Mental health & crisis management 7 APRIL qui z

Jack Fowler

Week11-Part1-DepressiveDisorders2.pptx

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Depressive Disorders

Week 11 – Part 1

Major depressive disorder (MDD) - Introduction

One of the most common psychiatric disorders

Almost 1 in 8 adults (12.6%) have identified symptoms that met the criteria for a mood disorder at some point during their lifetime

Major depressive disorder, or major depression, is characterized by a persistently depressed mood lasting for a minimum of 2 weeks

The length of a depressive episode may be 5 to 6 months

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Major depressive disorder (MDD) - Introduction

About 20% of cases become chronic (i.e., lasting more than 2 years)

While depression begins with a single occurrence, most people experience recurrent episodes

People experience a recurrence within the first year about 50% of the time and within a lifetime up to 85% of the time

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Clinical Picture: Major Depressive Disorder

Depressed mood, impairing functioning with:

Emotional

Cognitive

Physical, and

Behavioural symptoms

And experienced for over 2 weeks

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Clinical Picture (Cont.)

Major depressive disorder, with subtypes:

Psychotic features

Melancholic features

Atypical features

Catatonic features

Postpartum onset

Seasonal features (seasonal affective disorder [SAD])

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Video

Video link: https://www.youtube.com/watch?v=1RXnE2tyHdw

MDD

The diagnosis for MDD may include one of the following specifiers to describe the most recent episode of depression:

Psychotic features

Indicates the presence of disorganized thinking, delusions (e.g., delusions of guilt or of being punished for sins, somatic delusions of horrible disease or body rotting, delusions of poverty or going bankrupt), or hallucinations (usually auditory, voices berating person for sins)

Melancholic features

This outdated term indicates a severe form of endogenous depression (not attributable to environmental stressors) characterized by severe apathy, weight loss, profound guilt, symptoms that are worse in the morning, early morning awakening, and often suicidal ideation

Atypical features

Refers to dominant vegetative symptoms (e.g., overeating, oversleeping). Onset is younger, psychomotor activities are slow, and anxiety is often an accompanying problem, which may cause misdiagnosis.

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

MDD

Catatonic features

Marked by nonresponsiveness, extreme psychomotor retardation (may seem paralyzed), withdrawal, and negativity

Postpartum onset

Indicates onset within 4 weeks after childbirth. It is common for psychotic features to accompany this depression

Seasonal features (seasonal affective disorder [SAD])

Indicates that episodes mostly begin in fall or winter and remit in spring

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Etiology (Biological factors)

Genetic

Certain genetic markers seem to be related to depression when accompanied by early childhood maltreatment or a history of stressful life events

There is no gene directly related to the development of the mood disorder

There is a genetic marker associated with depression in the context of stressful life events

Biochemical

Two of the main neurotransmitters involved in mood are serotonin (5-hydroxytryptamine [5-HT]) and norepinephrine

Serotonin is an important regulator of sleep, appetite, and libido

Dysfunction can result in sleep disturbances, decreased appetite, low sex drive, poor impulse control, and irritability

Norepinephrine modulates attention and behaviour - it is stimulated by stressful situations, which may result in overuse and a deficiency of norepinephrine

A deficiency, an imbalance or an impaired ability to use available norepinephrine can result in apathy, reduced responsiveness, or slowed psychomotor activity

Stressful events

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Etiology (Biological factors)

Hormonal

Most widely studied in relation to depression has been hyperactivity of the hypothalamic–pituitary–adrenal axis

People with major depression have increased urine cortisol levels and elevated levels of corticotrophin-releasing hormone

Ensure blood testing on TSH levels

Inflammation

While we do not believe that inflammation causes depression, research indicates that it does play a role

Support for this belief includes the finding that about a third of people with major depression have elevated inflammatory biomarkers in the absence of a physical illness

Also, people who have inflammatory diseases have increased risk for major depression

Diathesis–stress model

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Etiology (Psychological factors)

Cognitive theory

The underlying assumption is that a person's thoughts will result in emotions.

If a person looks at their life in a positive way, the person will experience positive emotions, but negative interpretation of life events can result in sorrow, anger, and hopelessness

Beck and Rush (1995) found that people with depression process information in negative ways, even in the midst of positive factors

Three thoughts constitute Beck's cognitive triad:

A negative, self-deprecating view of self

A pessimistic view of the world

The belief that negative reinforcement (or no validation for the self) will continue in the future

Realizing that one has an ability to interpret life events in positive ways provides an element of control over emotions and, therefore, over depression

Learned helplessness

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Assessment)

Assessment tools

The Patient Health Questionnaire-9 (PHQ-9), a short inventory that highlights predominant symptoms of depression

Many clinicians also use the mnemonic SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor activity, and suicidal thoughts) to guide their assessment

Assessment of suicide potential

The most dangerous aspect of MDD is a preoccupation with death

A patient may fantasize about funeral or experience recurring dreams about death

Beyond these passive fantasies are thoughts of wanting to die

As a whole, all of these nihilistic thoughts are referred to as suicidal ideation

These thoughts may be relatively mild and fleeting, or persistent and involve a plan

Suicidal ideation, especially that in which the patient has a plan for suicide and the means to carry the plan out, represents an emergency requiring immediate intervention

Suicidal thoughts are a major reason for hospitalization for patients with major depression

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Assessment)

Key assessment findings

A depressed mood and anhedonia (loss of ability to experience joy or pleasure in living) are the key symptoms of depression

Psychomotor agitation may be evidenced by constant pacing and wringing of hands

The slowed movements of psychomotor retardation, however, are more common

Somatic complaints (e.g., headaches, malaise, backaches) are also common

Vegetative signs of depression—alterations in those activities necessary to support physical life and growth (e.g., change in bowel movements and eating habits, sleep disturbances, lack of interest in sex)—are universally present

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Cont.)

Areas to assess

Affect

Thought processes

Mood

Feelings

Cognitive changes

Physical behaviour

Communication

Religious beliefs and spirituality

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Cont.)

Age considerations

Children and adolescents

Older adults

Self assessment

Feeling what the patient is feeling

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Cont.)

Nursing diagnosis

Risk for suicide—safety is always the highest priority

Hopelessness

Ineffective coping

Social isolation

Spiritual distress

Self-care deficit

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Cont.)

Outcomes identification

Recovery model

Focus on patient’s strengths

Treatment goals mutually developed

Based on patient’s personal needs and values

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Cont.)

Planning

Geared toward:

Patient’s phase of depression

Particular symptoms

Patient’s personal goals

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Cont.)

Implementation

Three phases

Acute phase (6 to 12 weeks)

Continuation phase (4 to 9 months)

Maintenance phase (1 year or more)

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Cont.)

Counselling and communication

Health teaching and health promotion

Promotion of self-care activities

Milieu management and teamwork

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Psychopharmacology

Antidepressants

Selective serotonin reuptake inhibitors (SSRIs)

First-line therapy

Indications

Adverse reactions

Potential toxic effects

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Psychopharmacology (Cont.)

Tricyclic antidepressants (TCAs)

Neurotransmitter effects

Indications

Adverse effects

Toxic effects

Adverse drug interactions

Contraindications

Patient and family teaching

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Psychopharmacology (Cont.)

Monoamine oxidase inhibitors (MAOIs)

Neurotransmitter effects

Indications

Adverse/toxic effects

Interactions

Drugs

Food

Contraindications

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Other Treatments for Depression

Electroconvulsive therapy (ECT)

Transcranial magnetic stimulation

Vagus nerve stimulation

Deep brain stimulation

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Complementary and Integrative Therapies

Light therapy

St. John’s wort ** CAUTION – taking with other medications – MANY contraindications

Exercise and outdoor activity

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Advanced-Practice Interventions

Psychotherapy

Cognitive-behavioural therapy (CBT)

Interpersonal therapy (IPT)

Time-limited focused psychotherapy

Behaviour therapy

Group therapy

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Nursing Process (Cont.)

Evaluation

Suicidal ideation

Intake

Sleep pattern

Personal hygiene and grooming

Self-esteem

Social interaction

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Post-partum depression (PPD)

Post-Partum Depression

Post-partum depression (PPD), also called post-natal depression, is a type of mood disorder associated with childbirth

Onset is typically between one week and one month following childbirth (can occur any time in the first year post-partum)

PPD can also negatively affect the newborn child

While the exact cause of PPD is unclear, the cause is believed to be a combination of physical and emotional factors

These may include factors such as hormonal changes and sleep deprivation

While most women experience a brief period of worry or unhappiness after delivery, post-partum depression should be suspected when symptoms are severe and last over two weeks

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Postpartum Depression: What You Need to Know

Mayo Clinic. (2015, October 15). Postpartum depression: what you need to know. Retrieved from https://www.youtube.com/watch?v=fBYYr_kEjmo

Diagnostic criteria

The criteria required for the diagnosis of post-partum depression are the same as those of non-childbirth related major depression or minor depression. The criteria include at least five of the following nine symptoms, within a two-week period:

Feelings of sadness, emptiness, or hopelessness, nearly every day, for most of the day or the observation of a depressed mood made by others

Loss of interest or pleasure in activities

Weight loss or decreased appetite

Changes in sleep patterns

Feelings of restlessness

Loss of energy

Feelings of worthlessness or guilt

Loss of concentration or increased indecisiveness

Recurrent thoughts of death, with or without plans of suicide

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Risk Factors

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Prior episodes of post-partum depression

Bipolar disorder

Family history of depression

Psychological stress

Complications of childbirth

Lack of support

Substance use disorder

Mayo Clinic Minute: Understanding postpartum depression

Mayo Clinic. (2018, February 20). Mayo clinic minute: Understanding postpartum depression. Retrieved from https://www.youtube.com/watch?v=pGk4pd8_ezY

Treatment

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Treatment for PPD may include counseling or medications

Types of counseling that have been found to be effective include:

Interpersonal psychotherapy (IPT)

Cognitive behavioural therapy (CBT), and

Psychodynamic therapy

Tentative evidence supports the use of selective serotonin reuptake inhibitors (SSRIs)

Post-Partum Psychosis

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Post-partum psychosis is not a formal diagnosis

Widely used to describe a psychiatric emergency that appears to occur in about 1 in a 1000 pregnancies

Symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations and delusions begin suddenly in the first two weeks after delivery; the symptoms vary and can change quickly

It is different from post-partum depression and from maternity blues

It is important not to confuse psychosis with other symptoms that may occur after delivery, such as delirium.

Delirium typically includes a loss of awareness or inability to pay attention

Post-Partum Psychosis

Half of women  no risk factors; but a prior history of mental illness, especially bipolar disorder, a history of prior episodes of post-partum psychosis, or a family history put some at a higher risk

Post-partum psychosis often requires hospitalization, where treatment is antipsychotic medications, mood stabilizers, and in cases of strong risk for suicide, electroconvulsive therapy

The most severe symptoms last from 2 to 12 weeks, and recovery takes 6 months to a year

Women who have been hospitalized for a psychiatric condition immediately after delivery are at a much higher risk of suicide during the first year after delivery

Source: Austin, W. & Boyd, M.A. (2015). Psychiatric & mental health nursing (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Postnatal Psychosis: The stigma of mothers with mental illness

The Feed SBS. (2018, April 12). Postnatal Psychosis: The stigma of mothers with mental illness. Retrieved from https://www.youtube.com/watch?v=JUFRZ6PgfQE

Other Depressive Disorders

Disruptive mood dysregulation disorder

Persistent depressive disorder (dysthymia)

Premenstrual dysphoric disorder

Substance/medication induced depressive disorder

Depressive disorder due to another medical condition

Depression and grieving

Disruptive Mood Dysregulation Disorder

A disorder characterized by severe and recurrent temper outbursts that are inconsistent with developmental level

This disorder was introduced in 2013 in response to an alarming number of children and adolescents being diagnosed with bipolar disorder

A bipolar diagnosis resulted in exposure to powerful medications that probably were not helping and a lifelong label of serious mental illness

The most compelling reason to change this diagnostic practice was that most of the young people who received a diagnosis of bipolar disorder did not go on to exhibit classic bipolar symptoms as adults

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Disruptive Mood Dysregulation Disorder

In fact, most children and adolescents once diagnosed with bipolar disorder actually converted to major depressive disorder or an anxiety disorder in adulthood

The basic symptoms of disruptive mood dysregulation disorder are constant and severe irritability and anger in individuals between the ages of 6 and 18

Onset is before age 10

Temper tantrums with verbal or behavioural outbursts out of proportion to the situation occur at least three times a week

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Other Depressive Disorders

Persistent depressive disorder (dysthymia)

Is diagnosed when feelings of depression occur most of the day, for the majority of days

These low-level depressive feelings last at least 2 years in adults and 1 year in children and adolescents

In addition to depressed mood, individuals with this disorder have at least two of the following: decreased appetite or overeating, insomnia or hypersomnia, low energy, poor self-esteem, difficulty thinking, and hopelessness

Premenstrual dysphoric disorder

A relatively new addition to the diagnostic system for psychiatry

Referring to a cluster of symptoms that occur in the last week before the onset of a woman's period

Premenstrual dysphoric disorder causes problems severe enough to interfere with the ability of a woman to work or interact with others

Symptoms decrease significantly or disappear with the onset of menstruation

The prevalence of premenstrual dysphoric disorder is about 2% to 6% of menstruating women

Symptoms cease after menopause, although they may return with hormone replacement therapy

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.

Other Depressive Disorders

Substance/medication induced depressive disorder

Depressive disorder due to another medical condition

Depression and grieving

Source: Halter, M.J., Pollard, C.L. & Jakubec, S.L. (2019). Varcarolis's Canadian Psychiatric Mental Health Nursing: A Clinical Approach (2nd ed.). Elsevier.