Depressive Disorders and Treatments

Mood Disorders

  • Articles for mood disorders and Seasonal Affective Disorder (SAD) are in the module.
  • Chapter 25 covers mood disorders.
  • SAD is a sub-study module.
  • Chapter references:
    • Chapter 25: Depressive disorders.
    • Chapter 4: Psychopharmacology (medications).
    • Chapter 26: Bipolar and related disorders.

Depression

  • Everyone experiences feeling depressed at some point; it's normal.
  • It becomes a disorder: when it causes dysfunction in everyday life, social functioning, career, work, and family relationships.
  • Characterized by periods of despair and pessimism.
  • Loss of interest in usual activities.
  • Somatic symptoms.
  • Suicidal behaviors.
  • Significant impairment in functioning.
  • Sleep disturbances:
    • Sleeping too much (hypersomnia).
    • Unable to sleep (insomnia).
  • Anxiety often goes hand in hand with depression.
  • Psychomotor agitation: restlessness, inability to sit still.
  • Ambivalence: inability to make decisions.
  • Anhedonia: loss of enjoyment in activities previously enjoyed.
  • Loss of energy, feeling fatigue.
  • Guilt:
    • Self-reproach: feeling of responsibility for wrongdoing characterized by harsh criticism and disapproval of oneself.
    • Shame, regret, penitence.
  • Low self-esteem: feeling unworthy and negative about oneself.
  • Cognitive changes:
    • Negative thinking, pessimistic.
    • Unable to concentrate.
    • Feeling helpless and hopeless.
    • Feeling of having no control.
  • Appetite changes:
    • Increased appetite or decreased appetite.
    • Weight gain is more common.
  • Mood changes:
    • Feeling depressed or empty.
  • Physical symptoms:
    • Headaches.
    • Gastrointestinal (GI) symptoms.
    • Chronic pain related to a medical condition.
  • Substance use disorder: tendency to develop due to negative coping skills.
    • Increased alcohol or drug use.
  • Suicidal behaviors:
    • Ideation, urges, attempts.
  • Signs and symptoms of suicidal behavior:
    • Giving away things they love.
    • Saying goodbye to loved ones.
    • Sudden statements that everything is fine after a suicide attempt.
    • Feelings do not subside easily.
  • Sometimes there are no signs or symptoms of suicidal behavior.
  • Need to be attuned to the patient's words, behavior, and history.

Contributing Factors to Depression

  • Genetics: increases the risk but is not definitive.
  • Brain nervous system and neurochemical imbalances.
  • Physical conditions:
    • Cancer, HIV, any medical condition that impairs activities or changes lifestyle.
    • News of potentially dying sooner than later.
  • Drug use/abuse: high risk for suicidality.
  • Stress injury.
  • Individual factors:
    • Negative self-talk.
    • Anger turned inward.
    • Learned helplessness.
    • Negative thinking.
  • Withdrawal from antibiotics can trigger depression. Medications can have depression as a side effect.

Clinical Management of Depression

Nursing Implications

  • Treatments available:
    • Psychotherapy:
      • Cognitive Behavioral Therapy (CBT).
      • Therapeutic groups (with or without medication, depending on severity).
    • Pharmacogenomics: DNA test to compare individuals to medications.
      • Commonly used for child adolescents to avoid experimenting with different medications.
      • Helps determine which treatment is more conducive for the individual.
      • Medicaid often pays for this test, which costs around 5,000.
    • Electroconvulsive Therapy (ECT): inducing seizures to reboot the brain.
    • Transcranial Magnetic Stimulation (TMS): pulsation of magnetic stimulation, also used for anti-anxiety.
    • Vagus Nerve Stimulation (VNS) device: intrusive, requires implantation.
    • Light therapy.
  • Informed consent is required for any of these treatments.
    • The doctor obtains informed consent.
    • The nurse witnesses.
    • If the patient says they don't understand the ECT just before being wheeled in, the nurse should alert the doctor.

Assessment

  • Complete mental and physical assessment.
  • Use Evidence-Based Practice (EBP) tools like the Hamilton Depression Rating Scale.
  • Directly ask about suicidal risk.
  • Medication reconciliation.

Intervention

  • Create a safe environment.
    • Staying with the patient (one-to-one) if they are severely suicidal.
    • If a patient expresses thoughts of killing themselves, never leave them alone; stay within arm's reach.
  • Address physical symptoms.
  • Encourage discussion about grief or loss.
  • Promote constructive verbalization of feelings.
  • Be a voice of reason in terms of cognitive distortions, such as negative thinking.
  • Explore coping abilities and skills, enhance existing ones.
  • Encourage perception of self-respect.
  • Discuss how to manage depression daily and the risk of relapse.
  • Re-evaluate interventions.

Positive Outcome Goals

  • Scheduling follow-up appointments.
  • Taking medications and asking questions about them.
  • In the hospital:
    • Coming out of their room.
    • Socializing.
    • Eating outside of their room.
    • Compliance with treatments.
    • Making time for appointments.

Antidepressants

  • Selective Serotonin Reuptake Inhibitors (SSRIs):
    • Increase serotonin in the brain by preventing its reuptake.
  • Selective Serotonin Norepinephrine Reuptake Inhibitors (SSNRIs).
  • Atypical:
    • Tricyclics and Monoamine Oxidase Inhibitors (MAOIs) are hardly used.
  • NMDA:
    • Ketamine; not used in inpatient hospitals but available in outpatient services.
  • Atypical antipsychotics:
    • Can be used for depression and anxiety.
  • Anxiolytics:
    • Usually prescribed with antidepressants because anxiety and depression often go hand in hand.

Non-Pharmacological Management

  • Herbal boosts like St. John's Wort.
  • Assess for over-the-counter and herbal medications.
  • Other treatments:
    • ECT, TMS, and VNS.

Medications: Things to Know

  • Be familiar with generic names of medications.
  • Antidepressants work on serotonin, norepinephrine, and dopamine.
  • Cytochrome P450 enzyme: tested in pharmacogenetics.

Role of the Nurse

  • Safe administration.
  • Assess for alcohol or substance use abuse.
  • Pregnancy test.
  • Monitor vital signs.
  • Know baseline Electrocardiogram (EKG) and lab values.

Side Effects of Antidepressants

  • Weight gain or loss: teach exercise, dietary changes, increased activity.
  • Vision: blurry vision, especially if lasting more than three weeks.
  • Cardiovascular: arrhythmias, blood pressure fluctuations; educate about postural changes and increasing fluids.
  • Gastrointestinal: dry mouth, nausea, constipation, diarrhea; increase fluid intake, sugarless gum/candy, take medications with food.
  • Genitourinary: sexual dysfunction (common reason for discontinuation); instruct patients to call their doctor before stopping meds.
  • Urinary retention: increases risk for Urinary Tract Infection (UTI).
  • Central Nervous System (CNS): headache, drowsiness, dizziness, sedation, impaired sleep, and seizures.
  • Other: rash, photosensitivity (wear sunglasses, sunblock, long sleeves).
  • The professor is not familiar with the concept of skipping antidepressant medications on the weekend.

Antidepressant Adverse Effects

  • SSRI discontinuation syndrome:
    • Occurs when a patient abruptly stops their SSRI medication.
    • Clinical manifestations: restlessness, anxiety, dizziness.
    • Duration: can last for two to four weeks.
    • Can cause relapse with depression and increased suicide risk.
    • Treatment: symptomatic treatment.
    • Prevention: tapering off medication slowly and safely.
  • Serotonin Syndrome:
    • Increased serotonin activity in the brain.
    • Caused by increased dosage or sensitivity to serotonin.
    • Also caused by overdose.
    • Manifestations: anxiety, restlessness, tremors, changes in mental status, increased vitals, seizures.
    • Treatment: stop the antidepressant immediately and provide symptomatic treatment.

Antidepressant Medication Administration

  • Prescribed in the morning because of energizing effects, except for trazodone (given PRN for sleep).
  • Black box warning for antidepressants: increased risk of suicidal ideation.
    • Effectiveness of antidepressants may take four to six weeks.
    • Patients may feel energized in the first four weeks, increasing the risk of suicide if suicidal tendencies are present.
  • Take medication as prescribed.
  • Do not stop abruptly.
  • Can take up to four weeks to achieve optimum therapeutic effects.
  • Assess for symptoms of improvement.
  • Be mindful of grapefruit and its effect on medication efficacy.
  • Use sunscreen due to photosensitivity.

MAOIs

  • Severe hypertensive crisis if taken with foods rich in tyramine.
  • Tyramine-restricted diet is important.
    • Avoid aged cheese (except cottage cheese and cream cheese), cold cuts, processed meats, red wines, and smoked foods.

TCAs

  • (Tricyclic Antidepressants): rarely used
  • Risk of cardiotoxicity and contraindicated with benign prostatic hyperplasia. (BPH)