NU 125 Mental Health Nursing: Mood Disorders + Depression

Mood

pervasive and sustained emotion that has major influences on a person's perception of the world

Affect

external, observable emotional reaction associated with an experience

Mood continuum

Range of emotional states from depression to mania

Normal emotional states

Sad, euthymia, happy

Euthymia

normal range of moods and emotions

There are many different ________ of depression.

types

Dysthymia

a form of depression that is not severe enough to be diagnosed as major depression

Substance/medication induced depression

Depressed mood and physiological affects due to direct use of a substance or medication

Depression occurs due to..

a combination of genetics, biochemical, and psychosocial experiences

Depression is more common in..

women

Risk factors for depression

Genetics

Prior depressive episodes

Lack of social supports

Stressful life events

Multiple medical problems

Substance use

Depression can occur..

from childhood to the elderly

Depression ranges from..

transient to severe

DSM 5: Major Depression

Depressed mood or anhedonia with impairment in function for at least 2 weeks and at least 5 of the listed symptoms

Symptoms of Major Depression

1. Decrease or increased in appetite

2. Psychomotor agitation or slowing

3. Insomnia or hypersomnia

4. Fatigue or anergia

5. Feelings of worthlessness, excessive guilt

6. Decreased concentration or decisiveness

7. Suicidal ideation

Anhedonia

inability to feel pleasure

Common neurotransmitter disturbances with depression

Serotonin

Norepinephrine

Dopamine

Areas of the Brain Impacted by depression

Hippocampus

Amygdala

Hypothalamus

Limbic structures

Frontal cortex

Medications for Depression

SSris/SNRis

What do SSRIs and SNRIs do?

Increase serotonin and or norepinephrine

When assessing symptoms of depression, the nurse should assess what 4 areas?

Affective

Cognitive

Behavioral

Physiological

Affective

despair, feelings of worthlessness, hopelessness, sadness, anger, anhedonia, anxiety

Cognitive

delusional, confusion, indecisiveness, decreased concentration, self-deprecating, thoughts of self-harm, suicidal ideations

Behavioral

tearfulness, social isolation, anger outbursts, self-harm

Physiological

decreased appetite, sleep disturbances, psychomotor slowing, psychomotor agitation

Levels of Depression

Transient

Mild

Moderate

Severe

Transient depression

normal, "the blues"

Affective symptoms of transient depression

"the blues"

Cognitive symptoms of transient depression

some difficulty getting mind off one's disappointment

Behavioral symptoms of transient depression

some crying

Physiological symptoms of transient depression

feeling tired and listless

Mild depression

less severe symptoms, but can last for years

Affective symptoms of mild depression

Anger and anxiety

Cognitive symptoms of mild depression

preoccupied with loss

Behavioral symptoms of mild depression

tearful, age-related regression

Physiological symptoms of mild depression

insomnia, anorexia, pain sensations, headaches

Moderate depression

dysthymic disorder persistent depressive disorder

Affective symptoms of moderate depression

helpless, powerless

Behavioral symptoms of moderate depression

slowed physical movements, slumped posture, limited verbalization

Cognitive symptoms of moderate depression

slowed thinking processes, difficulty with concentration

Physiological symptoms of moderate depression

anorexia, overeating, sleep disturbance, or headaches

Severe depression

major depressive disorder and bipolar depression

Affective symptoms of severe depression

feelings of total despair, worthlessness, flat affect, and anger

Behavioral symptoms of severe depression

psychomotor retardation, curled-up position, absence of communication, and social isolation

Cognitive symptoms of severe depression

presents of psychosis, prevalent delusional thinking, delusions of persecution and somatic delusions, confusion, suicidal thoughts

Physiological symptoms of severe depression

general slow down of the body

Most Effective Treatment Modality for Depression

Antidepressants paired with talk therapy

Other treatment

Antidepressants

Light box therapy

Talk therapy

Cognitive behavioral therapy (CBT)

Electroconvulsant Therapy (ECT)

Repetitive transcranial magnetic stimulation (rTMS)

How long do antidepressants take to work?

2-6 weeks for mood changes

Monoamine Oxidase Inhibitors (MAOIs)

antidepressant medications that block the enzyme monoamine oxidase

What do MAOIs result in?

elevated levels of norepinephrine

Why are MAOIs not a first-line treatment?

risk of hypertensive crisis and other fatal side effects

Risk of hypertensive crisis due to increased epinephrine levels in blood is associated with..

foods high in tyramine

Foods high in tyramine

cheese, soy sause, pepperoni, salami, processed meats, bananas, wine, bear, nuts

phenelzine (Nardil)

MAOI antidepressant

MAOIs also have many..

drug-drug interactions that can lead to hypertensive crisis, such as some decongestants

Tricyclic antidepressants (TCA)

antidepressants that prevent the reuptake of norepinephrine and serotonin and require medical clearance before starting

Why is medical clearance needed with TCAs?

EKG changes

What should be noted with TCAs?

Overdose is very dangerous

Discontinue SLOWLY

Assess serum levels to assess toxicity

Narrow window of safety

Side effects of TCAs

anticholinergic effects, orthostatic hypotension, lowered seizure threshold

Anticholinergic effects

dry mouth, blurred vision, constipation, urinary retention

nortriptyline (Pamelor)

tricyclic antidepressant

Selective Serotonin and Serotonin Norepinephrine Reuptake Inhibitors (SSRI and SNRI)

front line and most widely used antidepressants that inhibit reuptake of serotonin at the pre-synaptic neuron, increasing levels

Side effects of SSRI and SNRI

GI disturbances and sexual disturbances, and should not be stopped abruptly

Can SSRIs and SNRI be used for other disorders?

yes

fluoxetine (Prozac)

SSRI

escitalopram (Lexapro)

SSRI

citalopram (Celexa)

SSRI

Serotonin Syndrome

potentially life-threatening condition from excess serotonin with symptoms that range from mild to severe

SHIVERS mnemonic for serotonin syndrome

Shivering

Hyperreflexia and myoclonus

Incr. temp

Vital signs instability

Encephalopathy

Restlessness

Sweating

Examples of contraindications for Serotonin Syndrome

SSRI

St. John's Wort

Tryptophan

MAOI

Agents that stimulate the release of seratonin, such as ectasy

Serotonin syndrome explains why..

one should never take 2 SSRIs at once

Black Box Warning

on all antidepressants and warns for increased risk of suicidality in children, adolescents, and adults with major depressive disorder

Electroconvulsant Therapy (ECT)

treatment that induces a grand mal seizure and is performed in the PACU under general anesthesia

What is ECT effective for?

depression and mania

When is ECT considered?

after trials of antidepressants are ineffective or pregnancy

What is prioritized immediately after treatment?

post-operative nursing care, such as airway, vitals, LOC

Typical ECT course is _______ treatments.

12

Risk of ECT

short term memory loss, especially in combination with medications such as Lithium

Repetitive Transcranial Magnetic Stimulation (RTMS)

use of high frequency and low frequency to stimulate prefrontal cortex done in 40 minute sessions, 3-5 times a week for 4-6 weeks

Is anesthesia required for RTMS?

no

Cognitive Behavioral Therapy (CBT)

type of talk therapy that addresses perceptions and negative thoughts and focuses on the client's thoughts that impact behaviors

CBT can be used for..

many disorders

When assessing a patient for depression, the nurse should prioritize ..

safety and screen for suicide or homicidal ideation

Behaviors/Cues the Nurse may Look for

General presentation

Mood

Affect

Thought Content

Thought process

Perceptions

Behaviors

Sleep pattern

Functional status

Screening tools for Depression

Hamilton Depression Rating Scale

Nursing Interventions for Depression

Maintain client safety with suicide precautions

Management of the illness

Client and family education

Maintaining Client Safety

Remove access to lethal means

Address all needs and implications

Teach and educate about coping and symptoms

Facilitate access to support

Management of illness

treatment of symptoms and use of medications

Client and family education

Relapse prevention

Recovery process

Develop a crisis plan

Intended outcome for depressed patients

The patient will not harm self while hospitalized