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What is important to remember about depression?
- Most common mental health problem in the US
- Can be a symptom, syndrome, disorder or illness
- Is painful and debilitating
- 15% of the general population experience
- Women are at 2X greater risk --> women take care of home, earn less, attitudes are different
Who are some highly creative people who have suffered from depression?
- Sigmund Freud
- Winston Churchill
- Abe Lincoln
- Ernest Hemingway
What are some environmental events that are likely to trigger onset?
- death or anniversary of a death
- separation or divorce
- physical illness
- sexual identity crisis
- work or school failure
- disappointment in a child
What are some important indications of medical disorders?
- multiple sclerosis
What are some drugs that may induce depression?
- Cardiovascular Agents
- Sedatives and Antianxiety Drugs
- Steroids and Hormones
What are the basics of major depression?
- No history of manic or hypomanic episodes
- interfere with social or occupational functioning
- may include psychotic or delusional aspects
What is Dysthymia depression?
- Chronic depressive syndrome and onset age varies
- Present most of the day for at least 2 years
- May not be distinguished from the usual functioning
- Minimal social or occupational impairment
- Main differences are in duration and severity
What is transitory depression?
- SAD: seasonal affective disorder
- grief reacting --> (give them a year or two!)
- postpartum onset --> worsens w/ each pregnancy, interferes with bonding
What are the different bipolar disorders?
Bipolar I --> major depression and mania
Bipolar II --> major depression and hypomania
Cyclothymia --> (moderate) hypomania and depression of at least 2 years duration
What is included in the biological theory of depressive disorders?
- Sleep abnormalities
What is the genetic link found in primary major depressive disorders?
monozygotic (identical) twins 60%, other sibs 12%
What is the biochemical link found in primary major depressive disorders?
- heterogeneous disorder with many CNS neurotransmitter abnormalities
- may result from inherited or environmental factors or even medical conditions
- lower levels of serotonin and norepinephrine
- likely these lower catecholamines is a result not a cause
What role do sleep abnormalities play in primary major depressive disorders?
- biological marker for depression
- REM latency --> dreaming occurs earlier in 2/3 with bipolar and major depression
What role does neuro-endocrine play in primary major depressive disorder?
- 1/2 depresed people have hypersecretion of cortisol
- basis for dexamethasone (exogenous steroid that suppressed cortisol suppression test --> only 50% effective!!)
Describe the cognitive theory to primary major depressive disorders
- depression product of formant irrational or illogical thinking activated with stress
- Becks cognitive triad
- goal of behavioral therapy --> identify and test negative thoughts then develop alternative thing pattern and rehearse new responses
- remarkably successful with lower relapse rate
What is Becks cognitive triad?
- negative, self deprecating self view
- pessimistic world view
- belief that negative reinforcement will continue in the future
Describe the psychoanalytical theory of primary major depressive disorder
loss: early loss leaves person vulnerable later in life, child interprets loss as rejection and feels unworthy of love and approval
Aggression: depression in a result of anger turned inward to self
Describe the learned helplessness theory of primary major depressive disorder
- person feels no control over outcome of situation
- some groups in society at higher risk --> aged, lower SEC, women, POWs
Describe the therapeutic approachs to learned helplessness theory of primary major depressive disorder
- teaching new and more effective coping
- teaching ways to increase self-confidence
What are the different assessment tools for depression?
- Beck depression inventory
- Hamilton depression scale
- Geriatric depression scale
- Zung depression scale
What are you assessing when you look at a patients communication?
look for slowed speech and comprehension
What are you assessing when you look at a patients affect?
look for poor posture, look older than age, facial expression convey sadness, may weep or be unable to cry, feel hopeless, despair, anxiety, guilt, may also be angry or irritable --> covering up depression
What is assessed when looking at a patient's thought process?
- suicidal thoughts and potential --> essential to identity in initial assessment, HIGHEST priority
- Risk of suicide NOT corrected with severity of symtoms
- Also assess --> ability to solve problems and think clearly, judgement and decisiveness, memory and concentration
Describe what is documented in the physical behavior section of assessing for major depression
- Psychomotor retardation --> lethargy and fatigue, slowed movement, fixed gaze and decrease facial expression
- Psychomotor agitation --> figgety and unable to relax
- Grooming, dress and hygiene
- Vegetative signs
What are the vegetative signs?
- bowel habits
- interest in sex
What are the indications of masked depression
- not recognized in usual form
- may depend on one's culture, age, gender
- may be more common is adolescents
List some indications of masked depression
- truancy, school phobia
- hyperactivity, hypochondriasis
- underachievement, learning disorders
- use of drugs or sex, delinquent behabior
- compulsive gambling or work habits
- accident proneness, anorexia or bulimia
do not find pleasure
lack of energy
hypoactive or slowed
Describe the nurses feelings regarding patient depression
- Can experience frustration, hopelessness and annoyance
- Ways of coping --> recognize unrealistic expectations, need to identify feelings, important to understand process, important to understand process
- Need to be needed and appreciated
- Effort should be responded to
What are the phases of implementation in treatment for depression
- Acute --> 6-12 week may include hospitalization
- Continuation --> 4-9 months
- Maintenance --> 1 year or more
What are the basics of self-care treatments in implementation of treatment for depression?
- 1:1 treatment
- gross motor with minimal concentration
- eventually bring into contact with others
- then evaluate group activities
- evaluate --> diet and bowel movements, grooming and sleep
What is important to remember about the medication typically given for treatment of depression?
- 75% respond to medication
- need to consider suicide potential
- Rx impacts more symtoms
- takes 1-3 weeks for improvement noticed and full impact of RX
What are the statistics to pharmacutical treatment for MDD
Out of every 100 people..
9 are diagnosed and prescribed ADM
7 follow through and fill the RX
3 comply for 14+ weeks
What are the first line agents prescribed for depression?
- Selective serotonin reuptake inhibitors (SSRIs)
- Newer atypical antidepressants
- Tricyclic antidepressants (TCAs)
What are the second-line interventions for depression?
- Monoamine oxidase inhibitors (MAOIs)
- Electroconuilsive therapy (ECT)
List some SSRIs
Hoe do SSRIs work?
- selectively block neural uptake of serotonin and permits serotonin to act longer time at synaptic binding sites
- have little effect on norepinephrine or dopamine
What are some of basics to remember about SSRIs
- good from most kinds of depression and OCD
- less dangerous when taken as overdose due to low cardiotoxicity
- fewer side effects and most selective action
- Serious side effect--> central serotonin syndrome
Central serotonin syndrome
- related to overactivation of central serotonin receptor
- risk greatest when SSRI administered with 2nd generation enhancing agent (MAO inhibitor) or St. Johns wart (herb used for depression)
- closely resembles neuroleptic malignant syndrome and malignant hyperthermia
What are some symptoms of Serotonin Syndrome?
- abdominal pain and diarrhea
- sweating and fever even hyperpyrexia
- tachycardia and increased BP
- altered mental status (delirium)
- increased motor activity
- irritable, hostile, mood change
- cardiovasuclar shock, apnea and death
What is the emergency treatment for serotonin syndrome?
- remove or CD offending agents
- administer serotonin receptor blockade --> ie propranolol
- cooling blanket
- diazepam for muscle rigidity or rigors
- artificial ventilation
What are some selective serotonin/norepinephrine reuptake inhibitors (atypical)
- serzone --> no longer available (liver tox)
How does atypical selective serotonin/norepinephrine reuptake inhibitors work?
enrich the synapse with serotonin while inhibiting the reuptake
What are the basics of Atypical meds?
- may lead to anxiety more than the other RX
- unrelated to any of the current antidepressants and is potential of serotonin and norepinephrine in CNS
- Wellbutrin --> Do NOT use with patients w/seizure history
- Adds dopamine enhancement to norepinephrine effect through inhibitor of reuptake inhibition
What are some tricyclic antidepressants?
How do tricyclic antidepressants work?
inhibit or blocks the reuptake of norepinephrine and serotonin at the presynaptic neurons
What are the basics to remember about TCAs
- the blockage (med blocks reuptake of norepi and serotonin and presynaptic neurons) leads to typical anticholinergic effects
- least selective and most side effects
- benefit 65 to 80% non-delusional patients
- taken 6-12 months prevent relapse
- dose should initially be low and gradually increase
What is Surmontil?
good choice for elderly due to low side effects and rapid effects on promoting sleep
What are the side effects of TCA?
- common side effects:
- no serious and often transitory
- urinary retention and severe constipation need immediate medical attention
- Serious side effects:
- antidepressant may precipitate and psychotic episode
What are the contra-indications for TCAs?
- narrow-angle glaucoma
- history of seizures
What are some examples of MAOIs?
What is the serious food interaction with MAOIs?
interact foods containing tyramine, a natural product or bacterial fermentation
List the dietary restrictions for MAOIs
- Fruits: spoiled or overripe fruit
- Vegetables: pickles, sauerkraut, fava/italian/broad bleans
- Alcohol: beer, Chianti wines
- Ages cheeses (cream, cottage OK)
- Aged meats, sausages, salami, liver, canned ham
- Other antidepressants
- Decongestants or nasal sprays
What can happen if you take MAOIs and eat food containing tyramine?
Can cause hypertensive crisis, can be FATAL
Immediate medica attention with RX (BP)
Pyrexia (fever) treatment with hypothermia packs
What are MAOIs contraindicated for?
- those with hypertension
- severe renal or hepatic disease
What are the side effects of MAOI's?
- Orthostatic hypotension
- Weight gain and edema
- Change in heart rate and rhythm
- Constipation and urinary hesitancy
- Sexual dysfunction and weakness/fatigue
- Vertigo and insomnia
- Overactivity and muscle twitching
- Hypomanic and manic behavior
What are some adverse reactions of MAOIs?
- intercranial hemorrhage
- Hyperpyrexia (fever)
What is the prevalence and comorbidity of bipolar disorder?
- 1.2% - 3%
- Substance abuse
- Personality disorder
- Anxiety disorder
What is the theory of biopolar disorder?
thought to be distinctly different from unipolar depression
What is the genetic link of bipolar disorder?
joger in relatives and highest in identical twins (80%)
What is Biogenic Amines?
higher norepi and epi plasma levels during manic episodes
What is an interesting fact regarding the demographics of biopolar disorder?
More prevalent in upper SEC and among creative artists, educated and professional
What are some observable actions described under the mood section of the bipolar assessment?
- euphoric, unstable, unconsistant
- may change to irritation and quick anger if thwarted
- reactions out of proportion to stimulus
- boundless enthusiasm, treat everyone as confidential friend
- seem to have boundless energy and self-confidence
- often give away money, prized possessions and expensive gifts
- spend money freely, charging excessively
What does the behavior of a person with bipolar look like during mania?
go from 1 activity to another, 1 place to another, 1 project to another--often w/o completing anything
inactivity is impossible
hyperactivity may range from mild to constant motion to frantic wild activity
sexual indiscretions frequent
constantly push limits
often alienate family, friends, employers
voracious appetite for food & indiscriminate sex
- may NOT sleep for several days in a row
- this nonstop activity & lack of sleep & food can lead to physical exhaustion & death
grandiose dress & make-up
concentration is poor
judgment is very poor
What feelings do a person with bipolar have after mania?
may be depressed or embarrased
What is flight of ideas?
nearly continuous flow of accelerated speech with abrupt changes from topic usually based on understandable associations or play on words
What is clang association?
stringing together words because of their rhyming sound without regard to their meaning
What are the phases of outcome criteria for bipolar and the basic goals for each?
Phase I (Acute mania) --> prevent injury
Phase II (Continuation of treatment) --> relapse prevention, medication compliance
Phase III (maintenance treatment)
What is part of the planning phase for bipolar treatment?
- Need to direct away from active environmental stimuli
- Because of highly distractable, can redirect to other activities
- Activities that use large muscle groups are helpful
- Writing may prove creative outlet
What are some of the nurse feelings for bipolar?
- May elicit intense emotions as they resist control as may be confrontational, demanding and aggressive
- May be genuinely funny and entertaining --> need to not be involved and remain neutral
- Avoid power struggles
- Consistency among staff is important
What are some interventions used in biopolar disorder?
- Self-care activities
- support groups
- milieu therapy
What is part of milieu therapy for bipolar disorder?
- reduce overwhelming stimuli
- protect patient from hurting self or others
- prevent destruction of personal property
Lithium Carbonate effective in 90%
Less effective with mixed mania or rapid cyclers (4X or more a year)
If hospitalized with severe mania may also use antipsychotic for a short time
Lithium Carbonate --> naturally occurring metallic salt. Prototype mood stabilizer
Thought to affect electrical conductivity and thus stabilize mood. Also effects the "G Proteins" which are regulatory protein, thereby slowing cell activity
Li therapy alone can reverse mild to moderate manic symptoms in 1-3 hours
Describe Lithium toxicity
and S/S for each stage
Theraputic level (0.5-1.5) --> Mild hand tremors, mild thirst, nausea, weight gain, acne
Early signs of toxicity (<1.5) --> nausea, vomiting, diarrhea, polyuria, slurred speech, muscle weakness
Advanced toxicity (2.0-2.5) --> Course hand tremors, confusion, EEG changes, lack of coordination
Severe toxicity (>2.5) --> Ataxia, stupor, blurred vision, tinnitus, large output of dilute urine, severe hypotension, seizures, coma, death R/T pulmonary complications
Cardiac arrhythmia, peripheral circulatory collapse, proteinuria, oliguria, death
What are some fluid and dietary considerations for Lithium?
- Normal Na+
- Drink 2-3L of water daily
What possible complications are there with Lithium due to the risk associated with electrical currents?
- Cardiac contractions
- Tremors or more extreme motor dysfunction
What disturbances in fluid balance are possible with Lithium?
- Risk of kidney and thyroid disease with long term use
How long does it take Lithium to reach therapeutic levels in the blood?
7 - 14 days
What is the maintenance level for lithium in the blood?
What is the initial treatment for acute mania while Lithium takes effect?
(and side effects/adverse effects also)
- Slow speech
- Inhibit aggression
- Decrease psychomotor activity
- Antisychotic or benzodiazepine to prevent
- Coronary collapse
What are contraindications for Lithium?
- Cardiovascular disease
- Brain damage
- Renal disease
- Thyroid disease
- Myasthenia gravis
- Breast feeding mothers
- Children under 12 (maybe! try other things 1st!)
What is the protocol for blood draws for a patient on Lithium?
- Blood drawn 8-12 hours after last dose
- Levels every month until stable, then 3-6 months ongoing
What is included in the family teaching for Lithium?
- Not addicting
- Need to monitor lithium blood levels
- Side effects and toxic effects
- When to call the physician
- May need to take with food
- Normal diet with normal salt intake
- NOTE: causes greater neuron system toxicity in African Americans than whites
What are some antiepileptic meds?
- Carbamazepine (Tegretol)
- Dibalproex (Depakote)
- Lamotrigine (Lamictal)
- Gabapentin (Neurontin)
- Topiramate (Topamax)
- Structurally different from other anticonvulsant drugs
- First line treatment for bipolar and better tolerated than lithium in some patients
- Helpful with rapid cyclers
- Common side effects: hair loss, tremor, weight gain, sedation
- Serious side effects: thrombocytopenia, pancreatitis, hepatic failure, birth defects
- Need baseline liver function and CBC before beginning drug
- Newer agent used for acute and maintenance therapy
- Generally well tolerated
- Rare and potentially life-threatening dermatological symptoms may develop (3 in 1000)
- used as a adjunct to lithium to increase time between mood cycles
- serious drawback: tolerance and dependence
What are some antipsychotics and what is their action?
- Antipsychotics afford a rapid slowly of hyperactive disorder whe symptoms are acute and before the Lithium (or other antimanic (begins to have its effect)
What is ECT used for?
- Severe manic behavior
- Rapid cycling
- Paranoid, destructive features
- Acutely suicidal behavior
When is seclusion used in Milieu therapy?
Emergency for client when:
- clear risk of harm to client or others
- clients behavior has continued despite use of less restrictive methods to keep client and others safe
What are the basics to remember for suicide?
- Ultimate ask of self-destruction
- 9th cause of death in the US
- 3rd for adolescents
- 2nd for white adolescents
- Elderly account for 25% and make up 10% of pop
- Rate among black women up 80% past 30 years
- Monday is the most frequent day
- Morning is the most frequent time
- April is the most frequent month
- 75% of people have suicidal thoughts
- "Right to die" need to address for self prior to dealing with suicidal client
- Suicides outnumber homicides 3:2
- Suicide by firearm is most common for both sexes
What occupations are at the highest risk?
What occupations have elevated risk?
Physicians and dentists
Nursing and social work
What is important to remember about suicide in the elderly?
- Elderly attempt suicide less often but have a higher rate of completion because their methods are more lethal
- 2/3 of adults older than 60 years were in relatively good health when they died by suicide
- 66% to 90% of elderly suicide victims had at least one psychiatric diagnosis; 2/3 of these diagnoses were late-onset, single episode depression
What is important to remember about suicide in youth?
- Firearms are the most commonly used suicide method
- The largest increase in suicide rates since 1980 has been among black makes aged 10-19 years
- Self-report syrveys show that nationwide, 1 in 5 high school students has seriously considered attempting suicide in preceding 12 months
Know the difference:
- completed suicide --> when the action causes death
- suicide attempt --> trying to do it
- suicide ideation --> thinking about it
What are some comorbidities to suicide?
- depression and bipolar
- CD + panic disorder
- borderline and antisocial PD
What is the theory behind suicide?
underlying factor--> hopelessness
- acted out most likely if:
- suffered a loss of love
- suffered a narcissistic injury (humiliation, loss of job, threat of incarceration)
- experience overwhelming mood (rage, guilt)
- identify with suicide victim (copycat suicide)
What are the basics of the suicide assessment?
- Verbal and nonverbal cues
- overt statements and actions
- covert statements and actions
- nurse need to make overt what is covert
- ask directly
- be direct to behavioral, somatic and emotional cues
suicide is not necessarily synonymous with mental disorders
The act of purposeful self-destruction represented by taking one's own like is usually accompanied by intense feelings of pain and hopelessness, coupled with the belief that no solutions exist
What are the different psychosocial factors associated with suicide?
Freud: Aggression turned inward toward and internalized love object
- The wish to kill
- The wish to be killed
- The wish to die
Aaron Beck: Central emotional factor --> hopelessness
What are some Overt Statements a patient can make that we must be aware of in a suicidal patient?
- "I can't take it anymore!"
- "Life isn't worth living anymore"
- "I wish I were dead"
- "Everyone would be better off if I died"
What are some Covert Statements a patient can make that we must be aware of in a suicidal patient?
- "Its okay, now. Soon everything will be fine"
- "Things will never work out"
- "I wont be a problem much longer"
- "Nothing feels good to me anymore and probably never will"
- "How can I give my body to medical science?"
What are some methods that are considered higher risk methods during a suicide assessment?
- Using a gun
- Jumping off a high place
- Hanging oneself
- Poisoning with carbon monoxide
- Staging a car crash
What are some major risk factors on the SAD PERSONS scale?
- Age 25-40 or 65+
- Previous attempt
- ETOH use
- Lack of social supports
- Lethal plan
- Divorced, widowed, separated or single male
- Severe or chronic sickness
What should be included in the self-assessment by the nurse?
The extreme feelings in suicidal people can evoke strong negative reactions in staff
To avoid countertransference that will limit effective intervention, the intense emotional reactions of staff need to acknowledged
- Expected reactions of the nurse:
What are the levels of intervention for suicide?
- Primary --> activities that provide support, information, and education to prevent suicide
- Secondary --> treatment of the actual suicidal crisis
- Tertiary --> interventions with the family and friends of a person who has committed suicide to reduce traumatic after effects
What are basic level interventions for suicide?
- Milieu therapy with suicidal precautions
- Health teaching
- Case management
- Psychobiological interventions
So someone just told you they want to hurt them self, what do you do?
- deal directly with topic of suicide
- encourage problem-solving and constructive actions
- get assistance, talk to supervisor
- negotiate a no-suicide plan or contract
What are traditional suicide precautions?
- 1:1 --> in view and within arm's length at all times including toileting and sleeping
- suicide observation --> q 15 min checks, vary the time
- for each of the above: behavior, mood and verbatim statements need to be recorded
What is the most important thing to do when someone says they are thinking about suicide?
Take all suicidal ideation and gestures seriously!!