Depressive Disorders & ECT

Question 1

Concepts

• Mood
• Affect
• Depression

Question 2

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Is the loss of interest or pleasure

Answer 2

Anhedonia

Question 3

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Is a pervasive and sustained emotion that may have a major influence on a person’s perception of the world. i.e., depression, joy, elation, anger, anxiety

Answer 3

Mood

Question 4

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Is described as the external & observable emotional rxn assoc w/an experience

Answer 4

Affect

Mood and affect are used interchangeably, but mood is subjective, and affect is more objective and observed

Question 5

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Is an alteration in mood that may be expressed by feelings of sadness, despair, & pessimism
- There’s a loss of interest in usual activities & somatic sx’s may be evident
- Changes in appetite, sleep pattern, and cognition are common

Answer 5

Depression

> Pathological depression occurs when adaptation is ineffective, & the sx’s are significant enough to impair functioning

Question 6

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This is 1 of the leading causes of disability in the US
- Most prevalent psychiatric disorder
- Women > men 2:1

Answer 6

Major depressive disorder (MDD)

Question 7

Major depressive disorder (MDD)

• depressed mood
• loss of interest or pleasure in usual activities
• impaired social & occupational functioning for @ least 2 wks
• no other cause

Answer 7

• No h/o manic behavior & sx’s that cannot be attributed to the use of substances or a general medical condition
• Dx will also identify the degree of severity of sx’s (mild/moderate/severe) & whether there is evidence of psychotic, catatonic, or melancholic features

Question 8

DSM 5 - MDD

Answer 8

Question 9

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This condition involves a persistent depressive disorder
- Feeling sad or “down in the dumps”

! No evidence of psychotic sx’s

Answer 9

Dysthymic disorder

Question 10

Dysthymic disorder

! Essential feature is the chronically depressed mood or possibly an irritable mood in children or adolescents
- Occurs for most of the day; more days than naught, for @ least 2 years
- For children & adolescents, a 1-year timeframe

Answer 10

> Dx is identified as early-onset, which occurs < age 21 or late-onset, which occurs @ 21 & older

Question 11

Premenstrual dysphoric disorder (PMDD)

• markedly depressed mood
• excessive anxiety, mood swings
• dec interest in activities (in the wk prior to menses)

Answer 11

> Improves shortly after the onset of menstruation & becomes minimal or absent in the wk post-menses

Question 12

Substance/Medication-Induced Depressive Disorder

Depressed mood is assoc w/intoxication or withdrawal from -

> alcohol, amphetamines
cocaine, hallucinogens
opioids
phencyclidine-like substances
sedatives, hypnotics, anxiolytics

Answer 12

Depressive Disorders d/t another medical condition -

• Stroke, TBI
• Thyroid disorders, Cushing’s dz
• Huntington’s, Parkinson’s
• MS

Question 13

Predisposing Factors

• Biological theories
• Genetics
  > a genetic link found in family & twin studies
• Biochemical influences
  > May be d/t a deficiency in the neurotransmitter’s norepinephrine, serotonin, dopamine, & most recently discovered, acetylcholine

Answer 13

• Neuroendocrine disturbances
  > Depression is assoc w/the dysfunction of the adrenal cortex & possibly diminished release of TSH
• Physiological influences
  > an imbalance of estrogen & progesterone has also been implicated in the predisposition to PMDD

Question 14

Psychosocial Theories

Question 15

Learning Theory

It was theorized that learned helplessness predisposes individuals to depression by imposing a feel of lack of control over their life situation

Answer 15

Psychoanalytical Theory

Freud postulated that the loss of a loved one either actually by death or emotionally by rejection can lead to melancholy

Question 16

Learning Theory

It was theorized that learned helplessness predisposes individuals to depression by imposing a feel of lack of control over their life situation

Answer 16

Psychoanalytical Theory

Freud postulated that the loss of a loved one either actually by death or emotionally by rejection can lead to melancholy

Question 17

Object Loss Theory

Absence of attachment

Question 18

Cognitive Theory (Beck)

• The underlying cause of depression is cognitive distortions that result in negative, defeated attitudes (rather than affective)
• These cognitive distortions arise out of a defect in cognitive development & the individual feels inadequate, worthless, & rejected by others
• Outlook of the future is one of pessimism & hopelessness

Answer 18

Negative expectations of
1. environment
2. future
3. self

Question 19

___ Model

Combined effects of genetic, biochemical, & psychosocial influences

Answer 19

Transactional

Question 20

Developmental Implications: Childhood

> Childhood depression can include hyperactivity, delinquency, school problems, psychosomatic complaints, sleeping & eating disturbances, social isolation, delusional thinking, & suicidal thoughts or action

> In many depressed children, there’s a genetic predisposition towards the condition which is then precipitated by a stressful situation

Answer 20

> Common precipitating factors include physical or emotional detachment by the primary caregiver; parental separation or divorce; death of a loved one, person, or pet; a move; academic failure; or physical illness
- In any event, the common denominator is loss

Question 21

Developmental Implications: Elderly

Answer 21

• High % of suicide among the elderly
• ECT is an important alternative in treatment of depression in the elderly, esp considering the problematic side effects of antidepressant agents in this population

Question 22

Developmental Implications: Adolescence

visible manifestation of behavioral change that lasts for several weeks

Answer 22

Question 23

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• This can also include concern of an inability to care for infant
• In severe forms, it can produce a psychotic-like state & require hospitalization & removal of the infant

Answer 23

Postpartum depression

Question 24

Assessment

• Affect
• Behavioral
• Cognitive
• Physiological

Answer 24

Continuum of Depression

> Transient depression - life’s everyday disappointments

> Mild depression - normal grief response

> Moderate depression - dysthymia

> Severe depression - major depressive disorder (MDD)

Question 25

Behaviors & nursing diagnoses

Answer 25

Question 26

Outcomes

Question 27

Interventions * Risk for Suicide * Complicated Grieving

Answer 27

* Low self-esteem/self-care deficit * Powerlessness

Question 28

Patient Education * Nature of the Illness > Talking about the stages of grief & the sx's assoc w/each > Talking about what depression is, why people get depressed, & what the sx's are * Support services > Suicide Hotline; support groups; legal &/or financial assistance support

Answer 28

* Management of the Illness > Medication management; talking about side effects (especially those to report to the physician); the importance of taking the medication regularly; the length of time it takes to take effect; diet (especially important with MAOI’s) > Assertiveness techniques; stress management techniques; ways to increase self-esteem; ECT

Question 29

Treatment Modalities for Depression - Individual psychotherapy - Group therapy; family therapy - Cognitive therapy

Answer 29

- Transcranial Magnetic Stimulation - Vagal Nerve Stimulation & Deep Brain Stimulation - Light Therapy

Question 30

Electroconvulsive Therapy (ECT) - Is the induction of a grand-mal (aka generalized) seizure. Done through application of electrical current to the brain. Is safe and effective - It’s a treatment alternative for the individual w/depression, mania, or schizoaffective disorder who does not respond to other forms of therapy - Has been shown effective in the treatment of severe depression, particularly among depressed clients who are experiencing psychotic symptoms, catatonia, psychomotor retardation, and neuro-vegetative changes such as disturbances in sleep, appetite, & energy - ECT is typically considered only after a trial of therapy w/antidepressant medication has proven ineffective. Could be used for the patient who is extremely suicidal or is refusing food & are nutritionally compromised or schizoaffective disorder who does not respond to any other form of treatment

Answer 30

! No absolute contraindication(s) for ECT but those with cardiovascular, increased intracranial pressure, intracranial lesions impose a higher risk for adverse effects. Also, osteoporosis, acute & chronic pulmonary disorders, & high-risk or complicated pregnancy > Exact MOA is unknown & there are multiple effects on the CNS activity incl hormones, hippocampal and amygdala area suggesting that neuroplasticity & possible neurorestorative effects of ECT. The ***most common side effect is temporary memory loss and confusion*** > *Although occurrence is rare*, the **major cause of death w/ECT is of cardiovascular complications such as an myocardial infarction (MI) or a cerebrovascular attack (CVA)**

Question 31

? Is a form of psychosurgery An electrode is implanted w/the intent of stimulating brain function

Answer 31

Deep Brain Stimulation

Question 32

? Was found to improve client’s mood. Involves implanting an electronic device into the skin to stimulate the vagus nerve

Answer 32

Vagal Nerve Stimulation

Question 33

? Has been shown to be an affective treatment for seasonal affective disorder. Is administered by a light box which contains white fluorescent light tubes covered w/a plastic screen that blocks UV rays. The individual sits in front of the box w/their eyes open

Answer 33

Light Therapy

Question 34

? Is used to treat depression by stimulating nerve cells in the brain. It involves the use of very short pulses of magnetic energy to stimulate nerve cells @ localized areas, like the electrical activity observed with ECT > *Unlike ECT, the electrical waves **do not result in a generalized seizure activity***

Answer 34

Transcranial Magnetic Stimulation (TMS)

Question 35

Antidepressants ! Increase the conc of norepinephrine, serotonin, &/or dopamine ! All of these carry an FDA black-box warning for inc risk of suicidality in children & adolescents

Answer 35

> Be alert to sudden lifts in mood > All classes have side effects of dry mouth, sedation, & discontinuation sx's > Avoid drinking alcohol while taking antidepressant therapy (these rx's can potentiate the effects of others) > Use sunblock & wear protective clothing as well [skin may be sensitive to sunburn]

Question 36

? The blockade of norepinephrine uptake results in s/e's of tremor, cardiac arrhythmias, sexual dysfunction, & HTN Blockade of serotonin reuptake results in GI disturbances, incr agitation, & sexual dysfunction > Other s/e incl insomnia, HA, & wt loss ! Several rx interactions & incl supplements, lithium, & dig

Answer 36

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Question 37

? > Trazodone can cause prolonged penile erection (if this erection persists longer than an hour, seek emergency treatment) > Teach the patient taking bupropion (Wellbutrin) to not double-up on the rx (this rx is given in divided doses because it can incr the risk of sz)

Answer 37

Atypical antidepressants

Question 38

? Inhibit monoamine oxidase from metabolizing norepinephrine, serotonin, & dopamine > Grp of rx is often reserved for those who don’t respond to any other depressants & aren’t regularly used as a 1st line treatment b/c of their adv rxn > rx interactions are vast [concomitant use w/ results in serious, sometimes fatal effects resembling neuroleptic malignant syndrome (NMS)]

Answer 38

Monoamine oxidase inhibitors (MAOIs)

Question 39

Monoamine oxidase inhibitors (MAOIs) ! Avoid ___ containing foods This is found in aged cheese, wine (chianti), beer, chocolate, colas, coffee, tea, sour cream, smoked & processed meats, beef & chicken liver, canned figs, soy sauce, overripe & fermented foods, pickled herring, raisins, caviar, yogurt, yeast products, broad beans (fava), cold remedies, & diet pills

Answer 39

TYRAMINE ! Consumption with tyramine can lead to a life-threatening hypertensive crisis !

Question 40

? This condition is characterized by fever, muscle rigidity, diaphoresis, tachycardia, as well as labile BP

Answer 40

NMS (Neuroleptic Malignant Syndrome)

Question 41

? - Is 1 of the oldest known groups of antidepressants - Incr the combo of serotonin, norepinephrine, & dopamine - Are older & less expensive than newer drugs *but b/c of the high risk of fatality w/overdose, these rx's are not given to the suicidal pt* ! Also have more side effects than any other antidepressant ! * Blurred vision * Constipation * Urinary retention * Orthostatic hypotension * Decr the sz threshold

Answer 41

Tricyclic antidepressants (TCAs)

Question 42

Tricyclic antidepressants (TCAs) > Teach pt to drink fluids & incr their fiber intake ! Fatal cardiac dysrhythmia can occur w/overdose **TCAs are not given to patients with glaucoma or BPH**

Answer 42

! *Avoid smoking* while taking TCAs **TCAs & MAOIs are never given together b/c of their rx interactions**

Question 43

? > Are the 1st line of rx treatment Work by inhibiting the reuptake of serotonin. May need 4-6 weeks or longer before seeing signs of benefit. Generally adv rxns decr within 2-4 wks of starting therapy Do not stop the drug abruptly; taper slowly to prevent the discontinuation of sx's > Pregnant women should avoid paroxetine (Paxil) as it has been shown to cause birth defects

Answer 43

Selective serotonin reuptake inhibitors (SSRIs) s/e - GI disturbances incr agitation sexual dysfunction hyponatremia (common in the elderly) ! Insomnia, HA, wt loss

Question 44

? ! This is the most severe, adverse reaction to monitor for (effects are potentiated with the combination of SSRIs, MAOIs, & St. John’s wort) ➭ change in mental status; restlessness; hyperreflexia ➭ tachycardia, labile BP, sweating, shivering, tremors

Answer 44

Serotonin syndrome *If this is noted, requires immediate discontinuation of medications that have causative factors*

Question 45

? ➭ Citalopram ➭ Escitalopram ➭ Fluoxetine ➭ Fluvoxamine ➭ Paroxetine ➭ Sertraline ➭ Vilazodone

Answer 45

Selective serotonin reuptake inhibitors (SSRIs)

Question 46

? ➭ Desvenlafaxine (Pristiq) ➭ Duloxetine (Cymbalta) ➭ Venlafaxine (Effexor)

Answer 46

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Question 47

? ➭ Isocarboxazid (Marplan) ➭ Phenelzine (Nardil) ➭ Tranylcypromine (Parnate) ➭ Selegiline Transdermal System (Emsam)

Answer 47

Monoamine oxidase inhibitors (MAOIs)

Question 48

? ➭ Bupropion (Wellbutrin, Zyban) ➭ Forfivo XL ➭ Maprotiline ➭ Mirtazapine (Remeron) ➭ Nefazodone (Serzone) ➭ Trazodone

Answer 48

Atypical antidepressants

Question 49

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Answer 49

Tricyclic Antidepressants (TCAs)