so blueuserpages.flemingc.on.ca/~lmathews/pn 3/mental health/depression.pdftal tasks in their...

Given that more than 19 million Ameri-cans suffer from depression each year—about 10% of the nation’s adult popula-tion—it’s probably not uncommon for

you to care for patients with depres-sion on a fairly regular basis. In fact,just being admitted to the hospitalfor surgery or treatment of an acuteor chronic condition is enough totrigger depression. So you need to

keep an eagle eye out for patientsshowing signs of being depressed.

In this article, I’ll help you under-stand what factors contribute to depres-sion, how it develops, and how it can betreated.

More than the “blues”The American Psychiatric Association’sDiagnostic and Statistical Manual of MentalDisorders identifies two types of unipolardepression: major depression and dysthymia.Major depression is defined as a sad, anx-ious, or empty mood that occurs daily for2 weeks or more, with a loss of interest in

activities of daily living. People sufferingfrom depression often describe feelings ofbeing “down in the dumps,” sad, hope-less, or lethargic. Major depression can se-verely disrupt an individual’s life, affect-ing appetite, sleep, work performance, andrelationships.

Dysthymia is milder, characterized by achronically depressed mood that persists formost of the day, for more days than not, andfor at least 2 years. It, too, can interfere witha person’s effectiveness on the job and activi-ties of daily life.

It’s all in your headIn real-life terms, depression is manifestedas the avid runner who suddenly stopsmeeting a friend for a morning jog be-cause he just doesn’t feel like it anymore.Or the older woman who can’t work upenough enthusiasm for the weekly bingogames she used to love.

These people may have family and friendstelling them “it’s all in your head” and thatthey just need to “snap out of it.” After all,

34 Nursing made Incredibly Easy! July/August 2004

Why Am ISo Blue?

My MIpatient’s not

doing too well.Could he be

depressed too?

KATHRYN MURPHY, NP, CS, MSN Nursing Faculty • Muskegon Community College • Muskegon, Mich.

The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to thiseducational activity.

Depression is a serious condition that affects the mind andthe body. In fact, it can influence how quickly a patient recoversfrom an acute illness or surgery or how well he manages achronic disorder. We’ll help you understand how depressiondevelops, how you can screen your patients, and how drugs andpsychotherapy can help a patient lead a healthier, happier life.

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“what do you have to be depressed about?” If only it were that easy! Depression does

originate in the head—the brain, to be moreexact—but it’s a very real illness that affectsall parts of the body.

I just don’t careThe symptoms of depression fall into threegeneral categories:• emotional—lack of pleasure, sadness,hopelessness• physical—change in weight, sleep diffi-culties, restlessness, lack of energy• cognitive functioning—decreased con-centration, difficulty making decisions,suicidal ideation.

A diagnosis of depression is made whenat least 5 of these symptoms have been pre-sent most of the day for 2 weeks or more.

Depression occurs across the lifespan,although symptoms are different in eachage-group. In children, symptoms of depres-sion include hyperactivity, poor school per-formance, somatic complaints, sleeping andeating disturbances, lack of playfulness, andsuicidal ideation or actions.

It’s tougher to figure out if an adolescentis depressed or just being a typical teenager.Adolescents undertake certain developmen-tal tasks in their teenage years as they pre-pare for adulthood, such as separating fromtheir parents and establishing their ownidentities. Sadness, loneliness, hopelessness,and changes in mood can be symptoms ofdepression, but they can also be appropriateresponses to these developmental tasks.

Other indicators of depression in teensinclude aggressiveness, social withdrawal,

July/August 2004 Nursing made Incredibly Easy! 35

Looking at the physiology behind the pharmacology

Specific levels ofneurotransmitters,such as serotoninand norepinephrine,keep a person from becomingdepressed. In a per-son with normal lev-els of neurotransmit-ters, serotonin andnorepinephrine arereleased from oneneuron and travel toanother one, activat-ing receptors. Oncethe receptors areactivated, the neuro-transmitters aretaken up by thepresynaptic neuron.

A patient withdepression, howev-er, has inadequatelevels of serotonin ornorepinephrine.Selective serotoninreuptake inhibitorsblock the reuptakeof serotonin. Novelantidepressants vari-ously affect the lev-els of norepineph-rine, serotonin, anddopamine. Tricyclicsreduce reuptake ofnorepinephrine andserotonin. With ade-quate serotonin andnorepinephrine lev-els, the patient willhave fewer feelingsof depression.

Normal

Depression

SSRI action

SSRI

Neuroreceptors

Norepinephrine

Serotonin

Neuron

running away, drug abuse, sexual promiscu-ity, and school delinquency. If these behav-iors are repetitive, the teen should be evalu-ated for depression.

Tread especially carefully and call in amental health professional if you suspectdepression in a teenager. It’s better for you tobe wrong than to dismiss the signs as normalteenage angst. Depression is a major cause ofsuicide in adolescents, with the rate threetimes that of other age-groups.

Depression is the most common psychi-atric disorder in older adults. Symptoms ofdepression in this age-group are similar tothose in younger adults, but they’re oftenconfused with dementia. Lack of concentra-tion, memory loss, and difficulty makingdecisions may be attributed to senility rather

than a treatable depression. Also, depressionoften accompanies many of the chronic ill-nesses that affect older adults.

For more information, see Symptoms ofDepression Across the Lifespan.

Root causeDepression can be caused by genetics, ex-ternal events, medical conditions, bio-chemical alterations, or—most likely—acombination of these factors. Let’s take acloser look.

All in the familyIndividuals with depression in their fam-ily history are more biologically vulnera-ble to depression themselves. Having closerelatives with depression increases the in-dividual’s risk, similar to being at risk fordiabetes when it’s in the family. In manycases, if one identical twin suffers fromdepression, the second twin is likely to bediagnosed with depression as well.

Outside forces at workExternal events, such as loss of a lovedone, financial worries, legal problems, andsubstance abuse, can lead to depression.When some people become depressedfrom a trauma or stress in their life, theymay begin to abuse alcohol and drugs tomask their symptoms. If the depressionisn’t treated by a health care professional,this self-medication may turn into a sub-stance abuse problem. In other cases, peo-ple who are abusing these substances maydevelop depression from their chronic ef-fects on the body.

Feeling sick and sadIt’s not uncommon for you to encounterpatients with serious or chronic medicalailments who exhibit symptoms of depres-sion—for example, the patient who’s justhad cardiac bypass surgery or suffered amyocardial infarction. Unfortunately, de-pression can adversely affect the patient’soutcome, influencing how quickly—or

36 Nursing made Incredibly Easy! July/August 2004

Under age 3• Feeding problems or unusual

aggressivenessAges 3 to 5 • Phobias• Accident-prone• Excessive bad feelings when

disciplinedAges 6 to 8 • Physical symptoms• Suicidal ideation• School avoidance• Increased dependence on

parentsAges 9 to 12 • Preoccupation with death• Suicidal ideation• Excessive worryingTeenagers• Aggressiveness• Suicidal ideation• Social withdrawal• Running away• Drug abuse• Sexual promiscuity• School delinquency

Adults• Persistent sad mood• Feelings of hopelessness• Loss of interest in pleasurable

activities• Sleep difficulties• Appetite changes• Decreased energy• Thoughts of suicide or death• Difficulty concentrating or making

decisions• Physical symptomsOlder adults• Lack of concentration• Suicidal ideation• Difficulty making decisions• Memory loss

Symptoms of depression across the lifespan

how slowly—he recovers. That’s why it’sso important for you to recognize thesymptoms of depression: Your patient willhave a much better chance for a full recov-ery if his depression is treated at the sametime as his other illness.

Diabetes is a classic example of how amedical condition can be affected by depres-sion. Overwhelmed by his diagnosis, thepatient with diabetes may become depressedand stop managing his disease or manage ithaphazardly. He may not follow his diet,take care of his feet, monitor his blood glu-cose, or take his medications as prescribed.As a result, he may develop more diabetes-related complications, which can worsen hisdepression.

Diabetes isn’t the only chronic illness thatputs the patient at risk for depression.Others include chronic renal disease, cancer,neuroendocrine disorders, stroke, headinjury, liver disease, congestive heart failure,electrolyte disorders, hormonal distur-bances, nutritional deficiencies, and autoim-mune diseases, such as lupus.

Not everyone who suffers from thesediseases experiences depression, of course,but the risk increases with the presence of achronic illness. So you need to carefullyscreen all patients with any of these condi-tions for depression (see Two Simple—butCrucial—Questions and Is It ReallyDepression?)

Setting the moodAn imbalance of chemicals in the braincalled neurotransmitters can cause depres-sion (see Looking at the Physiology behind thePharmacology). Electrochemical impulsesare generated and transmitted in the neu-rons—the basic cellular structure of thenervous system. Each neuron has a cellbody, dendrites, and an axon. Informationis transmitted from the presynaptic neu-ron through the synapse to the postsynap-tic neuron.

Think of neurotransmitters as the chemi-cal vehicles that allow smooth transmission

of these impulses.Neurotransmittersare produced in theneurons and storedin the synaptic vesi-cles until they’rereleased. After release, any neurotransmitterthat isn’t used to transmit an impulse is sentback for storage in the presynaptic neuronthrough a process called reuptake. The majorneurotransmitters involved in depression areserotonin, norepinephrine, and dopamine.

In depression, an individual may be eitherlacking or not releasing enough of these neu-rotransmitters. Medications are available tocorrect this chemical imbalance and alleviatedepression, which I’ll discuss next.

Striking a balanceA variety of antidepressant medicationsare available. If one medication doesn’tseem to help, the patient shouldn’t giveup: another one may turn out to be effec-tive. In some cases, a combination ofdrugs may be needed.

Let’s review some of the major antidepres-sant medications, focusing on selective sero-tonin reuptake inhibitors (SSRIs), novel anti-depressants, and tricyclics.

First line of attackSSRIs inhibit the reuptake of serotonin bythe presynaptic neurons, making serotoninmore available for use in transmitting im-pulses. This mechanism helps exert an an-tidepressant effect. Fluoxetine (Prozac),sertraline (Zoloft), paroxetine (Paxil),citalopram hydrobromide (Celexa), and es-citalopram oxalate (Lexapro) are the SSRIsmost commonly used to treat depression.

Potential adverse effects of SSRIs includesexual dysfunction, gastrointestinal upset,mild sedation, or restlessness (see Anti-depressants: Taking the Bad with the Good). Formany patients, these adverse effects dimin-ish after 2 to 4 weeks of taking the medica-tion. If they persist, though, the health careprovider may prescribe a different brand of

July/August 2004 Nursing made Incredibly Easy! 37

Two simple—butcrucial—questionsTo screen for depression, ask patients thesetwo questions:• Have you felt down, depressed, or hopelessfor most of the past 2 weeks?• Have you felt little interest or pleasure doingthings for most of the past 2 weeks?

If the patient answers “yes” to either ques-tion, he needs further assessment. This screen-ing helps increase the detection and treatmentof depression.

SSRI. SSRIs are often the first lineof medication treatment fordepression because they effective-ly decrease symptoms of depres-sion with minimal adverse effects.

Patients shouldn’t abruptly stoptaking an SSRI; if they do,

they may develop discon-tinuation syndrome.

Symptoms mayinclude dizziness,

headache, diarrhea,insomnia, irritability,

nausea, and loweredmood.

Warning: Interactions aheadSSRIs use the same drug-metabolizing en-zyme pathway in the liver as other med-ications, such as anticoagulants, cardiacdrugs, or drugs used to treat diabetes.When these drugs get together, it can be aproblem: the levels of both drugs could in-crease, both levels could decrease, or onedrug level could decrease while the otherincreases. Or nothing at all could happen.It’s impossible to predict because everyoneis different. But you need to be aware ofthe potential problem and be prepared tointervene if the patient is showing signs ofa drug-drug interaction with an SSRI.

Here’s an example. Suppose an SSRI isordered for a patient taking warfarin(Coumadin). Both drugs use the same drug-metabolizing enzyme pathway in the liver.The patient’s international normalized ratio(INR) will have to be closely monitored toensure adequate anticoagulation. The war-farin dose may have to be adjusted up ordown, depending on how that patient reactsto this drug-drug interaction.

Serotonin syndrome is a potentially life-threatening drug interaction. It can occurwhen two medications that increase the sero-tonin level are combined, potentiating sero-tonin neurotransmission. The increased sero-tonin level throws off the body’s autonomicregulation. Not all patients will develop

serotonin syndrome. It’s impossible to tellwho will and who won’t be affected, evenamong patients taking the same dosages ofthe same medications.

Symptoms of serotonin syndrome includehyperthermia (high temperature), restless-ness, tachycardia, labile blood pressure,changes in mental status, diaphoresis, andtremors. Serotonin syndrome progressesrapidly, and if the early signs aren’t promptlyrecognized, the patient can develop seizuresand respiratory failure and slip into a coma.

If your patient develops serotonin syn-drome, immediately discontinue all medica-tions, notify the health care provider, andtreat the symptoms. The health care providermay order medications to block the effects ofthe SSRIs and treat hyperthermia andseizures.

Single or doubleSeveral novel antidepressants can be usedto treat depression, including bupropion(Wellbutrin), venlafaxine (Effexor), andmirtazapine (Remeron). (Another antide-pressant—Serzone [nefazodone]—was re-cently removed from the market.) Allhave fewer sexual adverse effects than SS-RIs. These drugs can be successful as sin-gle agents to treat depression, or they canbe used with an SSRI to double-team de-pression and reduce the sexual adverse ef-fects.

Bupropion blocks the reuptake of norepi-nephrine, serotonin, and dopamine, whichincreases the availability of these neurotrans-mitters. This medication may be indicatedfor patients with depressive symptoms offatigue and sleepiness. Bupropion can lowerthe seizure threshold, so it shouldn’t begiven to patients with seizure disorders.

Venlafaxine affects different neurotrans-mitters, depending on the dose. At lowdoses, it increases serotonin; at mediumdoses, it increases norepinephrine; and athigh doses, it blocks the reuptake of bothneurotransmitters, plus dopamine. Patientstaking this medication at medium- or high-

38 Nursing made Incredibly Easy! July/August 2004

If at first we don’tsucceed, we’ll try

again with anotherantidepressant.

level doses may have elevated blood pres-sure with an accompanying headache, dueto the increased level of the vasoconstrictornorepinephrine.

Mirtazapine increases the transmission ofand amount of serotonin. This drug is indi-cated for patients with anxiety and depres-sion, and can be given at night to relieveinsomnia.

Many of these antidepressant medicationsare available in delayed-release or sustained-release formulations. Delayed-release med-ications are coated with substances thatdon’t dissolve until the drug has reached theintestines. Sustained-release medicationsmay be imbedded in materials that slow therelease of the active ingredient(s), thusresulting in a longer duration of action. Forexample, bupropion is available in regular-release (Wellbutrin), sustained-release(Wellbutrin SR), and delayed-release(Wellbutrin XL) formulations. Always checkcarefully to ensure that the correct formula-tion of the medication is prescribed to avoidmedication errors.

The senior classAnother class of medications used to treatdepression are the tricyclic antidepres-sants, including nortriptyline (Pamelor),desipramine (Norpramin), and imipramine(Tofranil). These drugs reduce the reup-

take of norepinephrine and serotonin inthe presynaptic neurons, which increasesthe availability of these neurotransmittersto help fight depression.

An older class of antidepressants, the tri-cyclics are less expensive than the neweragents, but they cause more unpleasantanticholinergic/antihistaminic adverseeffects, such as dizziness, blurred vision,drowsiness/sedation, reduced blood pres-sure, dry mouth, dry eyes, constipation, andweight gain. See Managing Adverse Effects ofAntidepressants for ways to prevent or dealwith some of these problems.

Patients taking tricyclic antidepressantsshould be closely monitored. These drugscan cause fatal cardiac arrhythmias, especial-ly when suicidal patients overdose.

I’m listeningPsychotherapy—or talk therapy—is a vitalcomponent of the treatment regimen fordepression. For some patients, in fact,counseling alone may be all they need. Inmost cases, though, a combination of psy-chotherapy and appropriate antidepres-sant medications is the most effectivemeans of alleviating symptoms.

Therapeutic approaches used to treatdepression include cognitive-behavioral,psychodynamic, and group therapy. Let’sexamine them in detail.

July/August 2004 Nursing made Incredibly Easy! 39

Antidepressants: Taking the Bad with the GoodDrug Dose (for adults)Fluoxetine (Prozac) 10 mg to 80 mgParoxetine (Paxil) 10 mg to 50 mgSertraline (Zoloft) 50 mg to 200 mgCitalopram hydrobromide (Celexa) 10 mg to 20 mgEscitalopram oxalate (Lexapro) 10 mg to 20 mg

Venlafaxine (Effexor) 75 mg to 225 mg

Imipramine (Tofranil) 75 mg to 300 mg

Bupropion (Wellbutrin) 200 mg to 300 mgMirtazapine (Remeron) 15 mg to 45 mg

A closer look

Adverse EffectsRestlessness, anxiety, weight loss, sexual dysfunctionSedation, gastrointestinal (GI) upset, weight gain, sexual dysfunctionGI upset, sedation, weight gain, sexual dysfunctionGI upset, sedation, sexual dysfunctionGI upset, insomnia, sexual dysfunction, sedation, increased sweating,fatigueIncreased blood pressure, headache, agitation, sexual dysfunction,insomnia, nauseaAnticholinergic effects, sedation, cardiac arrhythmias, orthostatichypotensionLowered seizure threshold, restlessness, weight lossSedation, weight gain

On the fast(er) trackCognitive-behavioral therapy is a cost-effective and successful treatment for de-pression; it’s also a faster route to success

than other forms of psychother-apy. More than half of patientsexperience remission of symp-toms. The goal is to change thepatient’s “automatic thoughts,”

which occur spontaneously andcontribute to dysfunctional

thinking. According to thistype of therapy, psycho-

logical pain stems fromwhat the person

thinks an eventmeans rather than

what actually hap-pens.

For example, suppose awoman assumes that a man

has canceled their date because he isn’treally interested in her. This thinking mayresult from an experience in her life thatmade her feel unwanted, such as a parentleaving because of divorce. Now, supposea man cancels a date with another womanwho hasn’t had the same life experience asthe first woman. Instead of feeling he isn’tinterested in her, the second woman may

conclude that the man had an unexpectedbusiness meeting and will reschedule thedate. These two different conclusions areinfluenced by each woman’s automaticthought process, and result in very differ-ent emotional responses.

The cognitive-behavioral therapist usescognitive restructuring to help the personidentify the habitual ways she reacts to situ-ations. Then, the therapist teaches the per-son to change her thinking about the situa-tion, thus changing her emotional response.Using this strategy, the therapist identifiesthe errors of thinking and logic that under-lie the depression, then uses behavioraltherapy to change these dysfunctional cog-nitive patterns.

Linking past and presentPsychodynamic therapy links depressionto traumatic events or conflicts from child-hood. For example, a man with major de-pression may have been abused as a child,and now as an adult, he doesn’t feel goodabout himself. The therapist helps makethe link between the current feelings andthe previous abuse. Exploring how de-pression affects various aspects of an indi-vidual’s life is important in this type oftherapy.

40 Nursing made Incredibly Easy! July/August 2004

Can wetalk? It mightmake you feel

better.

Managing Adverse Effects of AntidepressantsAdverse effect Patient teaching points Dry mouth • Drink plenty of water.

• Chew sugarless gum.• Clean teeth daily.

Constipation • Eat bran cereals, prunes, and other fruits and vegetables.

Sexual problems • Be aware that sexual functioning may change.• Discuss your problems with your partner.• Consider switching to another medication.

Dizziness • Rise slowly from the bed or chair.

Drowsiness • This will lessen as you adjust to the medication.• Don’t drive or operate machinery if you’re drowsy.

All together nowGroup therapy allows individuals suffer-ing from depression to meet with otherswho are experiencing similar symptoms.Sharing his or her feelings helps each per-son heal. Also, people suffering from thesame disorder may offer suggestions ondealing with everyday events or relation-ships. It often helps an individual just toknow that he’s not the only one feelingdepressed.

Mind-body connectionDepression is a serious illness that, be-cause of the mind-body connection, affectsboth mental and physical health. Fortu-nately, depression can be effectivelytreated once diagnosed.

You may be the first person to screen apatient for depression. As a nurse, you havethe unique skills and ability to observe andtreat the whole patient. With the help of thisarticle, you’ll be prepared to identify thesymptoms of depression across the lifespan,

help the patientcome to terms withthe diagnosis, andeducate him aboutthe actions and possible adverse effects of hisprescribed medication. ■

Learn more about itAntai-Otong, D., editor: Psychiatric Nursing, Biological & Be-havioral Concepts. New York: Delmar Learning Division ofThompson Learning, Inc., 2003. p. 205.

Ciechanowski, P., et al.: “Community-Integrated Home-Based Depression Treatment in Older Adults: A Random-ized Controlled Trial,” JAMA. 291(13):1569-1577, April 7,2004.

Delgado, P.: “How Antidepressants Help Depression:Mechanisms of Action and Clinical Response,” Journal ofClinical Psychiatry. 65(Suppl 4):25-30, 2004.

Green, W.: Child and Adolescent Clinical Psychopharmacology,3rd edition. Philadelphia: Lippincott, Williams & Wilkins,2001.

“Practice Guidelines for the Treatment of Patients with Ma-jor Depressive Disorder,” American Psychiatric AssociationCME, http://www.psych.org/cme/apacme/courses/sections.cfm?apacme=0004 0007, accessed May 14, 2004.

Piette, J., et al: “Addressing the Needs of Patients withMultiple Chronic Illnesses: The Case of Diabetes andDepression,” American Journal of Managed Care. 10(2 Pt 2):152-162, February 2004.

July/August 2004 Nursing made Incredibly Easy! 41

Is it really depression?Consider obtaining an order for a thyroid-stimulating hormone (TSH) level if a patientseems to have signs and symptoms of depres-sion. Many of these signs and symptoms arethe same as those of hypothyroidism, so thisendocrine disorder should be ruled out beforeinitiating treatment for depression. A patientwhose TSH level is elevated should be referredfor further evaluation and treatment of hypothy-roidism.

CE TestWhy Am I So Blue?

Instructions• Read the article beginning on page 34.• Take the test, recording your answers in the test answerssection (Section B) of the CE enrollment form on page 43. Eachquestion has only one correct answer.• Complete registration information (Section A) and courseevaluation (Section C).• Mail completed test with registration fee to: Lippincott Williams& Wilkins, CE Group, 333 7th Ave., 20th Floor, New York, N.Y.10001.• Within 3 to 4 weeks after your CE enrollment form is received,you will be notified of your test results.• If you pass, you will receive a certificate of earned contact hoursand an answer key. If you fail, you have the option of taking thetest again at no additional cost.• A passing score for this test is 11 correct answers.• Need CE STAT? Visit http://www.nursingcenter.com for immedi-ate results, other CE activities, and your personalized CE plannertool. • No Internet access? Call 1-800-933-6525, ext. 331 or ext. 332,for other rush service options.• Questions? Contact Lippincott Williams & Wilkins: 646-674-6617 or 646-674-6621.

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Your certificate is valid in all states. This means that your certifi-cate of earned contact hours is valid no matter where you live.

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1. An older patient reports a chronically depressed moodlasting most of every day for the past 2 years. Thissuggestsa. dysthymia.b. major depression.c. dementia.

2. Which cognitive manifestation would you expect toobserve in a patient who is diagnosed with depression?a. loss of intellectual capacityb. significant daily confusionc. decreased ability to concentrate

3. Which question should you ask a parent when assessinga 4-year-old child for depression?a. “Is your child accident-prone or fearful?”b. “Are your child’s vaccines up-to-date?”c. “Is your child able to dress himself?”

4. Which of these adolescents should be evaluated fordepression?a. a 14-year-old who isn’t interested in sportsb. a 14-year-old who repeatedly runs away and skips schoolc. a 14-year-old who doesn’t make the cheerleading team

5. Which of these diseases is associated with an increasedrisk of depression?a. arthritisb. hiatal herniac. diabetes mellitus

6. Which of these biochemical alterations is associatedwith depression?a. excessive dopamine availabilityb. increased norepinephrine productionc. decreased availability of serotonin

7. Symptoms of SSRI discontinuation syndrome includea. insomnia, irritability, and dizziness.b. sexual dysfunction, sedation, and fatigue.c. gastrointestinal upset, increased appetite, and tremors.

8. Which symptoms should a patient taking an SSRI beinstructed to report immediately?a. sweating, fever, and tremorsb. insomnia, daytime drowsiness, and loss of appetitec. headache, weight gain, and lethargy

9. You should question an order forbupropion (Wellbutrin) for a. a patient who has gout.b. a patient who has a seizure disorder.c. a patient who has decreased peripheral

circulation.

10. Which of these instructions shouldyou give to a patient who’s takingmirtazapine (Remeron)?a. “Limit your fluid intake.”b. “Avoid foods that contain fiber.”c. “Take this medication at bed-

time.”

11. Adverse effectsassociated with tricyclicantidepressants includea. dizziness and constipation.b. weight loss and diarrhea.c. urinary frequency and back pain.

12. Which of these patients is likely to benefit fromcognitive therapy for depression?a. a patient who can’t remember daily eventsb. a patient who’s unable to perform basic calculationsc. a patient who has dysfunctional thinking

13. When using a cognitive-behavioral approach with adepressed patient, the focus should be ona. modifying inappropriate social behaviors.b. promoting the use of expressive behaviors.c. changing ineffective thoughts and behaviors.

14. Which question should you include when screening fordepression?a. “Have you lost interest in usual activities for the past 2

weeks?”b. “Have you experienced pain for the past 2 weeks?”c. “Have your life’s circumstances changed over the past 2

weeks?”

15. Which of these patients will need close monitoringwhile taking sertraline (Zoloft)?a. a patient who takes decongestants for allergiesb. a patient who takes warfarin (Coumadin) for DVTc. a patient who takes sleeping medication for insomnia

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See facing page for the CE Enrollment Form.

Why am I so blue?GENERAL PURPOSE: To provide nurses with information on how depression develops, how to screen pa-tients for depression, and how drugs and psychotherapy can help patients who are depressed. LEARNINGOBJECTIVES: After reading this article and taking this test, you’ll be able to: 1. Identify risk factors andcauses of depression. 2. List signs and symptoms of depression across the life span. 3. Outline treatmentstrategies for depression.

You’ll feel greatwhen you ace this

test!

July/August 2004 Nursing made Incredibly Easy! 43

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Photocopies of this page will be accepted.*In accordance with the Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of the CE offering may be submitted directly to the Iowa Board of Nursing.

Take a deep breath...and conquer your fear of mechanical ventilation (page 10)B. Test Answers: Darken one circle for your answer to each question.

a b c1. ❍ ❍ ❍2. ❍ ❍ ❍3. ❍ ❍ ❍

a b c4. ❍ ❍ ❍5. ❍ ❍ ❍6. ❍ ❍ ❍

a b c7. ❍ ❍ ❍8. ❍ ❍ ❍9. ❍ ❍ ❍

a b c10. ❍ ❍ ❍11. ❍ ❍ ❍12. ❍ ❍ ❍

a b c13. ❍ ❍ ❍14. ❍ ❍ ❍15. ❍ ❍ ❍

C. Course Evaluation*

1. Did this CE activity's learning objectives relate to its general purpose? ❑ Yes ❑ No

2. Was the journal home study format an effective way to present the material? ❑ Yes ❑ No

3. Was the content relevant to your nursing practice? ❑ Yes ❑ No

4. How long did it take you to complete this CE activity?___ hours___minutes

5. Suggestion for future topics

____________________________________________________________________________________

The ABCs—and more—of hepatitis (page 22)B. Test Answers: Darken one circle for your answer to each question.

a b c1. ❍ ❍ ❍2. ❍ ❍ ❍3. ❍ ❍ ❍

a b c4. ❍ ❍ ❍5. ❍ ❍ ❍6. ❍ ❍ ❍

a b c7. ❍ ❍ ❍8. ❍ ❍ ❍9. ❍ ❍ ❍

a b c10. ❍ ❍ ❍11. ❍ ❍ ❍12. ❍ ❍ ❍

a b c13. ❍ ❍ ❍14. ❍ ❍ ❍

C. Course Evaluation*

1. Did this CE activity's learning objectives relate to its general purpose? ❑ Yes ❑ No

2. Was the journal home study format an effective way to present the material? ❑ Yes ❑ No

3. Was the content relevant to your nursing practice? ❑ Yes ❑ No

4. How long did it take you to complete this CE activity?___ hours___minutes

5. Suggestion for future topics

____________________________________________________________________________________

Registration deadline:

August 31, 2006

Contact hours: 1.5

Fee: $12.95

Registration deadline:

August 31, 2006

Contact hours: 1.5

Fee: $12.95

Registration deadline:

August 31, 2006

Contact hours: 1.5

Fee: $12.95

Mail completed test with registration fee to: Lippincott Williams & Wilkins,CE Group, 333 7th Ave., 20th Floor, New York, N.Y. 10001.