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Mental Health
Chapter 14 Depressive Disorders
| Question | Answer |
|---|---|
| Depressive Disorders | All share symptoms of: Sadness, emptiness, irritability, somatic (body) concerns, and impairment of thinking All impact a person’s ability to function T •Think about the neurotransmitters that deals with depression (Serotonin, Dopamine, Norepinephrine) * MDD is not an episode occurs almost everyday and last > two months *Always ask the patient how long have you been feeling like this |
| Depressive Disorders Classified: | • Major depressive disorder • Persistent depressive disorder (previously dysthymia) • Premenstrual dysphoric disorder • Seasonal affective disorder • Postpartum Depression |
| Mood | -Is an emotional state -The patient tells you |
| Affect | -The patient shows you what that mood is -How the patient respond in the environment |
| Congruent | Mood & Affect are equal |
| Incongruent | Mood & Affect are not equal |
| Typical | Sadness Tiredness |
| Atypical | -Suddenly loses all interest that brings pleasure -Lethargy -Anhedonia (The inability to feel pleasure) |
| Hormones that decrease in MDD | Adrenocorticotropic hormones' (ACTH) decreases Epinephrine (Affects the heart) decreases Serotonin decreases Norepinephrine (Affects on the blood vessels) decreases Hemoglobin decreases |
| Persistent Depressive Disorder | Formerly known as dysthymia Low-level depressive feelings through most of each day, for the majority of days: At least 2 years in adults At least 1 year in children and adolescents Must have two or more of the following: Decreased appetite or overeating, insomnia or hypersomnia, low energy, poor self-esteem, difficulty thinking, and hopelessness |
| Premenstrual Dysphoric Disorders (an extreme level of PMS) | Symptom clusters in the last week before (Luteal Phase) onset of a woman’s period; include: Mood swings, irritability, depression, anxiety, feeling overwhelmed, and difficulty concentrating Occurs with most menses approximately 5 days preceding the onset of menses. Symptoms decrease significantly or disappear with the onset of menstruation -SSRIs are the treatment (Antidepressants) |
| Major Depressive Disorder (commonly diagnosed) | Five (or more) of the following in 2-week period up to a period of 6 months : (2 weeks x 6 months) • Weight and appetite changes • Sleep disturbances • Fatigue • Worthlessness or guilt • Loss of ability to concentrate • Recurrent thoughts of death • Psychomotor agitation PLUS—at least one symptom is also either: Depressed mood or Loss of interest or pleasure (anhedonia) • Anhedonia (loss of interest and activity that brings you joy) |
| Major Depressive Disorder (commonly diagnosed) cont. | Persistent for minimum of 2 weeks to 6 months Chronic: Lasting more than 2 years Recurrent episodes common Symptoms cause distress or impaired function Episode not attributed to physiological effects Absence of a manic or hypomanic episode ** Mania or Hyper mania bumps you into a different classification, it is not Major Depressive Disorder*** |
| Seasonal affective disorder | • As creatures, we are affected by the season – the winter month causes people to stay in more. • This affects individuals differently |
| Postpartum Depression | • Hormonal shifts after a baby • Cultural phenomenon – many helping hands (family) make like easier. |
| Risk Factors | Biological factors Genetic (first-degree family members) Biochemical • Stressful life events Hormonal Inflammatory Diathesis-stress model • Interplay between genetic and biological Cognitive: Cognitive theorists believe that people may acquire a psychological predisposition to depression due to early life experiences. These experiences contribute to negative, illogical, and irrational thought processes that may remain dormant until they are activated during times of stress |
| Nursing Process: Assessment | (Importance of this disorder is suicidal ideation) Assessment of suicidality Self-assessment Behavior/Affect: Anergia Mood: Depressed mood and anhedonia Emotions: Anxiety; feelings of worthlessness, hopelessness, guilt, anger, helplessness Thoughts/Perceptions: delusions and/or hallucinations Comorbidity: chronic pain (sometimes) |
| Self-Assessment | • Patients with depression: Often reject the advice, encouragement, and understanding • A nurse’s best response: Recognize unrealistic expectations for yourself or the patient Identify feelings that originate with the patient Understand the roles biology and genetics play in major depressive disorder |
| Nursing Process : Nursing Diagnosis | Risk for suicide—safety is always the highest priority Chronic low self-esteem Imbalanced nutrition Constipation Disturbed sleep pattern Ineffective coping Disabled family coping |
| Nursing Process: Outcomes Identification | Recovery model Focus on the patient’s strengths Treatment goals mutually developed Based on the patient’s personal needs and values ** We want the patient to come up with these goals themselves*** |
| Nursing Process: Planning | Geared toward Patient’s phase of depression Particular symptoms Patient’s personal goals |
| Nursing Process: Implementation | Three phases (Different phases in a person’s clinical presentations) • Acute phase (6 to 12 weeks) • Continuation phase (4 to 9 months) • Maintenance phase (1 year or more) ** Approach might be different depending on the phase a person is in*** Counseling and communication Health teaching and health promotion Promotion of self-care activities Teamwork and safety |
| Nursing Process: Evaluation | Tailored to each patient’s unique presentation Basic self-care, thought processes, self-esteem, and social interactions |
| Communication Techniques | Use simple, concrete words Allow time for a response Listen for covert messages Ask about suicide plans Avoid platitudes (for example: “live, life, love.” “Time heals all wounds”) When a patient is silent: Avoid direct questions Make observations to reinforce the reality |
| Treatment Modalities: Choosing an antidepressant: SSRI | Selective serotonin reuptake inhibitors (SSRIs) (treat depressive disorders and anxiety disorders) • First-line therapy • Rare risk of serotonin syndrome (Elevated BP, fever, cardio shock, abd pain) • Takes 4-6 weeks to work • Black box warning for SI under the age of 24 • Help with symptoms of depression • Side effects: Lowers sex drive, GI issues, H/A *** Can activate Mania or Hyper mania*** Block the synaptic reuptake of serotonin Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Proz |
| Choosing an antidepressant: SNRI | Serotonin-norepinephrine reuptake inhibitors (SNRIs) SNRIs may be tolerated better when SSRIs are not. - Great for individuals who have lethargic depression - Not good for individuals with HBP |
| Choosing an antidepressant: TCA's | Tricyclic antidepressants Anticholinergic adverse reactions -Causes adverse symptoms such as Dry mouth, constipation, HTN, urinary retention, cardiac toxicity and sedation. |
| Choosing an antidepressant: MAOI | 4. Monoamine oxidase inhibitors Effective for unconventional depression -Side effects: Insomnia, confusion, watch the diet* |
| Choosing an antidepressant: NDRI | Bupropion -Works great for depression -Helps people to stop smoking -Used for ADHD |
| The Newer Antidepressants | Serotonin antagonists and reuptake inhibitors (SARIs) Norepinephrine dopamine reuptake inhibitor (NDRI) Noradrenergic and specific serotonergic antidepressant (NaSSA |
| Antidepressant: SNRI: Desvenlafaxine | Desvenlafaxine (Pristiq, Khedezla) Blocks the synaptic reuptake of serotonin and norepinephrine Side Effects: Nausea, headache, dizziness, insomnia, diarrhea, dry mouth, sweating, constipation Warning: Neonates with in utero exposure have required respiratory support and tube feeding |
| Antidepressant: SNRI: Duloxetine (Cymbalta) | Duloxetine (Cymbalta) Blocks the synaptic reuptake of serotonin and norepinephrine FDA approved for use in generalized anxiety disorder Side Effects: Nausea, dry mouth, insomnia, somnolence, constipation, reduced appetite, fatigue, sweating, blurred vision Warning: May reduce pain associated with depression FDA approved for fibromyalgia, diabetic peripheral neuropathic pain, and chronic musculoskeletal pai |
| Antidepressant: SNRI: Levomilnacipran (Fetzima) | Levomilnacipran (Fetzima) Blocks the synaptic reuptake of serotonin and norepinephrine Unlike other SNRIs, inhibits reuptake of norepinephrine more than serotonin Side Effects: Nausea, orthostatic hypotension, constipation, sweating, increased heart rate, palpitations, difficulty urinating, decreased appetite, sexual dysfunction Warning May increase the effects of anticoagulants |
| Antidepressant: SNRI: Venlafaxine (Effexor, Effexor XR) | Venlafaxine (Effexor, Effexor XR) Blocks the synaptic reuptake of serotonin and norepinephrine Effexor is a popular next-step strategy after trying SSRIs Side Effects: Hypertension, nausea, insomnia, dry mouth, sedation, sweating, agitation, headache, sexual dysfunction Monitor blood pressure, especially at higher doses and with a history of hypertension Warning: Discontinuation syndrome with dizziness, insomnia, nervousness, irritability, nausea, and agitation may occur with abrupt withdrawa |
| Antidepressant: Serotonin Antagonists and Reuptake Inhibitors (SARIs): Nefazodone (generic only) | Blocks reuptake of serotonin Lower risk of long-term weight gain than SSRIs or TCAs Lower risk of sexual side effects than SSRIs Side Effects: Sedation, hepatotoxicity, dizziness, hypotension, paresthesias Warning: Life-threatening liver failure is possible but rare; priapism of penis and clitoris is a rare but serious side effect |
| Antidepressant: Serotonin Antagonists and Reuptake Inhibitors (SARIs): Trazodone (generic only), Trazodone ER | Moderate blockade of 5-HT synaptic reuptake Significant sedative effect. Help with antidepressant- induced insomnia Severe sedation, hypotension, nausea Warning: Priapism has been reported |
| Antidepressant: Serotonin Antagonists and Reuptake Inhibitors (SARIs): Vilazodone (Viibryd) | Blocks reuptake of serotonin and serotonergic (5-HT1A) receptor partial agonist activity Take this medication with food to reduce GI disturbances Side Effects: Diarrhea, nausea, vomiting, dry mouth, dizziness, insomnia Warning: Palpitations, ventricular premature beats, serotonin syndrome |
| Antidepressant: Serotonin Antagonists and Reuptake Inhibitors (SARIs): Vortioxetine (Trintellix) | Blocks reuptake of serotonin May improve memory and cognition Side Effects: Constipation, nausea, vomiting Warning: Hyponatremia, rare induction of manic states, serotonin syndrome |
| Antidepressant: Norepinephrine Dopamine Reuptake Inhibitor (NDRI): Bupropion (Wellbutrin, Aplenzin, Forfivo XL, Zyban for smoking cessation) | Blocks the synaptic reuptake of norepinephrine and dopamine Stimulant action may reduce appetite. May increase sexual desire Used as an aid to quit smoking Side Effects: Agitation, insomnia, headache, nausea and vomiting, seizures (0.4%) Warning: High doses increase seizure risk, especially in people who are predisposed to them |
| Antidepressant: Noradrenergic and Specific Serotonergic Antidepressant (NaSSA): Mirtazapine (Remeron) | Enhances the release of norepinephrine and serotonin by blocking α2-adrenergic receptors that normally inhibit norepinephrine and serotonin Antidepressant effects equal SSRIs and may occur faster Side Effect: Weight gain/appetite stimulation, sedation, dizziness, headache; sexual dysfunction is rare Warning: Drug-induced somnolence exaggerated by alcohol, benzodiazepines, and other CNS depressants |
| Antidepressant: Tricyclic Antidepressants (TCAs) | Amitriptyline (generic only) Amoxapine (generic only) Desipramine (Norpramin) Doxepin (Sinequan) Imipramine (Tofranil) Maprotiline (generic only) Nortriptyline (Aventyl, Pamelor) Protriptyline (Vivactil) Trimipramine (Surmontil) |
| Antidepressant: Tricyclic Antidepressants (TCAs) cont. | Inhibit the synaptic reuptake of serotonin and norepinephrine. Antagonize adrenergic, histaminergic, muscarinic receptors Amoxapine antagonizes dopamine receptors Therapeutic effects similar to SSRIs, but side effects are more prominent |
| Antidepressant: Tricyclic Antidepressants (TCAs) Side Effects: | Side Effect: May work better in melancholic depression and in people with comorbid medical conditions Some therapeutic serum levels may be monitored Dry mouth, constipation, urinary retention, blurred vision, hypotension, cardiac toxicity, sedation Warning: Lethal in overdose; use cautiously in older adults with cardiac disorders, elevated intraocular pressure, urinary retention, hyperthyroidism, seizure disorders, and liver or kidney dysfunction |
| Antidepressant: Monoamine Oxidase Inhibitors (MAOIs): | Isocarboxazid (Marplan) Phenelzine (Nardil) Selegiline (Emsam Transdermal System Patch) Tranylcypromine (Parnate) |
| Antidepressant: Monoamine Oxidase Inhibitors (MAOIs) cont. | Inhibits the enzyme monoamine oxidase, which normally breaks down neurotransmitters, including serotonin and norepinephrine Efficacy similar to other antidepressants, but strict dietary (tyramine) restrictions and potential drug interactions make this drug class less desirable |
| Antidepressant: Monoamine Oxidase Inhibitors (MAOIs): Side Effects: | Side Effect: Insomnia, nausea, agitation, and confusion; hypertensive crisis Warning: Contraindicated in people taking SSRIs, used cautiously in people taking TCAs; tyramine-rich food could bring about a hypertensive crisis. Many other strong drug and dietary interactions |
| Serotonin Syndrome: Signs and Interventions | Symptoms • Hyperactivity or restlessness • Tachycardia → cardiovascular shock • Fever → hyperpyrexia • Elevated blood pressure • Altered mental states (delirium) • Irrationality, mood swings, hostility • Seizures → status epilepticus • Myoclonus, incoordination, tonic rigidity • Abdominal pain, diarrhea, bloating • Apnea → death |
| Serotonin Syndrome: Interventions | • Remove offending agent • Initiate symptomatic treatment • Serotonin-receptor blockade with cyproheptadine, methysergide, propranolol • Cooling blankets, chlorpromazine for hyperthermia • Dantrolene, diazepam for muscle rigidity or rigors • Anticonvulsants • Artificial ventilation • Induction of paralysis |
| Foods That Can Interact With Monoamine Oxidase Inhibitors | Unsafe Foods (High Tyramine Content): Vegetables: Avocados, especially if overripe; fermented bean curd; fermented soybean; soybean paste. Fruits: Figs, especially if overripe; bananas, in large amounts Meats: Meats that are fermented, smoked, or otherwise aged; spoiled meats; liver, unless very fresh Sausages: Fermented varieties; bologna, pepperoni, salami, others |
| Foods That Can Interact With Monoamine Oxidase Inhibitors cont. | Foods with yeast: Yeast extract (e.g., Marmite, Bovril) Fish Dried or cured fish; fish that is fermented, smoked, or otherwise aged; spoiled fish Milk, milk products: Practically all cheeses Beer, wine: Some imported beers, Chianti wines Other foods: Protein dietary supplements; soups (may contain protein extract); shrimp paste; soy sauce |
| Adverse Reactions to and Toxic Effects of Monoamine Oxidase Inhibitors | Hypotension Sedation, weakness, fatigue Insomnia Changes in cardiac rhythm Muscle cramps Anorgasmia or sexual impotence Urinary hesitancy or constipation Weight gain Hypotension is an expected side effect of monoamine oxidase inhibitors. Orthostatic blood pressures should be taken—first lying down, then sitting or standing after 1–2 min. This may be a dangerous side effect, especially in older adults who may fall and sustain injuries as a result of dizziness from the blood pressure drop. |
| Adverse Reactions to and Toxic Effects of Monoamine Oxidase Inhibitors cont. | Hypertensive crisis Severe headache Tachycardia, palpitations Hypertension Nausea and vomiting Patient should go to local emergency department immediately—blood pressure should be checked. One of the following may be given to lower blood pressure: 5 mg intravenous phentolamine (Regitine) or sublingual nifedipine to promote vasodilation. Patients may be prescribed a 10-mg nifedipine capsule to carry in case of emergency. |
| Brexanolone (Zulresso): | First and only FDA-approved medication specifically for postpartum depression |
| St. John’s Wort | Flower processed into tea or tablets Thought to increase serotonin, nerepinephrin, and dopamine in the brain Useful in mild to moderate depression **Can give negative interactions with other medications** |
| Electroconvulsive Therapy | **Use when drug & psychotherapy does not work** The most effective depression treatment Psychotic illnesses = second most common indication ECT the primary treatment in: Severe malnutrition, exhaustion, and dehydration due to lengthy depression Safer than meds with certain medical conditions Delusional depression Failure of previous medication trials Schizophrenia with catatonia |
| Vagus Nerve Stimulation | Originally used to treat epilepsy Decreases seizures and improves mood Electrical stimulation boosts the level of neurotransmitters Side effects : Voice alteration (nearly 60% of patients) Neck pain, cough, paresthesia, and dyspnea, which tend to decrease with time |
| Deep Brain Stimulation | Surgically implanted electrodes (in the brain) Stimulates those regions identified as underactive in depression More invasive than VNS Electrodes placed directly into the brain |
| Light Therapy | First-line treatment for seasonal affective disorder (SAD) Efficacy due to influence of light on melatonin Effective as medication for SAD Negative effects: headache and jitteriness |
| Exercise | Biological, social, and psychological effects Increases serotonin availability Dampens HPA axis (thought to be overly active in depression) |
| Advanced Practice Interventions: Psychological therapies | • Cognitive-behavioral therapy (CBT) |
Created by:
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