Depressive Disorders

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Chapter 13

• Depressive Disorders

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Major Depressive Disorder

• History of one or more major depressive episodes
• No history of manic or hypomanic episodes
• Symptoms interfere with social or occupational
  functioning
• May include psychotic features
• Affects twice as many women as men
• Onset usually occurs in the persons mid-30s

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Major Depressive DisorderSubtypes

• Psychotic features
• Melancholic features
• Atypical features
• Catatonic features
• Postpartum onset
• Seasonal features seasonal affective disorder
  (SAD)

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Proposed Subtypes

• Premenstrual dysphoric disorder
• Mixed anxiety-depression
• Recurrent brief depression
• Minor depression

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Dysthymic Disorder

• Chronic depression for the majority of most days
  for at least 2 years
• Symptoms are less severe than major depression
  with fewer physiologic symptoms
• Predispose people to develop major depression
• Often occur in childhood and adolescence

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Epidemiology

• Leading cause of disability in the United States
• Children and adolescents
• Older adults
• Comorbidity

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Etiology

• Biological factors
• Genetic
• Biochemical
• Alterations in hormonal regulation
• Diathesis-stress model
• Psychological factors
• Cognitive theory
• Learned helplessness

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Nursing Process

• Assessment
• Self-assessment
• Unrealistic expectations of self
• Feeling what the patient is feeling
• Assessment tools
• Assessment of suicide potential
• Key assessment findings

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Assessment

• Subjective Data
• Suicidal ideation
• Feelings of sadness
• Fatigue
• Lack of interest
• Feelings of worthlessness
• Impaired concentration and decision-making
  ability
• Sleep disturbance (insomnia or hypersomnia)
• Appetite changes (weight gain or weight loss)
• Somatic concerns

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Assessment

• Objective Data
• Females under the age of 40
• Prior episodes of depression
• Family history of mood disorder
• History of recent stressful event
• Lack of social support
• Psychomotor agitation or retardation
• Pattern of social withdrawal
• Lack of social participation

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Nursing ProcessContinued

• Areas to assess
• Affect
• Thought processes
• Mood
• Feelings
• Physical behavior
• Communication
• Religious beliefs and spirituality

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A Mnemonic for Symptoms of MDD SIGECAPS

• Sleep changes
• Interest (lost of)
• Guilt (worthlessness, hopelessness, regret)
• Energy loss of fatigue
• Concentration difficulties
• Appetite changes (low or increased appetite,
  weight loss or gain)
• Psychomotor retardation or agitation
• Suicidality

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• Which question would be a priority when assessing
  for symptoms of major depression?

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• Tell me about any special powers you believe you
  have.
• You look really sad. Have you ever thought of
  harming yourself?
• Your family says you never stop. How much sleep
  do you get?
• Do you ever find that you dont remember where
  youve been or what youve done?

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Nursing ProcessContinued

• Nursing Diagnosis
• Risk for suicide safety is the highest priority
• Hopelessness
• Ineffective coping
• Social isolation
• Spiritual distress
• Self-care deficit

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Nursing ProcessContinued

• Outcomes Identification
• Recovery model
• Focus on patients strengths
• Treatment goals mutually developed
• Based on patients personal needs and values

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Nursing ProcessContinued

• Planning
• Geared towards
• Patients phase of depression
• Particular symptoms
• Patients personal goals

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Nursing ProcessContinued

• Implementation
• Three phases
• Acute phase (6 to 12 weeks)
• Continuation phase (4 to 9 months)
• Maintenance phase (1 year or more)

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Nursing ProcessContinued

• Basic Level Interventions
• Counseling and communication
• Health teaching and health promotion
• Promotion of self-care activities
• Milieu therapy

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Nursing ProcessContinued

• Identify the patients potential for suicide
• Create a safe environment
• Formulate verbal contract with patient to notify
  staff members when feelings begin to get out of
  control
• Encourage patient to express anger in acceptable
  ways
• Assists patient in recognizing strengths and
  accomplishments
• Assist patient in performing activities of daily
  living

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Nursing ProcessContinued

• Assess for suicide risk by direct questioning
  about suicidal thinking, history of suicide
  attempts, and whether the client has a specific
  suicide plan
• The more organized the plan is, the more concern
  it generated as safety is a priority
• Suicidal clients should be placed under suicide
  precautions
• Close staff supervision
• Remove items such as sharps, belts, shoe laces,
  mirror etc.
• No-suicide contract

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Nursing ProcessContinued

• Advanced Practice Interventions
• Psychotherapy
• Cognitive behavioral therapy (CBT)
• Interpersonal therapy (IT)
• Time-limited focused psychotherapy
• Behavior therapy
• Group therapy

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Psychopharmacology

• Tricyclic antidepressants (TCAs)
• Neurotransmitter effects (5HT, NE)
• FDA Indications MDD, Childhood Enuresis
• Contraindications mitral valve disease, heart
  blocks increased heart rate and fatal arrhythmias
• Overdose Effects Delirium, hyperthermia,
  convulsion, coma, respiratory failure and death.

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Side Effects of TCA

• Anticholinergic (dry mouth, dry eyes, blurred
  vision, constipation, palpitations, and urinary
  retention)
• Tremors, Twitching
• Orthostatic hypotension
• Paresthesias
• Ataxia
• Increased suicidal thoughts
• Sexual Dysfunction
• Weight gain 10 20 lbs
• Dizziness
• Sedation

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Tricylic Antidepressant

• Amitriptyline - Elavil (25 - 300 mg/d)
• Amoxapine - Asendin (25 - 600 mg/d)
• Clomipramine - Anafranil (25 - 250 mg/d)
• Desipramine - Norpramin (10 - 300 mg/d)
• Doxepin - Sinequan (10 - 300 mg/d)
• Imipramine - Tofranil (10 - 300 mg/d)
• Maprotiline - Ludiomil (25 - 225 mg/d)
• Nortriptyline - Pamelor (50 - 150 mg/d)
• Protriptyline - Vivactil (5 - 60 mg/d)
• Trimipramine - Surmontil (25 - 200 mg/d)

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PsychopharmacologyContinued

• Monoamine oxidase inhibitors (MAOIs)
• Neurotransmitter effects
• Indications useful in atypical depression
  (increased sleep, increased appetite, anxiety,
  rejection
• Adverse/toxic effects hypertensive crisis
• Interactions
• Drug Sympathomimetics, SSRIs, SNRIs, TCA
• Food Foods containing tyramine

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Monoamine Oxidase Inhibitors (MAOI)

• Phenelzine - Nardil (7.5 - 90 mg/d)
• Tranylcypromine - Parnate (10 - 60 mg/d)
• Isocarboxazid - Marplan (20 - 60 mg/d
• Selegiline - Emsam (Patch) 6mg - 12mg/d
• Moclobemide Manerix (Canada)
• St. Johns Wort
• Side effects Dizziness, headache, stiff neck,
  N/V, restlessness, insomnia, dry mouth, sexual
  dysfunction, weight gain and Hepatic necrosis

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The BIG Deal with MAOI

• Food interaction pickled, fermented, smoked, or
  aged foods, such as red wine, preserved food,
  aged stinky cheese, which leads to hypertensive
  crises resulting in intracranial bleed.
• Drug Interaction
• Other antidepressants
• OTC cold and flu medications
• Demerol

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Psychopharmacology

• Antidepressants
• Selective serotonin reuptake inhibitors (SSRIs)
• First-line therapy
• Indications
• Adverse reactions
• Potential toxic effects

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Selective Serotonin Reuptake Inhibitor (SSRI)

• Citalopram - Celexa (20-60 mg/d) 1998
• Escitalopram - Lexapro (10-20 mg/d) Isomer of
  Citalopram
• Fluoxetine - Prozac (20-80 mg/d) 1987
• Prozac Weekly (90 mg enteric-coated delayed
  release capusule)
• Sarafem (20 - 60 mg/d for PMS)
• Fluvoxamine - Luvox (50 - 300 mg/d)
• Paroxetine - Paxil (20 - 50 mg/d)
• Paxil CR (12.5 - 62.5 mg/d) enteric coated
• Sertraline - Zoloft (50 - 200 mg/d) 1992

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Possible Side Effects SSRI

• Nausea and Vomiting
• Nervousness
• Sleep disturbance
• Somnolence
• Constipation
• Sexual dysfunction libido and orgasm
• GI upset
• Tremors
• Weight gain
• Cognitive problems word finding

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Issues With SSRIs

• Discontinuation Symptoms
• Dizziness
• Nausea
• Pins and needles
• Zappers
• (Prozac does not cause discontinuation symptoms
  16 weeks half life)
• Loss of efficacy poop out
• Partial response

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Serotonin Norepinephrine Reuptake Inhibitor SNRI

• Venlafaxine - Effexor, (75 - 225 mg/d)
• Effexor XR (75 - 225 mg/d)
• Desvenlafaxine Pristiq (50 400 mg/d)
• Duloxetine Cymbalta (20-60 mg/d for depression
• 60 - 120 mg/d for diabetic peripheral
  neuropathy)

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Other Antidepressants

• Bupropion - Wellbutrin, Wellbutrin SR,
  Wellbutrin XL, Zyban - (75-450 mg/d)
• Enhances release of norepinephrine and dopamine
  (NDRI)
• Be careful in people with history of seizure
  disorder, head
• trauma and eating disorders.
• Side effects anxiety, agitation, insomnia,
  nausea, tremor and
• weight loss
• Mirtazapine - Remeron (15 - 45 mg/d) SN
• Nefazodone - Serzone (200 - 600 mg/d)
• Trazadone - Desyrel (200 - 600 mg/d)

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Serotonin Syndrome

• Mild in most people, recovery within 24 - 72
  hours, although it can cause death under
  circumstances
• Seen in people taking two or more medications
  that increase levels of serotonin in the CNS
• Symptoms 3 of the following must be present
• Mental status changes
• Agitation
• Myoclonus
• Shivering
• Hyperreflexia
• Ataxia
• Diaphoresis
• hyperpyrexia

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Management and Prevention of Serotonin Syndrome

• Supportive measures
• Discontinue medication
• Provide benzodiazepine
• Anti-serotonergic agents Periactin, Sansert,
  Inderal
• Dantrium for relieving muscle rigidity and
  hyperthermia

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Other Treatments for Depression

• Electroconvulsive therapy (ECT)
• Transcranial magnetic stimulation
• Vagus nerve stimulation
• Light therapy
• St. Johns wort
• Exercise

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Electroconvulsive Therapy (ECT)

• Treatment procedure during which an electric
  current is passed through the brain. Unilateral
  or bilateral
• Indication severe depression, acute mania,
  psychotic symptoms, acutely suicidal
• Treatment is 3 times a week until the course of
  12 treatments is completed
• Causes generalized seizure (tonic-clonic)
• Contraindication ICP and recent MI
• Side effects transient short-term memory loss
• Not a cure

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Working with Clients Receiving ECT

• Consent forms completed
• Keep pt NPO for at least 4 hours
• Ask the patient to void and remove contact
  lenses, jewelry, hairpins, and dentures prior to
  treatment
• Assess vital signs
• Medications Robinul, Brevital, Anectine
• Recovery lateral recumbent position, orient to
  time, place and situation
• Offer food
• Offer medication for Headache

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Complimentary and Alternative Medicine

• St Johns Wort (Hypericum perforatum) (1,200mg
  1,800mg)
• SAM-e (s-adenosylmethionine) (800mg/d)
• Omega 3 FFA (1 2 grams/d)
• Folic Acid (0.3mg/d)
• Nature Made
• Jarrow
• Life Extension

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Complimentary and Alternative Medicine

• Meditation help with stress, mood disturbance,
  anxiety, depression, pain of chronic illness,
  other conditions
• Pressure point therapies (acupuncture,
  acupressure) healing, pain relief, physical and
  emotional well-being
• Touch therapies, including massage reduced pain
  and anxiety, relaxation and healing help for
  depression, addiction, dementia, anxiety

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Nursing ProcessContinued

• Evaluation
• Short-term indicators and outcome criteria
• Reassess and reformulate care plan as necessary
• Future of treatment