3210 D
Transcript of 3210 D
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Depressive Disorders: Diagnosis & Treatment
Objective 1: read Townsend (2014) page 379 (historical perspective) before listening to
the recording for this handout. This handout will inform you about how the DSM-5
presents this weeks assigned psychiatric disorders. Assigned questions 2/student are
noted on this handout. We will apply the NP in class on Friday, February 7, 2014. NP
content is in Townsend (2014) pages 392-403. My apology for the page numbers from
DSM-5 (2013) just ignore those; any important page numbers for Townsend have been
added to this handout.
The depressive disorders these depressive disorder diagnoses relate to Objective 3,
Townsend (2014) page 378Disruptive mood dysregulation disorderMajor depressive disorderPersistent depressive disorder (dysthymia)Premenstrual dysphoric disorderSubstance/medication-induced depressive disorderDepressive disorder due to another medical conditionOther specified depressive disorderUnspecified depressive disorder
DSM-IV-TR -> DSM-5Unlike in DSM-IV depressive disorders is separated from bipolar disorders.Depressive disorders in DSM-5 differ by :
duration,timing,or presumed etiology
The common feature of all depressive disorders in DSM-5 is the presence of :sad, empty, or irritable moodaccompanied by somatic changesand cognitive changesthat significantly affect capacity to function
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Disruptive Mood Dysregulation Disorder
296.99 Coding numbers associated with each diagnosis are used to receive
reimbursement for services related to the particular psychiatric diagnosis; we will
discuss related nursing diagnoses in class. There is a very helpful Table 16-5 in Townsend
(2014) pages 395-396)
This section relates to Objective 6, Townsend (2014) page 378 (symptomatology):A. Severe recurrent temper outbursts manifested verbally &/or behaviorally that are
grossly out of proportion in intensity or duration to the situation or provocation.B. The temper outbursts re inconsistent with developmental level.C. The temper outbursts occur, on average, three or more times per week. D. The mood between temper outbursts is persistently irritable or angry most of the
day, nearly every day, and is observable by others. E. Criteria A-D present for 12 or more months with no period lasting 3 or more
consecutive months without A-D.F. Criteria A & D present in at least 2 of 3 settings & severe in at least 1 setting.G. The diagnosis should not be made for the first time before age 6y or after age
18y.H. By history or observations, the age of onset of Criteria A-E is before 10y.
I. There has never been a distinct period lasting >1d during which the full symptoms
criteria, except during, for a manic or hypomanic episode have been met.J. The behaviors do not occur exclusively during an episode of major depressive
disorder and are not better explained by another mental disorder.K. The symptoms are not attributable to the physiological effects of a substance or
to another medical or neurological condition.Diagnostic Features
Core feature is chronic, severe persistent irritability with 2 prominent
manifestations:frequent temper outbursts &chronic, persistently irritable or angry mood present between severe temper
outbursts
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Prevalence this relates to Objective 2, Townsend (2014) page 378 (epidemiology)Disruptive mood dysregulation disorder is common among children presenting to
pediatric mental health clinicsPrevalence estimates of the disorder in the community are unclear but probably
fall in the 2-5% rangeRates are expected to be higher in males & school-age children than in females &
adolescentsDevelopment & Course this relates to Objective 5, Townsend (2014) page 378
Onset must be before age 10yThe diagnosis should not be used for children < 6yApproximately 50% of children with severe, chronic irritability will have a
presentation that continues to meet criteria for the condition 1y laterRates of conversion to bipolar disorder are very low & these children tend to
develop unipolar depressive &/or anxiety disorders as adultsRisk & Prognostic Factors
TempermentalChildren typically exhibit complicated psychiatric historiesPre-diagnostic presentations of chronic irritability may meet the diagnostic
criteria for oppositional defiant disorderChildren may also meet the diagnostic criteria for ADHD and an anxiety disorder
from a relatively early ageFor some children diagnostic criteria for major depressive disorder may also be
metGenetic & physiological
This disorder tends to be associated with familial anxiety disorders, mood
disorders, and substance abuseGender-Related Diagnostic Issues
Children presenting to clinics with features of disruptive mood dysregulationdisorder are predominately maleA male preponderance also appears to be supported in the communityThis is a difference when compared to bipolar disorder, in which there is an equal
gender prevalence
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Suicide RiskIn general, evidence documenting suicide behavior and aggression, as well as
other severe functional consequences, in disruptive mood dysregulation disorder
should be noted when evaluating children with chronic irritabilityFunctional Consequences
Marked disruption in a childs:family relationships
peer relationships - trouble initiating & sustaining friendshipsschool performance
Common to both DMDD and pediatric bipolar disorder are:dangerous behaviorSuicidal ideation or attemptssevere aggressionpsychiatric hospitalization
Differential DiagnosisBipolar disordersOppositional defiant disorderADHDMajor depressive disorderAnxiety disordersAutism spectrum disorderIntermittent explosive disorder
Co-morbidityRates of comorbidity in DMDD are extremely highIt is rare to find persons whose symptoms meet criteria for DMDD aloneAlso, the range of comorbid illnesses appears particularly diverseHowever, children with DMDD should not have symptoms that meet criteria for
bipolar disorderIf symptoms meet criteria for ODD or IED & DMDD, only the diagnosis of DMDD
should be assignedAlso, DMDD should not be assigned if the symptoms occur only in an anxiety-
provoking context (ex. ASD, OCD, MDD)
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Major Depressive DisorderThis section relates to Objective 6, Townsend (2014) page 378
(symptomatology for MDD)
A. Five or > present during the same 2w period representing a change from previous
functions with at least one symptom either depressed moor or loss of
interest/pleasure:Depressed mood, diminished interest, change in >5% of weight/m with
change in appetite, sleep changes, psychomotor retardation or agitation,
fatigue, feelings of worthlessness/guilt, difficulty concentrating, and
thoughts of deathB. Symptoms cause clinically significant distress or impairment in social,
occupational or other important areas of functioningC. Episode not attributable to the physiological effects of a substance or to
another medical conditionOccurrence of MDE is not better explained by:
Schizoaffective disorderSchizophreniaSchizophreniform disorderDelusional disorder orOther specified & unspecified schizophrenia spectrum & other
psychotic disordersE. There has never been a manic or hypomanic episode
Diagnostic FeaturesSymptoms of MDD must be present nearly every day with the exception of weight
change and SIDepressed mood must also be present for most of the day in addition to being
present nearly every dayCaution: insomnia or fatigue is often the presenting complaintPsychomotor disturbance much < common but indicative of greater overall severity,
as is delusional or near-delusional guiltAnhedonia is nearly always present to some degreeAppetite & sleep disturbances considered hallmarksDistractible, difficulty thinking may be mistaken for dementia (pseudodementia)
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Thoughts of death, SI, suicide attempts may range from passive to transient but
recurrent to putting affairs in order, acquiring means, and choosing a location and
time.Associated Features
MDD is associated with high mortality mostly suicide but other examples include
greatly increased likelihood of death in the first year after being admitted to a
nursing homeOften present:
tearfulirritablebroodingobsessively ruminatingphobicexcessively worrying about physical healthcomplaints of painin children separation anxiety
Prevalence -this relates to Objective 2, Townsend (2014) page 378 (epidemiology) 12m prevalence of MDD in US is ~7% with marked differences by age and gender:
Age: 18-29y 3x > persons 60yGender: females 1.5-3x > males beginning in early adolescence
Development & Course
May first appear at any ageLikelihood of onset increases markedly with pubertyU.S. incidence appears to peak in 20sHowever, first onset in late life is not uncommon Course is:
VariableChronicity > underlying personality, anxiety and substance use disordersRecovery typical within 3m of onset for 40% & within 1y for 80%Risk of recurrence becomes progressively lower as duration of remission
increasesRisk & Prognostic Factors this relates to predisposing factors in Townsend (2014)
Temperamental -Neuroticism (negative affectivity)
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Environmental -Adverse childhood experiences & stressful life eventsGenetic & physiological - First-degree family members with MDD increases risk 2-4X >
than the general population (or ~40% heritability)Course modifiers:
Substance abuseAnxietyBPDChronic, disabling medical conditions
Culture-Related Diagnostic IssuesClinicians should be aware that in most countries the majority of cases of
depression go unrecognized in primary care settingsIn many cultures, somatic symptoms are very likely to constitute the presenting
complaint insomnia and loss of energy most commonly reported
Gender-Related Diagnostic IssuesAside from prevalence of MDD there are no clear differences between genders
observed in:SymptomsCourseTreatment responseFunctional consequences
Suicide RiskSuicide attempt > in females; completion > in males but disparity in suicide rate
by gender is not as great with depressive disorders as it is in the general
populationMost consistently described risk is past history of suicide attempts or threats (BPD
markedly increases risk for future attempts)However, most completed suicides are not preceded by unsuccessful attempts Other risk factors include:
MaleSingle or living aloneProminent feelings of hopelessness
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Functional ConsequencesImpairment may be mild such that persons who interact with the depressed person
are unaware of his/her depressed symptomsImpairment may range to complete incapacity with the person unable to attend to
basic self-care needs or is mute or catatonicIn general medical settings persons experiencing MDD have > pain and physical
illnessDifferential Diagnosis
Manic episodes with irritable mood or mixed episodesMood disorder due to another medical conditionSubstance/medication-induced depressive or bipolar disorderADHDAdjustment disorder with depressed moodSadness
Co-morbiditySubstance-related disordersPanic disorderOCD
Anorexia nervosaBulimia nervosaBPD
300.4Persistent Depressive Disorder- This section relates to Objective 6, Townsend(2014) page 378 (symptomatology)
A. Depressed mood most of day, > days than not, subjective or objective, for at least2yB. While depressed 2 or > of appetite changes, sleep changes, fatigue, low self-
esteem, poor concentration, feelings of hopelessnessC. During the 2y period (1y for C&A) person never without criteria A & B > 2m at a
time
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D. Criteria continually present for 2yE. Never a manic or hypomanic episode nor cyclothymiaF. Not better explained by persistent schizophrenia spectrum or psychotic disorderG. Not attributable to physiological effects of a substance or another medical
conditionH. Symptoms cause significant distress or functional impairmentSee specifiers, DSM-5 (2013) page 169
Diagnostic FeaturesEssential feature of dysthymia is depressed mood for most of day, > days than not
for at least 2y (1y for C&A)Consolidates DSM-IV chronic MDD & dysthymic disorder
Prevalence12m U.S. prevalence ~0.5% for persistent depressive disorder and ~1.5% for chronic
major depressive disorderDevelopment & Course- this relates to Objective 5, Townsend (2014) page 378
Onset is often early & insidiousEarly onset associated with a higher likelihood of co-morbid Personality disorders
& Substance use disordersBy definition the course is chronic
Risk &Prognostic FactorsTemperamental
Factors predictive of poorer long-term outcome include:higher levels of negative affectivityGreater symptom severityPoorer global functioningPresence of anxiety disorder or
Presence of conduct disorderEnvironmental
Parental lossParental separation
Genetic & physiologicalPersons with dysthymia will have a higher proportion of
first-degree relatives with dysthymia
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A number of brain regions have been implicated in
dysthymiaPossible polysomnographic abnormalities exist as well
Functional ConsequencesThe degree to which dysthymia impacts functioning likely varies widely, but effects
can be as great or > than with MDDDifferential Diagnosis
MDDPsychotic disordersDepressive or bipolar & related disorder due to another medical conditionSubstance/medication-induced depressive or bipolar disorderPersonality disorders
Co-morbidityHigher risk for psychiatric comorbidity in general & particularly anxiety disorders
and substance use disorders than persons with MDDEarly-onset dysthymia strongly associated with DSM-IV personality disorders in
cluster B (antisocial, borderline, histrionic, narcissistic) & cluster C (avoidant,
dependent, OCD)625.4
Premenstrual Dysphoric Disorder-This section relates to Objective 6, Townsend
(2014) page 378 (symptomatology)A. In the majority of menstrual cycles, at least 5 symptoms present the final week
before onset of mensesB. One or > marked affective lability, irritability, depressed mood, anxietyC. One or > must also be present to total 5:
Decreased interest in usual activitiesSubjective difficulty concentratingEasy fatigabilityAppetite changesSleep changesSense of being overwhelmed or out of controlPhysical symptoms such as breast tenderness, joint or muscle
pain, bloating, weight gainD. Clinically significant distress or functional impairment
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E. Not just an exacerbation of another disorders but may co-occurF. Provisional diagnosis made until at least 2 symptomatic cycles are confirmedG. Not attributable to a substance or another medical condition
Recording ProceduresIf symptoms have not been confirmed by prospective daily ratings of a least two
symptomatic cycles, thenprovisionalshould be noted after the name of the
diagnosis:Premenstrual dysphoric disorder, provisionalDiagnostic Features
Mood labilityIrritabilityDysphoriaAnxietyThere must be a symptom-free period in the follicular phase after the menstrual
period beginsAssociated Features
Delusions & hallucinations have been described in the late luteal phase of the
menstrual cycle but are rare
The premenstrual phase has been considered by some to be a risk period for suicidePrevalence
12m prevalence 1.8 5.8% in menstruating womenBest estimate is 1.3% meeting current criteria with functional impairment and
without co-occurring symptoms from another mental disorderDevelopment & Course - this relates to Objective 5, Townsend (2014) page 378
Any time after menarcheSymptoms cease after menopauseCyclical hormone replacement can trigger the re-expression of symptoms
Risk & Prognostic FactorsEnvironmental
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StressHistory of interpersonal traumaSeasonal changesSociocultural factors related to:
Female sexual behaviorFemale gender role
Genetic & physiologic - UnknownCourse modifiers - Fewer premenstrual complaints are associated with use of oral
contraceptivesCulture-Related Diagnostic Issues
Not a culture-bound syndromeUnclear whether rates differ by raceHelp-seeking patterns may be significantly influenced by cultural factors
Diagnostic MarkersDaily Rating of Severity of ProblemsVisual Analogue Scales for Premenstrual Mood SymptomsPremenstrual Tension Syndrome Rating Scale
Functional ConsequencesSymptoms must be associated with clinically meaningful distress or functional
impairment in the week prior to menses
Chronic interpersonal problems should not be confused with the dysfunction that
occurs only in association with premenstrual dysphoric disorder.Differential Diagnosis
Premenstrual syndromeDysmenorrheaBipolar disorderMajor depressive disorder
Persistent depressive disorder (dysthymia)Use of hormonal treatments
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Co-morbidityA wide range of medical and mental disorders may worsen in the premenstrual
phase:MigraineAsthmaAllergiesSZdepressive disorderBipolar disorderAnxiety disordersBulimia nervosaSubstance use disorders
Substance/Medication-Induced Depressive Disorder (DSM-5, 2013)ICD-9-CM Recording Procedures
Naming the substance/medication-induced depressive disorder begins with:The specific substance presumed to be causing the
depressive symptomsFollowed by specification of onset - Onset during
intoxication or onset during withdrawalExample: 292.84 cocaine-induced depressive disorder, with onset during withdrawalDiagnostic Features
The depressive symptoms are associated with the ingestion, injection or inhalation
of a substance and symptoms persist beyond the expected length of the
physiological effects, intoxication or withdrawal periodPrevalence
In a nationally representative U. S. adult population, the lifetime prevalence of
substance/medication-induced depressive disorder is 0.26%Development & Coursethis relates to Objective 5, Townsend (2014) page 378
Onset must occur while the person is using the substance OR during withdrawalMost often onset is within the first few weeks or 1m use of the substanceOnce the substance is D/Cd symptoms usually remit within days to several weeks
(depending upon half-life)
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A history of certain identified substances may help increase diagnostic certaintyRisk &Prognostic Factors
Temperamental - Pertain to the specific type of drugEnvironmental - Pertain to the specific type of medicationCourse modifiers - more likely to be:
MaleBlackHave at most a high school educationLack insuranceLower family incomeStressful life events in past 12mHigher family history of: substance abuse
and/or APDDiagnostic Markers
Laboratory assays of the suspected substance in blood or urine to corroborate the
diagnosisSuicide Risk
FDA meta-analyses reveal an absolute risk of suicide in patients taking
investigational antidepressants of 0.01% (this evidence indicates that suicide is an
extremely rate treatment-emergent phenomenon)FDA Black Box Warning (2007) carefully monitor treatment-emergent SI in
patients receiving antidepressantsDifferential Diagnosis
Substance intoxication and withdrawalPrimary depressive disorderDepressive disorder due to another medical condition
Co-morbidityAny DSM-IV mental disorderPathological gamblingParanoid personality disorderHistrionic personality disorderAPD
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Alcohol use disorderDepressive Disorder Due to Another Medical DisorderThis section relates to Objective 6,
Townsend (2014) page 378 (symptomatology)A. A prominent and persistent period of depressed mood or markedly diminished
interest or pleasure in all, or almost all, activities that predominates the clinical
picture B. Evidence from history, physical exam or lab findings that the disturbance is the
direct consequence of another medical conditionC. Not better explained by another mental disorder in which the stressor is a serious
medical conditionD. Does not occur exclusively during the course of a delirium
E. Causes clinically significant distress or functional impairment
Specify if:With depressive features
With major depressive-like episodeWith mixed features
Diagnostic FeaturesClinician must first establish the presence of a general medical conditionMood disturbance is present in time of onset, exacerbation or remission of the
general medical conditionFeatures are atypical of primary mood disorders
Associated FeaturesThe list of medical conditions that are able to induce major depression is never
completeClinicians best judgment is the essence of this diagnosisHowever, there are clear associations with:
StrokeHuntingtons diseaseParkinsons diseaseTBICushings diseaseHypothyroidismMS
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Development & Coursethis relates to Objective 5, Townsend (2014) page 378Example: Following stroke the onset of depression has been observed to be very
acute, occurring within 1d or a few days of the CVA; however, cases have been
noted where onset of depression was weeks to months following CVA Risk & Prognostic Factors
Risk of acute, early onset of MDD following CVA appears to be strongly correlated
with lesion location, with the greatest risk associated with (L) frontal strokesGender-Related Diagnostic Issues
Gender differences pertain to those associated with the medical condition (ex. SLE,
CVA)Diagnostic Markers
Diagnostic markers pertain to those associated with the medical condition (ex.
Cushings)Suicide Risk
No epidemiological studies providing evidence to differentiate risk from suicide
related to MDD versus MDD due to another medical conditionThere is a clear association between serious medical illness and suicide, particularly
shortly after onset or diagnosis of the illness
Functional ConsequencesFunctional consequences pertain to those associated with the medical condition
Differential DiagnosisDepressive disorders not due to another medical conditionMedication-induced depressive disorderAdjustment disorders
Co-morbidityConditions comorbid with depressive disorder due to another medical condition are
those associated with the medical conditions of etiological relevanceDelirium may occur before or along with depressive symptoms in persons with a
variety of medical conditions
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The association of anxiety symptoms is common in depressive disorders regardless
of the cause
311 Other Specified Depressive DisorderThis section relates to Objective 6, Townsend
(2014) page 378 (symptomatology)Used in situations in which the clinician chooses to communicate the specific reason
this presentation does not meet the criteria for any specific depressive disorderExamples:
Recurrent brief depressionShort-duration depressive episode (4-13d)Depressive episode with insufficient
symptoms311 Unspecified Depressive Disorder
Applies to presentations in which symptoms characteristic of a depressive disorder
causing clinical significant distress or functional impairment do not meet the full
criteria for any of the disorders in this depressive disorders diagnostic classUse this diagnosis in situations in which you choose not to specify the reason that
the criteria are not met for a specific depressive disorder (possibly due to
insufficient information to make a > specific dx such as in the emergency
department)Specifiers for Depressive Disorders
With anxious distress
With mixed featuresWith melancholic featuresWith atypical featuresWith psychotic featuresWith catatoniaWith peripartum onsetWith seasonal patternAlso specify if in partial remission or full remissionAlso specify current severity
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Objectives 7 -12, Townsend (2014) will be discussed in class 2/7/14.
Student assignments:
Herbert: (1) Describe how individual psychotherapy is used as a treatmentmodality for depression (supplement your answer with the information from at least
one current scholarly article & attach the article to your answer). (2) Describe how group
therapy is used as a treatment modality for depression (supplement your answer with
the information from at least one current scholarly article & attach the article to your
answer).
Allyson:(1) Describe how family therapy is used as a treatment modality for
depression (supplement your answer with the information from at least one current
scholarly article & attach the article to your answer). (2) Describe how cognitive therapy
is used as a treatment modality for depression (supplement your answer with the
information from at least one current scholarly article & attach the article to your
answer).
Shauntay: (1) Describe how electroconvulsive therapy (ECT) is used as a treatment
modality for depression (supplement your answer with the information from at least
one current scholarly article & attach the article to your answer). (2) Describe how
transcranial magnetic stimulation is used as a treatment modality for depression
(supplement your answer with the information from at least one current scholarly
article & attach the article to your answer).
Erica: (1) Describe how light therapy is used as a treatment modality for depression
(supplement your answer with the information from at least one current scholarly
article & attach the article to your answer). (2) Describe how psychopharmacology is
used as a treatment modality for depression (supplement your answer with the
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information from at least one current scholarly article & attach the article to your
answer).
Tatyana:(1) Describe the interactions the nurse needs to be aware of that may
occur when a patient is prescribed a tricyclic antidepressant (TCA) to treat depression
(supplement your answer with the information from at least one current scholarly
article & attach the article to your answer). (2) Describe the interactions the nurse needs
to be aware of that may occur when a patient is prescribed a monoamine oxidase
inhibitor (MAOI) to treat depression (supplement your answer with the information
from at least one current scholarly article & attach the article to your answer).
Denea:(1) Describe the interactions the nurse needs to be aware of that may occur
when a patient is prescribed a selective serotonin reuptake inhibitor (SSRI) to treat
depression (supplement your answer with the information from at least one current
scholarly article & attach the article to your answer). (2) Describe the interactions the
nurse needs to be aware of that may occur when a patient is prescribed a serotonin-
norepinephrine reuptake inhibitor (SNRI) to treat depression (supplement your answer
with the information from at least one current scholarly article & attach the article to
your answer).
Sophie:(1) Describe the most common side effects that occur with SSRIs
(supplement your answer with the information from at least one current scholarly
article & attach the article to your answer). (2) Describe the most common side effects
that occur with MAOIs (supplement your answer with the information from at least one
current scholarly article & attach the article to your answer).
Samantha: (1) Describe the client/family education related to antidepressants
(supplement your answer with the information from at least one current scholarly
article & attach the article to your answer). (2) Describe the epidemiology of suicide
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(supplement your answer with the information from at least one current scholarly
article & attach the article to your answer).
Cheryl:(1) Describe how to assess the client for suicide potential (supplement your
answer with the information from at least one current scholarly article & attach the
article to your answer). (2) Describe protective factors for suicide risk (supplement your
answer with the information from at least one current scholarly article & attach the
article to your answer).
Garrett:(1) Identify nursing diagnoses and related outcomes for the suicidal client
(supplement your answer with the information from at least one current scholarly
article & attach the article to your answer). (2) Identify appropriate nursing
interventions for the suicidal client (supplement your answer with the information from
at least one current scholarly article & attach the article to your answer).
Anna: (1) What suggestions should be made for the family and friends of a person
who is suicidal? (supplement your answer with the information from at least one current
scholarly article & attach the article to your answer). (2) What are appropriate nursing
interventions for families and friends of suicide victims? (supplement your answer with
the information from at least one current scholarly article & attach the article to your
answer).
Juliana: (1) How does the RN conduct evaluation of the suicidal client? (supplement
your answer with the information from at least one current scholarly article & attach the
article to your answer). (2) Juliana & Dana: Remaining questions will be
assigned for chapter 17: Bipolar and Related Disorders.
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Reviewed & revised 2/4/14 -lgf