Week 6 - Outline

Sadness vs. Depression

• Mood: A feeling state, an emotional experience that influences thoughts, behaviors, and overall well-being.

  • Time: Mood fluctuations are normal, but persistent negative moods may indicate a deeper issue.

  • Adaptation: Individuals typically adapt to changing moods, but difficulty in regulation can signal maladaptive emotional responses.

  • Dysfunction: When mood disturbances impair daily functioning, they may indicate a mental health disorder such as depression.

Emotional Responses

Adaptive Emotional Responses

• Reflect a healthy awareness and expression of emotions.

• Allow individuals to process grief, stress, and emotional changes effectively.

• Example: Uncomplicated grief reaction, where sadness gradually subsides with time and support.

Maladaptive Emotional Responses

• Indicate an inability to process or express emotions healthily.

• Can lead to prolonged distress, detachment, or emotional suppression.

• Examples:

  • Suppression of emotions, leading to physical and psychological stress.

  • Delayed grief reaction, where an individual postpones dealing with loss.

  • Mania and Depression, characterized by extreme emotional highs and lows.

Lifetime Risk for Depression

• Women: 20-30% risk, often influenced by hormonal changes, societal expectations, and caregiving roles.

• Men: 7-12% risk, potentially underdiagnosed due to societal stigma around male emotional expression.

• Ethnic Disparities:

  • Higher incidence in Whites/Hispanics compared to African-Americans.

  • More prevalent in lower socioeconomic groups, due to increased stressors, reduced access to mental health resources, and stigma.

• Common in the elderly, often linked to isolation, chronic illness, and bereavement.

• Frequently coexists with medical and psychiatric illnesses, complicating diagnosis and treatment.

Risk Factors for Depression

• Psychiatric and Personal History

  • Prior episodes of depression increase susceptibility to recurrence.

  • Family history of depression suggests genetic predisposition.

  • Prior suicide attempts indicate severe depressive symptoms.

  • Personal history of sexual abuse can contribute to emotional trauma and depression.

  • Current substance abuse often coexists with depression, exacerbating symptoms.

  • Narcissistic abuse, leading to emotional manipulation, low self-esteem, and trauma.

• Demographic Factors

  • Female gender: Higher risk due to hormonal fluctuations, pregnancy, and societal pressures.

  • Age of onset <40 years: Early onset is linked to more severe and recurrent episodes.

  • Postpartum period: Hormonal shifts and lifestyle changes contribute to postpartum depression.

• Medical and Social Factors

  • Medical co-morbidities such as chronic pain, diabetes, and cardiovascular diseases heighten depression risk.

  • Lack of social support can lead to increased feelings of loneliness and hopelessness.

  • Stressful life events, including job loss, financial instability, and major life transitions, act as significant triggers.

Prognosis for Major Depression

• Can be well managed with medications, counseling, and self-help strategies.

• However:

  • 50-80% of individuals will experience a subsequent depressive episode.

  • 20% of those affected do not fully recover within one year.

  • Some may succumb to severe depression and commit suicide.

  • Recommended to stay on antidepressants for at least 2 years to reduce relapse risk.

Postpartum Depression

• Postpartum Blues: Short-lived episodes lasting 1-4 days, affecting 50-80% of women, usually occurring within 1-5 days after delivery.

• Postpartum Depression: Develops 2-12 months after delivery, affecting 10-15% of women.

• Postpartum Psychosis:

  • Rare but severe condition with onset 2-3 days post-delivery.

  • Characterized by confusion, irrational thoughts, and thoughts of self-harm or harm to the baby.

  • Requires immediate medical intervention, including antipsychotic medications.

Seasonal Affective Disorder (SAD)

• A type of depression linked to reduced daylight hours in fall and winter.

• Symptoms improve during spring and summer.

• Often treated with light therapy, lifestyle modifications, and medication if necessary.

Dysthymic Disorder

• Chronic, low-level depression lasting 2 years

• Symptoms:

  • Sadness, Dejection, Helplessness, Hopelessness

  • Flat Affect/emotions

  • Difficulty Experiencing Pleasure

  • Psychomotor Retardation:

    • Slowness to process things

    • Slow speech and thinking

  • Self-Destructive Behavior (self-harm)

  • Anorexia or Overeating

  • Insomnia or Hypersomnia:

    • Hypersomnia = sleeping too much

  • Decreased Libido

  • Feels Best Early in the Morning, becomes more sad throughout the day

Three Phases of Treatment for Depression

1. Acute Treatment (6-12 weeks)

   • Goal: Eliminate symptoms

   • High risk of relapse; requires close monitoring.

2. Continuation Treatment (4-9 months)

   • Goal: Prevent relapse and promote recovery.

3. Maintenance Treatment (1+ years)

   • Goal: Prevent recurrence (new episode of illness).

Antidepressants

SSRI’s (Selective Serotonin Reuptake Inhibitors)

• Most common antidepressants

• Block serotonin reabsorption, increasing availability for communication between neurons

• Examples:

  • Fluoxetine (Prozac)

  • Sertraline (Zoloft)

  • Paroxetine (Paxil)

  • Escitalopram (Lexapro)

  • Citalopram (Celexa)

  • Fluvoxamine (Luvox)

• Pros: Faster onset, milder side effects

• Cons: Can cause sexual dysfunction

SNRI’s (Serotonin-Norepinephrine Reuptake Inhibitors)

• Block serotonin and norepinephrine reabsorption

• Examples:

  • Duloxetine (Cymbalta)

  • Venlafaxine (Effexor)

  • Levomilnacipran (Fetzima)

• Important: Taper off gradually; do not abruptly stop

Tricyclic Antidepressants (TCAs)

• Block serotonin and norepinephrine but also affect other neurotransmitters, leading to more side effects

• Examples:

  • Amitriptyline (Elavil)

  • Imipramine (Tofranil)

• Risks: Overdose can be fatal due to cardiac effects

• Less commonly used due to higher side effects

MAOI’s (Monoamine Oxidase Inhibitors)

• One of the earliest antidepressants, rarely used today due to dietary and drug interactions

• Why not commonly used?

  • Require strict dietary restrictions (avoid aged cheese, liver, fermented foods, Chianti & Sherry wine, ripe avocados/figs, deli meats)

  • Danger: Risk of hypertensive crisis if combined with foods high in tyramine or drugs like ephedrine (cold remedies, nasal decongestants, asthma meds, cocaine, amphetamines)

• Symptoms of Hypertensive Crisis: Headache, stiff neck, nausea/vomiting, diaphoresis

• Client Education is Critical!

Serotonin Syndrome

• Potentially life-threatening

• Sudden onset due to excess CNS serotonergic activity and individual sensitivity, drug interactions (prescribed or recreational), and overdose

• Symptoms: Increased heart rate, shivering, sweating, dilated pupils

Planning Care

• Reduction and removal of maladaptive emotional responses

• Restoration of the patient’s occupational and psychosocial functioning

• Improvement in the patient’s quality of life

• Minimization of the likelihood of relapse and recurrence

• GI symptoms are normal

• Encourage showers, as they can improve well-being

• Educate patients on their condition and treatment options

Alternative Therapies

• Group Therapy: Provides a supportive environment where individuals can share their experiences, challenges, and coping strategies.

• Individual Psychotherapy: One-on-one sessions with a therapist to explore personal thoughts, emotions, and behaviors to improve mental well-being.

• Family Therapy: Involves family members to improve communication and relationships, helping to create a supportive environment for the patient.

• Light Therapy: Uses exposure to bright light to regulate mood and alleviate symptoms of seasonal affective disorder (SAD).

• Cognitive Therapy – Teaches individuals to control negative thought distortions related to expectations of the environment, self, and future. Studies suggest it may be equally or more effective than antidepressants.

Bipolar Disorder

A depressive episode with previous or current manic episodes.

Introduction

• Mood: A pervasive and sustained emotion that influences perception.

  • Examples: Depression, joy, elation, anger, anxiety.

• Affect: The emotional reaction associated with an experience.

• Mania:

  • Elevated or irritable mood.

  • Characterized by:

    • Feelings of elation

    • Inflated self-esteem

    • Grandiosity

    • Hyperactivity & agitation

    • Accelerated thinking & speaking

Epidemiology

• Age of Onset: Late teens to early 20s.

• Gender Differences:

  • Men & Women affected equally.

  • Women: First episode typically manic, but overall more depressive episodes.

  • Men: First episode typically depressive, but overall more manic episodes.

• Higher Risk Groups:

  • More common in higher socioeconomic classes.

  • More frequently seen in socially active & creative individuals.

Etiology (Causes)

• No single cause identified.

• Neurotransmitter Dysregulation:

  • Imbalance in norepinephrine & serotonin levels.

• Genetic Linkage:

  • 25% increased risk if a first-degree relative has bipolar disorder.

Manic Episode Features

• Episodes can last several weeks.

• Delusions or hallucinations may or may not be present.

• Onset may follow a seasonal pattern.

• Hospitalization often required for severe episodes.

• Symptoms are not due to other causes.

Key Manic Symptoms

• Persistent, elevated, expansive, or irritable mood lasting > 1 week.

• Decreased need for sleep (may not sleep at all but still feel energetic).

• Pressured speech (talking too fast, difficult to understand, can’t stop).

• Distractibility (easily diverted, inability to focus).

• Increased energy & hyperactivity (excessive goal-directed activity).

• Impaired judgment (risky behaviors, reckless spending).

• High rate of infidelity & divorces (due to impulsivity).

Clinical Behaviors

• Mood instability (labile, easily agitated).

• Racing thoughts (rapid, disorganized thinking).

• Impaired judgment & concentration.

• Little to no sleep, but doesn’t feel the need.

• Excessive engagement in pleasurable activities (e.g., sexual encounters, intrusive behaviors).

• Grandiosity (inflated self-importance, unrealistic confidence).

• Possible delusions or hallucinations.

Clinical Course

• Chronic, cyclic disorder → time between episodes shortens over time.

• 90% of patients will experience future episodes.

• Repeated hospitalizations may be required.

• Consequences of untreated bipolar disorder:

  • Alienation from family/friends

  • Divorce

  • Job loss

  • High suicide risk

Nursing Goals

1st Priority: Safety!

• Prevent physical injury.

• Ensure patient has not harmed self or others.

Other Nursing Goals

• Reduce physical agitation.

• Encourage adequate nutrition (well-balanced diet + snacks to prevent weight loss).

• Help patient verbalize accurate interpretation of reality.

• Reduce hallucinatory activity (ensure patient does not display outward behavior indicating hallucinations).

Psychopharmacology: Mood Stabilizers and Lithium Carbonate

Behavioral and Sleep Considerations:

• Accepts responsibility for own behaviors

• Does not manipulate others for personal gratification

• Interacts appropriately with others

• Able to fall asleep within 30 minutes of retiring

• Able to sleep 6-8 hours per night

Mood Stabilizers: Use in Mania and Depression

• For Mania:

  • Mood Stabilizers (e.g., Lithium carbonate, anticonvulsants, verapamil, antipsychotics)

  • For Depressive Phase:

    • Antidepressants (use with caution as they may trigger mania)

    • Mood-stabilizing agents (e.g., Lithium, anticonvulsants, antipsychotics)

    • Indications: Prevention and treatment of manic episodes associated with bipolar disorder

Examples of Mood Stabilizers:

• Lithium carbonate

• Clonazepam

• Carbamazepine

• Valproic acid

• Lamotrigine

• Gabapentin

• Topiramate

• Oxcarbazepine

• Verapamil

• Antipsychotics

Lithium Carbonate:

• Indications: Treatment and prevention of manic episodes in bipolar disorder

• Narrow Therapeutic Index:

  • Therapeutic range: 0.5 – 1.2 mEq/L

  • Initial therapeutic target for acute mania: 1.0 to 1.5 mEq/L

  • Maintenance level: 0.6 to 1.2 mEq/L

• Blood Monitoring: Regular blood level checks required

• Combined Use: Often combined with antipsychotics or antianxiety medications during the initial phase of treatment (response > 1 week)

Side Effects of Lithium:

• Fine hand tremor

• Gastrointestinal disturbances

• Mild polyuria (increased urination) and polydipsia (increased thirst)

• Lethargy

Lithium Toxicity:

• Initial Symptoms of Toxicity:

  • Blurred vision

  • Ataxia (lack of muscle coordination)

  • Tinnitus (ringing in ears)

  • Persistent nausea and vomiting

  • Severe diarrhea

• Management of Toxicity:

  • Therapeutic Range:

    • Acute mania: 1.0 to 1.5 mEq/L

    • Maintenance: 0.6 to 1.2 mEq/L

  • Signs of toxicity when levels exceed the therapeutic range.

Lithium and Sodium Relationship:

• Increased dietary sodium → Decreased serum lithium levels

• Decreased sodium (from diet or loss due to vomiting/diarrhea) → Increased serum lithium levels

  • Patient Teaching:

    • Maintain consistent salt intake based on their diet

    • Monitor sodium intake carefully

Nursing Considerations and Patient Education for Lithium:

• Medication Adherence:

  • Take lithium regularly as prescribed

  • Do not skip or reduce dietary sodium intake without medical advice

  • Drink 6-8 glasses of water per day to prevent dehydration

  • Notify Physician if vomiting or diarrhea occur as it can affect lithium levels

  • Have serum lithium levels checked every 1-2 months, or as directed by the physician

• Notify Physician if Any of the Following Symptoms Occur:

  • Persistent nausea and vomiting

  • Severe diarrhea

  • Ataxia

  • Blurred vision

  • Tinnitus

  • Excessive urination

  • Increasing tremors

  • Mental confusion

Anticonvulsants

General Instructions:

• Do not discontinue the drug abruptly without medical advice to avoid withdrawal seizures or other complications.

• Notify the physician immediately if any of the following symptoms occur:

  • Skin rash

  • Unusual bleeding

  • Spontaneous bruising

  • Sore throat

  • Fever

  • Malaise

  • Dark urine

  • Yellow skin or eyes (potential signs of liver problems)

• Avoid alcohol and over-the-counter medications unless approved by the physician to prevent interactions.

Monitor for Side Effects of Anticonvulsants:

• General Side Effects:

  • Nausea and vomiting

  • Drowsiness and dizziness

  • Prolonged bleeding time (particularly with valproic acid)

  • Risk of severe rash (especially with lamotrigine)

  • Decreased efficacy of oral contraceptives (with topiramate)

Common Anticonvulsant Medications:

• Clonazepam (Klonopin)

• Topiramate (Topamax)

• Valproic Acid (Depakote)

• Lamotrigine (Lamictal)

• Carbamazepine (Tegretol)

• Oxcarbazepine (Trileptal)

Patient Education:

• Medication Adherence: Always take anticonvulsants as prescribed. Do not adjust the dose or stop the medication without consulting the physician.

• Monitor for Symptoms: Be vigilant for signs of serious reactions like skin rash, unusual bleeding, or liver issues (yellowing of skin/eyes, dark urine).

• Avoid Alcohol and OTC Medications: Discuss all medications, including OTC drugs, with your doctor to prevent interactions.

• Contraceptive Considerations: For women on anticonvulsants, topiramate can decrease the efficacy of oral contraceptives, so an alternative form of contraception may be necessary.

Verapamil (Calcium Channel Blocker)

Monitor for Side Effects of Verapamil:

• Drowsiness and dizziness

• Hypotension and bradycardia (slow heart rate)

• Nausea

• Constipation

Patient Education:

• Do not discontinue the drug abruptly: Stopping verapamil suddenly can cause a rebound increase in heart rate and blood pressure. Always consult a physician before adjusting the medication regimen.

• Rise slowly: To prevent sudden drops in blood pressure, patients should rise slowly from sitting or lying positions.

• Report the following symptoms to the physician immediately:

  • Irregular heartbeat or chest pain

  • Shortness of breath or pronounced dizziness

  • Swelling of hands and feet

  • Profound mood swings

  • Severe and persistent headache

Nursing Implications for Verapamil:

• Monitor vital signs regularly, especially heart rate and blood pressure.

• Check for signs of fluid retention (swelling of the extremities) and assess the patient's electrolyte levels if necessary.

• Ensure adequate hydration and provide education on dietary fiber to manage constipation.

Antipsychotics

Common Antipsychotic Medications:

• Risperidone (Risperdal)

• Ziprasidone (Geodon)

• Quetiapine (Seroquel)

• Aripiprazole (Abilify)

General Instructions:

• Do not discontinue the drug abruptly: Stopping antipsychotics suddenly can lead to withdrawal symptoms or a relapse of psychiatric symptoms. Always consult a healthcare provider before making any changes.

• Use sunblock lotion when outdoors: Antipsychotics can increase sensitivity to sunlight, leading to sunburn.

• Rise slowly from sitting or lying position: These medications may cause orthostatic hypotension, leading to dizziness or fainting.

• Avoid alcohol and over-the-counter medications: Alcohol and certain OTC medications may interact with antipsychotics, increasing the risk of adverse effects.

• Continue taking the medication, even if feeling well and as though it is not needed: Symptoms may return if the medication is discontinued prematurely.

Report the Following Symptoms to the Physician Immediately:

• Sore throat, fever, malaise (could indicate agranulocytosis, a severe side effect)

• Persistent nausea and vomiting

• Severe headache and rapid heart rate

• Difficulty urinating or excessive urination

• Muscle twitching, tremors (could indicate extrapyramidal symptoms or tardive dyskinesia)

• Darkly colored urine or pale stools (signs of liver dysfunction)

• Yellow skin or eyes (jaundice, possible liver issues)

• Excessive thirst or hunger (possible sign of metabolic disturbances, including diabetes)

• Muscular incoordination or weakness (may indicate neuroleptic malignant syndrome, a rare but serious condition)

Nursing Implications for Antipsychotics:

• Monitor vital signs regularly, especially heart rate and blood pressure.

• Monitor for signs of infection (sore throat, fever, malaise), and check white blood cell count if necessary.

• Monitor for extrapyramidal side effects (tremors, rigidity, muscle twitching).

• Assess for signs of metabolic syndrome, including weight gain, excessive thirst, and hunger.

• Encourage regular check-ups and laboratory tests, including liver function and glucose levels, for long-term use.