DEPRESSION

1. DEPRESSION

2. What Does Depression Feel Like? • Lost, in a dark tunnel, hopeless, doomed, dying • Empty, nothingness, blank, no feelings, dead • No energy, tired, heavy, paralyzed • Afraid, vulnerable, defenseless • Unlovable, worthless, useless, stupid • Guilty, evil, contaminated • Suffering, miserable, in unrelenting emotional pain

3. Incidence and Prevalence • NIMH --Depression Rate: • 7.1% in women/Postpartum Depression • 3.5% in men • 7 % of US adult population in a given year • Age of onset- any time, highest in 20’s • Highest Prevalence-ages 25-44. • General Hospital admits: 10 to 15% are depressed • See Box 29-3 p. 380- 5th ed. Facts p. 272- 6th ed.

4. Many Forms of Depression

5. SELECTED DISORDERS • DSM IV-TR Depressive Disorders • Major Depressive Disorder (MDD) • (several subcategories or “specifiers”) • Dysthymia • Depressive Disorder, Not Otherwise Specified (NOS) • Has characteristics of depression but does not fit exact criteria for the above

6. Criteria forMajor Depressive Disorder 5 of the following 9 Symptoms > 2 weeks • Depressed Mood • Anhedonia (or Apathy) • Significant change in weight • Insomnia or hypersomnia • Increased or decreased psychomotor activity • Fatigue or energy loss • Feelings of worthlessness or guilt • Diminished concentration or indecisiveness • Recurrent death or suicidal thoughts

7. Symptoms of Major Depressive Disorder • One of the of the criteria must be: • Depressed Mood • Anhedonia (or Apathy)

8. Dysthymic Disorder • Chronic disorder • Depressed mood at least 2 years for more days than not (>50% of the time) • 2 or more of the following • Poor appetite or overeating • Insomnia or hypersomnia • Fatigue or low energy • Low self-esteem • Poor concentration • Feelings of hopelessness • Never free of symptoms for 2 months

9. What Does Depression Look Like?

10. Symptoms of Depression • Alterations in Activity • Psychomotor agitation • Tired (fatigue) • Poverty of speech • Poor hygiene • Weight loss or gain • Insomnia or hypersomnia • Altered Social Interactions • Poor social skills • Withdrawn, prefer isolation

11. Symptoms • Alterations of Cognition • Inability to concentrate • Confusion • Easily distracted • Problems with thinking ideas and problem solving • Uninterrupted self-defeating ruminations • Alterations of Affect • Low-self esteem • Worthlessness • Guilt • Anxiety • Hopelessness

12. Symptoms • Alterations of a Physical Nature • Somatic Complaints • Preoccupation with their bodies • Panic Attacks in 15% to 30% of people with MDD

13. Symptoms of Depression • Alterations of Perception: UsuallyMood Congruent • Hallucinations • Voices accusing or blaming of self • Delusions (really, these are cognitive alterations!) • Delusion of Persecution: • e.g. For a moral or ethical mistake • Somatic Delusions • e.g. “I am full of cancer”

14. Depression Model and Theories • Unified Model of Mood Disorders • Genetic Vulnerability • Developmental Events • Physiological Stressors • Psychosocial Stressors Any of these can start the cycle of disturbed neurochemistry

15. Serotonin and Norepinephrine Level is altered at the receptor site Receptor sensitivity changes The cells they activate have lost the capacity to respond Neurochemical Theories

16. Genetic Theories • Depression - major correlation, but not clear • Two thirds of twins are concordant for MDD if one or both parents have MDD

17. Endocrine Theory • Elevated levels of corticotropin-releasing hormone • Elevated pituitary release of andreno-corticotropic hormone • Early life exposure to overwhelming trauma

18. Circadian Rhythm Theory • Medications • Nutritional deficiencies • Physical illness • Wake-sleep cycles • Hormonal fluctuations

19. Psychosocial Perspectives • Freud believed depression was anger turned on the self; overactive superego • Sullivan-problems in the interpersonal areas of neglect, abuse, rejection, loss • Cognitive theories • Beck-Depression based on distorted thinking patterns • Ellis-Concept of negative self-talk and catastrophising

20. Beck Depression Inventory: Assesses severity of depressive symptoms

21. Psychosocial Perspectives, con’td. • BehavioralTheories- The way you act affects people’s response • Seligman- Developed theory of learned helplessness, hopelessness and being unassertive • LossTheory • Bowlby-Loss during childhood predisposes to depression, esp. another loss

22. TREATMENT FOCUS: Cognitive Theory • Core beliefs: How you think about your situation • Identify self-defeating thoughts, beliefs • Change beliefs and you will change your behavior (Review p. 35, 43-45)

23. Treatment Efficacy • Depression very treatable disease • Episodes usually last 6 to 9 weeks • Endogenous: no identifiable trigger or event – tx: medications with psychotherapy • Exogenous: identifiable event(s) or stressor(s)– tx: counseling/psychotherapy may be enough to resolve symptoms

24. Nursing Dx For Depressive Disorders • Alteration in Nutrition: Less than body requirements • Sleep pattern disturbance • Self care deficit • Alterations in perception:Hallucinations • Alteration in thought process: Delusions • Potential for Violence: directed at self, or Risk for Suicide

25. Nursing Care and Milieu Management • Safety First: The milieu or environment should keep the client safe • Check all clients every 15 minutes • Locked environment • Remove all harmful items • Mirrors, pocket knives, razors, shoelaces, hangers, etc.

26. Milieu Management, cont’d • Balance Sleep/activity • Assess hours of sleep • Encourage exercise/Walking • Relaxation tapes • Medication as needed for sleep

27. Nursing Care and Milieu Management • Monitor and Provide Adequate Nutrition • Observation of client during meals • Record weight < weekly • Record amount eaten • Vital signs • Lab work • A low albumin level or total protein will let you know the client has not been eating well

28. Nursing Care, Milieu, cont’d • Decrease Isolation • Approach is firm kindness and being direct • “It is time for our 1-1 (or Art Class or Coping Skills Group, etc.)” • Listen and Acknowledge Negative Feelings • Acknowledge even the most negative or suicidal feelings. You do not agree with them, but you let them know you hear them.

29. What Will the Nurse Say? Client: “What I’ve done to my family can’t be fixed, and it’s all my fault.” Client: “Why are you trying to keep me alive? You should just let me get it over with.”

30. Interventions for Other Issues: • Anger:writing, discussing, and exercise and . . . • Agitated depression:walk with patient and . . . . • Simple, structured activitiesbest in early treatment (why?)

31. Group Therapies • Assertiveness training • Coping Skills • Grief group • Art therapy • Insight oriented psychotherapy (outpatient) • Family therapy

32. Establish trust Show sincere concern Assess client’s negative self-talk Provide another point of view Do not attempt to reason Don’t reinforce delusions May be resistant to come to 1-1 Active listening, non-directive style Cognitive Therapy Strategy Have client list 3 negative thoughts about self This must be limited in number or could initiate rumination Have client list 3 positive qualities about self Talk with client about positive qualities Goal = to begin to replace negative thinking with more positive thoughts Nurse-Client Communication

33. Medications • Antidepressants • Tricyclics (TCAs) • Serotonin re-uptake Inhibitors /SSRIs • Monoamine Oxidase Inhibitors (MAOIs) • Atypical/Novel Antidepressants (SNRIs, NDRIs, and receptor antagonists) See Chart in Keltner pp. 236-237 5th ed. pp. 182-183 6th ed.

34. Other Medications Used for Depression • Antianxiety medications • Atypical Antipsychotics • Psychostimulants • OTC meds: • St. John’s Wort (hypericum)--herbal remedy • SAM-e –natural remedy, generally considered safe

35. Comparison of Modes of Action • Tricyclics: • a) Non-selectively inhibit reuptake of serotonin and norepinephrine • b) Increase receptivity to serotonin and norepinephrine • SSRI’s:Selective inhibition of serotonin reuptake  fewer side effects

36. Tricyclics (TCAs) • amitriptyline - Elavil • desipramine - Norpramin • imipramine - Tofranil • Nortriptyline - Pamelor, Aventyl • clomipramine - Anafranil (most often used for OCD, not depression)

37. Selective Serotonin Reuptake Inhibitors (SSRIs) • citalopram - Celexa • escitalopram - Lexapro • fluoxetine - Prozac • fluvoxamine - Luvox • paroxetine - Paxil • sertraline - Zoloft

38. TCAs Dry mouth Blurred vision Constipation Sedation  appetitewt gain Postural hypotension Cardiac effects Can be cardiotoxic EKG prior to starting Slow onset 2-4 weeks Overdose potential SSRIs Nausea, diarrhea, GI upset Nervousness, anxiety Insomnia Sexual dysfunction Headache Slow onset 2-4 weeks This length of time is a consideration if client is suicidal Low OD risk Antidepressant Side Effect Profiles

39. Legal/Ethical Issue: SSRIs and Suicide • Activating effects of some SSRI medications (fluoxetine/Prozac and sertraline/Zoloft appear to be implicated in increased suicidal behavior (to be discussed in suicide lecture)

40. Client Teaching: Managing Common Medication Side Effects • Orthostatic Hypotension • Teach the patient to rise slowly • Insomnia • Schedule dose early in day • Dry mouth • Hydrate • Hard candy or gum • Drowsiness • Schedule dose at night • Cardiac effects • Tricyclics may be supplied one week at a time

41. Serotonin Syndrome • A potentially fatal syndrome • Too much serotonin • Results from: Combination of therapy • Serotonin Reuptake Inhibitors combined with: • Prescribed: • Tricyclic Antidepressants • Monoamine Oxidase Inhibitors • Lithium • Over the Counter Medications: • Cough and cold meds. • Diet drugs • St. John’s Wort • Other • LSD, Ecstasy

42. Serotonin Syndrome, cont’d • Symptoms: • CNS-confusion • Agitation • Hypomania • Myoclonus • Tremor • Hyperreflexia • Autonomic signs • Fever • Tachycardia OR bradycardia • Hypertension OR hypotension • Diaphoresis, diarrhea • Severe dehydration can be fatal

43. Serotonin Syndrome

44. Other Antidepressants:Monoamine Oxidase Inhibitorsand Atypical Antidepressants

45. Monoamine Oxidase Inhibitors (MAOIs) • Inhibit enzyme that breaks down serotonin and norepinephrine • Non-Selective (older) and Selective types • Usually last choice of pharmacotherapy

46. MAOIs • Nonselective • phenylzine - Nardil • tranylcypromine - Parnate • Selective • moctobemide - Manerex • selegiline - Emsam

47. MAOIs can cause very serious hypertensive crisis Client must be instructed not to drink red wine, beer, eat aged cheese, yogurt, pickled foods, sausage, etc. anything fermented/preserved: Tyramine is chemical ingredient. Check with MD before taking any new meds. AVOID Side Effects of MAOIs

48. Atypical/Novel Antidepressants • Selectively prevent reuptake of specific neurotransmitters, e.g. • Serotonin and Norepinephrine (SNRI) • Norepinephrine and Dopamine (NDRI) • Norepinephrine only (NRI) add to your outline or are • Receptor Antagonists - increase activity of neurotransmitters

49. Side Effects of Atypicals • trazodone/desyrel- Usually used for sleep: rare side effect: priapism • buproprion/Wellbutrin (SDRI): seizures at high doses, irritability, decreased appetite, worsening of tics • venlafaxine/Effexor (SNRI): Nausea, agitation, headache and increase in blood pressure • mirtazapine/Remeron (tetracyclic): Sedation, increased appetite • duloxetine/Cymbalta (SNRI): GI probs., wt. loss

50. Some Newer Medications for Depression (NOT ON TEST!) • SNRI • desvenlafaxine - Pristique • Norepinephrine reuptake inhibitor (NRI) • reboxetine - Edronax • Sigma receptor agonist • opripramole - Insidon, Pramolan • Rapid acting medications (few hrs-few days) • Scopolamine, ketamine (not approved)