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Chapter 25
Depressive Disorders
Copyright © 2014. F.A. Davis Company
Introduction
• Depression is the oldest and one of the
most frequently diagnosed psychiatric
illnesses.
• Transient symptoms are normal, healthy
responses to everyday disappointments in
life.
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Introduction (cont.)
• Pathological depression occurs when
adaptation is ineffective.
• Mood is also called affect.
• Depression is an alteration in mood that is
expressed by feelings of sadness, despair,
and pessimism.
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Historical Perspectives
• Many ancient cultures believed in the
supernatural or divine origin of mood
disorders.
• Hippocrates believed that melancholia was
caused by an excess of black bile, a heavily
toxic substance produced in the spleen or
intestine, which affected the brain.
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Epidemiology
• During their lifetimes, about 21
percent of women and 13 percent
of men will become clinically
depressed.
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Epidemiology (cont.)
• Gender Prevalence
– Depression is more prevalent in women
than in men by about 2 to 1.
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Epidemiology (cont.)
• Age
– Depression is more common in young women
than in young men.
– The gender difference is less pronounced
between ages 44 and 65, but after age 65,
women are again more likely to be depressed
than men.
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Epidemiology (cont.)
• Social Class
– There is an inverse relationship between social
class and report of depressive symptoms.
• Race
– No consistent relationship between race and
affective disorder has been reported.
– One recent survey revealed:
• Depression is more prevalent in whites than blacks.
• Depression is more severe and disabling in blacks.
• Blacks are less likely to receive treatment than whites.
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Epidemiology (cont.)
• Marital Status
– Single and divorced people are more likely
to experience depression than married
persons or persons with a close
interpersonal relationship (differences occur
in various age groups).
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Epidemiology (cont.)
• Seasonality: Affective disorders are more
prevalent in the spring and in the fall.
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Types of Depressive Disorders
• Major Depressive Disorder
– Characterized by depressed mood
– Loss of interest or pleasure in usual activities
– Symptoms have been present for at least 2
weeks
– No history of manic behavior
– Cannot be attributed to use of substances or
another medical condition
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Types of Depressive Disorders (cont.)
• Persistent Depressive Disorder (Dysthymia)
– Sad or “down in the dumps”
– No evidence of psychotic symptoms
– Essential feature is a chronically depressed
mood for:
• Most of the day
• More days than not
• For at least 2 years
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Types of Depressive Disorders (cont.)
• Premenstrual Dysphoric Disorder
Essential features:
– Depressed mood
– Anxiety
– Mood swings
– Decreased interest in activities
– Symptoms begin during week prior to menses,
start to improve within a few days after the onset
of menses, and become minimal or absent in the
week postmenses
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Types of Depressive Disorders (cont.)
• Substance-Induced Depressive Disorder
– The depression is considered to be the direct
result of physiological effects of a substance.
• Depressive Disorder Associated with Another
Medical Condition
– The depression is attributable to the direct
physiological effects of a general medical
condition.
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Predisposing Factors to Depression
• Biological Theories
– Genetics
• Hereditary factor may be involved.
– Biochemical influences
• Deficiency of norepinephrine, serotonin, and
dopamine has been implicated.
• Excessive cholinergic transmission may also be a
factor.
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Predisposing Factors to Depression
(cont.)
• Neuroendocrine Disturbances
– Possible failure within the hypothalamicpituitary-adrenocortical axis
– Possible diminished release of thyroidstimulating hormone
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Predisposing Factors to Depression
(cont.)
• Physiological Influences
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–
–
–
–
–
Medication side effects
Neurological disorders
Electrolyte disturbances
Hormonal disorders
Nutritional deficiencies
Other physiological conditions
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Predisposing Factors to Depression
(cont.)
• Psychosocial Theories
– Psychoanalytical theory
• A loss is internalized
and becomes directed
against the ego.
S. Freud
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Predisposing Factors to Depression
(cont.)
• Psychosocial Theories (cont.)
– Learning theory
• Learned helplessness
—The individual who experiences numerous
failures learns to give up trying.
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Predisposing Factors to Depression
(cont.)
• Psychosocial Theories (cont.)
– Object loss
• Experiences loss of significant other during first 6
months of life
• Feelings of helplessness and despair
• Early loss or trauma may predispose client to lifelong
periods of depression.
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Predisposing Factors to Depression
(cont.)
• Psychosocial Theories (cont.)
– Cognitive theory
• Views primary disturbance in depression as
cognitive rather than affective
• Three cognitive distortions that serve as the
basis for depression:
—Negative expectations of the environment
—Negative expectations of the self
—Negative expectations of the future
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Predisposing Factors to Depression
(cont.)
• The Transactional Model
Depression is likely related to multiple
factors, including genetic, biochemical and
psychosocial.
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Developmental Implications
• Childhood Depression
– Symptoms
• Younger than age 3: feeding problems, tantrums, lack
of playfulness and emotional expressiveness
• Ages 3 to 5: prone to accidents, phobias, excessive selfreproach
• Ages 6 to 8: physical complaints, aggressive behavior,
clinging behavior
• Ages 9 to 12: morbid thoughts and excessive worrying
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Developmental Implications (cont.)
• Childhood Depression (cont.)
– Precipitated by a loss
– Focus of therapy: Alleviate symptoms and
strengthen coping skills
– Parental and family therapy
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Developmental Implications (cont.)
• Adolescence
– Symptoms include:
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•
•
•
•
•
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Anger, aggressiveness
Running away
Delinquency
Social withdrawal
Sexual acting out
Substance abuse
Restlessness, apathy
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Developmental Implications (cont.)
• Adolescence (cont.)
– Best clue that differentiates depression from
normal, stormy adolescent behavior:
• A visible manifestation of behavioral change
that lasts for several weeks
– Most common precipitant to adolescent suicide:
• Perception of abandonment by parents or close peer
relationship
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Developmental Implications (cont.)
• Adolescence (cont.)
– Treatment with:
• Supportive psychosocial intervention
• Antidepressant medication
NOTE: All antidepressants carry an FDA blackbox warning for increased risk of suicidality in
children and adolescents.
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Developmental Implications (cont.)
• Senescence
– Bereavement overload
– High percentage of suicides among elderly
– Symptoms of depression often confused with
symptoms of neurocognitive disorder.
• Treatment
– Antidepressant medication
– Electroconvulsive therapy
– Psychosocial therapies
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Developmental Implications (cont.)
• Postpartum Depression
– May last for a few weeks to several months.
– Associated with hormonal changes, tryptophan
metabolism, or cell alterations
– Symptoms include:
• Fatigue, irritability
• Loss of appetite
• Sleep disturbances
• Loss of libido
• Concern about inability to care for infant
– Treatments
• Antidepressants and psychosocial therapies
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Nursing Process: Assessment
• Transient Depression
– Symptoms at this level of the continuum not
necessarily dysfunctional
• Affective: the “blues”
• Behavioral: some crying
• Cognitive: some difficulty getting mind off of
one’s disappointment
• Physiological: feeling tired and listless
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Nursing Process: Assessment (cont.)
• Mild Depression
– Symptoms of mild depression are identified by
clinicians as those associated with normal
grieving
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•
•
•
Affective: anger, anxiety
Behavioral: tearful, regression
Cognitive: preoccupied with loss
Physiological: anorexia, insomnia
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Nursing Process: Assessment (cont.)
• Moderate Depression
– Symptoms associated with dysthymia:
• Affective: helpless, powerless
• Behavioral: sluggish physical movements, slumped
posture, limited verbalization
• Cognitive: slow thinking processes, difficulty with
concentration
• Physiological: anorexia or overeating, sleep
disturbance, headaches
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Nursing Process: Assessment (cont.)
• Severe Depression
– Includes symptoms of major depressive
disorder and bipolar depression
• Affective: feelings of total despair, worthlessness,
flat affect
• Behavioral: psychomotor retardation, curled-up
position, absence of communication
• Cognitive: irrelevant delusional thinking with
delusions of persecution and somatic delusions,
confusion, suicidal thoughts
• Physiological: a general slow-down of the entire
body
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Diagnosis/Outcome Identification
• Risk for suicide related to:
– Depressed mood
– Feelings of worthlessness
– Anger turned inward on the self
– Misinterpretations of reality
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Nursing Diagnosis
• Complicated grieving related to:
– Real or perceived loss
– Bereavement overload
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Nursing Diagnosis (cont.)
• Low self-esteem related to:
– Learned helplessness
– Feelings of abandonment by significant
others
– Impaired cognition fostering negative view
of self
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Nursing Diagnosis (cont.)
• Powerlessness related to:
– Complicated grieving process
– Lifestyle of helplessness
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Nursing Diagnosis (cont.)
• Spiritual distress related to:
– Complicated grieving process over loss of
valued object evidenced by anger toward
God, questioning meaning of own
existence, inability to participate in usual
religious practices
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Nursing Diagnosis (cont.)
• Social isolation/impaired social interaction
related to:
– Developmental regression
– Egocentric behaviors
– Fear of rejection or failure of the interaction
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Nursing Diagnosis (cont.)
• Disturbed thought processes related to:
– Withdrawal into self
– Underdeveloped ego
– Punitive superego
– Impaired cognition fostering negative
perception of self or environment
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Nursing Diagnosis (cont.)
• Imbalanced nutrition less than body
requirements
• Insomnia
• Self-care deficit
• All related to depressed mood
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Nursing Diagnoses
1. An individual experienced the death of a parent two
years ago. This individual has not been able to work
since the death, cannot look at any of the parent’s
belongings, and cries daily for hours at a time. Which
nursing diagnosis most accurately describes this
individual’s problem?
A.
B.
C.
D.
Posttrauma syndrome R/T parent’s death
Anxiety (severe) R/T parent’s death
Coping, ineffective, R/T parent’s death
Grieving, complicated, R/T parent’s death
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Nursing Diagnoses (cont.)
• Correct answer: D
– The excessive reactions the individual continues
to exhibit such as daily crying, the inability to
return to work, and the inability to look at
parent’s belongings after a two-year period, are
indicative of dysfunctional or complicated
grieving. This individual’s grieving response has
arrested in the anger stage, is being turned
inward on the self, and is manifested by
symptoms of depression.
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Criteria for Measuring Outcomes
• The Client:
– Has experienced no physical harm to self
– Discusses the loss with staff and family members
– No longer idealizes or obsesses about the lost
entity
– Sets realistic goals for self
– Attempts new activities without fear of failure
– Is able to identify aspects of self-control over life
situation
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Criteria for Measuring Outcomes
(cont.)
• The Client (cont.):
– Expresses personal satisfaction and support
from spiritual practices
– Interacts willingly and appropriately with
others
– Is able to maintain reality orientation
– Is able to concentrate, reason, and solve
problems
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Planning/Implementation
• Nursing interventions are aimed at:
– Maintaining client safety
– Assisting client through grief process
– Promoting increase in self-esteem
– Encouraging client self-control and control over
life situation
– Helping client to reach out for spiritual support of
choice
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Planning/Implementation (cont.)
• Nursing interventions (cont.)
– Assistance in confronting anger that has been
turned inward on the self
– Ensuring that needs related to nutrition,
elimination, activity, rest, and personal hygiene
are met
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Client/Family Education
• Nature of the Illness
– Stages of grief and symptoms associated with
each stage
– What is depression?
– Why do people get depressed?
– What are the symptoms of depression?
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Client/Family Education (cont.)
• Management of the Illness
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Medication management
Assertive techniques
Stress-management techniques
Ways to increase self-esteem
Electroconvulsive therapy
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Client/Family Education (cont.)
• Support Services
– Suicide hotline
– Support groups
– Legal/financial assistance
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Nursing Process: Evaluation
• Evaluation of the effectiveness of nursing
interventions is measured by fulfillment of
the outcome criteria.
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Nursing Process: Evaluation (cont.)
• Has self-harm to the client been avoided?
• Have suicidal ideations subsided?
• Does the client know where to seek
assistance outside the hospital when
suicidal thoughts occur?
• Has the client discussed the recent loss
with the staff and family members?
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Nursing Process: Evaluation (cont.)
• Is he or she able to verbalize feelings and
behaviors associated with each stage of the
grieving process and recognize own
position in the process?
• Have obsessions with and idealization of
the lost object subsided?
• Is anger toward the lost object expressed
appropriately ?
• Does client set realistic goals for self?
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Nursing Process: Evaluation (cont.)
• Is the client able to verbalize positive
aspects about self, past accomplishments,
and future prospects?
• Can the client identify areas of life situation
over which he or she has control?
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Treatment Modalities
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•
•
•
•
•
•
Individual Psychotherapy
Group Therapy
Family Therapy
Cognitive Therapy
Electroconvulsive Therapy
Transcranial Magnetic Stimulation
Light Therapy
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Treatment Modalities (cont.)
• Psychopharmacology
– Tricyclics (TCAs)
– SSRIs
– MAO inhibitors
– Heterocyclics
– SNRIs
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Treatment Modalities (cont.)
• Psychopharmacology (cont.)
– Action
• TCAs, heterocyclics, SSRIs, SNRIs
– Block reuptake of norepinephrine, serotonin,
and/or dopamine
• MAOIs
– Inhibit monoamine oxidase, an enzyme known to
inactivate norepinephrine, serotonin, and
dopamine
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Psychopharmacology (cont.)
– Contraindications/Precautions
• Contraindicated in known hypersensitivity (all), acute
phase of recovery from myocardial infarction, angleclosure glaucoma (tricyclics), and concomitant with
MAOIs (TCAs, heterocyclics, SSRIs, SNRIs)
• Caution with elderly or debilitated clients; clients with
hepatic, cardiac, or renal insufficiency; psychotic
clients; clients with benign prostatic hypertrophy; and
those with history of seizures
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Psychopharmacology (cont.)
– Interactions (with tricyclics)
• Increased effects of tricyclics with bupropion,
cimetidine, haloperidol, SSRIs, and valproic acid
• Decreased effects of tricyclics with rifamycin,
carbamazepine, and barbiturates
• Hyperpyretic crisis, convulsions, and death can occur
with MAOIs
• Hypertensive crisis can occur with clonidine
• Decreased effects of levodopa and guanethidine
• Potentiation of pressor response with direct-acting
sympathomimetics
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Psychopharmacology (cont.)
– Interactions (MAOIs)
• Hypertensive crisis with amphetamines, methyldopa,
levodopa, dopamine, epinephrine, norepinephrine,
reserpine, vasoconstrictors, or foods with tyramine
• Hypertension, hypotension, coma, convulsions, and
death with narcotic analgesics
• Additive hypotension with antihypertensives
• Additive hypoglycemia with antihyperglycemic agents
• Potentially fatal reactions with all other
antidepressants, carbamazepine, buspirone,
sympathomimetics, tryptophan, dextromethorphan,
CNS depressants, and amphetamines (avoid use within
2 weeks of each other)
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Psychopharmacology (cont.)
– Interactions (SSRIs)
• Toxic, sometimes fatal, reactions have occurred with
concomitant use of MAOIs.
• Increased effects of SSRIs with cimetidine, Ltryptophan, and lithium
• Concomitant use of SSRIs may increase effects of
hydantoin, tricyclic antidepressants, benzodiazepine,
beta-blockers, carbamazepine, clozapine, haloperidol,
phenothiazine, St. John’s wort, sumatriptan,
sympathomimetics, theophylline, and warfarin.
• Concomitant use of SSRIs may decrease effects of
buspirone and digoxin.
• Serotonin syndrome can occur with concurrent use of
other drugs that increase serotonin.
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Psychopharmacology (cont.)
2. When teaching about the tricyclic group of
antidepressant medications, which information
should the nurse include?
A. Strong or aged cheese should not be eaten while
taking this group of medications.
B. The full therapeutic potential of tricyclics may not
be reached for four weeks.
C. Long-term use may result in physical
dependence.
D. Tricyclics should not be given with antianxiety
agents.
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Psychopharmacology (cont.)
• Correct answer: B
– A client needs to be advised that it may take
several weeks for tricyclic medications to reach
their full therapeutic effect and for relief of
symptoms to be noted.
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Psychopharmacology (cont.)
– Side effects
• May occur with all chemical classes:
– Dry mouth, sedation, nausea
– Discontinuation syndrome with abrupt withdrawal
• Most commonly occur with tricyclics and heterocyclics:
– Blurred vision, constipation, urinary retention,
orthostatic hypotension, reduction of seizure
threshold, tachycardia, arrhythmias,
photosensitivity, weight gain
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Psychopharmacology (cont.)
– Side effects (cont.)
• Most commonly occur with SSRIs and SNRIs:
– Insomnia, agitation, headache, weight loss, sexual
dysfunction, serotonin syndrome
• Most commonly occur with MAOIs:
– Hypertensive crisis
– Application site reactions (transdermal system)
• Miscellaneous side effects:
– Priapism (with trazadone)
– Hepatic failure (with nafazodone)
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Psychopharmacology (cont.)
• Client/Family Education Related to
Antidepressants
– Therapeutic effect may not be seen for as long
as 4 weeks.
– Do not discontinue use of the drug abruptly.
– Avoid smoking and drinking alcohol.
– Be aware of risks of taking antidepressants
during pregnancy.
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Psychopharmacology (cont.)
• Avoid foods and medications high in
tyramine when taking MAOIs. These include:
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•
•
•
•
•
•
•
•
Aged cheese
Caviar
Wine; beer
Raisins
Chocolate; colas
Pickled herring
Coffee; tea
Yeast products
Sour cream; yogurt
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• Broad beans
• Smoked and processed
meats
• Soy sauce
• Beef or chicken liver
• Cold remedies
• Canned figs
• Diet pills
Psychopharmacology (cont.)
1. A client has been diagnosed with major
depression. The psychiatrist prescribes paroxetine
(Paxil). Which of the following medication
information should the nurse include in discharge
teaching?
A. Do not eat chocolate while taking this medication.
B. The medication may cause priapism.
C. The medication should not be discontinued
abruptly.
D. The medication may cause photosensitivity.
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Psychopharmacology (cont.)
• Correct answer: C
– Antidepressants such as paroxetine must be
tapered and not stopped abruptly. All
classifications of antidepressants have varying
potentials to cause discontinuation syndromes.
Abrupt withdrawal from SSRIs, such as paroxetine,
may result in dizziness, lethargy, headache, and
nausea.
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