Emotional and Mood Disorders and Treatments

Emotional and Mood Disorders: Management and Drugs

Introduction to Emotional and Mood Disorders

• This presentation covers emotional and mood disorders and the medications used to treat or manage their symptoms, including antidepressants, drugs for bipolar disorder, and treatments for Attention Deficit and Hyperactivity Disorder (ADHD).

• Simplified Definitions: The definitions provided are simplified compared to the extensive diagnostic criteria found in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition).

• Co-occurrence: These conditions are not mutually exclusive and an individual may experience several at once.

• Chronicity: Most conditions discussed are chronic rather than situational, often requiring prolonged or lifelong treatment.

  • Exception: Situational depression can occur and may resolve.

• These conditions will be discussed in greater depth in psychiatric nursing courses, but this provides a foundation for understanding related medications.

  • Electroconvulsive Therapy (ECT): A non-pharmacologic treatment for treatment-resistant depression (depression that has failed multiple pharmacological attempts), with potential significant side effects.

Definitions of Specific Disorders

• Major Depressive Disorder (MDD):

  • The most common presentation of depression.

• Dysthymic Disorder:

  • Characterized by less severe symptoms of depression than MDD, but still significantly interferes with normal functioning.

  • More treatment-resistant than MDD.

  • Individuals often have a poor prognosis for achieving complete relief from symptoms.

• Mood Disorders:

  • Defined as severe changes in mood.

  • Bipolarity is classified as a mood disorder.

• Postpartum Depression:

  • Depression occurring during the first few weeks or months after childbirth.

  • Caused by hormonal shifts and situational stressors.

  • Covered in more detail in maternal health courses.

• Serotonin Syndrome (SES):

  • A potentially serious condition that can be induced by medications used to treat depression.

  • Will be discussed in more detail later.

Prevalence and Presentation of Depression

• Depression is prevalent across all age groups: adults, elderly, children, and adolescents.

• Hospital Presentations:

  • Primary reason for admission: Patients may be hospitalized due to overwhelming depression requiring intensive management.

  • Concurrent treatment: Patients hospitalized for unrelated issues may have a history of depression being treated concurrently.

  • New/recurrent episode: Symptoms of depression may emerge or recur as a result of hospitalization itself (e.g., prolonged stay) or the diagnosis (e.g., terminal or debilitating illness).

  • Nurses must be vigilant in identifying these symptoms during hospitalization, even if depression was not the initial reason for admission.

Underlying Causes and Diagnosis of Depression

• Physiological Conditions:

  • Certain physiological conditions (e.g., thyroid disease) can cause depressive symptoms.

  • Treating the underlying physiological condition can resolve depression without antidepressants.

• Medication-Induced Depression:

  • Many medications can cause depressive symptoms.

  • If depression appears after a new medication is started, consider it as a potential cause and explore alternatives.

• Familial Tendency: There is often a familial tendency for depression.

• Diagnosis: Made via psychiatric evaluation using DSM-5 criteria.

Treatment Approaches for Depression

• Combined Therapy (Medication + Psychotherapy):

  • Offers the most optimal and robust results for successfully treating and managing depression.

  • Medication alone has low success rates.

  • Psychotherapy alone also tends not to treat depression very well.

• Medication Duration:

  • Ideally, patients are treated for a minimum of 1 year on an antidepressant that is effectively improving symptoms before considering tapering off.

  • Patients often need to try several medications (different classes or within the same class) to find an effective treatment.

• Challenges: Depression can be very challenging to treat, often recurs, and recovery can be prolonged.

Pharmacological Theories for Depression

• Neurotransmitter Dysfunction (Chemical Imbalance):

  • This theory, while not the only one, currently guides most pharmacotherapy.

  • Focuses on imbalance of neurotransmitters affecting cognition and emotion, primarily serotonin and norepinephrine.

  • The goal is to increase neurotransmitter availability in the synaptic cleft.

Antidepressant Drug Classes and Mechanisms

• Blocking Reuptake: The first classes of antidepressants work by blocking the reuptake of neurotransmitters, making them more available for neuronal stimulation.

1. Selective Serotonin Reuptake Inhibitors (SSRIs)

• First-Line Choice: Generally the first choice due to relative safety and fewer, more tolerable side effects compared to older classes.

• Mechanism: Block the reuptake of serotonin, increasing its availability.

• Examples: Fluoxetine (Prozac) – still widely used.

• Therapeutic Effect:

  • Symptoms may improve in about 2 weeks.

  • Maximum effect takes about 6 weeks.

  • Dose may be increased if initial improvement is minimal before deeming the drug ineffective.

  • Patients may need to try multiple SSRIs or switch to a different class.

• Patient Frustration: The trial-and-error process can be incredibly frustrating and disheartening for patients already feeling hopeless.

  • Anticipatory Guidance: Nurses should provide upfront information about the treatment plan, expected duration, and potential need for dose adjustments or medication changes to manage patient expectations and reduce frustration.

• Gene Site Study:

  • A genetic test that can help predict which medications are more likely to work for an individual, potentially reducing trial-and-error.

  • Not perfect, but can narrow down choices.

• Effectiveness: Only about 30 ext{%} of patients ultimately respond to SSRIs.

• Nursing Considerations:

  • Careful Intake: Rule out potential drug interactions.

  • Liver Function: Ensure baseline liver function is intact, as SSRIs are metabolized by the liver.

  • Drug Interactions: Account for all prescriptions, over-the-counters, and herbals (e.g., St. John's Wort).

  • Abrupt Cessation: Should be avoided after chronic use due to negative side effects; however, early cessation (first 6 weeks) due to intolerable side effects is generally not problematic.

  • Common Side Effects (Compliance Issues): Sexual dysfunction, weight gain, insomnia, GI issues, increased insatiability (rarely).

    • Some side effects can be mitigated by adjusting dosing time or switching to a different antidepressant with a better side effect profile (e.g., Bupropion for sexual side effects).

  • Smoking: Patients should avoid smoking as it enhances liver metabolism, which can reduce drug effectiveness.

2. Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)

• Mechanism: Inhibit the reabsorption of both serotonin and norepinephrine (and sometimes dopamine).

• Examples: Venlafaxine (Effexor).

• Rationale: Developed after SSRIs due to the limited effectiveness of SSRIs, based on the theory that more neurotransmitters like norepinephrine might also be involved.

• Side Effects:

  • Generally have more severe/intolerable side effects than SSRIs.

  • Can work for patients who don't respond to SSRIs.

• Titration: Must be tapered up and down carefully; abrupt cessation is not safe and can cause significant issues, making them unsuitable for patients with poor medication adherence.

  • This is a key difference from SSRIs, where early abrupt stopping is generally safe.

• Sexual Side Effects: Can have fewer sexual side effects for some individuals.

3. Atypical Antidepressants

• Mechanism: Work on different pathways than SSRIs and SNRIs.

• Selection: Chosen if SSRIs/SNRIs are ineffective, or if the patient's specific symptoms are better suited to these options.

• Examples:

  • Bupropion (Wellbutrin/Zyban):

    • Can be activating, useful for depression with fatigue.

    • Tends to have fewer sexual side effects.

    • Zyban brand is also used for smoking cessation.

  • Trazodone:

    • Very sedating, useful for depression with comorbid anxiety and sleep disturbances.

4. Tricyclic Antidepressants (TCAs)

• Rarely Used: Infrequently used due to more intolerable side effects and significant drug interaction potential.

• Mechanism: Inhibit the reuptake of norepinephrine and serotonin (non-selectively), as well as other neurotransmitters, leading to widespread neurotransmitter changes.

• Historical Significance: First drugs to effectively target depression; SSRIs replaced them due to better side effect profiles.

• Side Effects:

  • Take several weeks for therapeutic effect.

  • Common: Orthostatic hypotension, nausea, significant sedation.

    • Patients need to be cautioned about slow position changes and driving, especially during initiation.

  • Anticholinergic effects (e.g., dryness).

  • High incidence of sexual dysfunction (adherence issue).

• Cautions:

  • Use caution with cardiovascular history.

  • Significant drug interactions, especially with other CNS depressants.

  • Long half-life.

5. Monoamine Oxidase Inhibitors (MAOIs)

• Rarely Used: Almost never seen in practice now due to severe side effects and numerous drug/food interactions.

• Mechanism: Decrease the enzyme monoamine oxidase, which typically terminates the action of epinephrine, norepinephrine, dopamine, and serotonin, leading to increased levels of these neurotransmitters. They are non-selective.

• Reserved For: Patients who fail all other antidepressants, though most providers would not prescribe them due to risks.

• Side Effects/Interactions:

  • Hypertensive Crisis: High risk when taken with other MAOIs or foods containing tyramine (strict dietary restrictions required).

  • Patients need to wear a medical alert tag.

  • Drug-drug interactions (e.g., other antidepressants).

  • Monitor insulin/hypoglycemic medications more closely in diabetic patients.

  • Take a long time for therapeutic effect.

Black Box Warning: Suicidal Ideation in Children and Adolescents

• Warning: Antidepressants, particularly SSRIs and SNRIs, carry a black box warning regarding increased risk of suicidal ideation in children and adolescents.

• Nurse's Role: Advise and monitor patients and families for suicidal ideation when medications are initiated or changed in this age group.

• Context/Controversy:

  • Warning issued in 2004 based on placebo-controlled studies.

  • Subsequent research has refuted some of the initial findings, suggesting the increased risk is more theoretical or not disproportionately higher in this age group compared to others.

  • FDA has been reluctant to remove the warning despite current evidence.

• Importance: While the warning exists, it should not deter parents from allowing appropriate treatment, as the risk of untreated depression may outweigh the theoretical risk of medication-induced suicidal ideation.

• Suicidal Ideation and Depression:

  • Most depressed patients do not attempt or complete suicide, and many never experience suicidal ideation.

  • Depression is not synonymous with suicidal ideation.

  • Suicidal ideation is complex and often more successfully treated with pharmacotherapy outside the antidepressant class