Depressive Disorders
depressive disorders all share symptoms of sadness, emptiness, irritability, somatic concerns, and impairment of thinking and all impact a persons ability to function
the 2 we discussed are Disruptive mood dysregulation disorder and MDD
explain the diagnosis component of MDD in the nursing process
risk for suicide is the HIGHEST PRIORITY !, chronic low self esteem, imbalanced nutrition, constipation, disturbed sleep pattern, ineffective coping, disabled family coping
what are the different types of bipolar disorder ?
Bipolar 1 = most severe, at least 1 manic episode
Bipolar 2 = at least 1 hypomanic and 1 MDD episode
Cyclothymic disorder = symptoms of mild-mod depression for at least 2 years, rapid cycling possible
what kinds of therapy do we recommend with bipolar disorder ?
CBT - in adjunt to pharm
interpersonal and social rhythm therapy - aims to regulate social routines and stabilize interpersonal relationships to improve depression and prevent relapse
family focused therapy - helps improve communication among members
explain DMDD (when is it diagnosed, symptoms, management)
- diagnosed in children ages 6-18
symptoms : constant/severe irritability and anger, tantrums out of proportion to the situation ( > 3x a week), exhibits symptoms in at least 2 settings
management : symptomatic medications, CBT, parental training, facial expression recognition training
what model do we use for outcomes with MDD and what do we focus on with planning ?
recovery model - focus on patients strengths, treatment foals mutually developed, based on PATIENTS personal needs/values
planning is geared towards their phase of depression, symptoms, and personal goals
explain the difference between hypomanic episodes and manic episodes
hypomanic - a low level of mania, tends to be euphoric and often increases functioning, usually accompanied by excessive activity and energy
manic - worse level of hypomania
explain SSRIs
med - prozac, lexapro, zoloft
indications - MDD, BP, PD, OCD, bulimia nervosa
AE - insomnia, anxiety, sexual dysfunction, n/v, weight gain, dry mouth, hyponatremia, SI, serotonin syndrome
NC - morning med, 4-6 weeks for effectiveness, contraindicated with MAOIs, increase in suicidal thoughts, hyperactivity/tachy should be reported, stopping it abruptly can lead to discontinuation syndrome
with MDD... what are most common co-mo, and what is are the requirements to be diagnosed
co-mo : anxiety and depression
requirments (per DSM5) -
5 or more in a two week period : weight and appetite changes, sleep disturbances, fatigue, worthlesness or guilt, loss of ability to concentrate, reccurent death thoughts, psychomotor agitation
PLUS at least 1 symptom of depreesed mood or loss of interest/pleasure, persistent for 2 weeks-6 months (chronic = > 2 years), recurrent episodes common, symptoms cause distress/impaired function, and an absence of a manic or hypomanic episode
how should we communicate with these patients when forming a plan of care ? what do we need to implement for their care ?
make sure to use simple concrete words and allow time for a response, make sure to listen for covert messages and directly ask about SI and avoid platitudes.
make sure to implement counseling/communication, health edu/promotion, promotion of self care, and teamwork/safety
explain the RF as well as why someone with BD may have to be hospitalized
RF = genetics, neurobiological factors, neuroendocrine, and peripheral inflammation as well as our typical environmental and cognitive factors
Hospitalization : Hospitalization for suicidal, psychotic, or catatonic signs, depressive episodes, or Medication concerns about bringing on a manic phase
- Provides safety for a person experiencing acute mania
- Imposes external control on destructive behaviors
- Provides medication for stabilization
explain SNRIs
med - effecxor
indications - MDD, social anxiety, GAD
AE - nausea, HTN
NC - morning med, 4-6 weeks, contraindicated with MAOIs, increased SI, take with food for GI upset, monitor BP
discuss the risk factors for MDD
biological : genetic (1st degree), biochemical, hormonal, inflammatory, diathesis stress model (genetic and biological)
cognitive : females more than males, adverse childhood events, substance abuse, anxiety, personality disorders, chronic or disabling medical conditions
what are the various treatment options for patients with MDD ?
- antidepressants, integrative medicine (st. john's wort), brain stimulation therapy, light therapy, and exercise.
- therapies include CBT, interpersonal therapy, and time limited focused psychotherapy
what kind of thought processes, speech patterns, and thought content might these patients present with ? why is this important with cognitive dysfunction ?
- pressured, circumstantial, or tangential speech
- loose associations or flight of ideas
- grandiose or persecutory delusions
these are important because they affect patients overall function with mania and chronicity of illness
explain TCA
med - amitriptyline
indication - MDD
AE - sedation, anticholinergic effects, postural htn, increased SI, lethal if OD
NC - monitor ortho VS, dont stop abruptly or take with MAOIs, bedtime med, urinate before daily dose, increase fiber and fluids, dry mouth !, caution in elderly with cardiac disease
explain mood stabilizers
med - Lithium carbonate
indications - acute mania, bipolar
AE - GI, muscle weakness, drowsy, HA, confusion, polyuria, tremor, goiter and hypothyroidism
NC - monitor for toxic levels (should be < 1.0), monitor sodium, take with food or milk, stop taking and alert MD if you have hand tremors, diarrhea, or vomiting, and expect to gain 5 lbs of water weight in the first week
what are the ways we assess for someone with MDD
- suicide assessment
- self assess
- behavior and affect
- mood, emotions, thoughts/perceptions, co-mo
explain the different types of brain stimulation therapies with MDD
ECT : most effective, primary treatment in severe malnutrition exhaustion or dehydration, safer than meds with some conditions, delusional depression, failure with other meds, and schizophrenia with catatonia
RTMS : MRI strength magnetic pulses stimulate focal areas of the cerebral cortex ; AE = HA, lightheaded, seizures (rare), scalp tingling
VNS : electrical stimulation boosts the level of neurotransmitters (can cause voice alterations, neck pain, cough, paraesthesia, and dyspnea
DBS : surgically implanted electrodes in the brain that stimulate the regions that are under active in depression
what kind of communication techniques will we use with these patients ?
- firm and calm approach
- short and concise explanations
- identify expectations in simple, concrete terms
- hear and act on legitimate complaints
- firmly redirect energy to more appropriate channels
explain MAOIs
med - phenelzine (nardil)
indications - depression not responding to other meds
AE - ortho htn, HTN crisis, insomnia, N/V, SI, agitation, constipation
NC - foods with tyramine must be eliminated, maintain restrictions for 2 weeks after stopping meds, avoid caffeine, stimulants, or OTC cold meds, dont stop abruptly, ER if severe HA occurs, monitor BP, contraindicated with cardiac, liver, renal disease, or > 60 y.o.
explain anticonvulsants
med - valproic acid (depakote, depacon, depakene)
indications - mania
AE - bruising, prolonged bleeding times, GI symptoms, liver toxicity, neural tube defects, skin rash, pancreatitis
NC - monitor bleeding time and platelet count, report bleeding, bruising, rash, jaundice, n/v, take with food