DEPRESSION

2 MAIN TYPES OF DEPRESSIVE

DISORDER
1. MAJOR DEPRESSION
 One or more major depressive episode
 At least two weeks of depressed mood or
loss of interest accompanied by at least
four additional symptoms of depression
 Disorder of severity
 treatable
 MAIN TYPES OF DEPRESSIVE
DISORDER
2. DYSRHYTHMIC DISORDER
 at least two years of depressed mood for
more days than not
 Accompanied by additional depressive
symptoms
 But does not meet the criteria for major
depression
 Disorder of chronicity
Mood – is a person’s state of mind
- exhibited through feelings and
emotions
- mood is considered abnormal when
the individual has problems with daily
functioning because of the presence of
exaggerated feelings and emotions
- DSM-IV-TR defined mood disorder as
one which the predominant feature is the
disturbance in person’s mood
 4 categories of Mood disorder

1. depressive disorder
2. bipolar disorder
3. mood disorder resulting from a general
medical condition
4. substance induced mood disorder
 Criteria and symptoms of Major
Depressive disorder

 At least a 2 week period of maladaptive

functioning is present that is a clear change
from previous level of functioning
At least five of the following must be present
during the two week period, one of which
must be (1) or (2)
1. depressed mood
2. Anhedonia (apathy)
3. significant change in weight
4. insomnia or hypersomnia
5. increased or decreased psychomotor activity
6. fatigue or energy loss
7.Feelings of worthlessness or guilt
8. diminished concentration or indecisiveness
9. recurrent death or suicidal thoughts
 Criteria and symptoms of Major
Depressive disorder

 the mood disturbance causes marked

distress or significant impairment in social
or occupational functioning
 No evidence of a physical or substance
induced cause exists for the presence of
another major mental disorder that accounts
for the patient’s depressive symptoms
 Specifiers or variants of Major
Depressive disorder
 MDD with atypical feature
 melancholic feature
 catatonic feature
 postpartum onset
 psychotic feature
 seasonal patterns
 symptoms are the same but different
in expression
 ATYPICAL DEPRESSION
 occurs in younger population
 more common in women than in men
 increased appetite or weight gain
 hypersomnia
 extreme sensitivity to interpersonal rejection
 mood reactivity
 MAOI’s are the Drug Of Choice
 MELANCHOLIC DEPRESSION
 occurs most often in older adults
 misdiagnosed as dementia
 anhedonia
 inability to be cheered up
 mood does not improve even temporarily

 MELANCHOLIC DEPRESSION
 at least three of the following
1. depression worst in the morning, early morning
awakening
2. Psychomotor retardation or agitation
3. Significant anorexia or weight loss
4. excessive or inappropriate guilt
 CATATONIC FEATURE

 significant psychomotor alteration

 immobility
 excessive motor activity
 mutism
 echolalia
 inappropriate posturing
 POSTPARTUM DEPRESSION
 occurs during the first 30 days postpartum
 feeling anxious
 irritable
 tearful
 with moments of normalcy
 over concern or even delusional thoughts
about the baby’s health are not uncommon
 with or w/o psychotic features
 PSYCHOTIC DEPRESSION
 patient has delusion and hallucination in
conjunction with mood disorder
Associated with poorer prognosis compared
with other forms of depression
Required Treatment- antidepressants and
antipsychotics
 Seasonal Affective Disorder
is depression occurring in conjunction
with a seasonal change most often
beginning in fall or winter and remitting in
spring
Common in females
 Occurrence in Specific
Populations
 Adults

Although depression can occur at any age,

the average age of adult onset is in mid to
late 20’s
 Children and adolescents
• Occurrence of depression in children and
adolescents can be even more
devastating than adults
• Children of depressed parents are at
greater risk of developing the disorder
Predisposing factors in developing depression
in children and adolescents

 loss of parents through divorce,

separation or death
Death of other individuals close to the
child
Death of a pet
Move to another neighbourhood or town
Academic problems or failure
Significant physical illness or injury
 Behavior Symptomatic of
Depression
 Objective Signs
o exhibit psychomotor agitation
o Pacing, hand wringing and unable to sit still
o Pull or rub their hair, skin, clothing or other
objects
o Psychomotor retardation- slowing of speech,
increased pauses before answering, soft
monotonous speech, decreased frequency of
speech and muteness
o Defer carrying basic hygiene measures
such as bathing, shaving, putting clean
clothes or wiping their mouths after eating
o Apathy
o Incontinence or constipation
o Change in eating behavior- weight loss or
weight gain
o Change in sleeping pattern
 Altered Social Interactions
o Lack of productivity in the job and at home
o Get easily distracted
o Reduces interest in people, their ideas,
and their problems
o Withdrawn and prefers social isolation
 Subjective Symptoms
 Alterations of Affect
o When the pain becomes too great patients
shut down and become apathetic
o Overall affective sense is low self esteem
o Guilt might include an over reaction to
some current failing or might be
associated with an indiscretion in the
distant past that cannot be forgiven
o Anxiety is the companion of depression
o worthlessness
 Alterations in cognition
o Ambivalence
o Indecisiveness
o Inability to concentrate
o Confusion
o Loss of interest and motivation
o Memory problems
o pessimism
o Self blame
o Destructive thoughts
o Thoughts of death and dying
o Major decisions can be immobilizing.
Alteration of a Physical nature
o Abdominal pain
o Anorexia
o Chest pain
o Constipation
o Dizziness
o Fatigue
o Headache
o Indigestion
o Insomnia
o Menstrual changes
o Nausea and vomiting
o Sexual dysfunction
Alteration of Perception

o Delusions and hallucinations are typically

congruent with the depressed mood
 Etiology of Depression
NEUROCHEMICAL THEORIES
 Alterations with the neurotransmitters;
norepinephrine, serotonin and dopamine
Dysregulation of acetycholine and
gamma-aminobutyric acid might contribute
with the development of biochemical
depression
GENETIC THEORIES

o Several Studies have examined the

incidence of depression in twins
 ENDOCRINE THEORIES
o In some depressed people this system
malfunctions and creates cortisol,
thyroid and hormonal abnomalities.
o Dysregulation in Hypothalamic-
Pituitary-Adrenal axis results in
HYPERCORTISOLEMIA (present in
about 40% to 60% depressed clients)
CIRCADIAN RHYTHM THEORIES
o Individuals experiencing changes in the
circadian rhythm are at increase risk for
developing depressive symptoms and
MDD
o Circadian Rhythm is responsible for the
daily regulation of wake-sleep cycles,
arousal and activity patterns
o Caused by medications, nutritional
deficiencies, physical or psychological
illness, hormonal fluctuations and aging
CHANGES IN BRAIN ANATOMY

o Evidence exists indicating that

depression might result from or cause
atrophy of specific brain locations.
PSYCHOLOGICAL THEORIES OF
DEPRESSION

Psychoanalytic theorists have contended

that depression occurs as a result of an
early life loss
Cognitive theorists have contended that
depression results when a person
perceives all stressful situations as being
negative.
 Interpersonal Theorists believe that when
a person has interpersonal difficulties,
coping with individuals, life events and life
changes can be inordinately stressful and
lead to depression.
 Behavioral Theorists propose that a
person develops depression when he or
she develops feelings of helplessness and
unworthiness and then learns to use these
attitudes to evaluate life outcomes
ASSESSMENT OF DEPRESSION
 Non Biologic Assessment Measures
o Composed of standardized verbal and
written measurements scales.
 Biologic Assessment Measures
o Dexamethasone Suppression Test
- Urine and blood samples are collected
before the test to determine the levels of
cortisol
- A positive result occurs when cortisol
levels do not fall or return to 5mg/dL or
higher within 24 hrs.
- Forty percent of severely depressed
patients fail to suppress cortisol
 Growth Hormone Assessment

o Past Research indicated that some

depressed children might have
decreased secretion of the growth
hormone during the day and increase
secretion while asleep.
o Useful in adolescent and adult
population.
 Polysomnographic Measurements

o Used to assess depression in adult

populations.
o In depressed adults, the REM latency
phase is shortened , which results in
frequent night and early morning
wakening.
 Nurse Patient Relationship
 Depressed individuals suffer from low self
esteem.
Development of a meaningful relationship
in which depressed individuals are valued
as human
The nurse who works effectively with
depressed patients must have sincere
concern for patients and be emphatic
Point out even small visible
accomplishments and strengths
 Depressed clients are typically dependent
The nurse should not attempt to
embarrass patients out of being depressed
Never reinforce hallucinations, delusions,
or irrational beliefs
Depressed individuals tend to be angry.
 The nurse can help withdrawn patients
emerge from their social isolation by
spending time with them
 Depressed individuals can have difficulty
in making even simple decisions.
 Suicide and Depression
 Suicide is a complex phenomenon
influenced by a person’s cultural beliefs,
values and norms.
 Suicide might occur in children,
adolescent, and adult population
 Most often is the result of depression
 Risk Factors of Completed Suicide
 Male
 Caucasian or Native American
 Age 60 years and older
 Hopelessness
 General Medical Illness
 Severe Anhedonia
 Living alone
 Prior Suicide attempts
 Unemployed or financial problems
Assessment of Suicidal Patients
 Plan
The more develop the plan is, the higher is
the risk of suicide.
 Method
Some methods of attempting suicide are
more lethal than others
 Rescue

The person who deliberately attempts to

deceive would be rescuers has an
increased lethality potential.
Antidepressant Drugs
 Selective Serotonin Reuptake
Inhibitors
 are effective antidepressants that have
fewer side effects than TCA’s and are far
less dangerous than MAOI’s
First line drugs for treatment of depression
 Fewer anticholinergic, cardiovascular and
sedating side effects
 Side Effects
Nausea
Diarrhea
Loose stools
Weight loss or gain
 SSRI’s
 Citalopram (Celexa)
 Escitalopram (Lexapro)
 Flouxetine (Prozac)
 Fluvoxamine (Luvox)
 Paroxetine (Paxil)
 Sertraline (Zoloft)
 Tricyclic Antidepressants
 block the reuptake of the serum level of
monoamines (norepinephrine, serotonin)
Therapeutic effect- sedation, alleviate
lethargy, improved appetite, anxiety
reduction and urinary hesitancy.
 Generally highly toxic
 Side Effects
Dry mouth
Anhidrosis
Blurred vision
Constipation
Urinary Retention
 TCA’s
 Amitriptyline (Elavil)
 Amoxapine (Asendin)
 Desipramine (Norpramine)
) Doxepine (Sinequan)
 Imipramine (Tofranil)
 Maprotiline (Ludiomil
 Nortriptyline (Aventyl)
 Protriptyline (Vivactil)
Trimipramine (Surmontil)
 Monoamine Oxidase Inhibitors
 third major class of antidepressants, are
usually administered to hospitalized
patients or to clients who can be closely
supervised.
 have serious adverse reactions
 Once interact with other drugs or tyramine
rich foods can cause Hypertensive Crisis
 MAOI’s
 Tranylcypromine (Parnate)
 Phenelzine (Nardil)
 Maclobemide (Manerex)
Depression- Post Test
• 1. Which of the following is a cause
of depression?
• A. Genetics
• B. Medications
• C. Stressful environment
• D. All of the above
• 2. Which of the following is a
symptom of depression for
adolescents and children?
• A. Poor school performance
• B. Persistent boredom
• C. Complaints of headaches and
stomach aches
• D. All of the above
•
3. planning care for a newly admitted
patient with major depression, the
highest priority of the nurse is:
a. Orienting the patient to the unit
b. Encouraging expression of feelings
c. Providing a safe environment
d. Meeting the patient at an
appropriate affective level
4. General feeling: Chronically unhappy
Onset; Chronic, at least 2 years

A. bereavement
B. dysthymic disorder
C. major depressive disorder
D. Seasonal Affective Disorder
•
5. An example of affect:
a.Smiling
b.Happy
c.Sad
d.grieving
6. May cause sexual dysfunctions

a.TCA’s
b.MAOI’s
c.SSRI’s
d.All of the above
7.Common side effects of
antidepressants except
a.Blurring of vision
b.Excessive sweating
c.Constipation
d.Urinary retention
8. Your client is taking MAOI’s,
he/she must avoid eating/drinking
the following food except:

a.Yogurt
b.Chocolate
c.Orange juice
d.Banana
9. Cardiac side effects are
common to these drugs

a.TCA’s
b.SSRI’s
c.MAOI”S
d.All of the above
10. Safest antidepressant drugs to be
prescribed

a.TCA’s
b.SSRI’s
c.MAOI”S
d.All of the above
11. A 60-year old man who comes to the health
clinic fro his annual flu shot tells the nurse
he feel tired all the time, finds little pleasure
in things anymore, and has difficulty
sleeping. The best nursing intervention
would be:
a. Have him remain in the clinic until evaluated by
a mental health professional
b. Instructs him how to manage these typical
complaints associated with aging
c. Explore his psychiatric history and current
assess his mental status
d. Explain that this is not a psychiatric clinic and
provide a follow-up referral.
12. Nursing care of the depressed and
manic patient are similar in that both
call for
a.Providing challenging group
interactions
b.Limiting stimulation
c.Observation of sleep and intake pattern
d.Suicide and escape precaution
13. What can a nurse do to avoid feelings
of frustration when establishing a
relationship and working with a severely
depressed patient? Expect the patient to
a.Be receptive to the plans for nursing care
b.Be withdrawn and disinterested in a
relationship
c.Show signs of improvement after several
scheduled sessions
d.Show gratitude for attention
14. A depressed patient is admitted following a
suicide attempt. She had taken an overdose
of sedatives and has found by her husband.
Presently she states that she is too tired to
consider signing a no-harm contract and
that she is angry that her spouse thwarted
her attempt. What, if any, level of suicide
precautions should the nurse recommend?
a. No precaution
b. Routine observation appropriate for all patient
c. Every 15-minutes observation by staff
d. One-to-one close supervision by staff
15. Also known as a
DISORDER OF SEVERITY