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Psychotherapeutic Management for Depression

Antidepressants
Tricyclic antidepressants: imipramine, amitriptyline

SSRI: Fluoxetine HCL, Sertraline


Lowers down libido

MAOIs: Phenelzine, Tranylcypromine


last resort due to increased complications; only given if no response to TCA, SSRI
drug to drug interaction: cannot be combined with anti-depressants, or other MAOI
food to drug interaction: cannot take tyramine rich food (banana, preserved food, Processed
food, cheese
risk for development of hypomania; permanently blocks the enzyme from destroying the
neurotransmitter

Depression: rapid reuptake of neurotransmitters


Increased destruction of neuro transmitters by enzymes by MAOI
Post synaptic neurons not able to absorb bc pre synaptic neurons reuptake agad
Monoamineoxydase
Increased GABA, increase impulse control

Antidepressants take time to take effect (2-4 weeks)


Condition improves, precaution for suicide
Monitor for cheeking, hoarding
Possible hypotension
Drug interaction

Electroconvulsive therapy – written consent


Pre ect lab workout
Pre ect meds – barbiturate short acting anesthetics , succinylcholine muscle relaxant, atropine
sulfate decrease salivation
Prior to tx: NPO, atropine s04, urinate, dentures, jewelry, hairpin, vital signs, reduce anxiety
During: IV line inserted, electrodes bilateral, bite block, barbiturate, succinylcholine,
hyperoxigenate

Blood brain barrier, gets thinner. Easier penetration of meds


Reactivation of brain activity in depressed px
-suicidal, catatonic, manic, depressed
contraindicated: cardiovascular problems, hx of brain injury, seizure disorder,
fractures/dislocations, severe respiratory problems,
grandmal seizure – 70-150 volts 0.8-2 seconds machine on
seizure should last 30-60 seconds
risk for injury, turn px to drain saliva
respiratory thumping – to expand the lungs (done in NCMH as substitute for hyperoxigenation)
check gag reflex – risk for aspiration
side effects- temporary amnesia, confusion; reorient patient
observe until condition becomes stables
ECT up to 12 sessions, 3/week maximum
Advantages: safe procedure as long as patient is properly prepared
Effective and economical because hospital stays are shortened
Fast improvement
Can be done to out patients

Disadvantage: temporary improvement, antidepressants must be continued


Client may experience memory gap, memory lapse
May experience seizure episodes even if without history (POST ECT seizure)

Nursing Problems
- Risk for violence/injury towards self
- Altered nutrition
- Self-care deficit
- Sleep disturbance
- Altered social interaction
- Isolation
- Low self esteem
- Social impairment

Assessment
- Onset of symptoms
- Presence of comorbid substance, alcohol, and medications (to rule out side effects from
substances)
- Functioning of the patient
- Physical examination
- Presence of non-mood psychiatric disorders (schizophrenia, Alzheimer’s, anxiety)
- Resources and social support system
- Interpersonal and coping abilities
- Level of stressors
- Presence and or level of suicidal ideations

Level 1 – low risk of suicide


Frequent monitoring
Level 2 – high risk suicide
Complete monitoring

Principles of communication
1. Depressed person suffers from low self esteem
2. Developing meaningful relationship is important to the client’s sense of worth
3. The nurse must be sincere and empathetic
4. Intellectual understanding does not help severely depressed clients
5. Typically dependent
6. Do not embarrassed clients out of being depressed
7. Never reinforce hallucinations, delusions, and irrational beliefs
8. Depressed clients tend to be angry
9. Withdrawn patients can be helped by spending time with them
10. Depressed persons can have difficulty in decision making
11. It may help to categorize depressed persons as suicidal risk individuals

Milieu management

Nutrition
Encourage to eat, can be small frequent feeding
Do not force to finish meal
Allow the patient to have participation in selecting meal
Make sure that proper diet, adequate fluid, and proper exercise

Sleep disturbance
Record the amount and quality of patient’s sleep
Establish client’s sleeping pattern before hospitalization
Adjusting TCA’s dosage to single bedtime dose
Discourage daytime napping, give activities to spend energy
Discourage consumption of stimulation food

Psychotherapy
- Individual – exploring feelings, thoughts, behaviors.
o To understand themselves and their behavior
o To make personal changes
o To improve interpersonal relationships
o To get relief from emotional pain or unhappiness
- Group – clients participate in sessions with group of people
o To learn about ther behavior
o To make positive changes in their behavior
o Communicate with others
o Formal in structure
o Gives a sense of belongingness
o To establish the rules for the group
- Family therapy – to understand the family dynamics
o Mobilizes the family’s strength and functional resources
o Maladaptive family behaviors
o Strengthening family problem solving
- Play therapy
- Reminiscence therapy
- Life review therapy

Complementary and alternative treatments


- St john’s wort
- Light therapy – seasonal affective depression
- Acupuncture
- Message
- Exercise

Bipolar disorder – individuals who are experiencing the extremes of mood polarity
- Person may feel euphoric or very depressed
- Equal for both men and women
- Early 20’s
- Runs in the family
- 15% will die at their own hands

DSM category for bipolar episodes


- manic episodes
- Hypomanic episode
- Bipolar episode
o Bipolar I: MDD and manic
o Bipolar II: MDD and hypomanic
o Cyclothymic – long term but less potent

- Manic episode - serious impairment in daily functioning


- Hypomanic episode - less severe level of impairment, at least 4 days
Mania low levels of serotonin and GABA- serotonin regulation of mood and impulse control =
labile mood (shifting mood)

Psychodynamic – unstable emotional experience during childhood


- Alternating identification with parents
- Massive denial of depression
- Mania Symptoms
o Elevated mood
o Feeling of grandiosity
o Irritability
o Anger
o Lack of sleep
o Lack of appetite
o Flight of ideas
o Distractibility
o Hyperactive
o Excessive involvement in pleasurable activities
o Loud rapid speech
o Lack of awareness of illness
o Resistance to treatment
o Unpredictable and changing mood
o Depression
o Hallucinations

Bipolar disorder - manic episodes usually behinds suddenly, escalate rapidly and last from a
few days to several months

Psychotherapeutic management
- Anti-manic medications: lithium, anticonvulsants
- Nurse-patient relationship
- Milieu management
Anti mania – actions: Blocks the influx of Na ions intracellular
- Inhibition of the “kindling” activity of the brain
- Effects: sedation, drowsiness
- Side effects: polyuria, polydipsia, mild hand, tremors, metallic taste
- Agranulocytosis, nausea, anorexia, and vomiting, transient hair loss, weight gain,
tremors, GI upset, thrombocytopenia

NURSING CONSIDERATIONS
- Lithium – contraindicated to clients with cardiovascular and renal problem
- Normal serum level and the manifestation of toxicity
- If toxicity occurs, discontinue drug and appropriate nursing intervention is implemented
to maintain life
- Increase fluid intake 8-10 glasses
- Eat diet that has adequate salt
- Coffee eliminates lithium and counteract

Nursing problems
- Risk for violence
- Impaired nutrition
- Sleep disturbance
- Self-care deficit
- Fatigue
- Altered social interpersonal and occupational relationships
- Alterations in activity and appearance
- Alterations of affect
- Alterations of perception

Tendencies of manic clients


- manipulation of self-esteem of others
- ability to find vulnerability of others
- ability to shift responsibility to others
- limit testing
- alienate others

Nurse-patient relationship
- matter of fact attitude
- clear, concise direction, and comments
- limit setting
- reinforcement of reality
- respond to legitimate complaints
- redirect to healthy activity

Milieu Management
1. safety
2. consistency
3. decrease stimuli
4. management of aggression
5. reinforcement appropriate hygiene and grooming
6. nutrition and sleep issue

Toxicity Management
- mild – withhold net dose, call physician, serum level determination
- moderate – same as mild, gastric lavage, iv infusion of plain NSS
- severe – same as moderate, aminophylline, mannitol

Suicide FACTS:
- Predisposed: Male
- Previous suicide attempts
- Hx of completed suicide/attemps in the family
- Hx of psychiatric illness
- Severe depressive illness
- Alcoholics

- Suicidal ideation
- Suicidal gestures
- Suicidal threats
- Suicidal attempts
- Completed suicide

Common expression of suicidal client


- Cry for help
- Escape/desperation
- Heroic
- Loss of self esteem
- Manipulation
- Martyrdom
- Rebirth
- Redemption/cult
- Relief of pain
- Retaliatory/revenge
- Reunion

Major themes of suicidal individuals are


- Loss
- Unbearable psychic pain
- Helplessness
- Hopelessness
- Loneliness
- Abandonment

Interventions
- Face to face
- Over the telephone
- Internet

Face to face intervention


- Always remember that depressed patient are suicidal patients
- To assess risk: ask directly if they plan to hurt themselves
- If positive with a plan: ask about the plan and method
- Ask about previous attempt

Suicide Interventions
- Developing nurse-patient relationship=positive client outcome
- Screening client for risk of committing suicide
- Evaluate patient’s depression, recent loss, alcohol or drug abuse, self-destructive
hallucination
- Implement level of suicide prevention
- Frequent observation (level 1) – not immediate risk
- Continuous observation (level 2) – immediate and serious threat of suicide
- Encourage exploration and expression of suicidal feelings

Level 1 risk
- Periodic observation (every 10 minutes)
- Monitor activities: shaving, use of eating utensils, drug intake
- Staff communicating the concern and control

Level 2 risk
Assessment
Plan – the more developed the plan the higher the risk of successfully completing the plan
- Impulsive acts are less often lethal
Methods – lethality
- Gun
- Jumping from high places
- Drowning
- Hanging
- Carbon monoxide poisoning
- Drugs and alcohol
Accessibility
Rescue – deceiving a would be rescuer is a high lethality
- Leaving notes or messages is likely to be rescued

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