NR 507 Week 5 Assignment; Alterations in Neurobiological Function

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Matthew Perry

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Nursing

Course

NR 507 Advanced Pathophysiology

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Chamberlain

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14

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Week 5 Alterations in Neurobiological functions Depression Major Depressive Disorder (MDD) is known as clinical depression where approximately 20% of females are clinically depressed compared to males at 12%. To be clinically depressed means that the symptoms experienced interfere with the individual’s daily life. It leads to an overall feeling that life is not an enjoyable experience. The exact cause of MDD is unknown, but most likely due to a combination of genetic, biologic and environmental factors. Genetic: Family members who have depression are three times more likely to have it themselves. This link tends to increase with how close the members are related. Biological: From a biological perspective, most medications used to treat depression focus on the neurotransmitters of the brain. Neurotransmitters are signaling molecules that are released by one neuron and received by receptors of another neuron. A message is relayed from one neuron to the next. Regulation of how many neurotransmitters are being sent at any given time plays a significant role in the development of the symptoms of depression since they are involved in the regulation of many brain functions like mood, attention, sleep, appetite and cognition. The three major neurotransmitters that are involved in the development of depression are serotonin, norepinephrine and dopamine. These are significant because medications that cause there to be more of these neurotransmitters in the synaptic cleft (the space between the neurons) are shown to be effective antidepressants. This finding led researchers to develop the Monoamine Deficiency Theory that indicates that the underlying basis of depression is low levels of serotonin, norepinephrine and dopamine. These are known as monoamines because they have one amine group. In addition, it is thought that each of these may have an impact on certain sets of symptoms of depression: Serotonin: obsessions and compulsions Norepinephrine: anxiety and attention Dopamine: attention, motivation and pleasure If one of these neurotransmitters are low a specific set of symptoms may be experienced by the individual. Serotonin, particularly, is thought to be a major player. Some theories suggest that it may be capable of regulating the other neurotransmitters, norepinephrine and dopamine. However, there is limited evidence to support this theory. More concrete evidence that supports the role of serotonin in the development of depression, relates to tryptophan depletion. This is the amino acid that the body uses to make serotonin. If there is a decrease in tryptophan, there will be a decrease in the production of serotonin. Without a normal level of serotonin, individuals begin showing symptoms of depression. However, the reasons why serotonin, norepinephrine and dopamine might be decreased in patients with depression is not well understood. Thus, significant resources are dedicated to continuing research in this area. Environmental: Environmental components include loss from death or from sexual or physical abuse. In order to diagnosis MDD, patients must meet certain criteria that are outlined in the Diagnostic and Statistical Manual, 5th edition (DSM-5) for Mental Disorders. The patient must be affected by at least five of nine of the following symptoms mostly or every day, for at least 2 weeks: Depressed mood Diminished interest of pleasure in activities Significant weight loss or gain Inability to sleep or oversleeping Psychomotor agitation (pacing, wringing hands, psychomotor impairment or overall slowing of thought processes) Fatigue Feelings of worthlessness or guilt Decreased ability to think or concentrate Recurrent thoughts of death or suicide ideations (including suicidal thoughts with or without a specific plan and/or suicide attempt) The symptoms must cause distress in the individual’s daily life. The symptoms cannot be due to a substance or other medical condition. The symptoms cannot be better explained by another mental disorder (e.g. schizoaffective disorder). The individual cannot have had a manic or hypomanic episode at any point. MDD Sub-Types: Post-partum depression: occurs following childbirth. Although studies have shown that it can occur prior to childbirth as well. The actual diagnosis is Depressive Disorder with Peripartum Onset because the onset occurs during pregnancy or four weeks following delivery. The cause is generally unknown but is suspected that hormonal factors play a role in its development, especially estrogen and progesterone. The impact of childbirth on lifestyle may also play a role in its development because it can happen in men as well as in women. Atypical depression: characterized by an improved mood when exposed to pleasurable or positive events. This is known as mood reactivity in contrast from other subtypes like melancholy even during what used to be pleasurable events. Atypical depression also includes the symptoms of weight gain, increased appetite, oversleeping, heavy feeling limbs (leaden paralysis) and rejection sensitivity where the individual feels anxiety at thoughts of rejection. Dysthymia: persistent depressive disorder used to describe milder symptoms of depression that happen over longer periods of time, specifically over two or more years with at least two of the following symptoms: Change in appetite Change in sleep Fatigue or low energy Decreased self-esteem Decreased concentration Feelings of hopelessness or pessimism Treatment: Non-Pharmacologic Approaches Awareness of the many factors involved in the diagnosis of depression can pose treatment challenges. With the correct treatment, the individual can have a significant reduction in symptoms. Treatment can come in several forms and are grouped into one of two major categories non-pharmacologic, and pharmacologic approaches. Non-pharmacologic approaches include: Physical activity is thought to be related to the release of neurotransmitters, endorphins, and endocannabinoids as well as raising the body temperature to cause muscle relaxation. Regardless of the exact mechanisms, data suggests that exercising for 20 minutes for three times per week can help alleviate symptoms of depression. Diet may also impact symptoms of depression. Some research suggests that healthy eating habits with increased consumption of fruits and vegetables may play a role in reducing depressive symptoms. Psychotherapy is “talk therapy” that is preferred for younger individuals and those who have mild symptoms. Techniques include cognitive behavioral therapy and interpersonal therapy. The most important point is that success of these techniques depends significantly on the individual’s relationship with the therapist as well as the clinical skills of the therapist. In more severe depression or for long-term symptoms of depression, pharmacologic intervention is indicated. Motivational interviewing is an encouraged communication technique that helps to influence change in the individual’s behavior through exploring and resolving ambivalence to the change and then helping the individual facilitate the change. It is a collaborative process that involves the use of open-ended questions, affirmations, reflections and summarizations. Electroconvulsive Therapy (ECT) is usually tried when all other treatments have failed. A small electrical current is passed through the brain while patients are under general anesthesia. It induces a brief seizure. Although ECT has been used for many years and seems to be effective for at least some patients. Treatment: Pharmacologic Approaches Involves the use of single or a combination of medications: 321456494228Antidepressants: Selective Serotonin Reuptake Inhibitors (SSRIs): these are the most common antidepressants prescribed. In the synaptic cleft, after neurotransmitters get released, they are normally reabsorbed. Selective Serotonin Reuptake Inhibitors (SSRIs) block the reabsorption or inhibits the reuptake of serotonin that allows for more of it in the synaptic cleft. Some of the side effects of SSRIs include nausea, headaches, restlessness and insomnia. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): these drugs increase levels of serotonin and norepinephrine in the brain by blocking or delaying their reuptake by nerves. Norepinephrine is another neurotransmitter that regulates emotions and thought processes. They are also weak inhibitors of dopamine reuptake. Side effects include insomnia, dizziness, weakness, hypotension, tachycardia and diaphoresis. Despite the different classifications, all antidepressant medications are equally effective in reducing the major symptoms of MDD. One of the roles of the NP, then, is to determine which medication is appropriate for the individual patient. One consideration is the side effects of the medication, especially if the drug aggravates an existing medical condition. For example, the drug, mirtazapine, may need to be avoided in the obese patient with diabetes as it increases appetite and weight, thus leading to poor glycemic control in the patient. This underscores the need for the NP to be fully aware of each antidepressant’s side effects and interactions with other medications and diagnoses. The NP must also consider the patient’s preference of antidepressant drugs available. This will contribute to the patient's compliance with the treatment regimen. Cost may also be a factor in adherence to treatment as well. Patient referral

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