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Chapter 12
Mood Disorders: Depression
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
1
Concept of Depression
• Individuals with depression experience
great personal pain and suffering
• Depression common to all ages, races,
and both sexes
• Vulnerability to depression can be related
to genetics and life stressors
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
2
Depressive Disorders:
Prevalence and Comorbidity
• Prevalence
– Fourth leading cause of disability in U.S.
– Lifetime prevalence of major depressive
disorder is 16.6%
• More common in women
• Comorbidity
– Frequently with other psychiatric disorders
• Anxiety disorders, schizophrenia, substance
abuse, and eating disorders
– Increases with presence of medical disorder
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
3
Depressive Disorders:
Developmental Aspects
• Children as young as age 3 have been
diagnosed with depression
• Adolescents have increased incidence
– Often associated with substance abuse and
antisocial behaviors
• Older adults (>65) increased incidence
– Increased suicide rate occurs with depression
in this age group
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
4
Biological Theories Related to
Depressive Disorders
• Genetics
– Twin and adoptive studies point to genetic
factors
• Biochemical factors: multiple
neurotransmitters (NT) may be involved
– Monoamine NT (serotonin, noradrenaline)
– Research focused on role of dopamine,
acetylcholine, and GABA receptors
– Stressful life events can deplete NTs
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
5
Biological Theories Related to
Depressive Disorders
• Neuroendocrine factors
– Hyperactivity of hypothalamic-pituitaryadrenal cortex axis implicated
– Increased cortisol secretion
• Dexamethasone suppression test (DST) helps
determine cortisol oversecretion
• Imaging results
– CT and MRI scans show ventricle
enlargement, cortical atrophy, sulcal widening
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
6
Other Theories Related to
Depressive Disorders
• Psychodynamic factors: stress-diathesis
model
– Early life trauma sensitizes stress pathways in
brain, increasing vulnerability to depression
• Cognitive theory: Aaron Beck
– Automatic negative thoughts (of self, future
and the world) related to depression
• Learned helplessness: Martin Seligman
– Individual’s perception of lack of control over
stressful life events leads to depression
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
7
Major Depressive Disorder (MDD)
• Manifested by emotional, cognitive,
physical, and behavioral symptoms
occurring nearly every day for at least a 2week period
– Symptoms represent a change in functioning
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
8
Major Depressive Disorder (MDD)
• DSM-IV-TR diagnosis can include
specifiers
– Psychotic features; catatonic features;
melancholic features; postpartum onset;
seasonal affective disorder (SAD); atypical
features
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
9
Major Depressive Disorder:
Common Symptoms
• Emotional and cognitive symptoms:
depressed mood, feelings of
worthlessness and guilt, anhedonia,
hopelessness, decreased concentration,
recurrent thoughts of death/suicide
• Physical: weight gain or loss, insomnia or
hypersomnia, increased or decreased
motor activity, anergia, constipation
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
10
Dysthymic Disorder: DD
• Characterized by chronic depressive
syndrome usually present for most of day,
more days than not, for at least a 2-year
period (APA, 2000b)
– Not usually severe enough for hospitalization
unless person becomes suicidal
• Onset is usually early childhood, teenage
years, or early adulthood
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
11
Nursing Process:
Assessment Guidelines
• Use any of the multiple standardized
depression screening tools available
• Evaluate patient for suicidal ideation
• Determine presence of emotional,
cognitive, and physical symptoms of
depression
• Determine presence of other medical
conditions contributing to depression
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
12
Nursing Process:
Assessment Guidelines
• Determine history/current support system
• Ascertain recent “triggering event” related
to loss
• Determine cultural beliefs/spiritual
practices related to mental health
treatment
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
13
Nursing Process: Diagnosis and
Outcomes Identification
• Common nursing diagnoses assigned
– Risk for suicide, Hopelessness, Ineffective
coping, Social isolation, Self-care deficit
• Outcomes identification
– Important to include specific goals for patient
safety and outcomes related to
vegetative/physical signs of depression
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
14
Nursing Process:
Planning and Implementation
• Planning
– Geared toward specific phase of depression
and particular symptoms exhibited
• Implementation
– Focus interventions on specific symptoms
with priority related to suicide prevention
– Teach patient and family about symptoms of
depression, treatment, and medication
– Focus on predischarge counseling to alleviate
tension on family system
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
15
Communication Guidelines for
Patient with Depression
• Understand that patient may need more
time to reply to communication
– Silence/sitting with patient can be therapeutic
– Allow time for patient to respond
• Make observations related to
patient/situation or environment
• Avoid platitudes
• Listen carefully for covert messages and
question directly about suicide
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
16
Treatment for Depression
• Milieu therapy
– Structured hospital environment helpful
– Follow protocol for suicide prevention
• Psychotherapy
– Cognitive-behavioral (CBT) and interpersonal
(IPT) therapies used
• Group therapy
– Helps decrease feelings of isolation,
hopelessness, helplessness and alienation
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
17
Treatment for Depression:
Antidepressant Medications
• Advantage
– Can help alter withdrawal, vegetative
symptoms, activity level; improve self-concept
• Drawback
– Can take 1-3+ weeks to note improvement
• Safety considerations
– Concerns about relationship between use of
antidepressant drugs and suicide; however,
no conclusive evidence to support this
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
18
Treatment for Depression: Tricyclic
Antidepressants (TCAs)
• Action: inhibit reuptake of norepinephrine
and serotonin by presynaptic neurons
• Dose: start low and gradually increase
• Common adverse reactions
– Dry mouth, blurred vision, constipation, and
urinary retention
– Sedation
• Potential dysrhythmias, hypotension,
myocardial infarction
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
19
Treatment for Depression: Selective
Serotonin Reuptake Inhibitors (SSRIs)
• Action: selectively block neuronal uptake
of serotonin
• Common adverse reactions
– Agitation, anxiety, sleep disturbance, tremor,
sexual dysfunction, headache, weight
changes, nausea, diarrhea, dry mouth
• Potential toxic effect
– Serotonin syndrome (SS): potentially fatal
reaction when more than one antidepressant
used
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
20
Symptoms and Treatment of
Serotonin Syndrome (SS)
• Symptoms
– Hyperactivity, severe muscle spasms,
tachycardia leading to cardiovascular shock,
hyperpyrexia, hypertension, delirium,
seizures, coma, death
• Treatment
– Stop offending agents
– Provide respiratory, circulatory support in
intensive care environment
– Use medications to reverse excess serotonin:
cyproheptadine, methysergide, propranolol 21
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
Treatment for Depression:
Newer Atypical Agents
• Action: affect variety of NTs including
those affecting serotonin and
norepinephrine
• Advantage
– Can target unique populations of depressed
individuals
– Can be used to treat other conditions
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
22
Treatment for Depression:
Monoamine Oxidase Inhibitors (MAOIs)
• Action: enhance NTs at synapse by
preventing the enzyme monoamine
oxidase from breaking them down
• Common adverse reactions
– Hypotension, sedation, insomnia, changes in
cardiac rhythm, muscle cramps, sexual
impotence, anticholinergic effects, weight gain
• Potential toxic reaction
– Hypertensive crisis
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
23
Hypertensive Crisis and MAOIs
• Can occur when monoamine oxidase
inhibition prevents the breakdown of
tyramine, which is used by the body to
make norepinephrine
• Preventing hypertensive crisis involves
maintaining a special diet (low tyramine)
and avoiding medications that contain
ephedrine/other psychoactive substances
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
24
Treatment for Depression:
Somatic Treatments
• Electroconvulsive therapy (ECT)
– Course of treatment: 2 or 3 treatments/week for
total of 6 to 12 treatments
– For patients not responding to antidepressants
or for depression with psychosis
– Potential adverse reactions
• Initial confusion and disorientation on awakening
from treatment
• Memory deficits
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
25
Treatment for Depression:
Somatic Treatments
• Vagus nerve stimulation: long-term
implanted treatment device approved by
FDA for patients with treatment-resistant
depression
– Action: not well understood, affects
neurotransmitters implicated in depression
– Device implanted in upper chest that sends
electrical signals to left vagus nerve in the
neck at regular intervals
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
26
Treatment for Depression:
Integrative Therapies
• Light therapy
– First-line treatment for seasonal affective
disorder (SAD)
– Action: suppresses nocturnal secretion of
melatonin, which seems to have beneficial
effect on depression
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
27
Treatment for Depression:
Integrative Therapies
• St. John’s wort
– Plant with antidepressant properties
– Not regulated by FDA
– Research suggests effective in mild
depression
• Exercise
– Research indicates mood elevation and
decreased depression occurs with moderate
exercise
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
28
Nursing Process: Evaluation
• Evaluate short-term indicators and
outcome criteria
– Reduction in suicidal thoughts
– Able to state alternatives to suicide
– Decrease in severity of emotional, cognitive
and vegetative/physical symptoms of
depression
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
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