Module 4: Depression & Suicide

light therapy

-15-25% have a seasonal patter -major depressive disorder, recurrent, with seasonal pattern (was seasonal affective disorder) -thought to be in relation to melatonin and its regulation in biological rhythms for sleep and activation and increase serotonin -don't look directly at it, but eyes must be open, 10-15 minutes → 30-45 minutes some with rapid improvement -SE: headache, eyestrain, nausea, irritability, photophobia, insomnia, agitation

facts about suicide

-8 out of 10 people have given definite clues and warnings of their intentions -if you ask someone about suicide it will not change their risk of attempt

PHQ-9

-9 question assessment of depression severity -commonly used in primary care, emergency department PHQ-2

nutritional deficiencies you might observe that can produce symptoms of depression

-B1 -B12 -niacin -vitamin C -iron -folic acid -zinc -calcium -potassium

phenelzine (nardil)

-MAOi -indication: depression -mechanism of action: inhibit the enzyme that breaks down serotonin and norepinephrine, but it also inhibits the breakdown of tyramine (enzyme: MAO-monoamine oxidase) -common side effects: -serious side effects: hypertensive crisis due to inability to break down tyramine (HA, flushing, stiff neck, palpitations, nausea → MI, stroke) -special diet

bupropion (zyban)

-NDRI -indications: treatment of depression -mechanism of action: decreases neuronal reuptake of dopamine in the CNS; diminished neuronal uptake of serotonin and norepinephrine (less than tricyclic antidepressants) -common side effects: insomnia, dry mouth, tremor, agitation, headache, N/V -serious side effects: seizures, homicidal thoughts/behavior, suicidal thoughts/behavior -used for smoking cessation -decreased ADHD symptoms -lowers seizure threshold

70% of all suicides are among white males

-SI risk and men are positively correlated and increase with age -rates among women are fairly constant throughout their life -males over 80 are the greatest risk -suicide is the third leading cause of death in adolescents

venlafaxine (Effexor)

-SNRI -indications: major depressive disorder -mechanism of action: inhibits serotonin and norepinephrine reuptake in the CNS -common side effects: nausea, increased sweating, insomnia, tremors, sexual disfunction, brain zaps -serious side effects: neuroleptic malignant syndrome, seizures, suicidal thoughts, serotonin syndrome -increased risk of bleeding with blood thinners -discontinuation syndrome: pt teaching → dizzy, headache, lethargy, withdrawal, symptoms improve when tapered slowly

citalopram (celexa)

-SSRI -indications: depression -mechanism of action: selectively inhibits the reuptake of serotonin in the CNS -common side effects: apathy, confusion, drowsiness, insomnia, weakness, abdominal pain, anorexia, diarrhea, dry mouth, dyspepsia, flatulence, increased saliva, nausea, sweating, tremor -serious side effects: neuroleptic malignant syndrome, suicidal thoughts, torsade de points, serotonin syndrome

paroxetine (paxil)

-SSRI -indications: major depressive disorder -mechanism of action: inhibits neuronal reuptake of serotonin in the CNS, potentiating the activity of serotonin. has little effect on norepinephrine or dopamine -common side effects: anxiety, dizziness, drowsiness, headache, insomnia, weakness, constipation, diarrhea, dry mouth, nausea, ejaculatory disturbance, sweating -serious side effects: neuroleptic malignant syndrome, suicidal thoughts, stevens-Johnson syndrome, serotonin syndrome -associated with highest risk of discontinuation syndrome -not safe with pregnancy → birth defects

sertraline (zoloft)

-SSRI -indications: major depressive disorder -mechanism of action: inhibits neuronal uptake of serotonin in the CNS, potentiating the activity of serotonin -common side effects: headache, agitation, nausea, weight gain, sexual dysfunction, dizziness, drowsiness, fatigue, insomnia, diarrhea, dry mouth, increased sweating -serious side effects: suicidal thoughts, serotonin syndrome

fluoxetine (prozac)

-SSRI -indications: major depressive disorder -mechanism of action: selectively inhibits the reuptake of serotonin in the CNS -common side effects: anxiety, drowsiness, headache, insomnia, nervousness, diarrhea, sexual dysfunction, increased sweating, pruritis, tremor -serious side effects: neuroleptic malignant syndrome, seizures, suicidal thoughts, torsades de pointes, serotonin syndrome

amitriptyline (Elavil)

-TCA -indications: depression -mechanism of action: potentiates the effect of serotonin and norepinephrine in the CNS; has significant anticholinergic properties -common side effects: lethargy, sedation, blurred vision, dry eyes, dry mouth, hypotension, constipation, -serious side effects: suicidal thoughts, arrhythmias, torsade de pointes -cardiotoxic with overdose -many drug to drug interactions make it less desirable

notriptyline

-TCA -indications: various forms of depression, neurogenic pain -mechanism of action: potentiates the effect of serotonin and norepinephrine; has significant anticholinergic properties -common side effects: drowsiness, fatigue, lethargy, blurred vision, dry eyes, dry mouth, hypotension, constipation -serious side effects: suicidal thoughts, arrhythmias -cardiotoxic with overdose -many drug to drug interactions make it less desirable

other risks factors suicide

-adolescents who have panic attacks -auditory hallucinations, consider command auditory hallcuination -suicide completion of a first degree relative -early childhood verse experiences lead to genetic changes -hopelessness, substance abuse -quick access to a means, recent purchase of a handgun -LGBTQI+, gay men (40-55%) compared to (18-30%) in heterosexual men -young african american/black men -completed sucides highest for whites 40-64% -previous attempts

why do people stop taking SSRIs?

-affective flattening -weight gain -sexual disfunction

TCAs examples

-amitriptyline -nortriptyline

children under 10

-average of 33 die per year between 5 and 11 -direct inquiry about suicide ideas is a necessary component in healthcare encounters with children

what are things that should be considered and or removed in the environment?

-belts -sharps -straps -shoelaces -ace wraps -canes -ties -glass -alcohol -supervise meds -perform room searches

prolonged response to grief

-characterized by an intense preoccupation with memories of the lost entity for many years after the loss has occurred behaviors associated with the stages of denial or anger are manifested and disorganization of functioning and intense emotional pain related to the lost entity are evidenced

s/s serotonin syndrome

-confusion, restlessness -pupil dilation -rapid heartbeat -HA -diarrhea -agitated emotional state -muscle coordination difficulties -nausea -body temp fluctuations -BP fluctuations -shivering or tremors -vomiting -muscle spasms -abnormal sweating -hallucinations

patient education medications

-do not stop antidepressant abruptly, discuss with provider to reduce withdrawal -therapeutic effect may take weeks to achieve (4-6): encourage patients not to stop if it "doesn't seem to be working" -avoid drinking alcohol, the medication potentiates the effects of one another -never double up on doses -tell your doctor about new medications, OTC such as st john's wort can increase serotonin -increased risk of bleeding with NSAIDs -troubleshoot if there are compliance issues -don't stop taking because you feel better -BLACK BOX WARNING: SUICIDE IDEATION

electroconvulsive therapy (ECT)

-electrodes place bilateral/unilateral, induces grand mal seizures -right unilateral ECT has fewer cognitive side effects -used in treatment of mania, depression, schizoaffective disorder who do not respond to other treatments -possible contraindicated: increase in ICP, cardiac history (MI, CVA) -most clients average 6-12 treatments, but may require up to 20 -seizures threshold determines electrical stimulus supplied -seizure should last between 15-25 seconds -movements are minimal due to muscle relaxants being administered prior to treatment -temporary vs permanent memory loss, memory gaps can date back years is the most common side effect; assess for headaches!

distorted response to grief

-fixed in the anger stage of grieving -all the normal behaviors associated with grieving, such as helplessness, hopelessness, sadness, anger, and guilt are exaggerated out of proportion to the situation -individual turns anger inward on the self, is consumed with overwhelming despair, and is unable to function in normal activities of daily living -pathological depression

areas of the brain affected with depression

-frontal cortex: depressed mood, problems concentrating -amygdala: anhedonia, reduces motivation, anxiety -hippocampus: feeling worthless, memory impairment, guilt -ventricle enlargement: brain is shrinking

predisposing factors of major depressive disorder

-genetics -biochemical influences -psychosocial experiences

cognitive behavioral therapy (CBT)

-goal: create change in thinking and belief system to create emotional and behavioral change -situation → automatic thought → emotional response -nursing interventions: problem solve, guide thinking and reframing -value: cost effective, short term, evidence based

treatment for therapy

-group, individual, and family talk therapies -cognitive behavioral therapy -pharmacological treatment -transcranial magnetic stimulation (TMS) -electroconvulsive therapy -light therapy -many other modalities and approaches exist

CNS areas affected by ECT

-hormones, neuropeptides, neurotropic factors, and nearly every neurotransmitter -serotonin, norepinephrine, and dopamine possible increased GABA/endogenous opioids -possibly neurorestorative

RN assessment suicide

-identify and distinguish ideas (thoughts), plans (intentions), and attempts (behavior) as there are levels to the risk -it is important to ask directly and differentiate between killing and self harm -demographics, presenting symptoms, medical-psychiatric diagnoses, suicidal ideas or acts, support system, family history, coping strategies -it can help normalize the suicidal thoughts and communicate that the client is not the only one who experiences suicidal ideation -screen for suicide risk, should be conducted as an essential component of health assessment -establish a therapeutic relationship -collaborate with the patient and others for information and confidence in clinical judgements -suicide risk assessments are done with DIRECT rather than indirect language/questions -consider cultural context -suicide risk and intervention documented in detail

factors placing individuals at risk

-impulsive, high risk behaviors -untreated mood disorders -access to lethal means -substance abuse

aripriprazole (Abilify)

-indications: adjunctive treatment of depression in adults (used with antidepressant) -mechanism of action: psychotropic activity may be due to agonist activity in dopamine D2 and serotonin 5-HT receptors and antagonist activity at the 5HT receptor; also has adrenergic blocking activity -common side effects: drowsiness, extrapyramidal reactions, constipation, tremor, sedation, weight gain, orthostasis, blurred vision, dry mouth -serious side effects: suicidal thoughts, agranulocytosis, hypersensitivity reactions, neuroleptic malignant syndrome

delayed or inhibited response to grief

-individual becomes fixed in the denial stage of the grieving process -emotional pain associated with the loss is not experienced but anxiety disorders or sleeping and eating disorders may be evident -may remain in denial for many years until grief response is triggered by a reminder of the loss or even by an unrelated loss

types of depressive disorders

-major depressive disorder (MDD) -persistent depressive disorder

normal grieving

-majority of people experience this -normal, dynamic process that occurs in response to any type of loss -highly individualized, depending on person's perception of the loss and influenced by context and concurrent stressors -physical, emotional, cognitive, spiritual, and behavioral reactions

nurses role ECT

-make sure informed consent has been signed -support before, during, and after -NPO status, ECT usually done in the AM -EKG prior to treatments done in the AM -no anticonvulsants prior

persistent depressive disorder (dysthymia)

-milder than MDD, chronic depressed mood (irritated in children/adolescents) -for most of the day, more days than not for at least 2 years (1 year for children and adolescents)

90% of people who kill themselves have a diagnosable mental illness

-most common: substance abuse disorder or mood disorder -individuals who have been hospitalized for psychiatric illness have a 5-10x greater risk than those with psychiatric illness in the general population -periods following discharge from a psychiatric facility high risk -bathroom on inpatient unit most dangerous place

educating patient and family

-nature of the illness -management of the illness (treatment options) -supportive services (NAMI includes support for family members)

maladaptive grieving

-occur when an individual is not able to satisfactorily progress through the stages of grieving to achieve resolution -usually occur when an individual becomes fixed in the denial or anger stage of the grief process

myths about suicide

-people who talk about suicide won't act on it -once suicidal, a person is suicidal forever -suicidal thoughts and actions are manipulations -young children can't be suicidal

protective factors for suicide

-pets, especially when they care for them -caring for others -religion -acceptance of LCBTQ status -access to social services -future oriented -hope -connected to provider/therapist -resilient temperament -alarmingly school aged children younger than 12 found suicide rates for black children 5-11 nearly doubled between 1993 and 2012

MAOIs examples

-phenelzine

safety

-safety planning takes collaboration -no contracts -keep home environment safe (remove pills/firearms) -recognizing warning signs/triggers/coping -how to cope with suicidal thoughts, how to recognize when they change -identifying friends/family/community resources for help (24 hours) -emergency room, call 911

SSRIs

-selective serotonin reuptake inhibitors -often first line treatment for depression and anxiety disorders -used with depression and anxiety -believed to increase serotonin at the extracellular level by limiting the reabsorption back into the postsynaptic receptor -increases serotonin the synaptic cleft -careful titration when moving from one SSRI to another to reduce serotonin syndrome -discontinuation syndrome can occur -SE: insomnia, agitation, headache, sexual dysfunction, dry mouth, nausea

SSRIs examples

-sertraline -paroxetine -fluoxetine -citalopram

more risk factors suicide

-severity of suicide attempts/rehearsals -chronic pain and illness -severe insomnia -family history of suicide, especially in same gender parent -history of violent behavior -shame and humiliation -unemployment or recent financial concerns -divorced, separated or widowed -social isolation -prior abuse/trauma -chronic mental illness -substance use

transcranial magnetic stimulation (TMS)

-short pulses of magnetic energy to stimulate nerve cells but do not result in seizure activity, stimulates nerve cells -a magnetic field generator, or "coil" is placed near the head -providers vary on this treatment from promising to skeptical -40 minute sessions, 2-3 times a week -treatment resistant patients

risk factors for suicide

-single never married -divorced men -more women than men attempt suicide (30% successful) -more men complete suicide (70%) successful -women are more likely to seek help from friends or professionals

SIG E CAPS

-sleep changes, could be increased (hypersomnia) or decreased (insomnia) -interested decreased in activities (anhedonia) -guilt or worthlessness -energy decreased -concentration difficulties -appetite changes, increase or decrease -psychomotor retardation/agitation -suicidal thoughts

medications that can alone or in combination produce a depressive syndrome

-steroids -hormones -sedatives -antibacterial and antifungals -antineoplastics -analgesics -antiulcer

MAOIs and tricyclics

-still around, less common -MAOIs have dietary instructions

family and friends of the suicidal client

-take hints of suicide seriously -do not keep secrets -be a good listener -restrict access to firearms or other self harm means: change combination to guns are, separate ammunition -communicate caring -familiarize yourself with suicide interventions -try to challenge judgement -consider dependents safety

RN interventions

-therapeutic communication -safe environment: people die in inpatient, hanging most common -close observation, Q15 checks, rounds done at irregular intervals, 1:1 if needed -double room, near the nurses station -care in administering meds, check mouth! -encourage honest feelings, including anger -collaborate with client to develop a safety plan -assess verbal and nonverbal communication

warning signs of suicide

-threatened to harm or end one's life -seeking access to means -evidence of a suicide plan -rage, anger, self revenge -acting reckless, risky -anxiety, agitation -abnormal sleep -dramatic changes in mood -express no reason for living -hopelessness -giving things away -sudden mood lifting -getting financial affairs in order -substance use

serotonin syndrome

-too much serotonin causes symptoms that can range from mild to sever -sever serotonin syndrome can be fatal if not treated -can occur with tramadol, st johns wort, and others -unaccustomed amounts of serotonin overexcite the brain's neurons and provoke unsustainable spikes in neuron activity -onset abrupt!

hamilton depression rating scale (HRDS)

-track baseline and changes through treatment -see how the questions in the HRDS relate back to the DSM 5

SNRI, NDRI

-uses are similar to SSRIs

SNRIs examples

-venlafaxine -duloxetine (also approved for the treatment of pain)

lethality matters

-women tend to overdose on medications/drugs -men tend to use firearms

persistent depressive disorder (dysthymia) DSM 5 criteria

A. depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others for at least 2 years B. presence, while depressed, of two or more of the following: 1. poor appetite or overating 2. insomnia or hypersomnia 3. low energy or fatigue 4. low self esteem 5. poor concentration or difficulty making decisions 6. feelings of hopelessness C. during the 2 year period of the disturbance, the individual has never been without the symptoms in criteria A and B for more than 2 months at a time D. criteria for major depressive disorder may be continuously present for two years E. there has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder F. the disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder G. the symptoms are not attributable to the physiological effects of a substance H. the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

premenstrual dysphoric disorder

depressed mood, excessive anxiety, mood swings, decreased interest in activities during the week prior to menses, then improving after the onset of menstruation

discontinuation syndrome

dizzy, headache, lethargy, withdrawal symptoms improve when tapered slowly

a client has just been admitted to the psychiatric unit with a diagnosis of major depressive disorder. which of the following behavioral manifestations might the nurse expect to assess? (select all that apply) a. slumped posture b. delusional thinking c. feelings of despair d. feels best early in the morning and worse as the day progresses e. anorexia

a, b, c, e

severe serotonin syndrome

muscle rigidity, fever, seizures

transactional model

no single theory or hypothesis provides a clear cut explanation, there are multiple casualties

ketamine

now FDA approved in nasal spray version; previously given IV in specialized clinics as an off label treatment

secondary depression can

occur in response to other psychological disorders

mild serotonin syndrome

shivering and diarrhea

depressive disorder due to another medical condition

substance/medication induced depressive disorder, many medications that can produce a depressive syndrome

adjunct examples

aripiprazole

An acutely depressed client isolates herself in her room and just sits and stares into space. Which of these is the best example of an active communication approach with this client? A. "Do you like exercise?" B. "Come with me. I will go with you to group therapy." C. "Would you like to go to group therapy, stay in bed, or come out to the day lounge for some activities?" D. "Why do you stay in your room all the time?"

b

In determining degree of suicidal risk with a client, the nurse assesses the following behavioral manifestations: severely depressed, withdrawn, statements of worthlessness, difficulty accomplishing activities of daily living, no close support systems. The nurse identifies the client's risk for suicide as which of the following? a. Low risk b. High risk c. Imminent risk d. Unable to be determined

b

Success of long-term psychotherapy with Theresa (Who attempted suicide following a break up with her boyfriend) could be measured by which of the following behaviors? A. Theresa has a new boyfriend B. Theresa has an increased sense of self-worth C. Theresa does not take antidepressants anymore D. Theresa told her old boyfriend how angry she was with him for breaking up with her

b

a patient has been ordered ECT and asks the nurse "exactly how does ECT work?" which of the following is the most accurate response by the nurse? a. i'm not allowed to tell you that because that would be informed consent? b. the exact mechanism is unknown, but there are several ways that ECT may have antidepressant effects c. the administration of a shock to the brain induces memory loss, which will make you forget you are depressed d. the neuroplasticity affected by seizure activity prevents further brain damage

b

atropine sulfate is administered to a client receiving ECT for what purpose? a. to alleviate anxiety b. to decrease secretions c. to relax muscles d. as a short acting anesthetic

b

the physician orders sertraline (zoloft) 50mg PO bid for margaret, a 68 year old women with major depressive disorder. after three days of taking the medication, margaret says to the nurse, "I don't think this medicine is doing any good. I don't feel a bit better." what is the most appropriate response by the nurse? a. cheer up margaret. you have so much to be happy about b. sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms c. i'll report that to the physician, margaret. maybe he will order something different d. try not to dwell on your symptoms, margaret. why don't you join the others down in the dayroom?

b

which of the following best describes the average number of ECT treatments given and the timing of administration? a. one treatment per moon for 6-12 months b. one treatment every other day, three times a week for a total of 6-12 treatments c. one treatment three times per week for 6-12 months d. one treatment every day for a total of 10-20 treatments

b

Theresa, who has been hospitalized following a suicide attempt, is placed on suicide precautions on the psychiatric unit. She admits that she is still feeling suicidal. Which of the following interventions is the most appropriate in this instance? (select all that apply) A. Obtain an order from the physician to place Theresa in restraints to prevent any attempts to harm herself. B. Check on Theresa every 15 minutes or assign a staff person to stay with her on a one-to-one basis. C. Obtain an order from the physician to give Theresa a sedative to calm her and reduce suicide ideas. D. Do not allow Theresa to participate in any unit activities while she is on suicide precautions.

b e

Theresa is hospitalized following a suicide attempt after breaking up with her boyfriend. Theresa says to the nurse, "When I get out of here, I'm going to try this again, and next time I'll choose a no-fail method." Which is the best response by the nurse? A. You are safe here. We will make sure nothing happens to you. B. You're just lucky your roommate came home when she did. C. What exactly do you plan to do? D. I don't understand. You have so much to live for.

c

Theresa, age 27, was admitted to the psychiatric unit from the medical intensive care unit where she was treated for taking a deliberate overdose of her antidepressant medication, trazodone (Desyrel). She says to the nurse, "My boyfriend broke up with me. We had been together for 6 years. I love him so much. I know I'll never get over him." Which is the best response by the nurse? a. "You'll get over him in time, Theresa." b. "Forget him. There are other fish in the sea." c. "You must be feeling very sad about your loss." d. "Why do you think he broke up with you, Theresa?"

c

electroconvulsive therapy is most commonly prescribed for which of the following? a. bipolar disorder, manic b. paranoid schizophrenia c. major depression d. obsessive compulsive disorder

c

sam, who has been hospitalized for ECT treatments says to the nurse on admission, "I don't want to end up like mcmurphy in one flew over the cuckoo's nest! i'm scared!" which of the following statements would be most appropriate by the nurse in response to sam's expression of concern a. I guarantee you won't end up like mcmurphy, sam b. the doctor knowns what he is doing. there's nothing to worry about c. I nknow you are scared sam, and we're going to talk about what you can expect from the therapy d. i'm going to stay with you as long s you are scared

c

succinylcholine is administered to a client receiving ECT for what purpose? a. to alleviate anxiety b. to decrease secretions c. to relax muscles d. as a short-acting anesthetic

c

Education for the client who is taking MAOIs should include which of the following? a. Fluid and sodium replacement when appropriate, frequent drug blood levels, signs and symptoms of toxicity. b. Lifetime of continuous use, possible tardive dyskinesia, advantages of an injection every 2 to 4 weeks. c. Short-term use, possible tolerance to beneficial effects, careful tapering of the drug at end of treatment. d. Tyramine-restricted diet, prohibitive concurrent use of over the counter medications without physician notification.

d

Theresa is hospitalized following a suicide attempt after breaking up with her boyfriend. Freudian psychoanalytic theory would explain theresa's suicide attempt in which of the following ways? a. she feels hopeless about her future without her boyfriend b. without her boyfriend, she feels like an outsider with her peers c. she is feeling intense guilt because her boyfriend broke up with her d. she is angry at her boyfriend for breaking up with her and has turned the anger inward on herself

d

the most common side effects of ECT are: a. permanent memory loss and brain damage b. fractured and dislocated bones c. myocardial infarction and cardiac arrest d. temporary memory loss and confusion

d

what is the priority nursing intervention before starting ECT therapy? a. take vital signs and record b. have the patient void c. administer succinylcholine d. ensure that the consent form has been signed

d

major depressive disorder dsm 5 criteria

A. five (or more) of the following symptoms have been present during the same 2 week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure 1. depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others 2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day 3. significant weight loss when not dieting or weight gain 4. insomnia or hypersomnia nearly every day 5. psychomotor agitation or retardation nearly every day 6. fatigue or loss of energy nearly every day 7. feelings of worthlessness or excessive or inappropriate guilt 8. diminished ability to think or concentrate, or indecisiveness nearly every day 9. recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. the symptom cause clinically significant distress or impairment in social, occupational, or other important areas of functioning C. the episode is not attributable to the physiological effects of a substance or to another medical condition D. the occurrence is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders E. there has never been a manic episode or a hypomanic episode

premenstrual dysphoric disorder DSM 5 criteria

A. in the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses B. one or more of the following symptoms must be present: 1. marked affective lability 2. marked irritability or anger or increased interpersonal conflicts 3. marked depressed mood, feelings of hopelessness, or self-deprecating thoughts 4. marked anxiety's tension, feelings of being keyed up or on edge C. one or more of the following symptoms must additionally be present, to reach a total of five symptoms when combined with the symptoms from criterion B 1. decreased interest in usual activities 2. subjective difficulty in concentration 3. lethargy, easy fatigabilitiy, or marked lack of energy 4. marked change in appetite; overeating; or specific food cravings 5. hypersomnie or insomnia 6. a sense of being overwhelmed or out of control 7. physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating," weight gain D. the symptoms are associated with clinically significant distress or interferences with work, school, usual social activities, or relationships with others E. the disturbance is not merely an exacerbation of the symptoms of another disorder such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder F. criteria A should be confirmed by prospective daily ratings during at least two symptomatic cycles G. the symptoms are not attributable to the physiological effects of a substance or another medical condition

CSSRS

Columbia Suicide Severity Rating Scale

The goal for cognitive therapy with depressed clients is to: a. identify and change dysfunctional patterns of thinking b. resolve the symptoms and initiate or restore adaptive family functioning c. alter NTs that are creating a depressed mood d. provide feedback from peers who are having similar experiences

a

a client with depression asks the nurse, "why would they be checking my thyroid function when I clearly have depression and i'm not overweight?" which of these is an accurate response? a. an underachieve thyroid gland can manifest as depression b. depression has been proven to be a hormonal illness c. thyroid hormone replacement is a first line treatment for most clients with depression d. all of the above

a

sam has a diagnosis of major depression. after an unsuccessful trial of antidepressant medication, sam's physician has hospitalized him for a course of ECT treatments. sam says to the nurse on administration, "I don't want to end up like mcmurphy in one flew over the cuckoo's nest! i'm scared!" what is sam's priority nursing diagnosis a this time a. anxiety related to deficient knowledge about ECT b. risk for injury related to risks associated with ECT c. deficient knowledge related to negative media presentation of ECT d. acute confusion related to side effects of ECT

a

the nurse identifies the primary nursing diagnosis for theresa as risk for suicide related to feelings of hopelessness from loss of relationship. which is the outcome criterion that would be most appropriate for this diagnosis? a. the client has experienced no physical harm to herself b. the client sets realistic goals for herself c. the client expresses some optimism and hope for the future d. the client has reached a stage of acceptance in the loss of the relationship with her boyfriend

a

which of the following individuals is at highest risk for a suicide attempt? a. john, who reports he is in deep emotional pain, feels hopeless, and says "no one is there for me" b. kelly, who has been seeing a doctor for chronic, intractable pain and is taking pain medication c. jim, an american indian who just graduated from high school with ohnors d. mike, a physician who reports feeling "burnt out" and is considering retirement

a

which of the following interventions are appropriate for a client on suicide precautions? (select all that apply) a. remove all sharp objects, belts, and other potentially dangerous articles from the client's environment b. accompany the client to off unit activities c. reassess intensity of suicidal thoughts and urges on a regular basis d. put all of the client's possessions in storage and explain to her that she may have them back when she is off suicide precautions

a b c

which of the following conditions increases risk of adverse events associated with ECT? (select all that apply) a. increased intracranial pressure b. recent myocardial infarction c. severe underlying hypertension d. congestive heart failure e. breast cancer

a b c d

Sally is admitted to the hospital with Major Depressive Disorder and repeatedly makes negative statements about herself. Which of the following interventions is identified as an approach that promotes positive self-esteem in the patient? Select all that apply. a. Teach assertive communication skills. b. Make observations to Sally when she completes a goal or task. c. Instruct Sally that you will not talk with her unless she stops talking negatively about herself. d. Offer to spend time with Sally using a nonjudgmental, accepting approach.

a b d

a client expresses interest in alternative treatments for depression with seasonal variations and asks the nurse about light therapy. which of the following are evidence-based teaching points that the nurse may share with the client? (select all that apply) a. light therapy has demonstrated effectiveness that is comparable to antidepressants b. light therapy should be used regularly until the season changes c. light therapy should be used only when ECT has proven to be ineffective d. side effects such as headache, nausea, or agitation, when they occur, are usually mild and transient e. light therapy causes sedation, so the best time to use it is before bed

a b d

the nurse in the emergency department encounters a patient, niko, who is expressing suicide ideation. the nurse recognizes that which of the following considerations are important to good suicide risk assessment? (select all that apply) a. collaborating with the patient b. asking specific questions about leisure activities c. establishing trust and open communication with the patient d. asking the patient specific questions about the strength of his intention to die e. identifying whether the patient has thought about a plan for trying to kill himself

a c d e

foods to avoid MAOIs

aged cheese, raisins, beans, red wines, liqueurs, smoked and processed meats, caviar, pickled foods, soy sauce

NDRIs examples

bupropion

A client whose husband died 6 months ago is diagnosed with major depressive disorder. She says to the nurse, "I start feeling angry that Harold died and left me all alone; he should have stopped smoking years ago! But then I start feeling guilty for feeling that way." What is an appropriate response by the nurse? a) "Yes, he should have stopped smoking. Then he probably wouldn't have gotten lung cancer." b) "I can understand how you must feel." c) "Those feelings are a normal part of the grief response." d) "Just think about the good times that you had while he was alive."

c

Margaret, age 68, is a widow of 6 months. Since her husband died, her sister reports that Margaret has become socially withdrawn, has lost weight, and does little more each day than visit the cemetery where her husband was buried. She told her sister today that she "didn't have anything more to live for." She has been hospitalized with Major Depressive Disorder. The priority nursing diagnosis for Margaret would be: a. imbalanced nutrition; less than body requirements b. complicated grieving c. risk for suicide d. social isolation

c