COURSE PRICE: $18.00
CONTACT HOURS: 2
This course will expire or be updated on or before January 15, 2014.
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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Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Wild Iris Medical Education, Inc. (CBRN Provider #12300) is approved as a provider of continuing education for RNs and LVNs by the California Board of Registered Nursing.
Nurse practitioners may apply these contact hours to pharmacy continuing education and prescriptive authorization.
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 health care. See our disclosures for more information.
Copyright © 2011 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to provide caregivers with an overview of mood disorders in general, and major depressive disorders in particular, their prevalence, causes, suicide risk, assessment, diagnosis, treatment, and care.
Upon completion of this course, you will be able to:
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, folks may say they feel “depressed” or “down in the dumps,” yet rarely are they clinically depressed or grieving a significant loss.
At other times, people feel energetic, good about themselves, hopeful concerning the future, and successful in their endeavors and relationships. After a few days, these feelings of elation taper off and folks return to a less euphoric but realistic and balanced frame of mind. Such variations in mood are normal ups and downs of daily life and do not interfere with the fundamental way individuals feel about themselves, their relationships, or their ability to function in the world.
Mood disorders, on the other hand, are pervasive alterations in temperament manifested by periods of profound depression, exaggerated mania, or both. Such variations in mood significantly interfere with the lives of those who are afflicted, causing extremes of depression, elation, and agitation. 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 mood disorders are the most common psychiatric diagnoses associated with suicide (Sudak, 2009).
There are two primary mood disorders: bipolar disorder (formerly called manic-depressive illness) and depressive disorders. The focus of this course is depressive disorders.
In order to help caregivers recognize and treat depressive disorders more effectively, the American Psychiatric Association has identified two major types of depressive disorders: dysthymia and major depressive disorder.
Dysthymia is characterized by a chronic depressed mood that is present most of the time and lasts for at least 2 years in adults and 1 year in children. This joyless disorder may begin in early childhood, adolescence, or adulthood. Though people afflicted with dysthymia suffer from social and occupational distress, only rarely are they hospitalized unless they threaten or attempt suicide or develop some other psychiatric disorder. The primary difference between dysthymia and major depression is the duration and severity of symptoms.
Major depressive disorder is not the occasional “down day” people ordinarily experience. Neither is it the chronic depression of dysthymia. 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.
During times of such profound depression, individuals may develop some of the following unusual symptoms, called features:
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. At least 60% of individuals have a second episode, and those who have two episodes have a 70% chance of having a third episode. Individuals who have had three episodes have a 90% change of future episodes (APA, 2000b). Of persons afflicted with severe depression, 15% eventually commit suicide. In the United States, 32,000 persons die by suicide every year, or about 87 deaths by suicides every day (Dryden-Edwards, 2010).
In the United States, major depression is the leading cause of disability among adults 15 to 44 years of age (Kessler et al., 2007). Children as young as 3 years of age have been diagnosed with the disorder. Among preadolescents, the prevalence of depression is said to be as high as 18%; and girls 15 years of age and older are twice as likely to experience major depressive episodes as boys (NIMH, 2006). In one study, researchers found that 40% of the elderly living in retirement facilities suffered from major depression (Fuller & Sajatavic, 2000).
People with medical disorders are more likely to suffer depression than those who enjoy physical health. In fact, depression has been found to accompany a host of neurological, endocrine, metabolic, respiratory, cardiovascular, cancerous, gastrointestinal, and infectious conditions. Of course, some degree of depression is associated with normal bereavement and end-of-life issues. For this reason, it is not surprising to find a high rate of depression among the sick and elderly, especially those who are housed in nursing homes, where loneliness, loss, and death are daily realities.
People with psychiatric disorders are at high risk of developing major depression, particularly those with schizophrenia, schizoaffective disorder, substance abuse, anxiety, and eating disorders. In addition, 70% of individuals with major depression develop symptoms of anxiety. Such comorbidity leads to reduced response to treatment, more psychotic depression, lower social and occupational functioning, and higher rates of suicide (Simon & Rosenbaum, 2003).
What causes the despair and anguish of major depressive disorder? Recent studies point to chemical biologic imbalances, psychosocial stressors, and interpersonal events that appear to trigger physiologic and chemical changes in the brain. Akiskal (2009) theorized that these stressors alter the balance of neurotransmitters and cause a depressed mood. Other causal factors include neuroendocrine, neurochemical, psychodynamic, genetic, age and culture.
The powerful secretions of endocrine glands—specifically the adrenal, thyroid, parathyroid, pituitary, and reproductive glands—are a source of many mood disturbances. Gotlib & Hammen (2009) found that 40% of depressed patients have an increase in adrenal cortisol secretion, with the highest rates found among the elderly. Thase (2009) found that 5% to 10% of those with major depression have thyroid dysfunction. Progesterone and estrogen are well known for their effect on individuals suffering postpartum depression and psychoses.
The influence of neurochemical transmission between neurons of the brain is the focus of intense research. Of particular interest are norepinephrine, serotonin, acetylcholine, and dopamine.
Studies of twins show that genetics plays a role in the development of depressive disorders, but it is not the sole factor. If one identical twin is afflicted, the second twin has a 45% to 60% chance of being afflicted. If a nonidentical twin is afflicted, the nonidentical twin has a 12% chance of being afflicted (Kelsoe, 2009). Genetic studies indicated that first-degree relatives, (e.g., father-son) are at twice the risk of developing depression as are members of the general population (APA, 2000b).
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.
Bibring (1954) believed that the ego (the self) aspires to be ideal (good, loving, superior, and strong). In order to be worthy of love, the ego must achieve high standards, and when people fail to achieve these ideals, they becomes depressed.
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).
Similar to Jacobson’s explanation, Beck saw depression as the result of negative childhood experiences toward the self, the world, and the future. These three things are called Beck’s cognitive triad. Treatment focuses on changing the individual’s view of the self, the world, and the future(Beck & Rush, 1995).
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.
Both age and cultural issues influence or reveal depression. For example, in recent years, bullying by classmates has been identified as a cause of depression and suicides by children (NIH, 2010). Low self-esteem, unresolved grief, loneliness, and public shame appear to lead to both dysthymia and major depressive disorder. Too often, adolescents who are depressed join gangs, abuse substances, engage in risky behavior, and drop out of school.
Adults may manifest depression with compulsive behavioral conditions, such as eating disorders, gambling, and substance abuse. Depressed elderly individuals may become bitter and friendless curmudgeons.
People within certain cultures exhibit depression in a variety of typical ways. Andrews and Boyle (2007) found that Asians who are depressed are more likely to complain of somatic problems such as headaches and backaches, Latinos are more likely to complain of nerves or headaches, and Middle Easterners of heart problems. Hamilton (1997) found that although the high rate of self-mutilation and suicide by male Micronesian youths is linked to anger, it is also associated with depression and lack of purpose (1997). Videbeck (2011) suggests that depression is more apparent in cultures that avoid verbalization of emotions.
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, or what their medical diagnosis, 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.
A brief depression assessment includes evaluation of the three key elements: mood that is gloomy, energy that is low, and pleasure that has vanished. Listen to what clients say, observe their body language, and ask yourself these questions:
If all three key elements of depression are at low levels most of the time, the individual probably is suffering some degree of depression. A comprehensive assessment is highly recommended.
A comprehensive assessment of depression includes gathering information about the individual’s family and personal history, general appearance and 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.
A family history of mood disorders, suicides, or suicide attempts is valuable because mood 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:
To assess the current episode of depression, caregivers ask afflicted individuals:
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:
Clients with depression describe themselves as hopeless, helpless, worthless, a burden on others, and a failure. Common symptoms of mood and affect include:
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.
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:
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:
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, self-concept, roles, and relationship symptoms include:
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:
Many rating scales have been designed to help professionals assess the severity of depression in clients. Some of the best known of these assessment tools are the Beck Depression Inventory II, Clinical Global Impression-Severity Scale, Hartford Institute Geriatric Depression Scale, and Zung Self-Rating Depression Scale. (See box below.)
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” below). When such a test confirms depression, the person should be encouraged to consult a mental health professional for further assessment and care.
Beck Depression Inventory II (BDI-II)
Assesses depression in individuals ages 13 to 80 years; 21 items, administration takes 5 minutes; uses criteria of the DSM-IV.
Clinical Global Impression-Severity Scale (CGI-S)
A 7-point scale allowing clinician to rate the illness-severity of a patient and compare results to the past.
Depression Screening Test
Assesses depression in youths and adults; 10 items, self-administered, multiple-choice questionnaire; evaluated electronically, immediately.
Geriatric Depression Scale Short Form
Assesses depression of elder adults; 15 items, either self-administered or by a caregiver; scoring and evaluation provided in text of online source.
Zung Self-Rating Depression Scale
Assesses the level of depression of patients diagnosed with depressive disorder; assesses four common characteristics of depression (physiologic, psychomotor, pervasive effect, and other disturbances); 21 items; scores fall into four ranges (normal, mild, moderate, and severe).
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.
|Caregiver/Nursing Diagnosis||Outcome Goals||Interventions|
|Risk of suicide||Client will not harm himself/herself.||Take suicide precautions; observe client closely and often.|
|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 of adequate nutrition, hydration, and elimination.||Plan and provide a diet of food and water with dietitian, staff, and client.|
|Self-care deficit||Client will carry out personal hygiene (bathing, clothing, grooming).||Create and check to see that self-care is maintained by client.|
|Chronic low self-esteem||Client will evaluate self-attributes 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.|
|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; give prescribed medications.|
|Ineffective role performance||Client will feed, cloth, and care for her/his family.||Refer client to home health service for follow-up care.|
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. They use criteria of the two major types of depressive disorders identified by the American Psychiatric Association: dysthymia and major depressive.
|Major Depressive Disorder||Dysthymia|
|Source: Modified from American Psychiatric Association, 2000a.|
Because scientific evidence suggests that mood disorders are caused by a flaw in chemistry, not character, it is logical to conclude that drugs that alter brain chemistry play an important role in psychiatric treatment (Bussing, 2011). Even so, brain chemistry is not the only factor that affects depressed people. Research shows that when psychopharmacology (drugs) are combined with psychotherapy (counseling), outcomes are better than when either one is prescribed alone (Sutherland et al., 2003).
Psychopharmacology requires an understanding of how the brain works or functions, considerations of the effects of various drugs, and information about their availability.
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 functions 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, 2011).
After neurotransmitters relay their message to receptor cells, one of two things happen. 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 restoration of normality to neurotransmitter systems by:
In recent years scientists have found that the process of neuron interaction is not the entire story. Many other factors influence neurons and their function. Thus, research continues with a goal of gaining greater understanding of how the brain works.
|Neurotransmitter||Effects/Actions||Disorders Related to Neurotransmitter Amounts|
|Source: Adapted from Vascarolis et al., 2011.|
|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
|Gamma-amnobutiyric 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
|Acetylcoline (ACh)||Plays 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
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.
In addition to client responses, 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:
Antidepressant interventions are classified as first line (preferred) and second line (back-up, used when a preferred intervention cannot be used).
First-line interventions include:
Second-line interventions include:
Selective serotonin reuptake inhibitors (SSRIs) are the newest category of antidepressants. They are recommended as first-line therapy for all types of depression except those with psychotic and melancholic features (see “Diagnostic Criteria” table above). SSRIs are effective for most clients, and since they have low cardio-toxicity, 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. Some common SSRI antidepressants, their side effects, and care-giving recommendations are listed below.
|Generic (Trade) Name||Side Effects||Caregiving Recommendations|
|Source: Adapted from Videbeck, 2011.|
|Flouxetine (Prozac)||Anxiety, sedation, headaches, tremor, sexual dysfunction, anorexia, constipation, nausea, diarrhea, weight loss||Encourage adequate fluids; if anxious, give drug in AM; if drowsy, give drug in PM; monitor hyponatremia.|
|Sertraline (Zoloft)||Dizziness, sedation, headache, insomnia, tremor, sexual dysfunction, diarrhea, dry mouth and throat, nausea, vomiting, sweating||Encourage adequate fluids, sugar-free beverages, and hard candy; if drowsy, give drug in PM; monitor hyponatremia.|
|Paroxetine (Paxil)||Dizziness, sedation, headache, insomnia, weakness, fatigue, constipation, diarrhea, nausea, vomiting, dry mouth and throat, sweating||Encourage adequate fluids, sugar free beverages, and hard candy; administer drug with food; if drowsy, give drug in PM.|
|Citalogram (Celexa)||Drowsiness, insomnia, nausea, vomiting, weight gain, constipation, diarrhea||Encourage balanced nutrition and exercise; give drug with food in PM; monitor hyponatremia.|
|Excitalopram (Lexapro)||Drowsiness, dizziness, weight gain, sexual dysfunction, restlessness, dry mouth, headache, nausea, diarrhea||Give drug with food; check orthostatic blood pressure; teach client to rise slowly to sitting or standing position; encourage sugar-free beverages and hard candy.|
When clients do not respond to SSRIs or have side effects from SSRIs, atypical, novel antidepressants may be prescribed. These drugs are called “atypical” because they affect the reuptake of unique neurotransmitters and transmitter subtypes and have diverse side effects. Thus, they help a select group of depressed individuals. Another advantage is that these drugs may be prescribed for other conditions than depression, such as anxiety disorders. Some common atypical antidepressant drugs, their side effects, and care-giving recommendations are listed below.
|Generic (Trade) Name||Side Effects||Caregiving Recommendations|
|Source: Adapted from Videbeck, 2011.|
|Bupropoin (Wellbutrin)||Nausea, vomiting, lowered seizure threshold, insomnia, weight gain, headache||Give dose in AM; encourage balanced nutrition.|
|Duloxetine (Cymbalta)||Nausea, insomnia, constipation, dry mouth, decreased appetite, sweating, sexual dysfunction||Give drug with food and twice a day dosing; ensure adequate fluids; encourage sugar-free beverages.|
|Mirtzapine (Remeron)||Drowsiness, dizziness, dry mouth, weight gain, sexual dysfunction, constipation||Give drug in PM, encourage adequate fluids and balanced nutrition; encourage sugar-free beverages.|
|Veniafaxine (Effexor)||Increased blood pressure, drowsiness, dry mouth, sweating, headache, nausea||Give drug with food in PM; encourage adequate fluids; encourage sugar-free beverages.|
Tricyclics (TCAs) are the oldest antidepressant drug 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 anticholergenic 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, their side effects, and caregiving recommendations are listed below.
|Generic (Trade) Name||Side Effects||Caregiving Recommendations|
|Source: Adapted from Videbeck, 2011.|
|Amitriptyline (Elavil, Endep)||Orthostatic hypotension, sedation, tachycardia, headache, blurred vision, tremor, weight gain, dry mouth constipation, urinary hesitancy, sweating||Administer in PM; encourage adequate fluids. balanced nutrition, and hard candy; monitor cardiac function; teach client to rise slowly from sitting or lying position; encourage exercise.|
|Amoxapine (Asendin)||Orthostatic hypotension, sedation, tachycardia, headache, blurred vision, tremor, weight gain, dry mouth constipation, urinary hesitancy, sweating, rashes, dizziness||Administer in PM; encourage adequate fluids, balanced nutrition, and hard candy; monitor cardiac function; teach client to rise slowly from sitting or lying position; encourage exercise; report rash to physician.|
|Doxepin (Sinequan)||Orthostatic hypotension, sedation, tachycardia, headache, blurred vision, tremor, weight gain, dry mouth constipation, urinary hesitancy, sweating||Administer in PM; encourage adequate fluids, balanced nutrition, and hard candy; monitor cardiac function; teach client to rise slowly from sitting or lying position; encourage exercise.|
|Imipramine (Tofranil)||Orthostatic hypotension, sedation, tachycardia, headache, blurred vision, tremor, weight gain, dry mouth, constipation, urinary hesitancy, sweating||Administer in PM; encourage adequate fluids, balanced nutrition, and hard candy; monitor cardiac function; teach client to rise slowly from sitting or lying position; encourage exercise.|
|Desipramine (Norpramine)||Cardiac dysrhythmias, orthostatic hypotension, excitement; insomnia, sexual dysfunction, dry mouth, rashes||Administer in AM if stimulated; encourage adequate fluids, balanced nutrition, and hard candy; monitor cardiac function; report rashes to physician.|
|Nortriptyline (Pamelor)||Cardiac dysrhythmias, tremor, confusion; excitement; tremor; constipation; dry mouth||Administer in AM if stimulated; encourage adequate fluids, balanced nutrition, and hard candy; monitor cardiac function; encourage exercise.|
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 a MAO inhibitor, mood-elevating neurotransmitters are not broken down and they are available for synaptic release.
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, and most cheeses. 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 MAOI.
Some common monoamine oxidase inhibitor antidepressants, their side effects, and caregiving recommendations are listed below.
|Generic (Trade) Name||Side Effects||Caregiving Recommendations|
|Source: Adapted from Videbeck, 2011.|
|Isocarboxazid (Marplan)||Drowsiness, dry mouth, over activity, insomnia, nausea, anorexia, constipation, urinary retention, orthostatic hypotension||Administer in AM with food; assist client to rise slowly from sitting or lying position; encourage adequate fluids; teach about low-tyramine diet.|
Electroconvulsive therapy (ECT) is one of the most effective yet most stigmatized remedies for major depression. It is especially useful for individuals who cannot take or do not respond to antidepressant drugs as well as for those who are at high risk for suicide. Furthermore, it is safe for pregnant woman and the fetus. Within 1 to 2 weeks of beginning electroconvulsive treatment, depression is reduced in 90% of clients (NIMH, 2006).
ECT involves applying electrodes to the head and delivering an electric impulse to the brain. It is believed the shock works by causing a massive neurochemical release in the brain in response to the controlled seizure (Panzarino, 2002).
Historically, clients did not receive sedation or anesthetic before ECT. They were placed on a narrow table, electrodes attached to their head, and held down by attendants as the electric current produced a grand mal seizure. After a long, deep sleep, they gradually awoke, confused, disoriented, and often with significant memory loss.
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, though they may have short term amnesia, memory returns quickly. 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.
Glenna celebrated her 16th 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. 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 girl friends. 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 come in to 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, 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 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.
Drugs may improve the transmission of messages from one neuron to another, but they do not solve human problems like Glenna’s; comfort the grieving; bestow hope, joy, and self-worth; or help people make constructive choices. Those things come from the supportive care and interactive learning by means of various psychotherapeutic interventions. From psychotherapy, clients receive comfort, become emotionally aware, gain self-understanding, learn coping skills, and acquire problem-solving abilities. Caregivers of many competency levels provide such interventions. They address issues of safety and security, interpersonal support and interaction, family and individual education, and various psychotherapeutic approaches.
Depressed individuals are all around us, in the medical, surgical, and pediatric units of general hospitals and in clinics, schools, social meetings, and family gatherings. As caregivers assess depression, they need to remember the three key elements of depression: a mood that is sad, energy level that is low, and pleasure that has vanished. Depressed people feel hopeless, helpless, and worthless. When caregivers see these symptoms, they reach out, offer to help, and refer depressed people to sources of care. If an individual threatens suicide, caregivers take immediate action.
In clinic settings, such as the women’s clinic where Glenna went for help, the environment was comfortable, the people warm and friendly, and confidentiality assured.
When depressed individuals are hospitalized in psychiatric units, just being there gives patients a measure of safety and security. If they were admitted because of a suicide attempt, agency suicide precautions will be instituted. Such measures include removing all sharps and harmful items, increasing supervision, and managing drugs.
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.
In order to give supportive care to depressed individuals, caregivers:
Whether clients are hospitalized in a psychiatric unit or served by caregivers outside of 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:
Advanced psychotherapeutic approaches are employed by healthcare providers who specialize in psychotherapy. These professionals may be advanced-practice nurses, marriage and family therapists, social workers, psychologists, and psychiatrists.
The goal of advanced psychotherapy for depressed individuals is to help them:
Psychotherapy is provided by means of three arrangements:
Advanced-care professionals use a variety of theoretical systems with depressed patients, including the following:
This system is based on the assumption that a person is mentally ill because of unresolved, generally unconscious conflicts, often stemming from childhood. The goal of this therapy is for the client to understand the emotions they experience by talking about them. Such therapy usually lasts several months or even many years.
This modality focuses on the behaviors and interactions a client has with other individuals and family members. The goal of this therapy is to improve communication skills and increase self-esteem within a short period of time. This therapy is especially effective for depression caused by mourning, relationship conflicts, major life events, and social isolation. Often it is problem-focused, such as with Glenna, described in the case above. Individual therapy usually lasts 3 to 4 months, depending on the circumstances.
This form of therapy helps people with mental illness identify and change inaccurate perceptions they have of themselves and the world around them. Therapists help clients learn new ways of thinking by directing attention to both the inaccurate and the accurate assumptions they make about themselves and others. It is recommended for those who think and behave in ways that trigger and perpetuate mental illness and for those who suffer disability or interpersonal problems.
These focus on inner peace, relaxation, and awareness of the spiritual element of life. Often this type of therapy is conducted in groups in which individuals gather together to support and share life experiences. There is no timeline, and the therapy may continue through life.
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 (melancholy mood, anhedonia, and 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.
National Institute of Mental Health
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