depression, BD, antimanic (Ch. 16, 25-26)

key features of depression

• depressed mood

• anhedonia - lack of pleasure

• appetite disturbance

• sleep disturbance

• fatigue/loss of energy

• worthlessness/guilt

• poor concentration

• recurrent thoughts of death/suicide

nurse-patient relationship in depression

• acknowledge emotional pain

• point out accomplishments and strengths

• do not reinforce hallucinations or delusions

• accept their anger and negativity without reinforcing them

  • deescalate by being calm, using a soft voice, reassure patient you understand

• spend time with withdrawn patient

  • communicates their worth

• provide achievable activities

• make decisions for patients who are indecisive

• present situations to patients that do no require decision making

  • ex. its time to go for a walk

indications for electroconvulsive therapy (ECT)

major depression

• suicidal or catatonic patients

• cannot tolerate pharmacotherapy

• not responding to multiple and adequate trials of meds

electroconvulsive therapy (ECT)

most common form of somatic therapy

most effective antidepressant remedy

used to reboot, rebalance, and rebuild

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

used for temporary relief, NOT a cure

is safe and effective

risk factors for suicide

• male

• caucasian or native american

• 60 yrs+

• hopelessness

• general medical illness

• severe anhedonia

• living alone

• prior suicide attempts

• unemployed

• relationship difficulties

• sexual identity

• HIV / AIDS

bipolar disorder

individuals experience the extremes of mood polarity

depressive episode is NOT required for diagnosis but manic episode is

is the most expensive mental health disorder

manic episode

elevated mood for at least 1 week

have 3 of the following:

• inflated self-esteem, grandiosity

• decreased need for sleep, insomnia

• low appetite

• anger

• very talkative, flamboyant gestures

  • loud, rapid

• flight of ideas - racing thoughts

• distractibility

• increased goal-directed activity ex. trying to open 5 businesses by the end of the week

• excessive involvement in pleasurable activity

• excessive makeup

hypomanic episode

persistent elevated, expansive, or irritable mood

impairment less severe than a manic episode

lasts at least 4 days

not severe enough to get hospitalized

can have 3 of the following:

• increased self-esteem, grandiosity

• decreased need for sleep

• talkative, racing thoughts, distractibility

• increased goal-directed activity

• excessive involvement in pleasurable activity with high potential of negative consequences

depressive episode of BD

• withdrawal, passivity

• hypersomnia or daytime sleepiness

• hyperphagia (excessive hunger) and weight gain

• sluggish thinking

• anergia

• diminished interest in activities

• guilt

• decrease in speech

• craving for carbs

• paranoid thoughts, hallucinations

• irritability

this is more disabling than manic or hypomanic episodes

bipolar I disorder

swings between manic episodes and major depression

rapid cycling of mood episodes in previous year

melancholic features (feeling sad), psychotic features (hallucinations and delusions), and anxious distress (stress)

bipolar II disorder

similar to BD I

exception: NO manic episodes, but at least one hypomanic episode lasting at least 4 days

major depression lasts at least 2 weeks

cyclothymic disorder

numerous swings between a hypomanic episode and dysthmia - persistant sadness

swings either way, are not severe as mania or major depression

symptoms have occurred for at least 2 years without symptom remission for more than 2 months

objective behaviors of BD

• disturbed speech patterns

• disturbance of relationships, activity, and appearance

• violent behavior

• divorce

• job loss

• academic failure

• rapid, excited speech

• pressured speech - persistant need to talk

• loud speech

• easily distracted

• increased sex drive

• alienation of family

• cannot maintain long-term friendships and relationships

• a need to engage people, even strangers

• fall in and out of 

tendencies that cause relationship problems in BD

• manipulation of other’s self-esteem

  • know how to make other people feel good or bad

• ability to find vulnerability in others

• ability to shift responsibility - blame others

• limit testing

treatment goals of BD

• getting acute mania under control

• preventing relapse

• returning to the prior level of functioning

Debra has not been able to eat sufficient calories to sustain her increased activity. what nursing intervention would assist her?

a. provide a larger high-calorie mean

b. distract her to encourage eating

c. provide an increase in high-calories snacks

d. provide frequent portable food items

provide frequent portable food items - for those who cannot sit still

you can also provide high protein and high calorie snacks, give daily multivitamins, and weigh the patient regularly

sleep interventions for patients with BD

• structure to avoid stimulating activities during the evening

• reduce caffeine intake in the evening

• assess sleep-rest patterns

gold standard medication for BD?

lithium

NO SAD ME mneumonic

Non-antidepressant therapy should be considered ex. lithium

Safe to use adjunctive antidepressants can be considered if relapse occurs

Avoid antidepressant monotherapy

DO not use TCAs - high risk of inducing elevates states of mood and behavior

Monitor closely

contraindications for electroconvulsive therapy (ECT)

patients with:

• substance abuse problem

• personality disorders

• preexisting neuro disorders ex. dementia

• history of not responding to this treatment

• cardiovascular disease

• recent cerebral hemorrhage or stroke

• intracranial lesions with elevated ICP

• bleeding or unstable aneurysm

• severe pulmonary disease

important points when administering antidepressants

• 2-4 weeks for full effect

• provoke suicidal ideation and behavior in the beginning

• patients may cheek them

• monitor VS

  • TCAs → orthostatic hypotension, reflex tachy

  • MAOIs → hypertensive crisis

• sexual dysfunction

• food interactions with MAOIs

• signs of toxicity

  • TCAs: drowsy, tachy, hypotension, agitation, vomiting, confusion

  • MAOIs: dizziness, vertigo, fatigue

medical conditions and drugs that cause mania

• anoxia

• hyperthyroidism

• hypercalcemia

• AIDS

• stroke

• brain tumor

• MS

• antidepressants

• steroids

• anticholinergics

• stimulants

• Levodopa

treatment goals for BD

• prevent relapse

• reduce suicide risks

• improve functioning

• reduce subthreshold symptoms

  • symptoms not quite reaching a level of clinical significance (like needing to go to the hospital

reference range of lithium

0.6-1.2mEq/L

has a narrow therapeutic index

peaks in 1-3 hours

absorbed in GI, excreted through kidneys → monitor kidney function

electrolytes and neurotransmitters involved in BD

• calcium

• sodium

• potassium

• ATPase

• neurotransmitters

  • dopamine, serotonin, norepi????

lithium guidelines

• take at the same time daily

  • if you miss a dose, skip it and take the next one at the regular time

  • DO NOT double up on the dose

• maintain salt intake

• fever and excessive sweating might need dose readjustment

• do a morning blood draw about 12 hrs after last dose

• take with meals to decrease nausea

• 10-12 glasses of water daily

• elevate feet and ankles if there is swelling

• avoid unexpected pregnancy

• kidney function labs done twice a year

• thyroid lab test annually

lithium diet modifications

increased salt intake = increased lithium elimination

decreased salt intake → increased Li in body

if person sweats a lot, sodium goes out = increase in serum lithium

side effects of lithium

• constipation, thirst, fine hand tremors are transient

• nausea

• dry mouth

• diarrhea

• report: (med should be discontinued)

  • vomiting

  • coarse hand tremor

  • sedation

  • weakness

  • vertigo

mild to moderate toxic effects of lithium (1.5-2.0)

• red rash

• drowsiness

• mild hand tremor

• polyuria and polydipsia

• weight gain

• bloated feeling

• sleeplessness

• lightheadedness

moderate to severe toxic effects of lithium (2.0-3.0)

• ataxia (loss of balance)

• giddiness

• tinnitus

• blurred vision

• large output of urine

• delirium

• nystagmus

severe toxicity of lithium (3+)

• seizures

• organ failure

• renal failure

• coma

• death

lithium toxicity treatment

• stomach pumping / gastric lavage

• whole bowel irrigation

• activated charcoal (if person took other meds/substances as well)

• kidney dialysis

• IV fluids

what dietary practice should robert use on a night when he is sweating heavily?

a. carry glucose tablets

b. drink an electrolyte supplement

c. increase salt intake

d. reduce salt intake

increase salt intake

Valproates ex. Divalproex

anticonvulsant effective for acute mania - works quickly

side effects include:

• hair loss

• weight gain

• menstrual effects

• decrease intelligence in children

NOT given in hepatic disease (hepatotoxic)

Carbamazepine

anticonvulsant used if patient does not respond to lithium or valproates

potential for agranulocytosis

major side effects of Lamotrigine and Oxcarbazepine

steven-johnson syndrome

skin sloughs off and could kill the patient

first, second and third line approaches to BD and mania

1. lithium, a valproate or medication used for acute stage

2. atypical antipsychotic

3. anticonvulsants

   1. Carbamazepine, Lamotrigine, Gabapentin, or Topiramate

for severe acute mania: lithium OR valproate + atypical antipsychotic

for BD: lithium, OR lamotrigine, OR fluoxetine and olanzapine OR ECT

electroconvulsive therapy (ECT) (from video)

delivers electricity to the brain to cause a generalized seizure to treat psychiatric conditions (mainly depression)

used in patients who have not responded to prior meds

also indicated in patients who are extremely suicidal and cannot wait 2-3 weeks to see if medication is effective

IV meds are given to relax the muscles, O2 is given, and patient is made unconscious

electricity used is very low, patient can still be touched

will have short term memory loss that may or may not return