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Download THE CLIENT EXPERIENCING DEPRESSION
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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