Continuing Education (CEU) course for healthcare professionals. View the course online at wildirismedicaleducation.com for accreditation/approval information, course availability and other details, and to take the test for CE credit. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional healthcare.
Contact Hours: 3
Depressive Disorders COPYRIGHT © 2014, WILD IRIS MEDICAL EDUCATION, INC. ALL RIGHTS RESERVED. BY Judith Swan, RN, MSN; Persis Mary Hamilton, RN, CNS, MS, EdD
COURSE OBJECTIVE: The purpose of this course is to provide caregivers with an overview of
depressive disorders, including their prevalence, causes, assessment, diagnosis, treatment, and care. LEARNING OBJECTIVES: Upon completion of this course you will be able to: •
Identify types of depressive disorders as defined by DSM-5.
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Discuss the epidemiology of depressive disorders.
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Describe psychosocial theories of depressive disorders.
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Identify critical depression assessment concerns/issues.
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Discuss medical and nursing diagnoses related to depression.
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Relate treatment modalities for depression.
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Explain elements of effective therapeutic communication when interacting with a depressed person.
Almost everyone has days when they feel discouraged, disheartened, and a bit grouchy. Usually, these times of reduced energy and irritability last only a short time and soon vitality and enthusiasm for life returns. During these low periods, people may say they feel “depressed” or “down in the dumps,” yet rarely are they clinically depressed or grieving a significant loss. Depressive disorders, on the other hand, are pervasive alterations in body, mood, and thoughts. Such alterations significantly interfere with the daily lives and normal functioning of those who are afflicted, causing distress for both the person with the disorder and those around them. The resulting self-doubt, guilt, and anger affect the self-esteem, interpersonal relationships, and livelihood of these individuals. It is no surprise to find that suicide is associated with depressive disorders and is often the result of experiencing undiagnosed, undertreated, or untreated
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depression (University of Washington, 2013). Depressive disorders are common but serious and come in different forms.
TYPES OF DEPRESSIVE DISORDERS In order to help caregivers recognize and treat depressive disorders more effectively, the American Psychiatric Association in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has identified the following types of depressive disorders.
Persistent Depressive Disorder (Dysthymia) This disorder is a consolidation of the formerly defined chronic major depressive disorder and dysthymic disorder. It is similar to, but milder than, major depressive disorder, characterized by a chronic depressed mood that is present most of the time, identified subjectively or by observation by others, and lasts for at least 2 years in adults. In children and adolescents the mood can be irritable and must be present for at least 1 year. There is no evidence of psychotic symptoms. This joyless disorder may begin in early childhood, adolescence, or adulthood. Though people afflicted with persistent depressive disorder suffer from social and occupational distress, only rarely are they hospitalized unless they threaten or attempt suicide or develop some other psychiatric disorder.
Major Depressive Disorder (MDD) Major depressive disorder is not the occasional “down day” people ordinarily experience. Neither is it the chronic depression of persistent depressive disorder. It is a noticeable change in a person’s usual pattern of functioning that lasts two weeks or more. It is a terrible state of darkness, despair, and gloom, a debilitating condition in which people feel empty, hopeless, joyless, enervated, and believe that life is not worth living. When sufferers regain just a bit of strength, they may use that energy to commit suicide. With major depressive disorder there is no history of manic behaviors, and the symptoms cannot be attributed to substance use or a general medical condition. It is now evident that bereavement and major depression are not always completely separate. Grief following a loss is a considerable psychological stressor and may generate a major depressive episode in some persons. Gradually, without treatment, episodes of major depression recede and sufferers return to their former cognitive, emotional, and physical state. Regrettably, recurrence is high, as is the rate of suicide. In one study, those at five years in remission were at a 13.2% increased risk for relapse; those 10 years in remission had a 23.2% chance; and those who had gone beyond 10 years were at a 42% greater risk of another episode (Hardeveld, 2013). Of persons afflicted with major depression, 15% eventually commit suicide. In the United States, 32,000 persons die by suicide every year, and the lethality of depression can be elucidated by the fact that suicide is the eighth leading cause of death (Andrew, 2012). ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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With appropriate treatment, however, 70%–80% of persons with major depressive disorder can experience a significant reduction in symptoms (Halverson, 2013). SPECIFIERS FOR PERSISTENT DEPRESSIVE DISORDER AND MAJOR DEPRESSIVE DISORDER To clarify the course of diagnoses of depressive disorders, extensions known as “specifiers” may be added. These can describe the severity, onset, and special features of a disorder. The following specifiers apply to both persistent depressive disorder and major depressive disorder. •
Anxious distress includes feeling keyed up or tense, feeling unusually restless, having difficulty concentrating due to worrying, dreading that something awful is going to happen, and feeling the possible loss of control. To have this specified in the diagnosis, at least two of these symptoms must be present most days.
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Mixed features include elevated or expansive mood, inflated self-esteem or grandiosity, being more talkative or feeling pressure to keep talking, flight of ideas and racing thoughts, increased energy, increased or excessive involvement in activities that have high risk for painful consequences, and a decreased need for sleep.
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Melancholic features are lack of pleasure in almost anything, marked retardation or agitation, greater depression worse in the morning, excessive or inappropriate guilt, significant weight loss, and early morning awakening.
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Atypical features are unusual symptoms such as hypersomnia, leaden paralysis (heavy feelings in legs or arms), appetite changes, significant weight gain, or extreme sensitivity to perceived interpersonal rejection.
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Psychotic features include hallucinations (false perceptions) and/or delusions (false ideas). For example, a seriously depressed man pushes his plate away and says, “I can’t eat that stuff, it’s crawling with worms.” A deeply depressed widow keeps getting up from her chair, going to the window, and anxiously looking up and down the street. When asked why she is doing this, she says, “He’s coming to see me.” When asked who is coming to see her, she responds, “My husband.”
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Peripartum onset applies to an episode of major depression that occurs during pregnancy or in the four weeks following delivery.
The following are specifiers that apply only to major depressive disorders: •
Catatonia includes odd behaviors, such as posturing, peculiar voluntary movements, waxy flexibility, mutism, agitation, grimacing, stupor, echopraxia (involuntary mimicking of another’s movements), echolalia (involuntary mimicking of another’s speech), and extreme negativism.
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Seasonal pattern or seasonal affective disorder (SAD) are periods of increased depression in the autumn or winter and decreased depression in the spring or summer, when there is more sunlight.
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Premenstrual Dysphoric Disorder Persons suffering from this disorder experience a markedly depressed mood, excessive anxiety, marked irritability or anger, and mood swings. In addition there can be a decreased interest in activities, difficulty concentrating, lethargy, changes in appetite, and sleep disturbances. The symptoms begin to improve within a few days following onset of menstruation and then become minimal or absent in the week postmenses. The disorder is associated with interference with work, school, usual social activities, or relationships with others.
Substance/Medication-Induced Depressive Disorder This disorder is characterized by a prominent and persistent depressed mood and or a strikingly decreased interest or pleasure in all, or almost all, activities. The symptoms of this disorder are considered to be the direct result of the physiological effects of a substance such as a drug of abuse, a medication, or an exposure to a toxin. These substances cause clinically significant distress or impairment in social, occupational, or other areas of functioning. The depressed mood is the result of intoxication or withdrawal from substances such as alcohol, opioids, sedatives, hypnotics, anxiolytics, amphetamines, cocaine, or hallucinogens. Medications known to cause depression include antihypertensives, analgesics, anticonvulsants, cardiac medications, and many other classifications.
Depressive Disorder Due to Another Medical Condition People with medical conditions are more likely to suffer depression than those who enjoy good physical health. This disorder presents with symptoms associated with a major depressive episode that are the direct physiological consequences of a medical condition. The depression causes a persistent period of depressed mood or significantly decreased interest or pleasure in all, or almost all, activities. The depression causes significant anguish or impairment in social, occupational, or other important areas of functioning. Depression has been found to accompany a host of neurological, endocrine, metabolic, respiratory, cardiovascular, cancerous, gastrointestinal, and infectious conditions.
Disruptive Mood Dysregulation Disorder (DMDD) The American Psychiatric Association (2013) has included this new diagnostic category in the DSM-5 chapter on depressive disorders. Children may become depressed for many reasons, and the symptoms of depression can be manifested differently in children and change with age. DMDD is characterized by severe and recurrent temper outbursts that are wholly out of proportion in intensity or duration to the circumstances. These temper outbursts can be verbal (rages) or behavioral (physical aggression toward people or property). They occur, on average, three or more times a week for one year or more.
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Diagnosis of DMDD requires that the symptoms be present in at least two settings (home, school, with peers) for 12 or more months, and the symptoms must be severe in at least one of these settings. During this period the child will not have gone three or more consecutive months without symptoms. The onset must be before age 10 and a diagnosis should be made for the first time before age 6 or after age 18. The common factor leading to depression in children is loss. This can include physical or emotional indifference by a primary caregiver, parental separation or divorce, death of a loved person or pet, a move, scholastic failure, or physical illness.
EPIDEMIOLOGY In the United States 1 in 6 people experience a depressive episode during their lifetime, yet only 50% of the people who meet the criteria for diagnosis seek treatment (Swierzewski, 2011). In 2011, 6.6% of persons 18 or older had at least one major depressive episode in the past year (SAMHSA, 2012). Among children of pre-school age, 0.9% were reported to have depression, and among adolescents, 11% have a depressive disorder by age 18. Girls are more likely than boys to experience depression. Prevalence of major depressive disorder in college-age youths is about 8.7%, higher than any other adult age-group (Melnyk & Lusk, 2013). Major depression is the leading cause of disability among Americans age 15 to 44 (NIMH, 2013). The incidence of depressive disorder is 20% in women and 12% in men, and women experience depression beginning around age 10 and continuing throughout midlife. After age 65, women again are more likely to be depressed than are men. The incidence of persistent depressive disorder increases with advancing age, and this is especially true when associated with medical illness or institutionalization (Halverson, 2013). Studies have shown socioeconomic status to have an impact on the incidence of depression among youths, and as income decreased, the average prevalence of depression increased (Halverson, 2013). The CDC (2012) reports that blacks, Hispanics, and non-Hispanic persons of other races or multiple races are more apt to meet the criteria for major depression, as well as persons with less than a high school education, those previously married, those unable to work or unemployed, and people without health insurance coverage.
ETIOLOGY What causes the despair and anguish of depressive disorders? The etiology is unclear, and no single theory or hypothesis has been put forth that demonstrates a precise explanation for the ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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disorders. Studies continue to produce evidence supporting multiple causes, including the combined effects of genetics, biologic imbalances, psychosocial stressors, and interpersonal events that appear to trigger physiologic and chemical changes in the brain.
Biological Theories NEUROENDOCRINE DISTURBANCES The powerful secretions of endocrine glands—specifically the adrenal, thyroid, parathyroid, pituitary, and reproductive glands—are a source of many mood disturbances. It is well known that there are marked instabilities in mood with the administration of certain hormones or in the presence of an endocrine disease. Cortisol, a glucocorticoid hormone secreted by the adrenal glands, is known to be hypersecreted in depressed patients. The relationship between thyroid function and depression has long been accepted. It is recognized that disturbances in thyroid function can alter mental status significantly, both emotionally and cognitively. Both an excess and an insufficiency can cause changes in mood, but the underlying mechanisms are unknown. Because patients with depression may have normal thyroid function, a causal relationship remains to be clarified (Hage & Azar, 2012) GENETICS A genetic link has been suggested as a strong predisposing factor for depression. Various studies have been conducted involving twins, families, and adopted offspring showing evidence that a link exists; however, a definitive mode of genetic transmission has yet to be confirmed. BIOCHEMICAL INFLUENCES The influence of neurochemical transmission between neurons of the brain is the focus of intense research. Of particular interest are the biogenic amines norepinephrine, serotonin, acetylcholine, and dopamine. •
Norepinephrine levels are low in depression and high in mania. This biogenic amine energizes the body during stress and inhibits the process of seizure activity.
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Serotonin has many roles in behavior, including mood, cognition, pain, aggressiveness, biorhythms, and neuroendocrine processes. Because it is not possible to measure serotonin levels in the brain, there is no proof that it or any neurotransmitter is in short supply when depression or other mental illness develops. Blood levels of serotonin, however, are measureable and have been revealed to be lower in people with depression, but there is no evidence that blood levels reflect the brain’s level of serotonin (Bouchez, 2011).
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Acetylcholine alters mood, sleep, neuroendocrine function, and electroencephalographic patterns. It has been suggested that the problem in depression may be an imbalance between the biogenic amines and acetylcholine.
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Dopamine plays a significant role in motivation and is associated with the pleasure system of the brain, where its continued release gives feelings of joy. Dopamine is released in order to achieve something perceived as good or to avoid something perceived as bad. It is the central neurotransmitter to be considered for symptoms such as lack of energy, which occurs in depression (Salamone & Correa, 2012).
PHYSIOLOGIC INFLUENCES AND SECONDARY DEPRESSION Depressive symptoms occurring as a result of a non-mood disorder or as an adverse effect of certain medications are known as secondary depression. Secondary depression can be due to medication side effects, neurological disorders, electrolyte or hormonal disturbances, nutritional deficiencies, or other physiological or psychological conditions. •
Medications that can produce a depressive syndrome are those that have a direct effect on the central nervous system and include anxiolytics, antipsychotics, and sedativehypnotics. Other medications include antihypertensives such as propranolol and reserpine.
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Neurological disorders can result in depressive disorders. These disorders include stroke, brain tumors, Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease. Multiple sclerosis may also involve an underlying depression.
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Electrolyte disturbances, such as excessive levels of sodium bicarbonate or calcium and deficits in magnesium and sodium, can produce depressive symptoms. Potassium excess or depletion has also been connected to depressive disorders.
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Hormonal disturbances such as occur with Addison’s disease and Cushing’s syndrome are associated with depression. Imbalances of estrogen and progesterone have also been shown to predispose to premenstrual dysphoric disorder.
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Nutritional deficiencies may be implicated in the development of depressive disorders, but no definitive evidence exists to support any specific nutritional alteration in the cause of symptoms.
Psychosocial Theories of Depression PSYCHOANALYTIC THEORIES Freud (1963) likened major depression to bereavement, explaining, “In grief, the world becomes poor and empty; in melancholia, the ego (self) becomes empty.” He hypothesized that depressed individuals first love themselves (narcissism), then lose their love object (themselves), and as a consequence, suffer profound grief and depression. ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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Jacobson compared the state of depression with a situation in which the ego (the self) is powerless, a helpless child, victimized by the superego (conscience). Further, he likened the superego to a powerful, sadistic mother who takes delight in torturing the child, thus causing depression (Videbeck, 2011). COGNITIVE THEORY Beck suggested that the major disturbance in depression is cognitive rather than affective, the result of negative expectations of the world, the self, and the future. These three things are called Beck’s cognitive triad and are the result of a defect in cognitive development (Beck & Rush, 1995). LEARNING THEORY Seligman (1973) is famous for his theory of “learned helplessness.” He proposed that although anxiety is an initial response to a stressful situation, it is replaced by depression when individuals believe that problems in their lives are their fault and that there is nothing they can do to change them. This theory has been used to explain the prevalence of depression in lower socioeconomic groups. OBJECT LOSS THEORY This theory was introduced by Spitz (1946) and suggests that depressive disorders occur because of abandonment or separation from a significant other during the first six months of life. The absence of attachment can be either physical or emotional and leads to feelings of helplessness or despair, which contribute to lifelong patterns of depression in response to loss. It is suggested that losses as an adult result in depression if the person has suffered early childhood loss.
ASSESSING DEPRESSION Depression is not a condition like a broken bone or a sore throat that motivates the sufferers to seek help. Quite the opposite, depression depletes energy, promotes inaction, and slows mental processes. Even family members may not recognize the condition until a loved one displays obvious symptoms or attempts suicide. For this reason, it behooves caregivers to assess all patients for depression, no matter what their age, where they are seen, what their medical diagnoses are, and particularly if they are suffering chronic pain. Without cost or fanfare, caregivers can make a brief assessment for depression and, if indicated, refer the person to a mental health professional for a comprehensive assessment.
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Brief Assessment When assessing a person who may have depression, two questions should be asked: •
During the last month have you been feeling down, depressed, or hopeless?
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During the last month have you often been bothered by having little interest or pleasure in doing usually enjoyable things?
If a patient answers yes to either of the questions, the following should be asked: •
During the past month have you been bothered by . . . o Feelings of worthlessness? o Problems concentrating? o Thoughts of death?
Comprehensive Assessment A comprehensive assessment of depression includes gathering information about the individual’s family and personal history, general appearance, motor behavior, mood and affect, thought processes and content, judgment and insight, self-concept, roles and relationships, and physiologic responses and self-care. A formal rating scale may be useful. FAMILY AND PERSONAL HISTORY A family history of depressive disorders, suicides, or suicide attempts is valuable because these disorders occur more often in people who have family members with major depression. To assess the personal history of clients, caregivers ask both family members and afflicted individuals: • Have they experienced episodes of depression before? • When did these episodes occur? • How long did the episodes last? • What treatment was provided? • What was their response to the treatment? • Were they hospitalized for depression? • Have they ever attempted suicide?
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To assess the current episode of depression, caregivers ask afflicted individuals: • How are you feeling now? • When or how long have you felt this way? • What precipitated these feelings? • What have you done about your feelings? • Have you thought of hurting or killing yourself? GENERAL APPEARANCE AND MOTOR BEHAVIOR Depressed individuals usually show how they feel about themselves by the way they appear and behave. Often, their facial expression is fixed, they barely move, and they rarely smile. Sometimes depressed persons are distraught or irritable, but they are never truly joyful. Common psychomotor signs of depression are: •
Posture: slouched with head down or gazing into space
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Response to questions: negligible and slow; answers questions with one or two words or says, “I don’t know”; gives minimal eye contact
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Psychomotor retardation: slow body movement, little verbal interaction, limited cognitive processing
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Psychomotor agitation with anxiety: accelerated thoughts and body movement, difficulty sitting still, hand wringing, pacing, and sometimes argumentative
MOOD AND AFFECT In mild depression, clients may experience only a feeling of being down-hearted, “blue,” sad, discouraged, or irritable, but as depression increases in severity they may describe themselves as hopeless, helpless, worthless, a burden on others, and a failure. Common symptoms of mood and affect include: •
Anhedonia: lack of pleasure in activities they formerly enjoyed
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Apathy: little interest in almost everything
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Flat affect: expressionless; show no emotion, especially joy and hope
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Down-hearted: discouraged, feel blue or numb
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Easily provoked: frustrated and angry with self and others
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THOUGHT PROCESS AND CONTENT Thinking is difficult for severely depressed individuals. Both the processing of information and the content of thought is compromised. Negativity and pessimism prevail and hope vanishes. In mild depression a person might have some difficulty getting his mind off of a disappointment. As depression deepens, however, symptoms may include delusional thinking, confusion, indecisiveness, inability to concentrate, hallucinations, and strong thoughts of suicide. When clients have psychotic delusions (false ideas), they may believe they are responsible for all the tragedies of the world or the calamities of their family. When they suffer hallucinations (false perceptions), they may hear voices that condemn them and/or command them to punish themselves. Suicidal ideations are common. For this reason, it is vital to ask directly, “Are you thinking about hurting yourself or killing yourself?” Without hesitation, clients usually admit they have suicidal thoughts, although they may not have the energy to fashion a detailed plan. Common symptoms of a compromised thinking process and content include: •
Slow-motion thought processes and sometimes no verbal responses at all
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Compromised ability to solve problems, concentrate, or think clearly
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Impaired memory
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Rumination, repeating the same words over and over
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Negativity and pessimism, belief that things will never get better and nothing will help
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Self-deprecating, self-critical, focused on personal failures
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Suicidal ideation: thoughts of death and suicide
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Psychotic delusions and hallucinations: false ideas or perceptions, often guilt-ridden and pessimistic
JUDGMENTS AND INSIGHT Because of their apathy and negativity, depressed individuals use poor judgment and make poor use of their time because “it doesn’t matter anyway.” Clients who have suffered prior depressed episodes may have some understanding of their disorder, but most have no insight into their problem (Videbeck, 2011). Common judgment and insight issues include: •
Difficulty making decisions and solving problems
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Limited understanding of the feelings and behaviors of depression
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SELF-‐CONCEPT, ROLES, AND RELATIONSHIPS The self-concept of depressed individuals is extremely low. They may describe themselves as “worthless” and “good for nothing.” Often they feel guilt about poor decisions they have made and may declare their family “would be better off without me.” Depressed individuals have difficulty fulfilling work and family responsibilities. These failures confirm their feelings of worthlessness and complicate their relationship with others. Friends and family may not understand the depths of the disorder and believe the depressed person is lazy and “should just snap out of it and get on with life.” As depressed individuals feel less and less able to cope, they withdraw even more. Thus, selfconcept, roles, and relationship symptoms include: •
Low self-concept, feelings of worthlessness
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Poor decision making, feelings of guilt
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Failure in role responsibilities and relationships
PHYSIOLOGIC RESPONSES AND SELF-‐CARE Often, depressed individuals experience sleep disturbances, loss of appetite, weight loss or weight gain, dehydration, constipation, lack of interest in sex, and impotency. Because they lack energy or motivation, depressed individuals may disregard personal hygiene, neglect their children and their pets, and allow their homes to become dirty and cluttered. Physiologic responses and self-care symptoms commonly include: • Sleep disturbances • Appetite changes, weight loss or gain • Constipation • Impotency • Neglect of personal hygiene, living space, children, and pets
Assessment Tools Many rating scales have been designed to help professionals assess the severity of depression in clients. Some are meant to be clinician-administered and others may be self-administered. (See “Resources” at the end of this course for links to rating scales.)
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PREFERRED RATING SCALES The following tools meet the “gold standard” of rating scales: •
Hamilton Rating Scale for Depression (HAM-D or HRSD) (clinician-administered): Used to measure mood, guilt feelings, suicidal ideation, sleep disturbances, anxiety levels, and weight loss
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Beck Depression Inventory (BDI) (patient- or clinician-administered): Assesses depression in individuals ages 13 to 80 years, 21 items, administration takes 5 minutes
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Inventory of Depressive Symptomatology (IDS) (clinician-administered) or Quick Inventory of Depressive Symptomatology (QIDS) (patient-administered): Designed to assess the severity of depressive symptoms over the past 7 days; IDS takes 10 to 15 minutes to administer to a client; QIDS takes 5 to 7 minutes for the client to complete
OTHER RATING SCALES Other commonly used scales include: •
Zung Self-Report Depression Scale: Assesses the level of depression of patients diagnosed with depressive disorder; assesses four common characteristics of depression (physiologic, psychomotor, pervasive affect, and other disturbances); 21 items; scores fall into four ranges (normal, mild, moderate, and severe)
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Patient Health Questionnaire 9 (PHQ-9): A multipurpose tool for screening, diagnosing, monitoring, and measuring the severity of depression as well as the presence and duration of suicide ideation
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Clinical Global Impression-Severity Scale: A 7-point scale allowing the clinician to rate the illness-severity of a patient and compare results to the past
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Hartford Institute Geriatric Depression Scale: Assesses depression of elderly adults; 15 items, either self-administered or by a caregiver; scoring and evaluation provided in text of online source
SELF-‐SCREENING TESTS Numerous self-screening tests for depression are available without cost to the public via the Internet. These tests are designed to give individuals preliminary data about the presence of mild to moderate depressive symptoms. One of these tests is the NYU Langone Medical Center Depression Screening Test (see “Resources” at the end of this course). When such a test confirms depression, the person should be encouraged to consult a mental health professional for further assessment and care.
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ANALYZING AND DIAGNOSING DEPRESSION Caregiver/Nursing Diagnoses Caregiver/nursing diagnoses address functional issues that affect the care of depressed individuals. The table below gives some typical nursing/caregiver diagnoses, goals, and interventions for depressed individuals.
ADDRESSING FUNCTIONAL ISSUES Diagnosis
Outcome Goals
Interventions
Risk of suicide
Client will not harm himself/herself
Take suicide precautions; observe client closely and often
Complicated grieving
Client will discuss feelings, recognize own position in grief process while moving at own pace toward resolution
Encourage expression of the normal stages of grief and the client’s relationship with the lost entity
Disturbed sleep patterns
Client will establish a balance of rest, sleep, and activity
Plan with client and fulfill daily schedule to provide balance of rest, sleep, and activity
Nutritional imbalance
Client will establish a balance Plan and provide a diet of food and of adequate nutrition, hydration, water with dietitian, staff, and client and elimination
Self-care deficit
Client will carry out personal hygiene (bathing, dressing, grooming)
Create and check to see that self-care is maintained by client; assist as needed
Chronic low selfesteem
Client will evaluate selfattributes realistically
Check to see that client identifies at least one positive self-attribute each day and shares it with others
Anxiety
Client’s anxiety will lessen; he/she will learn measures that reduce anxiety
Teach client anxiety-reducing measures; administer prescribed medication(s)
Social isolation/impaired social interaction
Client will socialize appropriately with staff, peers, family, and friends
See that client participates in daily group therapy and keeps record of family interactions
Anergia, anhedonia, hopelessness
Client will comply with antidepressant regimen
Provide personal and/or group counseling; administer prescribed medication(s)
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Diagnosis
Outcome Goals
Interventions
Powerlessness
Client will effectively problemsolve ways to take control of his/her life
Encourage self-care responsibility, setting realistic goals, and identifying areas that can or cannot be controlled
Ineffective role performance
Client will feed, clothe, and care for her/his family
Refer client to home health service for follow-up care
Spiritual distress
Client will express achievement of support and personal satisfaction from spiritual practice
Contact spiritual leader of client’s choice, if requested, and encourage familiar religious practices for support
CASE Edna Fox is a 72-year-old widow admitted to the psychiatric unit for evaluation and treatment of depression. Her husband died six months ago, and Mrs. Fox has become more and more depressed and neglectful of herself and her home. A family member became concerned when visiting from out-of-state and took her to see her family doctor, who requested admission for evaluation and treatment of major depressive disorder. Following her nursing assessment, Sheila, the unit RN, reviews Mrs. Fox’s symptoms and develops a nursing care plan for her. One of the nursing diagnoses she includes is “self-care deficit as evidenced by an inability to bathe, groom, or dress herself independently.” Sheila understands that being clean and well-groomed can temporarily increase self-esteem and that slowed thinking and difficulty concentrating makes organizing simple tasks difficult. She chooses the following interventions. 1. Assist with self-care needs to avoid energy expenditure and frustration 2. Ensure that bathing, hygiene, and grooming supplies and utensils are readily available 3. Give step-by-step reminders while assisting with self-care activities 4. Use consistent routines and allow adequate time for self-care tasks Sheila determines the expected outcome will be that Mrs. Fox will safely perform self-care activities to her maximum ability.
Medical Diagnoses Just as caregivers/nurses analyze data and identify diagnoses, goals, and interventions, advance practice nurses, psychologists, and psychiatrists interview depressed clients, analyze assessment findings, and diagnose disorders. The American Psychiatric Association (2013) identifies the criteria upon which a depressive disorder can be diagnosed. The following are three examples of those criteria. ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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MAJOR DEPRESSIVE DISORDER (MDD) DIAGNOSTIC CRITERIA 1. Five or more of the following symptoms reported subjectively or observed by others have been present over a two-week period and represent a change from previous functioning; at least one of the symptoms is either a depressed mood or loss of interest or pleasure: •
Depressed mood most of the day and nearly every day
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Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
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Changes in appetite nearly every day; in children, failure to make expected weight gain
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Psychomotor agitation or retardation nearly every day
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Significant weight loss or gain: more than 5% of body weight in 1 month
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Insomnia or hypersomnia nearly every day
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Chronic fatigue, low energy nearly every day
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Feelings of worthlessness/guilt nearly every day
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Difficulty thinking, concentrating, or making decisions nearly every day
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Recurrent thoughts of death or suicide, plans, or attempt
2. Symptoms cause significant distress in social, occupational, or other important areas of functioning 3. Symptoms cannot be attributed to the physiological effects of a substance or other medical condition 4. The occurrence of MDD is not better explained by other psychiatric psychotic disorder 5. Specifiers/special features: •
With anxious distress
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With mixed features
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With melancholic features
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With atypical features
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With mood-congruent psychotic features
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With mood-incongruent psychotic features
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With catatonia
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With peripartum onset
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With seasonal pattern Source: APA, 2013.
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PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA) DIAGNOSTIC CRITERIA 1. Depressed mood for most of the day, for more days than not for at least two years, reported subjectively or through observation by others 2. Presence, while depressed, of two or more of the following: •
Poor appetite or overeating
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Insomnia or hypersomnia
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Low energy or fatigue
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Low self-esteem
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Poor concentration or difficulty making decisions
•
Feelings of hopelessness
3. During the two-year period (one year for children or adolescents), the person has never been without the above symptoms for more than two months at a time 4. Criteria for a major depressive disorder may be continuously present for two years 5. There has never been a manic episode or hypomanic episode, and criteria have never been met for cyclothymic disorder 6. The symptoms cannot be attributed to the physiological effects of a substance or another medical condition 7. The symptoms cause major impairment in social, occupational, or other areas of functioning 8. Specifiers include: •
With anxious distress
•
With mixed features
•
With melancholic features
•
With atypical features
•
With mood-congruent psychotic features
•
With mood-incongruent psychotic features
•
With peripartum onset
•
With pure dysthymic syndrome
•
With persistent major depressive episode
•
With intermittent major depressive episodes, with current episode
•
With intermittent major depressive episodes, without current episode
•
In partial remission
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•
In full remission
•
Early onset (before 21 years)
•
Late onset (21 years or older)
•
Mild
•
Moderate
•
Severe
Source: APA, 2013.
PREMENSTRUAL DYSPHORIC DISORDER DIAGNOSTIC CRITERIA 1. For a majority of menstrual cycles, five or more symptoms must be present in the final week before the onset of menstruation, then start to improve within a few days after the onset, and become minimal or absent in the week after menstruation ends 2. One or more of the following must be present: •
Significantly depressed mood
•
Irritability, anger, or increased interpersonal conflicts
•
Mood swings
•
Excessive anxiety
3. Additionally, one or more of the following must be present to reach a total of five when combined with criteria #2 above •
Decreased interest in usual activities
•
Difficulty concentrating
•
Lethargy or significant lack of energy
•
Changes in appetite, overeating, or having food cravings
•
Insomnia or hypersomnia
•
Feeling overwhelmed, out of control
•
Physical symptoms including breast tenderness or swelling, joint or muscle pain, a bloating sensation, weight gain
4. Symptoms are associated with significant interference with school, work, social activities, or relationships •
Symptoms are not part of the physiological effects of a substance, another psychiatric disorder, or medical condition Source: APA, 2013.
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CASE Avery is a 19-year-old female college student who has been referred to the on-campus healthcare center to meet with a nurse practitioner for psychiatric evaluation following a physical altercation with her roommate. The roommate reports that Avery has been very depressed off and on and has been having increasing problems with her relations with classmates. During her evaluation, Avery reports that she has always had mood swings that were related to her menstrual cycle, but things have been getting “out-of-hand lately.” She reports being severely depressed during the week before menstruation begins, and she gets extremely irritable and angry over “little things.” She reports that when her period starts, she begins to feel better, and she always feels back to normal after her period ended. Now, however, the symptoms seem to continue, although milder, until the week before her period begins again. She reports she is currently failing some of her classes, has problems concentrating, and feels very overwhelmed with everything she cannot seem to accomplish. She denies any drug or other substance use and denies any history of mental or physical disorder. A recent physical exam was within normal limits. She is not taking any medications. During the evaluation Avery begins to sob and says she is feeling bad about losing control and striking her roommate. “I have never done anything like that before,” she says. Following complete assessment, the nurse practitioner determines that Avery meets the criteria for the diagnosis of premenstrual dysphoric disorder. A plan of care is discussed with Avery that includes a nutritional supplement, an antidepressant medication, and lifestyle modifications. The nurse suggests Avery begin to take a calcium supplement for two weeks prior to the start of her menstrual periods, which will assist in reducing any physical symptoms and is known to improve mood. Because her symptoms are moderate to severe, Avery is given a prescription for Effexor, an SSNI antidepressant, along with a patient medication information sheet. In addition, the nurse provides her with a list of lifestyle modifications that are known to be of benefit for treatment of premenstrual dysphoric disorder. The list includes: 1. Begin a program of regular aerobic exercise 2. Do not skip meals and maintain a regular routine for mealtimes 3. Eat a diet that includes complex carbohydrates and avoid refined sugars 4. Get 6–8 hours of sleep each night 5. Reduce caffeine, alcohol, red meat, and salty food consumption 6. Practice relaxation techniques 7. Quit smoking
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At the conclusion of the visit, the nurse recommends a follow-up appointment in two weeks and provides a referral for therapy.
INTERVENTIONS Psychopharmacology Interventions Because scientific evidence suggests that depressive disorders are caused by a flaw in chemistry, not in character, it is logical to conclude that drugs that alter brain chemistry play an important role in psychiatric treatment (Bussing, 2011). Psychopharmacology requires an understanding of how the brain works or functions, consideration of the effects of various drugs, and information about their availability. BRAIN FUNCTION AND DRUG TREATMENT The brain is composed of millions of nerve cells, or neurons, that conduct electrical impulses from one to another. Although nerve cells come in a great variety of shapes and sizes, they all perform the same functions. They 1) respond to stimuli, 2) conduct electrical impulses, and 3) release and receive chemicals called neurotransmitters. Neurotransmitters are chemical substances that function as messengers. When a neuron is stimulated, it releases a neurotransmitter, which defuses across a narrow space, or synapse, to an adjacent neuron. There, the neurotransmitter attaches to specialized receptors on the cell surface, either inhibiting or exciting the neuron. The exchange between the transmitter (presynaptic) cell and the receptor (postsynaptic) cell allows a neuron to communicate with the next. Depending on the chemical structure of the transmitter cell and type of receptor cell, the receptor will be more or less likely to initiate an electrical impulse. This interaction is the major target of drugs used to treat psychiatric disorders (Varcarolis et al., 2011). After neurotransmitters relay their message to receptor cells, one of two things happens. Neurotransmitters either return from the synapse to the presynaptic cell for later use in a process called cellular reuptake, or neurotransmitters are inactivated/destroyed by a specific enzyme. For example, norephinephrine, dopamine, and serotonin are destroyed by an enzyme called monoamine oxidase (MAO). Psychopharmacologic treatment is based on the theory that normality of the neurotransmitter systems can be restored by: 1. Stimulating the release of neurotransmitters 2. Inhibiting neurotransmitter breakdown 3. Blocking neurotransmitter reuptake at the presynaptic nerve ending (Meyer & Quenzer, 2013) ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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These actions are believed to affect the brain based upon the efficacy of certain drugs but are not proof that depression is caused by lack of a specific neurotransmitter.
NEUROTRANSMITTERS AND ASSOCIATED DISORDERS Neurotransmitter
Effects/Actions
Disorders Related to Neurotransmitter Amounts
Dopamine
Integrates emotions and thoughts; affects decision making, motivation, and feelings of reward; stimulates hypothalamus to release hormones (sex, thyroid, adrenal)
Decreased: Depression, Parkinson’s disease Increased: Schizophrenia, mania
Serotonin
Regulates mood, sleep, hunger, and pain perception; affects aggression and sexual behavior
Decreased: Depression Increased: Anxiety states
Norepinephrine
Regulates mood; stimulates sympathetic branch of autonomic nervous system in response to stress
Decreased: Depression Increased: Mania, anxiety states, schizophrenia
Histamine
Affects alertness and feelings of joy and success; affects inflammatory response; stimulates gastric secretions
Decreased: Sedation, depression, weight gain Increased: Anxiety
Gammaamnobutyric acid (GABA)
Reduces aggression and anxiety; plays a role in inhibition, pain perception, and muscle relaxation
Decreased: Anxiety disorders, schizophrenia, Huntington’s chorea Increased: Reduced anxiety
Acetylcholine (ACh)
Plays a major role in cortical circuitry, learning, and memory; regulates mood and sexual aggression; stimulates parasympathetic nervous system
Decreased: Alzheimer’s disease, Huntington’s chorea, Parkinson’s disease Increased: Depression
Source: Adapted from Vascarolis et al., 2011.
CONSIDERATIONS IN DRUG CHOICES All neurotransmitters affect mood, but they don’t affect every person in the same way or to the same extent. For this reason, it may be necessary to try different antidepressants or combinations of drugs to find the most effective treatment.
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In addition to client responsiveness, drugs have different costs, safety features, and maintenance considerations. These factors affect how faithfully a client follows the prescribed plan of care. Some of these important considerations are: •
Safety: risk of suicide, medical factors, history of prior drug responses
•
Effectiveness: neurotransmitter specificity
•
Side effects: weight gain, dry mouth, blurred vision, sexual dysfunction
•
Ease of administration: daily oral dose versus monthly intramuscular injections
•
Blood-level testing: required frequency, availability
•
Cost of medication: out-of-pocket versus insurance-paid
ANTIDEPRESSANT MEDICATIONS Drugs used for the treatment of depression include: • Selective serotonin reuptake inhibitors (SSRI) • Tricyclics • Serotonin-norepinephrine reuptake inhibitors (SNRIs) and heterocyclics • Monoamine oxidase inhibitors (MAOI) Selective Serotonin Reuptake Inhibitors (SSRIs) SSRIs are recommended as first-line therapy for all types of depression except those with psychotic and melancholic features (see “Diagnostic Criteria” tables above). SSRIs are effective for most clients, and since they have low cardiotoxicity, they are safer for older adults. In addition, these drugs have a low suicide-lethality risk and low incidence of anticholinergic side effects (dry mouth, blurred vision, sweating, sexual dysfunction, urinary retention). As a result, clients are more likely to comply with treatment regimes of these drugs. SRRI antidepressants include: • • • • • • • •
Fluoxetine (Prozac; Serafem) Fluvoxamine (Luvox) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro) Vilazodone (Viibryd) Vortioxetine (Brintellix) ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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SSRI SIDE EFFECTS AND CAREGIVER RECOMMENDATIONS
Side Effect
Caregiver Recommendations
Insomnia and/or agitation
Administer early in the day; avoid caffeinated food and drinks; teach relaxation techniques to use at bedtime
Headache
Administer analgesics as prescribed
Weight loss
Provide with sufficient caloric intake to maintain desired weight; weigh daily or every other day at the same time, on the same scale
Sexual dysfunction
If side effect becomes intolerable, switch to another medication when necessary
Serotonin syndrome
Monitor vital signs, provide safety measures, assist with temperature regulation, monitor intake and output
Source: Townsend, 2014.
CASE Jennifer, a 42-year-old accountant, had recently been diagnosed with persistent depressive disorder with anxious distress and was started on citalopram (Celexa) five weeks ago. Today she came in to her psychiatrist's office because of a “personal problem.” Marjorie, the office nurse, obtained a history of her present complaint. Jennifer said that lately she has lost all interest in sex, and when she and her husband do have intercourse, she finds no enjoyment in it and no longer has orgasms. She said her sexual desires have always been strong before but wonders if the Celexa is causing the problem, which has now become intolerable and is making her depression and anxiety even worse. Following her visit with the psychiatrist, Marjorie met with Jennifer again to discuss the new medication being prescribed and to address any other concerns she may have. Jennifer was given a prescription for Viibryd (vilazodone). She said the doctor explained that this drug is technically an SSRI, but it has a second action. She said she understood what serotonin was and how the Celexa worked, but she was not able to recall what she had been told about this new drug. Marjorie drew a picture for Jennifer to help her understand. The picture showed a presynaptic nerve ending, the synapse, and the postsynaptic nerve ending. She described how the SSRI she had been taking prevented the reabsorption of serotonin back into the presynaptic nerve end, and that the new medication pretends to be serotonin and activates the receptors of the postsynaptic nerve ending. She told Jennifer that this second action helps reduce side effects such as loss of sexual interest, but as yet it is not known exactly how or why. At the end of the visit, Marjorie provided Jennifer with written directions for stopping Celexa and starting the new medication. ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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Tricyclic Antidepressants (TCAs) Tricyclic antidepressants (TCAs) are the oldest antidepressant drugs and the least costly because they are available in generic forms. Tricyclics inhibit the reuptake of norepinephrine and serotonin, and thus they increase the time norepinephrine and serotonin are available to the postsynaptic receptor. It is believed this factor accounts for their ability to elevate mood. In addition to treating depression, these drugs are used to treat such conditions as panic disorder, obsessive-compulsive disorder, and eating disorders. Unfortunately, there are many drawbacks to tricyclic drugs. They take 2 to 6 weeks to begin taking effect, they produce anticholinergic side effects (dry mouth, weight gain, sweating, blurred vision, sexual dysfunction), and an overdose can be lethal. Furthermore, tricyclics must be used cautiously with people with glaucoma, liver impairment, diabetes mellitus, cardiovascular disease, renal impairment, and respiratory disorders. Some common tricyclic antidepressant drugs are: • • • • • • • • •
Amitriptyline Amoxapine Clomipramine (Anafranil) Doxepin (Sinequan) Imipramine (Tofranil) Desipramine (Norpramin) Nortriptyline (Aventyl, Pamelor) Protriptyline (Vivacil) Trimipramine (Surmontil)
TCA SIDE EFFECTS AND CAREGIVER RECOMMENDATIONS
Side Effect
Caregiver Recommendations
Blurred vision
Instruct not to drive until vision is clear; clear walkways to avoid falls; offer reassurance of the short-term of this side effect
Constipation
Offer a high fiber diet and encourage increased fluids and physical activity
Urinary retention
Encourage reporting of hesitancy or inability to void; monitor intake and output; offer methods to stimulate urination (warm water, running water)
Orthostatic hypotension
Instruct patient to rise slowly from lying or sitting and to avoid long hot showers or baths; monitor orthostatic blood pressures
Reduced seizure threshold
Follow seizure precautions
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Tachycardia or arrhythmias
Monitor blood pressure and pulse
Photosensitivity
Encourage the use of sunblock, sunglasses, and protective clothing
Source: Townsend, 2014.
Serotonin-‐Norepinephrine Reuptake Inhibitors (SNRIs) and Heterocyclics SNRIs and heterocyclics increase serotonin levels as well as norepinephrine, two neurotransmitters important in mood regulation. SNRIs include: • • •
Desvenlafaxine (Pristiq) Duloxetine (Cymbalta) Venlafaxine (Effexor)
Heterocyclics include: • • • • •
Bupropion (Wellbutrin) Maprotiline Mirtazapine (Remeron) Nefazodone Trazodone
SNRI SIDE EFFECTS AND CAREGIVING RECOMMENDATIONS* Side Effect
Caregiver Recommendations
If taking bupropion . . .
Give doses at least 4 hours apart
Priapism in men taking trazodone
Withhold medication and notify physician immediately if prolonged or inappropriate penile erection occurs
Hepatic failure in persons taking nefazodone
Observe for jaundice, anorexia, GI complaints, or malaise
* Heterocyclics have the same side effects as tricyclics. Source: Townsend, 2014.
Monoamine Oxidase Inhibitors (MAOIs) The enzyme monoamine oxidase is responsible for inactivating such amines as serotonin, norepinephrine, dopamine, and tyramine—all neurotransmitters that raise the mood of individuals. Thus, when a person ingests an MAO inhibitor, mood-elevating neurotransmitters are not broken down and they are available for synaptic release. ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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An increase in tyramine can also create problems; it can increase blood pressure and cause a hypertensive crisis and cerebrovascular accidents. For this reason, those taking MAOIs must reduce their intake of foods and drugs that contain high levels of tyramine. These include fermented or smoked products such as bacon, ham, bologna, aged cheeses, red wines, and chicken or beef liver. Individuals who are seriously depressed may not be able to adhere to these dietary limitations. Furthermore, there is a 2- to 4-week lag period before MAOIs reach therapeutic levels. Before clients can start a different antidepressant drug, they must wait at least 5 weeks for the body to eliminate residual MAOIs. Common MAOIs include: • • • •
Isocarboxazid (Marplan) Phenelzine (Nardil) Tranylcypromine (Parnate) Selegiline transdermal system (Ensam)
MAOI SIDE EFFECTS AND CAREGIVING RECOMMENDATIONS
Side Effect
Caregiver Recommendations
Hypertensive crisis
Can occur if foods containing tyramine are ingested; observe for occipital headache, palpitations, chest pain, nausea or vomiting, nuchal rigidity, fever, sweating, significantly increased blood pressure, and coma; monitor vital signs; administer prescribed antihypertensives; use external cooling measures if fever is present
Skin reactions in those using transdermal system (Emsam)
Topical corticosteroids can be used for treatment; if problematic, report to physician
Electroconvulsive Therapy (ECT) Electroconvulsive therapy (ECT) is a controversial treatment for major depression. ECT involves applying electrodes to the head and delivering a small electric impulse to the brain. The mechanism of action is unknown but has been effective for individuals who cannot take or do not respond to antidepressant drugs as well as for those who are at high risk for suicide. It is often chosen only after a trial of therapy with medications has proved ineffective. ECT is safe for pregnant woman and the fetus (Mayo Clinic, 2012a). ECT was first used in the 1930s as a treatment for patients with a wide range of severe mental disturbances and was also used to control difficult patients. Many of the general public and psychiatrists opposed its use because it seemed brutal and uncivilized. Often patients who received ECT described it as frightening.
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Historically, clients did not receive sedation or anesthesia before ECT. They were placed on a bed or table, electrodes were attached to their heads, and they were held down by attendants as the electric current produced a grand mal seizure. After a long, deep sleep, they gradually awoke, confused, disoriented, often with significant memory loss and broken bones. Nowadays ECT is administered in a hospital to anesthetized clients who have received muscle relaxants. Carefully calculated current, monitored by an electroencephalogram, is passed through one or both sides of the brain, resulting in a carefully controlled seizure that lasts 20 to 90 seconds. Clients awaken in 5 to 10 minutes and may have short term amnesia. Commonly, a course of treatment is 3 times a week for 2 to 5 weeks. After an initial course of treatment, ECT may be administered on an outpatient basis if needed. Common side effects include memory loss for recent memories, which usually returns in a few days or weeks, and confusion. Retrograde memory loss can extend back to months before treatment. Elderly patients may experience cardiac problems such as bradycardia or tachycardia and an increased risk for falls. Death from ECT is rare, with the major cause of death from cardiovascular complications. Currently there remain critics and proponents of ECT. Review of the literature indicates that there is strong evidence of persistent, and for some people, permanent brain dysfunction, mostly in the form of retrograde and anterograde amnesia, along with a slight but significant increased risk of death. “The cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified” (Read & Bentall, 2010). In contrast, the opposite point of view notes that there is no evidence to support the claim that ECT produces any permanent changes in brain structure or functioning (McClintock & Husain, 2011).
Transcranial Magnetic Stimulation (TMS) Transcranial magnetic stimulation is a relatively new treatment for patients who have not responded to more conventional treatments for depression. TMS treats depression by stimulating nerve cells in the brain using very short pulses of magnetic energy similar to the electrical activity observed with ECT. Waves are passed through a coil placed on the scalp to areas of the brain involved in mood regulation. Exactly how it works is unknown, but its use appears to alleviate depressive symptoms and improve mood. Unlike ECT, TMS does not cause generalized seizure activity in the majority of cases. TMS does not require hospitalization, requires no anesthesia, is less expensive than ECT, and is relatively free of serious side effects. Common side effects include headache; scalp discomfort at application site; spasms, tingling, or twitching of facial muscles; and lightheadedness. More serious side effects include seizures, mania in persons with bipolar disorder, and hearing loss from inadequate ear protection during the procedure. Studies are underway to determine its effectiveness, what techniques work best, and whether there are any long-term side effects (Mayo Clinic, 2012b).
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Light Therapy The use of artificial light that mimics natural outdoor light is used for treating major depressive disorder, recurrent, with seasonal pattern, commonly referred to as seasonal affective disorder (SAD). This disorder is thought to be related to melatonin, which is produced by the pineal gland and plays a role in regulating biological rhythms for sleep and activation. Melatonin is produced nocturnally and stops in daylight. During months of longer darkness, there is an increase in melatonin production that seems to trigger symptoms of depression in susceptible persons. This is a form of treatment that is comparable to the use of antidepressant medications, but with fewer adverse effects. Persons receiving light therapy sit with eyes open in front of a box containing white fluorescent lights with a screen that blocks ultraviolet rays. Treatment lasts for 10 to 15 minutes initially and progresses to 30 to 45 minutes. Some patients experience improvement within a few days, and others may take several weeks before feeling better. Side effects seem to be dosage related and include headache, eyestrain, nausea, irritability, photophobia, insomnia, and rarely, hypomania.
Vagus Nerve Stimulation (VNS) This new FDA-approved modality is effective for treatment-resistant depression. Currently it is not widely available, and studies continue to be done to determine how it works and its effectiveness. It induces changes in brain metabolism in areas of the brain associated with depression and involves activation of brainstem regions associated with dopamine activity. The treatment requires a surgical procedure to insert the VNS device, which delivers electronic stimulus to the vagus nerve every 5 minutes (Lowry, 2013).
Psychotherapeutic Interventions Psychotherapy is commonly referred to as talk therapy or counseling. Psychotherapy uses shortterm approaches that have been found to be effective for the treatment of psychiatric disorders including depression and is effective as a primary treatment for major depression. The role of psychotherapy is to help patients develop coping strategies to deal with everyday stressors. It is the therapist’s responsibility to provide a safe environment and a caring therapeutic milieu. Psychotherapeutic approaches are employed by healthcare practitioners who specialize in psychotherapy. These professionals may be advanced-practice nurses, marriage and family therapists, social workers, psychologists, and psychiatrists. There are various types of psychotherapy that can be given in a variety of formats and approaches. TYPES OF THERAPY •
Individual therapy involves only the patient and the therapist in private sessions. ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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•
Group therapy involves two or more patients and the therapist participating in therapy at the same time. They can share their experiences and hear that others feel the same way and have had similar experiences.
•
Marital/couples therapy helps spouses and partners deal with troublesome issues in their lives and learn new behaviors.
•
Family therapy relies on awareness that the family is a major part of the team that helps persons with mental illness improve. It is helpful for family members to understand what the depressed person is experiencing, how they can help, and how they can cope
THERAPEUTIC APPROACHES •
Psychodynamic therapy is based on the assumption that a person is having difficulties due to unresolved, mostly unconscious conflicts that stem from childhood. The goal of psychodynamic therapy is to gain understanding and learn to cope better with these feelings by talking about experiences. This approach takes generally 3 to 4 months but can last for years.
•
Interpersonal therapy is focused on behaviors and interactions a person has with family and friends. Its main goal is improving communication skills and increasing self-esteem in a short span of time, usually 3 to 4 months. This approach works well for persons depressed due to bereavement, relationship conflicts, major life events, and social isolation.
•
Cognitive behavior therapy is designed to help identify and change patients’ inaccurate perceptions both of themselves and the world around them. It can be done individually or in groups and focuses on the immediate present. It is interested in what and how, more than why, persons think the way they do. This approach requires the patient and therapist to actively work together to challenge irrational beliefs and requires homework by the patient. Therapy is problem-focused and goal-directed, helping to establish new ways of thinking about wrong or right assumptions. This approach has been shown to be as effective as antidepressant medications for some with depression and superior in preventing relapse. Cognitive behavior therapy is time-limited, lasting 14 to 16 weeks.
DEPRESSION AND SUICIDE A high risk of suicide is one of the costs of depression. The American Association of Suicidology (2012) points out that suicide is the tenth leading cause of death in the United States and the second leading cause of death for ages 15 to 24 years. Depressive disorders account for 80% of those suicides. These are the numbers for completed suicide, but many more attempt suicide than succeed, and many, many others contemplate suicide without carrying it out. The nursing diagnosis for a person who is suicidal may address many areas, but the highest priority is “risk for suicide.” Feelings of hopelessness, anger, poor impulse control, frustration,
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abandonment, and rejection are common among people who are suicidal, and suicide is often related to a loss. A suicidal person may present with overt or covert clues, has a plan, and is in a high-risk category on assessment (elderly, teenager, isolated, depressed, has had a recent loss). If suicidal intent is low, the person may be treated in outpatient settings. Arrangements must be made so that the person is not left alone and that the environment is free of dangerous items such as firearms. If there is no family or friends, then the person should be hospitalized. When such patients are hospitalized, they are put on suicide precautions or one-to-one observation (Andrew, 2012). Even in a psychiatric unit, the condition of depressed patients is dynamic, changing from hour to hour. As antidepressant medications begin to take effect, patient outlook and behavior changes. On admission, they may be too depressed to carry out a plan of suicide. However, as energy returns, they may gain enough energy to carry out their plan. For that reason, suicide precautions and caregiver vigilance should increase rather than decrease with time. SUICIDE PRECAUTIONS The patient: • Suicide precautions for a patient assessed as actively suicidal include one-on-one monitoring at all times including during toileting and during the night. •
Suicide observations include a 15-minute visual check when the patient is not assessed to be actively suicidal.
•
For each of the above, behavior, mood, and verbatim statements are recorded in the chart every 15 minutes.
The environment: • Use plastic utensils. •
Do not assign to a private room.
•
Hang-proof the bathrooms; install break-away shower rods and recessed shower nozzles.
•
Keep electrical cords to a minimal length.
•
Install unbreakable glass in windows and keep windows locked.
•
Lock all utility rooms, kitchens, stairwells, and offices.
•
Take all potentially harmful gifts from visitors before allowing them to see the patient.
•
Go through belongings with the patient and remove all potentially harmful objects.
•
Ensure that visitors do not leave potentially harmful objects in the patient’s room.
•
Search patients for harmful objects on return from pass. ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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INTERPERSONAL SUPPORT AND THERAPEUTIC COMMUNICATIONS The relationship between nurse or other healthcare practitioner and patient is different from a social or intimate relationship. The therapeutic relationship is focused on the patient’s needs, thoughts, feelings, and goals and not those of the provider. Genuineness, positive regard, and empathy are personal strengths in the helping person that foster growth and change in others. The nurse and patient identify areas that need exploration and periodically evaluate the degree of change in the client. The nurse may assume a variety of roles, such as teacher, counselor, socializing agent, and liaison of change. Within the context of the helping relationship, alternate problem-solving approaches are taken, new coping skills may develop, and behavioral change is encouraged. •
Genuineness is the ability to be at home with one’s self, to meet person to person, listening and communicating without distorting messages, and being clear and concrete in communication.
•
Positive regard implies respect. It is the ability to view another person as being worthy of caring about and as someone who has strengths and achievement potential. Respect is shown indirectly by actions such as attending (being fully present) and suspending value judgments.
•
Empathy is the ability to see things from another person’s perspective and to communicate this understanding to the other person. It denotes understanding and acceptance of the patient and his or her situation and tells the patient that the caregiver understands.
In order to give supportive care to depressed individuals, caregivers: •
Establish a connection with clients: Introduce yourself. Reach out in kindness. No matter how depressed a person may be, they will know you are there and you care. They may be silent, agitated, or freely respond. Self-disclosure, even in minor things, establishes trust and connection with others. For example, in the clinic, a receptionist can say, “My name is Julie, what’s yours?”
•
Demonstrate care: You may not be able to “do anything” and feel quite useless or even frustrated. Yet, by simply “being there” you convey a message of genuine interest and concern.
•
Affirm by your behavior that the depressed individual is valuable and autonomous and that there is hope—the very opposite of feelings of worthlessness, helplessness, and hopelessness. These messages can be offered in simple ways, such as giving patients or clients choices, affirming their value, and mentioning future events. If clients begin to communicate, allow them to lead the conversation.
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CASE Glenna celebrated her sixteenth birthday three weeks ago. She had hoped things would change and that everything she hated about herself and her life would get better. They hadn’t. In fact, she never felt so low in her entire life. Her period had not come, there were two new zits on her face, and she felt awful. Glenna could barely get out of bed in the morning, she hadn’t done her homework, and she couldn’t concentrate on anything. Her boyfriend Harold was avoiding her, and she just wanted to die. In fact, she had been thinking about ways to kill herself. Last month Glenna had done something she couldn’t tell her mother about, or even her girlfriends. Harold had asked her to go to a party at his house, but when she got there, nobody else was around. They sat on the couch, drank sodas, and looked at the TV. Pretty soon they began to fool around. He touched her breasts and other places, and before long, she let him “go all the way” with her. On Monday, Harold acted as if he didn’t even know her. As the days went by, Glenna became more and more depressed and fearful. What if he had given her a disease? What if she were pregnant? Glenna had heard about a nonprofit women’s clinic that was just two blocks from school. The next day she told her mother she had to work on a project and would be a little late getting home. After class, Glenna started down the street to the clinic. She could barely walk; she felt totally exhausted. When she got to the clinic, Glenna walked up to the door, opened it, and looked around. There was a person sitting in the waiting room and a young woman standing at the reception desk. “Hello. Can I help you?” The receptionist smiled as she spoke. Glenna moved toward the desk hesitantly. “Well . . . I guess so. I, I need . . . I need to talk to someone.” Glenna didn’t really know what she needed. She felt befuddled and even more confused than before. “Would you like to talk to our nurse? She’ll be available in just a few minutes. You can sit here while you wait.” The receptionist nodded toward the chairs and kept talking. “My name is Julie; what’s yours?” The receptionist’s sincere smile relieved some of Glenna’s anxiety. “Glenna . . . Yes, yes, I guess so . . . I just want to ask a few questions.” Her voice trailed off to a whisper. In a few minutes a woman dressed in a white lab coat opened the door from the clinic and stepped to the receptionist desk and then to where Glenna was sitting. “Hi. I’m Cyndi, the nurse. Are you Glenna?” Glenna nodded. “Julie told me you’d like to speak to someone. I’ll be happy to talk with you, but let’s go back to my office. It’s more private there.” Glenna felt relieved and followed Cyndi through the door, down the hall, and into a small office. When they were seated, Cyndi said, “Now, what is it that’s troubling you?” Glenna burst into tears and she told the whole story of how she felt so ugly, how no one liked her, and then how Harold asked her to his house and what happened there. She admitted she ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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was thinking of killing herself. “Let’s start by finding out if you really are pregnant. Then we’ll take it from there. Sometimes women have irregular periods.” Cyndi had a practical yet kind and hopeful spirit about her. She gave Glenna accurate empathy, genuine concern, and nonjudgmental warmth. Although Glenna still felt frightened, she felt a glimmer of hope.
Family and Individual Education Whether depressed persons are hospitalized in a psychiatric unit or served by caregivers outside the hospital, they and their families need to learn about the illness of depression and the medications they are taking. Some important learning objectives are: • Teach about the illness of depression. • Identify early signs of relapse. • Discuss the importance of support groups and assist in locating resources. • Teach the client and family about the benefits of therapy and follow-up appointments. • Encourage participation in support groups. • Teach the action, side effects, and special instructions regarding medications. • Discuss methods to manage side effects of medication. (Videbeck, 2011)
CONCLUSION Depression is the leading cause of disability in the United States, often associated with medical and other mental disorders. It is caused by many factors, both chemical and psychological, and often goes untreated for years. Thus, caregivers must increase their awareness of depression, recognize its key elements—depressed mood, lack of pleasure or enjoyment in usual things, (anhedonia), and lethargy (anergia)—and take action, especially when there is risk of suicide. They should give every client nonpossessive warmth, genuineness, accurate empathy, and unconditional positive regard, and refer depressed individuals to professionals for psychiatric evaluation.
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RESOURCES Beck Depression Inventory II (BDI-‐II) pearsonclinical.com/psychology/products/100000159/beck-‐depression-‐inventoryii-‐bdi-‐ii.html Clinical Global Impression-‐Severity Scale (CGI-‐S) ncbi.nlm.nih.gov/pmc/articles/PMC2880930/ Hamilton Rating Scale for Depression healthnet.umassmed.edu/mhealth/HAMD.pdf Hartford Institute Geriatric Depression Scale (Short Form) consultgerirn.org/uploads/File/trythis/try_this_4.pdf Inventory of Depressive Symptomatology (IDS or QIDS) ids-‐qids.org National Institutes of Mental Health nimh.nih.gov/health/publications/depression/ New York University Langone Medical Center, Depression Screening Test psych.med.nyu.edu/patient-‐care/screening-‐tests/depression-‐screening-‐test Patient Health Questionnaire 9 (PHQ-‐9) integration.samhsa.gov/images/res/PHQ%20-‐%20Questions.pdf Zung Self-‐Rating Depression Scale healthnet.umassmed.edu/mhealth/ZungSelfRatedDepressionScale.pdf
REFERENCES American Association of Suicidology. Suicide in the USA based on 2010 data. Washington, DC: Author. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-‐5). Washington, DC: Author. Andrew LB. (2012). Depression and suicide. Retrieved from http://emedicine.medscape.com/article/805459-‐ overview#aw2aab6b4. Beck AT & Rush AJ. (1995). Cognitive theory. In HI Kaplan & BJ Saddock (Eds.), Comprehensive textbook of psychiatry (6th ed., vol. 2). Baltimore: Williams & Wilkins. Bouchez C. (2011). WedMD: serotonin: 9 questions and answers. Retrieved from http://www.webmd.com/depression/features/serotonin. Bussing R. (2011). Choosing the best SSRI. Retrieved from http://psychcentral.com/library/choosing_ssri.htm. Centers for Disease Control and Prevention (CDC). (2012). CDC features: data & statistics: an estimated 1 in 10 U.S. adults report depression. Retrieved from http://www.cdc.gov/Features/dsDepression/. Freud S. (1963). General psychological theory: papers on metapsychology. New York: Collier Books. ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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Hage MP & Azar ST. (2012). The link between thyroid function and depression. J. Thyroid Res. 590648. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3246784/. doi:10.1155/202/590648/. Halverson JL. (2013). Depression. Retrieved from http://emedicine.medscape.com/article/286759-‐overview. Hardeveld F, et al. (2013). Recurrence of major depressive disorder and its predictors in the general population: results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Psychological Medicine, 43(1), 39–48. Lowry F. (2013). Vagus nerve stimulation effective in resistant depression. Retrieved from http://www.medscape.com/viewarticle/804311. Mayo Clinic. (2012a). Electroconvulsive therapy (ECT). Retrieved from http://www.mayoclinic.com/health/electroconvulsive-‐therapy/MY00129/DSECTION=results. Mayo Clinic. (2012b). Transcranial magnetic stimulation. Retrieved from http://www.mayoclinic.com/health/transcranial-‐magnetic-‐stimulation/MY00185/DSECTION=risks. McClintock SM & Husain MM. (2011). Electroconvulsive therapy does not damage the brain. Journal of the American Psychiatric Nurses Association, 17(3), 212–3. Melnyk BM & Lusk P. (2013). Opportunities and challenges in treating adolescents and young adults with depressive disorder. Retrieved from http://www.psychiatrictimes.com/opportunities-‐and-‐challenges-‐treating-‐ adolescents-‐and-‐young-‐adults-‐major-‐depressive-‐disorder. Meyer JS & Quenzer LF. (2013). Psychopharmacology: drugs, the brain, and behavior (2nd ed.). Sunderland, MA: Sinauer & Associates, Inc. National Institute of Mental Health (NIMH). (2012). Depression in children and adolescents (fact sheet). Retrieved from http://www.nimh.nih.gov/health/publications/depression-‐in-‐children-‐and-‐ adolescents/index.shtml. Read J & Bentall R. (2010). The effectiveness of electroconvulsive therapy: a literature review. Epidemiol Psychiatr Soc, 19(4), 333–47. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21322506. Salamone JD & Correa M. (2012). The mysterious motivational functions of mesolimbic dopamine. Neuron, 76(3), 470. Seligman ME. (1973). Fall into hopelessness. Psychology Today, 7, 43. Spitz RA. (1946). Hospitalism; a follow-‐up report on investigation described in volume I, 1945. The Psychoanalytic Study of the Child, 2, 113–7. Substance Abuse and Mental Health Services Administration (SAMHSA). (2012). Results from the 2011 national survey on drug use and health: mental health findings. NSDUH Series H-‐45, HHS Publication No. (SMA) 12-‐4725. Rockville, MD: SAMHSA. Swierzewski SJ. (2011). Incidence & prevalence of depression. Retrieved from http://www.healthcommunities.com/depression/incidence-‐prevalence.shtml. Townsend MC. (2014). Essentials of psychiatric mental health nursing (6th ed.). Philadelphia: F.A Davis Company. ! © 2014 WILD IRIS MEDICAL EDUCATION, INC.
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University of Washington. (2013). Mental health reporting: facts about mental illness and suicide. Retrieved from http://depts.washington.edu/mhreport/facts_suicide.php. Vascarolis EM, Carson VB, & Shoemaker NC. (2011). Foundations of psychiatric mental health nursing (6th ed.). St. Louis: Saunders Elsevier. Videbeck SL. (2011). Psychiatric-‐mental health nursing (5th ed.). Philadelphia: Wolters, Kluwer, Lippincott, Williams & Wilkins.
" DISCLOSURE Wild Iris Medical Education, Inc., provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional healthcare. Neither the planners of this course nor the author have conflicts of interest to disclose. (A conflict of interest exists when the planners and/or authors have financial relationship with providers of goods or services which could influence their objectivity in presenting educational content.) This course is not co-‐provided. Wild Iris Medical Education, Inc., has not received commercial support for this course. There is no “off-‐label” use of medications in this course. All doses and dose ranges are for adults, unless otherwise indicated. Trade names, when used, are intended as an example of a class of medication, not an endorsement of a specific medication or manufacturer by Wild Iris Medical Education, Inc., or ANCC. Product trade names or images, when used, are intended as an example of a class of product, not an endorsement of a specific product or manufacturer by Wild Iris Medical Education, Inc., or ANCC. Accreditation does not imply endorsement by Wild Iris Medical Education, Inc., or ANCC of any commercial products or services mentioned in conjunction with this activity. ABOUT THIS COURSE You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.
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TEST [ Take the test online at wildirismedicaleducation.com ]
1. A characteristic feature of major depressive disorder is a: a. Chronic depressed mood often associated with psychotic features. b. Noticeable change in a person’s pattern of functioning. c. Range of feelings such as irritability, anger, and mood swings. d. Strong association to an underlying medical condition.
2. The common factor leading to depression in children is: a. Peer pressure. b. Parental demands. c. Loss. d. Poor self-esteem.
3. What percentage of Americans meeting the criteria for a diagnosis of depression seek treatment? a. 35% b. 50% c. 65% d. 80%
4. A biogenetic amine that has been linked to depression is: a. Epinephrine. b. Cortisol. c. Histamine. d. Serotonin.
5. Seligman’s theory of learned helplessness explains the development of depression as a result of: a. A belief that a person’s problems are his or her own fault and cannot be changed. b. Adverse childhood experiences directing negativity toward oneself, the world, and the future. c. Failure of the ego to achieve high standards, taking one further away from the worthy goal of love. d. A feeling of powerlessness from an ego that is victimized by a powerful, sadistic superego.
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6. The “gold standard” for the assessment of depression is met by the: a. Hamilton Rating Scale for Depression. b. Patient Health Questionnaire. c. Clinical Global Impression-Severity Scale. d. Hartford Institute Geriatric Depression Scale.
7. Rating scales for depression are designed to help professionals: a. Calculate the number of months the person has suffered. b. Decide which antidepressant drug would be most effective. c. Analyze the impact of intellectual capacity on depression. d. Assess the severity of depression in clients.
8. When developing a care plan for a client who is depressed, the healthcare practitioner prioritizes addressing: a. Criteria identified by the American Psychiatric Association. b. Biochemical imbalances in the client’s blood tests. c. Functional issues that affect client outcomes. d. Brain structure and function in the client.
9. Which symptom is uniquely seen in a client with major depression? a. Appetite changes b. Seasonal pattern c. Low energy d. Depressed mood
10. Psychopharmacologic treatment is based on restoring normal neurotransmitter systems by: a. Stemming the release of neurotransmitters. b. Enhancing neurotransmitter breakdown. c. Blocking neurotransmitter reuptake. d. Stimulating the release of corticosteroids.
11. Selective serotonin reuptake inhibitors are specifically prescribed for older adult clients because these medications have a lower: a. Risk of suicide lethality. b. Incidence of anticholinergic side effects. c. Cost compared to other antidepressants. d. Incidence of cardiotoxicity.
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12. Which is a true statement about tricyclic antidepressants? a. They are one of the newest types of antidepressant drugs available today. b. They inhibit the reuptake of norepinephrine and serotonin. c. They are frequently used for patients with glaucoma and diabetes. d. They do not cause anticholergenic side effects such as dry mouth and weight gain.
13. When a client takes a monoamine oxidase inhibitor for depression, he or she must reduce the intake of foods that contain high levels of: a. Serotonin. b. Tyramine. c. Dopamine. d. Norepinephrine. 14. The main goal of interpersonal therapy is to: a. Improve communication skills and increase self-esteem. b. Gain understanding and learn better coping skills. c. Identify one’s inaccurate perceptions that require change. d. Teach a family coping strategies for a member’s mental disorder.
15. After a patient begins treatment with antidepressants, caregiver vigilance must increase because: a. Some of the new medications are toxic. b. The patient’s normal level of food intake will be inadequate. c. Not all medications act in the same way. d. The patient’s energy to carry out a suicide plan is regained. 16. Therapeutic communication includes: a. Being sympathetic and nonjudgmental. b. Making valid judgments and being genuine. c. Avoiding self-disclosure and hopefulness. d. Having positive regard and being empathic.
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