Chapter 14: Depressive Disorders
Major Depressive Disorder s/s Criteria
Five (or more) of the following in 2-week period ➢ Weight loss and appetite changes ➢ Sleep disturbances ➢ Fatigue ➢ Worthlessness or guilt ➢ Loss of ability to concentrate ➢ Recurrent thoughts of death PLUS—at least one symptom is also either ➢ Depressed mood or ➢ Loss of interest or pleasure (anhedonia)
A patient with major depression walks and moves slowly. Which term should the nurse use to document this finding?
A. Psychomotor retardation
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 - Do not stop medications abruptly
Which question would be a priority when assessing for symptoms of major depression?
B. "You look really sad. Have you ever thought of harming yourself?"
Which assessment finding in a patient with major depression represents a vegetative sign?
B. Hypersomnia
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
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
D. Anhedonia
Epidemiology
Leading cause of disability in the United States ➢ Children and adolescents ➢ Older adults ➢ Comorbidity
Self assessment
patients may not respond to nursing interventions and may be resistant to change. If this occurs the nurse may experience feelings of frustration and annoyance • Feeling what the patient is feeling
Implementation Three phases
➢ Acute phase (6 to 12 weeks) - directed at reducing depressive symptoms and restoration of psychosocial and work function. Hospitalization may be required ➢ Continuation phase (4 to 9 months) - working to prevent relapse with meds/therapy ➢ Maintenance phase (1 year or more) - preventing further episodes of depression
Areas to assess
➢ Affect - poor posture, looks older than stated age, facial expression is sad ➢ Thought processes - judgment is poor, unable to problem solve or think clearly ➢ Mood - pt.'s subjective experience of emotions/feelings ➢ Feelings - guilt, helpless, hopeless, worthless ➢ Physical behavior - slow movement, decreased facial expressions, poor hygiene ➢ Communication - speaks slowly, decreased comprehension ➢ Religious beliefs and spirituality - how has this affected their faith
Assessment of Depression
➢ Assessment tools - depression scale ➢ Assessment of suicide potential - always assess for SI/HI. Approximately 15% of people with clinical depression commit suicide Key assessment findings ➢ Depressed mood and anhedonia (inability to feel pleasure) ➢ Anergia ( Lack of Energy) ➢ Anxiety ➢ Psychomotor agitation or retardation ➢ Vegetative signs ➢ Comorbidity: chronic pain
Exercise
➢ Biological, social, and psychological effects ➢ Increases serotonin availability ➢ Dampens HPA axis (thought to be overly active in depression)
Electroconvulsive Therapy: Risk Factors
➢ Cardiac related to the heart being stressed at the onset of the seizure and for 10 minutes after. ➢ Careful assessment and management in HTN, CHF, Arrhythmias and other cardiac conditions require monitoring. ➢ Brain tumors and Subdural Hematomas may increase the risk of using ECT.
Age considerations
➢ Children and adolescents - wide range of mood and behavior making it easy to overlook signs of depression. ➢ Older adults -easy to overlook in the older adult because they may complain of physical illness over emotional concerns.
Psychological factors
➢ Cognitive theory - a person's thoughts will result in emotions - a positive thought will result in positive outcomes, a negative thought will result in negative outcomes ➢ Learned helplessness - a person feels no control over the outcome of a situation
Nursing Process
➢ Counseling and communication - remember to give 100% to the patient that may be unable to speak during sessions ➢ Health teaching and health promotion -patient has control over their treatment based on personal goals and learning from information provided to them ➢ Promotion of self-care activities - patient needs to be taught to do ADL's regularly ➢ Teamwork and safety
Selective serotonin reuptake inhibitors (SSRIs)
➢ First-line therapy- for most depressions/ low side effects ➢ Indications -depression/ anxiety/ OCD/ panic attacks/bulimia ➢ Adverse reactions- sleep disturbances, anxiety, dry mouth, weight gain ➢ Potential toxic effects- serotonin syndrome - excessive serotonin in the body, usually an interaction with OTC's, illegal drugs, antibiotics EX: Celexa, Lexapro, Paxil, Prozac and Zoloft •
Recovery model
➢ Focus on patient's strengths ➢ Treatment goals mutually developed ➢ Based on patient's personal needs and values
Biological factors
➢ Genetic ➢ Biochemical - CNS neurotransmitters abnormalities may cause clinical depression • Stressful life events ➢ Alterations in hormonal regulation ➢ Inflammatory process ➢ Diathesis-stress model - depression results from interplay between biology and environment. Some are born with a predisposition toward depression and is triggered by experiencing a stressful life event.
Electroconvulsive Therapy Pre-Procedure
➢ Informed Consent is required prior to the procedure. ➢ Patient is given a general anesthetic to induce sleep and a muscle paralyzing agent to prevent muscle distress and fractures. ➢ Pre ECT workup includes: chest x-ray, ECG, UA, CBC and benzodiazepines should be stopped prior to the procedure. succinylcholine- muscle relaxant short term paralytic
Tricyclic antidepressants (TCAs)
➢ Neurotransmitter effects- inhibit reuptake of norepinephrine/serotonin increasing the amount of time norepinephrine/serotonin is available to the postsynaptic receptors, believed to cause mood elevation. ➢ Indications - taken 10-14 days before effects are seen and 4-8 weeks for full effect of medication ➢ Adverse effects- dry mouth, blurred vision ➢ Toxic effects- potential toxic effect is cardiovascular: dysrhythmias, tachycardia, MI and heart block. ➢ Adverse drug interactions - MAOI's, barbiturates, Antabuse, anticoagulants, benzos and alcohol. ➢ Contraindications- recent MI, narrow angle glaucoma, H/O seizures ➢ Patient and family teaching
Monoamine oxidase inhibitors (MAOIs) - Nardil and Marplan
➢ Neurotransmitter effects- mood elevation, thiamines are not activated ➢ Indications- effective for people with atypical depression ➢ Adverse/toxic effects- orthostatic hypertension, weight gain, vertigo ➢ Interactions • Drugs - alcohol, drugs, TCA's, OTC's, stimulants • Food- avocados, figs, bologna, cheese, beer, wine, chocolate ➢ Contraindications - HTN, CHF, liver disease ➢ Other Treatments for Depression
Planning Geared toward
➢ Patient's phase of depression ➢ Particular symptoms ➢ Patient's personal goals
Electroconvulsive Therapy Post Procedure
➢ Patients usually wake up 15 minutes after the procedure. ➢ The patient is often confused and disoriented for several hours. ➢ The patient may need to be reoriented frequently. ➢ May experience retrograde amnesia - the loss of memory of events leading to the treatment as well as the treatment itself.
Major Depressive Disorder
➢ 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
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
Electroconvulsive Therapy Duration and Plan
➢ The usual course of ECT treatments for patients with depression is 2-3 treatments per week for a total of 6-12 treatments. ➢ The doctor will determine the amount of treatments based on individual cases. ➢ Continued ECT and medication may help to prevent relapse rates.