MOOD DISORDERS DEPRESSION

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MOOD DISORDERSDEPRESSION
Mercedes A. Perez-Millan, ARNP, MSN
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LEVELS OF DEPRESSION

• COMMON FEELING
• BEREAVEMENT AND GRIEF
• DYSTHYMIA
• MAJOR DEPRESSION
• SECONDARY TO A MEDICAL CONDITION
• ACCOMPANING OTHER PSYCH ILLNESS

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RELEVANT STATISTICS

• Lifetime prevalence for Major Depression is up to
  12 for men and 25 women
• Adolescents 14 to 16 years of age 4 - 7
  incidence
• Elderly individuals 65 years of age and older
  have 10 to 15 incidence of Major Depression and
  30 of Dysthymia

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DEPRESSIVE DISORDERS PREDISPOSING FACTORS

• BIOLOGIC THEORIES
• 1. Genetics
• 2. Biochemical
• 3. Neuroendocrine
• 4. Physiologic influences

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DEPRESSIVE DISORDERS PREDISPOSING FACTORS

• PSYCHOSOCIAL THEORIES
• 1. Psychoanalytic
• 2. Learning
• 3. Object loss
• 4. Cognitive

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DEPRESSIVE DISORDERS PREDISPOSING FACTORS

• DEVELOPMENTAL INFLUENCES
• Childhood
• Adolescent
• Postpartum depression
• Senescence

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THE GRIEF RESPONSE

• Normal adaptive response to a loss of a valued
  object or situation.
• Change or failure may be perceived as a loss.
• Consists of a set of predictable behaviors
  towards resolution.
• Resolution is complete when the individual is
  able to comfortably remember both pleasures and
  disappointments with what has been lost.

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STAGES OF GRIEF

• ELIZABETH KUBLER-ROSS
• Denial
• Anger
• Bargaining
• Depression
• Acceptance

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MALADAPTIVE RESPONSES TO GRIEF

• Delayed or inhibited grief
• Exaggerated grief
• Prolonged
• Normal Versus Maladaptive
• (Intact self-esteem versus feelings of guilt
  worthlessness)

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TYPES OF MOOD DISORDERSDSM-IV-TR

• Major depression
• Single or recurrent
• With psychotic features
• With melancholic features
• Chronic
• With post-partum onset
• Dysthymia
• early or late onset

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NURSING DIAGNOSIS

• Risk of suicide related to depressed mood
• Low self esteem related to learned helplessness.
  
• Disturbed thought process related to withdrawal
• Powerlessness related to dysfunctional grieving
• Dysfunctional grieving related to real or
  perceived loss
• For complete listings see textbook!!!!

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NURSING INTERVENTION FOR THE DEPRESSED CLIENT

• Safety!!! Prevent suicide!
• Assist through grief process
• Increase self-esteem
• Increase reality testing
• Decrease anxiety
• Confronting anger
• Teaching coping mechanisms
• Ensuring all basic needs are met
• Approach Caring, supportive, and firm

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SUICIDEPsychological Theories

• Anger Turned Inward
• Hopelessness
• Desperation and Guilt
• History of Aggression and Violence
• Shame and Humiliation
• Developmental Stressors

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THEORIES OF SUICIDE

• SOCIOLOGICAL
• BIOLOGICAL
• GENETICS
• NEUROCHEMICAL

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SUICIDEDEMOGRAPHICS

• AGE- Adolescents and males older than 50
• GENDER- Males
• ETHNICITY- 1 Caucasians, 2 Native Americans,
• 3 African Americans
• MARITAL STATUS- Single, Divorced, Widow
• SOCIOECONOMIC STATUS- High Low classes
• OCCUPATION- Healthcare professionals, Business
  exe.
• METHOD- Firearms
• RELIGION- Protestants highest
• FAMILY HISTORY- Highest with family History

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ASSESSING SUICIDAL POTENTIAL

• Admits to suicide thoughts? Clues?
• Has a plan? Means?
• Support systems
• Past or family history of suicide?
• Coping strategies?
• Alcohol or drug abuse
• Anxiety, agitation
• Depression, hopelessness, isolation, withdrawal

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NURSING INTERVENTION OF SUICIDAL PATIENT

• One to One, Nurse-client relationship
• Stay with the person
• No suicide contract
• Non- judgmental, accepting attitude
• Listen and be attentive
• Encourage to verbalize, provide hope
• Safety in the environment
• Assist in meeting basic needs
• Provide activity

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CRITICAL SITUATION
A 25 y.o. female is brought to the E.R. by
police after she was found walking in the
center line of the express-way during rush hour.
She is crying, hyperventilating and asking to be
allowed to die. 1) What could be the possible
problems? 2) What should you assess? 3) What
should you do about it?
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TREATMENT MODALITIES

• PSYCHOLOGICAL TREATMENTS
• Individual psychotherapy
• Group therapy
• Family therapy
• Cognitive therapy
• ORGANIC TREATMENTS
• ECT
• Psychopharmacology
• Alternative or Complementary therapy

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PSYCHOPHARMACOLOGYANTIDEPRESSANTS

• TRICYCLIC (TCAS)
• MONOAMINE OXIDASE INHIBITORS (MAOIS)
• SELECTED SEROTONIN REUPTAKE INHIBITORS (SSRIS)
  (first-line of Rx)
• ATYPICAL

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SSRIS

• GRATER SAFETY PROFILE
• IN ADDITION TO DEPRESSION, THEY ARE USED
  SUCCESSFULLY IN
• ANXIETY DISORDERS
• PD, OCD, GAD, PTSD SAD
• PMDD
• BULIMIA
• SLEEPING DISORDERS
• ALCOHOLISM
• SCHIZOPHRENIA

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SSRIS

• PROZAC (fluoxetine)
• CELEXA (citalopram)
• LUVOX (fluvoxamine)
• PAXIL (paroxetine)
• ZOLOFT (sertraline)
• LEXAPRO (escitalopram)

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SSRIS

• Block the reuptake of serotonin
• (5-HT), allowing serotonin to act
• for an extended period of time at
• the synaptic binding sites.
• Less ability to block the muscarinic and H1
  receptors resulting in decreased
  anti-cholinergic and sedating side effects which
  limits client compliance.

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SSRIS SIDE EFFECTS

• Agitation
• Anxiety
• Sleep disturbance
• Tremor
• Sexual dysfunction
• Tension headache
• Initial autonomic reactions
• Rare toxic effect Serotonin Syndrome

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SSRIS CLIENT TEACHING

• May cause anxiety, insomnia, agitation, sexual
  dysfunction
• Do not discontinue medication abruptly
• Medication interaction 14-Day clearance from
  MAOIs 4 weeks after Prozac
• Many interactions, check with health care
  professionals before taking any drugs or OTC
• Common side effects
• Check Liver/Renal/Blood count periodically

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ANTIDEPRESSANTS NOVEL (ATYPICAL)

• Differ from the SSRIs and TCAs in that these
  drugs and their metabolites can act directly on
  the 5-HT postsynaptic receptors for serotonin.
  Norepineprine and dopamine may also be involved.
• The drugs can antagonize receptors
• Their metabolites act as receptor agonists
• Resulting in an increase in concentration of
  neurotransmitters at the synapse

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ANTIDEPRESSANTS NOVEL (ATYPICAL)

• Wellbutrin, Zyban (buproprion)
• Remeron (mertazapine)
• Ludiomil (maproptiline)
• Desyrel (trazodone)
• Serzone (nefazodone)
• Effexor (venlafaxine)
• Cymbalta (duloxetine)

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ANTIDEPRESSANTS NOVEL (ATYPICAL)SIDE EFFECTS/
CONTRAINDICATIONS

• Wellbutrin (Bupropion) (Zyban) seizures,
  insomnia
• watch for other names of same medication
• Serzone (Nefazodone) Hypotension, sedation,
• cardiotoxic effects with allergy meds,
  such as Seldane and Hismanal
• Desyrel (Trazadone) Priapism risk, sedation
• risk of digitalis toxicity with digoxin
• Effexor (Venlafaxine) Hypertension
• Remeron (Mirtazapine) Anticholinergic ,sedation

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ANTIDEPRESSANTS NOVEL (ATYPICAL) CLIENT TEACHING

• Teach individual drug interactions and side
  effects for each drug and report to health care
  provider
• Do not perform activities requiring alertness
  until drug effects realized
• Perception of taste and appetite may change,
  weigh weekly and report changes
• May take up to 3 weeks to work
• Do not discontinue abruptly
• Get up slowly
• Do not drink alcohol or other CNS depressants
• Report any mood changes or suicidal ideations

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TRICYCLICS (TCAS)
First antidepressants developed Work by blocking
the reuptake and destruction of norepinephrine
and/or serotonin thus increasing the level of
these neurotransmitters at the synapses
Muscarinic receptors are also blocked resulting
in anticholinergic side effects TCAs are not
used as first line treatment
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TRICYCLICS (TCAS)

• Level of norepinephrine and/or serotonin
  in the synapses by inhibiting their reuptake.
• Up to 80 effective in the treatment of symptoms
  of non-psychotic depressions including depressed
  mood, loss of interest in activities or pleasure,
  altered sleep patterns, somatic complaints, and
  anxiety.

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TRICYCLICS (TCAS)

• ELAVIL (amitriptyline)
• ASENDIN (amoxapine)
• NORPRAMIN (desipramine)
• SINEQUAN (doxapin)
• TOFRANIL (imipramine)
• ANAFRANIL (clomipramine)
• PAMELOR (nortriptyline)
• VIVACTIL (protriptyline)

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TRICYCLICS (TCAS)

• Full effect may take 4 to 6 weeks.
• Used with caution in the elderly.
• Contraindicated with CV disease, glaucoma, BPH,
  liver and renal diseases.
• Many interactions when combined with other drugs.
  ( additive anticholinergic, serotonergic,
  sympathomimetic, hypotensive, and increased
  bleeding with Coumadin)
• Overdose can be lethal.

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TRICYCLICS (TCAS) SIDE EFFECTS

• ANTICHOLINERGIC
• DRY MOUTH, BLURRED VISION, URINARY RETENTION,
  CONSTIPATION
• TACHYCARDIA
• OTHER
• HYPERTENSION, ARRYTHMIAS
• PHOTOSENSITIVITY, ANOREXIA, NAUSEA
• SEXUAL DYSFUCNTION, FATIGUE, SEDATION, SEROTONIN
  SYNDROME
• SEIZURES, OVERDOSE

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TRICYCLICS (TCAS) DRUG INTERACTIONS

• Cannot be used with
• Alcohol
• MAOIs
• Barbiturates
• Disulfiram
• Oral contraceptives
• Anticoagulants

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TRICYCLICS (TCAS) CLIENT TEACHING

• May take 4-6 weeks for full effect
• Try to take at h.s.
• Initial side effects such as drowsiness,
  dizziness and hypotension usually subside after
  the first few weeks
• Do not stop taking abruptly.

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Monoamineoxidade Inhibitors (MAOIS)

• Medication blocks monoamineoxydase (an enzyme-
  MAO ) from destroying neurotransmitters
  therefore increasing their availability at the
  synapses. It also blocks the metabolism of
  Tyramine resulting in a danger for
  hypertensive crisis.
• Best for depression associated with acute anxiety
  attacks, phobic attacks, or many physical
  complaints.

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Monoamineoxidade Inhibitors (MAOIS)

• MARPLAN
• NARDIL
• PARNATE

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Monoamineoxidade Inhibitors (MAOIS) CLIENT
TEACHING

• May take 4-6 weeks to reach therapeutic level
• Report any hypertensive episodes
• Diet restrictions and Medication interactions
• Should be discontinued 2 weeks before surgery
• Danger!! Failure to follow diet/med restrictions
  may result in hypertensive crisis.

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ELECTROCONVULSIVETHERAPY (ECT)

• ECT- used primarily for severely psychotic
  depressed patients
• 90 remission rate
• Side effects Short term memory loss. Confusion
  and disorientation may be present upon awakening
  after the treatment.
• Medications used Robinul, Diprivan, Anectine

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NURSES ROLE IN ECT

• PRE-ECT TEACHING
• MONITOR VITAL SIGNS DURING TREATMENT
• ORIENTATE PATIENT UPON AWAKENING

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ALTERNATIVE OR COMPLEMENTARY THERAPY

• St Johns Wort- Used in the treatment of mild to
  moderate depression. May block the reuptake of
  serotonin/ norepinephrine and have mild MAOI
  inhibiting effect.
• Exercise/ activity
• Light therapy