Depressive Disorders (Chapter 14)

What is the diagnostic criteria for 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

What is the significance on major depressive disorder diagnosis requirements?

Patients must have one or more major depressive episodes → This can be difficult for patients! They have to go through this several times before they can get on medication

What are the subtypes of major depressive subtypes?

• Psychotic features

• Melancholic features: sad, somber

• Atypical features: don’t act themselves

• Catatonic features: staring blankly like a zombie

• Postpartum onset:

• Seasonal features (seasonal affective disorder (SAD)): prominent in Alaska because of light!)

Proposed subtypes of major depressive disorder

• Premenstrual dysphoric disorder

• Mixed anxiety depression

• Recurrent brief depression

• Minor depression

Dysthymic disorder

• Chronic depressive syndrome

• Present for most of the day

• More days than not

• At least present for 2 years

Epidemiology of depression

• Leading cause of disability in the United States and around the world

• Children and adolescents

• Older adults (mainly due to isolation, can’t do what they used to)

• Comorbidity

Etiology of major depressive disorder

Biological factors

• Genetic (runs in the family like most other mental illnesses)

• Biochemical: alterations in hormonal regulation (Diathesis stress model)

Psychological factors

• Cognitive theory

• Learned helplessness

Nursing process: assessment

Self-assessment:

• Unrealistic expectations of self: feeling what the patient is feeling

• Assess suicide potential (usually take anger or negative feelings and bring it inward to self, so not as often a homicidal risk)

Other areas to assess

• Thought process

• Mood

• Feelings

• Physical behavior

• Communication

• Religious beliefs and spirituality

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 don’t remember where you’ve been or what you’ve done?

B: Suicide risk is a critical concern in depression assessment:

Asking about suicidal thoughts is essential to identify potential self-harm behaviors and provide necessary support.

What is always the highest priority for the nursing assessment of someone with depression?

Risk for suicide! Safety is always the highest priority.

3 phases of treatment:

1. Acute phase (6-12 weeks)

2. Continuation phase (4-9 months), when meds start to work

3. Maintenance phase (1 year or more), starting to see positive results

Basic level interventions

• Counseling and communication

• Health teaching and health promotion

• Promotion of self-care activities

• Milieu therapy

What is the BEST kind of therapy for depression?

Cognitive behavioral therapy

The therapist educates the patient to become their OWN therapis and work through their problems

What is the second-best kind of therapy for depression?

Group therapy

The patient identifies good and bad coping mechanisms and can relate to the other group members

Advanced practice interventions

Psychotherapy:

• Cognitive behavioral therapy (CBT)

• Interpersonal therapy (IT)

• Time-limited focused psychotherapy

• Behavior therapy

• Group therapy

What kind of antidepressants are the first-line therapy for depression?

Selective Serotonin Reuptake Inhibitors (SSRI)

• Indications

• Adverse reactions

• Potential toxic effects

Sometimes the best to use in conjunction with drugs like Abilify, which is normally for Schizophrenia; very small amount with SSRI will enhance the SSRi and will get better relief!

Tricyclic antidepressants (TCAs)

• Neurotransmitter effects

• Indications:

• Adverse effects:

• Contraindications:

Monoamine oxidase inhibitors

• Neurotransmitter effects:

• Indications:

• Adverse/toxic effects:

• Interactions:

  • Drugs

  • Food: smoked cheese, smoked salmon, smoked meats, avocado

• Contraindications:

Can lead to serotonin syndrome → seizures!!

What are some of the other treatments for depression?

• Electroconvulsive therapy (ECT) - only do this if NOTHING ELSE WORKS!!! AFFECTS THE HEART

• Transcranial magnetic stimulation

• Light therapy

• St. John’s Wort

• Exercise- THE BEST! 🙂 Release endorphins!

Disruptive mood dysregulation disorder

• Symptoms of constant and severe irritability and anger

• Diagnosis made between the ages of 6 and 18 with onset before age 10

• Must exhibit symptoms in at least 2 of the following settings: home, school, and with peers:

• More common in males than females

• More common in children

• If symptoms resemble major depressive disorder, antidepressants can be used

• If manic episode occurs, bipolar disorder may be a possibility

• CBT is essential

Persistent Depressive Disorder (Dysthymia)

• Low-level depression occurs most of the day for the majority of days

• Last at least 2 years in adults and 1 year in children and adolescents

• Depressed mood with 2 of the following:

  • decreased appetite or overeating

  • Insomnia or hypersomnia

  • Low energy

  • Poor self esteem

  • Difficulty thinking

  • Hopelessness

• Not severe enough to require hospitalization

• “Always felt this way” and depression seems like nromal functioning

• Early onset and chronic illness

• More common in women

• Common to go undiagnosed

• Similar to major depressive disorder

• Psychotherapy (CBT), antidepressants (SSRIs, SNRIs, TCAs)

Premenstrual dysphoric disorder

• Cluster of symptoms that occur in the last week before the onset of a woman’s period

• Severe enough symptoms to interfere with the ability to work or interact with others

• S/s: mood swings, irritability, depression, anxiety, feeling overwhelmed, difficulty concentrating, lack of energy, overeating, bloating, weight gain, etc

• Symptoms decrease with the onset of menstruation

Substance/medication-induced depressive disorder

• Result of prolonged use of or withdrawal from drugs and alcohol

• Depressive symptoms last longer than the length of physiological effects

• Symptoms appear within one month of use

• Once the substance is removed, depressive symptoms remit within a few days to several weeks

Depressive disorder due to another medical condition

• Depression may be caused by another medical condition

• May affect the body’s system or from long-term illness that causes ongoing pain

  • Cushings disease

  • Hypothyroidism

  • HIV

  • Arthritis

  • Back pain

  • Metabolic conditions

  • Diabetes

What is one of the most common psychiatric disorders?

Major Depressive Disorder

• 17 million adults in US (7% of the population)

• Characterized by persistently depressed mood lasting for a minimum of two weeks

• Length of a depressive episode maybe 5 to 6 months

• May be chronic >2 years

• Recurring episodes

Depression and the seasons (SAD)

• Same diagnosis as major depressive disorder but with the addition of a seasonal pattern

• 2 seasonal depressive episodes during the same time period

• Symptoms: hypersomnia, overeating, weight gain, and carbohydrates

• More common in women 18-30 years old

• Populations farthest from the equator most affect

What is bereavement exclusion

Clinicians were once advised against diagnosing a person with depression in the first two months following a signficant loss = bereavement exclusion

• Normal mourning could be labeled pathological

• A psychiatric diagnosis could result in a lifelong label

• Unnecessary medications might be described

HOWEVER, things have changed and now someone can receive medication given in the first 2 months following the death of a loved one or other loss

What is the leading cause of disability worldwide?

Depression

• More common in females

• Most common in young adults (18-25)

• Having two or more races or being white = higher rates of depression

• 7% of US adults

Psuedodementia

Psychomotor and cognitive slowing of depression may resemble a neurocognitive disorder, such as Alzheimer disease

Depressive syndromes frequently accompanies other psychiatric problems such as:

• Schizophrenia

• Substance use

• Eating disorders

• Borderline personality

• Schizoaffective disorder

Combination of depression and anxiety is one of the most common psychiatric presentation

Risk factors for depression

Combination of biological, psychological, and cultural variables

Unlikely that there is a single cause of depression

• female gender

• ACEs

• Stressful life events

• first-degree family members with major depressive disorder

• Neuroticism (negative personality trait)

• Substance use, anxiety, personality disorders

• Chronic medical conditions

Biological factors for depression

Genetic

• Identical twins have a 50% chance of depression of the other has it

• Multiple genes involved

Biochemical

• CNS neurotransmitter abnormalites as result of genetic or enviroenmtnal factors, or other meci al condiiotns (cerebral infaraction, Parkinsons, hypothyroidism, AIDs, or drug use)

• Serotonin and o

What main 2 neurotransmitters are responsible for mood?

1. Serotonin: a regulator of sleep, appetite, and libido (if deficient, can lead to low appetite, low sex drive, poor impulse control and irritability)

2. Norepinephrine: modulates attention and behavior, and is stimulated by stressful situations which may result in overuse and deficiency, which can cause apathy, reduced responsiveness, or slowed psychomotor activity

Depression may result from other dysregulations, such as glutamate and GABA. Stressful life events also can trigger depression, as it affects neurotransmitters like norepinephrine, serotonin and acetylcholine!

How do hormones affect depression?

Neurotransmitters and hormones have the same receptors and pathways in the mood area of the brain

People with depression have increased cortisol levels and elevated corticotropin-releasing hormone

Estradiol (form of estrogen) affects receptors sensitive to serotonin in the areas of the brain a

How does inflammation affect depression?

Inflammation may be the result of psychological injury as well

In young females with a history of adversity depression is accompanied by elevations in C-reactive protein and interleukin-6

Many people with major depression have elevated inflammatory biomarkers in the absence of physical illness

What is the diathesis stress model?

• Considers the interplay between genetic and biological predisposition toward depression and life events

• Physiological vulnerabilities, such as genetic and biological predisposition, biochemical makeup, and personality structure are all referred to as diathesis

• The stress part refers of the life events that impact the individual’s vulnerabilities

• Biochemically, psychosocial stressors and interpersonal events trigger neurophysical and neurochemical changes in the brain

• Early trauma may lead to neuronal loss and lead to exaggerated stress responses

What is the cognitive theory?

The underlying assumption that a person’s thoughts will result in emotions

If someone looks at life in a positive way, they will experience positive emotions and vice versa

People may acquire a psychological predisposition to depression due to early life experiences, which contribute to negative, illogical and irrational thought process that are activated during times of stress

How do we screen for depression?

• Beck Depression inventory

• Hamilton Depression Scale

• Geriatric Depression Scale

• Patient Health Questionnaire

What is the most dangerous aspect of major depressive disorder? What should you ask the patient?

Preoccupation with death

• Negativistic thoughts are referred to as suicidal ideation

• May be mild and fleeting or persistent and involve a plan

• Always evaluate for suicidal ideation

  • You said you are depressed. Tell me what that is like for you.

  • When you feel depressed, what sort of thoughts do you have?

  • Have you had thoughts of ending your life? Do you have any plans? Do you have the means to carry out your plan?

What are the key symptoms in depression

• Depressed mood

• Anhedonia (inability to feel pleasure)

• Anxiety

• Exaggeraton on percived faults anf ailures

• Unable to recognize strengths and successes

• Delusions congruent with negative mood

• Feeling sof worthlessenss, hoplessness, guilt, anger, and helpenessess

Describe the relationship between pain and depression.

• Depression and chronic pain are often seen together in primary care

• Neurotransmitters and nerve pathways are shared

• Acts in a vicious cycle

• Two-way Interaction between pain and depression

Nursing assessment: Appearance

• Poor grooming

• Poor hygiene

• Do not take pride in appearance

• No eye contact

• slumped or hunched, low head, and shoulders forward

Nursing assessment: Behavior

• Anergia: abnormal lack of energy

• Psychomotor agitation: pacing, nail biting, finger tapping

• Vegetative signs of depression: alterations in activities necessary to support physical life and growth (eating, elimination, sleeping, and sex)

• Sleep pattern disturbance is hallmark sign of depression (insomnia or hypersomnia)

Nursing assessment: Mood

Mood = general emotional state

Depressed mood evident for weeks

Nursing assessment: Feelings and emotions

Emotions/feelings = related to and flow from mod, more specific and can come and go quickly

• Worthlessness

• Guilt

• Helplessness

• Hopelessness

• Anger

• Suicidality

• Anger and irritability (usually directed inward as self-destructive behaviors)

• Anhedonia: inability to feel pleasure or happiness, disinterest in interaction with others resulting in insolation

Nursing assessment: Affect

Affect = outward representation of a person’s internal state and is objective finding based on the nurse’s assessment

• Constricted affect (reduction in the range and intensity of normal expression)

• Blunted (or shallow) affect is more severe and represents significant decrease in emotional reactivity

• Flat affect is no or nearly no emotional expression or reactivity

Nursing assessment: Speech

• Slow and softly

• Monotone

• Lack of spontaneity

Nursing assessment: Thought processes

• Slow thinking

• Poverty of though

• Absent responses or slow responses

• May be mute

Nursing assessment: Thought content and perceptions

In profound depression, psychotic features (delusions, hallucinations) may be present

• May be mood congruent and focus on depressive themes

• May hear critical voices

• Psychosis increases the risk of suicide, self-harm and other-directed violence

Nursing assessment: Insight and judgment

• Cannot problem solve

• Poor judgment

• Indecisiveness

Nursing assessment: Cognitive changes

Decreased ability to concentrate and decide

Deficits in short-term and working memeory

Issues with problem solving

Dysfunctions in processing speed

Dysfunction in auditory and visual processing

How do we screen older adults for depression?

Geriatric Depression Scale - uses yes and no so it is easier to answer

3 phases of implementation of treatment for depression

1. Acute phase - 6 to 12 weeks, reduction if depressive symptoms and restoration of psychosocial and work function, may need hospitalization and medication or other biological treatments

2. Continuation phase: 4 to 9 months, directed at prevention of relapse through meds, education, and psychotherapy

3. Maintenance phase: 1 year plus, directed at prevention of further episodes

What is important to remember about conversing with patients with depression?

Silence is a good thing! Just sitting with them can be helpful

What is the prefrontal cortex responsible for?

Regulates role in executive functions and emotional control and memory

What is the limbic system responsible for?

Regulates activities such as emotions, physical and sexual drives, the stress response, and learning and memory

What is the anterior cingulate cortex responsible for?

Regulates heart rate and blood pressure, decision making, emotional regulation, error detection, preparation for tasks and executive functions

Imbalance of ______ contribute to depression

Neurotransmitters like serotonin and norepinephrine

What medications are used to treat depression?

• Selective reuptake inhibitors (SSRIs)

• Serotonin reuptake inhbitors (SNRIs)

• Serotonin antagonists and reputake inhibitors (SARIs)

• Norepinephrine dopamine reupake inhibitor (NDRI)

• Noradrenergic and specific sertotonergic antidepresants (NaSSAs)

• Ticyclic antepressants (TCAs)

• Monamine oxidase inhibitors (MAOIs)

What do antidepressants help treat

Positively impact poor self-concept, social withdrawal, vegetative signs of depression, and activity level

• Sleep disturbance

• Appetite disturbance

• Fatigue

• Decreased sex drive

• Psychomotor retardation or agitation

• Impaired concentration

• Anhedonism

What is the drawback to antidepressant drugs? What can we do if someone is acutely suicidal?

Improvements may take 1 to 3 weeks or longer → electroconvulsive therapy

• May precipitate psychotic episode in a person with schizophrenia or manic episode with a patient with bipolar

How do SSRIs work?

• Block the neuronal uptake of serotonin to increase the availability of serotonin in the synaptic cleft

SSRI side effects

Low side-effect profile compared to other antidepressants

Do not create anticholinergic effects, dry mouth, blurred viosn or urinary retention.

BUT they mat cause:

• agitation

• Anxiety

• Sleeo distubrnace

• Tremor

• Sexual dysfunction

• Tension headache

• Autonomuc reactions (dry mouth, sweating, weight chance, nausea, loos bowel movements)

Indications for SSRIs

• First line treatment for depression

• Help with OCD and panic disorer

• Can helpw tih prenmenttural dsysphric disorder and bulimia

Poteitnial toxic effects of SSRIs

Serotonin syndrome

Overactivation of central serotonin receptors

Symptoms:

• abdominal pain

• Diarrhea

• Sweating

• Fever

• Tachycardia

• Elevated BO

• Altered mental state (delirium)

• Myoclonus (muscle spasm)

• Increased motor activity

• Irritability

• Mood change

  May lead to hyperpyrexia (HGIH FEVER), cardiovascular shock, DEATH

HIGHEST RISK IF administered with monoamine oxidase inhibitors (MAOI). Patient should discontinue SSRIs before starting MAOIs.

Serotonin norepinphrine inhibitors

• Inibit the reuptake of serotonin and norepinephine

• Similar affects of SSSRIs but not tolerated as well

• May increase BP

Action of tricyclic antidepressants

• Inhibit the reuptake of norpepinephrine and serotonin and parkinsonain symtoms

• Followed by CNS depression

• Used caustiously in suicidal patients

Tricyclic antidepressant contraindications

People who have recently had an MI, narrow-angle glaucoma, hx of seizures, pregnancy

How do monoamine oxidase inhibitors work?

• Monoamine oxidase is responsible for inactivating monamine neutrotransmitters such as norepinipehrine, serotnin, dopamine and tyramine → fewer amines get inactvated → increased mood-elevating neurotrasmitters

Indications for MAOIs

Third line antidepressants

Significant drug reactions and dietary restrictirions

Common adverse reactions for MAOIs

• Orthostatic hypotension

• Weight gain

• Edema

• Change in cardiac rate and rhtyhm

• Constipation

• Urianry heistance

• Sexual dysfunction

• Vertigo

• Overacitivty

• Muscle twitching

• Hypomanic and manic behacior

• Insomnia

• Weakesess

• Fatigue

Toxic effects of MAOIs

Inability ti break down tyramine

At risk if people eat tyramine rich foods → risk for hypertensive crisis!!! CVA, intracranial hemorrhage, and death

MONITOR BLOOD PESSURE DURING TREATMENT AND D NOT EAT FOODS WITH TYRAMINE

Early signs of MAOI toxicity

Irritability

Anxiety

Flushing

Sweai=ting

Severe headache

Later signs of MAOI toxicity

• Anxiety

• restlessness

• Fever

• Seizures

• Coma

• death

Treatment for MAOI toxicity hypertensive crisis

• Gastric lavage and chacoal

• Treat purexia with hypothemic blankets or ice packs

• Fluid therapy

• Short-acting antihypertenive agent

• Intravenous benzos for anxiety and agitation and seixure control

Contraindications for MAOIs

• Cerebrovascular disease

• Hypertension

• Congestive heart failure

• Liver disease

• Consumption of foods containing tyramine

• Certain medications

• Surgery in past 10 days

• Age <16

What is St. johns wort?

Flower processed into tea or tablets, increases serotonin, norepinephirne and dpamine effects on the brain resulting in antidpressant effects

Risks for ECT

• Seozure

• Hupertension

• Congestive heart failure

• Cardiac arrhythmias

• Increased cerebtal oxygen, blood flow and ICP

CORRECT ANSWER: D

CORRECT ANSWER: B, C, D

CORRECT ANSWER: A

CORRECT ANSWER: B, C, E

CORRECT ANSWER: A

CORRECT ANSWER: A

CORRECT ANSWER: D

CORRECT ANSWER: C

CORRECT ANSWER: B

CORRECT ANSWER: A