Depressive and Anxiety Disorders

DEPRESSIVE AND ANXIETY DISORDERS ANNIE SMITH, RN-BC, MSN 02/12/2025 1 OBJECTIVES  1. Identify symptomatology associated with depression and use this information in patient assessment.  2. Describe appropriate nursing interventions for behaviors associated with depression.  3....

DEPRESSIVE AND ANXIETY DISORDERS ANNIE SMITH, RN-BC, MSN 02/12/2025 1 OBJECTIVES  1. Identify symptomatology associated with depression and use this information in patient assessment.  2. Describe appropriate nursing interventions for behaviors associated with depression.  3. Differentiate between facts and myths regarding suicide.  4. Apply the nursing process to individuals exhibiting suicidal behavior.  5. Describe various types of anxiety, obsessive-compulsive, and related disorders and identify symptomatology associated with each.  6. Describe appropriate nursing interventions for behaviors associated with anxiety, obsessive-compulsive, and related disorders. 02/12/2025 2 02/12/2025 3 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 adaptation is ineffective, and functioning is impaired.  Depression is an alteration in mood that is expressed by feelings of sadness, despair, and pessimism. 02/12/2025 4   Major depressive disorder  Characterized by depressed mood  Loss of interest or pleasure in TYPES OF usual activities DEPRESSIVE  Symptoms present for at least 2 weeks DISORDERS  No history of manic behavior  Cannot be attributed to use of substances or another medical condition   Persistent depressive disorder (dysthymia)  Sad or “down in the dumps” TYPES OF  No evidence of psychotic symptoms DEPRESSIVE  Essential feature is a chronically depressed DISORDERS mood for  Most of the day  More days than not  At least 2 years   Premenstrual dysphoric disorder  Depressed mood  Anxiety  Mood swings TYPES OF  Decreased interest in activities DEPRESSIVE  Symptoms begin during the week DISORDERS 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- or Considered to be the direct medication-induced result of physiological effects depressive disorder of a substance Depressive disorder Attributable to the direct associated with another physiological effects of a medical condition general medical condition  Biological theories  Genetics  Hereditary factor may be involved PREDISPOSIN  Biochemical influences G FACTORS  Deficiency of TO norepinephrine, DEPRESSION serotonin, and dopamine has been implicated.   Childhood depression  Symptoms  < Age 3: Feeding problems, tantrums, lack of playfulness and emotional expressiveness  Ages 3 to 5: DEVELOPMENTA Accident proneness, phobias, excessive self-reproach L IMPLICATIONS  Ages 6 to 8: Physical complaints, aggressive behavior, clinging behavior  Ages 9 to 12: Morbid thoughts and excessive worrying DEVELOPMENTAL IMPLICATIONS  Adolescence  Symptoms include  Anger, aggressiveness  Running away  Delinquency  Social withdrawal  Sexual acting out  Substance abuse  Restlessness, apathy DEVELOPMENTAL IMPLICATIONS  Senescence  Bereavement overload  High percentage of suicides among elderly  Symptoms of depression often confused with symptoms of neurocognitive disorder  Treatment  Antidepressant medication  Electroconvulsive therapy  Psychotherapies DEVELOPMENTAL IMPLICATIONS  Postpartum depression  May last for a few weeks to several months  Associated with hormonal changes, tryptophan metabolism, or cell alterations  Treatments  Antidepressants and psychosocial therapies TREATMENT MODALITIES  Individual psychothera py  Group therapy  Family therapy  Cognitive therapy   Electroconvulsive therapy  Mechanism of action: Thought to increase levels of biogenic amines  Side effects: Temporary memory TREATMENT loss and confusion MODALITIES  Risks: Mortality; permanent memory loss; brain damage  Medications: Pretreatment medication; muscle relaxant; short-acting anesthetic   Psychopharmacology  Tricyclics  Selective serotonin reuptake TREATMENT inhibitors MODALITIES  Monoamine oxidase inhibitors (M A O I’s)  Serotonin-norepinephrine reuptake inhibitors ANTIDEPRESSANTS  Norepinephrine and serotonin play a major role in regulating mood  Pharmacological goal is to increase the synaptic level of one or both  Black box warning due to increased suicidality (especially in teens and young adults) during initial weeks of therapy 02/12/2025 17 TRICYCLIC ANTIDEPRESSANTS (TCAS)  No longer first-line treatment due to side effects and lethality in overdose  Block reuptake of norepinephrine  Anticholinergic side effects, sedation, drowsiness Nortriptyline (Pamelor) Imipramine (Tofranil) 02/12/2025 18 MONOAMINE OXIDASE INHIBITORS (MAOIS)  MAO is the enzyme that destroys monoamines (dopamine, norepinephrine, serotonin, histamine)  MAOIs inhibit the action of MAO to prevent this destruction  Increase 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. Must restrict tyramine from diet if taking MAOI due to risk of hypertensive crisis Isocarboxazid (Marplan) Phenelzine (Nardil) Selegiline (EMSAM) Tranylcypromine (Parnate) 02/12/2025 19 SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)  Block the reuptake of serotonin, therefore making it more available  May cause decreased libido, nausea, or vomiting Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Fluvoxamine (Luvox) Escitalopram (Lexapro) Citalopram (Celexa) 02/12/2025 20 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 Venlafaxine (Effexor) Duloxetine (Cymbalta) Desvenlafaxine (Pristiq) 02/12/2025 21 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) 02/12/2025 22 SEROTONIN SYNDROME  Results from excess serotonin  Symptoms include  Neuromuscular excitation  Altered mental status  Autonomic dysfunction (diaphoresis, hypertension, hyperthermia) 02/12/2025 23 CLIENT/FAMILY EDUCATION RELATED TO ANTIDEPRESSANTS 1 2 3 Continue to take Do not discontinue Report sore throat, medication for 4 medication abruptly. fever, malaise, yellow weeks. skin, bleeding, bruising, persistent vomiting or headaches, rapid heart rate, seizures, stiff neck, and chest pain to physician. CLIENT/FAMILY EDUCATION RELATED TO ANTIDEPRESSANTS  Avoid foods and medications high in tyramine when taking M A O I’s. These include  Aged cheese  Wine; beer  Smoked and processed meats  Chocolate; colas  Beef or chicken liver  Coffee; tea  Canned figs  Sour cream; yogurt 02/12/2025 25  Between 30 and 50% of patients do not respond to first antidepressant prescription. PHARMACOGENOMIC S A study is needed to identify benefits of routine testing, cost effectiveness, and ability to provide timely results. 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. Long-term use may result in physical dependence. D. Tricyclics should not be given with anti- anxiety agents. QUESTION ANSWER 2  Correct Answer: B A client needs to be advised that it may take several weeks for tricyclic medications to reach their full therapeutic effect and for relief of symptoms to be noted. 02/12/2025 28 3. A client has been diagnosed with major depression. The psychiatrist prescribes Paroxetine (Paxil). Which of the following medication information should the nurse include in discharge teaching? A. Do not eat chocolate while taking this medication. B. The medication may cause priapism. C. The medication should not be discontinued abruptly. D. The medication may cause photosensitivity. QUESTION ANSWER 3  Correct Answer: C Antidepressants such as paroxetine must be tapered and not stopped abruptly. All classifications of antidepressants have varying potentials to cause discontinuation syndromes. Abrupt withdrawal from S S R I’s, such as paroxetine, may result in dizziness, lethargy, headache, and nausea. 02/12/2025 30 INTRODUCTION- CHAPTER 11  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. 02/12/2025 31   Suicide is:  The second-leading cause of death among Americans 10 to 34 years of age EPIDEMIOLOGICA  The fourth-leading cause of death L FACTORS 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 The suicide rate for single persons is twice that of married persons. status Women attempt suicide more often, Gende but more men succeed. r Men commonly choose more lethal methods than do women.  Age  Risk of suicide increases with age, particularly among men.  White men older than 80 years are at the greatest risk of all age, gender, and race groups.  Religion  Affiliation with a religious group decreases the risk of suicide. Catholics have lower rates than do Protestants or Jewish people. RISK FACTORS  Socioeconomic status  Individuals in the very highest and lowest social classes have higher suicide rates than those in the middle class.  Ethnicity  Whites are at the highest risk for suicide, followed by Native Americans, African Americans, Hispanic Americans, and Asian Americans. RISK FACTORS  Psychiatric illness: 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  Anxiety disorders  Severe insomnia is associated with increased risk of suicide. RISK FACTORS  Use of alcohol and barbiturates  Psychosis with command hallucinations  Affliction with a chronic, painful, or disabling illness  Family history of suicide  L G B TQ+ individuals have a higher risk of suicide than do their heterosexual counterparts. RISK FACTORS  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 RISK FACTORS  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 NURSING PROCESS: ASSESSMENT Seriousness of Presenting intent symptoms/medi cal-psychiatric diagnosis Plan Suicidal ideas or acts Means Interpersonal support system Verbal and behavioral clues  Interpersonal support system  Analysis of the suicidal crisis  Precipitating stressor  Relevant history  Life-stage issues  Psychiatric/medical/family history  Coping strategies  Presenting symptoms NURSING PROCESS: ASSESSMENT INFORMATION FOR FAMILY AND FRIENDS OF THE SUICIDAL CLIENT 01 02 03 04 05 06 Take any hint Do not keep Be a good Express Know about Restrict of suicide secrets. listener. feelings of suicide access to seriously. personal intervention firearms or worth to the resources. other means client. of self-harm.   Acknowledge and accept the person’s feelings. INFORMATIO  Provide a feeling of hopefulness. N FOR FAMILY  Do not leave him or her alone. AND  Show love and encouragement. FRIENDS OF  Seek professional help. THE  Remove children from the home. SUICIDAL  Do not judge or show anger toward CLIENT the person or provoke guilt in him or her. 02/12/2025 44 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. It is not the same as stress. 02/12/2025 45   Anxiety disorders are the most common of all psychiatric illnesses. EPIDEMIOLOGICA  More common in women than in L STATISTICS men  A familial predisposition probably exists. HOW MUCH IS 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 02/12/2025 47 APPLICATION OF NURSING PROCESS  Generalized anxiety disorder (G A D)  Characterized by chronic, unrealistic, and excessive anxiety and worry 02/12/2025 49   Panic disorder: Assessment  Characterized by recurrent panic APPLICATIO attacks, the onset of which are unpredictable and manifested by N OF intense apprehension, fear, or terror, often associated with NURSING feelings of impending doom and accompanied by intense physical PROCESS discomfort  May or may not be accompanied by agoraphobia   Symptoms of panic attack  Sweating, trembling, shaking  Shortness of breath, chest pain, or discomfort APPLICATION  Nausea or abdominal distress OF NURSING  Dizziness, chills, or hot flashes PROCESS  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 source of feelings.  Listen and assess hopelessness and helplessness.  Assess suicidal risk plan and intent directly.  Involve in activities as tolerated. 02/12/2025 52 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. 02/12/2025 53 PROBLEM SOLVING*  Teach relaxation exercises.  Promote hobbies and recreation according to patient’s preferences and abilities. 02/12/2025 54 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. 02/12/2025 55 PANIC ATTACK: INTERVENTIONS (CONT.)*  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. 02/12/2025 56 OBSESSIVE-COMPULSIVE DISORDER (O C D)  Assessment data  Recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or significant impairment  Obsessions  Recurrent thoughts, impulses, or images experienced as 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 event or situation 02/12/2025 57 3. When caring for a client who is experiencing a panic attack, which of the following nursing actions should be implemented? A. Leave the client alone to maintain privacy. B. Instruct the client regarding unit rules and regulations. C. Sit with the client in the day room to provide comfort. D. Communicate with simple words and brief messages. QUESTION ANSWER 3  Correct Answer: D When communicating with a client experiencing a panic attack, the nurse needs to use simple words and brief messages, spoken calmly and clearly. Any communication that is loud and demanding would only escalate anxiety. 02/12/2025 59 TREATMENT MODALITIES: PSYCHOPHARMACOLOGY  Examples of anti-anxiety agents  Hydroxyzine (Vistaril)  Alprazolam (Xanax)  Clonazepam (Klonopin)  Diazepam (Valium)  Lorazepam (Ativan) 02/12/2025 60 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 (same mechanism as alcohol), used at low doses to treat anxiety Alprazolam (Xanax) Lorazepam (Ativan) Diazepam (Valium) Clonazepam (Klonopin) 02/12/2025 61