Psych depression

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jam110007
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Psych depression
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2014-10-01 19:06:31
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Psych Exam 3
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depression
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  1. Depression
    • - an alteration in mood that is expressed by feeling of sadness, despair and pessimism 
    • - oldest and most frequently diagnosed psychiatric disorder 
    • - leading cause of disability in the U.S.
    • - prevalence more in women than men by 2:1
  2. Mood
    • - Also called affect
    • - a pervasive and sustained emotion that may have a major influence on a person's perception of the world
  3. Major Depressive Disorder S/S
    • - Anhedonia
    • - Fatigue
    • - sleep disturbance 
    • - changes in appetite
    • - feeling of hopelessness or worthlessness
    • - persistent thoughts of death or suicide
    • - inability to concentrate or make decisions
    • - changes in physical activity
  4. Anhedonia
    loss of interest in something the patient used to find pleasurable
  5. how long does a patient have to report s/s of MDD until they can be diagnosed with it?
    persistently depressed mood lasting a minimum of 2 weeks
  6. depressive disorder classifications
    • - disruptive mood dysregulation disorder
    • - dysthymic disorder 
    • - premenstrual dysphoric disorder
    • - substance abuse depressive disorder
    • - depressive disorder associated with another medical condition
  7. disruptive mood dysregulation disorder
    • - relates to children from ages 6 - 18
    • - refers to situation in which a person has frequent temper tantrums resulting in verbal or behavioral outburst 
    • - not diagnosed in children unless they are free of other medical and mental problems or not between the ages of 6-18
  8. dysthymic disorder
    • - occurs when feeling of depression persist consistently  for at least two years 
    • - social and occupation distress, usually not severe enough to cause hospitalization 
    • - teenage years
    • - "i've always felt this way"
  9. premenstrual dysphoric disorder
    • - cluster of S/S that occur in the last week prior to the onset of a period 
    • - s/s include: physical discomfort, emotional symptoms similar to depression
  10. substance-induced depressive disorder
    - s/s of major depressive episode arise as a result of prolonged alcohol/drug intoxication or as a result of withdrawal from drugs and alcohol
  11. presentation of depression in children
    • - may be irritable rather than depressed
    • - very young children may cry
    • - school-aged child might withdraw 
    • - teens may become irritable in response to feeling sad or hopeless
  12. MDD: sleep disturbances
    • insomnia 
    • - inability to sleep: trouble sleeping, or difficulty sleeping after taking a nap
    • - terminal insomnia: early morning awakening: this is a red flag for depression
    • Hypersomnia:
    • - people can become extremely exhausted and sleep too much
  13. MDD: appetite changes
    • dec. appetite
    • - dec weight, as much as 5% body weight loss

    • inc. appetite
    • - c/o weight gain
  14. MDD: physical activity
    • psychomotor retardation 
    • - reduction in physical activity
    • move more slowly with stooped posture

    • psychomotor agitation
    • - restless, changes position often, pace but does not feel energized
  15. MDD: death/suicidal thoughts
    suicidal thoughta, especially those with a plan and the means to carry it out, represents an emergency requiring immediate intervention
  16. bereavement exclusion
    • someone not diagnosed with depression in the first two months following significant loss
    • - is now common to diagnose within the first two months
  17. subsyndromal depression
    • - can occur in older adults
    • - which they experience major depressive episode(s)
  18. Depression: genetic factor
    there is a genetic marker associated with depression in the context of stressful life events
  19. biochemical
    genetic and environmental factors
  20. two main neurotransmitters involved in mood are?
    serotonin and norepinepherine
  21. serotonin
    • regulator of 
    • - sleep
    • - appetite
    • - libido
    • dysfunction can result in sleep disturbances, decreased appetite, low sex-drive, poor impulse control, irritability
  22. Norepinephrine
    • modulates
    • - attention
    • - behavior 

    • stimulated in stressful situations which can result in over use and deficient norepi which can result in 
    • - apathy
    • - reduced responsiveness
    • - slowed psychomotor activity
  23. Glutamate
    - increases ability of a nerve fiber to transmit information 

    deficiency can interfere with normal neuron transmission in the areas of the brain that affect mood, attention and cognition
  24. stressful life events
    • - sginificant factor in the development of depression 
    • - norepi, serotonin, and acetylcholine play a role in stress regulation 
    • - depletion of these neurotransmitters may occur when overtaxed
    • - assocaited with a reduction a neurogenisis: ability of the brain to produce new brain cells
  25. alterations in hormonal regulation
    • - hyperactivehypothalamic pituitary-adrenal axis
    • - people with depression tend to have increased urine cortisol levels and elevated corticotrophin-relaxing hormone 
    • - decline in the levels of estrogen around menstruation and menopause create changes in nerve structures in the brain = dendritic pruning
  26. inflammatory processes
    • - elevated c-reactive protein and interleukin-6 is shown in those with depression 
    • -
  27. diathesis-stress model
    • - takes genetics and environmental factors into consideration 
    • - page 255
  28. cognitive theory
    • - underlying assumption is that a person's thoughts will result in emotions 
    • - looking at life in a positive manner, the person will experience positive emotions vise versa for negative 
    • - people with depression process information in negative ways
  29. Beck's cognitive triad
    • 1. a negative, self-deprecating view of self
    • 2. a pessimistic view of the world
    • 3. the belief that negative reinforcement (or no validation for the self) will continue in the future
  30. learned helplessness
    • when a person feels like they have no control over a situation, a person feels that an undesired event is their fault and that not can be done 
    • - proposed by Seligman 
    • - subset of cognitive theory of depression
  31. depression is underdiagnosed in which population
    minority and older adults
  32. areas to assess for depression
    • - affect
    • - thought process
    • - mood
    • - feelings
    • - physical behavior
    • - communication 
    • - religious beliefs and spirituality
  33. Evidence based scales for depression
    • - beck depression inventory
    • - hamilton depression rating scale
    • - zung self rating scale
  34. The Patient Health Questionnaire (PHQ-9)
    short inventory that highlights predominant symptoms seen in depression
  35. Beck's depression inventory
    • - measures the severity and depth of depression symptoms listed in DSM-4
    • - not meant to severe as an instrument of diagnosis
  36. Hamilton Depression Scale
    measures the severity of depression
  37. Zung Self-Rating Depression Scale
    - originally used on patients already diagnosed with a depressive disorder to determine how depressed they are
  38. risk for suicide in patients with major depression is increased in the presence of which of the following?
    • - severe hopelessness
    • - overuse of alcohol
    • - recent loss or separation 
    • - hx of past and serious suicide attempts 
    • - acute suicidal ideation
  39. anergia
    • - lack of energy
    • - 97% of people with depression
  40. vegetative signs of depression
    • - change in bowel movements and eating habits
    • - sleep disturbances 
    • - disinterest in sex
  41. affect
    • - outward representation of a person;s internal state of being 
    • - sees world through grat colored glasses, posture is poor, may look older than stated age 
    • - facial expression may look sad and dejected 
    • - numb, unable to cry
    • - bouts of weeping 
    • - avoid eye contact 
    • - speak monotone 
    • - sighing and yes or no responses
  42. thought process
    • - ability to problem solves and think clearly is negatively affected 
    • - judgment is poor
    • - mind is slowing down 
    • - indecisiveness
    • - negative thoughts
    • - delusional thinking may be seen
  43. mood
    • - subjective experience of sustained emotions or feelings
    • - anxiety, worthlessness, guilt, reflect a low self-esteem
  44. communication
    • - speak and comprehend very slowly 
    • - may need more time to respond 
    • - in extreme depression, person may become mute
  45. which nursing diagnosis is always priority?
    • risk for suicide 
    • - safety is always highest priority
  46. presentation of depression in older adults
    • - fatigue
    • - pain 
    • - weakness
    • - use geriatric scale
  47. nursing process: outcomes identification
    • recovery model
    • - focus on patient's strengths
    • - tx goals mutually developed
    • - based on patient's personal needs and values
  48. nursing process: planning
    • geared toward
    • - patient's phase of depression 
    • - particular symptoms
    • - patient's personal goals
  49. nursing process: implementation
    • three phases
    • - acute phase
    • - continuation phase
    • - maintenance phase
  50. acute phase
    • - 6 to 12 weeks
    • - reduction of depressive symptoms 
    • - restoration of psychosocial and work function
    • - maybe hospitalization and medication
  51. continuation phase
    • - 4 to 9 months
    • - prevention of relapse through: medication, education, depression-specific psychotherapy
  52. maintenance phase
    • - prevention of further episodes of depression 
    • - medication may be phased out or continued
  53. basic levels of intervention?
    • - counseling and communication 
    • - health teaching and health promotion 
    • - promotion of self-care activities
    • - milieu therapy
  54. which class of medication is firs-line when treating depression?
    SSRIs (selective serotonin reuptake inhibitors)
  55. draw back of antidepressants?
    • may take 1 to 3 weeks or longer to take full effect 
    • - if patient is acutely suicidal, ECT can be a reliable and effective alternative for some
  56. antidepressants work with which neurotransmitters?
    norepinepherine, serotonin, dopamine
  57. SSRIs
    • - selectively block the neuronal uptake of serotinin which increases the availability of serotonin in the synaptic cleft/gap
    • - low SE compared to older antidepressants (TCAs)
    • - no anticholenergic effects
    • - effective for depression with anxiety features or psychomotor agitation
  58. SSRIs indications
    used for depression, anxiety (OCD, PD)
  59. SSRI common adverse reactions
    - may induce agitation, anxiety, sleep disturbance, tremor, sexual dysfunction, tension headache 

    other effects include: dry mouth, sweating, weight change, mild nausea, loose BM
  60. SSRIs potential toxic effect
    serotonin syndrome
  61. serotonin syndrome
    • POTENTIALLY
    • LIFE THREATENING!!

    Symptoms:

    • Changes
    • in mental status, restlessness, mycoclonus, hyperreflexia, tachycardia, labile blood pressure, diaphoresis, shivering, tremors

    • **DISCONTINUE DRUG IMMEDIATELY
    • can lead to cardiac shock and death
  62. serotonin syndrome treatment
    • - may prescribe meds to block serotonin receptors, relieve hyperthermia, muscle
    • rigidity and prevent seizures

    - Monitor vital signs, prevent injury, monitor mental status, cooling blankets

    - Cyproheptadine (histamine receptor antagonist) commonly used
  63. discontinuation syndrome
    • can occur when on SSRIs, over a couple of days pt may experience feelings of nervousness, dizzy, agitated, N/V, 
    • - tell them to resume medication, speak to PCP, to get on tapering schedule
  64. SSRIs drugs
    • –- Fluoxetine (Prozac)
    • - –Sertraline (Zoloft)
    • - –Paroxetine (Paxil)
    • - Citalopram (Celexa)
    • - Escitalopram (Lexapro)
    • - –Fluvoxamine (Luvox)
  65. which SSRI drug causes the most anticholinergic effect
    Paxil (citalopram)
  66. SSRI interactions
    • —- Toxic and sometimes fatal reaction to concomitant use with MAOI
    • - Increased effects with cimetadine, Lithium St. Johns Wort, L-tryptophan
    • - —Concomitant use with buspirone and digoxin may decrease effectiveness
    • —- Lithium levels may be increased or decreased by use with SSRI
  67. SNRI drugs
    • –- Venlafaxine (Effexor)  
    • - –Duloxetine (Cymbalta)
    • - –Desvenlafaxine (Pristiq)
  68. Venlafaxine (Effexor)
    • - SNRI
    • - lower therapeutic dose
    • - affects serotonin
    • - at higher doses, tends to block more epi
  69. Desvenlafaxine (Pristiq)
    similar to effexor
  70. Duloxentine (Cymbalta)
    - can also be used for neuropathic pain
  71. common SE of SSRI and SNRI
    • insomnia
    • - take drug early in the day
    • - avoid caffeinated food
    • - use relaxation techniques
    • dry mouth
    • - offer fluids freq
    • - encourage use of sugar free candy
    • good oral hygiene 
    • headache
    • - use PRN aspirin or Tylenol
    • sexual dysfunction
    • - impotency or delayed orgasm
    • - may wish to switch to another antidepressant
    • weight loss
    • - monitor food intake
    • - encourage sufficient food intake
    • - weight client every other day
  72. SNDI drugs
    • Mirtazapine (Remeron)
    • - can cause weight gain
  73. Tricyclic antidepressants (TCAs) drugs
    • –- Amitriptyline (Elavil)
    • - –Imipramine (Tofranil)
    • - Nortriptyline (Pamelor)
    • - Clomipramine (Anafranil)
    • - –Desipramine (Norpramin)
    • - Protriptyline (Vivactil)
    • - Trimipramine (Surmontil)
  74. risk of serotonin syndrome increases when?
    when given in combination with aonther serotonin-enhancing agent such as MAOIs,
  75. why are SSRI a black box warning medication
    it has an increase rate o suicide in the first few weeks
  76. TCAs function
    • inhibit reuptake of norepi and serotonin by the presynaptic neurons in the CNS
    • - full effect may not been seen until 4 to 8 weeks
    • - cause sedation due to blockade of histamine receptors. be cautious with CNS depression
  77. TCA SE
    • —Blurred vision
    • - Remind this is temporary
    • - Avoid driving until vision clears
    • —Urinary retention (requires immediate intervention)
    • - Monitor I&O: Try various methods to stimulate urination
    • Constipation
    • —Orthostatic hypotension
    • - Change position slowly
    • —Tachycardia, arrhythmias (requires different medication)
    • —Photosensitivity
    • - Use sun block, protective clothing, sunglasses
    • —Weight gain (education on nutrition)
  78. MAOI function
    blocks the enzyme the breaks down dopamine, tyramine, norepi, serotonin
  79. MAOI drugs
    • –- Phenelzine (Nardil)
    • –- Tranylcypromine (Parnate)
    • - Selegiline (ENSAM PATCH)
    • - –Isocarboxazid (Marplan)
  80. MAOI SE
    • **hypertensive crisis:
    • - may occur with ingestion of food or products containing tyramine;
    • - may occur with concurrent use of amphetamines, carbamazepine and other
    • antidepressants;
    • - consumption of foods or beverages with high caffeine content
  81. Hypertensive Crisis S/S
    • - Severe occipital headache
    • - Palpitations
    • - n/v
    • - Fever
    • - Sweating
    • - Marked
    • - increase in BP
    • - Chest pain
    • - Coma
  82. HTN crisis tx
    • —Discontinue drug, monitor VS, administer short acting antihypertensive such as a calcium channel blocker nifedipine or a alpha-adrenergic blocker such as Phentolamine, use external
    • cooling measures for hyperpyrexia
  83. Which TCA drugs are useful for patients who are lethargic/fatigued
    • - Desipremine (Norpramine)
    • - Protriptyline (Vivactil)
  84. which TCA drugs are useful for patient experience psychomotor agitation
    • - Amitriptyline (Elavil)
    • - Doxepin (Sinequan)
  85. TCA potential toxin effects
    • Cardiovascular 
    • - dysrythmias
    • - tachycardia
    • - MI
    • - heart block
  86. TCA adverse drug interaction
    • - MAOIs
    • - Phenothiazine
    • - barbiturates
    • - disulfiram
    • - OC
    • - anticoagulants 
    • - some antihypertensives 
    • - Benzos
    • - alcohol
  87. foods that can interaction with MAOIs
    • - avacados, soybeans
    • - figs, bananas, 
    • - sausages: pepperoni, salami 
    • - dried/cured fish 
    • - all cheeses
    • - yeast
    • - beer/wines
    • - chocolate = vasopressant
  88. ECT
    • Electroconvulsive therapy 
    • - commonly used for depression 
    • - used for rapid cyclers
    • - 2 to 3 tx per week
    • - no contraindications but be careful with heart conditions
  89. rapid cycler
    patient with bipolar disorder who has many episoides of mood swings close together (4+ in 1 year)
  90. transcranial magnetic stimulation
    • - noninvasive tx that uses MRI-strength magnetic pulses to stimulate focal areas of the cerebral cortex 
    • - an effective stand alone tx
    • - 30 mins, 5 days/wk for 4-6 wks
  91. vagus nerve stimulation
    • - boost levels of neurotransmitters thereby improving mood
    • - used for tx-resistant depression 
    • - pacemaker like device implanted into the left chest wall 
    • - antidepressant effects could take several weeks
    • - adverse effects: voice change, risk for infection, neck pain, cough, parasthesia
  92. light therapy
    • first line tx for seasonal affective disorder
    • - adjunct in treating chronic major depressive disorder or dysphoric disorder with seasonal exacerbation 
    • influence of light on melatonin which is secreted by the pineal gland 
    • - SE: jitteriness, headaches
  93. St. John's Worts
    • - thought to increase amt of serotonin, norepi, and dopamine
    • - useful in mild to moderate depression but not so much in severe
  94. which form of psychotherapy proves more effective in the maintenance phase
    • - cognitive therapy 
    • - interpersonal therapy
  95. cognitive behavioral therapy
    helps people reconstruct their negative thought patterns and behaviors
  96. interpersonal therapy
    focuses on working through personal relationships that may contribute to dpression

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