12/2/2013 - hhvna.com · 4 2013c&v senior care specialists,inc nursing interventions and...

12/2/2013

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DEPRESSIVE DISORDERS:MAJOR DEPRESSION; GRIEF AND SUICIDE

DR. VERNA BENNER CARSON, PMHCNS-BC

&

KATHERINE J. VANDERHORST, BSN

2013C&V Senior Care Specialists,Inc

PURPOSE OF CAREGUIDE

STANDARDIZE CARE

PROVIDE CARE PLANNING

ASSESSMENT PROCESS

INTERVENTION

SUPPORTIVE THERAPIES'

TEACHING TOOLS

MEDICATIONS

TELEPHONE ASSESSMENT

CASE STUDY

LET’S REVIEW MAJOR DEPRESSION


LEARNING OBJECTIVES:

AFTER CONTENT PRESENTATION, PARTICIPANTS WILL BE

ABLE TO:

• DEFINE MOOD, MOOD DISORDERS

• IDENTIFY SYMPTOMS OF DEPRESSION, RISK FACTORS

FOR DX, PHARM & NON-PHARM TREATMENT, NURSING

INTERVENTIONS FOR MAJOR DEPRESSION

• DISCUSS SUICIDE AS RISK WITH DEPRESSION

• DISTINQUISH DEPRESSION AND DEMENTIA

• UNDERSTAND AND RESPOND TO GRIEF

• ASSESS FOR DEPRESSION, DEMENTIA, GRIEF AND

SUICIDE RISK

• DISCUSS CASE STUDIES2013C&V Senior Care Specialists,Inc

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MOOD DISORDERS

• THE MENTAL DISORDERS THAT ARE

CHARACTERIZED BY A PROMINENT OR

PERSISTENT MOOD DISTURBANCE.

• MOST COMMON OF ALL PSYCHIATRIC

ILLNESSES.


DEPRESSION

• ONE OF THE MOST COMMON HUMAN EMOTIONS

• A NORMAL HEALTHY REACTION THAT CAN MOTIVATE ONE TO DEAL WITH EVENTS AND EMOTIONS.

• EXISTS ON A CONTINUUM

• CRITICAL FOR CLINICIAN TO DETERMINE THE DIFFERENCE BETWEEN NORMAL AND PATHOLOGICAL LEVELS OF DEPRESSION.


DEPRESSIVE DISORDER:MAJOR DEPRESSION

DEFINED: WHEN A PERSON IS SAD WITH DEPRESSED MOOD OR IRRITABLE MUCH OF EACH DAY FOR TWO WEEKS OR MORE. THERE IS A CLEAR CHANGE FROM PREVIOUS FUNCTIONING.

• THE SYMPTOMS CAUSE SIGNIFICANT IMPAIRMENT

OR DISTRESS IN SOCIAL, OCCUPATIONAL, SCHOOL,

RECREATIONAL, OR RELATIONAL FUNCTIONING.

• THE SYMPTOMS ARE NOT DUE TO MEDICAL

CONDITION (HYPOTHYROID), SUBSTANCE USE OR

MEDICATION.


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SYMPTOMS OF MAJOR DEPRESSION

ANHEDONIA – ALMOST ALWAYS PRESENT

APPETITE CHANGES – USUALLY WEIGHT LOSS

SLEEP DISTURBANCES – INSOMNIA (MORE COMMON) OR HYPERSOMNIA

RESTLESSNESS OR PSYCHOMOTOR

RETARDATION

FATIGUE – DECREASED ENERGY

FEELING WORTHLESS, GUILTY,

HOPELESS OR HELPLESS

INABILITY TO THINK CLEARLY

OR MAINTAIN

CONCENTRATION

DIFFICULTY WITH MAKING

DECISIONS

THOUGHTS OF DEATH OR

SUICIDE: SUICIDE ATTEMPTS 2013C&V Senior Care Specialists,Inc

DEPRESSION DEPRESSION IS HIGHLY PREVALENT IN PRIMARY

HEALTH CARE SETTINGS AND FREQUENTLY GOES UNRECOGNIZED BY HEALTH CARE PRACTITIONERS

1 OUT OF 5 PATIENTS SEEING A PCP HAS SIGNIFICANT SYMPTOMS OF DEPRESSION

HEALTH CARE PROVIDERS FAIL TO RECOGNIZE DEPRESSION IN THEIR PATIENTS 50% OF THE TIME

DEPRESSION IS TREATABLE – PTS DO RETURN TO FULLY FUNCTIONAL LEVELS.

UNTREATED DEPRESSION CAN LEAD TO SUICIDE2013C&V Senior Care Specialists,Inc

RISK FACTORS FOR DEPRESSION

• PRIOR EPISODES OF DEPRESSION

• FAMILY HISTORY OF DEPRESSION

• PRIOR SUICIDE ATTEMPTS

• CHRONIC ILLNESSES

• UNRELENTING PAIN

• FEMALE GENDER

• AGE OF ONSET LESS THAN AGE 40

• POSTPARTUM PERIOD


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Nursing Interventions and Treatments in Major

Depressive Disorder

Maintain pt. safety

Empathy & compassion

Instill hope

Nutrition

Sleep

Hygiene

Social skills


Nursing Interventions and Treatments in Major Depressive Disorders

Convey acceptance of patients

feeling and symptoms

• Health Teaching and

Psychoeducation

Offer hope – self limiting illness

• Challenge cognitive distortions (e.g.

negative thinking)



Depressive Disorders

Psychopharmacology - Antidepressants**MAOI’s – Inhibit enzymes that

metabolize serotonin and norepinephrine**TCA’s: Inhibit the reuptake of serotonin

and norepinephrine**SSRI’s: Inhibit the reuptake of

serotonin > Increases availability of serotonin-(Viibryd or vilazodone – released 2011),

**Other antidepressants Effexor – (SSNRI)PRISTIQ® (Desvenlafaxine) Extended-Release

Tablets (SSNRI)Wellbutrin – (NDRI)Cymbalta-(SSNRI)

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Nursing Interventions and Treatments in

Major Depressive Disorder

Electroconvulsive Therapy (ECT)

- Used in those who are medication

resistant or have recurrent episodes.


Nursing Interventions and Treatments in

Major Depressive Disorders

• Phototherapy – exposure to bright artificial light >

improves depressive sx’s

Used for tx in SAD – “Winter Blues”



Depressive Disorders

• Patient & Family Education

• Individual, couples, and family therapy

• Group Therapy

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WHAT DO WE NEED TO BEGIN TO ASSESS IN HOME CARE?

(M1730) Depression Screening: Has patient been screened for depression, using a standardized depression screening tool? □ - 0 -No

□ - 1--Yes, patient was screened using the PHQ2© scale. (Instructions for this two-question too. Ask patient:”Over the last two weeks have you been bothered by the following problems”)

PHQ2

□ - 2 –Yes, with a different standardized assessment and the patient meets criteria for further evaluation for depression.□ - 3 – Yes, patient was screened with a different standardized assessment

and the patient does not meet criteria for further evaluation for depression.

DEPRESSION- (Continued)

A score of 3 on PHQ-2 or higher should trigger a complete Depression Assessment using a Standardized Tool such as PHQ-9 or Geriatric Depression Scale

(short version)

HOW COMFORTABLE ARE MOST NON-PSYCH HOME CARE CLINICIANS IN INTRODUCING

SUBJECT OF DEPRESSION? HOW ABOUT SUICIDALITY?




DEPRESSION PROTOCOL

1. Administers MINI-COG, PHQ-9 or GDS & OASIS

2. Provides pt./family education/self management support

3. Provides proactive follow-up, tracks pt. clinical responses via GDS or PHQ9

.

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DEPRESSION- INTERVENTIONS4. Evaluates outcomes of counseling and med mgmt.5. Facilitates adherence to antidepressant meds via med teaching, supervision and med mgmt. 6. Monitors response to psych meds7. Assesses and follows up for changes in meds or other TX if pt not responding.

.


.


8. Obtains order from PCP for psychiatric evaluation and refers to

our psychiatrist if patient not responding to TX

9. Provides relapse prevention techniques and education

*Important-Critical to track scores across all episodes of care.

DEMENTIA AND DEPRESSION


Patients with Alzheimer’s

become depressed;

Important to pay attention to

sad face, change in appetite,

change in weight, change in

sleep, slow movements,

expressions of despair,

suicidal talk.

Untreated depression adds to

patient’s confusion.

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2013C&V Senior Care

Specialists,Inc

C&V SENIOR CARE SPECIALISTS,INC All

Rights Reserved 2013

Patient with Symptoms of Depression and

Dementia. Referred for Depression

Assess with GDS and Mini-Cog

If non-verbal, use Faces

Reassess at 6-8 weeks

with Mini-Cog GDS

GDS Improved

Mini-Cog (Still Positive from Initial

Assessment)

Probably Depression

Refer to MD for the Dementia Assessment

Do FAST as well

GDS Improved

Mini-Cog Improved

Probably Depression

All Rights Reserved

C&V Senior

Care Specialists Inc. 2013


Grief


Typical Symptoms Characteristic of Grief

Reaction• Disbelief, shock, numbness

• Anger

• Feeling of guilt

• Sadness, tearfulness

• Preoccupation with the deceased

• Disturbed sleep and appetite

• Seeing or hearing the voice of the deceased.

• With time –symptoms abate –usually clears within 6 months. Can last for 12 months

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Pathological Grief Reactions

• Delayed Grief

▫ Persistent absence of any emotion

• Distorted Grief

▫ Abnormal mourning at the time of the loss

to include:

SXS of major depression: prolonged

functional impairment, suicidality,

preoccupation with feelings of

worthlessness, & marked psychomotor

retardation.

Psychotic symptoms

Substance abuse


Goal of Evaluation & Tx

• FACILITATE NORMAL GRIEVING PROCESS AND TO

IDENTIFY AND TREAT PATHOLOGICAL PROCESS


Dysthymic Disorder: Chronic Depression

Characterized by the following:

- Chronic less severe form of depression

- Low, gloomy, or sad mood every day for

2 years

- Not easily distinguishable from persons

“usual” functioning – “I have always

been this way”

- Prevents full enjoyment of life

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Dysthymic Disorder:

Chronic Depression

- Thoughts of death or suicide

absent

- As common as Major Depression

- Occurs twice as often in females

when compared to males

- Dx typically missed in primary care

settings

ASSESSMENTS FOR DEPRESSION

• DEPRESSION

▫ PHQ9

▫ GDS (SHORT VERSION)

▫ SAD PERSONS


TREATMENT GOALS FOR DEPRESSION

• PSYCHOEDUCATION

• MEDICATION

▫ UNDERSTANDING & ADHERENCE

• CHARTING – MOOD, SLEEP, APPETITE,

EXERCISE, ETC

• RECOGNIZE EARLY WARNING SIGNS

• RELAPSE PREVENTION

• IMPROVED FUNCTIONING2013C&V Senior Care Specialists,Inc

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Suicide: Epidemiology

Suicide was the seventh leading cause of death for males and the fifteenth leading cause of death for females in 2007.1

Almost four times as many males as females die by suicide.1

Firearms, suffocation, and poison are by far the most common methods of suicide, overall. However, men and women differ in the

method used, as shown below


Suicide Epidemiology cont…

Question???

Which demographic group of U. S. has the

highest suicide rate?


ANSWER

Older Americans are disproportionately likely to die by suicide.Of every 100,000 people ages 65 and older, 14.3 died by suicide in 2007. This figure is higher than the national average of 11.3 suicides per 100,000 people in the general population. 1

Non-Hispanic white men age 85 or older had an even higher rate, with 47 suicide deaths per 100,000

http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml#CDC-Web-Tool



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More Suicide Facts

• In the U.S., teen suicide is nearly five (5) times as common among boysas among girls.

• Women attempt suicide twice oftenas men.

• Suicide is more common among whites than blacks of all ages.

• The use of guns in suicide is increasing rapidly.


Assessment of Risk for Self-Harm• Behaviors:

Observe and identify Non-

Compliance with healthcare

recommendations/treatment plan.

▫ Clinical Examples:

Non-compliant diabetic patient

Non-compliant depressed patient


Self-Injury

• Defined: An act of deliberate harm to one’s

own body. This injury is done to oneself

without the aid of another person and the

injury is severe enough to cause tissue

damage.

• What are some forms of self-injury?

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Self-Injury

• Self-Injury and Suicide attempts are two separate phenomena!!!

• Persons who self-injure typically want relief from tension, not to kill themselves.

▫ Self injury is a contained event that occurs in a short time span with an awareness of the consequences of the act.

▫ Lethality is usually low.


Self-Injury

Categorized by the type of patient and the clinical context in which it occurs:

• Individuals with mental retardation

• Psychotic patients

• Prison populations

• Character disordered individuals, particularly personality disorders such as borderline personality disorder


Assessment of Risk for Self-Harm

Suicidal behavior: • Divided into categories

▫ Suicidal ideation

▫ Suicidal threats

▫ Suicidal attempts

▫ Completed suicides

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Suicidal Ideation

Defined: The thought of

self-inflicted death

Vary in seriousness

Passive: thoughts with no intent to act

Active: plans or thoughts of causing one’s own death

All suicidal behavior is serious, whatever the intent, and thus suicidal ideations deserves the nurses highest priority care


Suicidal Threat

• Defined: A warning, direct or

indirect, verbal or non-verbal,

that a person is planning to

take one’s own life.

• Usually occurs prior to suicidal

activity.

• A threat is often an indicator

of ambivalence.


Suicide Attempt

• Defined: Any self-destructive action taken by a person that will lead to death if not stopped.

• When assessing a suicide attempt, the lethality of the attempt is considered.

• All suicide threats must be taken seriously.

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Lethality of Method

• High: gunshot, hanging,

jumping

• Medium: overdose of

pills/alcohol because allows

time for discovery

• Low: superficial scratching,

head banging, pillow over face,

biting, holding breath.


Suicide Assessment

• Nursing assessment Includes the

following questions: Does the person have a plan?

Does the person have the means available to

carry out the plan?

How lethal is the plan?


Suicidal behaviors

• There are many different clinical

presentations

• Mood disturbances often present

• Somatic complaints often present

• Feelings of hopelessness/

helplessness present

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FACTS45% of people who completed suicide

had visited their primary care provider

within one month of their attempt

20% had contact with their mental

health provider within one month of

their attempt

Among the Elderly:

> 80% give clues of their intent

75% are known to have visited their

PCP in the month before they took

their life


Predisposing Factors:Psychiatric Diagnosis

> 90% of adults who end their lives by

suicide have associated psychiatric

illness

Mood disorders

Substance abuse

Schizophrenia

Anxiety disorders

2013C&V Senior Care Specialists,IncMood disorders & Suicidal Behavior

• Suicide is the most serious complication of a mood disorder, 15% of those with this illness, end their lives by suicide.

• Suicide is particularly common in the depressed elderly men

• Patients with bipolar disorder and psychotic depression are at greatest risk.

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Alcohol Use and Suicidal Behavior:

• Alcohol use is associated

with 25-50% of suicides.

• Among patients who are

alcohol dependent, suicide

often occurs late in the

disease often related to

interpersonal loss or onset

of medical complications


Predisposing factors cont…Personality

Traits

• Four aspects of personality that are most

closely associated with suicidal behaviors

are:

hostility

impulsivity

depression

hopelessness

• These traits cross diagnostic groups

• Loss or lack of social support

• Negative life events

• Chronic medical illness


Predisposing Factors cont…

Family History

• A family history of suicide is a

significant risk factor for self-

destructive behavior.

• Offspring of those who attempt

suicide are at markedly greater

risk of suicide themselves.

▫ Identification and imitation of

family member

▫ Family stress related to

suicide

▫ Transmission of genetic

factors

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Presenting symptoms for self-destructive

behavior

HopelessnessWeight lossSocial withdrawalSlowed speech, fatigueSuicidal thoughts/plansAgitation/restlessnessPersistent insomniaHelplessnessSelf-reproachFeelings of failureUnworthinessDepressed mood


Nursing Interventions

• Take a detailed medical and psychiatric history

• Take a family history

• Mental status examination

• Psychosocial history

• Evaluate for recent losses, stressors, substance abuse

• Ask direct questions about suicidal thoughts, plans, & intent.

• SAD PERSONS

SUICIDALITY

M1730 a Score of 3 on PHQ2 should trigger additional depression assessment tool – PHQ9 or GDS which would ask about suicide risk

HISTORY – SUICIDAL ATTEMPT?? CURRENT PLAN? METHOD TO CARRY OUT PLAN?

These items MUST be explored – Remember that YOU WILL NOT MAKE SOMEONE COMMIT SUICIDE IF YOU ASK

THEM ABOUT IT – TO THE CONTRARY – TALKING ABOUT IT DECREASES THE DESIRE TO FOLLOW THROUGH WITH IT-

COMPLETE “SAD PERSONS” Suicide Assessment Tool –

IMPLEMENT PSYCHIATRIC EMERGENCY POLICY IF NECESSARY


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SUICIDALITY

Suicide Thinking; Suicidal Gestures or Attempts may be Associated with any of the Psychiatric Disorders –Depression, Bipolar, Schizophrenia or Anxiety. The Risk is Especially High When Patients Engage in Alcohol and/or Substance Abuse and/or Experience

Command Hallucinations.

There are two OASIS items relevant to Suicide Risk –

These are M1730 and M1740


SUICIDALITY

M1740:#2-Impaired Decision-making

#4- Physical Aggression

# 6-Delusional, hallucinatory, or paranoid

HISTORY – SUICIDAL ATTEMPT??

USE COMMENT SECTION – COMPLETE “SAD PERSONS” Suicide Assessment Tool or Assessing Suicide Risk as a Spectrum

IMPLEMENT PSYCHIATRIC EMERGENCY POLICY IF NECESSARY


IF SUICIDAL

CALLING 911 IS THE

BEST RESPONSE IF A

PATIENT IS

THREATENING

SUICIDE AND/OR

HOMICIDE – NO

OTHER RESPONSE

WILL DO!


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• WE ASK THE PATIENT OR THE CALLER(IF ON-CALL)

THE FOLLOWING QUESTIONS:

• ARE YOU PLANNING TO HARM YOURSELF?

• HOW WILL YOU DO THIS? WHAT ARE YOUR PLANS?

• DO YOU HAVE THE MEANS AVAILABLE (I.E. GUN, MEDS

FOR OVERDOSE, CAPACITY TO JUMP FROM A BRIDGE

OR HIGH BUILDING, ETC.) TO HARM YOURSELF OR

OTHERS?

• IS THERE ANYONE ELSE WITH YOU THAT I CAN TALK

TO?’

• I WANT TO HELP YOU – WHAT CAN I DO TO KEEP YOU

SAFE?

• REASSURE PATIENT THAT YOU ARE CONCERNED AND

WILL HELP.

DETERMINING RISK

IF ANYONE ELSE IS WITH YOU –GET THE ATTENTION OF THAT PERSON – HAVE HER/HIM CALL 911 WITH PATIENT’S ADDRESS/TELEPHONE

NUMBER.


ON-GOING ACTIONS..

• DEVELOP A STRATEGY WITH

SUPPORT PERSON THAT INVOLVES:

CONTINUED VERBAL SUPPORT

REINFORCE COMMITMENT NOT TO

HARM SELF.

COMMITMENT OF SUPPORT

PERSON TO REMAIN WITH PATIENT

A STRATEGY TO TRANSPORT

PATIENT TO AN EMERGENCY ROOM

IF SITUATION WORSENS

• CONTINUE TO REASSURE

PATIENT.

• REPEATEDLY SAY THAT YOU ARE

CONCERNED AND WANT TO

HELP.

• ASK IF ANYONE ELSE IS WITH

PATIENT AND ASK IF YOU CAN

TALK TO THAT PERSON.

• OBTAIN VERBAL COMMITMENT

FROM PATIENT THAT HE/SHE

WILL NOT HARM SELF.

IF PATIENT IS ALONE AND SITUATION IS UNSAFE –FIND OUT PATIENT’S LOCATION AND TELEPHONE NUMBER AND TELL PATIENT EMERGENCY

HELP WILL BE OBTAINED IMMEDIATELY – CALL 911 TO REPORT PSYCHIATRIC EMERGENCY



Exploring Predisposing/Precipitating Factors:

• Help patients understand high-risk times

and situations that lead to suicidal/self-

destructive thoughts and behaviors.

• Help the patient identify the triggers for

their self-destructive thought, feelings,

behaviors.

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Factors that Protect Against Suicide

• Effective treatment for psychiatric, medical illness and substance abuse

• Support system (family, community, healthcare providers)

• Access to treatment• Restricted access to high lethal methods of suicide• Learned skills in problem solving, conflict

resolution, non-violent handling of disputes• Cultural and Religious beliefs that discourage

suicide and support self-preservation

CASE STUDIES


ANY QUESTIONS???


12/2/2013 - hhvna.com · 4 2013c&v senior care specialists,inc nursing interventions and...

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