N1025 Exam 4 ( Depressive Disorder)

Depression

• an alteration in mood that is expressed by feelings of sadness, despair, and pessimism, loss of interest in usual activities and somatic symptoms may be evident.

• Changes in appetite and sleep

Anhedonia

Loss of interest in usual activities

Anergia

No energy / low energy

Avolition

Without drive, without goal driven behavior

Rumination

overthinking / constantly thinking negatively over and over

Somatic Symptoms

Headaches, body aches, stomach aches, etc are magnified

Transient Depression

Life’s everyday disappointments

• getting a bad test score, hopefully bounces back the next day or next week

Mild Depression

Normal Grief Response

• feeling sad but keeps going on with life

• e.g. kids, groceries, studying

Moderate Depression (Persistent Depressive Disorder)

Dysthmic Disorder (think of Eeyore)

• e.g. living in a negative down life

Severe Depression

Major depressive disorder

• e.g. not getting out of bed

Substance/Medication

Induced depressive disorder

• always rule this out before jumping to conclusions

Childhood Depression (up to age 3)

• Feeding problems

• tantrums

• lack of playfulness

• emotional expressiveness

• failure to thrive

• Delays in speech and gross motor development

Childhood Depression (ages 3-5)

• accident proneness

• phobias

• aggressiveness

• excessive self-reproach (rumination) for minor infractions

Childhood Depression (ages 6-8)

• Vague physical complaints (somatic) and aggressive behavior

• may cling to parents and avoid new people/challenges

• may lag their classmates in social skills/academic competence

Childhood Depression (ages 9-12)

• morbid thoughts/excessive worrying (rumination)

• may believe that they are depressed because they have disappointed their parents

• may have lack of interest( anhedonia) im playing with friends

Depression in Adolescence (ages 13-18)

• inappropriately expressed anger

• aggressiveness

• running away

• delinquency

• social withdrawal

• sexual acting out

• substance abuse

• restlessness

• apathy

• loss of self-esteem

• sleeping and eating disturbances

• somatic complaints

Senescence

Normal aging

Depression in Elderly (65+)

• symptoms of depression in the elderly are not very different from those of younger adults

• depressive syndromes are often confused by other illnesses associated with the aging process

Neurocognitive Disorder (NCD)

previously called Dementia

Progression of symptoms:

Memory:

Orientation:

Task Performance:

Symptom Severity:

Affective Distress:

Appetite:

P: Slow

M: Progressive deficits; recent memory loss greater than remote; may confabulate for memory “gaps”; no complaints of loss

O: Disoriented to time and place; may wander in search of the familiar

TP: Consistently poor performance, but struggles to perform (could be trying with all their might)

SS: worse as the day progresses

AD: appears unconcerned

A: unchanged

Depression

Progression of Symptoms:

Memory:

Orientation:

Task Performance:

Symptom Severity:

Affective Distress:

Appetite:

P: Rapid

M: More like forgetfulness; no evidence of progressive deficit; recent and remote loss equal; complaints of deficits; no confabulation (will more likely answer “I don’t know”

O: Oriented to time and place; no wandering

TP: Performance is variable; little effort is put forth

SS: Better as the day progresses

AD: Communicates severe distress

A: Diminished (or increased)

Confabulation

telling something not true, but NOT used to deceive you.

SAD PERSONS

Acronym for suicide risks

Sex

Men die by suicide more than women do; but women make more attempts

Age

Those at greater risk of suicide are younger than 19 and older than 45 years

Depression

The risk of suicide increases with depression

Previous Attempt

greater risk

Ethanol or alcohol abuse

greater risk with alcohol or drug abuse

Rational Thinking

impaired thinking = greater risk

Social Support

greater risk if lacking support

Organize plan

more organized the greater the risk

No significant other

greater risk for single, divorced, widowed, or separated individuals

Sickness

greater risk with a chronic or debilitating illness

Selective Serotonin Reuptake Inhibitors (SSRIs)

first choice drug

• produce fewer sedating, anticholinergic, and cardiovascular side effects (more compliance and safer for older people)

• takes 3-4 weeks for medications to reach therapeutic levels

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

inhibits the reuptake of both serotonin and norepinephrine at the synapse

Black Box Warning

patient is at increased risk of suicide while on these medications

(SSRIs and SNRIs)

Tricyclic antidepressants (TCAs)

• inhibits the reuptake of both serotonin and norepinephrine at the synapse

• TCAs have many side effects including dizziness, orthostatic hypotension, sedation, insomnia, constipation, and dry mouth

• potentially lethal when taken in overdose!

• Black Box warning

Monoamine oxidase inhibitors (MAO Inhibitors)

last choice

• avoid food containing tyramines (wines, aged meats, and cheeses) as the drug interaction may cause hypertensive crisis and death

• potentially lethal when taken in overdose

• Black box warning

Serotonin Syndrome

potentially a life threatening condition when there is excessive serotonin in the body

Causes:

• inadequate washout period between one antidepressant and another

• combining SSRIs or MAOIs with certain serotonergic drugs

Symptoms:

• change in LOC with agitation

• neuromuscular excitement (rigidity, weakness, shivering, tremors, jerking, paralysis)

• autonomic abnormalities (hyperthermia, tachycardia, tachypnea, hypersalivation, diaphoresis

Cognitive-Behavioral Therapy (CBT)

think, act, feel

CBT- Mindfulness

grounding techniques:

S: stop
T: take a breath
O: observe
P: proceed mindfully

grounding practice

guided imagery

relaxation techniques

Electroconvulsive Therapy (ECT)

More Invasive

the induction of a grand mal (generalized) seizure through the application of electrical current of the brain

Side Effects: temporary memory loss and confusion

Medications Used with ECT:

• pre-procedure medication may include meds that decrease secretions (to prevent aspiration) and counteract the effects of vagal stimulation (bradycardia) induced by ECT

• during procedure, meds will be given to prevent severe muscle contractions during seizure, thereby reducing the possibility of fractured or dislocated bones. These meds may paralyze the respiratory muscles. Respiratory support will be given by anesthesiologist

Nursing Interventions for ECT

• monitor vital signs

• position on side to prevent aspiration until patient is awake

• may be dizzy- use caution with ambulation

• allow pt to sleep- they will be very tired

• headaches are treated symptomatically

• patient may eat as soon as they are hungry

Transcranial Magnetic Stimulation(TMS)

(like ECT)

• involves very short pulses of magnetic energy to stimulate nerve cells in the brain

• electrical waves do not result in generalized seizure activity

Light Therapy

for seasonal pattern symptoms during the winter months

Ketamine- NDMA receptors

• treatment-resistant and acute suicidality

• prescribed as nasal spray (esketamine)

• monitor BP, dissociation, sedation, SI, risk of abuse

• off label use (IV, IM)

Nursing Interventions for Depression

• provide for the safety of the patient and others

• institute suicide precautions if indicated

• Begin a therapeutic relationship by spending non-demanding time with the patient

• promote completion of activity of daily living (ADLs) by assisted pt only as necessary

• establish adequate nutrition and hydration

• promote sleep and rest

• engage pt in activities

• encourage pt to verbalize and describe emotions

• work with the pt to manage medications and side effects

• routine cardiovascular exercise is as effective as some antidepressants.

Self-Mutilating Behaviors

Methods:

• cutting

• burning

• excessive tattooing and body piercing

Nursing Interventions

• take all self-harm seriously

• matter-of-fact response

• provide wound care

• follow through during counseling sessions