modalities

    • Psychopharmacology:
      • SSRIs (Selective Serotonin Reuptake Inhibitors): Usually first-line medications. Inhibit the reuptake of serotonin. Examples: Fluoxetine, paroxetine, citalopram, sertraline, escitalopram.
        • Side Effects: Suicidal ideation, insomnia, headache, nausea, anxiety, sexual dysfunction.
        • Less lethal in overdose.
        • Cannot take SSRIs and MAOIs together.
        • Do not stop medication abruptly (increased risk of serotonin syndrome).
      • SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors): Inhibit both norepinephrine and serotonin. Examples: Duloxetine, venlafaxine.
      • Tricyclics (TCAs): Examples: Amitriptyline, amoxapine, desipramine, doxepin, imipramine, maprotiline, nortriptyline, protriptyline.
        • Side Effects: Anticholinergic effects (dry mouth, hesitancy, blurred vision, orthostatic hypotension).
        • Very cardiotoxic
        • More prone to anticholinergic side effects and orthostatic hypotension.
      • Monoamine Oxidase Inhibitors (MAOIs): Examples: Isocarboxazid, phenelzine, tranylcypromine.
        • Inhibits the breakdown of monoamine neurotransmitters.
        • May require a wash-out period due to increased risk of cardiovascular damage (hypertensive crisis).
        • Tyramine foods should be avoided: aged cheese, wines, beers, smoked meats, soy, chocolate.
        • Not as commonly used due to side effects.
        • Not compatible with other antidepressants.
        • Tyramine restriction and wash-out period should continue for 14 days after stopping MAOIs.
      • Atypical Antidepressants: Trazodone, bupropion (Wellbutrin).
      • Atypical Antipsychotics
      • Ketamine: May be administered IV or nasal spray.
      • Brexanolone (Zulresso) and Zuranolone (Zurzuvae): Specific to postpartum depression.
    • Continue to take medication.
    • May take 4 weeks for full therapeutic effect.
    • Do not discontinue medication abruptly.
    • BLACK-BOX WARNING: All antidepressants have a Black Box Warning about increased risk of suicidality in children, adolescents, and young adults.
    • Report these symptoms to your healthcare provider: Sore throat, fever, malaise, yellow skin, bleeding, bruising, persistent vomiting or headaches, rapid heart rate, seizures, stiff neck, and chest pain.
    • Management of Anticholinergic Side Effects (especially with TCAs): Sugar-free hard candy, frequent sips of water, monitor for orthostatic hypotension (gradually get out of bed, sit on the side and dangle the legs).
    • Life-Threatening Syndromes (s/s and prevention):
      • Serotonin Syndrome: Too much serotonin in the patient's system.
        • Symptoms: High temperature, muscle spasms, VS instability, alteration in mental status, shivering, hyperreflexia/clonus, encephalopathy/change in mental status, severe abdominal pain and diarrhea.
        • Prevention: Discontinue medication causing this, provide supportive care.
        • Treatment: Treat the symptoms. May use anticonvulsants, diazepam for muscle spasms, cooling blankets for elevated temperature.
        • Avoid St. John's Wort with SSRIs, as it can increase the risk of serotonin syndrome.
      • Hypertensive Crisis: Caused by MAOIs.
        • Symptoms: Increase in blood pressure.
        • Prevention/Teaching: Avoid tyramine-containing foods, wash-out period may be needed.

    Clicker Question 1

    • Correct Answer: D. Grieving, complicated related to parent's death
      • Explanation: This individual is exhibiting signs of complicated grief, characterized by prolonged and intense grief reactions that interfere with daily functioning.
      • Incorrect Answers:
        • A. Post-trauma syndrome: Doesn't reflect the prolonged nature of grief.
        • B. Anxiety (severe): While anxiety might be present, the core issue is prolonged grief.
        • C. Coping, ineffective: The client is not coping, hence the complicated nature of the grief.

    Clicker Question 2

    • Correct Answer: B. The full therapeutic potential of tricyclics may not be reached for 4 weeks.
      • Explanation: Tricyclic antidepressants take a few weeks to reach therapeutic effect.
      • Incorrect Answers:
        • A. Strong or aged cheese: Tyramine is the concern with MAOIs, not TCAs.
        • C. Long-term use may result in physical dependence: TCAs don't generally lead to significant physical dependence.
        • D. Tricyclics should not be given with antianxiety agents: There's no specific contraindication against giving TCAs with antianxiety agents.

    Clicker Question 3

    • Paroxetine (Paxil) is an SSRI.

    Mood vs Affect

    • Mood: A pervasive and sustained emotion
    • Affect: The observable emotional reaction; how a person externally expresses emotions.
      • Flat affect: minimal facial expressions.
      • Slowing of movements & thinking: A common symptom of depression.

    Depression

    • Depression: An alteration in mood expressed by feelings of sadness, despair, and pessimism.
    • Transient symptoms: Are normal responses to disappointments.
    • When does Depression become a Mood Disorder? When it affects ability to perform Activities of Daily Living (ADLs), such as completing daily tasks, socializing, and managing daily life.
    • Pathological/Clinical Depression: Occurs when coping mechanisms are ineffective.
    • Epidemiology
      • Gender: Females are diagnosed with depression more often.
      • Age: Can occur at any age.
      • Social Class: Can affect anyone but can be more prevalent in lower socioeconomic groups.
      • Marital Status: Those who are single or divorced are more likely to experience depression.
      • Seasonality: Can be affected by seasonal changes.
      • Social connectedness: Marriage as an example, can be very helpful in mitigating the risk of depression.

    Types of Depressive Disorders

    • Major Depressive Disorder (MDD): Most Severe
      • Symptoms present for at least 2 weeks and last most of the day.
      • Interferes with daily functioning.
      • Characterized by depressed mood.
      • Anhedonia: Loss of interest or pleasure in usual activities.
      • Symptoms:
        • Depressed mood (present most of the day)
        • Diminished interest in pleasure
        • Weight changes (weight loss OR weight gain)
        • Insomnia or hypersomnia
        • Psychomotor agitation or retardation
        • Fatigue or loss of energy nearly every day
        • Feelings of worthlessness or inappropriate guilt
        • Diminished ability to think or concentrate
        • Recurrent thoughts of death (not just the fear of dying, recurrent suicidal ideation)
      • No history of manic behavior.
      • Cannot be attributed to substance use or medical conditions.
    • Persistent Depressive Disorder (Dysthymia) (PDD): Less severe disorder
      • Sad or “down in the dumps”
      • No evidence of psychotic symptoms
      • Essential feature: A chronically depressed mood, most of the days in the week, more days than not
        • At least 2 years for Adults
        • At least 1 year for Children & Adolescents
      • Can lead to MDD later in life
      • Symptoms:
        • Poor appetite
        • Insomnia/hypersomnia
        • Low energy or fatigue
        • Low self-esteem
        • Poor concentration
        • Feelings of hopelessness
    • Premenstrual Dysphoric Disorder (PMDD)
      • Symptoms begin during the week prior to menses and start to improve within a few days after menses start.
      • Symptoms:
        • Depressed mood
        • Anxiety
        • Mood swings
        • Decreased interest in activities
      • Can severely interfere with social, work, or school functioning
      • Treatment:
        • Exercise
        • Diet
        • Relaxation therapy
    • Substance or Medication–Induced Depressive Disorder
      • Direct result of the physiological effects of a substance or medication
        • Examples include:
          • Beta-blockers
          • Birth control
          • Anticonvulsants
          • Drugs of abuse
          • Medications
          • Toxin Exposure
      • Depressed mood associated with intoxication or withdrawal from substances or medications
        • Substances: Alcohol, amphetamines, cocaine, hallucinogens, opioids, phencyclidine (-like substances), sedatives, hypnotics, or anxiolytics.
        • Medications: Analgesics, anticonvulsants, cardiac medications, anticholinergics, anesthetics, antihypertensives, antiparkinsonian agents, antiulcer agents, oral contraceptives, psychotropic medications, muscle relaxants, steroids, and sulfonamides.
    • Depressive Disorder Associated with Another Medical Condition
      • Attributable to the direct physiological effects of a general medical condition.
        • Examples include:
          • Strokes
          • Amputations
          • Thyroid dysfunction
          • MI
          • Traumatic brain injuries
          • Cushing’s
          • Huntington’s
          • Parkinson’s
          • MS
      • Always check thyroid levels!

    Predisposing Factors to Depression

    • Genetics
    • Neurotransmitter Deficiencies:
      • Serotonin
      • Norepinephrine
      • Dopamine
    • Hypothalamic-Pituitary-Adrenocortical (HPA) Axis Failure: Possible role in development of depression.
    • Secondary Depression:
      • Medication side effects
      • Neurological disorders (ex: CVA)
      • Hormonal disturbances:
        • Hypothyroidism/hyperthyroidism
        • Estrogen and progesterone imbalance
      • Electrolyte disturbances:
        • Hypocalcemia
        • Hyponatremia
        • Hyperkalemia
      • Nutritional deficiencies:
        • Low protein
        • Low carbohydrates
        • Vitamin B1 (thiamine)
        • Vitamin B9 (folate)
        • Vitamin B12
        • Zinc
        • Iron
      • Physiological conditions:
        • Systemic Lupus Erythematosus (SLE)
        • Congestive heart failure
        • Myocardial infarction (MI)
        • Diabetes mellitus (DM) ­  - Infectious disorders (encephalitis, mononucleosis)
      • Inflammation

    Predisposing Factors to Depression: Psychosocial Theories

    • Psychoanalytic Theory:
      • Loss is internalized and directed against the ego.
        • Example: Loss of a loved one, anger is turned inwards.
    • Learning Theory:
      • Learned helplessness
        • Individuals experience numerous failures, leading to a belief that they are unable to control their life situation.
    • Object Loss Theory:
      • Results from abandonment or separation from a significant other during the first 6 months of life.
        • Example: Abandonment or death of a mother.
      • This loss leads to feelings of helplessness and despair, which contribute to lifelong patterns of depression.
      • Behaviors may include:
        • Excessive crying
        • Anorexia
        • Withdrawal
        • Psychomotor retardation (sluggish movements)
        • Stupor
    • Cognitive Theory:
      • Primary disturbance in depression is cognitive, not affective.
      • Cognitive distortions:
        • Negative expectations about the environment, self, and future.
      • Faulty thinking is the focus of this theory.

    Developmental Implications

    • Childhood Depression (Symptoms vary depending on age):
      • Under 3 years old: Feeding problems/changes in eating, tantrums, lack of playfulness and emotional expressiveness.
      • Ages 3 to 5: Accident proneness, phobias, excessive self-reproach.
      • Ages 6 to 8: Physical complaints (headache, stomach aches), aggressive behavior, clinging behavior.
      • Ages 9 to 12: Morbid thoughts, excessive worrying.
    • Adolescent Depression:
      • Symptoms:
        • Anger
        • Irritability
        • Aggressiveness
        • Acting out
        • Running away
        • Delinquency
        • Social withdrawal
        • Sexual acting out
        • Substance abuse
        • Restlessness
        • Apathy
      • Distinguish between depression and typical adolescent behavior by considering the timeframe and progression of symptoms.
      • A visible manifestation of behavioral change lasting for several weeks is the BEST clue for a mood disorder.
    • Senescence:
      • Bereavement overload: Experienced so many losses in life that they cannot resolve one grief before another one begins.
      • High percentage of suicides in the elderly population.
      • May be mistaken for pseudodementia.
      • Symptoms of depression may be confused with neurocognitive disorder.
      • Treatment:
        • Antidepressants (typically SSRIs due to fewer side effects)
        • Psychotherapy (group therapy, peer support)
        • Electroconvulsive Therapy (ECT)
    • Postpartum Depression
      • May last for a few weeks to several months.
      • Associated with:
        • Hormonal changes
        • Metabolic and psychosocial influences
        • Tryptophan metabolism
        • Cell alterations
      • Risk Factors:
        • History of depression
        • Family history of psychiatric disorders
      • Symptoms:
        • Fatigue
        • Irritability
        • Loss of appetite
        • Sleep disturbances
        • Loss of libido
        • Concern about the inability to care for the infant
      • Treatment:
        • Antidepressants (SSRIs)
        • Psychosocial therapies
        • Brexanolone (Zulresso) administered intravenously (available through a restricted distribution program)
        • Zurzuvae (treats PPD, may affect the CNS; educate patients about not driving)

    Treatment

    • Inpatient vs Outpatient:
      • Inpatient: When there is harm to self or others.
        • Criteria:
          • Harming themselves
          • Harming others
      • Outpatient: Therapy, medication management.
    • Supportive psychosocial interventions.
    • Parental and family therapy.
    • Medication (May take 4 weeks to work and see side effects):
      • All antidepressants carry a BLACK-BOX WARNING for an increased risk of suicidality in children, adolescents, and young adults.

    Nursing Process/Assessment

    • Transient depression:
      • Symptoms are not necessarily dysfunctional.
        • Affective: The "blues," sadness. ­  - Behavioral: Some crying.
        • Cognitive: Some difficulty getting one’s mind off of a disappointment.
        • Physiological: Feeling tired and listless.
    • Mild Depression:
      • Symptoms are similar to those associated with normal grieving.
        • Affective: Anger, anxiety.
        • Behavioral: Tearful, regression (acting younger).
        • Cognitive: Preoccupied with loss, self-blame, ambivalence.
        • Physiological: Anorexia, insomnia, headache, backache, chest pain.
    • Moderate Depression:
      • Symptoms associated with dysthymic disorder.
        • Affective: Helpless, powerless.
        • Behavioral: Slowed physical movements, slumped posture, limited verbalization.
        • Cognitive: Slowed thinking processes, difficulty with concentration.
        • Physiological: Anorexia or overeating, sleep disturbance, headaches.
    • Severe Depression:
      • Includes symptoms of MDD and bipolar depression
        • Affective: Feelings of total despair, worthlessness, flat affect.
        • Behavioral: Psychomotor retardation, curled-up position, absence of communication.
        • Cognitive: Prevalent delusional thinking, with delusions of persecution and somatic delusions. Confusion, suicidal thoughts.
        • Physiological: A general slow-down of the entire body.

    Diagnosis + Planning/Implementation

    • Risk for Suicide:
      • Be direct: "Are you having thoughts about harming yourself?"
      • Maintain close observation
      • Maintain a safe milieu/environment:
        • Minimize dangerous objects (car keys, writing utensils, cords)
      • Encourage verbalization of honest feelings
    • Complicated Grieving:
      • Develop a trusting relationship with the client
      • Encourage the client to express and identify emotions
      • Communicate that crying is acceptable
    • Low Self-Esteem/Self-Care Deficit
      • Be accepting of the client
      • Encourage the client to recognize areas of change.
      • Encourage independence in the performance of ADLs
    • Powerlessness:
      • Encourage the client to take responsibility
      • Help the client set goals
      • Help the client identify areas that they can and cannot control
    • Social Isolation:
      • Support groups
      • Group activities
    • Other Nursing Diagnoses:
      • Spiritual distress
      • Disturbed thought process
      • Imbalanced nutrition less than body requirements
      • Insomnia
      • Self-care deficits

    Client/Family Education

    • Nature of the illness:
      • Stages of grief
      • Symptoms
      • Education on depression
        • What are considered emergencies? How to respond to those situations?
    • Support services:
      • Suicide hotline
      • Support groups
      • Local resources
      • Legal/financial assistance
    • Management of the illness:
      • Medication management
      • Physical aspects:
        • Increase adequate nutrition
        • Optimal rest periods
        • Winding down period
        • Group activities
        • Having a dark environment for sleep
        • May see constipation (increase fluids, fiber, exercise)
        • Self-care deficits (work on a schedule for hygiene)
        • If severe issues with sleep, may be able to prescribe a medication that treats depression AND sleep
      • Assertiveness, stress-management, and coping skills techniques.
      • Ways to increase self-esteem
      • Therapy: Individual, Group, Family, etc.
      • Bright light therapy
      • Electroconvulsive therapy (ECT)
      • Transcranial magnetic stimulation
      • Vagal nerve and deep brain stimulation
        • ECT: Usually used for treatment-resistant depression.
        • Vagal nerve stimulation and deep brain stimulation: Invasive procedures, usually used as a last resort.
    • Reporting Side Effects to HCP: Sore throat Fever Malaise Yellow skin Bleeding Bruising Persistent vomiting Headaches Rapid heart rate Seizures Stiff neck Chest pain
    • Management of anticholinergic side effects (especially with TCAs):
      • Interventions: Sugar-free hard candy, frequent sips of water, monitor for orthostatic hypotension (gradually get out of bed, sit on the side and dangle the legs).
    • Life-threatening syndromes (symptoms & prevention): - Serotonin Syndrome: Too much serotonin in the body. - Symptoms: High temperature, muscle spasms, vital sign instability, altered mental status, shivering, hyperreflexia/clonus, encephalopathy/change in mental status, severe abdominal pain and diarrhea. - Prevention: Discontinue medication causing the syndrome, provide supportive care. - Treatment: Treat the symptoms (anticonvulsants, diazepam for muscle spasms, cooling blankets for elevated temperature.) - Avoid St. John’s Wort with SSRIs. - Hypertensive Crisis: Caused by MAOIs. - Symptoms: Increased blood pressure. - Prevention/Teaching: Avoid tyramine-containing foods. May require wash out period.

    Treatment Modalities

    • Psychopharmacology
      • **SSRIs (Selective Serotonin Reuptake Inhibitors): ** Usually the first-line medication.
        • Inhibit the reuptake of serotonin.
        • Examples: Fluoxetine, paroxetine (Paxil), citalopram, sertraline, escitalopram.
        • Side Effects: Suicidal ideation, insomnia, headache, nausea, anxiety, sexual dysfunction.
        • Less lethal if the patient overdoses on the medication.
        • Cannot take an SSRI & MAOI together.
        • Do not stop this medication abruptly, due to the increased risk of serotonin syndrome.
      • SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors):
        • Inhibit both norepinephrine and serotonin reuptake.
        • Examples: Duloxetine, venlafaxine.
      • Tricyclics (TCAs):
        • Examples: Amitriptyline, amoxapine, desipramine, doxepin, imipramine, maprotiline, nortriptyline, protriptyline.
        • Side Effects: Anticholinergic effects (dry mouth, hesitancy, blurred vision, orthostatic hypotension).
          • Interventions: Suck on sugar-free candy, dangle legs before standing.
        • Very cardiotoxic.
        • More prone to anticholinergic side effects and orthostatic hypotension.
      • Monoamine Oxidase Inhibitors (MAOIs):
        • Examples: Isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate).
        • Inhibits the breakdown of monoamine neurotransmitters.
        • May require a wash out period due to the increased risk of cardiovascular damage (hypertensive crisis).
        • Tyramine foods should be avoided: aged cheese, wines, beers, smoked meats, soy, chocolate.
        • Less commonly used due to their side effects.
        • Not compatible with other antidepressants.
        • Once a patient stops taking MAOIs, they must continue to avoid tyramine foods for at least 14 days.
      • Atypical Antidepressants: - Examples: Trazodone (Desyrel), Bupropion (Wellbutrin)
      • Atypical Antipsychotics
      • Ketamine:
        - May be administered intravenously or as a nasal spray.      - Zulresso (Brexanolone); Zurzuvae (Zuranolone): Specific to postpartum depression.
    • Continue to take medication.
    • Full therapeutic effect may take 4 weeks.
    • Do not discontinue medication abruptly.
    • Black-Box Warning:
      • All antidepressants carry a Black-Box warning for an increased risk of suicidality in children, adolescents, and young adults.
    • Report to HCP:
      • Sore throat
      • Fever
      • Malaise
      • Yellow skin
      • Bleeding
      • Bruising
      • Persistent vomiting
      • Headaches
      • Rapid heart rate
      • Seizures
      • Stiff neck
      • Chest pain
    • Management of anticholinergic side effects (especially with TCAs):
      • Interventions: Sugar-free hard candy, frequent sips of water, monitor for orthostatic hypotension (gradually get out of bed, sit on the side and dangle the legs).
    • Life-threatening syndromes (symptoms & prevention):
      • Serotonin Syndrome: Too much serotonin in the body.
        • Symptoms: High temperature, muscle spasms, vital sign instability, altered mental status, shivering, hyperreflexia/clonus, encephalopathy/change in mental status, severe abdominal pain, and diarrhea.
        • Prevention: Discontinue medication causing the syndrome, provide supportive care.
        • Treatment: Treat the symptoms (anticonvulsants, diazepam for muscle spasms, cooling blankets for elevated temperature.)
        • Avoid St. John’s Wort with SSRIs.
      • Hypertensive Crisis: Caused by MAOIs.
        • Symptoms: Increased blood pressure.
        • Prevention/Teaching: Avoid tyramine-containing foods. May require a wash out period.

    Clicker Questions

    • Question 1 An individual experienced the death of a parent 2 years ago. This individual has not been able to work since the death, cannot look at any of the parent’s belongings, and cries daily for hours at a time. Which nursing diagnosis most accurately describes this individual’s problem?

      • A. Post-trauma syndrome related to parent’s death
      • B. Anxiety (severe) related to parent’s death
      • C. Coping, ineffective related to parent’s death
      • D. Grieving, complicated related to parent’s death

    • Question 2 When teaching about the tricyclic group of antidepressant medications, which information should the nurse include?

      • A. Strong or aged cheese should not be eaten while taking this group of medications.
      • B. The full therapeutic potential of tricyclics may not be reached for 4 weeks.
      • C. …

    Assessment Questions

    • For a child:
      • Self-harm and suicide
      • History of depression diagnosis
      • Previous treatment for depression

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    Chapter 16: Depressive Disorders PDF

    Description

    This quiz covers nursing diagnoses related to grief and assessment questions for children coping with loss. Additionally, it focuses on teaching about tricyclic antidepressants and discharge information for clients prescribed Paroxetine. Test your understanding of nursing care for patients with major depression.

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