Transcript Mood Disorders - Austin Community College

Depression
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Incidence and Prevalence
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NIMH --Depression Rate:
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7.1% in women/Postpartum Depression
3.5% in men
5.8% overall
Age of onset- anytime, highest in 20’s
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Highest Prevalence-ages 25-44.
General Hospital adm. 10 to 15% depressed
Depression is a Type of
Mood Disorders
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Depressive
Disorders
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Major Depressive
Disorder (MDD)
Dysthymic Disorder
Depressive
Disorder NOS
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Bipolar Disorders
(also considered a
mood disorder)
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Bipolar I
Bipolar II
Mixed episode
Cyclothymia
Symptoms of
Major Depressive Disorder
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Depressed Mood
Anhedonia
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 following criteria must be
present:
• Depressed Mood
• Anhedonia
Dysthymic Disorder
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A Disorder of Chronicity
Depressed mood at least 2 years for more days
than not (>50% of the time)
Symptoms include:
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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
Symptoms of Depression
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Hopelessness
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
• 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• Withdrawn prefer Isolation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
• Affect is outwardly demonstrated emotion
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Low-self esteem
Worthlessness
Guilt
Anxiety
Hopelessness
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
• Delusions and Hallucinations
– Delusion of Persecution:
• For a moral or ethical mistake
– Somatic Delusions
• They are full of cancer
– Nihilistic Delusions
• Fears of death
Depression
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Unified Model of Mood Disorders
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Genetic Vulnerability
Developmental Events
Physiological Stressors
Psychosocial Stressors
This model proposes significant or
prolonged stress can initiate a
neurochemical imbalance
Neurochemical Theories
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Serotonin and
Norepinephrine
• Altered at the
receptor site
• Receptor
sensitivity changes
• The cells they
activate have lost
the capacity to
respond
Genetic Theories
Depression, linked to genetic
predisoposition, but not clear
 Two thirds of twins are concordant
for MDD if one or both parents have
MDD
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Endocrine
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Elevated levels of
corticotrophin
releasing hormone
Elevated pituitary
release of
andrenocorticotropic
hormone
Early life exposure
to overwhelming
trauma
Circadian Rhythm
Medications
 Nutritional deficiencies
 Physical illness
 Wake-sleep cycles
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Etiology/psychosocial/depression
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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 Cont.
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Behavioral Theories- Believes that the way
you act effects peoples 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
you to depression, esp. another loss
Cognitive Theory
How we think about our situation
 Aims at symptom removal by
identifying and correcting silent
assumptions
 Silent assumption: going to school is
something I am doing for me.
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Treatment Efficacy
Depression very treatable disease
 Episodes usually last 6 to 9 weeks
 Endogenous compared to
Exogenous depression
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Treatment Efficacy
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Endogenous means from within
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The client can not describe a specific event that
exacerbated the depression.
Exogenous means from without
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There is a specific event that triggers the depression
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Psychotherapy may be enough for exogenous
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Loss of a loved one
Surgery
Retirement
Group Therapy for Grief
Combination is best for endogenous
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Medications
Individual or Group psychotherapy
Nursing Dx
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Alteration in Nutrition: Less than body requirements
• Not eating or over eating can alter serotonin levels and give
relief
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Sleep pattern disturbance
Self care deficit
Alterations in perception:Hallucinations
Alteration in thought process:Delusions
Potential for Violence: directed at self
• Related to
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Low energy (decreased norepiniphrine)
Anhedonia (decreased serotonin)
Hopelessness
Anxiety
Neurochemical imbalance
Issues for Nurses with depressed
Patients
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Safety First: The milieu or environment
should keep the client safe
• Check all clients every 15 minutes
• Locked environment
• Remove all harmful items
– Mirrors, pocket knifes, razors, shoelaces, hangers
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Insomnia
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Assess hours of sleep
Encourage exercise/Walking
Use relaxation Tapes
Medication as needed for sleep
Weight Loss - Anorexia
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Observation of client during meals
Record weight weekly
• Can be recorded more frequently
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Record amount eaten
Assess client
• Vital signs
• Lab work
– A low albumin level or total protein will let you know
the client is not eating well
Decrease Isolation
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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If client has made suicide attempt,
important acknowledge their feeling.
You do not agree with it but you let
them know you heard it.
Other Issues
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Anger: Use activities such as writing, discussing,
and exercise
Agitated depression: May want to walk with
patient
Simple, structured activities best in early
treatment
• A one page work sheet on feelings
• An expressive drawing
– These are also activities that can be used to encourage
communication about feelings
– Should be easy to complete and structured so the client is
successful
Group Therapies
Assertiveness training
 Coping Skills
 Grief group
 Art therapy
 Insight oriented psychotherapy
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Communications and Supportive
Therapy
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Establish trust
Assess client’s negative
self talk
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• Ruminations
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Provide another point of
view
May be resistant to come
to 1-1
Active listening, nondirective style
Cognitive Therapy
Strategy
Have client list 3 negative
thoughts about self
• This must be limited in
number or could initiate
rumination
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Have client list 3 positive
qualities about self
• Talk with client about
positive qualities
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Goal to begin to replace
negative thinking with
more positive thoughts
Family therapy
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Depression of parent is very difficult for children
• There may be role reversal and depersonalization of the
child
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Child takes on care of younger children
Child tries to “cheer up parent”
Child tries to be prefect
Child acts out in order get attention (becomes a lightening
rod for the family)
Client may feel like victim and want to change
family relationships (described in your book as
feeling like “a doormat”
Marital relationship may need renegotiating
• Client who is depressed may be taking on too much
responsibility
Treatment/Medications
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Antidepressants
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Tricyclics
Selective serotonin re-uptake Inhibitors
/SSRI
Monoamine Oxidase Inhibitors
Serotonin Norepinephrine Re-uptake
Inhibitors
Atypical Antidepressants
Side Effect Profiles
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TCA’S
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Dry mouth
Blurred vision
Constipation
Sedation
Wt gain
Postural hypotension
Cardiac effects
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Can be cardiotoxic
EKG prior to starting
Dizziness
Slow onset 2 weeks
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SSRI’S
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Nausea
Nervousness
Insomnia
Sexual dysfunction
headache
Low addiction potential
Slow onset 2 weeks
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This length of time is a
consideration if client
is suicidal
Managing Medication Side
Effects
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Orthostatic Hypotension
• Teach the patient to rise slowly
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Insomnia
• Schedule dose early in day
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Dry mouth
• Hydrate
• Hard candy or gum
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Drowsiness
• Schedule dose at night
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Cardiac effects
• Tricyclics may be supplied one week at a time
Serotonin Syndrome
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A potentially fatal syndrome
Too much serotonin
Results from: Combination of Therapy
• Serotonin Reuptake Inhibitors used in combination with:
• Prescribed:
– Tricyclic Antidepressants
– Monoamine Oxidase Inhibitors
– Lithium
• Over the Counter Medications:
– Robitussin
– Cold medications
• Other
– LSD, Ecstasy
Serotonin Syndrome
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Too much serotonin
Symptoms:
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CNS-confusion
agitation
Hypomania
Myoclonus
Tremor
Hyperreflexia
Autonomic signs
• Fever
• tachycardia OR bradycardia
• hypertension OR hypotension
• Diaphoresis, diarrhea
• severe dehydration can be fatal
Serotonin Syndrome
Side Effects of MAO’s
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MAO’s can cause very
serious hypertensive
crisis
Client must be
instructed not to drink
red wine,eat cheese,
yogurt any thing aged.
Tyramine is chemical.
Also, pt must not take
any medications
without checking with
their MD.
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AVOID
Serotonin and Norepiniphrine
Reuptake Inhibhitors (SNRIs)
prevent re-uptake of:
 Serotonin
 Norepinephrine
 Dopamine
Venlafaxine- effexor- Pros: minimal drug interaction risk, effective with geriatric
pts., low sexual side effects; Energizing
Duloxetine (cymbalta) - Pros: minimal drug interaction risk,
effective with geriatric pts., low sexual side effects
Novel Antidepressants
Buproprion - wellbutrin - is unique in that it there is
dopamine uptake Effective as an addition to
SSRIs to diminish sexual dysfunction.
- Cons: SEIZURES
Trazodone- Desyrel: Decrease re-uptake of
serotonin and to a lesser extent, Norepinephrine
Great for sleep induction Nonaddicting
Cons: Can cause anticholenergic side effects
Mirtazapine - Remoran: Decrease re-uptake of
serotonin and to a lesser extent, Norepinephrine
Great for sleep induction Nonaddicting
Cons: Can decrease platelet count
Electroconvulsive therapy
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Beneficial for Clients with
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Severe Depression
Depression that is resistive to treatment with medications
Older adults
– Renal disease or Liver disease
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ECT seems to balance dopamine and serotonin
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Procedure- Administer barbiturate, muscle relaxant,
Side effects- short term memory loss
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Initially: memory of events immediately prior to the procedure
Treatment 6-10 times
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Blood serum levels of medication increases
Spaced several days apart
After Treatment
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Client may have immediate relief of Depression