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Quiz 3 part 2
Depression
| Question | Answer |
|---|---|
| Depression Diagnostic Criteria: | An episode of major depressive disorder is diagnosed when a person has five or more of the following symptoms. One of them MUST be #1Depressed mood or #2 Very diminished interest or pleasure |
| All symptoms of Depression: KEY FEATURES BOOK PG. 369 | Depressed mood,Diminished interest/ pleasure Significant weight loss/gain,Insomnia or hypersomnia,Psychomotor agitation/retardation,Fatigue/loss energy, Feelings of worthlessness,excessive quilt, Recurrent thoughts of death |
| Types of Depression: | 1. Unipolar Depression 2. Dysthymic disorder 3. Seasonal Affective Disorder (SAD) 4.Postpartum Depression (PPD) |
| Unipolar Depression: | aka Major Depressive Disorder) repeating, severe depressive episodes lasting more than 2 years. |
| Dysthymic disorder | daily moderate depression that lasts more than two years. Often ends up as a lifestyle in which the individual can function but does not enjoy life. acommpandied by additional depresive symptoms but DOES NOT MET CRITERIA fo major depression. |
| 1st Cause of Depression | Insufficiency of neurotransmitters: specifically norepinephrine and serotonin, but also dopamine, acetylcholine, and gamma-aminobutyric acid (GABA). |
| 2nd Cause of Depression | Unexpected negative life events (e.g. sudden death of a loved one, unemployment, medical illness, etc.) |
| 3rd Cause of Depression | Endocrine abnormalities such as excessive secretion of cortisol and abnormal thyroid-stimulating hormone (TSH) have been found in 45% to 60% of patients with depression |
| 4th Cause of Depression | Genetic factors also predispose patients to depression - relatives of patients are two to three times more likely to develop depression themselves. |
| Risk factors include: | Personal or family history of depression prior suicide attempts female gender lack of social supports stressful life events substance abuse, especially alcohol and cocaine medical illness |
| Onset of depression: | in late 20's but can occur at any age |
| Frequency: | appears to be as high as 26% for women and 12% for men. |
| WHAT QUESTION SHOULD YOU ASK EVERY time? | “Do you feel like hurting yourself?” |
| Depression can be: | so severe that the individual may think about, or actually succeed at, committing suicide. |
| It is estimated: | that up to 15% of those diagnosed with major depressive disorder die from suicide. |
| Mood: | a person's state of mind exhibited through feelins and emothion. |
| MDD involves: | psychological, biological and social symptoms that impair a persin's functioning. |
| The DSM- describes MDD as: | a mood disorder |
| Most likely to be Depressed: | Women 35-44 Caucassian, Hispanic Low income Less than high school education Urban |
| Least likely to be depressed: | Men 15-24 African American High income High school or more Rural |
| Nursing Assessmnet Tools: | The Hamilton Depression Scale (Appendix c) The Geriatic Depression Scale |
| The DSM categorizes MDD into several VARIENTS called: | SPECIFIERS. |
| Symptoms are the same across subgroups but: | variences in EXPRESSION OCCUR |
| DSM helps define: | the population, time frame and symptom for these subgroups. |
| Atypical Depression is a mood disturbance: | Generally occurs in young and women. Expressed by: increase appetite nd weight, hypersomnia, leaden paralysis(weighting down in arms and legs), and extreme sensitivity to interpersonal rejection.Moods brighten w/ positive events *MAOIs 1st-choice of drug |
| Melancholic Depression: occurs mostly in older adults and often misdiagnosed w/ dementia. Characterized by: | Anhedonia and inability to be cheered up. Mood does not improve even temp. |
| 3 or more of these symptoms present in Melancholic patients: | 1.depression worse in the morning. 2.early morning awakening. 3.pschyomotor retardation or agitation. 4.anorexia or weight loss. 5.excessive and inappopriate guilt |
| Diagnosis: | most likely to be associated with DEXAMETHASONE NONSUPPRESSION and elevated CORTISOL LEVELS |
| Catatonic Features: | 1. Significant psycomotor alterations which includes immobility, excessive motor activity, mutism, echolalia(parrot-like rep of words) and in appropriate posture. Remeber these signs are associate with schizo too. |
| Postpartum depression mood disturbances during 1st 30 days postparum and more servere than postpartum blues. Symptoms: | 1. feeling anxious, irritable, or tearful, but also having periods on normalcy. 2.Can be with or w/out psychosis. 3.Overconcern or delusional thoughts about baby's health are not uncommon. |
| Psychosis Depression: person has delusions and hallucinations in conjunction with mood disturbances which cause: | mood-congruent (delusions of guilt, deserved punishmnet), nilhilistic delusions (personal punishmnet), somatic delusions (my brain is dying)and delusions of poverty. |
| Psychotic depression: | 1.poorer prognosis compared to other forms of derpression 2.Antidepressants and Antipsychotics are usually required for satisfactory treetment. |
| Seasonal affetive Disorder (SAD): | 1.occurs in conjunction with changes in season. HIGHER THE LATITUDE more likely SAD to occur. Women more likely than men. |
| Events that might predispose children and adolescents to develop MDD: | 1.Loss of parent by divorce, seperation, or death. 2.Death of other close to child. 3.Death of pet. 4.Moving. 5.Academic problems or failure. 6.Significant physical illness or injury. |
| Cultural expression of depression: | 1.Hispanic,Latino,Mediterranean: describe sadness or guilt as being nervous or have head or stomach aches. 2.Asian: being out of balance or feeling weak and nervous. 3.Native-American and Asian-American withdrwl from medication and personal growth |
| FACTS ABOUT DEPRESSION: | Table on page 372 |
| Differences between Dysthmic disorder and MDD: | Dysthymic is chronic, depressed for more than 2 years, MORE DAYS THAN NOT. Severity is not the distinquishing factor as it is with MDD |
| Objective signs of depression | 1.Alterations of activity:pace,engage in handwriting,pull or rub hair, skin, clothing. Repetitive behavior.Slowed speech, pauses,mutenss, poverty of speech. Altered ADLs,feelings,motivation,sleeping. 2.Altered social Interactions |
| Subjective signs of depression: Alterations of affect, cognition, physical nature and perception | AFFECT:Anxiety, doom and gloom,fear, self-destructive thoughts, and panic attacks are products of a depressed mind. When pain becomes too much, shut down and become apathetic. |
| Alterations of cogniton: | Ambivalance and indecision, when does make a decision might be obsessed with "what if" questions. Inabilty to concentrate, confsion, memory problems, pessimism, self blame, self destructive thoughts and of death and dying uncertainty. |
| Alterations of a Physical Nature, almost all parts of body are affected. | Numerous Somatic complaints: abdominal pain,anorexia,chest pain, constipation, dizziness, fatigue, headache, indigestion, menses change,N/V and sex dysfunction. Over self assessmnet is pathologic and can lead to panic attacks- 15%-30% of MDD patients. |
| Alterations of perception: | 1.Hallucinations less elaborate than schizo's and tend to focus on personal faults, "You are no good. You don't deserve your family." 2.Delusions of perscution because of moral or ethical mistake. Somatic and nilhilistic delusions. |
| KNOW***Suicide | 1.Each year in the U.S. there are >30,000 lives lost d/t suicide 2.8th leading cause of death in the U.S. 3.Males are 4 times more successful than females 4.Females have more attempts |
| KNOW***Suicide*** | 7.Attempts increase with age, with men >65 having the highest success rate (84%) 6. Incident in postpartum up to 1 year. |
| KNOW***Suicide*** | 8.More teens and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, and chronic lung disease combined. 9. In recent years there has been a dramatic increase in 10-14 year olds. |
| KNOW***Suicide*** | 10.Many deaths due to accidental overdoses, automobile accidents, and refusing medical care could be considered hidden suicides even though they are not reported as such. |
| **Suicide Myths** As a Nurse you can make a packed with person every time you see them!!! | 1.“People who talk about it won’t really do it.” 2.“Anyone who tries to kill himself/herself must be crazy.” |
| **Suicide Myths** | 3.“If a person is determined to kill him/herself, nothing is going to stop him/her.” “People who commit suicide are people who were unwilling to seek help.” 4.“Talking about suicide may give someone the idea.” |
| Risk factors for Suicide*Similar to depression* | Death,terminal illness of relative/friend Divorce, separation,stress on family Loss of health(real or imagined) Overwhelming pain(exceeds coping ability) |
| Risk factors for Suicide | Loss of job, home, money, status, self-esteem, personal security ETOH or Drug abuse Difficult times (holidays, anniversaries, 1st week after discharge) |
| Know*Warning Signs of Suicide**always helplessnes and hopelessness!! | 1.Withdrawing from family or friends 2.Talking about death, the hereafter or suicide 3Giving away prized possessions 4.Drug or alcohol abuse 5.Personality changes, such as unusual anger, boredom, or apathy |
| Know*Warning Signs of Suicide**always helplessnes and hopelessness!! | Signs of depression: of physical prob.that have no cause;disturbed eating or sleeping patterns; self-esteem;feelings of helplessness, hopelessness. 7.Previously failed attempts w/verbalized regrets of failure |
| Suicide Precautions**Make frequent therapeutic verbal contact***!!! | 1.Do not leave gifts in room untill examined. 2.Make sure all medications swallowed,liquid forms when available,injectables if pt refuses oral forms as ordered. 3.Attend meals,keep track of utensils and dinnerware,used traysput up. |
| Treating Depression: | 1.Once depression is accurately identified, depression can almost always be treated successfully with medications, psychotherapy, or a combination of the two. 2.Clients are individuals and respond to treatment differently. |
| Treatment Options include | 1.Medication 2.Psychotherapy-talk to them 3. Combination of meds and psychotherapy 4. ECT 5. Light therapy |
| Psychotherapy treats these problems associated with depression: | Difficulty relating to others Low motivation Impaired mental concentration |
| Psychotherapy also: | 1.Usually used in addition to drug therapy for major depression 2.Clients experiencing mild to moderate depressive episodes without psychotic symptoms may benefit from psychotherapy alone. |
| Medications have been shown to: | be effective for all types of depression. |
| Limtations of RX: | 1. 2-4 weeks for full effects. 2. Might have to trial through several drugs, 30% first does not work. 3.Intolerable side effects early in therapy. 4.May inc. risk of suicide thinking and beh in all ages. *START FEELING BETTER HAVE ENERGY TO BUY GUN* |
| When selecting which antidepressant to prescribe, two factors should be considered: | 1.Patient’s history of response to previously prescribed antidepressants 2.Potential for adverse side effects |
| ***IMPORTANT***Contrary to marketing claims, | there are no differences among antidepressant drugs (with the exception of MAOIs) in relative overall therapeutic efficacy and onset caused by full therapeutic dosage. There are, however, significant differences in adverse effects. |
| Antidepressant Classifications: | 1.Monoamine Oxidase Inhibitors (MAOIs) 2.Selective Serotonin Reuptake Inhibitors (SSRIs) 3.Tricyclics 4.Miscellaneous Agents |
| Monoamine Oxidase Inhibitors (MAOIs)uses: | 1.Most effective in atypical depression, panic disorder, OCD, and some phobic disorders. 2.Also used when tricyclic antidepressant therapy is unsatisfactory and when ECT is inappropriate or refused |
| Monoamine Oxidase Inhibitors (MAOIs)actions: | Blocks destruction of epinephrine, norepinephrine,dopamine, serotonin by the enzyme monoamine oxydase in the presynaptic neurons of the brain. 2.effects first couple days, full 2-4 weeks. 3.60% improve first 2 weeks, max improve 4 weeks. |
| Monoamine Oxidase Inhibitors (MAOIs)side effects: | 1.Hypotension - most common SE; generally mild, although orthostatic hypotension in early therapy. Drowsiness, sedation; restlessness, agitation, insomnia; blurred vision, constipation, urinary retention, dry mouth. |
| *SIDE EFFECTS TO REPORT AND CONTRAINDICATIONS* | hypertensive crisis:MAOIs block amine metabolism outside the brain; patients who consume food or medications containing indirect sypathomimetic amines are at considerable risk for hypertensive crisis. |
| FOODS TO AVOID WITH MAOIs: | Foods containing sign. quant of tyramine: well-ripened cheeses(camembert,roquefort, parmesan, ozzarella, cheddar),yeast extract; red wines,sauerkraut, overripe bananas,figs avocados; chicken livers; and beer. Foods containing other vasopressors:fava bean |
| Common prodromal symptoms of hypertensive crisis include: | severe occipital headache, stiff neck, sweating, nausea, vomiting, sharply elevated BP. Auditory most dangerous. |
| Selective Serotonin Reuptake Inhibitors (SSRIs) | 1.most widely used class of antidepressants because they do not have the anticholinergic and cardiovascular side effects of the tricylic antidepressants |
| Only SSRI approved for use in children: | Fluoxetine (Prozac) |
| Selective Serotonin Reuptake Inhibitors (SSRIs) Action: | Inhibits the reuptake and destruction of serotonin from the synaptic cleft, thereby prolonging the action of the neurotransmitter |
| SSRIs Side Effects to report: | 1.Suicidal actions: Monitor pt for changes in thoughts, feelings, and behaviors during the initial stages of therapy. 2.Restlessness, Agitation, Anxiety, Insomnia - usually occurs early in therapy; 3.Gastrointestinal effects: administer with food. |
| Tricyclic Antidepressants:**After 2-4 weeks, elevate mood, improve appetite, and increase alertness in approx. 80% of patients** | USES:produce antidepressant and mild tranquilizing effects. |
| Action: | : Prolong the action of norepinephrine, dopamine, and serotonin to varying degrees by blocking the reuptake of these neurotransmitters in the synaptic cleft between neurons. The exact mechanism when used as antidepressants is unknown |
| Side Effects to Expect: | 1.Blurred vision, constipation, urinary retention, dry mouth - anticholinergic effects. 2.Orthostatic Hypotension - especially when initiating therapy. 3.Sedative effects - single doses at bedtime may diminish or relieve this effect. |
| Side Effects to Report: | 1.Tremor - Approx. 10% of patients will develop this. Numbness, tingling - report for further eval. Parkinsonian symptoms - dosage must be reduced or discontinued. Dysrhythmias, tachycardia, heart failure Seizure activity Suicidal actions |
| Misc:Bupropion hydrochloride (Wellbutrin) | 1.For patients unresponsive to tricyclic antidepressants and cant tolerate cholinerg SE. Disadvantages:seizures, requirement of multiple doses daily. Cannot be used with psychotic disorders because its dopamine agonist activity increased psychotic sym. |
| Misc:Mirtazepine (Remeron) | Tetracyclic antidepressant that is a serotonin antagonist. Mechanism of action is unknown, but pharmacologic response is similar to that of tricyclic antidepressants |
| Misc:Trazodone hydrochloride (Desyrel) | First of the triazolopyridine antidepressants to be released for clinical use. Exact mechanism of action is unknown - chemically unrelated to other classes of antidepressants. Low incidence of anticholinergic side effects |
| Misc:Venlafaxine (Effexor)** FDA has recommended that Effexor not be administered to those under the age of 18.** | Phenethylamine derivative antidepressant structurally related to buproprion (Wellbutrin). Potent inhibitor of reuptake of serotonin and norepinephrine and a weak inhibitor of dopamine reuptake in the neuronal cleft. |
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