Question

49-year-old married woman comes in to see her medical provider complaining of severe sleep difficulty involving initial insomnia, poor appetite, a severe decrease in her energy level to the extent that some weeks she calls into work 2 or more days, and lack of enjoyment in her usual hobbies and interests. She describes her mood as “depressed.” You observe the client to have a sad, blunted affect; slowed speech; and psychomotor retardation. In exploring the client’s life stressors, you learn that she has a 19-year-old daughter who is away at college and that 4 months ago, her 17-year-old daughter was killed in a car accident. The client admits to maladaptive grieving and an irrational fear that something “bad” will happen to her daughter at college. The client also admits that she is depressed and that she does have some vague suicidal ideation but no specific plan. She feels compelled to watch over her daughter as she feels a degree of guilt that she was not a good mother and that failing contributed to her 17-year-old daughter’s death. She tells you that she has been taking St. John’s wort for the past 2 months but has not thought that it has helped with her depression. The primary provider gives the client a prescription for escitalopram (Lexapro).


Discuss in detail the pharmacologic interventions for depressive disorders. What are the side effects? What are the nursing interventions in regards to side effects and client education?   

What are the psychosocial interventions for depressive disorders?  

Answer 1

DEPRESSIVE DISORDERS

A mental health disorder characterised by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life

Possible causes include a combination of biological, psychological and social sources of distress. It is also called major depressive disorder.It impacts mood and behavi\our as well as various physical functions such as appetite and sleep.

PHARMACOLOGICAL INTERVENTIONS FOR DEPRESSIVE DISORDERS

In all patient population, the combination of medication and psychotherapy generally provides the quickest and most sustained response

Drugs used in the treatment of depresssion includes the following

• Selective serotonin reuptake inhibitors
• Serotonin /norepinephrine reuptake inhibitors
• Atypical antidepressants
• Tricyclic antidepressants
• Monoaminase oxidase inhibitors
• N-methyl-D aspartate receptor antagonists

Selective serotonin reuptake inhibitors

• eg: fluoxetine, citalopram
• SSRIs are frequently prescribed type of antidepressants. SSRI work by helping inhibit the breakdown of serotonin in the brain, resulting in higher amounts of this neurotransmitter
• Serotonin is a brain chemical that is believed to be responsible for mood. It may help improve mood and produce healthy sleeping patterns.

Serotonin/norepinephrine reuptake inhibitors

• eg: desvenlafaxine, duloxetine, levomilnacipran, venlafaxine
• SNRIs are a class of medications that are effective in treating depression.
• SNRIs are also sometimes used to treat other conditions such as anxiety disorders and long term pain, especially nerve pain.
• SNRIs ease depression by affecting chemical messengers used to communicate between brain cells. SNRIs work by effecting changes in brain chemistry and communication in brain nerve cell circuitry known to regulate mood, to help relieve depression.
• SNRIs block the reabsorption of the neurotransmitters serotonin, and norepinephrine in the brain

Atypical antidepressants

• eg: Bupropion, mirtazapine, nefazodone, trazodone ,vortioxetine
• Atypical antidepressants are not typical- they dont fit into other classes of antidepressants.
• Atyppical antidepressants ease depression by affecting chemical messengers used to communicate between brain cells. Like most antidepressants, atypical antidepressants work by ultimately effecting changes in brain chemistry and communication in brain nerve cell circuitry.

Tricyclic antidepressants

• eg: Amitriptyline, amoxapine, dexepin, nortriptyline
• Tricyclic antidepressants help keep more serotonin and norepinephrine available to the brain. These chemicals are made naturally by the body and are thought to affect the mood.

Monoaminase oxidase inhibitor

• eg: selegiline, phenelzine, tranylcypromine
• MAOIs work with the chemicals in the brain called neurotransmitters that allow brain cells to communicate with each other. Depression is thought to be caused by low levels of the neurotransmitters which collectively called monoamines.

N-methyl D- aspartate receptor antagonists

• eg:memantine, tenocyclidine, ketamine, dextromethorphan
• Class of drugs that work to antagonize or inhibit the action of the N-methyl-D-aspartate receptor .

SIDE EFFECTS

SSRI AND SNRI

• Feeling agitated, shaky or anxious
• Feeling and being sick
• Indigestion
• Loss of appetite
• Dizziness
• Insomnia
• Low sex drive

TRICYCLIC ANTIDEPRESSANTS

• Dry mouth
• Slight blurring of vision
• Constipation
• Drowsiness
• Problems passing urine
• Weight gain
• Excessive sweating
• Heart rhythm problems

NURSING INTERVENTIONS

• Provide for patients physical needs: Assist with self care and personal hygiene, encourage patient to eat, give warm milk or back rubs at bedtime to improve sleep
• Assume active role in iniatiating communication: This can be done by sharing observationof patients behaviour, speaking slowly and allowing ample time for him to respond, encourage him to talk and write down feelings and by providing a structured routine which may include noncompetative activities
• Educate patient about depression: Explain that depression can be eased by expressing feelings and engaging in pleasurable activities.
• Help patient recognise distorted perceptions and link them to his depression
• Ask patient whether he thinks about death or suicide

PSYCHOSOCIAL INTERVENTIONS FOR DEPRESSION

There are a number of evidence based psychotherapeutic treatments for adults with major depressive disorder.

• Behavioral therapy
• Cognitive therapy
• Cognitive behavioural analysis of psychotherapy
• Interpersonal psychotherapy
• Problem solving therapy
• Self management therapy
• interpersonal psychotherapy
• Cognitive behavioural therapy