The nurse is caring for a patient who exhibits disorganized thinking and delusions. The patient repeatedly states, “I hear voices of aliens trying to contact me.” The nurse should recognize this presentation as which type of major depressive disorder (MDD)?
D. Psychotic
Rationale: Psychotic features of MDD include the presence of disorganized thinking, delusions, and/or hallucinations. Catatonic MDD is marked by nonresponsiveness and extreme psychomotor retardation. Atypical MDD refers to people who have dominant vegetative symptoms such as overeating and oversleeping. Melancholic MDD is characterized by severe apathy, weight loss, profound guilt, and (often) suicidal ideation.
DSM-IV-TR
Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision
Major Depressive Disorder
Five or more of the following occur nearly every day for most waking hours over the same 2-weekperiod:
Depressed mood most of day, nearly every day
Anhedonia (no joy or energy)
Significant weight loss or gain (more than 5% of body weight in 1 month)
Insomnia or hypersomnia
Increased or decreased motor activity
Anergia (fatigue or loss of energy)
Feelings of worthlessness or inappropriate guilt (may be delusional)
Decreased concentration or indecisiveness
Recurrent thoughts of death or suicidal ideation (with or without plan)
Specifiers Describing Most Recent Episode:
1. Chronic
2. Atypical features
3. Catatonic features
4. Melancholic features
5. Postpartum onset
and no history of manic or hypermanic episodes.
Dysthymic Disorder
Occurs over a2-yearperiod (1 year for children and adolescents), depressed mood "most of the day, more days than not".
Two or more of the following are present:
Decreased or increased appetite
Insomnia or hypersomnia
Low energy or chronic fatigue
Decreased self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness or despair
Specify if:
1. Early onset (before 21 years of age)
2. Late onset (21 years of age or older)
3. Atypical features
major depressive disorder (MDD)
Pts. experience substantial pain and suffering, as well as psychological, social, and occupational disability.
May include psychotic features, i.e. delusions and/or hallucinations.
Mood disorder
One that ranges from elation to depression and affects normal functioning.
MDD with psychotic features is a severe form of mood disorder.
How is the course of MDD variable?
60% of those with 1 episode will have another
70% of those with 2 episodes will have another
90% of those with 3 episodes will have another
MDD subtypes
Psychotic features. Indicates the presence of disorganized thinking, delusions or hallucinations
Melancholic features. a severe form of endogenous depression (not attributable to environmental stressors); worse in the morning, early morning awakening, and often suicidal ideation.
Atypical features. dominant vegetative symptoms (overeating and oversleeping) ; anxiety is often an accompanying problem, which may cause misdiagnosis.
Catatonic features. may seem paralyzed
Postpartum onset. within 4 weeks after childbirth. It is common for psychotic features to accompany this depression. Severe ruminations or delusional thoughts about the infant signify increased risk of harm to the infant.
Seasonal Affective Disorder, SAD. episodes mostly begin in fall or winter and remit in spring.
P 249: "Differentiating MDD from DD (Dysthymic Disorder) can be difficult because the disorders have similar symptoms. Main differences are duration and severity" For example:
MDD: 2-weeks, 5 or more symptoms
DD: 2-years, 2 or more symptoms
Primary Risk Factors for Depression
Female gender
Being unmarried
Low socioeconomic class
Early childhood trauma
The presence of a negative life event, especially loss and humiliation
Family history of depression, especially in first-degree relatives
High levels of neuroticism (predisposition to respond to stress poorly)
Postpartum period
Medical illness
Absence of social support
Alcohol or substance abuse
Diathesis–stress model
Diathesis (or vulnerability):
Once a person vulnerable person is subject to a stressor, and each subsequent stressor, it can cause a sensitization (or further sensitization) of their ability to deal with stress so that as adults even a "mild" stressor can lead to an exaggerated stress response.
This model is supported by this data:
60% of those with 1 episode will have another
70% of those with 2 episodes will have another
90% of those with 3 episodes will have another
Affect
p. 254: the outward representation of a person's internal state of being and is an objectivefinding based on the nurse's assessment.
Vegetative signs of depression
Changes in bowel movement and eating habits, sleep disturbances and disinterest in sex.
Note: A "vegetative" state is one where the patient is in a state of partial arousal as opposed to true awareness.
There are three phases in treatment and recovery from major depression:
1. The acute phase (6 to 12 weeks) is directed at reduction of depressive symptoms and restoration of psychosocial and work function. Hospitalization may be required.
2. The continuation phase (4 to 9 months) is directed at prevention of relapse through pharmacotherapy, education, and depression-specific psychotherapy.
3. The maintenance phase (1 year or more) of treatment is directed at prevention of further episodes of depression.
When a patient is mute, use the technique of making observations:
"There are many new pictures on the wall."
"You are wearing your new shoes."
When a patient is not ready to talk, direct questions can raise the patient's anxiety level and frustrate the nurse. Pointing to commonalities in the environment draws the patient into and reinforces reality.
Health teaching points
Depression is an illness that is beyond a person's voluntary control.
Although it is beyond voluntary control, depression can be managed through medication and lifestyle.
Illness management depends in large part on understanding personal signs and symptoms of relapse.
Illness management depends on understanding the role of medication and possible medication side effects.
Long-term management is best assured if the patient undergoes psychotherapy along with taking medication.
Identifying and coping with the stress of interpersonal relationships—whether they are familial, social, or occupational—is key to illness management.
Antidepressant therapy benefits about X% 0f MDD patients.
80
All antidepressants work to
p. 262 - increase the availability of one or more of the neurotransmitters: serotonin, norepinephrine and dopamine.
Use cautiously in older adults and those with cardiac disorders, elevated intraocular pressure, urinary retention, hyperthyroidism, seizure disorders, and liver or kidney dysfunction.
Contraindicated in people taking MAOIs
Phenelzine (Nardil)
Selegiline Transdermal System Patch (EMSAM) - "does not seem to affect tyramine sensitivity."
Tranylcypromine (Parnate)
MONOAMINE OXIDASE INHIBITORS (MAOIs)
Notes:
Efficacy similar to other antidepressants, but dietary restrictions and potential drug interactions make this drug less desirable
Side Effects:
Insomnia, nausea, agitation, and confusion
Potential for hypertensive crises or serotonin syndrome with concurrent use of other anti-depressants
Warnings:
Contraindicated in people taking other antidepressants
Tyramine-rich food could bring about a hypertensive crisis
Many other drug interactions
ECT - Electroconvulsive Therapy Stats
Used most commonly for depression.
While as many as 50% of people taking antidepressants fail to achieve full remission, clinical trials of ECT report 70-90% remission.
Suicidal thoughts respond to ECT in 80% of cases.
Psychotic illness are the 2nd most common indication for ECT and for drug-resistant Pts., the combo of drugs and ECT results in sustained improvement 80% of the time.
Can be used for pregnant pts.
The nurse is caring for a patient who exhibits disorganized thinking and delusions. The patient repeatedly states, “I hear voices of aliens trying to contact me.” The nurse should recognize this presentation as which type of major depressive disorder (MDD)?
A. Psychotic
Psychotic features of MDD include the presence of disorganized thinking, delusions, and/or hallucinations.
Catatonic MDD is marked by nonresponsiveness and extreme psychomotor retardation.
Atypical MDD refers to people who have dominant vegetative symptoms such as overeating and oversleeping.
Melancholic MDD is characterized by severe apathy, weight loss, profound guilt, and (often) suicidal ideation.
Which patient statement indicates learned helplessness?
C. “It's all my fault that my husband left me for another woman.”
Learned helplessness often occurs during depression if the person feels no control over the outcome of a situation. Those exhibiting symptoms of learned helplessness feel that undesired events in their lives are self-created, and that nothing can be done to change it. By blaming herself, the patient has taken accountability for her husband’s actions and assigned blame to herself.
Stating that one is a horrible person, hating oneself, or feeling that the world is “out to get” them is reflective of Beck’s cognitive triad as they contribute to depression.
The nurse is planning care for a patient with depression who will be discharged to home soon. What aspect of teaching should be the priority on the nurse's discharge plan of care?
D. Safety risk
Safety is always the highest priority in planning care. Even if the patient has not exhibited a risk for self-harm, the potential for this must be addressed with patients who have depression.
Note: I would argue that the best teaching for safety sake would be for "Awareness of symptoms increasing depression", i.e. something the Pt can do something about> What exactly is the teaching for safety risk?
The nurse is reviewing orders given for a patient with depression. Which order should the nurse question?
A. An SSRI given initially with an MAOI
Selective serotonin reuptake inhibitors (SSRIs) should be discontinued 2 to 5 weeks beforestarting an MAOI to avoid serotonin syndrome.
BUT - MAOIs are "contraindicated in people taking other antidepressants."
A female patient tells the nurse that he would like to begin taking St. John’s Wort for depression. What teaching should the nurse provide?
D. “St. John’s wort has generally been shown to be effective in treating depression.”
been shown to be effective as an antidepressant (but NOT along with other Rx antidepressants, only by itself) in cases of mild or moderate depression, but usefulness in severe depression has not yet been established.
The nursing diagnosis Imbalanced nutrition: less than body requirements has been identified for a client with severe depression. The most reliable evaluation of outcomes will be based on
D. weekly weights.
Client body weight is the most reliable and objective evaluation of success in treating this nursing diagnosis. Text page: 261
What statement about the comorbidity of depression is accurate?
C. Depression is commonly seen among individuals with medical disorders.
T/F: Depression may coexist with other disorders but is rarely seen with schizophrenia.
False
Beck suggests that the etiology of depression is related to
B. negative processing of information.
Beck is a cognitive theorist who developed the theory of the cognitive triad of three automatic thoughts responsible for people becoming depressed:
(1) a negative, self-deprecating view of self,
(2) a pessimistic view of the world, and
(3) the belief that negative reinforcement will continue.
Text page: 252
A client who has been assessed by the nurse as moderately depressed is given a prescription for daily doses of a selective serotonin reuptake inhibitor. The client mentions she will take the medication along with the St. John's wort she uses daily. The nurse should
A. explain the high possibility of an adverse reaction.
Serotonin malignant syndrome is a possibility if St. John's wort is taken with other antidepressants.
Which nursing diagnosis would be least useful for a depressed client who shows psychomotor retardation?
B. Death anxiety
A client with psychomotor retardation has vegetative signs of depression and is often constipated, too tired to engage in activities, and lacks the energy to attend to personal hygiene. Depressed clients usually do not have death anxiety. They are more likely to welcome the idea of dying. Text page: 254
When the nurse remarks to a depressed client "I see you are trying not to cry. Tell me what is happening." The nurse should be prepared to
D. wait quietly for the client to reply.
Depressed clients think slowly and take long periods to formulate answers and respond. The nurse must be prepared to wait for a reply. Text page: 259
A depressed client tells the nurse "There is no sense in trying. I am never able do anything right!" The nurse can identify this cognitive distortion as an example of
C. learned helplessness.
Learned helplessness results in depression when the client feels no control over the outcome of a situation. Text page: 252
A depressed client tells the nurse "There is no sense in trying. I am never able to do anything right!" The nurse can best begin to attack this cognitive distortion by
A. suggesting "Let's look at what you just said, that you can 'never do anything right.'"
Cognitive distortions can be refuted by examining them, but to examine them the nurse must gain the client's willingness to participate. Text page: 252
A depressed client tells the nurse he is in the 'acute phase' of his treatment for depression. The nurse recognizes that the client has been in treatment:
B. to reduce depressive symptoms
The acute phase of depression therapy (6 - 12 weeks) is directed towards the reduction of symptoms and restoration of psychosocial and work function and may require some hospitalization. Text page: 259
Acute: 6-12 weeks
Continuation: 4-9 months - no relapse
Maintenance: > 1 year - prevent further episodes
A client with severe depression has been regulated on a monoamine oxidase inhibitor because trials of other antidepressants proved unsuccessful. She has a pass to go out to lunch with her husband. Given a choice of the following entrees, which can she safely eat?
A. fruit and cottage cheese plate.
Fruit and cottage cheese do not contain tyramine. Avocados, fermented food such as sauerkraut, processed meat, and organ meat contain tyramine. Monoamine oxidase inhibitors inhibit the breakdown of tyramine, which can lead to high blood pressure, hypertensive crisis, and eventually a cerebrovascular accident. Text page: 267
Serotonin Syndrome
Thought to be related to over activation of the central serotonin receptors, caused by either too high a dose or interaction with other drugs.
Symptoms include:
abdominal pain
diarrhea
sweating
fever
tachycardia
elevated blood pressure
altered mental state (delirium)
myoclonus (muscle spasms)
increased motor activity
irritability
hostility
mood change
Severe manifestations can induce:
hyperpyrexia (excessively high fever)
cardiovascular shock
death.
The risk of this syndrome seems to be greatest when an SSRI is administered in combination with a second serotonin-enhancing agent, such as a monoamine oxidase inhibitor (MAOI). A patient should discontinue all SSRIs for 2 to 5 weeks before starting an MAOI.
A client with a severe major depressive episode isunable to address activities of daily living (ADL). The appropriate nursing intervention would be to:
C. Feed, bathe, and dress the client as needed until the client's condition improves so that he can perform these activities independently.
The symptoms of major depression include depressed mood, loss of interest or pleasure, changes in appetite and sleep patterns, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts ofdeath. Often, the client does not have the energy or interest to complete activities of daily living. Option 1 will increase the client's feelings of poor self-esteem and of unworthiness. Option 2 is incorrect because the client still lacks the energy and motivation to do these independently. Option 3 may lead to increased feelings of worthlessness as the client fails to meet expectations.
An emergency department staff member calls the mental health unit and tells the nurse that a severely depressed client is being transported to the unit. The nurse in the mental health unit expects to note which of the following on assessment of this client?
C. Reports of substantial weight loss, insomnia, and decreased crying spells
In the severely depressed client, loss of weight is typical, while the mildly depressed client may experience a gain in weight. Sleep is generally affected in a similar way with hypersomnia in the mildly depressed client and insomnia in the severely depressed client. The severely depressed client may report that no tears are left for crying.
A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to
the nurse, "Call the doctor. I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by:
A. Increasing the level of suicide precautions
A client who is moderately depressed and has only been hospitalized 2 days is unlikely to have such a dramatic cure. When a mood suddenly lifts, it is likely that the client may have made the decision to cause self-harm. Suicide precautions are necessary to keep the clientsafe. Therefore options 1, 2, and 3 are incorrect.
A client with a history of depression will be participating in cognitive therapy for health maintenance. The client asks the nurse. "How does this treatment work?" The nurse should make which statement to the client?
A. 'This treatment helps examine how your thoughts and feelings contribute toyour difficulties."
Cognitive therapy is frequently used with clients who have depression. This type of therapy is based on exploring the client's personal experience. It includes examining the client's thoughts and feelings about situations as well as how these thoughts and feelings contribute to and perpetuate the client's difficulties and mood. Options 1, 2, and 3 are not characteristics ofcognitive therapy.
A nurse is caring for a client who is receiving electroconvulsive therapy (ECT) for a major depressive disorder. Which assessment finding would the nurse identify as an unexpected side effect of ECT that requires notifying the physician?
C. Hypertension
The major side effects of ECT are confusion, disorientation, and memory loss. A change in blood pressure would not be an anticipated side effect, and
would be a cause for concern. If hypertension occurred after ECT, the physician should be notified.
