Depressive Disorders CHAPTER 14 Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. Primary Depressive Disorders Major depressive disorder Potential for pain and suffering in all aspects of life Affects children, teenagers, adults, elderly Dysthymia Chronic depressed mood > 1 year for children and adolescents > 2 years for adults and elderly 2 Depression 3 It is impossible to convey adequately the personal pain and suffering experienced by an individual going through a severe depressive episode. A races, all ages, and both genders are susceptible to depressive episodes, although some individuals are more vulnerable than others. Major Depressive Disorder (MDD) Epidemiology Lifetime Prevalence Rates Twice as common in women Children and adolescents Elderly Recurrence rates 1 episode 60% recurrence 2 episodes 70% recurrence 3 episodes 90% recurrence 4 Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. Comorbidity Anxiety disorders Substance abuse Schizophrenia Personality disorders (borderline personality disorder) Eating disorders 5 Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. Depression and Chronicity In terms of chronic conditions seen in medical practice, depression is secondary only to hypertension. Approximately 16.5% of people older than age 18 in the United States will have a major depressive disorder in their lifetime. 6 Depressive Disorders Classified Disruptive mood dysregulation disorder Premenstrual dysphoric disorder Substance abuse depressive disorder (Table 14-1) Depressive disorder associated with another medical condition (Table 14-1) Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 7 MDD DSM V 5 or more symptoms for greater than two weeks One must be either anhedonia or depressed mood Plus 4 of the following: Clear change from previous function Significant distress/impairment in social, occupational, or family functioning 8 Weight gain/lossGuilt Insomnia/hypersomniaPsychomotor agitation or retardation Anergia (decreased energy) or fatigue Decreased concentration WorthlessnessInappropriate guilt IndecisivenessSuicidal ideation Other MDD Symptoms Vague somatic aches and pains Uncharacteristic anger/frustration Vegetative symptoms Change in appetite Change in sleep Constipation Lack of interest in sex 9 Dysthymia (Persistent Depressive Disorder) DSM V Depressed mood for most of the day, for more days than not for at least 2 years in adults and one year in children Plus two or more of the following: Decreased or increased appetite Insomnia or hypersomnia Low energy or chronic fatigue Decreased self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness or despair 10 Dysthymia Continued Often occurs before 21 Even in childhood and adolescence Chronic course 0.5% lifetime prevalence 11 MDD in Children Children as young as 3 have been diagnosed with depression Somatic complaints Psychomotor retardation, hypersomnia Irritability/aggression 12 Mental Health Issues Related to Aging Depression is not a normal part of aging Late-Life Mental Illness Depression vs. dementia Depression and suicide risk 13 Tourettes Disorder Motor and verbal tics Causes marked distress Causes significant impairment in: Social functioning Occupational functioning Average age of onset of motor tics is 7 years of age; can appear as early as 2 years of age 14 Case Study A nurse is going to interview an elderly patient. What are some techniques the nurse could use to help the patient feel more comfortable? Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 15 Etiology Biological factors Genetic Biochemical Stressful life events Alterations in hormonal regulation Inflammatory process Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 16 Etiology continued Diathesis-Stress Model Psychological vulnerabilities Stress Neurochemical and neurophysical changes in the brain Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 17 18 All Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc. Positron-emission tomography (PET) scan: A 45-year-old woman with recurrent depression with no medication (left). Same patient treated with medication (right). The entire brain, particularly the left prefrontal cortex, is more active after recovery. Image courtesy Mark George, MD, NIMH Etiology (Cont.) Psychological factors Cognitive theory Becks negative triad Learned helplessness Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 19 Nursing Process: Assessment Safety first Suicide potential Key symptoms Depressed mood Anhedonia Anxiety Anergia Somatic complaints Vegetative signs 20 Nursing Process (Cont.) Areas to assess Affect Thought processes Mood Feelings Physical behavior Communication Religious beliefs and spirituality Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 21 Nursing Process (Cont.) Age considerations Children and adolescents Older adults Self assessment Feeling what the patient is feeling Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 22 Assessment Tools Beck Depression Inventory Hamilton Depression Scale Geriatric Depression Scale Zung Depression Scale National Mental Health Association23 Question 1 Which question would be a priority when assessing for symptoms of major depression? A.Tell me about any special powers you believe you have. B.You look really sad. Have you ever thought of harming yourself? C.Your family says you never stop. How much sleep do you get? D.Do you ever find that you dont remember where youve been or what youve done? Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 24 Nursing Process Continued Nursing Diagnosis Risk for suicide safety is always the highest priority Hopelessness Ineffective coping Social isolation Spiritual distress Self-care deficit 25 Nursing Process (Cont.) Outcomes identification Recovery model Focus on patients strengths Treatment goals mutually developed Based on patients personal needs and values Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 26 Nursing Process (Cont.) Planning Geared toward Patients phase of depression Particular symptoms Patients personal goals Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 27 Nursing Process (Cont.) Implementation Three phases Acute phase (6 to 12 weeks) Continuation phase (4 to 9 months) Maintenance phase (1 year or more) Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 28 Basic Level Interventions Observational status Contraband assessment/interventions Communication Counseling Encourage self-care activities Maintain therapeutic milieu Health teaching Administer medications per physician/ advanced practice nurse Assess effects of medications 29 Interventions Promoting improved self-esteem Provide distraction through milieu 1:1 therapeutic interactions with the staff Activities at patients level Increase difficulty as patient progresses Acknowledge accomplishments without flattery or excessive praise (matter-of-fact) Help patients identify own personal strengths 30 Interventions Help patient question underlying assumptions and consider alternate explanations Work with patient to identify cognitive distortions (review T14-4) Overgeneralizations Self-blame Mind reading Discounting positive attributes 31 Interventions Accept patients negative feelings but set limits on amount of time for negative expression Matter-of-fact style Redirect to neutral topics Teach assertiveness techniques Teach how to replace negative thoughts to positive focus Stop negative audiotapes Cognitive reframing 32 Interventions Promote feelings of control Team approach Give patient choices & responsibility whenever possible Decrease you make me feel terminology, replace with I feel _____ when ______. Set short term realistic goals with the patient Help patient identify ways to gain control Identify small manageable steps 33 Interventions Promote feelings of control Team approach Give patient choices & responsibility whenever possible Decrease you make me feel terminology, replace with I feel _____ when ______. Set short term realistic goals with the patient Help patient identify ways to gain control Identify small manageable steps 34 Communication Guidelines: Severely Withdrawn Patients Technique of making observations Simple, concrete words Allow time for response Listen for covert messages and ask about suicide plans Avoid platitudes Sit quietly with patient 35 Nursing Process Continued Advanced Practice Interventions Psychotherapy Cognitive behavioral therapy (CBT) Interpersonal therapy (IT) Time-limited focused psychotherapy Behavior therapy Group therapy 36 Treatments for Depression Electroconvulsive therapy (ECT) Transcranial magnetic stimulation Vagus nerve stimulation Light therapy St. Johns wort SAMe Exercise Ketamine 37 Electroconvulsive Therapy (ECT) Procedure NPO 4-6 hrs before procedure Hold antiseizure meds night before Atropine like drug Short acting anesthetic Skeletal muscle relaxant Artificial ventilation O2 Bite block, no restraints 38 ECT Continued Induces Grand Mal seizure Fatigue, confusion, disorientation initially Short term memory loss, headache Nursing interventions Re-orientation VS Check gag reflex Education Monitor bradycardia, hypotension Watch for post ECT agitated delerium 39 Psychopharmacology Classes of antidepressants First-line agents Selective serotonin reuptake inhibitors (SSRIs) Newer atypical antidepressants (SNRIs, NRIs, NDRIs, SNDIs, etc) Tricyclic antidepressants (TCAs) Second-line interventions Monoamine oxidase inhibitors (MAOIs) Electroconvulsive therapy (ECT) 40 Antidepressant Drugs (Cont.) Selective serotonin reuptake inhibitors (SSRIs) Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro) Fluvoxamine (Luvox) Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 41 Selective Serotonin Reuptake Inhibitors (SSRIs) Atypical antidepressant / first line agent Block reuptake of Serotonin (5HT) Increased 5HT in the synapse Fewer side effects Lower ACh effects, less cardiotoxicity than TCAs Faster onset of action Greatly reduced lethality in OD Safer, better compliance 42 SSRIs continued Common SE: agitation, anxiety, sleep disturbance, tremor, sexual dysfunction (anorgasmia), headache, GI upset, diarrhea Central Serotonin Syndrome rare and potentially life threatening Overactivity of the central serotonin receptors Highest potential when 2 serotonin enhancing antidepressant actions overlap (must consider half-life when changing drugs) CNS symptoms (similar to NMS) Treatment: supportive 43 Serotonin Syndrome 44 Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. Antidepressant Drugs (Cont.) Serotonin-norepinephrine reuptake inhibitors (SNRIs) Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Duloxetine (Cymbalta) Norepinephrine reuptake inhibitors (NRI) Roboxetine (Vestra, Edronax) Serotonin Antagonist and Reuptake Inhibitor (SARI) Trazodone (Desyrel) Used as a non addictive sleep medication at sub therapeutic doses Rare side effect: priapism Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 45 Newer Atypical Antidepressants Continued Neurotransmitters Norepinephrine Dopamine Reuptake Inhibitor (NDRI) Bupropion (Wellbutrin XR, SR) Helps in ADHD, chronic fatigue, sexual side effects from other antidepressants, anxiety disorders No weight gain Decreases seizure threshold, agitation, insomnia Smoking cessation (Zyban) Serotonin Norepinephrine Disinhibitors (SNDI) Mirtazepine (Remeron) Used in the elderly for the usually adverse effect of weight gain 46 Newer Atypical Antidepressants Continued Advantages Effexor: useful for treatment-resistant chronic depression, highest remission rates, low drug interactions, fast onset of action Remeron: Low sexual dysfunction, no sleep disturbance, low drug interactions Cymbalta: Fast onset of action, mild side-effects, decreases neuopathic pain Vestra: non-sedating Nefazodone: lower risk of weight gain and sexual side effects Disadvantages Effexor: possible increase in BP (10-15mg) Remeron: weight gain, sedation Cymbalta: twice a day dosing Vestra: ACh, decreased libido, drug interactions, twice a day dosing Nefazodone: liver toxicity, priapism 47 Psychopharmacology (Cont.) Tricyclic antidepressants (TCAs) Nortriptyline (Pamelor) Amitriptyline (Elavil) Imipramine (Tofranil) Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 48 Tricyclic Antidepressants (TCAs) Elevate mood blocks uptake of NE and to a lesser extent 5HT by the presynaptic cell Increased neurotransmitter in the synapse Promote circadian sleep patterns many cause sedation best if taken HS days to begin effectiveness, full effects may take 4-8 weeks 49 TCAs Disadvantages/Common Adverse Effects Sedation Anticholinergic action Cardiovascular effects Adrenergic action Caution in elderly and those with cardiac disease Highly lethal in OD Lowers seizure threshold Multiple drug interactions Weight gain 50 Antidepressant Drugs Second - Line Agents Monoamine oxidase inhibitors (MAOIs) Phenelzine (Nardil) Tranylcypromine (Parnate) Selegiline Transdermal System Patch (EMSAM) 51 MAOIs Continued Common adverse effects OH, weight gain, edema, constipation, urinary hesitancy, sexual dysfunction, insomnia, change in cardiac rate/rhythm Hypertensive crisis Many food/drugs also contain monoamines (tyramine) which are not broken down systemically as well as in the brain leading to a toxic level of monamines and hypertensive crisis Check all drugs even OTC with health practitioner Symptoms: headache, stiff/sore neck, palpitations, chest pain, n/v, pyrexia Elevated blood pressure with possible development of IC hemorrhage, hyperpyrexia, convulsions, coma, death 52 Foods That Contain Tyramine Vegetables: avocados, fermented beans, sauerkraut Fruits: overripe figs/bananas in large amounts Meats: fermented, smoked, aged meats (fresh meat is ok) Sausages: pepperoni, salami, bologna Fish: dried, pickled, smoked, cured or aged fish All cheeses except cottage cheese and cream cheese Most imported beer, Chianti Soy sauce, soups with protein extract, shrimp paste, protein dietary supplements 53 Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 54 Case Study Your patient was just diagnosed with a major depressive disorder. What medication do you anticipate the health care provider will start the patient on? Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 55 Case Study (Cont.) What side effects might the patient experience? Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 56 Nursing Process (Cont.) Evaluation Suicide ideation Intake Sleep pattern Personal hygiene and grooming Self-esteem Social interaction Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 57 Audience Response Questions 1.A patient with major depression walks and moves slowly. Which term should the nurse use to document this finding? A.Psychomotor retardation B.Psychomotor agitation C.Vegetative sign D.Anhedonia Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 58 Audience Response Questions 2.Which assessment finding in a patient with major depression represents a vegetative sign? A.Restlessness B.Hypersomnia C.Feelings of guilt D.Frequent crying Copyright 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc. 59 Audience Response Questions 3. Tyramine is found in which of the following? A. Fresh ground beef B. Corn C. Cucumber D. Avocado 60 All Elsevier items and derived items 2013, 2009 by Saunders, an imprint of Elsevier Inc.