Drug information provided by: IBM Micromedex Show It is very important that your doctor check your progress at regular visits to allow for changes in your dose and to check for any unwanted effects. You will also need to have your blood pressure measured before starting this medicine and while you are using it. If you notice any change to your recommended blood pressure, call your doctor right away. If you have questions about this, talk to your doctor. When taken with certain foods, drinks, or other medicines, phenelzine can cause very dangerous reactions, such as sudden high blood pressure (also called hypertensive crisis). To avoid such reactions, follow these rules of caution:
Phenelzine may cause some people to be agitated, irritable, or display other abnormal behaviors. It may also cause some people to have suicidal thoughts and tendencies or to become more depressed. If you or your caregiver notice any of these adverse effects, tell your doctor right away. Call your doctor or hospital emergency room right away if you have a severe headache, stiff or sore neck, chest pains, fast heartbeat, sweating, dizziness, or nausea and vomiting while you are taking this medicine. These may be symptoms of a serious side effect called hypertensive crisis. This medicine may cause blurred vision or make some people drowsy or less alert than they are normally. Make sure you know how you react to this medicine before you drive, use machines, or do anything else that could be dangerous if you are unable to see well or not alert. This medicine will add to the effects of alcohol and other CNS depressants (medicines that slow down the nervous system, possibly causing drowsiness). Some examples of CNS depressants are antihistamines or medicine for hay fever, allergies, or colds; sedatives, tranquilizers, or sleeping medicine; prescription pain medicine or narcotics; medicine for seizures or barbiturates; muscle relaxants; or anesthetics, including some dental anesthetics. Check with your doctor before taking any of the above while you are using this medicine. Dizziness, lightheadedness, or fainting may occur, especially when you get up suddenly from a lying or sitting position. Getting up slowly may help. When you get up from lying down, sit on the edge of the bed with your feet dangling for 1 or 2 minutes, then stand up slowly. If the problem continues or gets worse, check with your doctor. Do not stop taking this medicine without checking first with your doctor. Your doctor may want you to gradually reduce the amount you are using before stopping it completely. Before having any kind of surgery, dental treatment, or emergency treatment, tell the medical doctor or dentist in charge that you are using this medicine or have used it within the past 10 days. Taking phenelzine together with medicines that are used during surgery, dental, or emergency treatments may increase the risk of serious side effects. Your doctor may want you to carry an identification card stating that you are using this medicine. This medicine may affect blood sugar levels. If you are diabetic, be especially careful in testing for sugar in your blood or urine. If you have any questions about this, check with your doctor. After you stop using this medicine, you must continue to exercise caution for at least 2 weeks with your foods, drinks, and other medicines, since these items may continue to react with phenelzine. Do not take other medicines unless they have been discussed with your doctor. This includes prescription or nonprescription (over-the-counter [OTC]) medicines and herbal or vitamin supplements. Portions of this document last updated: Nov. 01, 2022 Copyright © 2022 IBM Watson Health. All rights reserved. Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. . Learning Outcome
IntroductionDepression is a mood disorder that causes a persistent feeling of sadness and loss of interest.[1][2] The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies the depressive disorders into:
The common features of all the depressive disorders are sadness, emptiness, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function.[3] Nursing DiagnosisThe nursing diagnoses found in people with depression should be individualized to the patient. The list below contains some nursing diagnoses that frequently occur due to their connection to the DSM 5 diagnostic criteria:
CausesThe etiology of major depressive disorder is multifactorial with both genetic and environmental factors playing a role. First-degree relatives of depressed individuals are about 3 times as likely to develop depression as the general population; however, depression can occur in people without family histories of depression.[4][5] Some evidence suggests that genetic factors play a lesser role in late-onset depression than in early-onset depression. There are potential biological risk factors that have been identified for depression in the elderly. Neurodegenerative diseases (especially Alzheimer disease and Parkinson disease), stroke, multiple sclerosis, seizure disorders, cancer, macular degeneration, and chronic pain have been associated with higher rates of depression. Life events and hassles operate as triggers for the development of depression. Traumatic events such as the death or loss of a loved one, lack or reduced social support, caregiver burden, financial problems, interpersonal difficulties, and conflicts are examples of stressors that can trigger depression. Risk FactorsTwelve-month prevalence of major depressive disorder is approximately 7%, with marked differences by age group. The prevalence in 18- to 29-year-old individuals is threefold higher than the prevalence in individuals aged 60 years or older. Females experience 1.5- to 3-fold higher rates than males beginning in early adolescence. AssessmentThe investigation into depressive symptoms begins with inquiries of the neurovegetative symptoms which include changes in sleeping patterns, appetite, and energy levels. Positive responses should elicit further questioning focused on evaluating for the presence of the symptoms which are diagnostic of major depression. These are the 9 symptoms listed in the DSM-5. Five must be present to make the diagnosis (one of the symptoms should be depressed mood or loss of interest or pleasure):
All patients with depression should be evaluated for suicidal risk. Any suicide risk must be given prompt attention which could include hospitalization or close and frequent monitoring. Other areas of investigation include:
EvaluationThe diagnosis of depression is based on history and physical findings. No diagnostic laboratory tests are available to diagnose major depressive disorder. Laboratory studies are, however, useful to exclude medical illnesses that may present as major depressive disorder. [6][7][8]These laboratory studies might include the following:
Medical ManagementMedication alone and brief psychotherapy (cognitive-behavioral therapy, interpersonal therapy) alone can relieve depressive symptoms. Combination therapy has also been associated with significantly higher rates of improvement in depressive symptoms; increased quality of life; and better treatment compliance. There is also empirical support for the ability of CBT to prevent relapse.[9][10] Electroconvulsive therapy is useful for patients who are not responding well to medications or are suicidal.[11][1] Medications
Electroconvulsive Therapy (ECT) ECT is a highly effective treatment for depression. Onset of action may be more rapid than that of drug treatments, with benefit often seen within 1 week of commencing treatment. A course of ECT (usually up to 12 sessions) is the treatment of choice for patients who do not respond to drug therapy, are psychotic, or are suicidal or dangerous to themselves. Thus, the indications for the use of ECT include the following:
Although advances in brief anesthesia and neuromuscular paralysis have improved the safety and tolerability of ECT, this modality poses numerous risks, including those associated with general anesthesia, postictal confusion, and, more rarely, short-term memory difficulties. Psychotherapy Cognitive Behavior Therapy and Interpersonal Therapy are evidence-based psychotherapies that have been found to be effective in the treatment of depression. Cognitive-behavioral therapy (CBT) CBT is a structured, and didactic form of therapy that focuses on helping individuals identify and modify maladaptive thinking and behavior patterns (16 to 20 sessions). It is based on the premise that patients who are depressed exhibit the “cognitive triad” of depression, which includes a negative view of themselves, the world, and the future. Patients with depression also exhibit cognitive distortions that help to maintain their negative beliefs. CBT for depression typically includes behavioral strategies (i.e., activity scheduling), as well as cognitive restructuring to change negative automatic thoughts and addressing maladaptive schemas. There is evidence supporting the use of CBT with individuals of all ages. It is also considered being efficacious for the prevention of relapse. It is particularly valuable for elderly patients, who may be more prone to problems or side effects with medications. Mindfulness-based cognitive therapy (MBCT) was designed to reduce relapse among individuals who have been successfully treated for an episode of recurrent major depressive disorder. The primary treatment component is mindfulness training. MBCT specifically focuses on ruminative thought processes as being a risk factor for relapse. Research indicates that MBCT is effective in reducing the risk of relapse in patients with recurrent depression, especially in those with the most severe residual symptoms. Interpersonal therapy (IPT) Interpersonal Therapy (IPT) Interpersonal therapy (IPT) is a time-limited (typically 16 sessions) treatment for major depressive disorder. IPT draws from attachment theory and emphasize the role of interpersonal relationships, focusing on current interpersonal difficulties. Specific areas of emphasis include grief, interpersonal disputes, role transitions, and interpersonal deficits. Nursing ManagementThe nurse, caring for the depressed person, should direct interventions toward resolving the issues identified through the nursing diagnoses. A priority is the patient’s safety, including alleviating the risk of suicide. The following list includes interventions for the depressed person:
Coordination of CareDepression is a very common disorder encountered by the nurse practitioner, primary care provider, psychiatrist, and mental health worker. The disorder has extremely high morbidity including the risk of suicide. All healthcare workers should be knowledgeable about this disorder and refer the patient to a psychiatrist if there is a risk of self-harm. Education plays an important role in the successful treatment of major depressive disorder. This would include the education of the family and the patient. Lack of accurate information and misperceptions of the illness as a personal weakness or failing leads to painful stigmatization and avoidance of the diagnosis by many of those affected. Patients should know the rationale behind the choice of treatment, potential adverse effects, and expected results. The involvement of the patient in the treatment plan can enhance medication compliance and referral for psychotherapy. Engaging family members can be a critical component of a treatment plan. Family members are helpful informants, can ensure medication compliance, be a big source of social support and can encourage patients to change behaviors that perpetuate depression (e.g., inactivity). The outcomes for patients with depression are guarded. There is no cure and the condition has frequent relapses and remissions, leading to a poor quality of life.[3][12][13] Health Teaching and Health PromotionEducation plays an important role in the successful treatment of major depressive disorder. This would include the education of the family and the patient. Lack of accurate information and misperceptions of the illness as a personal weakness or failings leads to painful stigmatization and avoidance of the diagnosis by many of those affected. Patients should know the rationale behind the choice of treatment, potential adverse effects, and expected results. The involvement of the pharmacist in the treatment plan can enhance medication compliance and referral for psychotherapy. Engaging family members can be a critical component of a treatment plan. Family members are helpful informants, can ensure medication compliance, be a big source of social support and can encourage patients to change behaviors that perpetuate depression (e.g., inactivity). Health Teaching and Health Promotion An important role of the nurse is teaching the patient about depression, its symptoms, treatments, and how to promote overall health and wellbeing. The following are points to include in the teaching of a depressed person: Teach the patient the signs and symptoms of depression. Emphasize that depression is a medical illness with treatments that are effective so that the patient does not feel stigmatized by the diagnosis. Reinforce the rationales for the medications and therapies. Describe the negative triad regarding self, the world, and the future as symptoms of depressive thinking. Reinforce mindfulness and challenging negative thoughts as strategies to decrease negative rumination Provide information on support groups, such as the National Alliance on Mental Illness (NAMI), that may have local chapters as well as online information. Support groups provide an opportunity to discuss how to live with depression with others who may have gone through similar experiences. Explain that it may take two to four weeks to reach a good response from the medications and that it is important to work with the prescriber regarding effects and side effects. It may take more than one trial of a medication to reach a good response. Explain that healthy life choices and behaviors can influence mood. Good sleep hygiene, healthy eating, and regular exercise are important to continue even when feeling depressed and not motivated. Inform patient to tell all prescribers all medications used, including over-the-counter drugs and supplements, because medications can interact with each other. Remind patient that alcohol and other mood-altering drugs, whether legal or illegal, can impact mood. Many, such as alcohol and opioids, are central nervous system depressants and can worsen depression. Risk ManagementPatients with moderate to severe depression should also be seen by a social worker to ensure that they have a support system and finances for treatment. Overall, depression is managed by an interprofessional team dedicated to the management of mental health disorders. Open communication between all the members is the key to lowering the morbidity of the disorder. Discharge PlanningThe entire interprofessional healthcare team, including the patient and family, should be part of the discharge planning with the goal of reducing the need for readmission and helping the person achieve the highest level of functioning possible. Hospitals utilize toolkits, such as the Re-Engineered Discharge (RED) toolkit to assist with discharge goals and their implementation. (reference) Nurses are an important part of the discharge team as the process progresses and review the plan again with the patient at the time of discharge. The nurse must insure that the patient has resources available prior to discharge. The nurse should complete medication reconciliation throughout this process. Important information that the patient with depression should have in writing at the time of discharge include: Information about the hospitalization: length of stay, the reason for admission Medications at time of discharge: name of each medication (generic and brand), amount, how much and how often to take, why the medication is taken, how it is taken Appointments: Dates, times, and what the appointment is for. The patient should have appointments with a psychiatric prescriber and a therapist Numbers to call if symptoms worsen before appointments as well as a crisis number, such as a suicide hotline A place for the patient to write notes about questions to ask during the next appointment (about symptoms, medications, side effects, treatment options) Evidence-Based IssuesThe outcomes for patients with depression are guarded. There is no cure and the condition has frequent relapses and remissions, leading to a poor quality of life.[3][12][13] Pearls and Other issuesDepression is a very common disorder encountered by the nurse practitioner, primary care provider, psychiatrist, and mental health worker. The disorder has extremely high morbidity including the risk of suicide. All healthcare workers should be knowledgeable about this disorder and refer the patient to a psychiatrist if there is a risk of self-harm. Review QuestionsReferences1.Salik I, Marwaha R. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 8, 2022. Electroconvulsive Therapy. [PubMed: 30855854] 2.Singh R, Volner K, Marlowe D. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jun 20, 2021. Provider Burnout. [PubMed: 30855914] 3.Ormel J, Kessler RC, Schoevers R. Depression: more treatment but no drop in prevalence: how effective is treatment? And can we do better? Curr Opin Psychiatry. 2019 Jul;32(4):348-354. [PubMed: 30855297] 4.Pham TH, Gardier AM. Fast-acting antidepressant activity of ketamine: highlights on brain serotonin, glutamate, and GABA neurotransmission in preclinical studies. Pharmacol Ther. 2019 Jul;199:58-90. [PubMed: 30851296] 5.Namkung H, Lee BJ, Sawa A. Causal Inference on Pathophysiological Mediators in Psychiatry. Cold Spring Harb Symp Quant Biol. 2018;83:17-23. [PubMed: 30850434] 6.Mangla K, Hoffman MC, Trumpff C, O'Grady S, Monk C. Maternal self-harm deaths: an unrecognized and preventable outcome. Am J Obstet Gynecol. 2019 Oct;221(4):295-303. [PubMed: 30849358] 7.Shelton RC. Serotonin and Norepinephrine Reuptake Inhibitors. Handb Exp Pharmacol. 2019;250:145-180. [PubMed: 30838456] 8.Tanner J, Zeffiro T, Wyss D, Perron N, Rufer M, Mueller-Pfeiffer C. Psychiatric Symptom Profiles Predict Functional Impairment. Front Psychiatry. 2019;10:37. [PMC free article: PMC6396718] [PubMed: 30853916] 9.Horowitz MA, Taylor D. Tapering of SSRI treatment to mitigate withdrawal symptoms. Lancet Psychiatry. 2019 Jun;6(6):538-546. [PubMed: 30850328] 10.Knappe S, Einsle F, Rummel-Kluge C, Heinz I, Wieder G, Venz J, Schouler-Ocak M, Wittchen HU, Lieb R, Hoye J, Schmitt J, Bergmann A, Beesdo-Baum K. [Simple guideline-oriented supportive tools in primary care: Effects on adherence to the S3/NV guideline unipolar depression]. Z Psychosom Med Psychother. 2018 Sep;64(3):298-311. [PubMed: 30829159] 11.Saracino RM, Nelson CJ. Identification and treatment of depressive disorders in older adults with cancer. J Geriatr Oncol. 2019 Sep;10(5):680-684. [PMC free article: PMC7457378] [PubMed: 30797709] 12.Hengartner MP, Passalacqua S, Andreae A, Heinsius T, Hepp U, Rössler W, von Wyl A. Antidepressant Use During Acute Inpatient Care Is Associated With an Increased Risk of Psychiatric Rehospitalisation Over a 12-Month Follow-Up After Discharge. Front Psychiatry. 2019;10:79. [PMC free article: PMC6396716] [PubMed: 30853919] 13.Rootes-Murdy K, Carlucci M, Tibbs M, Wachtel LE, Sherman MF, Zandi PP, Reti IM. Non-suicidal self-injury and electroconvulsive therapy: Outcomes in adolescent and young adult populations. J Affect Disord. 2019 May 01;250:94-98. [PubMed: 30844603] |