Ch 14 Depressive disorders

Assess behavioral, emotional, and cognitive symptoms associated with depressive disorders.

2. Identify risk factors for the development of depressive disorders, including biological, psychological and environmental influences.

3. Implement therapeutic nursing intervention, including safety planning, therapeutic communication, and support for clients with depression.

4. Explain the nurse’s role in client education related to treatment adherence, medication side effects, and relapse prevention in depressive disorders.

What do all depressive disorders share

•All share symptoms of

•  Sadness, emptiness, irritability, somatic (body) concerns, and impairment of thinking

•All impact a person’s ability to function

Start getting hope/ feeling good after 2 to 4 weeks after being on med

Jeff, 19, is brought to the hospital after a suicide attempt. His parents found him in his back yard, wearing his favorite black jeans and black t-shirt, but with one of his father’s neckties. He had overdosed on some of his “mother’s pills”, but his stomach was pumped in time. He has just been admitted to your floor for 24-hour suicide observation.

What is disruptive mood dysregulation disorder

•Diagnosed in children ages 6 to 18

•Symptoms

• •Constant and severe irritability and anger

• •Temper tantrums out of proportion to the situation at least 3 times per week

• •Exhibits symptoms in at least two settings: home, school, and with peers

•Management

• •Symptomatic medications; CBT & parent training & facial expression recognition training

• •Risperidone (Risperdal)

• Aripiprazole (Abilify)

If misbehaving at school and home- red flag

What is perisistent depressive disorder

•Formerly known as dysthymia

•Low-level depressive feelings through most of each day, for the majority of days

• •At least 2 years in adults

• •At least 1 year in children and adolescents

•Must have two or more of the following:

•Decreased appetite or overeating, insomnia or hypersomnia, low energy, poor self-esteem, difficulty thinking, and hopelessness

Persistent mood disorder- mood that last longer than 2 weeks, can last up to 2 yrs. When its very severe they have to be hospitalized

What are Premenstrual Dysphoric Disorders

•Symptom cluster in last week prior to onset of a woman’s period; include

•Mood swings, irritability, depression, anxiety, feeling overwhelmed, and difficulty concentrating

•Symptoms decrease significantly or disappear with the onset of menstruation

What are other depressive disorders 

•Substance-induced depressive disorder

• •Person does not experience depressive symptoms in the absence of drug or alcohol use or withdrawal.  substance/ medication induced depressive disorder, depressive disorder due to another medical condition.

•Depressive disorder associated with another medical condition

• •CVA, Parkinson’s Huntington’s, Alzheimer’s, TBI, Cushing’s disease, hypothyroidism, arthritis, back pain, metabolic conditions, HIV, diabetes, infection, cancer, and autoimmune problems

What is major depressive disorder

•Five (or more) of the following in 2-week period

• •Weight and appetite changes

• •Sleep disturbances

• •Fatigue

• •Worthlessness or guilt

• •Loss of ability to concentrate

• •Recurrent thoughts of death

• •Psychomotor agitation

•PLUS—at least one symptom is also either

• •Depressed mood or

• Loss of interest or pleasure (anhedonia)

physical over mental

Major Depressive Disorder (Cont.)

•Persistent for minimum 2 weeks to 6 months

•Chronic: Lasting more than 2 years

•Recurrent episodes common

•Symptoms cause distress or impaired function

•Episode not attributed to physiological effects

•Absence of a manic or hypomanic episode

What do people with depression also have 

•Leading cause of disability in the United States

•Children and adolescents

•Older adults- not a normal process aging. Common depression- increases as health getting worse

•Comorbidity

•Combination of anxiety and depression is perhaps one of the most common. Psych probelsm schixoprhenia, subsatance abuse, eating, schizoaffectiv, BPD

During intake, Jeff doesn’t speak much, but his parents are able to list the following symptoms they have observed:

•Weight loss and appetite changes

•Insomnia

•Fatigue

•Worthlessness or guilt

•Loss of interest in his college classes and even the online games he usually plays with friends

•“Constant sadness”

Jeff’s parents have described his lack of interest in things he used to enjoy, like games with his friends, and his classes, which he used to like. This may be best described by the term

A.Inappetance

B.Impetance

C.Indolence

Anhedonia

D

What are the risk factors for depression

•Biological factors

•Genetic (first-degree family members)

female, adhverese childhood experine, stressful events, neuorticim , med , personality disorders, anx, subt abuse decrease neurotransmitt

•Biochemical - Stressful life events

•Hormonal- increase cortisol

•Inflammatory

•Diathesis-stress model- Interplay between genetic and biological- genetic dispiosed , stress -

•Cognitive- ngeative self talk

How do we assess someone w depression 

•Assessment of suicidality

•Self-assessment

•Behavior/Affect: Anergia

•Mood: Depressed mood and anhedonia- no pleasure doing things

•Emotions: Anxiety; feelings of worthlessness, hopelessness, guilt, anger, helplessness

•Thoughts/Perceptions: delusions and/or hallucinations

•Comorbidity: chronic pain (sometimes)

Motor retardation

Poverty of thought- responses slow or absent

decrease concentrate

Assessment tools (PHQ9)

Suicide potential – Ask Suicide-Screening Questions (ASQ), Columbia Suicide Severity Risk Scale (C-SSRS)

What self assessment do we do

•Patients with depression:

•Often reject the advice, encouragement, and understanding

•A nurse’s best response:

•Recognize unrealistic expectations for yourself or the patient

•Identify feelings that originate with the patient

•Understand the roles biology and genetics play in major depressive disorder

Which question would be a priority when assessing for symptoms of major depression?

A.“Tell me about any special powers you believe you have.”

B.“You look really sad. Have you ever thought of harming yourself?”

C.“Your family says you never stop. How much sleep do you get?”

D. Do you ever find that you don’t remember where you’ve been or what you’ve done?”

B

What nursing diagnosis do we do

•Risk for suicide—safety is always the highest priority

•Chronic low self-esteem

•Imbalanced nutrition

•Constipation

•Disturbed sleep pattern

•Ineffective coping

Disabled family coping

What planning do we do

•Planning

•Geared toward

•Patient’s phase of depression

•Particular symptoms

•Patient’s personal goals

What implementation do we do

•Implementation

•Three phases

•Acute phase (6 to 12 weeks)- reduce symptoms and restore func

•Continuation phase (4 to 9 months)- prevent relapse

Maintenance phase (1 year or more)- further epsidose

•Counseling and communication

•Health teaching and health promotion

•Promotion of self-care activities

•Teamwork and safety

•Evaluation

•Tailored to each patient’s unique presentation

•Basic self-care, thought processes, self-esteem, and social interactions

med is not a fix all

What communication techniques do we use 

•Communication Techniques

•Use simple, concrete words

•Allow time for a response

•Listen for covert messages

•Ask about suicide plans

•Avoid platitudes- things will look up

•When a patient is silent:

•Avoid direct questions

Make observations to reinforce reality

What treatment modalities do we do

•Choosing an antidepressant

•Symptom profile of the patient

•Side-effect profile (e.g., sexual dysfunction, weight gain)

•Ease of administration

•History of past response

Safety and medical considerations

How do you choose an antidepressant

•Choosing an antidepressant

•Symptom profile of the patient

•Side-effect profile (e.g., sexual dysfunction, weight gain)

•Ease of administration

•History of past response

Safety and medical considerations

risk of serotonin syndrome- abx, Zofran

What are the types of antidepressants

•Selective serotonin reuptake inhibitors (SSRIs)

•First-line therapy

•Rare risk of serotonin syndrome

•Serotonin norepinephrine reuptake inhibitors (SNRIs)

•SSRIs may be tolerated better

•Tricyclic antidepressants

•Anticholinergic adverse reactions

•Monoamine oxidase inhibitors

Effective for unconventional depression

Jeff was just diagnosed with a major depressive disorder. Which medication is the health care provider most likely to start the patient on?

A.SSRI

B.SNRI

C.Tricyclic antidepressant

D.Monoamine oxidase inhibitor

•Plan patient and family education to discuss what side effects Jeff might experience on his new medication regimen.

A

What are other treatments for depression

•Integrative Medicine

•St. John’s wort tea

•Brain Stimulation Therapies

•ECT- careful heart and brain

•Repetitive ranscranial magnetic stimulation (rTMS)

•Vagus nerve stimulation (VNS)

•Deep brain stimulation (DBS)

•Light therapy

and Exercise

What are Advanced Practice Interventions

•Psychological therapies

•Cognitive-behavioral therapy (CBT)

•Interpersonal therapy (IPT)

•Time-limited focused psychotherapy

•Behavior therapy

•Group therapy

A patient with major depression walks and moves slowly. Which term should the nurse use to document this finding?

A.Psychomotor retardation

B.Psychomotor agitation

C.Vegetative sign

D.Anhedonia

A

Which assessment finding in a patient with major depression represents a vegetative sign?

A.Restlessness

B.Hypersomnia

C.Feelings of guilt

Frequent crying

Look at 14.2