Transcript depression ppt. - Austin Community College

DEPRESSION
What Does Depression
Feel Like?
 Lost, dark, in a tunnel, dying or dead
 Emptiness, nothingness, blank, no feelings
 No energy, tired, heavy, paralyzed
 Anxious, fearful, vulnerable, defenseless, weak
 Rejected, unlovable, unworthy
 Guilty, at fault, bad, sick, contaminated
 Unrelenting emotional pain, suffering, miserable
Incidence and Prevalence
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NIMH --Depression Rate:
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7.1% in women/Postpartum Depression
3.5% in men
6.7 % of US adult population in a given year
Age of onset- anytime, highest in 20’s
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Highest Prevalence-ages 25-44.
General Hospital admits: 10 to 15% are depressed
 Box 29-3 page 380
Many Forms of Depression
SELECTED DISORDERS
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DSM IV-TR Depressive Disorders
 Major Depressive Disorder (MDD)
 (several subcategories or “specifiers”)
 Dysthymia
 Depressive Disorder, Not Otherwise
Specified (NOS)
 Has
characteristics of depression but does
not fit exact criteria for the above
Criteria for
Major Depressive Disorder
5 of the following 9 Symptoms > 2 weeks
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Depressed Mood
Anhedonia (or Apathy)
Significant change in weight
Insomnia or hypersomnia
Increased or decreased psychomotor activity
Fatigue or energy loss
Feelings of worthlessness or guilt
Diminished concentration or indecisiveness
Recurrent death or suicidal thoughts
Symptoms of
Major Depressive Disorder
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One of the of the criteria must be:
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Depressed Mood
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Anhedonia (or Apathy)
Dysthymic Disorder
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Chronic disorder
Depressed mood at least 2 years for more days
than not (>50% of the time)
2 or more of the following
 Poor appetite or overeating
 Insomnia or hypersomnia
 Fatigue or low energy
 Low self-esteem
 Poor concentration
 Feelings of hopelessness
Never free of symptoms for 2 months
What Does Depression
Look Like?
Symptoms of Depression
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Alterations in Activity
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Psychomotor agitation
Tired; poverty of speech
Poor hygiene
Weight loss or gain
Insomnia or hypersomnia
Uninterrupted self-defeating ruminations
Altered Social Interactions
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Poor social skills
Withdrawn, prefer isolation
Symptoms of Depression
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Alterations of Cognition
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Inability to concentrate
Confusion
Easily distracted
Problems with thinking ideas and problem solving
Alterations of Affect
Low-self esteem
 Worthlessness
 Guilt
 Anxiety
 Hopelessness
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Symptoms of Depression
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Alterations of a
Physical Nature
 Somatic Complaints
 Preoccupation with
their bodies
 Panic Attacks in
15% to 30% of
people with MDD
Symptoms of Depression
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Alterations of Perception: Usually
Mood Congruent
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Hallucinations
 Voices accusing or blaming of self
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Delusions (really, these are cognitive
alterations!)
Delusion of Persecution:
 e.g. For a moral or ethical mistake
 Somatic Delusions
 e.g. “I am full of cancer”
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Depression Model and Theories
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Unified Model of Mood Disorders
Genetic Vulnerability
 Developmental Events
 Physiological Stressors
 Psychosocial Stressors
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Any of these can start the cycle of
disturbed neurochemistry
Neurochemical Theories
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Serotonin and
Norepinephrine
 Level is altered at
the receptor site
 Receptor sensitivity
changes
 The cells they
activate have lost
the capacity to
respond
Genetic Theories
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Depression, major correlation, but not
clear
Two thirds of twins are concordant for
MDD if one or both parents have MDD
Endocrine Theory
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Elevated levels of
corticotropin-releasing
hormone
Elevated pituitary
release of andrenocorticotropic hormone
Early life exposure to
overwhelming trauma
Circadian Rhythm Theory
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Medications
Nutritional deficiencies
Physical illness
Wake-sleep cycles
Hormonal fluctuations
Psychosocial Perspectives
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Freud believed depression was anger turned on
the self; overactive superego
Sullivan-problems in the interpersonal areas of
neglect, abuse, rejection, loss
Cognitive theories
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Beck-Depression based on distorted thinking patterns
Ellis-Concept of neg. self talk and catastrophising
Psychosocial Perspectives, con’td.
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Behavioral Theories- The way you act affects
people’s response
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Seligman- Developed theory of learned helplessness,
hopelessness and being unassertive
Loss Theory
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Bowlby-Loss during childhood predisposes to
depression, esp. another loss
TREATMENT FOCUS:
Cognitive Theory
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Core beliefs: How you think about your
situation
Identify self-defeating thoughts, beliefs
Change beliefs and you will change
behavior
(Review p. 35, 43-45)
Treatment Efficacy
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Depression very treatable disease
Episodes usually last 6 to 9 weeks
Endogenous: no identifiable trigger or
event-- medications with psychotherapy
Exogenous: identifiable event(s) or
stressor(s)-- counseling/psychotherapy
may be enough to resolve symptoms
Nursing Dx For Depressive
Disorders
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Alteration in Nutrition: Less than body
requirements
Sleep pattern disturbance
Self care deficit
Alterations in perception:Hallucinations
Alteration in thought process: Delusions
Potential for Violence: directed at self,
or Risk for Suicide
Nursing Care and Milieu
Management
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Safety First: The milieu or environment
should keep the client safe
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Check all clients every 15 minutes
Locked environment
Remove all harmful items
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Mirrors, pocket knifes, razors, shoelaces, hangers
Balance Sleep/activity
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Assess hours of sleep
Encourage exercise/Walking
relaxation tapes
Medication as needed for sleep
Nursing Care and Milieu
Management
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Monitor and Provide Adequate Nutrition
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Observation of client during meals
Record weight < weekly
Record amount eaten
Vital signs
Lab work
 A low albumin level or total protein will let you
know the client is not eating well
Nursing Care, Milieu, cont’d
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Decrease Isolation
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Approach is firm and direct
“It is time for our 1-1 or Art Class or Coping
Skills Group”
Listen and Acknowledge Negative
Feelings
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Acknowledge even the most negative or
suicidal feelings. You do not agree with them,
but you let them know you hear them.
Interventions for Other Issues
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Anger: writing, discussing, and exercise
Agitated depression: walk with patient
Simple, structured activities best in
early treatment (why?)
Group Therapies
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Assertiveness training
Coping Skills
Grief group
Art therapy
Insight oriented psychotherapy (outpatient)
Family therapy
Nurse-Client Communication
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Establish trust
 Show sincere concern
Assess client’s negative self
talk
Provide another point of view
 Do not attempt to reason
 Don’t reinforce delusions
May be resistant to come to
1-1
Active listening, non-directive
style
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Cognitive Therapy
Strategy
 Have client list 3 negative
thoughts about self
 This must be limited in
number or could initiate
rumination
 Have client list 3 positive
qualities about self
 Talk with client about
positive qualities
 Goal = to begin to replace
negative thinking with
more positive thoughts
Medications
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Antidepressants
 Tricyclics (TCAs)
 Serotonin re-uptake Inhibitors /SSRIs
 Monoamine Oxidase Inhibitors (MAOIs)
 Atypical/Novel Antidepressants
Misc. agents
Atypical Antipsychotics
Medications, cont’d
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Psychostimulants (e.g. amphetamines)
St. John’s Wort (hypericum)--herbal
remedy (described in Chap 40 p. 584-585)
Comparison of Modes of
Action: TCAs and SSRIs
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Tricyclics: a) non-selectively inhibit
reuptake, b) increase receptivity to
serotonin and norepinephrine
SSRI’s: Selective inhibition of serotonin
reuptake  fewer side effects
Antidepressant
Side Effect Profiles
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TCAs
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Dry mouth
Blurred vision
Constipation
Sedation
 appetitewt gain
Postural hypotension
Cardiac effects
 Can be cardiotoxic
 EKG prior to starting
Slow onset 2-4 weeks
Overdose potential
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SSRIs
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Nausea
Nervousness, anxiety
Insomnia
Sexual dysfunction
Headache
Slow onset 2-4 weeks
 This length of time
is a consideration if
client is suicidal
Low OD risk
Client Teaching: Managing
Common Medication Side
Effects
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Orthostatic Hypotension
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Insomnia
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Hydrate
Hard candy or gum
Drowsiness
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Schedule dose early in day
Dry mouth
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Teach the patient to rise slowly
Schedule dose at night
Cardiac effects
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Tricyclics may be supplied one week at a time
Monoamine Oxidase Inhibitors
(MAOIs)
 Inhibit enzyme that breaks down
serotonin and norepinephrine
 Non-Selective (older) and Selective types
 Usually last choice of pharmacotherapy
Side Effects of MAOIs
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MAOIs can cause very
serious hypertensive crisis
Client must be instructed
not to drink red wine, eat
cheese, yogurt anything
aged. Tyramine is
chemical ingredient.
Check with MD before
taking any new meds.:
many drug-drug
interactions with adverse
effects
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AVOID
Atypical Antidepressants
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Prevent reuptake of specific
neurotransmitters, e.g.
 Serotonin and Norepinephrine (SNRI)
 Norepinephrine and Dopamine (NDRI)
or are
Receptor Antagonists - increase activity of
neurotransmitters
Side Effects of Atypicals
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trazodone/Desyrel- Usually used for sleep: rare
side effect: priapism
buproprion/Wellbutrin: seizures at high doses,
irritability, decreased appetite, worsening of tics
venlafaxine/Effexor: Nausea, agitation,
headache and increase in blood pressure
mirtazapine/Remeron: Sedation, increased
appetite
Other Medications
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Used in conjunction with an
antidepressant for treatment of variants of
depression e.g. agitated-type depression,
or for treating anxiety, psychosis or severe
cognitive symptoms
Serotonin Syndrome
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A potentially fatal syndrome
Too much serotonin
Results from: Combination of therapy
 Serotonin Reuptake Inhibitors combined with:
 Prescribed:
 Tricyclic Antidepressants
 Monoamine Oxidase Inhibitors
 Lithium
 Over the Counter Medications:
 Cough and cold meds.
 Diet drugs
 St. John’s Wort
 Other
 LSD, Ecstasy
Serotonin Syndrome, cont’d
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Symptoms:
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CNS-confusion
Agitation
Hypomania
Myoclonus
Tremor
Hyperreflexia
Autonomic signs
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Fever
Tachycardia OR bradycardia
Hypertension OR hypotension
Diaphoresis, diarrhea
Severe dehydration can be fatal
Serotonin Syndrome
Somatic Therapy:
Electroconvulsive Therapy
(ECT) Described in Keltner p. 572-576
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Beneficial for for Clients with:
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Severe Depression
Depression that is resistive to treatment with
medications
Older adults
 Renal disease or Liver disease
 Blood serum levels of medication
increases
ECT, cont’d
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ECT seems to balance dopamine and serotonin
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Under supervision of anesthesiologist
Treatment series of 6-10 times; spaced several days
apart
Pre-op: Give atropine, barbiturate, muscle relaxant
Procedure: Induction of controlled seizure via electrical
current
Monitor LOC, orientation, vitals, resp. before return to
unit/home
Side effects- short term memory loss
 Initially: memory of events immediately prior to the
procedure
Client may have immediate relief of depression