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Course: Mental Health Nursing

Topic: Mood Disorder: Depression Part II

The Nurses International Community

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Module Goals

Learners will be able to

Identify the symptoms that are reported by clients with depressive disorder.
Identify the clinical manifestations of depressive disorder.
Discuss evidence-based management of depressive disorder.
Identify the appropriate nursing interventions for depressive disorder.

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Neurotransmitters and Depression

Depression has been linked to decrease in neurotransmitters

Serotonin
Norepinephrine
Dopamine

Serotonin influences

Sleep
Aggression
Eating
Sexual behavior
Mood

Nimade, 2021

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Neurotransmitters and Depression

Serotonin

Produced by serotonergic neurons.
Current research suggests that.

A decrease in the production of serotonin may cause depression or suicidal ideation.�

Norepinephrine:

Low serotonin levels trigger a drop in norepinephrine levels leading to depression.

Nimade, 2021

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Neurotransmitters and Depression

Dopamine

Plays an important role in controlling the drive to seek out rewards and the ability to feel pleasure.

Low dopamine levels may explain why people with depression don't get pleasure out of activities.

Nimade, 2021

Contact info: info@nursesinternational.org

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Critical Thinking Question

Depression is linked to low levels of which neurotransmitters? (Select all that apply)

Serotonin
Dopamine
Norepinephrine
Monoamine Oxidase inhibitors

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Clinical Manifestation of Depression

Common features of all depressive disorders.

Sadness
Emptiness
Irritable mood
Somatic and cognitive changes affecting function.

All depressive episodes should be evaluated for suicidal risk.

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Clinical Manifestations of Depression

DSM-5 recognizes 9 symptoms of depression
Five must be present to make a clinical diagnosis (one is required to be depressed mood or loss of interest/pleasure):

Sleep disturbances
Interest/pleasure reduction
Guilt feelings or worthlessness
Energy changes/fatigue
Concentration/attention impairment
Appetite/weight changes
Psychomotor disturbances
Suicidal thoughts
Depressed mood

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Psychotic Depression

Major depression can occur along with psychosis (a transient mental state characterized by abnormal perceptions including delusions and/or hallucinations).

Psychotic depression: Psychosis in conjunction with major depression.

Psychotic depression increases risk of self-harm.

Black, 2021

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Symptoms of Psychotic Depression

According to DSM-5

Major depression must be present along with delusions and/or hallucinations.

If psychotic features are present, they are either.

Mood-congruent (displays as depressive themes like personal inadequacy, death, or deserved punishment).
Non-mood-congruent (not involving depressive themes).

Psychotic symptoms have a depressive theme, such as delusions of guilt, poverty, or illness.

Black, 2021

Contact info: info@nursesinternational.org

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Critical Thinking Question

According to the (DSM-5), which of the following symptoms must be present to diagnose depression?

Sleep disturbance
Lack of appetite
Depressed mood/Loss of interest
Fatigue
Suicidal thought

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Management of Depression

Medication or psychotherapy.�
Combination therapy (medication combined with psychotherapy).

Associated with significantly higher rates of improvement in symptoms and increased quality of life.

Electroconvulsive therapy is helpful for clients who are not responding well to medications or who are suicidal.

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Management of Depression

Medications

Selective serotonin reuptake inhibitors (SSRIs)
Serotonin/norepinephrine reuptake inhibitors (SNRIs)
Atypical antidepressants
Serotonin-Dopamine Activity Modulators (SDAMs)
Tricyclic antidepressants (TCAs)
Monoamine oxidase inhibitors (MAOIs)

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Management of Depression

Selective serotonin reuptake inhibitors (SSRIs):

First-line medications for late-onset depression.

Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Vilazodone
Vortioxetine

Has the advantage of ease of dosing and low toxicity.

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Management of Depression

Serotonin/norepinephrine reuptake inhibitors (SNRIs):

May be used as first-line agents, prioritized in clients with significant fatigue or pain syndromes associated with depressive episodes
Include

Venlafaxine
Desvenlafaxine,
Duloxetine
Levomilnacipran

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Management of Depression

Monoamine oxidase inhibitors (MAOIs)

Isocarboxazid
Phenelzine
Selegiline
Tranylcypromine

Widely effective in affective and anxiety disorders.
* Client must follow low-tyramine diet due to risk of hypertensive crisis.

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Monoamine Oxidase Inhibitors (MAOIs)

Counsel clients to avoid fermented or cured foods high in tyramine:

Fermented vegetables (kimchi and sauerkraut)
Grapes, avocado, beetroot
Wine and beer
Cheese, especially cheddar and feta
Cured or salt dried meats
Chocolate
Coffee
Soy sauce
Worcestershire sauce
Pickled or salt-dried fish/shrimp

Burns & Kidron, 2020

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Monoamine oxidase inhibitors (MAOIs)

Dietary counseling

Begin the diet before MAOI therapy, throughout MAOI therapy, and continue for four weeks after stopping MAOIs.
Identification and avoidance of high tyramine foods.
Education about a low tyramine diet with consumption of fresh foods.

Instruct clients to keep a record of their blood pressures.

Burns & Kidron, 2020

Contact info: info@nursesinternational.org

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Monoamine oxidase inhibitors (MAOIs)

Ingestion of 10 to 25 mg of tyramine in clients taking MAOIs will produce a severe adrenergic response

Hypertension
Headaches
Possible intracranial hemorrhage

Burns & Kidron, 2020

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Critical Thinking

A client with Major Depressive Disorder is on Monoamine Oxidase Inhibitors (MAOI’s). Which of the following is the most common side effect a client is at risk to experience when they ingest foods with tyramine?

Hypotension
Hypertension
Nausea
Vomiting

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Electroconvulsive Therapy (ECT)

Highly effective treatment for depression
Rapid onset compared to drug management
A course of ECT (usually up to 12 sessions) is the treatment of choice for clients who do not respond to drug therapy

Indications:

Need for a rapid antidepressant response
Failure of drug therapies
History of a good response to ECT
Client preference
High risk of suicide
High risk of medical morbidity and mortality

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Psychotherapy

Also known as “talk therapy”
A client speaks with a trained therapist in a safe and confidential environment to explore and feelings and behaviors to gain understanding and coping skills
Cognitive Behavior Therapy
Interpersonal Therapy

National Alliance on Mental Illness, 2021

Image by, Wikimedia Commons

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Cognitive Behavior Therapy (CBT)

Explores relationships among a person's thoughts, feelings, and behaviors.

The core principles include identifying negative or false beliefs and testing or restructuring them.

National Alliance on Mental Illness, 2021

Contact info: info@nursesinternational.org

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Interpersonal Therapy

Focuses on the relationships a person has with others to improve the person’s interpersonal skills.
Therapist assists client in

Evaluating social interactions and recognizing negative patterns (social isolation or aggression) and develop strategies to have positive relationship interactions.

National Alliance on Mental Illness, 2021

Contact info: info@nursesinternational.org

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Dialectical Behavior Therapy (DBT)

Based on CBT and emphasizes:

Validation
Acceptance of uncomfortable thoughts, feelings, and behaviors.

Client seeks a balance between acceptance and change.
Client develops new skills (coping methods and mindfulness practices) increasing the power to improve unhealthy thoughts and behaviors.

National Alliance on Mental Illness, 2021

Contact info: info@nursesinternational.org

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Eye Movement Desensitization And

Reprocessing Therapy (EMDR)

Refer to this protocol as "dual stimulation".
An individual stimulates their brain with back and forth eye movements.
Performing a series of back and forth eye movements for 20-30 seconds can help individuals change identified emotional reactions.
Replaces negative emotional reactions to difficult memories with less-charged or positive reactions.

National Alliance on Mental Illness, 2021

Contact info: info@nursesinternational.org

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Exposure Therapy

The client identifies their anxiety triggers and learns techniques to avoid becoming anxious.
Methods

Flooding

Presented with a large amount of triggering stimuli at once.
Desensitization
Presented with small amounts of stimuli initially progressing to more over time.

National Alliance on Mental Illness, 2021

Contact info: info@nursesinternational.org

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Mentalization-Based Therapy (MBT)

Psychotherapy that engages and exercises the skill of mentalizing.

Mentalizing

Intuitive process giving one a sense of self.
Consciously perceiving and understanding one’s inner thoughts and feelings.
Perceiving and speculating other’s feelings and thoughts aiding in relational connections.

National Alliance on Mental Illness, 2021

Contact info: info@nursesinternational.org

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What Would the Nurse Do?

Which of the following foods would a nurse instruct a client to avoid when taking MAOI medication for Major Depressive Disorders? (Select all that apply)

Kimchi
Cheese
Soy sauce
Salt-dried meat

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Nursing Management

Client safety and reducing the risk of suicide is priority
Interventions

Monitor for suicidal risk.
Eliminate sharp objects and items from client’s environment.
Encourage client to engage in self-care.
Encourage rest and sleep.
Engage the client in a therapeutic relationship.
Use empathy when communicating with the client.

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Nursing Management

Reinforce elements of therapy such as challenging negative thoughts about self, the world, and the future.
Encourage client to participate in activities.
Have client list positive characteristics about themselves.
Review and evaluate client coping strategies and support systems.
Monitor eating patterns and encourage nutritional intake.
Monitor medications for effectiveness and side effects.
Include family in care if applicable.

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Health Teaching and Health Promotion

Education

Signs and symptoms of depression
Understanding that depression is a medical illness with effective treatments
Reinforce rationale for therapies
Describe the negative triad regarding self, world, and future
Reinforce strategies for mindfulness and challenging negative thoughts
Provide information on support groups, such as the National Alliance on Mental Illness (NAMI)

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Health Teaching and Health Promotion

Inform that medication may take two to four weeks to reach a therapeutic response.
Inform that healthy life choices and behaviors can influence mood:

Good sleep hygiene
Healthy eating
Regular exercise

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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Health Teaching and Health Promotion

Inform client to keep a list of prescribed medication, including over-the-counter drugs and supplements.
Remind the client that alcohol and other mood-altering drugs (whether legal or illegal) may impact mood.
Central nervous depressants may worsen depression

Alcohol
Opioids

Chand & Arif, 2021

Contact info: info@nursesinternational.org

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What Would the Nurse Do?

Discuss interventions the nurse may use when caring for a depressed client?

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Red Flag

A person is giving away all their prized possessions or clothing. (May indicate a plan for suicide)

Sudden improvement in mood in a person who has been very depressed (may feel relief after making a suicide plan)

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References

Black, R. (2021). Psychotic Depression: What It Is and What You Should Know. Psycom. https://www.psycom.net/psychotic-depression-what-you-should-know

Burns, C., & Kidron A. (2021). Biochemistry, Tyramine. [Updated 2020 Oct 16]. In: StatPearls [Internet]. StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563197/

Chand SP, & Arif H.(2021). Depression. [Updated 2021 Jul 26]. In: StatPearls [Internet]. StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430847/

National Alliance Mental Illness. (2021). Psychotherapy. https://www.nami.org/About-Mental-Illness/Treatments/Psychotherapy

Nimade, R. (2021). DEPRESSION: DEPRESSION & RELATED CONDITIONS: BIOLOGY OF DEPRESSION - NEUROTRANSMITTERS. Gulf Bend Center. https://www.gulfbend.org/poc/view_doc.php?type=doc&id=12999&cn=5

Contact info: info@nursesinternational.org

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