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What are the different depressive disorders? What are the different BPD disorders?
- Depressive Disorders:
- -MDD
- -Dysthymia
- -PPD
- -SAD
- -PMDD
- BPD:
- -Bipolar I
- -Bipolar II
- -Cyclothymia
- -Bipolar mixed; manic, depressed
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What are some diagnostic issues when it comes to mood disorders? What are the two important criteria in diagnosis?
- Two broad categories: unipolar and bipolar
- The two important criteria are duration and severity
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What are some important statistics about depression?
- 2:1 ratio females to males
- Median age of onset is 30y/o
- highest risk for reoccurring depression:
- 1. first case before 25 y/o
- 2. more than 16 wks of depression
- 3. recurrence after d/c antidepressant meds
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What are the emotional, physical and associated symptoms of depression?
- Emotional:
- - feelings of guilt
- -suicidal
- -lack of interest
- -sadness
- Physical:
- -lack of energy
- -no concentration
- -change in appetite
- -psychomotor changes
- Associated:
- -brooding
- -rumination
- -pain
- -irritability
- -worry
- -anxiety
- -phobias
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What are the different levels of depression?
- Mild
- Moderate
- Severe
- Severe with psychotic features
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What is MDD? What is the DSM-5 Criteria?
- Major Depressive Disorder or Unipolar
- DSM 5 Criteria: +5 core symptoms
- 1. Symptoms must be a change in functioning and be present every day, all day for at least 2 weeks and must cause distress in functioning
- 2. Anhedonia (lack of pleasure)
- 3. Thoughts of suicide
- 4. Anergia (decreased energy)
- 5. Change in appetite/sleep
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What are the core symptoms of MDD?
- Feelings of misery, apathy and pessimism
- Withdrawn
- Low self-esteem, feelings of guilt, inadequacy and ugliness
- Indecisiveness
- Psychomotor retardation (vegetative signs both in thought and action)
- Psychomotor agitation (doing meaningless/purposeless activity instead of what is important at the time)
- Sleep disturbances and significant weight change (without change in diet or appetite)
- In severe cases, MDD may be accompanied by hallucinations or delusions
- recurrent suicidal ideation, a suicide attempt or a specific suicide plan
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What is Persistent Depressive Disorder/Dysthymia?
- DSM-5 labels dysthymia as a mild depressive illness where symptoms are chronic and less severe than MDD
- Criteria: depressed or irritable mood most of the day for at least 2 years. Insomnia/hypersomnia. Decreased/increased appetite
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What are the s/s of dysthymia?
- Low energy
- Decreased self-esteem
- poor concentration
- difficulty in making decisions
- feeling hopeless
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Describe partpartum depression
- Meets the criteria for MDD with onset within 4 weeks of delivery
- 3 categories:
- 1. post partum blues
- 2. post partum depression
- 3. post partum psychosis
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What is postpartum psychosis?
- .01% experience severe/psychotic depression
- Depressed mood agitation, guilt, lack of concentration, lack of interest in baby
- Depersonalization
- Disturbed sleep, even when baby is sleeping
- Rejection of baby, lasts weeks-months
- Medical Emergency
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What is seasonal affective disorder (SAD)?
- MDD wit seasonal pattern- fall onset
- Depressive symptoms during winter/fall
- Increased sleep, appetite, carb cravings
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What is the etiology of depression?
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What is Beck's cognitive behavioral theory?
- Cognitive distortions:
- -magnification
- -minimization
- -personification
- -overgeneralization
- -all or nothing thinking
- -mind reading
depression is a result of negative interpretation (Wearing gray instead of rose colored glasses)
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What is Seligram's learned helplessness pessimistic attributional style?
- Internal/Personal: see selves as the cause
- Global/pervasive: affecting all aspects of their life
- Stable/permanent: see the situation as unchangeable
- "I am inadequate (internal) at everything (global) and I always will be (permanent)"
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Describe how serotonin and norepinephrine attribute to depression
- Serotonin:
- -Sex, Appetite, Aggression
- Norepinephrine:
- -Concentration, Interest, Motivation
- BOTH:
- -Decreased mood
- -Anxiety
- -Vague aches and pains
- -Irritability
- -Thought process
-both serotonin and norepinephrine mediate a broad spectrum of depressive disorders
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What general assessments should be done for depression?
- Severity exists along a continuum
- Assess for suicidal ideation
- Assess symptoms and impact on daily living
- Assess possible causes and past episodes
- Assess accompanying symptoms
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What initial assessments should be done for depression?
- Chief complaint
- History of present illness (HPI)
- Past psych history and treatment
- Substance Abuse
- Current stressors and coping skills
- Support Network
- Suicide risk assessment
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What assessment are done in a mental status exam?
- Affect
- Thought processes
- Mood
- Feelings
- Physical Behavior
- Communication
- Religious Beliefs and spirituality
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What is the recovery model for depression?
- Focuses on the client's strengths
- Treatment goals mutually developed
- Based on client's personal needs and values
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What nursing interventions can be done for depression?
- SAFETY
- Act on physical complaints (like pain, constipation)
- Interact at a slow pace in a low tone
- Encourage personal hygiene
- Recognize accomplishments
- Reinforce suicidal thoughts do make them a "bad" person
- Active listening and being present
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What are some standardized depression screening tools?
- Beck depression inventory
- Hamilton depression scale
- Zung's self-rating depression scale
- Geriatric depression scale
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How is alcohol r/t suicide?
- 96% of alcoholics who die by suicide continue their abuse up until the end of their lives
- Alcoholism is a factor in about 30% of all completed suicides
- Approximately 7% of those with alcohol dependence will die by suicide
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Compare and contrast men and women when it comes to suicide
- Females:
- -4x attmempts
- -poisoning
- -40-50s
- -16th leading cause of death
- Males:
- -4x completion
- -Firearms
- -75 and older
- -8th leading cause of death
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Describe the IS PATH WARM warning signs of suicide
- I: Ideation
- S: Substance Abuse
- P: Purposelessness
- A: Anxiety
- T: Trapped
- H: Hopelessness
- W: Withdrawal
- A: Anger
- R: Recklessness
- M: Mood change
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What questions should be asked during a suicide assessment?
- Ideation: Do you have thoughts of killing yourself? Who is in control, you or the thoughts?
- Plan: Do you have a plan? What method? Where? Access to means?
- Intent: How intent are you in carrying out the plan? What's stopping you?
- Contract for safety: Can you agree to speak to the staff if your thoughts change?
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What are the risk factors for suicide?
- Clearly defined plan
- Available means, clear intent
- Male, Caucasian
- Single, divorced or widowed
- Elderly
- Prior attempts
- Family History of suicide
- Chronic physical illness*
- Substance abuse*
- Lack of support
- Recent loss
- Hopelessness
- Mental health issues
- Prolonged exposure to stressful environment
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How do you plan for the acute phase of depression?
- #1 Goal is safety!
- Maintain adequate nutrition
- Maintain balance of rest/activity
- Interact with staff and peers
- Verbalize improvement in mood
- Demonstrate decrease in vegetative symptoms
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What safety interventions should be taken for a client with depression?
- Suicide assessment at least every shift, but best practice is more often
- Contract for safety: verbal, written
- Adjust level of monitoring
- Maintain Safe environment
- Maintain vigilance when mood improves
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What are some cognitive nursing interventions for a client with depression?
- Spend time with the client
- Identify relationships between thoughts and feelings
- Help Identify negative thought patterns
- Maintain thought diary
- Assist with problem solving
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What forms of psychotherapy are often used for depression?
- Cognitive Behavioral Therapy (CBT): changes negative way of thinking
- Interpersonal Therapy (IPT): focuses on working through personal relationships
- Group therapy: reduces isolation, share feelings
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How does ECT effect depression?
- Indicated for treatment resistant depression
- remission rate of 70-90%
- Decrease/elimination of SI in 80%
- 6-12 treatments
- Effective for pregnant women
- Short term memory loss and HA are main complaints
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What is TMS?
- Transcranial Magnetic Stimulation
- Treatment resistant depression
- Non-invasive while client is awake and alert
- MRI type magnets stimulate nerve cells in area of brain associated with mood and depression
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What are the phases of treatment and recovery for depression?
- Acute phase: 6-12 wks
- -hospitalization, restoration of functioning, symptom reduction
- Continuation Phase: 4-9 mo
- -prevent relapse, therapies
- Maintenance phase: 1 yr +
- -Prevent further episodes
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Describe the use of antidepressants, including the four kinds
- Most effective when combined with therapy
- Takes 1-3 wks to see improvement and 4-6 wks for Max, therapeutic effect
- Can precipitate mania
- Can precipitate suicidal ideation
- May need to treat concurrent anxiety
- 4 types: Tricyclic Antidepressants (TCAs), Monoamine oxidase inhibitors (MAOIs), Selective serotonin reuptake inhibitors (SSRIs), Atypical anti-depressants with as SNRI, SNDI
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Describe TCAs and name the most common ones
- Inhibit the reuptake of norepinephrine and serotonin
- Sedating effect, aids in sleep
- 4-6 wks for full effect
- Increased anticholinergic effects
- Cardiovascular side effects, need full workup, contraindication for cardiac disease and no longer often prescribed due to cardiotoxicity
- High lethality- fatal in overdose (2wk dose is deadly)
- Characteristic three ring nucleus of drug
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Name some TCA medications
- Amytriptiline (Elavil)
- Imipramie (Tofranil)
- Desipramine (Norpramin)
- Nortriptyline (Pamelor)
- Doxepin (Sinequan)
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What are the side effects of TCAs?
- Cardiotoxicity: palpitations, tachycardia, dizziness
- Increased norepinephrine is the culprit
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What are MAOI inhibitors? Name the most common ones
- Originally created for TB treatment
- Not widely used today
- Absorbed by the GI tract and widely distributed throughout the body
- Effects persist even after these drugs are no longer detectable in the plasma (1-3 weeks)
- MAIOs:
- Isocarboxacid (Marplan)
- Phenelzine (Nardil)
- Tranylcypromine (Parnate)
- Emsam patch
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What teaching is essential for MAOIs?
- DO NOT EAT FOODS WITH TYRAMINE
- Will lead to a hypertensive crisis (risk of CVA and organ damage)
- These foods include fermented foods (wine, cheese, chocolate, sausages, etc)
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What two antidepressant medications cannot be used together and why?
- MAOI with ____
- Has many negative drug interactions including:
- SSRIs
- TCAs
- Meperidine
- Alcohol
- CNS depressants
- Phenylephrine (OTC nasal decongestant)
- Will cause "hyperexcitiation syndrome" with hyperpyrexia, hypertension and delirium
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Describe SSRIs and the mechanism of actions
- Most widely prescribed for depression as they have fewer SE and better client adherence
- AE: nausea, decreased libido and sexual function
- Low threat to overdose. suicide may be considered in severe depression
- MOA: specific serotonin uptake inhibitor increases 5-HT by inhibiting reuptake. 6wks for full effect
- Dangerous if taken with other antidepressants, esp MAOIs*
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What are the most common SSRIs?
- Fluoxetine (Prozac)
- Sertraline (Zoloft)
- Paroxetine (Paxil)
- Fluvoxamine (Luvox)
- Citalopram (Celexa)
- Escitalporam (Lexapro)
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What is serotonin syndrome?
- Do not stop SSRI drug abruptly, titrate for 6 weeks to stop one and begin another antidepressant
- Hyperthermia (not first sign but most noticeable)
- Muscle rigidity
- Myoclonus
- Rapid changes in mental status and VS
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What are some newer antidepressants?
- Venlafaxine (Effexor): sometimes used for pain, split does for XR
- Duloxetine (Cymabalta): used in diabetic neuropathy and other pain syndrome
- Mirtazapine (Remeron): sleep promoting, appetite stimulation, few sexual SE
- Buproprion (Wellbutrin): fewer sexual SE, increases seizure risk, activating antidepressant, smoking cessation
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What are some atypical 2nd & 3rd gen antidepressants
- Amoxapine (Asendin)
- Reboxitine (Vestra)
- Desvenlafaxine (Pristiq)
- Trazodone (Desyrel)
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