ANCC Certification PMHNP Chapter 7 with complete verified solutions

Mood Disorders Most common psych illnesses Primary characteristic is persistent disturbance in mood Major Depressive Disorder Often occurs without precipitating event MDD Object loss theory Fairbairn, Winnicott & guntrip Aggression turned inward theory of MDD Freud Cognitive Theory Beck Learned Helplessness-Hopelessness Theory Seligman Genetic predisposition Strong genetic load for depression for child of depressed parent -having 3 fold increase in lifetime risk of MDD & 40% chance of depressive episode before age 18. Endocrine dysfunction Theory Probably related to etiology of MDD Sleep disturbances, appetite disturbances, libido disturbances, lethargy, anhedonia are neurovegitative symptoms that are related to functions of the Hypothalamus and pituitary gland secretions Endocrine dysfunction and pregnancy A high incidence of postpartum mood disturbances is suggested with this Hypothalamic-pituitary-adrenal axis (HPA) A theory of MDD, may be a result of an abnormal stress response related to dysregulation of this system HPA axis Controls the physiological response to stress and is composed of interconnective feedback pathways between the hypothalamus, pituitary gland, and adrenal gland. Hypothalamus releases corticotropin-releasing hormone (CRH) Adrenocorticotropin hormone (ACTH) Released by pituitary in response to CRH by hypothalamus Cortisol Released by adrenal glands in response to ACTH by pituitary gland Hyperactivity of the HPA axis Demonstrated to be present in individuals with MDD. May also have elevated cortisol levels Elevated cortisol levels Over time damages the CNS by altering neurotransmission and electrical signal conduction. Cortisol over time can cause changes in size and function of brain tissue Dexamethasone suppression test (DST) Not commonly used in clinical practice for screening of depression as it is too non specific. Hypovolemic hippocampus and hypovolemic prefrontal cortex-limbic striatal regions Abnormalities demonstrated by neuroimaging in individuals with chronic and severe depression Brain damage, including that from stroke and trauma Depression is a acommon comorbidity in individuals who have experienced these events What is the Chronobiological theory of MDD Desynchronization of the circadian rhythms produces the symptom constellation collectively called MDD Circadian rhythms control these biological processes that are frequent problems with depressed individuals Sleep-rest cycle disturbances Increased cortisol secretions REM abnormalities Increased emotional reactivity Frequent waking More intensified dreaming Diurnal variations to circadian-related behaviors Decreased arousal and energy levels Decreased activity patterns * Incidence of MDD 5% of U.S. population ages 18 and older each year. About 9.9 million Americans Most common psychiatric illness seen in primary care practices; only 50% of people receive treatment MDD 25% women, 12% men Risk during reproductive years Risk of MDD is ________ for both genders below puberty and after menopause equal MDD is (greater) or (lesser) source of morbidity for women than other illnesses. Greater Fifteen percent (15%) Of people with MDD will commit suicide People with MDD - Four times greater risk of premature death Than normal control population Episodes of MDD do not vary Not true. Disease course is variable and can involve isolated episodes separated by many years, clusters of episodes or a severe episode with some remission of symptoms but with chronic symptoms persisting over time. If untreated an episode of MDD Usually lasts 4 months or longer Major Depressive Disorder Tends to be a chronic, recurrent illness One year after initial diagnosis 40% of patients are symptom free Risk of future episodes of MDD: First episode = 60% risk of 2nd Second episode = 70% risk of 3rd Third episode - 90% risk of 4th Name 4 risk factors for MDD Family history (esp first degree relative); prior episode, female gender, postpartum period, medical comorbidity; single marital status; significant environmental stressors, esp multiple losses Four to six weeks: Length of time for therapeutic effect of antidpressants Appearance, speech, affect, mood, thought process, thought content (including suicidal thoughts/behaviors); cognition, orientation, memory, concentration, abstraction, judgment Mental Status Exam Endocrine Disorders implicated in MDD Hypothyroidism, DM, hyperaldosteronism, and Cushing's/Addison's Disease Infectious and inflammatory states implicated in MDD Mono, AIDS, viral and bacterial pneumonia; systemic lupus erythematosus, temporal arteritis, tuberculosis Nutritional disorders implicated in MDD Pernicious anemia and pellagra Psychiatric disorders commonly associated with MDD Anxiety disorders, eating disorders, Bipolar disorder, substance abuse/dependence disorders One should continue use of antidepressants for a minimum of 8-12 months If patient has prior episodes of depression, than consider using antidepressants For longer than 8-12 months Medication and counseling Research demonstrates that the most effective intervention is a combination of these two treatment modalities Action primarily to increase serotonin levels in CNS by inhibiting their reuptake: Selective Serotonin Reuptake Inhibitors (SSRIs) Elevate serotonin and norepinephrine levels primarily by inhibiting their reuptake Tricyclic Antidepressants (TCAs) Elevate serotonin and norepinephrine levels primarily by inhibiting MAO, the enzyme that destroys neurotransmitters Monoamine Oxidase Inhibitors (MAOIs) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) Inhibit dual reuptake; action very selective on neurotransmitters; elevate serotonin and norepinephrine levels by inhibiting their reuptake. Norepinephrine Dopamine Reuptake Inhibitors (NDRIs) Inhibit dual reuptake; action very selective on neurotransmitters; elevate dopamine and norepinephrine levels by inhibiting their reuptake. Serotonin Agonist and Reuptake Inhibitors (SARIs) Dual action; agonist of serotonin 5HT-2 receptors; action very selective on neurotransmitters; elevates serotonin levels by inhibiting serotonin reuptake SSRIs side effects Most common side effects of this class: gi upset, sexual dysfunction, nervousness, headache and dry mouth Name the six SSRIs Celexa, Lexapro, Prozac, Luvox, Paxil (Pexeva), Zoloft. Which is safer in overdose, Paxil or Nortriptyline? Paxil. SSRIs are safer in overdose than TCAs. SSRI's are also effective for treatment of panic disorder, OCD, bulimia, GAD social phobia and PTSD and premenstrual dysphoric disorder Which SSRI has long half-life? Prozac Two SSRIs have potential for teratogenic effects, name them. Paxil and Zoloft This SSRI has a black box warning for liver toxicity. Luvox GI upset, sexual dysfunction, nervousness, headache and dry mouth are common side effects associated with... SSRIs Second line drugs for treatment of MDD: Tricyclic Antidepressants (TCAs) The side effect profile for TCAs Dirty side-effect profile Dirty side effect profile contributes to Poor patient compliance