Antidepressants and Hospitalization

[DidiRN]

I'm curious about everyone else's opinions on this, so I thought I'd throw it out here.

Whenever I get a patient in an ICU who becomes depressed over a catastrophic illness, alot of the doctors will prescribe an antidepressant for them. Now I could be absolutely dead wrong on this, but this concerns me a bit. I'm wondering if it is truly appropriate to prescribe these medications for people who have no history of depression who are now depressed, but who have darn good reason to be depressed. They are trying to cope with a loss, and I'm not real sure if treating a situational depression with medication is a good idea.

Most of my coworkers disagree with me, they say it helps them deal with the short term depression. However, my own personal experience with antidepressants (which I've been on almost every one known to man), they have at times some pretty powerful side effects. Also, these things usually take time to become effective, and we usually are not able to evaluate their effectiveness in an ICU setting.

So am I wrong to be concerned? I would think coping with a loss is something you have to work out, along with some kind of counseling or support, and not necessarily medication as the very first line of defense. I could completely understand using them if other things such as counseling or talk therapy did not help, but not sure if it should be prescribed right away. But if any of you feel differently, and have some experience personally with these things, let me know. I'm willing to change my view on this if I'm wrong :)

Sherri

[zehava]

:stone I tend to agree with you about anti-depressent rx and would welcome your opinion. I am trying to decide if I should increase my mother's Zoloft of 25mg, taken since March 23, 2003 to 50mg. She has all her mental facilities and I don't want her zonked out. Because of my health I had to put her in a nursing home where she is bedridden for life. Further, she has macular degeneration and can hardly see, has two hearing aids but can barely hear. She is 97 going on 65. Not one health problem--it's justs that her body is losing strength and her bones break from ostesporsis, and she is on 100 duregesic patch. She is not the type that cries or whines, but now she is crying. It was her crying that finally convinced me, initially, after three days of quizzing to ascertain she was depressed enough for Zoloft. The Zoloft helped so much. I don't mind having the Zoloft increased but increased by 2x bothers me. Her body is also very strong when it comes to meds--the hospital has tried manytimes to knock her out for a while to get her pain under control but they never did.

Zehava

Yes....I agree with medical tx intervention early before their depression were to become severe. Many patients experience a feeling of loss once in icu. Its almost as if they feel they may never return to previous health. If it is a cardiac case where they have to change behaviors and learn new ways to prevent further problems, along with new medications with side effects that may cause them fatigue, that also can be depressing to some. And as you know, depression can also cause other illness...so yup, i agree. Its when a physician ignores depression that troubles me.

[lsyorke, RN]

Thunderwolf, I agree that all medications have side effects and adverse effects. Abrupt discontinuation can absolutely make that worse. But the new information is showing that even when the "weaning" schedule is followed withdrawal symptoms occur. This happened in the clinicial trials(which wasn't reported) and continues to happen in "real" life. Some of the classic withdrawal symptoms are "zaps"(electrical shocks in the head), dizziness,"eye trails"(your brain has trouble catching up with your eyes, and your vision has a blurred trail when you move your eyes), increased anger, insomnia, increased suicial ideation. Some report a more protracted withdrawal that can take months to recover from. Primetime Live did a show on this 2 weeks ago. http://abcnews.go.com/Health/story?id=311956&page=1 . It included a story of a young women who is unable to get off paxil due to the withdrawal symptoms. She is unable to do her job if she doesn't take the paxil, since the auditory sensitivity(another symptoms) is so interfering. OK, so it's not "officially" withdrawal, but when trying to stop a medication is so debilitating that you cannot function in your normal ADL's that's a big problem.By not recognizing these problems with discontinuance the patient can be led to believe that they need more medications which then starts the vicious cycle.

I have lived this with my son. Happily I can say that he's off paxil 8 months and it's taken until now for those mentioned symptoms to clear. He's now a happy,social,outgoing child again. If I hadn't learned what I have in the last year, I can guarentee you that he would have ended up on other psychiatric medications due to the withdrawal symptoms he exhibited.

This is the information that people need to make the decision to take one of these drugs. We owe it to those who are experiencing "discontinuance syndrome"(which was a phrase invented by Glaxosmithkline in their marketing tool)http://abcnews.go.com/images/Primetime/paxil_moneybag.pdf the knowledge that they are truly experiencing a drug problem and not necessarily an exacerbation of mental illness.

[begalli]

Thank you Thunderwolf and others! What I think I'm reading is that there is no simple fix to any kind of addiction of any kind and while antidepressants are not addictive, they certainly have their own problems in discontinuance. The hardest part of overcoming (is that the right word?) addiction, is staying clean.

It's no secret that mental health is so under-addressed and so under-appreciated. Addiction is a mental health issue and I think that most addicts do have an underlying problem that prompts them to self-medicate. Or, if they don't have an underlying problem before they start using, they develop one because of their use. I remember from the psych portion of my nursing program (which was outstanding!) that those individuals with "dual" problems were the most difficult to treat.

As for the situational depression vs something else (like a depressive disorder, for example [or is a situational depression a depressive disorder?]), the two are definitely not the same and shouldn't be treated the same. But is my thinking wrong? In a situational depression, do the neurotransmitters in the CNS undergo changes just like someone with an established disorder such as in maybe a bi-polar disease? If the "situation" is not dealt with and corrected can it become chronic?

I just feel SO bad for people who suffer the pain of a mental health disease and for whatever reason they don't or can't get the treatment or relief that they so desperately need.

I guess the clinicals I did while in nursing school in acute and chronic psych has just had a profound affect on me even years later. I often wonder about the 19 year old young man who had his first break from reality shortly after taking ecstacy, or the 20ish young woman who was suffering a bizarre phase of her bi-polar where she thought she alone had the key to the secrets of life and she told me that the secret was the number "ONE" as she literally bounced up and down in a chair during one of our talks, or the basically mute schizophrenic who was much more terrified of any of us than we ever should have been of her who actually sat down next to me one day and told me what the voices were saying at that moment, or the alcoholic woman who's son was killed in a car accident and she was so, so depressed that she began to ideate suicide and was completely paralyzed, or the young Asian woman who was under observation in seclusion and all she did for hours and hours on end was walk around the room making motions with her arms as though she was swimming, or the young guy who was coming off an addiction and actually stabbed himself in the abdomen with his plastic lunch fork before anyone could stop him.

How do people get to this place?

[Thunderwolf, MSN, RN]

Bengalli, mental illness is a devastating class of illnesses. You capture the frustration well in your post, as well as the angst. Each type deals its own devastating blow to the individual, at times it can be heart breaking. These folks do struggle, as well as their families. It is a costly illness, which unfortunately does not get adequately treated in our current day revolving door, insurance managed, health care system. Some times, one of the most important roles of a psych nurse is to help prevent folks from falling through the cracks in the system and/or managed poorly. Situational depression, bipolar depression, and clinical (major) depression are not the same! AND, the treatment is or needs to be different because they are different. You mentioned other illnesses as well, such as dual diagnosis, schizophrenia, and the like. They have their own differences too. My very first post on this thread was addressing depression and the use of antidepressants in the hospital, some times too liberally. And also, I agree, may not be prescribed enough because depression may be missed due to not being diagnosed. My concern in the first post, however, was to alert readers that often time depression or depressive like symptoms may be due to undiagnosed physical health problems...the underlying cause. If you do not address the underlying physical health problem, you can throw all the antidepressants you want at it and it will not fix the problem (it is like putting a bandaid on a gaping wound). The physical health problem needs to be addressed. This is my concern. In substance abuse, if the person still uses alcohol and street drugs, again you can throw all the antidepressants you want at it and it will never be resolved. The alcohol and the substances have to go and the body needs detoxed first. In situational depression, if a person flunks out of college or the person is out on the street because the house burnt down and the person gets depressed/blue because life has turned upside down, throwing antidepressants at it won't help. If a woman loses her son in a car accident and becomes depressed, throwing antidepressants will not help either...it is appropriate grief, not clinical depression. However, in time, if a person mentioned in all of the above (physical health problem, substance abuse, situational stress, or grief) does not get adequate help and assistance, does not take care of himself/herself, and has poor coping skills (especially if major/bipolar depression runs in the family)...a clinical depression CAN develop...which has its own criteria. Then, antidepressants ARE appropriate. The thing to be mindful is that if bipolar depression runs in that person's family, giving the person an antidepressant may kick off a manic/bipolar episode for that person due to genetics. This is something to be mindful of and monitored for. Bipolar depression has its own criteria. I encourage folks to become familiar with the DSM-IV (the psychiatrist's bible of diagnosing criteria put out by the American Psychiatric Association). Sorry to be long winded, but I wanted to respond to Bengalli and to provide the rationale to my previous posts on the thread.

[begalli]

Thunderwolf - thank you so much for your articulate posts. Sorry for straying away from the original topic of this thread, but this area of healthcare truely does fascinate me, but at the same time it gives me a feeling of helplessness in a deep compassion I have for folks who suffer mental health illnesses. I'm really not sure where this comes from. Fortunately my family does not suffer from any of this except that my dad was a recovering alcoholic for many years. I have however had lots of contact with with probably hundreds of people suffering from mental illness both in my personal and professional life and both in the acute and chronic form over the past 12 years. Nursing school kind of put a science behind what I observed, I guess.

What you said in your last post makes a world of sense. What you and others with your education and knowledge understand about the inner workings of mental health are so so important and is an absolute super-specialty. I feel that probably (this is a total guess; my opinion) 99% of doctors who perscribe antidepressants don't have half the knowledge that you and others like you who have obviously studied mental health extensively have and they don't follow through with the repercussions of doing so. And this, in part, minimizes the importance and validity of mental illness as a medical condition....and so the sprial of societal unacceptance of mental health issues goes on and on.

But I digress. I hope I'm making sense. It's difficult to express everything I want to say in a message board thread that was not meant for this conversation in the first place. My thoughts are so many in number about this (they are well-organized however )! Again, I appreciate your thoughtful posts.