NRSE345 EXAM#2 depressive disorder

depression overview

• Both a symptom and a disorder

• Depressive symptoms can occur throughout the lifespan, triggered by stressors such as loss, trauma, hormonal imbalance, or stress

• Can occur in Depressive and Bipolar disorders

Persistent depressive disorder

• Mild depression- early onset, 3 yrs min

Major depression (MDD):

•  Mild, Moderate, or Severe depression

postpartum depression

• Depression immediately after and may occur through the first year after giving birth

Premenstrual dysphoria:

depression right before menstruating

Substance-induced depressive disorder:

• Depression caused by use or w/d of medication or substance use 

Seasonal Affective disorder:

• Seasonal depression- lack of daylight

Disruptive mood dysregulation disorder DMDD:

• KIDS!!! extreme irritability, tantrums, and trouble functioning in school and with

major depressive disorder criteria

• Five or more of the following criteria must be present during the same two-week period and represent a change from previous functioning. At least one must be A1 or A2.

• A1 Depressed mood

• A2 Loss of interest or pleasure

• A3 Significant unintentional weight loss/gain

• A4 Sleep disturbance

• A5 Psychomotor changes (agitation /retardation)

• A6 Tiredness, fatigue, or low energy

• A7 A sense of worthlessness or excessive, inappropriate, or delusional guilt

• A8 Diminished ability to think, concentrate, or make decisions

• A9 Recurrent thoughts of death

Symptoms of major depressive disorder: SIGE CAPS

• S: sleep disturbance 

• I: interest (diminished)

• G: guilt

• E: energy loss

• C: concentration difficulties 

• A: appetite or weight changes

• P: psychomotor activity

• S: suicidal ideation

Signs/ symptoms: depressive disorder

• Anergia: low energy

• Anhedonia: loss of interest/ pleasure

• Anxiety, sad, blunted affect, poor hygiene, slumped, slow speech, delayed response

additional classifications of major depressive disorder

• “With psychotic features” (auditory hallucinations, delusions)

• “With post partum onset” (depressive episode that begins within 4 weeks of childbirth- Can be serious if delusions!!)

risk factors for depression

• Family History and/or a previous history of depression

• Old age- hard to recognize/diagnose. Can be confused with early dementia. Usually present with SOMATIC complaints

• Neurotransmitter deficiencies- Serotonin (Mood/sex/sleep) and/or Norepinephrine (attention)

• Stressful life event, Early trauma, Medical illness

• Comorbid anxiety, substance abuse, personality disorders

depression screening tool

• Beck Depression Inventory: 21-item self-assessment of the usual characteristic behaviors and attitudes present in depression

• PHQ-9: 9-question, self-administered assessment that clients can fill out to determine the amount and frequency of depression symptoms (there is also a PHQ-2)

• Always follow up with questions, pts dont always answer truthfully 

• Hamilton Depression Scale: also known as HDRS and Ham-D

• Geriatric Depression Scale

first line pharm treatment for depressive disorder

• Selective serotonin reuptake inhibitors (SSRIs)- first line treatment 

second line pharm treatment for depressive disorder

Serotonin norepinephrine reuptake inhibitors (SNRIs)- second line

third line pharm treatment for depressive disorder

• Other Antidepressants: NDRI - last line 

• Tricyclic antidepressants (TCAs)- last line 

• Monoamine oxidase inhibitors (MAOIs)- last line

• Second generation antipsychotics (SGAs)

• Mood stabilizers

• Anticonvulsants (antiepileptic agents)

Serotonin specific reuptake inhibitors: SSRI how they work

• They prevent the re-uptake of serotonin back into the neuron that released them---therefore, more floats in the synapse and more serotonin is available for use!

• They BOOST serotonin levels

SSRI meds

• fluoxetine (prozac)

• paroxetine (paxil)

• sertaline (zoloft)

• Citalopram (celeza)

• Escitalopram (lexapro)

Fluozetine (prozac)

SSRI

• 20-60mg/day

• - can be activating, long half life (7 days)

Parozetine (paxil)

SSRI

• short half

• SE hit hard contraindicated in pregancy

sertraline (zoloft)

• 50-200mg/day

• GI side effects

• OK in pregnancy/ breastfeeding

Citalopram (celexa)

SSRI

• 20-40 mg/day

Escitalopram (lexapro)

SSRI

• 10-20mg/day

• improved version of celexa

can you use SNRIs in pregnancy

contraindicated

Venlafaxine (effexor)

SNRI

• cause HTN

Desvenlafaxine (pristiq)

SNRI

Duloxetine (cymbalta)

SNRI

• good for pain management

SSRIs and SNRIs are used for: (7)

• Major Depressive Disorder (MDD)

• Anxiety Disorders (e.g., Generalized

• Anxiety Disorder, Panic Disorder)

• Obsessive-Compulsive Disorder (OCD)

• Post-Traumatic Stress Disorder (PTSD) 

• Premenstrual Dysphoric Disorder (PMDD) 

• Bulimia Nervosa & AN (in some cases)

When taking SSRIs and SNRIs when should you eat

Eat first (meal) than take medication 30mins-1hr after, swallow with water 

• food pillow

SSRIs and SNRIs potential side effects:

• Nausea

• Headache

• Insomnia or drowsiness

• Sexual dysfunction

• Dry mouth

• Weight gain or loss

• Increased sweating

SSRIs and SNRIs: nursing intervention

• Monitor for worsening depression or emergent suicidal thoughts, especially at initiation or dosage changes

• Educate patient to report symptoms of serotonin syndrome

Educate patient to report symptoms of serotonin syndrome

• 1st step: Instruct patient not to stop medication abruptly (titrate off)

• Monitor for adherence and effectiveness and suicidal ideations

• Let physician know if you're feeling too good all of the sudden 

HOW LONG DOES IT TAKE FOR SSRIs TO WORK?

• 4-6 WEEKS FOR MAX EFFECT!!!!

Other antidepressants

Mirtazapine, bupropion, trazodone

Trazodone (good to know)

antidepressant

• Fatigue main issue- therefore only really used as a sleep aid PRIPISM rare, but medical emergency!!!

Bupropion (wellbutrin)

antidepressant

NO serotonin, No sexual side effects
Can help with smoking cessation, low energy.
*Contraindicated in seizure disorder, bulimia, head injury patients -can lower seizure threshold.

Mirtazapine (remeron)

• antidepressant

Increases appetite, Causes weight gain, Makes you sleepy

Tricyclines overview

Oldest type of antidepressants! Messy drugs, many dangers, side effects

Tricyclines meds

“triptylines” and “ipramines”

• amitriptyline, desipramine, imiprine, nortiptyline

How do Tricyclines work

1.  Inhibit reuptake of serotonin and norepinephrine

2. Antagonize acetylcholine and histamine (result is anticholinergic and antihistamine side effects….)

3. Block sodium channels in heart and nerve cells. This slows down electrical signals— especially in the heart. This can cause widened QRS complex on ECG, arrhythmias, seizures

• This is a major reason TCAs are dangerous in overdose

• Think TCA – QRS -EKG

Nursing Monitoring for Patients on Tricyclines:

• For CNS monitor: Sedation, confusion, suicidal thoughts (take in p.m)

• For Cardiac monitor: ECG changes, arrhythmias, orthostatic hypotension!

• For GI/Urinary monitor: Constipation, urinary retention, dry mouth

• For Neurological monitor: Seizures, tremors

• For Safety monitor: Falls (due to sedation or hypotension)

• Anticillinergic S/S: dry eyes, urinary retention, constipation

MAOIs:

• Another old classification, not used nearly as much as the SSRIs/SNRIs

• VERY effective but can be dangerous!

How do MAOIs work

Monoamine oxidase (MAO) is an enzyme that breaks down serotonin, norepinephrine and dopamine in the synapse

• These drugs INHIBIT monoamine oxidase…the MAO cannot do its job!!

• Therefore, there in no breakdown of the serotonin, norepinephrine and dopamine in the synapse and MORE available for use

What to know about MAOIs:

• Can cause a HYPERTENSIVE CRISIS when paired with TYRAMINE

Foods high in tyramine: smoked meats, red wine, beer, aged cheeses, chocolate, avocado, soy products, and fermented foods

• ALSO!!! Lots of med/med interactions, esp cold meds. Review with Pharmacist or Prescriber

Common MAOIs:

• Selegiline (Emsam) **also used to treat Parkinsons b/c it increases Dopamine

• Phenalzine (Nardil) 

what meds can cause Serotonin Syndrome

SSRIs, SNRIs, TCAs, MAOIs-Adverse Events

shits and shivers

Serotonin Syndrome S/S

Diarrhea (serotonin receptors in the GUT!!)

• Shivering

• Hyperreflexes

• Increased temperature

• Vital sign changes, increase BP & Heart rate

• Encephalopathy- mental status changes –confusion, agitation

• Restlessness, Sweating, Dilated pupils

Avoid SSRI in combo with

• TCA, MAO, and St Johns Wort

Watch pts on Warfarin AND SSRI

• can increase warfarin levels

Avoid TCA and Lithium Combo

•  can result in higher lithium levels

Watch NSAIDS and antidepressants

Can suppress platelets and increase risk bldg.

Alcohol, opioids, antihistamines combined with SSRI/SNRIs can increase risk for..

CNS depression

activation syndrome

set of manifestations, which includes impulsivity and suicidal ideations, that may present after starting an antidepressant

• Common causes- Usually after start of SSRI, first few hours- weeks

• Manifestations: Irritability, anxiety, impulsivity, aggressiveness, agitation

• Possible increased thoughts of suicide

antidepressants black box warnings

• “Increased risk of suicidal thoughts and behaviors in children, adolescents, and young adults under age 24”

• increase risk temporarily during the initial period or dose changes.

• Patients should be closely monitored, especially in the first 4–6 weeks of treatment.

Antidepressants Discontinuation Syndrome (ADDS)

• Can happen when someone decides to stop antidepressant suddenly

• Manifestations: Difficulty sleeping, anxiety, depression, and flu- like symptoms 

• Brain zaps! 

Antidepressants Discontinuation Syndrome Teaching

• Teaching: The client should understand that antidepressants should never be suddenly discontinued but rather slowly tapered off.

• The nurse should encourage the client to express their comfort with their current medication regimen. 

• The client should have a discussion with their health care provider about possible alternatives, if necessary

nonpharm treatment for depressive disorders

• Cognitive behavioral therapy (CBT): Usually involves meeting with a trained therapist

• Electroconvulsive therapy (ECT)

• Transcranial magnetic stimulation (TMS)

• Vagal nerve stimulation (VNS)

• Deep brain stimulation (DBS)

• Light therapy: seasonal depression

• Alternative therapies: St John’s Wort (don’t take with SSRIs)

Seasonal therapy: 1st line treatment

• is light therapy 

when talking with patients who have depression be mindful to..

give pts enough time to respond to questions/express thoughts

• Note- slower response time-

inpatient: suicidality

• Clients may need to be carefully monitored for suicidality on the psychiatric unit.

• Clients experiencing depression need a structured plan that encourages them to get up, get dressed, and be with the other clients for group activities. BUT encourage independence

• Bowel movements may be slowed, so walking, fiber in the diet, and fluids may ease constipation.

outpatient plan for depressive disorders

• Psychotherapy, medications, support groups, activities, HPBs.

• Clients who have chronic depression may need case management to coordinate both the medication management and the psychotherapy.

• Monitor for SI or decompensation.