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Mood Disorders: Depressive Disorders

Maureen Eisenstein, RN, MS

Definition

page 100 ATI

Dysregulation of Mood/Affect Disturbances in functioning: Physical


somatic symptoms, neurovegetative

Cognitive
negative, pessimistic, slowed

Emotional
worthlessness, hopelessness, no pleasure

Behavioral
agitation, retardation, suicide attempt

What Depression is NOT


A passing blue mood A sign of personal weakness A condition that can be willed or wished away
People with a depressive disorder cannot merely pull themselves together and get better Because of inaccurate beliefs/stigma many do not seek/ cont in treatment

DSM IV T-R Diagnoses


Major Depressive Disorder, Single 296.2 Major Depressive Disorder, Recurrent 296.3 Dysthymia 300.4 Depressive Disorder Not Otherwise Specified 311 Mood Disorder Due to General Medical Condition 293.83 Substance-Induced Mood Disorder

Etiology
Exact cause remains unknown Multifactorial
Neurobiologic Psychosocial Cognitive factors

Mood disorder
As stress response to illness As physiologic response to pathology As physiologic response to medication Exacerbates due to medical pathology of Rx

Medical disorder
May develop in client with mood disorder

Etiology
Neurobiologic Factors Altered neurotransmission: 5HT, NE, MAO, DA Depression: underactivity Mania: overactivity Kindling: sensitivity to future stress is created: new hardwiring of brain (plasticity) Neuroendocrine:
HPA overactive w/depression, higher cortisol levels (damages healthy tissues, see Sx) chronobiological-circadian rhythms disrupted

Genetic transmission: 3X more often 1st degree biological relatives

Psychosocial Factors
Psychoanalytic Theory (few support)
Related to loss Mania, defense against depression

Cognitive
related to negative processing of information

Life events and Stress


mediated by genetic risk factors

Learned Helplessness
related perceived lack of control over stressors; dependent personality

Personality
Depressive personality disorder (research diagnosis), temperament

Epidemiology
Who Tends to be Most Depressed? CDC 2011 persons 45-64 years of age women blacks, Hispanics, non-Hispanic persons of other races or multiple races persons with less than a high school education those previously married individuals unable to work or unemployed: lower socioeconomic
persons without health insurance coverage

Epidemiology Mood and Medical disorders


30-50% Alzheimers SA 40% comorbidity 1/3 of patients admitted to medical units
Ages 20+ Fewer than 1/3 accurately diagnosed/ treated

WHO: by 2020 2nd largest cause of the global health burden Onset: 20s-30s
Can begin at any age

Depression:
DSM criteria: Must have a total of 5 symptoms for at least 2 weeks One of the symptoms must be depressed mood or loss of interest (is a change from previous functioning)

Emotional Symptoms
Anhedonia Depressed mood
sad, empty, hopeless, numb

Irritability
anxiety, anger

Depression: Cognitive Symptoms


Diminished ability to think, concentrate, make decisions Self absorbed Preoccupation with death
SI

Excessive focus on worthlessness and guilt Negative thoughts


cognitive distortions

Sometimes delusional
Psychotic symptoms

Depression: Behavioral Symptoms


Neurovegetative S&Sx (physical) Weight
Loss or gain

Change in appetite Sleep:


Insomnia or hypersomnia

Psychomotor
Retardation or agitation

Fatigue
Loss of energy

Depression: Social Symptoms


Withdrawal from family and social interactions Work problems
Organizing, initiating, completing Can influence work relationships

DSM Additional Features


Episode specifiers are provided to increase diagnostic specificity: (296.2X, 296.3X) Mild, moderate or severe, partial/full remission Catatonia Melancholia Psychotic symptoms Postpartum onset-occurs w/in wks 1-4 post Postpartum psychosis Seasonal pattern specifiers (SAD)

Dysthymia
Chronic, low-level depression, most days at least 2 yrs (1 for C&A) and at least 2 or more following symptoms Poor appetite or overeating Insomnia or hypersomnia Low energy/fatigue Low self-esteem Negative thinking/guilt Poor concentration/decision making Hopelessness Irritability/anger Anhedonia/withdrawal

Mood Disorders Across the Life Span/Special Populations p 265-266


DEPRESSION IN CHILDREN Extraordinary pain & distress

ATI

not prepared to understand/deal with emotions and behaviors

Initiates major difficulties during development/social learning


influence rest of life span

Stress, concern for family Presentation vary from one childhood stage to another
Sick, irritable, sadness, crying, decreased interest, poor concentration, critical, sarcastic, poor grades, dropping out of activities, skip school, runaway, SA Suicidal ideation-adols (1in 12 experience past year): 3rd leading cause of death age 15-24 (firearm, suffocation, poisoning)

DEPRESSION IN ELDERLY
NOT normal part of aging (510% Usually present with physical symptoms High co-morbidity-stroke, DM, CA, Parkinsons Older men & barriers to carereluctant to discuss-weak Widely under recognized/treated-up to 75% saw PCP w/in month Suicide/rates-highest suicide rate WM 85+ y.o. Symptoms can result in lifethreatening situation within a short time Brief psychotherapy useful

DEPRESSION IN MEN
Men are less likely to admit to depression
healthcare providers less likely to suspect it

Nearly 4X as many men suicide Typically shows as being irritable, angry, and discouraged Often masked by:
SA Excessive working

PROGNOSIS/CLINICAL COURSE
Can improve within 9 months if no complications Up to 40% have symptoms after 1 year 50-85% experience a subsequent episode; Nearly 2/3 experience recurrence within ten years > 50% of those with dysthymia go on to MDD Approximately 15% commit suicide

With treatment prognosis favorable Can be well controlled with


Medications Psychotherapy Self-help strategies
Including exercise

Need for education, lifetime monitoring, maintenance treatment Lack of adherence, resistance of symptoms
may lead to some impairments in daily functioning for long periods of time

Assessment
Physiologic- see lab studies to r/o organic causes
Appetite Vital signs Hydration Sleep pattern changes Activity level Fatigue-energy level Constipation Weight loss Sex drive

Diagnostic Evaluation Assessment of Mood


mood, affect, temperament, emotion, emotional/affective reactivity, emotional regulation, range of affect

Rating Scales: Hamilton, Becks, Zung, Scale of 1-10

Nursing Process: NANDAs


Imbalanced nutrition: more/less than Disturbed sleep patterns Activity intolerance Sexual dysfunction Risk for self directed violation Hopelessness Anxiety Noncompliance/ nonadherence Ineffective therapeutic regimen management Self care deficit Social isolation Self esteem disturbance Spiritual distress

NOCs
Patient will not harm self-no gestures/plans
Approach staff if feeling suicidal

Meets basic needs


Will function at highest level of (independent) functioning possible Make decision, state positive & helpful coping strategies

Participates in experiences/interactions that increases socialization


Speak with others, initiate conversation, go to groups

NOCs
Participates in experiences/interactions that promote self esteem
Self care (bathing, grooming, eating, etc.)

Decreased anxiety
Identify stressors, coping strategies

Demonstrates knowledge/understanding about diagnosis, prognosis, treatment needs, triggers Follow up with community based care
Adherent/compliant with meds and treatment

Intervention:
Avoid Pitfalls
Failing to recognize the severity of patients symptoms
depth to which depression can reach

Equating depression with own normal blues/passing moods of sadness


Lack of empathy & insight

Stereotyping, rigid thinking, inexperience, unrealistic expectations, stigma, lack of understanding and empathy
Interferes with developing NPR/trust, adequate treatment

TWO GENERAL PRINCIPLES to Help Depressed Clients


1. It is impossible to make depressed people feel better by being cheerful
Overly cheerful attitude can make them feel worse, it belittles their feelings Adopt more neutral emotional attitude Maintain and communicate confidence that they will feel better-it takes time

1.

Working with depressed may lower your mood and make you feel down; it may cause you to feel angry, anxious while caring for them
Stay in touch with your feelings, use supervision/ support from peers Change patient population if need be

NICs
Prevent suicide/promote safety ()
ongoing risk assessment weeks 1-6 crisis plan encourage verbalizing of feelings, not ruminating calm reassuring

Promote self esteem


provide distraction from self-absorption begin doing NOW, not waiting until feels better counseling: problem solving, assertiveness, etc.

Promote self care activities


plan when has energy reduce choices, easier decision making simple concrete directions

Monitor I&O, food intake and weight Assist patient in verbalizing feelings
Make observations vs asking questions, give time to respond

Instill hope
clients who feel hopeless tend to be dependent encourage client responsibility assist dont do for

Enhancing socialization
brief frequent contacts, develop trust, over time socialize w/others

Help patient identify external sources of stress


assist in coping in more effective manner

Teach patient and SOs about disorder & Tx


Medication teaching/management

Identify the patients social support system


are relationships impaired?

TREATMENT MODALITIES: Psychotherapeutic Interventions


CBT (cognitive behavioral therapy): Helps people learn new ways of thinking and behaving enables patients to correct false self-beliefs (cognitive distortions) that can lead to negative moods and behaviors Interpersonal Therapy: Emphasis: social functioning & interpersonal relationships; (how are relationships effected by the disorder? Are they considered a stressor?) Understand and work through troubled personal relationships
Psychodynamic (Freud), analysis, early loss, work through repressed memories

Treatments: Complementary Therapies


Family Intervention: education family conflicts communication Group Intervention-(can include psychoeducation) Benefits: education, socialization-decrease isolation & hopelessness need to assess readiness for: can be overwhelming community meetings/activities, groups less structured/imposing, better tolerated

Psychopharmacologyantidepressants
SSRI/SSNRI,TCAs, MAOIs Selecting effective drug & dosage often a difficult process Lag time-initial effect
1-6 weeks page 186 ATI

Therapeutic Improvements
3-4+ weeks

Recommend continue Rx:


3-6 months 1 year prevent relapse

TCAs
Amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramin)

MAOIs-atypical/refractory depression
Marplan, Nardil, Parnate

SSRIs
fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro)

SSNRIs
venlafaxine (Effexor), desvenlafaxine (Pristiq-active metabollite) duloxetine (Cymbalta)

Others:
Antianxiety meds Antipsychotic meds Herbal-St. Johns Wart

Biological Treatments for Depression


ECT-electroconvulsant therapy TMS-transcranial magnetic stimulation VNS-vagus nerve stimulation Phototherapy

ECT

Page 82 ATI book

Severe/refractory depression
Relieve severe symptoms e.g. psychosis (hallucinations, delusional thinking), persons refusing to eat, unable to take antidepressants, Suicidal

Brain defibrillator Need informed consent


Contraindicated: Recent MI, intracranial lesions/tumors, w/increased ICP (CVA), arrhythmias, aneurysms, acute Resp infection

NPO at least 8-12H


Assess vital signs, memory

Anesthesia preparation
atropine like prep-decrease secretions, short acting anesthetic (Brevital) IV skeletal muscle relaxant-Anectine to prevent injuries during the

Ventilate until muscle relaxant fully metabolized Electrical current passed through brain by means of unior bilateral electrodes placed on the temples
causes a grand mal seizure (effects often masked by muscle relaxant)
Meds affecting Sz threshhold should be d/cd prior to ECT

lasts about 30-60 seconds

Increases BP & P;
HTN, dysrhytmias, cardiac conditions treated prior to ECT small risk of death, (same as w/other procedures in which anesthesia is used)

SE: Headache, nausea, vomiting, muscle aches jaw pain

Post Procedure Care


Monitor VS Lateral recumbent
facilitate drainage, prevent aspiration

Reorient frequently Acetaminophen for headache Short-term memory loss


from several minutes to several hours occasionally, may last several days-quite distressing

ECT not curative


encourage Tx & meds to prevent relapse

Usually up to 12 treatments, 3X/week (individualized)

TMS
Oct. 2008, FDA approved for Tx of adult unipolar depression unresponsive to Rx Uses magnetic fields to alter brain activity Large electromagnetic coil held against the scalp near the forehead, (left side)
electric current is switched on & off

Electric current creates a magnetic pulse that travels through the skull, causing small electrical currents in the brain
Currents stimulate nerve cells in the region of the brain involved in mood regulation and depression Seizure rare Treatment in medical facility for seizure management

VNS
Vagus nerve: one of the primary communication pathways from the major organs of the body to the brain Implanted pulse generator and lead wire stimulate parts of the brain that affect mood-to decrease depression
precise mechanisms of how it works is unknown

Affects blood flow to different parts of the brain Affects neurotransmitters including Serotonin and Norepinephrine which are implicated in depression FDA approved 2005 for long term, chronic depression (at least 2 yrs) in conjunction with standard treatment Utilize when Depression has not improved after @ least 4 other Tx (can be antidepressants)

VNS (cont)
Pulse approx every 5 min Approx 30 sec duration No seizure/memory loss Response in 3-6+ months
Highly individual Adjunct to treatment SE: voice, SOB, cough, dif swallowing

Phototherapy
For SAD Light therapy (phototherapy)
exposure to light that is brighter than indoor light, not as bright as direct sunlight. Outdoor light is preferred

May help reset "biological clock" (circadian rhythms)


controls sleeping and waking.

Sit in front of high-intensity fluorescent lam 15/30 minutes to 1.5- 2 hours QAM Can be used in different ways & employ different types of light boxes, light visors, and lamps All designed to bring in extra light to the eyes. Check to be sure a light box filters out harmful ultraviolet light.

Other Biological Treatments: Cranial Electrotherapy Stimulation


Almost undetectable doses of electricity
Mimics bodys own natural electrical function

Microcurrents (thought to) stimulate areas of brain responsible for neurotransmitter and hormone function
depression, anxiety, insomnia, and pain

20-60 min/day or QOD, electrodes to the area between the mastoids and the jaw Almost NO side effects
can be used in any age group

Clinical studies have shown an increase in both serotonin and beta endorphin FDA approved, Class III

Other biological treatments MST: Magnetic Seizure therapy


Investigational brain stimulation Uses high doses of repetitive TMS Induces focal seizure under anesthesia for Depression No impedance by scalp and skull Less severe cognitive side effects vs ECT More rapid recovery of orientation SE: H/A, scalp pain

Other biological treatments Deep Brain Stimulation


Neurosurgery-1st: frontal cortex Electrodes implanted, pacemaker sends continuous impulses
Brodmanns 25 cingulate area of the cerebral cortex
Role with emotion and other areas involved with appetite & sleep (hypothalmus, brain stem), mood & anxiety (amygdala), memory (hippocampus) and self esteem (frontal cortex)

Metabolically over active in treatment-resistant depression (may also be treatment resistant to CBT) Chronic deep brain stimulation in the white matter adjacent to the area is a successful treatment for some patients Nucleus accumbens another possible area (reward circuit: dopamine-desire; and serotonin-satiety) Experimental

Goals for discharge


Verbalizes plans for future
absence of suicidal thoughts or behavior

Verbalizes realistic perceptions of self and abilities Relates realistic expectations for self and others Sets realistic attainable goals Identifies psychosocial stressors that may have negative influences
begins to modify them

Identifies signs and symptoms of prodromal phase of disorder


early symptoms may mark onset of the disorder clear deterioration in function before the active phase

Describes methods for minimizing stressors States therapeutic effects, dose, frequency, untoward effects, and contraindications for medications Makes and keeps follow-up appointments Expresses guilt and anger openly, directly, and appropriately Engages family of significant others as sources of support Structures life to include healthy activities and diversions

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