depression treatment

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  1. Psychotherapeutic
    Milieu therapy/CBT
    • Milieu Therapy
    • - suicide risk- provides safe environment
    • - self-care
    • - communication, psycho, education groups

    • CBT cognitive behavorial therapy
    • - helps people learn new ways of thinking and behaving
    • - enables pt to correct false seld beliefs (cognitive distortions) that can lead to negative moods and behaviors
    • - helps control negative thought that lead to misperceptions
    • - long term therapy
    • connects feelings to the feelings you are having ex mantra
  2. psychotherapeutic intereventions
    interpersonal therapy
    • emphasis: social functioning and interpersonal relationships (how are relationships effected by the disorder? are they considered stressor?)
    • understand and work thru troubled personal relationships ie psychodynamic (freud), analysis, early loss, work thru repressed memories
  3. complimentary therapy
    • Family interventions
    • - education
    • - family conflicts
    • - communication

    • Group intervention- can include psych-education groups
    • - education, socialization- dec isolation and hopelessness
    • - communities meetings/activities, group less structured/imposing, better tolerated
  4. biological treatment
    • ECT- thought to inc circulating levels of serotonin, norepine, improves mood
    • TMS- transcranialmagnetic stimulation (short pulses, but does not cause generalized seizures like ECT)
  5. Bilateral ECT
    • a depressed pt is receiving ECT tx
    • ECT is thought to effect a therapeutic response by
    • a. stimulation of the CNS
    • b. decreasing the levels of acety and monoamine oxidase
    • c. increasing the levels of serotonin, noreepine, and dopamine
    • d. altering sodium metabolism within nerve and muscle cells
  6. ECT brain stimulation therapies
    • severe refractory depression
    • - relieves severe symptoms ie psychosis (hallucinations, delusional thinking) person refusing to eat, unable to take antidepressants, suicidal
    • AKA brain defibrillator
    • need informed consent
    • - contraindicated recent MI intracranial lesion/tumors, w/incre ICP CVA, arrhythmias, aneurysms, acute resp infection
    • NPO at least 8-12 hrs
    • - assess vital signs, memory (remote, long term)
    • anesthesia preparation
    • - atropine like prep decrease secretions, prevent n/v, short acting anesthetic (brevital) IV
    • - skeletal muscle relaxant- to prevent injuries during the seizure
    • anectine (succinylcholine)- relax muscle
  7. ECT brain stimulation therapies
    • ventilate until muscle relaxant fully metabolized
    • electrical current passed through brain by means of uni- or bilateral electrodes placed on the temples
    • - causes a grand mal seizure (effects often masked by muscle relaxant)
    • NOTE: meds affecting seizure threshold should be d/c'd prior to ECT
    • - last about 30-60 sec
    • incre BP & P
    • - HTN dysrhythmias, cardiac condition treated prior to ECT
    • - small risk of death. same as w/other procedures in which anesthesia is used
    • SE: h/a, N/V, muscle aches (d/t muscle relaxant), jaw clenching (clenching jaw)
    • 10 min procedure
  8. ECT brain stimulation therapies
    nursing interventions
    • reorient frequently- loss short term memory- dont know where they are (anxious, scared)
    • monitor VS
    • Lateral recumbent
    • - facilitate drainage, prevent aspiration
    • acetaminophen for h/a
    • orient due to short term memory loss
    • - from several mins to several hours
    • - osscasionally, may last several days quite distressing
    • ECT not curative
    • - encourage other treatments & meds to prevent relapse
    • usually up to 12 txs (3 times per week)
  9. Other biological treatment
    vagus nerve tx etc
    • vagus nerve stimulation- implanted pulse generator and wire stimulate parts of the brain that affect mood to decrease depression. Affects serotonin and norepine, FDA approved for long term chronic depression after at least four other failed tx. no seizure or memory loss
    • cranial electrotherapy stimulation- small almost undetectable doses of electricity thought to stimulate areas of the 20-30 minutes per day electrodes placed near jaw with almost no side effects & FDA approved
  10. other biological tx
    phototherapy
    • for seasonal affective disorder thought to increa circulating levels of 5HT, norepine, improves mood
    • light therapy (phototherapy)
    • - exposure to light that is brighter than indoor light, not as bright as direct sunlight
    • - outdoor light is preferred
    • may help reset biological clock (circadian rhythms)
    • - controls sleeping and waking
    • sit in front of high intensity fluorescent 1 am
    • - 15/30 mins to 1.5-2 hours qAM
    • can be used in different ways & employ different types of light boxes, light visors and lamps
    • all designed to bring in extra light to the eyes
    • check to be sure a light box filters out harmful ultraviolet light
    • feels like spring- melatonin
  11. drug for tx mood disorders/antidepressants
    • TCA
    • SSRI
    • MAOIs
    • atypical/novel antidepressants
    • the most widely prescrived drugs in the US
    • - can have serious interactions with food, alcohol other drugs
    • - take a couple weeks to start working
    • - also used to tx pain syndrome, insomnia anxiety panic disorder, OCD ect
  12. factors to consider when prescribing antidepressants
    • dx
    • - comorbid diseases ** try to understand
    • age
    • weight
    • anticholinergic susceptibility- tend to get really dry stop urination
    • hx of adervse affects- any fam taking meds
    • previous response
    • compliance/adherence
    • financial/insurance
    • support system-
    • VNA
  13. depression and NT
    • NT deficiency
    • 1. serotonin to incr more available
    • 2. NE goal is to inc so more available
    • 3. dopamine and glutamate thought to play a part but current theories and drug therapies focus on 5HT and NE
    • Serotonin inhibitory monoamine NT
    • regulates
    • - memory
    • - body temp- look at children careful
    • - emotion/mood
    • - sleep, wakefulness
    • - vomiting, appetite
    • - sexual- libido- sexual dysfunction
  14. depression and NT
    NE
    • NE
    • - has some modulating effect is a hormone and NT
    • - it is thought that clients with mood disorders expecially MDD have decrease NE
    • NOTE: widely believed that MDD has 2 subtypes
    • - one caused by abnormal NE balance
    • - one caused by abnormal 5HT balance
    • MAO enzymes inactivates NE, 5HT, dopamine (decre NT availablility)
    • - MAOIs inhibit this enzyme
  15. antidepressants
    • classifications approximately same efficacy relieving depression/symptoms of primary action
    • choice based on SE and other variables
    • contraindications:
    • hypersensitivity during acute recovery phase s/p MI, angle-closure glaucoma, esp TCAs
    • CAUTION
    • - elders, children-start low, go slow, debilatated pts, hepatic, renal, cardiac insufficiency, (BPH), hx, seizure
    • CAUTION
    • - patients have incre energy, cognitive ability when drug takes effect
    • -- may incre suicide potential
  16. SSRI
    • First time/choice for depression
    • - wider therapeutic index
    • - fewer adverse effects less occurence of toxicity
    • Lack cardiotoxicity with OD
    • - SSRI OD-extreme doses
    • - multi drug OD- Serotonin syndrome side effect0 get symptoms clear
    • approved for depression, panic, OCD, PTSD, bulimia nervosa, social phobia- multi use
    • latest research: high seizure rate than TCA's children= close monitor
  17. Mode of Action
    • Actions- inhibits reutake of serotonin into presynaptic nerve terminals
    • - increased levels of serotonin available in synapse (more floating around)
    • - presynaptic receptors LESS sensitive
    • - post synaptic receptors MORE sensitive
  18. SSRI name
    • Citalopram (celexa) 20-60
    • Escitalopram(lexapro) 10-20
    • Fluvoxamine (luvox) 50-300
    • Paroxetine (paxil) 10-50 highest specificity for 5HT, wt gain
    • sertraline (zoloft) 50-200 full stomach for absorption
    • fluoxetine (Prozac)- 20-80 90 wkly capsule, wt gain
    • in slowly
    • withdraw slowly
    • major SE- agitated
    • 4 wks it starts work
    • prozac and ativan to help reach therapeutic
    • ativan (benzo will help w/agitation)
  19. withdrawal symptoms
    • anxiety
    • depression and mood swings
    • dizziness and balance problems
    • electric shock sensation- extremities
    • fatigue
    • flu- like symptoms with headache
    • loss of coordination & muscle coordination
    • N/V
    • nightmares
    • tremors
    • trouble sleeping
  20. adverse effects SSRI
    • sexual dysfunction 30% men
    • GI symptoms/bleed
    • CNS stimulation: anxiety, restlessness, nervousness
    • early weight loss followed by weight gin
    • insomnia, fatigue or sedation, dizziness
    • associated w/EPS including akathisia (cant sit), dystonia (muscle weakness)
    • use with caution in known seizure disorders (bc playing with NT)
  21. adverse effects SSRI 2
    • may have antichol adverse effects
    • sleepiness, lightheadedness
    • prolonged OT interval, ventricular tachycardia fluxetine (prozac)
    • rash, stevens johnson syndrome- red skin peeling rash
    • ANTIDEPRESSANTS BLACK BOXED
    • suicidal ideation
  22. serotinin syndrome
    • excessive 5ht with/in 2-72 hours
    • - usually with 2 or more antidepressants lithium, st. john's wort, benzo, phenothiazide, haldol, beta-blocker
    • sx (medical emergency)
    • - chx in mental status- mental confusion, difficulty concentration, hallucinations
    • - abdominal pain, diarrehea
    • - hyperprexia- fever
    • - restlessness, anxiety
    • - hyperreflexia, incoordination, myoclonus
    • - tachycardia, labile bp
    • - diaphoresis, shivering, tremors-elders more prone to neuromuscilar symptoms
  23. serotonin syndrome
    • Usually within 24 hours of start of medication or increase dose of a med
    • tx-  d/c offending med immediately. if needed a med can be prescribed to block serotonin receptors, also meds for muscle rigidity seizure etc
    • may be confused w/neuroleptic malignant syndrome (from antipsychotic meds, serotonin syndrome progresses more slowly than NMS
    • NMS: inc WBC and serum creatine phosphokinase muscle rigidity, bradykinesia (other symptoms for this. happen immediate)
  24. Tricyclic antidepressants (TCAs)
    second line treatment
    • action: inhibits presynaptic re-uptake of NE and or 5HT
    • TCAs block alpha receptors so get antichol SE (vasoconstriction)
    • lack of specificity affects other receptor systems as seen in side effects
    • dosages are highly individualized:
    • - nortriptyline (aventyl/pamelor) 30-200
    • - desipramine (norpramin) 25-300
    • - amitriptyline (elavil/endep) 50-300
    • - imipramine (tofranil) 30-300 enuresis
    • - clomipramine (anafranil) 25-250 OCD
    • - amoxapine (asendin) 75-100
    • - doxepin (sinequan) 30-150
    • - protripyline (vivactil) 15-40
    • - trimipramine (surmontil) 75-100
  25. TCA side effects
    • more side effects- Narrow therapeutic Index
    • - blood level monitoring useful
    • drowiness, sedation, dizziness
    • - confusion-especially in the elderly (decr over time)
    • - avoid other CNS depressants
    • Orthostatics hypotension especially elders
    • anticholin SE
    • - avoid antihistamines other antichol meds
    • wt gain- incr appetite
    • sexual dysfunction (not as big as problem as SSRI)
  26. antichol side effects***
    • dry mouth (tooth decay)
    • blurred vision
    • photophobia
    • urinary hesitancy/retention
    • constipation
    • tachycardia
    • tx: supportive measures (dec antidep)
  27. TCA adverse effects
    • can cause life threatening cardiotoxicity
    • - lethal in OD, toxicity (wont take meds-suicide pt)
    • -- even 1 weeks with of rx
    • - cardiovascular conduction disturbances
    • -- tachycardia, arrthymias, MI, heart block
    • -- ECG recommended initially and periodically thereafter
    • antichol delirum
    • SI
    • serotonin syndrome
    • agranulocytosis (dec WBC blood work)
    • bone marrow depression
    • seizures: decre seizure threshold (contraindicated w/seizure)
  28. TCA drug-drug
    • ETOH, benzo, opiods (CNS depressants)
    • - incre sedation
    • Barbs
    • - decre effectiviness
    • Cimetadine, haldol
    • - incre levels of TCAs
    • SSRIs
    • - incre levels, resulting in severe CNS toxicity
    • MAOIs- never give w/TCA's
    • - serotonin syndrome hyperpyretic crisis, seizures-severe, incre BP- hypertensive crisis, coma, death
  29. MAOI's
    third line mode of action
    • inhibiting mono amine oxidase break down of NE, 5HT, DA which increa concentration of them
    • - isocarboxazid
    • - phenelzine (nardil) 45-90
    • - tranylcypromine (parnate ) 30-60
    • indications:
    • - atypical/refractory depression/anxiety, phobias and or hypochondriacal
    • - some pain syndrome (migraines)
  30. MAOI
    contradications
    drug-drug
    • contraindications:
    • - hepatic dysfunction
    • - CHF
    • - caution w/cardiac disease, stroke, MI
    • - can worsen parkinson's, induce mania, worsen sx in schizo
    • drug- drug
    • - otc
    • - appetite suppressors
    • - avoid buspar demerol, SSRI (HTN crisis)
    • 14 day interval start of MAOIs from TCA/SSRI
    • 5 weeks for prozac (fluoxetine) *** stays in system for while
  31. side effects MAOIs
    • sleep disturbance, insomnia -tends to go away
    • weight gain
    • addictive- antichol effects
    • headache
    • tremor
    • sexual dysfunctin
  32. side effect MAOIs 2
    • orthostatic hypotension
    • - additive hypotension when used concurrently with antihypertensives
    • additive hypoglycemia w/concurrent use of insulin/oral hypoglycemic agents
    • SI
    • Serotonin syndrome
  33. HTN crisis
    MAOIs
    • preciptated by:
    • drug-drug
    • foods containing amino-acids: tyramine
    • s/s
    • - severe occipital h/a
    • - stiff neck
    • - N&V
    • - fever, diaphoresis
    • - marked incre in BP, chest pain, coma
  34. tx hypertensive crisis
    • discontinue drug immediately
    • monitor vs
    • administer short acting anti htn med as prescribed by MD
    • use of external cooling measure to control hyperpryrexia
  35. MAOI dietary restrictions
    • prohibited
    • aged cheese, ripe avocado
    • ripe figs, anchovies, bean curd
    • broad beans, yeast, liver, soy sauce
    • deli meat, pickled herring, sauerkraut
    • meat extracts, fermented foods
    • chianti, sherr
    • beer
  36. MAOI dietary restrictions
    • moderate use
    • beer, ale
    • wine, distilled spirits, cottage cheese, cream cheese
    • yogurt, sour cream
    • coffee, chocolate
    • spinach, raisins, tomatoes, eggplant
  37. MAOIs other restrictions
    • antiasthmatics
    • antihtyn
    • epinephrine
    • allergu, hay fever decongestants
    • cough and cold products
    • buspar
    • demtrol
    • SSRI
  38. atypical antidepressants
    • depression, anxiety, neuropathic pain
    • - duloxetine (cymbalta) SNRI 40-60
    • -- diab neuropathy
    • -- may incr BP
    • - venlafaxine (effexor) SNRI 75-225 QD divided doses 2-3x a day
    • -- d/c syndrome
    • -- HTN, wt loss, QT prolongation, short half life, good for geriatric pop
    • -- pristiq (desvenlafaxine) 50-400
    • - mirtazapine (remeron) 15-45
    • -- wt gain, orthstatic hypotension, orally disintergrating tabs
  39. atypical antidepressants
    • Busproprion (wellbutrin)
    • -200-300 divided doses QD
    • - SR/XR 150 BID
    • - SE: GI, dry mouth, restless leg syndrome
    • - avoid w.ED
    • - lowers seizure threshold
    • - smoking cessation
    • Trazodone (desyrel) tetracyclic
    • - 150-600 sleep
    • - cardiac SE priapism
    • Nefazadone (Serzone- unavailable in US)
    • - liver failur
    • Reboxetine
    • - not currentlt FDA approved denied 2001 used in europe
  40. all antidepressants ***
    abrupt d/c discontinuation withdrawal syndrome
    • Symptoms r/t antichol rebound effect
    • h/a nausea
    • confusion, visual disturbance
    • anxiety, panic
    • worsening of depressive symptoms
    • dizziness, tremors
    • NOT dangerous but can be extremely uncomfortable and distressing
    • TAPER over 1-2 weeks, prescribed schedule
  41. general course of AD therapy
    • 1st week- dec anxiety, improved sleep, client often unaware of changes
    • 1-3 week- incr activity, sex drive, self-care, improved concentration, memory, psychomotor retardation resolves
    • 2-4 wks- relief of depressed mood, less hopelessness, suicidal ideation subsides
    • maintenance tx at least 3 months, psych uses 1 yr duration

Card Set Information

Author:
Prittyrick
ID:
324333
Filename:
depression treatment
Updated:
2016-10-10 02:16:05
Tags:
tx
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Description:
unipolar treatment
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