Depression and Bipolar Disorder

What are antidepressant drugs used to treat?

primarily used in the treatment of major depressive illness, anxiety disorders, the depressed phase of bipolar disorder, and psychotic depression. 

The four groups of antidepressants are:

Tricyclic and related cyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), MAO inhibitors (MAOIs), and other (tramadol, bupropion, venlafaxine).

MAOI cautions:

Hypertensive crisis lf pt ingests tyramine, do not give w/other MAOIs or other CNS suppressants, suicide in depressed pts, lethal in overdose.

Preferred drug for high-risk suicide:

SSRIs, venlafaxine, nefazodone, and bupropion.

MOA of antidepressants:

Interact with the two neurotransmitters, norepinephrine and serotonin, that regulate mood, arousal, attention, sensory processing, and appetite.

When are antidepressants expected to peak?

[ ] MAOI peak:2-4 weeks 

[ ] SSRI peak:2-3 weeks 

[ ] Cyclic peak:4-6 weeks 

Mood-stabilizing drugs:

are used to treat bipolar disorder by stabilizing the client's mood, preventing or minimizing the highs and lows that characterize bipolar illness, treating acute episodes of mania. 

What are the types of mood-stabilizing drugs?

Lithium, anticonvulsants, Carbamazepine, valprolc acid.

Major depressive episode:

lasts at least 2 weeks, during which the person experiences a depressed mood or loss of pleasure in nearly all activities.

Bipolar disorder:

is diagnosed when a person's mood fluctuates to extremes of mania and /or depression. 

Manic phase:

clients are euphoric, grandiose, energetic, and sleepless. They have poor judgment and rapid thoughts, actions, and speech. Begin suddenly w/rapid escalation over a few days. last several weeks to several months 

Hypomania

is a period of abnormally and persistently elevated, expansive, or irritable mood and some other milder symptoms of mania. The difference is that hypomanic episodes do not impair the person's ability to function (in fact, they may be quite productive), and there are no Psychotic features (delusions and hallucinations). 

Bipolar I disorder:

one or more manic or mixed episodes usually accompanied by major depressive episodes  

Bipolar II disorder:

one or more major depressive episodes accompanied by at least one hypomanic episode 

Risk factors of bipolar disorder:

Genetics, serotonin or norepinephrine abnormalities, endocrine disorders.

Risk factors of major depressive disorder:

Female gender, divorce, environmental, genetics

When is ECT used/indicated?

Pregnancy, no response to pharmacology, intolerable side effects, actively suicidal 

Electroconvulsive therapy (ECT):

involves application of electrodes to the head of the client to deliver an electrical impulse to the brain; this causes a seizure. It is believed that the shock stimulates brain chemistry to correct the chemical imbalance of depression 3-15 treatments scheduled 3x a week.

Nursing interventions for ECT:

Supply oxygen, administer short-acting anesthetic and muscle relaxant, monitor vitals, apply EEG, test gag reflex/swallow ability.  

Depression treatment:

Antidepressants, SSRIs, ECT therapy, psychotherapy, somatic therapies, TMS

Serotonin syndrome S/S:

Confusion, agitation, muscle rigidity, weakness, sluggish pupils, shivering, tremors, muscle paralysis, myoclonic jerks, hyperthermia, tachycardia, tachypnea, hypersalivation, and diaphoresis. 

Common assessment data for depression:

Suicidal ideas or behavior, slow mental processes, disordered thoughts, feelings of despair, hopelessness, and worthlessness, guilt anhedonia (inability to experience Pleasure,) disorientation, generalized restlessness or agitation, sleep disturbances: early awakening, insomnia, anger or hostility (may not be overt), rumination, delusions, hallucinations, or other psychotic symptoms, diminished interest in sexual activity, fear of intensity of feelings, anxiety 

Nursing interventions for depression:

Provide for the safety of the client and others, institute suicide precautions if indicated, begin a therapeutic relationship by spending nondemanding time with the client, promote completion of activities of daily living by assisting the client only as necessary, establish adequate nutrition and hydration, promote sleep and rest, engage the client in activities, encourage the client to verbalize and describe emotions, work with the client to manage medications and side effects.

Education for depression:

Teach about the illness of depression, identify early signs of relapse, discuss the importance of support groups, assist in locating resources, teach the clients family about the benefits of therapy and follow-up appointments.  

Depressed phase:

mood behavior and thoughts are the same as in people diagnosed with major depression 

Manic episode diagnosis criteria:

at least 1 week and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: exaggerated self-esteem, sleeplessness, pressured speech, flight of ideas, reduced ability to fllter extraneous stimuli, distractibility, increased activities with increased energy, and multiple grandlose, high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments. 

Treatment for bipolar disorder:

Involves lifetime regimen of medications-either an antimanic agent called lithium or anticonvulsant medications used as mood stabilizers sometimes antipsychotics for manic episodes, psychotherapy is good during normal or mildly depressed phases. 

Common assessment data for bipolar:

Disorientation, decreased concentration, short attention span, loose associations (loosely and poorly associated ideas), push of speech (rapid, forced speech), tangentiality of ideas and speech hallucinations, delusions. 

Nursing interventions for bipolar disorder:

Provide for the client's physical safety and those around. Set limits on the client's behavior when needed. Remind the client to respect space between self and others. Use short, simple sentences to communicate. Clarify the meaning of the client's communication. Frequently provide finger foods that are high in calories and protein. Promote rest and sleep. Protect the client's dignity when inappropriate behavior occurs. Channel the client's need for movement into socially acceptable motor activities. 

Education for bipolar disorder:

Teach about bipolar illness and ways to manage the disorder. Teach about medication management, including the need for periodic blood work and management of side effects. For clients taking lithium, teach about the need for adequate salt and fluid intake. Teach the client and family about signs of toxicity and the need to seek medical attention immediately. Educate the client and family about risk-taking behavior and how to avoid it. Teach about behavioral signs of relapse and how to seek treatment in early stages 

Post-partum depression

Feelings of worthlessness, guilt, overwhelmed low energy after childbirth. Negative feelings towards newborn. Becomes evident around 6 weeks after birth.

Lithium toxicity

Levels above 1.2 mEq/L, can lead to seizures, arrythmias, brain damage, coma, etc. Beginning S/S include GI upset, change in mental state, LOC, and blurred vision. If suspected, stop drug immediately.