Chapter 14 Depressive Disorders

During intake, Jeff doesn't speak much, but his parents are able to list the following symptoms they have observed: ¬ Weight loss and appetite changes ¬ Insomnia ¬ Fatigue ¬ Worthlessness or guilt ¬ Loss of interest in his college classes and even the online games he usually plays with friends ¬ "Constant sadness"

Audience Response Question Jeff's parents have described his lack of interest in things he used to enjoy, like games with his friends, and his classes, which he used to like. This may be best described by the term A. Inappetance B. Impetance C. Indolence *D. Anhedonia*

Transcranial Magnetic Stimulation ¬ Noninvasive ¬ Uses MRI-strength magnetic pulses to stimulate focal areas of the cerebral cortex ¬ Presence of metal is the only contraindication

¬ Adverse reactions o Headache and lightheadedness o No neurological deficits or memory problems o Seizures rarely o Most are mild and include scalp tingling and discomfort at the administration site.

Areas to assess

¬ Affect ¬ Thought processes ¬ Mood ¬ Feelings ¬ Physical behavior ¬ Communication ¬ Religious beliefs and spirituality

Depressive Disorders

¬ All share symptoms of o Sadness, emptiness, irritability, somatic (body) concerns, and impairment of thinking ¬ All impact a person's ability to function

Exercise

¬ Biological, social, and psychological effects ¬ Increases serotonin availability ¬ Dampens HPA axis (thought to be overly active in depression)

Age considerations

¬ Children and adolescents ¬ Older adults

Nursing Process (Cont.)

¬ Counseling and communication ¬ Health teaching and health promotion ¬ Promotion of self-care activities ¬ Teamwork and safety

Jeff was just diagnosed with a major depressive disorder. Which medication is the health care provider most likely to start the patient on? A. SSRI B. SNRI C. Tricyclic antidepressant D. Monoamine oxidase inhibitor

A. SSRI

A patient with major depression walks and moves slowly. Which term should the nurse use to document this finding? A. Psychomotor retardation B. Psychomotor agitation C. Vegetative sign D. Anhedonia

ANS: A Invite students to share examples of assessment findings associated with the distracters.

Which assessment finding in a patient with major depression represents a vegetative sign? A. Restlessness B. Hypersomnia C. Feelings of guilt D. Frequent crying

ANS: B Ask students to identify other vegetative signs associated with depression.

Which question would be a priority when assessing for symptoms of major depression? A. "Tell me about any special powers you believe you have." B. "You look really sad. Have you ever thought of harming yourself?" C. "Your family says you never stop. How much sleep do you get?" D. Do you ever find that you don't remember where you've been or what you've done?"

B. "You look really sad. Have you ever thought of harming yourself?"

Epidemiology * Leading cause of disability in the United States ¬ Children and adolescents ¬ Older adults

Comorbidity

Persistent Depressive Disorder ¬ Low-level depressive feelings through most of each day, for the majority of days - At least 2 years in adults - At least 1 year in children and adolescents

Formerly known as dysthymia ¬ Must have two or more of the following: - Decreased appetite or overeating, insomnia or hypersomnia, low energy, poor self-esteem, difficulty thinking, and hopelessness

Planning

Geared toward ¬ Patient's phase of depression ¬ Particular symptoms ¬ Patient's personal goals

Case Study

Jeff, 19, is brought to the hospital after a suicide attempt. His parents found him in his back yard, wearing his favorite black jeans and black t-shirt, but with one of his father's neckties. He had overdosed on some of his "mother's pills", but his stomach was pumped in time. He has just been admitted to your floor for 24-hour suicide observation.

Assessment ¬ Assessment tools - PHS 9... ¬ Assessment of suicide potential

Key assessment findings ¬ Depressed mood and anhedonia ¬ Anergia - decreased energy ¬ Anxiety ¬ Psychomotor agitation or retardation ¬ Vegetative signs ¬ Comorbidity: chronic pain

Plan patient and family education to discuss what side effects Jeff might experience on his new medication regimen.

May induce agitation, anxiety, sleep disturbance, tremor, sexual dysfunction (primarily anorgasmia), or tension headache. The effect of the SSRIs on sexual performance may be the most significant undesirable outcome reported by patients. Autonomic reactions (e.g., dry mouth, sweating, weight change, mild nausea, and loose bowel movements) may also be experienced with the SSRIs.

Major Depressive Disorder ¬ Five (or more) of the following in 2-week period o Weight loss and appetite changes o Sleep disturbances o Fatigue o Worthlessness or guilt o Loss of ability to concentrate o Recurrent thoughts of death

PLUS—at least one symptom is also either ¬ Depressed mood or ¬ Loss of interest or pleasure (anhedonia)

Etiology - Biological factors ¬ Genetic - low serotonin and norepinephrine ¬ Biochemical ¥ Stressful life events ¬ Alterations in hormonal regulation ¬ Inflammatory process ¬ Diathesis-stress model

Psychological factors ¬ Cognitive theory - stress life ¬ Learned helplessness

Outcomes identification

Recovery model ¬ Focus on patient's strengths, previous coping ¬ Treatment goals mutually developed ¬ Based on patient's personal needs and values

Implementation

Three phases ¬ Acute phase (6 to 12 weeks) ¬ Continuation phase (4 to 9 months) ¬ Maintenance phase (1 year or more)

Other Depressive Disorders ¬ Substance-induced depressive disorder o Person does not experience depressive symptoms in the absence of drug or alcohol use or withdrawal

¬ Depressive disorder associated with another medical condition o Can be caused by kidney failure, Parkinson's disease, and Alzheimer's disease o Symptoms that result from medical diagnoses or certain medications are not considered major depressive disorder

Other Treatments for Depression

¬ ECT ¬ Transcranial magnetic stimulation (TMS) ¬ Vagus nerve stimulation (VNS) ¬ Deep brain stimulation (DBS) ¬ Light therapy ¬ St. John's wort - mild depression ¬ Exercise

Electroconvulsive Therapy ¬ The most effective depression treatment ¬ Psychotic illnesses = second most common indication

¬ ECT the primary treatment in ¥ Severe malnutrition, exhaustion, and dehydration due to lengthy depression ¥ Safer than meds with certain medical conditions ¥ Delusional depression ¥ Failure of previous medication trials ¥ Schizophrenia with catatonia

Self assessment

¬ Feeling what the patient is feeling

Light Therapy

¬ First-line treatment for seasonal affective disorder (SAD) ¬ Efficacy due to influence of light on melatonin ¬ Effective as medication for SAD ¬ Negative effects: headache and jitteriness

St. John's Wort

¬ Flower processed into tea or tablets ¬ Thought to increase serotonin, nerepinephrin, and dopamine in the brain ¬ Useful in mild to moderate depression

Quality Improvement National goals in Healthy People 2020

¬ Increasing the percentage of individuals with major depressive disorder who receive treatment to 75% ¬ Increasing the number of physicians' offices who routinely screen for depression ¬ Center of Quality Assessment and Improvement in Mental Health ¥ Links to reliable outcome measures

Major Depressive Disorder (Cont.)

¬ Persistent for minimum 2 weeks to 6 months ¬ Chronic: Lasting more than 2 years ¬ Recurrent episodes common ¬ Symptoms cause distress or impaired function ¬ Episode not attributed to physiological effects ¬ Absence of a manic or hypomanic episode

Advanced Practice Interventions

¬ Psychotherapy ¥ Cognitive-behavioral therapy (CBT) ¥ Interpersonal therapy (IPT) ¥ Time-limited focused psychotherapy ¥ Behavior therapy ¬ Group therapy

Future of Treatment - Healthy People 2020 Objectives ¬ Improving screening for children and adolescents in a variety of health care and community settings

¬ Reducing the incidence of depressive episodes in children, adolescents, and adults ¬ Increasing mental health treatment to adults, children, and adolescents in primary care ¬ Increasing the number of patients with depression, both children and adults, who receive treatment

Nursing diagnosis

¬ Risk for suicide—safety is always the highest priority ¬ Hopelessness ¬ Ineffective coping ¬ Social isolation ¬ Spiritual distress ¬ Self-care deficit

Antidepressants - Selective serotonin reuptake inhibitors (SSRIs) ¬ First-line therapy - 2 to 4 weeks t o work ¬ Rare risk of serotonin syndrome: high body temperature, agitation, increased reflexes, tremor, sweating, dilated pupils, and diarrhea.

¬ Serotonin norepinephrine reuptake inhibitors (SNRIs) o SSRIs may be tolerated better ¬ Tricyclic antidepressants o Anticholinergic adverse reactions - sedating effect, take 10-14 days to work ¬ Monoamine oxidase inhibitors o Effective for unconventional depression, breakdown in liver, hypertensive crisis

Vagus Nerve Stimulation ¬ Originally used to treat epilepsy ¬ Decreases seizures and improves mood ¬ Electrical stimulation boosts the level of neurotransmitters

¬ Side effects o Voice alteration (nearly 60% of patients) o Neck pain, cough, paresthesia, and dyspnea, which tend to decrease with time

Nursing Process - Evaluation

¬ Suicide ideation ¬ Intake ¬ Sleep pattern ¬ Personal hygiene and grooming ¬ Self-esteem ¬ Social interaction

Deep Brain Stimulation

¬ Surgically implanted electrodes (in the brain) ¬ Stimulates those regions identified as underactive in depression ¬ More invasive than VNS ¥ Electrodes placed directly into the brain

Premenstrual Dysphoric Disorders

¬ Symptom cluster in last week prior to onset of a woman's period; include o Mood swings, irritability, depression, anxiety, feeling overwhelmed, and difficulty concentrating ¬ Symptoms decrease significantly or disappear with the onset of menstruation

Psychopharmacological Interventions Choosing an antidepressant

¬ Symptom profile of the patient ¬ Side-effect profile (e.g., sexual dysfunction, weight gain) ¬ Ease of administration ¬ History of past response ¬ Safety and medical considerations

Depressive Disorders Classified o Major depressive disorder o Others

♣ Disruptive mood dysregulation disorder ♣ Persistent depressive disorder (previously dysthymia) ♣ Premenstrual dysphoric disorder ♣ Substance/medication-induced depressive disorder ♣ Depressive disorder due to another medical condition