depression 343

what are depressive disorders?

there are 4 major types of depressive disorders

major depressive disorder (MDD)

disruptive mood dysregulation disorder

persistent depressive disorder (dysthymia)

premenstrual dysphoric disorder (PMDD)

all share the common features of: sadness, feeling empty, irritable mood, and somatic and cognitive changes that significantly affect the person’s ability to function

what is major depressive disorder (MDD)?

characterized by one or more major depressive episodes- defined by at least 2 weeks of depressed mood or loss of interest accompanied by at least 4 additional symptoms

pts may describe their mood as: depressed, sad, hopeless, discouraged, down in the dumps

may have physical complaints- insomnia and fatigue

loss of interest or pleasure, social withdrawal

may present with psychomotor agitation or retardation

decreased appetite, tiredness, poor concentration, and low self esteem are also common symptoms

what are the s/s of MDD?

depressed mood

anhedonia- losing interest

appetitie disturbance/weight change

sleep disturbance

psychomotor disturbance

fatigue or loss of energy

worthlessness/guilt

indecision/poor concentration

recurrent thoughts of suicide/death

any manic episodes rule out depression and indicate bipolar

what are the risk factors for MDD?

family hx

hx of abuse

age 18-30

substance abuse

loss

financial changes

what is disruptive mood dysregulation disorder?

typically applied to children and adolescents ages 6-18

onset must occur before 10 years of age

established to differentiate between kids with severe irritability as opposed to kids with classic episodic BD

what is premenstrual dysphoric disorder?

mood swings, irritability, anger, dysphoria, and anxiety symptoms that occur before and after menstruation

also include: lethargy, fatigue, sleep disturbances, difficulty concentrating, changes in appetite

physical symptoms: breast tenderness, pain, bloating sensation, weight gain

what is persistent depressive disorder?

highly prevalent form of unipolar depression that has a chronic course

keyword: persistent

depressed mood that occurs for most of the day and has lasted for at least 2 years

3 subtypes

chronic depression with mild severity- known as dysthymia

major depressive episodes that occur continuously or intermittently with incomplete recovery inbetween

major depressive episodes superimposed on dysthymia known as double depression

suicide and depression

very high risk factor for suicide

risk factor for suicide completion r/t depression

male

caucasian or native american

age 60 or older

hopelessness

general medical illness

severe anhedonia

living alone

prior attempts

unemployed/financial problems

behavioral symptoms of depression

alterations in activity and social interactions

tired all the time even when not physically active

even the smallest task can seem unbearable

ADLs decline

apathy

change in eating and sleeping behaviors

alterations of mood, affect, cognition, physical nature, and perception

what are some signs of psychomotor retardation and agitation?

pacing, handwringing, inability to sit still, pull or rub their hair, skin, clothing, or other objects, tying and retying shoelaces, buttoning and unbuttoning a shirt

slowing of speech, increased pauses before answering, soft or monotonous speech, decreased frequency of speech, muteness, general slowing of body movements

depression theories

biological: neurochemical, genetic, endocrine, circadian rhythm, changes in brain anatomy

psychological: psychoanalytic, cognitive, interpersonal, behavioral

what are some nurse-patient interventions for depression?

demonstrate respect and rapport with patients

accept pt and focus on strengths

develop trust through direct, honest interactions

acknowledge the emotional pain and offer to help work through pain

point out accomplishments and strengths

reprograms negative thoughts through CBT

reinforce efforts to make decisions that promote health and wellness

do not reinforce hallucinations or delusions- point out reality

accept pt anger and negativity without reinforcing them

spend time with windrawn pt, according to their comfort level

provide achievable activities that are designed for success

make decisions for pts who are severely indecisive

assess for hopelessness and helplessness and for suicidal ideations

offer medications when needed

what are some milieu interventions for depression patients?

opportunity to experience accomplishment and receive positive feedback

assertiveness training

assist with grooming and hygiene

protect from suicidal intent

monitor and promote nighttime sleep

discourage daytime sleep

supportive group activities

somatic therapies for depression

electroconvulsive therapy is the most common form of somatic therapy

the most effective antidepressant remedy available

indications: major depression

rapid response for suicidal or catatonic pts

cannot tolerate pharmacotherapy

not responding to multiple and adequate trials of meds

safe and effective

temporary relief- not a cure

tx 2-3 times a week up to a total of 6-12 treatments

suicide assessment

ask about SI

plan

method

rehearsal

hx of past attempts

prevention of rescue

risk factors

protective methods

antidepressant therapy

used to treat depression and anxiety disorders

alleviate depressive symptoms and restore normal mood

may be used to stabilize the mood of a pt with bipolar

many people take more than 1 type

be aware of the black box warning

what is the black box warning on antidepressants?

they increase the risk of suicidal thoughts and behaviors in pts aged 24 and younger, monitor for clinical worsening and emergence of suicidal thoughts and behaviors

biochemical theories

there is a lack of neurotransmitters in the intrasynaptic area of the brain that are necessary for a normal mood state: serotonin, norepinephrine, dopamine

antidepressants make more neurotransmitters available in the intrasynaptic area of the brain, therefore stabilizing the person’s mood

alternative theories

receptor dysregulation

altered genetic output

premature neuronal death

lack of synaptogenesis

first line agents for depression medications

selective serotonin reuptake inhibitors (SSRIs)- sertraline (zoloft)

selective serotonin norepinephrine reuptake inhibitors (SSNRIs)- venlafaxine, duloxetine

norepinephrine and dopamine reuptake inhibitors (NDRIs)- bupropion

novel antidepressants- mirtazapine, bupropion, vortioxetine, trazodone

second and third line agents for depression medications

tricyclic antidepressants (TCAs)

monoamine oxidase inhibitors (MAOIs)

SSRIs

commonly used for depression

may also be used for anxiety, PTSD, OCD

increased risk of suicide within first few weeks of intake- monitor for mood changed and SI

may cause sexual dysfunction

do not stop abruptly (2-3 weeks to work)

never mix with St. John’s Wort or MAOIs (serotonin syndrome)

orthostatic hypotension

weigh daily

escitalopram (lexapro)

citalopram (celexa)

fluoxetine (prozac)

paroxetine (paxil)

sertraline (zoloft)

side effects of SSRIs

n/d

diarrhea/loose stools

weight gain/loss

dry mouth

sedation

excessive sweating

h/a

dizziness

tremors

anxiety

insomnia

hyponatremia- low sodium, mainly in older pts

sexual dysfunction- 50% of pts

SSRIs drug interactions

MAOI- serotonin syndrome

lithium- increased lithium level

antipsychotic- increases EPS

benzodiazepine- increases half life of benzos

TCA- increases serum level of TCA

SSRI mnemonic

S- suicide risk
S- slow onset/serotonin syndrome
S- sweaty
R- restless
I- increased HR/insomnia

issues r/t antidepressant use

serotonin syndrome

antidepressant apathy syndrome

antidepressant withdrawal syndrome

antidepressant loss of effectiveness

antidepressant induced suicide

pts start to feel better when they take the meds so it gives them the energy to carry out their suicide plan; mostly for people ages 18-24 when they first start tx

what is serotonin syndrome?

occurs if SSRIs are combined with: tryptophan, MAOIs, amphetamines, lithium, ecstasy, cocaine, dextromethorphan, some TCAs, venlafaxine, buspirone, LSD

serotonin syndrome s/s

cognitive- confusion, hypomania, hallucinations, agitation, coma

autonomic- shivering, sweating, hyperthermia, hypertension, tachycardia, n/d

somatic- ataxia, myoconus, twitching, hyperreflexia, rigidity, tremor, ataxia

SSNRIs

duloxetine (cymbalta): dual med; depression, fibromyalgia, neuropathy pain; few instances of sedation or insomnia, few h/a, infrequent anticholinergic effects; causes significant sexual dysfunction

venlafaxine (effexor): side effect profile similar to duloxetine; increases BP especially at higher doses; used in tx of generalized anxiety disorder, social phobias, OCD, panic disorder

TCAs

given for depression and fibromyalgia

amitriptyline

imipramine

pt education: never mix with MAOIs- hyperpyrexia, excitability, muscular rigidity, convulsions, fatal hypertensive crisis, mania

slow position changes r/t orthostatic hypotension

increase fluids r/t urinary retention

increase fiber r/t constipation

monitor for SI

highly toxic- pts use for overdoses

TCA side effects

blurred vision

arrhythmias

MI

dry mouth

anhidrosis- decreased sweating

tachycardia

orthostatic hypotension

urinary retention

constipation

seizures

TCA drug interactions

MAOIs- fever, hypertensive crisis

sympathomimetics- cardiac arrhythmias

warfarin- increased bleeding

barbiturates, anticonvulsants- decreased TCA effect

anticholinergics- increased anticholinergic effect

l-dopa- agitation, tremor, rigidity

alcohol, benzodiazepines- increased sedation

MAOIs

primarily used for depression and panic disorder

phenelzine (nardil)

isocarboxazid (marplan)

tranylcypromine (parnate)

selegiline (eldepryl, emsam, zelapar)- can be used in parkinson’s

MAOIs pt education

massive HTN risk

hypertensive crisis- palpitations, tightness in chest, stiff neck, throbbing/radiating h/a, elevated BP and tachycardia, diaphoresis, dilated pupils

avoid tyramine rich foods

increased risk for suicide

do not mix with any antidepressants

tyramine rich foods to avoid with MAOIs

alcohol- beer, ale, chianti, sherry wine, alcohol free beer

dairy- all mature cheese, sour cream, yogurt

fruits and vegetables- avocados, bananas, fava beans, canned figs

meats- bologna, salami, sausage

others: caffeinated coffee, cola, tea, chocolate, licorice, sauerkraut, soy sauce, yeast