Suicide, Depression, Bipolar Disorder

What is suicidality?

All suicide-related behaviors and thoughts of completed SI

What is a suicidal gesture (parasuicide)?

Voluntary, a gesture of suicidal behavior, but aim is not death (i.e. making a noose)

What are risk factors for suicide?

• Family Hx

• Childhood trauma

• Previous attempt

• Mental illness (especially depression)

• Substance abuse

• Cultural beliefs (some might see it as a noble act)

• Barriers to mental health care

• Loss/grief

• Access to lethal methods

What are some protective factors against suicide?

• Effective and accessible tx

• Support from family, community, and healthcare providers

• Skills in problem-solving and nonviolent solutions

• Culture that discourages suicide

Nursing Interventions for SI

• SAFETY!! → initiate restraint if needed (lest restrictive), remove dangerous objects, help pt feel secure

• Risk Assessment: family hx, suicide attempt hx, results of previous attempts, assess level of judgment

• Medications

• Challenge suicidal mindset + develop coping skills

• Develop support network

Impact of Suicide in Families

• Increased risk for another suicide in the family

• Grief, guilt, shame, self-blame

• Anxiety, depression

• Family dysfunction

What is Persistent Depressive Disorder?

Chronic low mood for >2yrs

What is Disruptive Mood Dysregulation Disorder?

• Chronic low moods for >1yr

• More common in children

Major Depressive Disorder (MDD)

Person presents with 5 or MORE of these s/s (red ones are MANDATORY)

• S - sleep (insomnia/hypersomnia)

• I - interest loss + depressed mood

• G - guilt/hopelessness

• E - energy loss

• C - concentration difficulties

• A - appetite changes

• P - psychomotor (restlessness)

• S - SI, suicide attempt

Differences in Presentation of Depression (Ages)

• Children/Adolescent: irritable (not sad), high risk suicide, anxiety, somatic s/s (headache, stomach ache), avoidance of peers

• Older Adults: depression associated w/ chronic illness or dementia

Risk Factors for Depression

• Prior episode of depression

• Family Hx

• Lack of social support

• Lack of coping skills

• Environmental stressors

• Substance abuse

• Medical comorbidities

Etiology of Depression

• Bio: genetics, neurotransmitter alteration, increased inflammation of brain

• Psych: lack of love early in life, lack of rewarding activities, negative thinking/pessimism, major life event

• Social: familial and social events

Goals of Tx for Depression

• SAFETY!

• Reduce depressive s/s

• Reduce likelihood of relapse

• Improve occupation and psychosocial function

Electroconvulsive Therapy

• Contraindicated in pts w/ IICP, recent MI or CVA

• RN Role Before: obtained informed consent, ensure pre-labs are complete, teach pt to create memory list, make sure pt wears nonrestrictive clothing, mare sure they have someone to accompany them

• RN Role During: obtain emergency equipment, insert IV, give O2

• RN Role After: assist w/ ambulation, monitor v/s and neuro status, assist w/ follow-up appts

Transcranial Magnetic Stimulation

• Magnetic field activates inhibitory and excitatory neurons, causing neuroplasticity

• Contraindicated in pts w/ seizure risk, implanted metallic hardware, cochlear implants

Light Therapy

• Effective for “seasonal” depression

• Resets or shifts circadian rhythm

• Contraindicated if pt has eye condition

SSRIs

• First-line tx for depression

• I.e. Prozac, Zoloft

• Adverse Reaction: prolonged QT interval, fertility issues in men, discontinuation syndrome (withdrawal)

SNRIs

• Same effect as SSRIs, but have more sweating as s/e

• Adverse reaction: HTN, bleeding risk, discontinuation syndrome

Bupropion (Wellbutrin)

• S/e: dry mouth, nausea, insomnia, weight loss, increased libido

• Adverse reaction: seizures, HTN, agitation, higher risk for OD

• DONT take w/ alcohol

Tricyclic Antidepressants (TCAs)

• Older med = more s/e

• Adverse reactions: FATAL in case of OD (as little as 10 doses), Cardiotoxicity (QT prolongation, seizures, MI)

MAOIs

• Have worst s/e

• MUST AVOID food w/ tyramine (fermented cheese, wine, chocolate, meats)

• CANNOT be combined w/ other antidepressants (risk of serotonin syndrome)

Ketamine

• Used to treat resistant unipolar major depression

• Use only AFTER exhausting all other treatments (at least 2 meds for full trial periods)

What are some considerations for antidepressants?

• Use cautiously in those w/ Bipolar (may cause manic episode)

• May take 4+ weeks to be effective (Educate that they must stick w/ med for 6mo-1yr!). Stopping too soon can lead to depressive episode

• Risk of increased suicidality in children/adolescents

• SEROTONIN SYNDROME: hallucination, agitation, tachycardia, hyperthermia, hyperreflexia, n/v/d

  • Can be FATAL → discontinue med

Bipolar 1 vs. Bipolar 2

• 1: must experience a manic episode that lasts >4 days (NEGATES EVERYTHING)

• 2: meets have a current or part hypomanic episode AND MDD

What is a hypomanic episode?

• The same as a manic episode BUT it is the pts BASELINE, doesn’t affect social/occupational functioning

• Must last >7 days

• DIG FAST (distracted, indiscretion, grandiosity, flight of ideas, activity increase, sleep, talkativeness

What are some risk factors that may cause poor outcomes for bipolar disorder?

• Mixed/rapid cycling (switching between manic + MDD)

• Co-occurring mental disorders

• Severe impairment in school, social activities

• Multiple hospitalizations

• Lack of support system

What are some nursing interventions for bipolar disorder?

• SAFETY!

• Acute Stage: decrease stimulation, short explanations, redirect energy, promote SLEEP, promote NUTRITION

• Maintenance Stage: CBT, anticipate stressors, identify new episodes, minimize function impairment

• Medications

Lithium (General info, toxicity?, s/e)

• A mood stabilizer used for Bipolar disorder (usually for maintenance stage)

• NARROW THERAPEUTIC WINDOW → watch for kidney toxicity

• Keep hydrated (it is a salt, so lower fluids = high lithium levels)

Lithium Side Effects

Excessive thirst, metallic taste, urinary frequency, drowsiness, nausea, muscle weakness, kidney dmg

Lithium Target Range

0.6-1.4mEq/L

Anticonvulsants

• Reduce repetitive firing of action potentials to reduce manic episodes

• Contraindicated in pregnancy/lactation

• s/e: dizziness, drowsiness, tremor, n/v, vision changed, weight gain, hypotension

Divalproex Sodium (Depakote)

• Anticonvulsant

• Monitor liver functions → risk for hepatotoxicity

Carbamazepine (Tegretol)

• Watch for agranulocytosis/leukopenia -→ report if pt feels fever, sore throat, bruising or petechiae

• Monitor CBC

Lamotrigine (Lamictal)

• Watch for Steven-Johnson’s Syndrome → SEVERE RASH that can blister over the body and become life-threatening

• D/c med if this occurs

Antipsychotics

• Metabolized by liver

• S/e: Diabetes, increased prolactin levels, prolonged QT interval, orthostatic hypotension, weight gain, agranulocytosis

• Atypical antipsychotics are better for combined presentations

Neuroleptic Malignant Syndrome

• Life threatening condition → must monitor and transfer to ICU

• s/s: altered mental status, muscle rigidity, fever, tachycardia, sweating, elevated CK protein (muscle injury)

Extrapyramidal Symptoms

• Side effect to antipsychotics

• Dystonia, pseudoparkisonism, restlessness

Tardive Dyskinesia

• Irregular, repetitive involuntary movement of the mouth, face, tongue (chewing, tongue protrusion, eye-blinking, “pill-rolling”)

• Must report these because they might become irreversible