Depression

Incidence and Prevalence

NIMH --Depression Rate:• 7.1% in women/Postpartum Depression• 3.5% in men• 5.8% overall

Age of onset- anytime, highest in 20’s• Highest Prevalence-ages 25-44. • General Hospital adm. 10 to 15% depressed

– Box 29-3 page 380

Depression is a Type of Mood Disorders

Depressive Disorders• Major Depression

Disorder (MDD)• Dysthymic Disorder• Depressive

Disorder NOS

Bipolar Disorders (also considered a mood disorder)• Bipolar I• Bipolar II• Mixed episode• Cyclothymia• Bipolar spectrum

Symptoms of Major Depressive Disorder

5 of the following 9 Symptoms-2 weeks Depressed Mood Anhedonia Significant change in weight Insomnia or hypersomnia Increased or decreased psychomotor activity Fatigue or energy loss Feelings of worthlessness or guilt Diminished concentration or indecisiveness Recurrent death or suicidal thoughts

Symptoms of Major Depressive Disorder

One of the of the criteria must be:

• Depressed Mood

• Anhedonia

Dysthymic Disorder

A Disorder of Chronicity Depressed mood at least 2 years for more days

than not (>50% of the time) 2 or more of the following

• Poor Appetite or overeating• Insomnia or hypersomnia• Fatigue or low energy• Low self-esteem• Poor concentration• Feelings of hopelessness

Never free of symptoms for 2 months

Symptoms of Depression

Hopelessness Alterations in Activity

• Psychomotor agitation• Tired; poverty of speech• Poor hygiene• Weight loss or gain• Insomnia or hypersomnia• Uninterrupted self-defeating ruminations

Altered Social Interactions• Poor social skills• Withdrawn prefer Isolation

Symptoms of Depression

Alterations of Cognition• Inability to concentrate• Confusion• Easily distracted• Problems with thinking ideas and problem solving

Alterations of Affect• Affect is outwardly demonstrated emotion

– Low-self esteem– Worthlessness– Guilt– Anxiety– Hopelessness

Symptoms of Depression

Alterations of a Physical Nature• Somatic Complaints• Preoccupation with their bodies• Panic Attacks in 15% to 30% of people

with MDD

Symptoms of Depression

Alterations of Perception• Delusions and Hallucinations–Delusion of Persecution:

• For a moral or ethical mistake

–Somatic Delusions• They are full of cancer

–Nihilistic Delusions• Fears of death

Depression

Unified Model of Mood Disorders• Genetic Vulnerability• Developmental Events• Physiological Stressors• Psychosocial Stressors

This model believes that any of these can start the cycle of disturbed neurochemistry

Neurochemical Theories

Serotonin and Norepinephrine• Altered at the

receptor site• Receptor

sensitivity changes• The cells they

activate have lost the capacity to respond

Genetic Theories

Depression, major correlation, but not clear

Two thirds of twins are concordant for MDD if one or both parents have MDD

Endocrine

Elevated levels of corticotrophin releasing hormone

Elevated pituitary release of andreno-corticotropic hormone

Early live exposure to overwhelming trauma

Circadian Rhythm

Medications Nutritional deficiencies Physical illness Wake-sleep cycles

Etiology/psychosocial/depression

Freud believed depression was anger turned on the self; overactive superego

Sullivan-problems in the interpersonal areas of neglect, abuse, rejection, loss

Cognitive theories• Beck-Depression based on distorted thinking

patterns• Ellis-Concept of neg. self talk and

catastrophising

Psychosocial Cont.

Behavioral Theories- Believes that the way you act effects peoples response• Seligman- Developed theory of learned

helplessness, hopelessness and being unassertive

Loss theory• Bowlby-Loss during childhood predisposes

you to depression, esp. another loss

Cognitive Theory

How we think about our situation Aims at symptom removal by

identifying and correcting silent assumptions

Silent assumption: going to school is something I am doing for me.

Treatment Efficacy

Depression very treatable disease Episodes usually last 6 to 9 weeks Endogenous compared to

Exogenous depression

Treatment Efficacy

• Endogenous means from within– The client can not describe a specific event that

exacerbated the depression.• Exogenous means from without

– There is a specific event that triggers the depression• Loss of a loved one• Surgery• Retirement

• Psychotherapy may be enough for exogenous– Group Therapy for Grief

• Combination is best for endogenous– Medications– Individual or Group psychotherapy

Nursing Dx

Alteration in Nutrition: Less that body requirements

Sleep pattern disturbance Self care deficit Alterations in perception:Hallucinations Alteration in thought process:Delusions Potential for Violence: directed at self

Issues for Nurses with depressed Patients

Safety First: The milieu or environment should keep the client safe• Check all clients every 15 minutes• Locked environment• Remove all harmful items

– Mirrors, pocket knifes, razors, shoelaces, hangers Insomnia• Assess hours of sleep• Encourage exercise/Walking• Use relaxation Tapes• Medication as needed for sleep

Weight Loss - Anorexia

Observation of client during meals Record weight weekly• Can be recorded more frequently

Record amount eaten Assess client• Vital signs• Lab work

– A low albumin level or total protein will let you know the client is not eating well

Decrease Isolation

Approach is firm and direct “It is time for our 1-1 or Art Class or

Coping Skills Group” Listen and Acknowledge negative

feelings• If client has made suicide attempt,

important acknowledge their feeling. You do not agree with it but you let them know you heard it.

Other Issues

Anger: Use activities such as writing, discussing, and exercise

Agitated depression: May want to walk with patient

Simple, structured activities best in early treatment• A one page work sheet on feelings• An expressive drawing

– These are also activities that can be used to encourage communication about feelings

– Should be easy to complete and structured so the client is successful

Group Therapies

Assertiveness training Coping Skills Grief group Art therapy Insight oriented psychotherapy

Communications and Supportive Therapy

Establish trust Assess client’s negative

self talk• Ruminations

Provide another point of view

May be resistant to come to 1-1

Active listening, non-directive style

Cognitive Therapy Strategy

Have client list 3 negative thoughts about self• This must be limited in

number or could initiate rumination

Have client list 3 positive qualities about self• Talk with client about

positive qualities Goal to begin to replace

negative thinking with more positive thoughts

Family therapy

Depression of parent is very difficult for children• There may be role reversal and depersonalization of the

child– Child takes on care of younger children– Child tries to “cheer up parent”– Child tries to be prefect– Child acts out in order get attention (becomes a lightening

rod for the family) Client may feel like victim and want to change

family relationships (described in your book as feeling like “a doormat”

Marital relationship may need renegotiating• Client who is depressed may be taking on too much

responsibility

Treatment/Medications

Antidepressants• Tricyclics• Serotonin re-uptake Inhibitors /SSRI• Monoamine Oxidase inhibitors• Atypical Antipsychotic

Side Effect Profiles

TCA’S• Dry mouth• Blurred vision • Constipation• Sedation• Wt gain• Postural hypotension• Cardiac effects

– Can be cardiotoxic– EKG prior to starting

• Dizziness• Slow onset 2 weeks

SSRI’S• Nausea• Nervousness• Insomnia• Sexual dysfunction• headache• Low addiction potential• Slow onset 2 weeks

– This length of time is a consideration if client is suicidal

Managing Medication Side Effects

Orthostatic Hypotension• Teach the patient to rise slowly

Insomnia• Schedule dose early in day

Dry mouth• Hydrate• Hard candy or gum

Drowsiness• Schedule dose at night

Cardiac effects• Tricyclics may be supplied one week at a time

Serotonin Syndrome

A potentially fatal syndrome Too much serotonin Results from: Combination of Therapy

• Serotonin Reuptake Inhibitors used in combination with:• Prescribed:

– Tricyclic Antidepressants– Monoamine Oxidase Inhibitors– Lithium

• Over the Counter Medications:– Robitussin – Cold medications

• Other– LSD, Ecstasy

Serotonin Syndrome

Too much serotonin Symptoms:

• CNS-confusion• agitation • Hypomania• Myoclonus• Tremor• Hyperreflexia

Autonomic signs• Fever• tachycardia OR bradycardia• hypertension OR hypotension• Diaphoresis, diarrhea• severe dehydration can be fatal

Serotonin Syndrome

Side Effects of MAO’s

MAO’s can cause very serious hypertensive crisis

Client must be instructed not to drink red wine,eat cheese, yogurt any thing aged. Tyramine is chemical.

Also, pt must not take any medications without checking with their MD.

AVOID

Atypicals

Trazodone-Desyrel Nefazadone-Serzone Bupropion-Wellbutrin SR • (increases availability of dopamine

not serotonin)

Venlafaxine-Effexor XR Duloxetine/Cymbalta Mirtazapine-Remoran

Side Effects of Atypicals

Trazodone/Desyrel- Usually used for sleep: rare side effect; priapism

Nefazadone/Serzone: taken off the market because of liver toxicity

Wellbutrin: seizures at high doses, irritability, decreased appetite, worsening of tics

Effexor: Nausea, agitation, headache and increase in blood pressure

Remoran: Sedation, increased appetite

Electroconvulsive therapy

Beneficial for for Clients with• Severe Depression• Depression that is resistive to treatment with medications• Older adults

– Renal disease or Liver disease• Blood serum levels of medication increases

ECT seems to balance dopamine and serotonin • Procedure- Administer barbiturate, muscle relaxant, • Side effects- short term memory loss

– Initially: memory of events immediately prior to the procedure• Treatment 6-10 times

– Spaced several days apart After Treatment

• Client may have immediate relief of Depression