depression and mood disorders

mood

pervasive and sustained emotion that colors one’s perception of the world and how one functions in it

affect

expression of mood

blunted

reduced intensity of emotional expression

flat

absent or nearly absent affective expression

inappropriate

discordant affective expression accompanying content of speech and ideation

labile

abrupt shifts from happiness to sadness

restricted or constricted

mildly reduced in emotional expression and intensity

major depressive disorder

episodes of depressed mood that impact functioning

disruptive mood dysregulation disorder

children between 6 and 18 with frequent temper tantrums, verbal, and behavioral outbursts

persistant depressive (dysthymic) disorder

feelings of depression lasting for at least 2 years

premenstrual dysphoric disorder

cluster of symptoms in last week prior to menstrual cycle

substance abuse depressive disorder

results from long-term use of alcohol or substances withdrawal

depressive disorder associated with another medical condtion

related to changes that may come with an illness

diagnostic criteria for major depressive disorder

change from previous level of functioning for at least 2 weeks

five or more symptoms:

1. disruption in sleep, appetite/weight, concentration, or energy

2. psychomotor agitation or retardation

3. excessive guilt or feelings of worthlessness

4. suicidal ideation

depressive disorders in children

anxiety and somatic symptoms more likely

decreased interaction with peers, avoidance of play and recreational activities

irritable rather than sad

high risk of suicide

depressive disorders in older adults

highest rates of suicide in people over 65

commonly associated with a chronic illness

symptoms may be confused with dementia or stroke

epidemiology

affects 7% of Americans annually

mean age of onset is 40 years

twice as common in women

pre-pubertal boys and girls are equally affected

often comorbid with other psychiatric or substance disorders

risk factors for depression

prior episode of depression

family history

lack of social support

lack of coping abilities

presence of life and environmental stressors

current substance use or abuse

medical comorbidites 

goals for treatment

reduce or control symptoms

improve occupational and psychosocial function

reduce the likelihood of relapse and recurrence

priority care issues

safety and assessment of suicide risk

nursing assessment for the biologic domain

physical systems review and thorough history of medical problems

medication history

physical examination

neurovegetative symptoms

depression assessment

sleep disturbances

interested decreased in pleasure activities and sex

guilty feelings

energy decreased

concentration decreased

appetite changes

psychomotor function decreases

suicidal ideation

concerns for the biologic domain

insomnia

imbalanced nutrition
fatigue
self-care deficit

nausea

sexual dysfunction

target symptoms of antidepressants

sleep/appetite disturbances

fatigue

decreased sex drive

psychomotor retardation of agitation

diurnal variation in mood

impaired concentration or forgetfulness

anhedonia

suicide assessment

past suicidal behavior is a strong risk factor

clients with depressive disorders are at high risk for suicidal ideation

look for cues in mental status assessment or interactions

frequency of suicidal thoughts

symptoms

suicide plan assessment

means assessment

social support and stressors

PHQ-9- self report level of depression

antidepressants 

improvement in mood can take 1-3 weeks or longer

trial of 3 months

selection based on symptoms, side effects, administration, history of past response, safety and medical considerations

selective serotonin reuptake inhibitors

first line therapy

block neuronal uptake of serotonin

low side effect

effective for depression with anxiety

low cardiotoxicity

low lethality in overdose

SSRI adverse reactions

agitation

anxiety

sleep disturbances

tremor

anorgasmia

tension headache

autonomic reaction

weight gain

mild nausea

loose stools

serotonin syndrome

rare but life-threatening

can lead to hyperpyrexia, cardiogenic shock, death

abdominal pain, sweating, diarrhea, fever, tachycardia, increased blood pressure, delirium, muscle spasms, increased motor activity, irritability/hostility, mood change

tricyclic antidepressants

reuptake of norepinephrine and serotonin

can later heart rhythm

high overdose toxicity

takes 10-14 days to work

4-8 weeks to see full affect

stimulating better for people with fatigue and lethargy

sedating better for people with agitation or restlessness

start with low dose and gradually increase

long half life

anticholinergic effects

TCA overdose

high lethality in overdose 1-4 hours after ingestion

death usually from cardiac, respiratory, circulatory failure

symptoms- nystagmus, tremor, restlessness, seizures, hypotension, dysrhythmias, myocardial depression

monoamine oxidase inhibitors

increase in tyramine can lead to increased blood pressure, hypertensive crisis, CVA

not first line treatment

indicated for those with unconditional depression

Maoi side effects

increased blood pressure; hypertensive crisis

monitor BP and cardiac rhythm for first 6 weeks

headache, stiff neck, increased HR, chest pain, n/v, pyrexia

St. John’s wort

flower processed into tea or tablets

increased serotonin, norepinephrine, dopamine

possibly effective for mild-moderate depression

not FDA regulated

potential interactions

antidepressant discontinuation syndrome

sudden termination of most antidepressants

taper off 6-8 weeks

SSRI symptoms- dizziness, dysphoria, GI upset, sleep problems, lethargy, headache, anxiety, hyper-arousal, aggression, hypomania, mood disturbances, suicidal tendencies

TCA symptoms- hyper-salivation, diarrhea, urinary urgency, abdominal cramping, sweating

electroconvulsive therapy

indicated for those with severe depression, intolerant to meds, and who are severely ill

light therapy (phototherapy)

mild to moderate seasonal non psychotic depression, recurrent night depression, and sleep deprivation

transcranial magnetic stimulation (TMS)

treats mild resistant depression

magnetic coil placed on scalp near left motor cortex

releases small electrical impulses to stimulate the left prefrontal cortex

anesthesia is not required so no sedation risks

nursing assessment for the psychological domain

mood/affect

though content- negative evaluation of self worth

suicidal behavior

impaired ability to think

nursing concerns for the psychological domain

risk for suicide

hopelessness

low self esteem

ineffective individual coping

decisional conflict

spiritual distress

dysfunctional gathering

nursing interventions for the psychological domain

therapeutic relationship

cognitive interventions

behavior therapy

make a safety plan with patient suicidal ideation

interpersonal therapy

family and marital therapy

group interventions

patient and family teaching

nursing concerns for the social domain

ineffective family coping

ineffective role performance

interrupted family processes

caregiver role strain

nursing interventions for the social domain

milieu therapy

safety- increased risk of self harm with feeling better and having more energy

family education and support