bipolar

how long does mania typically last?

1 week unless txt

major depressive episode lasts at least

2 weeks

situational depression

3 mths after event lasts no more than 6 maths risk factors: older adult resilience factor: capacity to respond to stressors cognitive behavioral therapy often enough

depressive disorders

Major Depressive Disorder MDD persistent depressive disorder (dysthymic) SAD postpartum depression situational depression

depression self-rating scales

Zung Beck

hypomania

abnormally & persistently elevated, expansive or irritable mood, lasts 4 days, does not impair ability to function, no psychotic features

excitatory or inhibitory neurotransmitter

acetylcholine

Lithium carbonate action, therapeutic range CI adverse effects drug-to-drug teaching

alters neurotransmission in CNS - 1-1.5 mEq/L (toxic above) * pregnancy/breastfeeding * impaired renal/cardiac function * sodium restricted diets * organic brain disease * impaired CNS function mild hand tremors, incr. thirst/urination, nausea, metalic taste, lithium toxicity, ACE inhibitors, NSAIDs, diltiazem, calan diuretics (incr. lithium lvls in blood) 1-3 weeks to work monitor lvl q2-3 days until adjusted, monthly when stable

what meds inhibit kindling?

anticonvulsives

Depression txt

antidepressants psychotherapy ECT

bipolar txt

antimanic agent = lithium anticonvulsive agents as mood stabilizer antipsychotics agents helpful reducing manic behavior psychotherapy in mild or normal portion of cycle, useless in mania

bipolar - aggressive behavior

assist in identifying feelings of frustration encourage pt. to talk rather than act out help in identifying precipitating events name consequences of behavior id prev. coping mechanisms assist in problem-solving techniques

s/s of major depressive disorder

changes in eating habits resulting in unplanned weight gain hypersomnia or insomnia impaired concentration, decision making & problem-solving inability to cope w/daily life feelings of worthlessness hopelessness guilt despair anhedonia psychomotor retardation/agitation thoughts of death/suicide overwhelming fatigue rumination w/negative impairment of social, occupational fct.

TCA overdose NI

check airway administer O2 check VS obtain ECG prepare for gastric lavage w/charcoal prepare administer physostigmine document

children depression scales

children's depressive inventory revised children's manifest anxiety scale beck depressive inventory preschool feelings checklist

persistent depressive disorder (dysthymic disorder)

chronic depression most days for at least 2 years (no more than 2 mths symptom free) less severe symptoms than MDD

dysthymic disorder (persistent depressive disorder)

chronic, persistent mood disturbance most days at least 2 years (no more than 2 mths symptom free) milder than depression similar s/s to depression

dopamine effect

complex movements motivation cognition regulation of emotional response

side effects of ECT

confusion memory loss (short term or permanent) <= less w/unilateral electrode placement

what disorders may underlie kindling

cycling of mood disorders addiction

norepinephrine in mental health

deficient in depression increased in mania

nonsuicidal self-injury

deliberate cutting, burning, scraping alleviation of negative emotions, self-punishment, attenting seeking, escaping situation

seasonal affective disorder - SAD

fall-onset = incr. sleep, appetite, CHO cravigings, weight gain, interpersonal conflict, irritability, heaviness in extremities (late fall to spring/summer) spring-onset = insomnia, weight loss, poor appetite, (late spring/early summer - early fall)

delusion

false belief held to be true, even if there is evidence to the contrary ideas, serve purpose in establishing identity & self-esteem (grandiose or persecutory)

epinephrine effect

fight-or-flight response

serotonin effect

food intake sleep/wakefulness temperature regulation pain control sexual behaviors regulation of emotions

psychodynamic theories for cause of mood disorders

freud = self-deprecation bibring = ideal ego jacobson = superego over powerless ego mania = defense against depression

biologic theories for development of mood disorders

genetic theories (increased risk in 1st degree relatives, but does not alone account for it) neurochemical theories (serotonin, norepinephrine, acetylcholine, dopamine) neuroendocrine theories (hormonal)

depression risk factors

h/o abuse, neglect, loss dysfunctional family relationships family h/o mental illness, substance abuse

clinician depression rating scales

hamilton rating scale

mental health assessment

history general appearance/behavior mood/affect through process/content sensorium/intellectual processes judgment/insight self-concept roles/relationships physiologic, self care considerations

s/s of manic episodes

inflated self-esteem/grandiosity decreased sleep excessive & pressured speech flight of ideas distractability increased activity or psychomotor agitation excessive pleasure seeking or risk-taking irritable when told to follow rules otherwise overly cheerful denies problems blame others hallucinations/delusions psychotic symptoms

MAOIs action use pharmacokinetics CI adverse reactions drug-to-drug/food

inhibits MAO (NE, 5HT, dopamin can accumulate) depression unresponsive to other agents - absorbed in GI, metabolized in liver, excreted in urine * pheochromocytoma, CV disease, headaches, renal/hepatic impairment - orthostatic hypotension, dizziness, CNS stimulation (excitement, nervousness, agitation), mania, - hyperreflexia, tremors, insomnia - liver toxicity, GI upset, weight gain, dry mouth (anticholinergic effect) - peripheral edema * other antidepressants -> hypertensive crisis, coma, * methyldopa, levodopa - incr. sympathomimetic effect * epinephrine, dopamine, amphetamines * nasal decongestants, * insulin & oral antidiabetic agents * tryamine -> hypertensive crisis * opioids (hyper-, hypotension, coma, seizure) - 4-8 wks to work, no tyramine foods, assess for pregnancy - lower seizue threshold, medic alert bracelet

action of antidepressant txt

inhibits effects MAO -> incr. NE, 5HT in synaptic cleft block reuptake by nerve regulate receptor sites & breakdown of neurotransmitters

psychotherapy types for depression

interpersonal therapy: relationship difficulties, behovior therapy: reinforcement of pos. interactions cognitive therapy: correction of cognitive distortions, identify patterns <= most effective

bipolar - deescalating techniques

maintain safety maintain large personal space, nonaggressive posture calm approach determine pt. needs avoid verbal struggles provide clear options

primary mood disorders

major depressive disorder bipolar disorder

txt of postpartum women w/risk factors

refer to mental health 2-6 weeks postpartum pharmacologic not during breastfeeding follow up 2-3 wks postpartum assess for: 3 symptoms of depression in 1 day 1 symptom of depression for 3 days rejection of infant threatened or actual aggression toward infant

NI depressive disorders

safety (suicide precautions) promote ADLs use therapeutic communication encourage pt. to discuss feelings manage meds pt./family teaching assist to id resources provide distraction from self-absorption involve pt. in recreational activities recognize accomplishments (do not flatter) accept pt's negative feelings ID strengths, screen for risk factors (access to weapons, substance abuse, h/o fighting)

hallucination

sense perceptions (one of the 5 senses) for which no external stimuli exists

inhibitory neurotransmittors

serotonin GABA

what neurochemical is lacking in depression?

serotonin trypophan (precursor to serotonin)

postpartum psychosis

severe psychiatric illness onset in the days following childbirth (1-3 maths) s/s fatigue, sadness, emotional lability, poor memory, confusion, delusions, hallucinations, poor insight & judgment, loss of contact w/reality children in danger MEDICAL EMERGENCY = needs txt

when are children & adolescents medicated?

severe symptoms preventing psychotherapy psychosis chronic or recurrent

acetylcholine effect

sleep/wake cycle signals muscles to become alert

endocrine disorder associated w/mood disorders

thyroid (5-10% of depression ppl have thyroid dysf.) adrenal parathyroid pituitary gland pospartum hormone alterations

alternative depression txt

transcranial magnetic stimulation vagus nerve stimulation (w/hard to txt seizure disorders, if resistent to antidepressants) accupuncture animal-assisted txt music therapy

ECT NI

BP ECG, EEG pulse oximetry 100% oxygen airway or bite-block

hypertensive crisis s/s

HTN occiptal headache radiating frontally neck stiffness & soreness N&V sweating fever & chills clammy skin dilated pupils palpitations, tachycardia, bradycardia consticting chest pain

antidepressants

SSRIs cyclic antidepressants atypical antidepressants monoamine oxidase inhibitors (MAIOs)

what cholinergic is thought to play a role in depression & mania?

acetylcholine

bipolar disorder split into

bipolar I bipolar II mixed

assessment scale for postpartum

edinburgh postnatal depression scale postpartum depression predictor inventory

bipolar I

recurring incr. in frequency as ages

postpartum depression

s/s of depression onset within 4 wks of delivery risk of suicide

pressured speech

words are being forced out quickly

bipolar II

= one or more major depressive episode accompanied by at least one hypomanic episode

bipolar I

= one or more manic or mixed episodes accompanied by major depressive episode

NI before ECT

NPO after midnight or at least 4 hrs prior, consent explain procedure remove any fingernail polish, remove lenses, jewelry, hairpins, dentures void just before the procedure baseline VS iv line for the administration of medication

A nurse is assessing an 82-year-old for depression. Because of the client's age, the nurses' assessment should be guided by the fact that:

Sadness of mood is usually present but it is masked by other symptoms.

what are important dietary considerations during txt w/lithium?

adequate sodium 2-3 L fluid

meds during ECT

atropine-like = decr. secretions, block cardiac vagal reflexes during seizure (robinul) short-acting anesthetic = brevital muscle relaxant = prevent injury during seizure (anectine) O2

norepinephrine effect:

attention learning memory sleep wakefulness mood regulation

tyramine foods

avocado banana liver brewer's yeast broad beans caffeine cheese (esp. aged) eggplant figs overripe fruit raisins red wine, beer, sherry sausage, peperoni, salami sour cream soy sauce yoghurt

SSRIs action use pharmacokinetics CI adverse reactions drug-to-drug/food teaching

block reuptake of 5HT, little effect on others depression, OCD, panic attacks, bulimia, PMDD posttraumatic stress disorder, social phobias, social anxiety disorders - absorbed in GI, metabolized in liver, associated w/congenital abnormalities * pregnancy, lactation, impaired renal/hepatic function - headache, drowsiness, dizziness, insomnia - CNS stimulation = akathisia (restlessness, agitation), anxiety, tremor, nervous - seizure, incr. sweating, photosensitivity * MAIOs -> seratonin syndrome, TCA increase therapeutic & toxic effect, St. John's Wort - notify provider before other drugs (St. John's Wort), - keep follow up apps, 4 wks to work - report side effects, do not stop suddenly - take in AM w/food, exercise (weight gain), - incr. suicide thoughts in teens

Misc. Antidepressants

bupropion (Wellbutrin) mirtazipine (Remeron) nefazodone (Serzone) trazodone (Desyrel) venlafaxine (Effexor)

substance-induced depressive or bipolar disorder

disturbance in mood that is a direct physiologic consequence of ingested substances

anticonvulsants/mood stabilizers examples

divalproex (Depakote) lamotrigine (Lamictal) topiramate (Topamax) carbamazepine (Tegretol) gabapentin (Neurontin) oxcarbezepine (Trileptal) Do not discontinue abruptly - hypotension

delusions NIs

do not argue/challenge beliefs <- increases anxiety reinforce reality by encouraging participation in real events, do not delve on delusional belief system

anticholinergic effects

dry mouth difficulty voiding dilated pupils & blurred vision decr. GI motility -> constipation

related mood disorders

dysthymic disorder cyclothymic disorder substance-induced depressive or bipolar disorder seasonal affective disorder postpartum, depression, psychosis, premenstrual dysphoric disorder nonsuicidal self-injury

excitatory neurotransmitters

epinephrine norepinephrine dopamine glutamate

mixed bipolar episode or rapid cycling

mania & depression nearly every day for 1 wk rapid cycling

bipolar disorder

mania and/or depression sudden onset in late teens, 20s, 30s

cyclothymic

mild mood swings between hypomania & depression without loss of social or occupational function chronic, fluctuating mood disturbances symptoms for at least 2 years considered moody, unpredictable, temperamental

postpartum blues

mild predictable mood disturbance first several days after delivery tearfulness w/out cause labile mood & affect, crying spells, sadness, insomnia, anxiety, anorexia, subsides w/out txt in 10-14 days, but fam. support beneficial

premenstrual dysphoric disorder

moderate psych & phys. symptoms during week before menses labile mood, irritability, icnreased interpersonal conflict, difficulty concentrating, feeling overwhelmed, unable to cope, anxiety, tension, hopelessness

GABA effect

modulation of other neurotransmitters

NI for MAIOs

monitor BP for HTN monitor for hypertensive crisis if palpitations or frequent headaches = withhold & notify HCP administer w/food for GI distress report headache, neck stiffness/soreness change position slowly avoid facing or OTC meds (cold, allergy, weight reduction) monitor compliance w/ meds med-alert bracelet avoid evening administration (insomnia) discontinue gradually foods that require bacteria or molds = tyramine

NI for TCAs

monitor suicidal ideation change position slowly monitor bowel patterns assess for urinary retention monitor liver/renal function administer w/food or milk if GI upset administer at bedtime (sedation) avoid alcohol taper off to discontinue poss. of interactions w/cold OTC sunburn precautions oral hygiene

biogenic amine theory

monoamine oxidase breaks down norepinephrine, dopamine, serotonin (5HT) rapid fire of neurons -> depletion of neurotransmittors incr. in receptors -> depleting neurotransmitter lvls

serotonin role in behavior

mood activity aggressiveness irritability cognition pain biorhythms

elders & depression

more common, esp. if markedly ill psychotic features common incr. tolerance to meds, 12-13 wks response ECT common txt, more repid response suicide increases

glutamate effect

neurotoxic effect at high levels

dx in mood disorders

no lab studies sleep abnormalities neurotransmitter & -peptide dysregularities hormonal disturbances brain imaging studies preventricular vascular changes urine & blood drug screen

antidepressant meds during pregnancy

non approved TCAs, SSRIs less risk for birth defects breastfeeding = SSRIs, anticonvulsants monitor infant!!!

NI for SSRIs

numerous drug-to-drug interactions monitor VS (BP up or down) monitor weight safety precautions (dizziness) avoid alcohol administer w/food monitor suicidal pt take early (interfere w/sleep) monitor liver, renal fct, WBC & neutrophils change position slowly serotonin syndrome OTC cold meds can cause serotonin syndrome pregnancy precautions encourage psychotherapy monitor kids & adolescents

bipolar disorders in children/adolescents

often irritable, hyperactive h/o parents = increased risk high rate of attempted suicide

mania dx

persistently elevated or irritable mood & 3 other symptoms of mania 1 week impairs social/occupational function generally = hospitalization

hypeertensive crisis antidote

phentolamine iv

postpartum depression risk factors

primiparity ambivalence about pregnancy h/o postpartum depression, bipolar illness lack of social support lack of stable supportive relationship

kindling

process by which seizure activity in specific area of the brain is initially stimulated by reaching a threshold of cumulative effects of stress, low amoutns of electric impulses or chemicals leads to spontaneous seizure activity w/out prior impulse

TCA action use pharmacokinetics CI adverse reactions drug-to-drug/food

reduce reuptake of 5HT & NE sleep disorders, depression, enuresis, chronic pain - absorbed in GI, metabolized in liver, excreted in urine, - T 1/2 8-46 hrs * recent MI, myeolography, pregnancy, lactation sedation, sleep disturbances, fatigue, ataxia, N&V, weight gain cv disturbances (tachycardia, orthostatic hypotension, dysrhythmias) sleep disturbances, fatigue, anticholinergic anxiety, irritability * MAOIs, cimetidine, fluoxetine, ranitidine, oral anticoagulants - 6-8 wks to work, anticholinergic, notify provider before other drugs - avoid alcohol, CNS depressants, change position slowly, do not drive until sedation known, take at bedtime if sedation, discuss potenital pregnancy * CV disease, angle closure glaucoma, urinary retention * manic depression

NI in mania

remove hazardous objects from environment assess the client closely for fatigue monitor sleep patterns, comfort measures to promote sleep provide frequent rest periods private room if possible encourage pt. to ventilate feelings use calm, slow interactions help pt. focus ignore or distract pt. from grandiose thinking present reality to pt. do not argue w/pt. limit group activities, solitary activities may be necessary supervise choice of clothing reduce environmental stimuli set limits on inappropriate behavior provide physical activities & outlets for tension avoid competitive games structured activities or one-to-one simple & direct explanations for routine procedures supervise meds seclusion if hyperactive behavior is dangerous due to altered sensory precautions

antipsychotic mood stabilizers examples adverse side effects drug-to-drug

risperidone (Risperadal), olanzapine (Zyprezia), aripiprazole (Abilify), quetiapine (Seroquel), ziprasidone (Geodon) hyperactive, agited behavior responds quickly - seizures, hypotension, akathisisa, - anticholinergic effect, suicidal thoughts, - agranulocytosis, tardive dyskinesia - extrapyramidal side effects (risperidone) - neuroleptic malignant syndrome * betablockers, anticholinergics - bipolar meds teaching, side effects, - take meds as ordered, keep lab visits to monitor lvls - diet & fluid intake, avoid alcohol, - notify provider before other drugs

NI bipolar

safety meet phys. needs therapeutic communication manage meds promote appropriate behavior pt/family teaching

When caring for an adolescent diagnosed with depression, the nurse should remember that depression manifests differently in adolescents than it does in adults. In an adolescent, signs and symptoms of depression are likely to include:

truancy, a change of friends, social withdrawal, and oppositional behavior.

meds used in the txt of bipolar disorder

valproic acid (Depakote) carbamazepine (Tegretol) lamotrigine (Lamictal) = maintenance atypical antipsychotics (olanzapine [Zyprexa], aripiprazole [Abilify], risperidone [Risperdal]

can you have delusions/hallucinations in depression?

yes