Unipolar Disorders

Unipolar disorders

• Major Depression (MDD or MDE)

• Dysthymia

• adjustment disorder w/ depression

• post-partum depression

• premenstrual dysphoric disorder

• psychotic depression

• seasonal affective disorder

• disruptive mood dysregulation disorder

• substance induced mood disorder

dysphoria

• consistent state of unhappiness, dissatisfaction

• may be sad, irritable, or angry

depression

• impairment in functioning

• may or may not be related to life situations

• involves physiological signs + sxs

• pro-inflammatory (along with anxiety) → increases SNS → increased circulating stress hormones

• LT stress → weakened immune system + comorbidities (CVD, diabetes progression)

• distortion of reality

Heart health = brain health

• vasculature affects brain health

• as well as proper diet

Depression screening

• all depressed individuals should be screened for suicide

• MBQ Tools:

  • BDI (Beck Depression Inventory)

  • Mood disorders questionnaire (MDQ)

  • PHQ-9 (9 sxs of depression + 2 suicide)

  • Geriatrics (GDS)

  • children (CES-DC)

  • Teens/young (CES-D)

• uses pt subjective data with objective measures

• establishes baseline

Perceptions/Distortions (of reality, perception, and thinking)

• contextual and modifiable

• persons with mental rigidity → thinking about the world from a limited perspective

• thinking impacts feelings, which reinforces bxs, reinforcing thinking

• need to challenge patterns of negative thinking to increase mental flexibility and resilience → holistic approach

Major depression

• 5+ total sxs (must include #1 and/or 2)

  • 1.) depressed mood (dysphoria)

  • 2.) anhedonia: reduced ability to experience pleasure or interest in activities that were once enjoyable

  • appetite: weight gain or loss

  • sleep

  • low energy

  • psychomotor agitation or retardation

  • poor concentration/decision making

  • worthlessness or inappropriate guilt

  • SI

Dysthymia

• mild to moderate depression; persistent 2+ yrs

• depressed most of the days

• 2+ years, 2+ sxs

  • under or over eating

  • sleep difficulties

  • fatigue

  • low self-esteem

  • difficulty with concentration/decision making

  • hopelessness

• impairment in functioning

• no MDD in first 2 yrs

• no manic episodes

• can’t be related to SUDs

post-partum depression

• commonly anxiety for well being of baby

• can occur 4-6 months out, not just immediately

• can lead to postpartum psychosis rarely → anxiety detaches from reality → killing child

Premenstrual dysphoric disorder (PMDD)

• occurs every month 2 weeks before onset of menses

• tx: oral contraceptive

Adjustment disorder

• life trigger for depression; temporary

• something precedes (condition or event)

• not trauma related or unexpected event

• could be move, graduation, change in relationship status

Substance induced mood disorder

• long term corticosteroid use → suppress immune system and cause depression

• opioids

Mood disorder d/t specific condition

• hypothyroidism

• treat condition and depression

Mood disorder unspecified

• severe sxs + cause impairment in functioning; do not fit into neat category

• 4 sxs and only one week of having them

• prediction + preventative method

Depression Tx

• tx to full remission (no s/sxs)

• requires psychotherapy + meds

• only 2 opportunities to get meds right → remission significantly decreases after 2 good med trials → chronic course

• brain can adapt to drugs → not a cure

Depression Epi

• more prevalent in women

• men more likely to choose more lethal methods for suicide

• high in AA’s (do not seek tx)

Depression in children

• M:F equal rates until puberty

• prevention: family bereavement program after childhood loss

• meds can be used depending on age

commons sxs of childhood depression

• irritability, sleep disturbance, sadness, SI

• don’t share crying & depressive thoughts

• somatic sxs (abd pain)

• deteriorating school performance

Disruptive mood dysregulation disorder

• 6-18 yrs old

• onset before age 10

• sxs:

  • severe, recurrent temper outbursts

  • grossly out of proportion to situation (3x/week for 12+ mos)

  • persistent, severe anger and irritability in b/w outbursts

• observable in 2+ settings over 12 months

adolescent depression

• F>M

• high suicide risk

• self harm strongest risk

• sxs:

  • difficulty expressing emotional distress

  • acting out/self-injurious bxs often r/t relationship crises

  • moodiness, anger, withdrawal, frustration, loss of interest, restlessness

• nurse role: build trust

Depression in elderly

• high prevalence in caucasian males > 75 yrs

• late onset can be d/t environmental factors such as pollution increasing inflammation in body

• risk factor for dementia

• Sxs:

  • anhedonia

  • decreased energy

  • increased dependence on others

  • somatic complaints (multiple)

  • wt. loss, PI, GI distress

  • “Pseudo-dementia”: confusion + memory deficits r/t depression

• Screening tool: GDS

suicide key sxs/bxs

• impulsivity

• insomnia

• overwhelming grief

• loss of identity/purpose

• isolation + loneliness

• jokes about suicide, giving away cherished belongings

• increased energy or extreme positivity

Prevention of suicide

• strengthen protective factors

• Internal: resilience, coping, mental flexibility + strong social support or through faith + tolerance of frustration

• External: sense of connection or responsibility to others → pets, children, sense of belonging; reduction of isolation → hobbies; restricted access to means; cultural + religious factors to discourage

EBP gold standard tx for depression

• psychotherapy + cognitive behavioral tools + meds

• include milieu management

Benzodiazepines

• secondary prevention → short term for acute sxs while antidepressants are on board

• PRN use for severe sxs

• breakthrough seizures + long term for seizure disorders

• misuse potential; work quickly but mask sxs; no long term physiological changes

• withdrawal may require medically supported detox

• Overdose: CNS & resp depression → Flumazenil (antagonist for overdose)

• Taper protocol

Benzos examples

• Ativan (Lorazepam)

• Klonopin (Clonazepam)

• Xanax (Aprazolam)

• Librium

• Serax

• Valium

• Tranxene

Benzo mech of action

• increases GABA → decrease excitation

• anticonvulsant

• sedation

Antidepressants

• TCA’s

• MAOI’s

• SSRI’s

• SSNRI’s

• takes 2-4 weeks to see effects or some improvement

• 6-8 weeks for SSRI’s for full therapeutic effect

• change underlying brain physiology

TCA’s

• can kill if more than one weeks supply taken

• 1st gen

• Elavil (Amitriptyline): widely used for chronic pain syndromes → neuropathy

• Tofranil (Imipramine)

• Anafranil (Clomipramine)

• block NE on post synaptic → increase epinephrine → increase serotonin

• anticholinergic SE’s → dry mouth, sedating, urinary retention, constipation, blurry vision

• buckshot properties

• EKG changes

MAOI’s

• 1st gen now 3rd or 4th line

• rarely prescribed d/t risks

• Marplan (Isocarboxazid)

• Nardil (Phenelzine Sulfate)

• Parnate (tranylcypromine sulfate)

• aka No Popular Meds

MAOI mech of action

• prevents monoamine from removing 5HT, NE, & DA from brain

• increase of these in CNS & gut

• OTC med restrictions and food restrictions → Hypertensive crisis → excess tyramine → high bp, sweat, tremors, palpitations

MAOI management

• self monitor BP

• avoid use with TCA’s, SSRI’s, and tyramine rich products (food decay/fermentation)

• need 14 day washout period after stopping and starting new med

SSRI’s

• 2nd gen but 1st line

• Prozac (Fluoxetine)

• Zoloft (Sertraline)

• Celexa (Citalopram)

• Lexapro (Escitalopram)

• Paxil (Paroxetine)

• Luvox (Fluvoxamine): also approved for OCD

SSRI mech of action

• presynaptic blockade increases relative conc. of 5HT in system

• 1-3 days some improvement

• 2-4 weeks ‘plateau’ effect → person may want to stop, med ed is key and encouragement

  • Provide more support during first 4 weeks until getting to therapeutic level → increased impulsivity (increased risk of suicide)

• 6-8 weeks full therapeutic effect

• 12-16 wks for anxiety disorders

Common SE’s of SSRI’s

• 4 S’s: Sleep, stomach, sexual (erectile dysfunction), suicidal thoughts

• discontinuation/withdrawal sxs bad

• GI: N/V; diarrhea

SSRI Discontinuation syndrome

• psychiatric: agitation, anxiety, crying spells, insomnia, nightmares, mood lability

• neurologic: dizziness, headache, paresthesia

• motor: tremors, dystonia

• somatic: chills, lethargy, fatigue, rhinorrhea

• GI: N/V

• Flu like sxs

Serotonin Syndrome

• excess 5HT activity related to meds + recently ingested meds

• potentially life threatening adverse reaction

• always ask what pt ingests

• SSRI’s + John Warts + herbs = HIGH RISK

• OTC cold products

• Nursing role: Take VS → Hold → discontinue meds

  • call prescriber

  • prep acute care

Serotonin Syndrome Sxs

• ABCs

  • Autonomic

  • Body (Somatic)

  • Cognitive

• Mild, rapid early onset

  • tremor, akathisia (subjective restlessness)

  • clonus (involuntary muscle contractions)

  • VS changes: increased HR, shivering, diaphoresis, dilated pupils, HA, confusion

• Severe:

  • severe HTN, hyperthermia, seizures, metabolic acidosis, rhabdomyolysis, renal failure, coma, death

Serotonin syndrome actions

• look drunk, slurred speech, unsteady gait, altered mental status, elevated temp

• Need IV fluids

• ongoing cardiorespiratory monitoring

• muscle relaxants

• antiepileptics

Atypical Antidepressants

• Target NE, DA, & 5HT

• NE blockade → increased DA

• Trazodone (Desyrel)

• Remeron (Mirtazipine)

• Effexor (Venlafaxine)

• Wellbutrin/ Zyban (Buproprion)

• Cymbalta (Duloxetine)

Trazodone

• terrible antidepressant; good for sleep PRN

• only drug to be used as PRN (under 200 mg)

• can give morning hangover

• priapism (prolonged painful erection)

Remeron (Mirtazipine)

• very sedating at low doses

• weight gain

• lacks 5HT reuptake

Effexor (Venlafaxine)

• 50-50 drug

• NE/5HT reuptake inhibitor

• 1st SNRI approved for MDD

• miss one dose → withdrawal syndrome

• Pristiq

Wellbutrin/ Zyban (Buproprion HCL)

• NE-DA reuptake inhibitor

• 1st line for MDD

• uses: smoking cessation, ADD/ADHD

• contraindicated in seizure disorders & bulimia nervosa

Cymbalta (Duloxetine)

• lots of withdrawal

• chronic or neuropathic pain

Ketamine

• tertiary intervention

• must fail usual med trials

• ST tx for tx-resistant depression

• blocks excitatory NT NMDA (glutamate); prevents overstimulation of brain cells

• high risk

• infusion in clinic 1-2x per week

End of Life Care for depression: Psychostimulants

• Methylphenidate (Ritalin)

• work more quickly → no time to wait for antidepressants to kick in

• increase cardiac demand

• elevate mood, energy, concentration