Download THE CLIENT EXPERIENCING DEPRESSION

THE PATIENT EXPERIENCING DEPRESSION
MOOD SWINGS
• Are part of the human experience
• Are normal – can last from hours to several days
• Long periods of down swings may be depression
• Loss can have a potent affect on mood
DEPRESSION
• Intense feeling of a depressed, down mood
• 7–12% of men & 20–25% of women are likely to become significantly depressed at some point in their life
• Mood Episode
Expression of a strong emotion of depression, mania, or a mixture of both for a period of at least 2 weeks
Symptom must be newly present or must have clearly worsened over the pre-episode state & must be
present nearly every day for most of the day over a period of 2 weeks
• Mood Disorder
Diagnosed based on the pattern of mood episodes
• DSM-IV-TR defines a range of depressive mood disorders
MAJOR DEPRESSIVE DISORDER
Episode must:
• Last at least two weeks
• Represent change from previous level of functioning
• Cause impairment in social or occupational functioning
MDD Diagnosis Requires:
Five or more symptoms – 1 must be either:
• Depressed mood
• Loss of interest in previously enjoyable activities
Plus - Four additional symptoms from this list:
• Changes in appetite or weight
• Sleep disturbance
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Difficulty concentrating
• Difficulty thinking/making decisions
• Recurrent thoughts of death or suicide
The Individual With MDD May Exhibit:
• Sadness
• Hopelessness
• Feeling empty
• Aches and pains
• Irritability
• Social withdrawal
• Neglect of previously enjoyed activities
MINOR DEPRESSIVE DISORDER
• Less severe symptoms
• Interferes with functioning
• Strongly associated with other psychiatric comorbidity
•
•
•
•
Alcohol dependence, anxiety disorders
May be brief
Involves fewer than the five symptoms required for major disorder
Does not feel minor to the patient
Diagnosis has not yet been validated for inclusion in DSM
DYSTHYMIC DISORDER
• Feel depressed nearly all the time
• Must exist for two or more years
Most of the day, more days than not
• Two other symptoms required for diagnosis
Appetite disturbance
Sleep disturbance
Fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness
• May cause clinically significant distress or impairment in social/occupational functioning
• Is rarer than major depressive disorder
POSTPARTUM DEPRESSION
• Occurs within 4 weeks of childbirth
• Occurs after 15% of births
• Affects mother and infant
• Ranges greatly in seriousness
• Symptoms do not differ from other mood disorders
• Increased risk factors:
Prior depression
Low level of social support
Complications
• May affect mother-infant bonding, breastfeeding, family
• May lead to psychosis or infanticide or both
Nursing Alert !!!
• Risk Factors for Depression
Family history of depression
Having experienced recent negative stressors
Having childhood experiences in a negative home environment
Lacking a social support system
Having significant physical disease
GRIEF AND BEREAVEMENT
• Are normal and healthy
• Stages of grieving may take up to 3 years
• Share symptoms of depression
• Are due to loss
• Are individual
• Can be successfully resolved
• Involve three stages
STAGES OF GRIEF & BEREAVEMENT
Stage 1: The Period of Shock
• Individual feels numb
• Lasts from days to a month or more
Stage 2: The Reality Stage
• Most pain felt in this stage
• Individual identifies the meaning of loss to his or her life
• Reactions may include anger, guilt, hurt, frustration, helplessness, or fear
Stage 3: The Recovery Stage
• Integrates loss into the reality of his or her life
• Begins to live again
ABNORMAL GRIEVING
• Chronic grief—grief never reaches conclusions
• Delayed grief—grief work not done at the time of the loss
• Exaggerated grief—overwhelming grief
• Masked grief—grief masked by physical symptom or maladaptive behavior & person is unaware of the
connections to grief & loss
Factors That Lead to Abnormal Grief
•
•
•
Ambivalence toward the person lost
Unresolved emotional conflicts with relationship
History of maladaptive coping behaviors
PSYCHOTHERAPY
• Over 250 types of verbal therapies designed to help persons with psychological stresses, including
•
•
•
•
depression
Brief dynamic therapy
Focuses on core conflicts derived from the personality & living situation
Marital therapy
Attempts to resolve problems that occur in a marriage
Cognitive therapy
Focuses on identifying & removing perceptual biases in patient’s thinking
Effect of psychotherapy
Brief Dynamic: Fairly consistent benefit for depression – about 35%
Marital: Effectively alleviates depressive symptoms in patients with marital discord
Cognitive: studies have not shown that it differs in effectiveness from any other psychotherapies or that
medication is less effective
PHYSICAL THERAPIES
• Electroconvulsive therapy
Patients treated with pulses of electrical energy sufficient to cause a brief convulsion or seizure
Carried out under anesthesia
Muscle-depolarizing agents also given so no actual convulsions occur
Primary effect is on the brain itself
EFFECTS: Highly effective in helping severe depression resistant to all other treatments
• Light therapy
Most commonly indicated for Seasonal Affective Disorder – a nonpsychotic depression that occurs primarily
during winter months
Light therapy simulates summer light conditions by exposing patients to bright lights for a period each day
EFFECTS: Relieves symptoms in about 75% of persons. Response should be within 2 weeks. No data on
treatment lasting longer
MEDICATIONS
• May take a month to be effective
• Prescribed for four to nine months
• Some may take meds indefinitely
• Antidepressants also treat anxiety
• Four classes
Lithium & some anticonvulsants
Tricyclic & related antidepressants
SRRIs
MAO inhibitors
TRICYCLIC & RELATED ANTIDEPRESSANTS
• May be used for other types of disorders
• Anticholinergic effects
• Orthostatic effects
• Weight gain
• Sexual dysfunction
• Improves sleep
• Full response in four to six weeks
• Examples: Elavil, Norpramin, Sinequan, Pamelor, Ludiomil
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
• Increase available serotonin
• Maximum effectiveness in four to six weeks
• Less troublesome side effects
• Side effects include agitation, restlessness, insomnia, weight loss, headache, nausea, diarrhea, sexual
dysfunction
• Examples: Prozac, Celexa, Paxil, Zoloft
MONOAMINE OXIDASE INHIBITORS
• Increase concentrations of serotonin, epinephrine, & norepinephrine in brain tissue
• Dangerous food interactions
• Cause dangerous rise in blood pressure
• Examples: Parnate, Nardil, Marplan
Nursing Alerts !!!
• Tricyclic Antidepressants
Are very dangerous in overdoses; must be carefully monitored, especially in patients with suicide risk
• Bupropion
May cause seizures, especially in doses over 300mg daily
ASSESSMENT
• Most patients seen in general medical settings
• Nurses will have contact with these patients in all areas of practice
• Self-assessment tools are available
• Nursing tools include observation, interview, and intuition
• Certain individuals should be interviewed more intensively:
Persons with prior episodes of depression or suicide attempts
Persons under age 40 or over age 70
Postpartum mothers
Persons with significant medical illnesses
Persons with limited social support or stressful life circumstances
Persons who abuse alcohol or other substances
NURSING DIAGNOSIS
• Hopelessness
• Powerlessness
• Spiritual distress
• Disturbed self-esteem
• Social isolation
• Self-care deficit
• Disturbed sleep pattern
OUTCOME IDENTIFICATION
• Outcomes are varied
• Depend upon patient’s need for care
PLANNING/INTERVENTIONS
• Include independent nursing actions
• Include collaborative interventions
EVALUATION
• Patient’s view of changes
• Improvements in sleep, appetite, sense of control, self-worth