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Affective Disorders
  • pervasive alterations in emotions manifested by depression, mania, or both
  • intererence with life (occasionally long term), sadness, agitation, or elation
Mood disorders
  • most common psych diagnosis associated with suicide
  • depression is one of the most important factors for suicide
  • risk also exists for mania, schizophrenia, personality disorders
Major Depressive Disorder
  • most common psych disorder leading to disability
  • 5% of the population
  • incidence women to men 2:1
  • decreses in women with age
  • increases in men with age
  • Highest in single divorced people
Major depressive disorder DSM IV
  • at least of 2 weeks of depressed mood and anhedonia
  • 4 of the following symptoms:
  • changes in weight, appetite, sleep, or motor activity
  • feelings of worthlessness or guilt
  • difficulty thinking, concentrating or making decisions
  • recurrent thoughts of suicide, plans or attempts
  • suicide is not essential for diagnosis
Age dependent symptoms of MDD: children
  • cranky, irritable
  • school phobia
  • hyperactivity
  • learning disorders
  • falling grades
  • antisocial behaviors
  • difficult to diagnose
  • children are not aware anything is wrong
Age dependent symptoms of MDD: Adolescents
  • substance abuse
  • eating disorders
  • risky behavior
  • underacheivers
  • drop out
  • most are reluctant to take medication
Age dependent symptoms of MDD: Adults
  • substance abuse
  • eating disorders
  • compulsive behaviors
  • hypochondriasis
MDD: elder considerations
  • common among the elderly
  • increaed when medically ill
  • sub-clinical depression + cardiac disease= more likely to die
  • worsens medical conditions
  • develop somatic symptoms
  • psychotic features are common
  • increased intolerance to medications
  • ECT commonly used for treatment d/t rapid response
  • suicide is increased among the elderly
Etiology: Biologic Theories
  • Genetic: first degree relatives of MDD and bipolar mroe likely to develop illness
  • Neruochemical: low serotonin, NE ↓ depression, ↑ mania, possibly acetylcholine and dopamine
Etiology: psychodynamic theories
  • may blame the client unnecessarily causing self doubt
  • Freud: self deprecation
  • Meyer: reaction to distressing life experience
  • Horney: family dynamics
  • BECK: cognitive distortions in susceptible people
Depression and psychosocial factors
  • depression is commonly linked to psychosocial stressors
  • stressors that contribute to depression can lead to changes in brain function requiring long term management with antidepressants (med use for 6-18 months is essential for preventing relapse)
  • relapse is far harder to treat than initial episode
  • talking therapes can be very helpful in alleviating depression
  • med with therapy ofter the best prognosis
Psychotherapy + meds
  • Interpersonal therapy: relationship difficulties
  • Behavior therapy: reinforcement of positive interactions
  • Cognitive therapy: correction of cognitive distortions
  • Beck refers to his work as CBT: thoughts, feelings, and actions impact each other
Psychopharmacology
  • SSRIs
  • TCAs
  • Atypical antidepressants
  • MAOIs
Key factors in choosing meds
  • Effectiveness (SSRI only for mild to moderate)
  • MAOI and TCA take extened time to begin effect
  • MAOI and TCAs can be fatal
ECT
  • Treatment of choice for:
  • intractable depression
  • when SSRIs are not enough
  • intolerable side effcts of meds
  • Dange to wait for meds to work
  • TCAs and MAOIs
  • pregnancy
  • can be used for relapse prevention
ECT cont.
  • unknown how it works
  • may alter electrochemical function at synase
  • FDA is working on studies of efficacy
ECT cont.
  • Outpatient minor surgery
  • can be done inpatient or outpatient
  • preop procedures
  • conset forms for each session
  • three times a week
  • done 6-15 times
ECT side effects
  • brief disorientation
  • fatigue
  • headache
  • short term memory loss
Investigational treatments
  • transcranial magnetic stimulation
  • magnetic seizure therapy
  • deep brain stimulation
  • vagal nerve stimulation
MDD: nursing assessment
  • History
  • general appearance, motor behavior (psychomotor retardation, latency of response, psychomotor agitation)
  • mood and affect (anhedonia)
  • thought process and content (rumination, suicide)
  • sensorium, intellectual processes (impaired memory)
MDD: assessment cont.
  • impaired judgement and insight
  • self concet (worthlessness)
  • roles, relationships (difficulty)
  • physiologic, self care considerations
  • Depression rating scales: self (zung, beck) clinician (hamilton rating scale)
MDD: data analysis and outcome identification
  • safety first
  • keep maslow in mind (oxygenation)
  • anxiety and depression are often linked
  • Outcome ID: free from self-harm, develop realistic view of self, develop balanced lifestyle
Interventions
  • provide for saety (suicide precaution)
  • promote therapeutic relationship
  • promote ADLs, physical care
  • use therapeutic communication
  • managing meds
  • client, family teaching
Bipolar Disorder
  • extreme mood swings from mania to depression
  • second only to major depression as cause of worldwide disability
  • onset usually in early 20s
  • manic episodes begin suddenly and last from a few weeks to several months
Bipolar disorder: treatment
  • Psychopharmacology:
  • ithium is an antimanic agent
  • anticonvulsants for mood stabilization
  • anticonvulsants helpful in reducing manic behavior and protecting against bipolar depressive cycles
  • Psychotherapy: useful in mildly depressive or nomal portion of cycle, not useful during mania
Bipolar: nursing assessment
  • History
  • general appearance, behavior: pressured speech, flamboyancy, sexually suggestive)
  • Mood, affect: euphoric, grandoise)
  • thought process, content: circumstantiality, tangentiality)
  • sensorium, intellectual processes: disoriented to time
Assessment cont.
  • judgement, insight
  • self-concept: exaggerated
  • roles, relationships: lability
  • physiologc, self care considerations
Bipolar: interventions
  • proved for safety
  • meeting physiologic needs
  • providing therapeutic communication
  • promoting appropriate behaviors
  • managing meds
  • providing client, family teaching
Suicde
  • the intentional act of killing oneself
  • suicidal ideation: thinking about killing oneself (active or passive)
  • warning signs
Suicide: assessment
  • prevent suicide attempts (first two years after, especially first 3 months)
  • relative who committed suicide?
  • watch for warnings of suicidal intent
  • lethality assessment
Sucide: interventions
  • authoritative role
  • safe enviroment
  • suicide precautions
  • no suicide, self harm contract
  • support system list
Suicide: family response
  • suicide is the ultimate rejection of family and friends
  • families react with guilt, shame, anger
Suicide: Nurse's response
  • need for unconditional positive regard for person
  • avoidance of client blame
  • nonjudgmental approach and tone
  • belief that one person can make a difference in another's life
  • possible devastation of staff if client commits suicide
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