Professional Documents
Culture Documents
Definition
Cognitive
negative, pessimistic, slowed
Emotional
worthlessness, hopelessness, no pleasure
Behavioral
agitation, retardation, suicide attempt
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
Psychosocial Factors
Psychoanalytic Theory (few support)
Related to loss Mania, defense against depression
Cognitive
related to negative processing of information
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
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
Sometimes delusional
Psychotic symptoms
Psychomotor
Retardation or agitation
Fatigue
Loss of energy
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
ATI
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
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
NOCs
Patient will not harm self-no gestures/plans
Approach staff if feeling suicidal
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
Stereotyping, rigid thinking, inexperience, unrealistic expectations, stigma, lack of understanding and empathy
Interferes with developing NPR/trust, adequate treatment
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
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
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
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
ECT
Severe/refractory depression
Relieve severe symptoms e.g. psychosis (hallucinations, delusional thinking), persons refusing to eat, unable to take antidepressants, Suicidal
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
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)
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
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.
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
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
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
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