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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Insomnia or hypersomnia Uninterrupted self-defeating ruminations Altered Social Interactions • Poor social skills • Withdrawn prefer Isolation Symptoms of Depression Alterations of Cognition • • • • Inability to concentrate Confusion Easily distracted Problems with thinking ideas and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 andrenocorticotropic 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 • • • • Psychotherapy may be enough for exogenous – • Loss of a loved one Surgery Retirement 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, nondirective 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 • 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 – Blood serum levels of medication increases Spaced several days apart After Treatment • Client may have immediate relief of Depression