Transcript Psychopharmacology and Other Biologic Treatments

Mood Disorders
Chapter 18
Impact of Mood Disorders
• Depression is number one leading
cause of disability worldwide.
• Associated with high levels of
impairment
• Often goes undetected and untreated
• Less than 50% receive treatment
• One-third of bipolar diagnosed
Key Concepts
• Mood:
– Pervasive and sustained emotion that colors one’s
perception of the world and how one functions in it
• Mood Disorder:
– Persisting or recurrent disturbances or alterations in
mood that continually cause psychological stress and
behavioral impairment over the years
– Alteration in mood, not thought
Observable Expressions of Mood
• Blunted
• Flat
• Inappropriate
• Labile
• Restricted or constricted
Primary Mood Disorders
• Bipolar
– Bipolar or manic depressive
– Manic
• Depressive (Unipolar)
– Unipolar
– Depression
Depressive Episode (DSM-IV-TR)
• Depressed mood (loss of interest for
two weeks)
• Somatic complaints rather than sadness
• Increased irritability
Depressive Disorders
Clinical Course
• Dysthymic Disorder
– Milder, but more chronic form than MDD
• Major Depressive Disorder
– Progressive, recurrent illness
– Over time, episodes are more frequent, severe
and longer in duration.
– Mean age of onset is about 40 years of age.
– An untreated episode lasts six to 13 months.
– Suicide is the most serious complication (10 to
15%).
Depression in Children
• Less likely to experience psychosis
• More likely to manifest symptoms of anxiety
(fear of separation) and somatic symptoms
• Mood may be irritable, rather than sad.
• Suicide is a real risk, which peaks during midadolescents.
• Mortality from suicide increases steadily
through the teens (third leading cause of
death).
Depression in the Elderly
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Most do not meet criteria for depression
8 to 20% of older adults in community
37% in primary care setting
Treatment successful in 60 to 80%, but
response slower
• Associated with chronic illness
• Highest suicide rate, especially over 85
years
Epidemiology
• Lifetime risk is 7 to 12% in men, 20 to
25% in women.
• Prevalence is unrelated to race.
• In some cultures, somatic symptoms
predominate rather than sadness.
Risk Factors
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Prior episode of depression
Family history of depressive disorder
Lack of social support
Stressful life event
Current substance use
Medical comorbidity
Major Depressive Disorder
• 17% of population will have a
depressive episode in their lifetime.
• Age – 25-44 years most affected
• Other ages increasing, especially in the
elderly
• More common in women
• Expressed in culture differently
• Often occur with other disorders
Clinical Course of a Major Depressive
Episode
• Usually develops over days - weeks
• Episode – minimum of two weeks
• Untreated lasts six months or more, but
then remits in most cases
• Recovery – eight weeks of remission
Etiological Factors
Biologic
– Genetics
• 1.5 to 3 times first-degree relative
• Alcoholism in biological parent
– Biochemical changes
• Serotonin, acetlycholine,
norepinephrine, dopamine and GABA
• Alterations in HPA, HPT axes
Etiological Factors
Psychological
– Psychodynamic
• Deprivation of love, loss
• Guilt
– Behavioral
• Reduction in pleasant activities
– Cognitive
• Irrational beliefs
• Distorted attitudes
– Developmental
• Premature loss of parent
Etiological Factors
Social
– Family interactions
– Adverse life event
– Sexual, physical abuse
Goals of Interdisciplinary Treatment
• Reduce, remove symptoms.
• Restore occupational and psychosocial
functioning.
• Reduce likelihood of relapse.
• Safety is a priority. Suicide assessment
Family Response
• Affects the whole family
• Often has financial hardships
Priority Care Issues
• Safety
• Risk for suicide
Nursing Management:
Biologic Domain
Assessment
– Systems Review (CNS, endocrine, anemia,
chronic pain, etc.)
– Physical exam: palpation of the neck for
thyroid abnormalities
– Appetite and weight
– Sleep disturbance
– Decreased energy
Nursing Diagnosis:
Biologic Domain
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Disturbed sleep pattern
Imbalanced nutrition
Fatigue
Many other possible
– Failure to thrive
– Bathing/hygiene deficit
– Pain
Nursing Interventions:
Biologic Domain
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Sleep hygiene
Nutritional intervention
Exercise
Pharmacologic interventions
– Acute
– Continuation
– Maintenance
– Discontinuation
Psychopharmacologic Interventions
• Cyclic antidepressants
• Selective Serotonin Reuptake Inhibitors
(SSRIs)
– Fluoxetine, sertraline, fluvoxamine, paroxtine,
citalopram, escitalopram
• Monoamine Oxidase Inhibitors (MAOIs)
– Phenelzine (Nardil), Tranylcypromine (Parnate)
• Atypical antidepressants
– Trazodone, bupropion, nefazodone,
venalfaxine and mirtazapine
Pharmacological Nursing Interventions
Monitoring and Administration
– Observe taking meds (acute phase)
– Vital signs (observe for orthostatic
hypotension), lab reports
– Diet restrictions as appropriate
Side Effects: SSRIs
• GI Distress
– Fluoxetine (Prozac)
– Sertraline (Zoloft)
– Paroxetine (Paxil)
– Fluvoxamine (Luvox)
• Low Anticholinergic
– Fluoxetine (Prozac)
– Fluoxetine (Luvox)
• Low sedation (All)
• Sexual Dysfunction (All)
• Orthostatic Hypotension
– Fluoxetine (Prozac)
– Fluvoxamine (Luvox)
Side Effects of TCAs: Anticholinergic and
Antihistaminic
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Sedation and drowsiness
Weight gain
Hypotension
Potentiation of CNS system drugs
Blurred vision
Dry mouth
Constipation
Urinary retention
Sinus tachycardia
Decreased memory
Monamine Oxidase Inhibitors
• Indications
– Depression with personality disorders, panic or
social phobia
• Side Effects
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Hypertensive crisis/interaction with food
Sudden, severe pounding or explosive headache
Anticholinergic
Elderly - sensitive to orthostatic hypotension
Sexual dysfunction
Serotonin Syndrome
• More likely to be reported in patients taking two or
more serotonin antagonists
• Usually mild, but can cause death
• Rapid onset (compared to NMS)
• Symptoms
– Mental status, agitation, myoclonus, hyperreflexia, fever,
shivering, diaphoresis, ataxia and diarrhea
• Treatment
– Stop offending drug.
– Provide supportive treatment.
– Notify physician.
Drug-drug Interactions
• SSRIs inhibit 1A2 system. (Theophylline
must be reduced.)
• Smoking induces 1A2 system; smokers
may need higher dosage.
• Fluoxetine and paroxetine inhibit 2D6.
Can increase plasma levels of TCA, so
avoid giving these meds with TCA.
Teaching Points
• If depression goes untreated or is
inadequately treated, episodes become
more frequent, severe and longer in
duration.
• Importance of continuing medication
• Avoid St. John’s Wort.
Other Somatic Treatments
• Electroconvulsive therapy (See Ch. 9)
• Light therapy
– SAD
– Light - very bright, full-spectrum light, usually
2,500 lux
– Immediately upon rising
– Exposure as little as 30 minutes and then increase
– Full effect after two weeks
Nursing Management:
Assessment
Psychological
–Assessment scales self-report
–Mood and affect
–Thought content
–Suicidal behavior
–Cognition and memory
Nursing Diagnoses
Psychological Domain
• Anxiety
• Decisional conflict
• Fatigue
• Grieving, dysfunctional
• Hopelessness
• Self-esteem, low
• Risk for suicide
Psychological Interventions
Nurse-Patient Relationship
– Withdrawn patients have difficulty
expressing feelings.
– Nurse should be warm and empathic, but
not a cheerleader.
– See Therapeutic Dialogue.
Psychological Interventions
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Cognitive therapy - psychotherapy
Behavior therapy
Interpersonal therapy
Marital and family therapy
Group therapy
Patient and family education
Nursing Management:
Assessment
Social Domain
• Developmental history
• Family psychiatric history
• Quality of support system
• Role of substance abuse in relationships
• Work history
• Physical and sexual abuse
Social Nursing Interventions
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Patient and family education
Medication adherence
Marital and family therapy
Group therapy
Continuum of Care
• Non-psychiatric setting
• Acute care – hospitalization
• Outpatient
• See appendices for clinical pathways.
Manic Episode
• Feeling unusually “high”, euphoric, irritable for
at least one week
• Four of the following:
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Needing little sleep, great amount of energy
Talking fast, others can’t follow
Racing thoughts
Easily distracted
Inflated feeling of power, greatness or importance
Reckless behavior (money, sex, drugs)
Types of Bipolar
• Bipolar I
– Combinations of major depression and full
manic episode
– Mixed episodes: alternating between manic and
depressive episodes
• Bipolar II
– Combination of major depression and
hypomania (less severe form of mania)
Specifiers
• Mixed episodes – criteria for both manic
and depressive episodes met
• Hypomanic episode – same as manic
but less than four days
• Secondary mania – caused by medical
disorders or treatment
• Rapid cycling – four or more episodes
within 12 months
Clinical Course
• Chronic cyclic disorder
• Later episodes occur more frequently than
earlier.
• Interpersonal relationships and occupational
functioning are affected.
• Patient may have rapid cycling.
Bipolar in Special Populations:
Children
• Recently recognized in children, it is
characterized by intense rage episodes
for up to two to three hours.
• Symptoms of bipolar disorder reflect the
developmental level of the child.
• First contact with mental health agency
is 5 to 10 years old.
• Often have other psychiatric disorders
Bipolar Disorder:
Elderly People
• More neurologic abnormalities and
cognitive disturbances
• Late-onset bipolar disorder recently
recognized
• Poorer prognosis because of comorbid
medical conditions
Bipolar Disorder: Epidemiology
• Prevalence - 0.4 to 1.6% of population
• Onset: 21-30 years
• Men and women equally
• Ten to 15% of adolescents with recurrent
depressive episodes develop bipolar I.
• Many comorbid disorders (substance abuse,
in particular)
Gender and Ethnic/Cultural
Differences
• No gender difference in incidence
• Gender differences reported in
phenomenology, course and treatment.
– Females at greater risk for depression and
rapid cycling
Etiology
Biologic
• Neurobiologic theories
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Neurotransmitter hypotheses
Chronobiologic theories
Sensitization and kindling theory
Genetic factors
– Bipolar I
– 4 to 24% first-degree relatives
– 80% concordance rate in identical twins
– Bipolar II
– 1 to 5% first-degree relatives
• Psychosocial factors
– Contribute to the timing of the disorder
Treatment Issues
• Complex issues treated by an
interdisciplinary team
• Priority issues:
• Safety from poor judgement and risk-taking
behaviors
• Risk for suicide during depressive disorders
• Devastating to families, especially
dealing with the consequences of
impulsive behavior
Nursing Management:
Biologic Domain
• Assessment
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Evaluation of mania symptoms
Sleep may be nonexistent.
Irritability and physical exhaustion
Eating habits, weight loss
Lab studies - thyroid
Hypersexual, risky behaviors
Pharmacologic (may be triggered by antidepressant), alcohol
use
• Nursing diagnosis
– Disturbed sleep pattern, sleep deprivation
– Imbalanced nutrition, hypothermia, deficit fluid balance
Nursing Interventions:
Biologic Domain
• Physical care
• Pharmacologic
– Acute - symptom reduction and
stabilization
– Continuation – prevention of relapse
– Maintenance - sustained remission
– Discontinuation - very carefully, if at all
• Electroconvulsive therapy
Mood Stabilizers
• Lithium Carbonate (Eskalith)
– Mechanism of action: unknown
– Blood levels 0.5-1.2
– Side effects: GI, weight gain
• Divalproex Sodium (Depakote)
– Increase inhibitory transmitter, GABA
– Sedation, tremor
• Carbamazepine
Mood Stabilizers
• Lithium Carbonate
• Drug profile
• Lithium blood levels
• Divalproex sodium (Depokote) (Drug Profile)
• Carbamazapine (Tegretol)
• Baseline liver function tests and complete blood count
• Newer anticonvulsants
• Lamotrigine (Lamictal)
• Gabapentin (Neurontin)
• Topiramate (Topamax)
Other Medications Used
• Antidepressants
– Used during depressed phases
– Can trigger manic phase
• Antipsychotics
– Psychosis
– Mania
– Dosage usually lower
• Benzodiazepines
– Short-term for agitation
Other Medication Issues
• Monitoring important
• Side effect monitoring important because
taking more than one medication
• Drug-drug interactions
– Especially, alcohol, drugs, OTC and herbal
supplements
• Teaching points
– Lithium (Change in salt intake can affect lithium.)
– Most of these medications cause weight gain.
– Check before using OTC.
Nursing Management:
Psychological Domain
Assessment
– Mood
– Cognitive
Nursing Diagnosis
– Disturbed sensory
perception
– Thought
– Disturbed thought
processes
– Defensive coping
– Risk for suicide
– Risk for violence
– Ineffective coping
Disturbances
– Stress and coping
factors
– Risk assessment
Nursing Management:
Social Domain
• Assessment
– Social and occupational changes
– Cultural views of mental illness
• Nursing Diagnosis
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Ineffective role performance
Interrupted family processes
Impaired social interaction
Impaired parenting
Compromised family coping
Nursing Interventions:
Social Domain
• Protect from over-extending boundaries
• Support groups
• Family interventions
– Marital and family interventions
Continuum of Care
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Inpatient management – short-term
Intensive outpatient programs
Frequent office visits
Crisis telephone calls
Family session or -