psych ch 16.pdf

Chapter 16: Depressive Disorders Mood is a pervasive & sustained emotion Affect is the external, observable emotional reaction; outward form of expressing emotions ○ Facial changes: flat affect, very minimal facial expressions; slowing down of movements & think...

Chapter 16: Depressive Disorders Mood is a pervasive & sustained emotion Affect is the external, observable emotional reaction; outward form of expressing emotions ○ Facial changes: flat affect, very minimal facial expressions; slowing down of movements & thinking (lecture) Depression: an alteration in mood that is expressed by feelings of sadness, despair, and pessimism ○ Transient symptoms are normal in response to disappointments When does depression become a Mood Disorder? When it starts affecting ability to do ADLs such as complete daily tasks, daily life, socializing Pathological/clinical depression occurs when adaptation is ineffective Epidemiology: Gender prevalence, Age, Social class, Marital Status Seasonality: affected by the seasons Social connectedness: such as marriage; can be very helpful Can affect ANYONE, females tend to get diagnosed more often, those with thyroid dysfunction and coronary artery disease Types of Depressive Disorders Major Depressive Disorder: MOST SEVERE ○ Symptoms present for at least 2 weeks and last most of the day Inferes with patient ability to function ○ Characterized by depressed mood ○ Loss of interest or pleasure in usual activities (Anhedonia) ○ Additional symptoms present ○ No history of manic behavior ○ Cannot be attributed to use of substances or another medical condition ○ Diagnostic criteria [5 or more s/s are present during same 2-week period & represent a change in previous functioning] [email her asking if we need to know this, NOT IN NOTES] 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) Persistent depressive disorder (dysthymia) PDD: Less severe disorders ○ Sad or “down in the dumps” ○ No evidence of psychotic symptoms (hearing voices, etc.) ○ Essential feature is a chronically depressed mood for: most of the days in the week, more days than not At least 2 years for Adults, 1 year for Children & Adolescents ○ Persistent depressive disorder can lead to MDD later on in life (ati book) ○ Must have two (or more) of the following: poor appetite, insomnia/hypersomnia, low energy or fatigue, low self-esteem, poor concentration, and feelings of hopelessness (book) Premenstrual Dysphoric Disorder (PMDD) ○ Symptoms begin during the week prior to menses and start to improve within a few days after menses start ○ S/sx: depressed mood, anxiety, mood swings, decreased interest in activities These s/s can be severe enough to interfere with one’s ability to function socially, at work, or at school (book)  ○ Tx: exercise, diet, and relaxation therapy (ati book) Substance or medication–induced depressive disorder ○ Considered to be the direct result of physiological effects of a substance (ex.: beta-blockers, birth control, anticonvulsants; a drug of abuse, a medication, or toxin exposure) ○ The depressed mood is associated with intoxication or withdrawal from either substances (such as alcohol or drugs) or medications (anticonvulsants, analgesics, muscles relaxants, etc.) 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 ○ Ex: strokes, amputations, thyroid dysfunction, MI, traumatic brain injuries, Cushing’s, Huntington’s, Parkinson’s, and MS ○ MUST CHECK thyroid levels Predisposing Factors to Depression Genetics Deficiency of neurotransmitters like serotonin, norepinephrine, & dopamine Possible failure within the HPA (hypothalamic-pituitary-adrenocortical) axis Secondary depression r/t: ○ Medication side effects, neurological disorders (ex: CVA) ○ Hormonal disturbances (ex: hypothyroidism/hyperthyroidism and imbalance of estrogen and progesterone) ○ Electrolyte disturbances (ex: hypercalcemia, hyponatremia, hyperkalemia) ○ Nutritional deficiencies (ex: low protein, carbs, vitamin B1 (thiamine), B9, B12, zinc, iron, etc.), ○ Other physiological conditions (ex: SLE, congestive HF, MI, DM, infectious disorders like encephalitis, mono, etc.) ○ Inflammation (find in book) Predisposing Factors to Depression: Psychosocial Theories Psychoanalytic theory: A loss is internalized, becomes directed against the ego ○ Loss of someone they love and cherish and their anger becomes inward Learning theory: Learned helplessness (numerous failures causes them to give up trying) ○ This predisposes individuals to depression by imposing a feeling of lack of control over their life situation (book) Object loss theory: results from having been abandoned by or other separated from a significant other during the first 6 months of life ○ Ex.: mother abandoning child or mother’s death ○ Feelings of helplessness and despair which contribute to lifelong patterns of depression ○ This condition includes behaviors such as excessive crying, anorexia, withdrawal, psychomotor retardation (sluggish physical movements), and stupor Cognitive theory: views primary disturbance in depression is cognitive rather than affective ○ Cognitive distortions that they believe serve as the basis for depression: Negative expectations of the environment, self, and future ○ Cognitive focuses in on faulty thinking (lecture) Developmental Implications Childhood depression s/sx (this is in the book but not split up into specific age groups)  ○ < Age 3: Feeding problems/changes in their eating, tantrums, lack of playfulness and emotional expressiveness ○ Ages 3 to 5: Accident proneness, phobias, excessive self-reproach ○ Ages 6 to 8: Physical complaints, aggressive behavior, clinging behavior Physical complaints: HA, stomach aches ○ Ages 9 to 12: Morbid thoughts and excessive worrying Adolescence depression s/sx ○ Anger, irritability, aggressiveness, acting out, running away, delinquency, social withdrawal, sexual acting out, substance abuse, restlessness, apathy Can distinguish between depression and typical adolescent behavior based on time frame and progression A visible manifestation of behavioral change that lasts for several weeks is the BEST clue for a mood disorder (book) Senescence → bereavement overload (have experienced so any losses in their life that they are not able to resolve one grief before another one begins) ○ Elderly-high percentage of suicides ○ May be mistaken for pseudodementia ○ Symptoms of depression often confused with symptoms of neurocognitive disorder ○ Treatment: Antidepressants (typically SSRIs due to less SE), Psychotherapies (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, and tryptophan metabolism (tryptophan is a precursor to serotonin), or cell alterations ○ RF: hx of depression, family hx of psych disorder ○ Symptoms include Fatigue/Irritability, Loss of appetite, Sleep disturbances, Loss of libido, Concern about inability to care for infant ○ Treatments: Antidepressants (SSRIs) and psychosocial therapies, Brexaolone (Zulresso) is administered IV and is only available through restricted distribution program ○ Zurzuvae (treats PPD, may have an effect on the CNS, so educate about not driving) Treatment Inpatient vs Outpatient treatment ○ Inpatient: harm to self or others What is the criteria for inpatient admission? Harming themselves OR others ○ Outpatient: therapy, med management Supportive psychosocial interventions Parental and family therapy May begin medication (does take time to work and see the side effects, may take 4 weeks - 1 month) ○ All antidepressants carry a BLACK-BOX WARNING for increased risk of suicidality in children, adolescents, & young adults. Nursing Process/Assessment Transient depression ○ Symptoms at this level of the continuum are not necessarily dysfunctional. Affective: having the “blues”, sadness Behavioral: Some crying Cognitive: Some difficulty getting mind off of one’s disappointment Physiological: Feeling tired and listless (lethargic)  Mild depression ○ Symptoms of mild depression are identified by clinicians as those associated with normal grieving. Affective: Anger, anxiety Behavioral: Tearful, regression 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 major depressive disorder 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 verbalizations of honest feelings Complicated grieving ○ Develop a trusting relationship with the client ○ Encourage the client to express & ID 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 ID areas that they can and cannot control Social isolation ○ Support groups ○ Group activities Other nursing dx: 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 and symptoms and education on depression ○ Education: s/s of depression, talking to the family about what are considered emergencies and how do we respond to that situation?  Support services → Suicide hotline, support groups, local resources, legal/financial assistance Management of the illness ○ Medication management ○ Help with physical aspects: increase in 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 (working with them to make a schedule to take care of their hygiene) If severe issues with sleep, may be able to prescribe a medication that treats depression AND sleep (lecture) ○ Techniques → Assertiveness, stress-management, coping skills ○ Ways to increase self-esteem ○ Therapy → Individual, Group, Family etc. ○ Other → Bright light therapy; ECT; Transcranial magnetic stimulation, Vagal nerve and Deep brain stimulation ECT → Usually used for tx resistant depression Vagal nerve stimulation and deep brain stimulation are Invasive procedure and are usually last resort Treatment Modalities Psychopharmacology ○ SSRI: (usually first line of medications) The inhibit the reuptake of serotonin Ex: fluoxetine, paroxetine (paxil), citalopram, sertraline, escitalopram A/E: suicidal ideation, insomnia, headache, nausea, anxiety, sexual dysfunction Less lethal if the pt overdoses on the medication Cannot take an SSRI & MAOI together Do not stop this medication abruptly Due to the increased risk for serotonin syndrome ○ SNRI: Inhibits both the norepinephrine and serotonin Ex: duloxetine, venlafaxine ○ Tricyclics (TCAs): Ex: amitriptyline, amoxapine, desipramine, doxepin, imipramine, maprotiline, nortriptyline, protriptyline A/E: anticholinergic effects such as dry mouth, hesitancy, blurred vision, orthostatic hypotension ○ Interventions: suck on sugar free candy, dangle leds before standing straight up Very cardiotoxic More prone to anticholinergic side effects, orthostatic hypotension ○ Monoamine oxidase inhibitors (MAOIs): Ex: isocarboxazid, phenelzine, tranylcypromine Inhibits the breakdown of monoamine neurotransmitters May do a wash out period due to the increase risk for cardiovascular damage (i.e., hypertensive crisis) Tyramine foods should be avoided: aged cheese, wines, beers, smoked meats, soy, chocolate Do not see these as much due to their side effects  Not compatible with other antidepressants Once they come off of this medication, they will have to keep these same precautions for at least 14 days after stopping the medication ○ Atypical Antidepressants: Trazodone, bupropion (wellbutrin) ○ Atypical Antipsychotics ○ Ketamine: May receive this IV or nasal spray ○ Zulresso (Brexanolone); Zurzuvae (Zuranolone) → specific to postpartum depression Client/Family Education Related to Antidepressants Continue to take medication May take 4 weeks for full therapeutic effect Do not discontinue medication abruptly BLACK-BOX WARNING ○ All antidepressants carry a BLACK-BOX WARNING for increased risk of suicidality in children, adolescents, & young adults. Report sore throat, fever, malaise, yellow skin, bleeding, bruising, persistent vomiting or headaches, rapid heart rate, seizures, stiff neck, and chest pain to HCP Management of anticholinergic side effects especially with TCAs ○ Intervention: sugar free hard candy, frequent sips of water, monitor for orthostatic hypotension (gradually gets out of bed and sit on the side and dangle the legs) Life-threatening syndromes s/s & how to prevent ○ SEROTONIN SYNDROME: too much serotonin in the patient’s system s/s: 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 that is causing this, provide supportive care Tx: treat the symptoms that they are experiencing. May use anticonvulsants, diazepam for muscle spasms Cooling blankets for elevated temperature Avoid the use of St. John's wort with SSRIs, as it may increase the risk of serotonin syndrome (ati book) ○ HYPERTENSIVE CRISIS: caused by MAOI s/s: increase in blood pressure Prevention/teaching: do not eat tyramine containing foods, may have to do a wash out period Clicker 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 What assessment questions would we ask the child? Self-harm, suicide; have you been diagnosed with depression, have you had treatment for depression? Clicker 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. Long-term use may result in physical dependence. D. Tricyclics should not be given with antianxiety agents. Clicker Question 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.