Chapter 16
Depressive Disorders
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Learning Outcomes
By the end of this session, students will be able to:
1. Recount historical perspectives of depression.
2. Discuss the epidemiology of depression.
3. Describe various types of depressive disorders.
4. Identify predisposing factors in the development of
depression.
5. Identify symptomatology associated with depression
and use this information in patient assessment.
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Learning Outcomes (continued)
6. Formulate nursing diagnoses and goals of care for
patients with depression.
7. Identify topics for patient and family teaching
relevant to depression.
8. Describe appropriate nursing interventions for
behaviors associated with depression.
9. Describe relevant criteria for evaluating nursing care
of patients with depression.
10.Discuss various modalities relevant to treatment of
depression.
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Introduction
 Depression is the oldest and one of the most
frequently diagnosed psychiatric illnesses.
 Transient symptoms of sadness are normal, healthy
responses to everyday disappointments in life.
 Pathological depression occurs when adaptation is
ineffective.
 Mood is defined as a way a person feels.
 Affect is the observable emotional reaction
associated with an experience.
 Depression is an alteration in mood that is expressed
by feelings of sadness, despair, and pessimism.
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Historical Perspective
 Many ancient cultures believed
in the supernatural or divine
origin of mood disorders.
 Hippocrates believed that an
excess of black bile produced in
the spleen or intestine affected
the brain causing melancholia.
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Epidemiology
 In 2019, 18.5% of adults reported feelings of
depression in the last 2 weeks.
 Prevalence is increasing among U.S. teens.
 Up to 50% of all depressions may be bipolar
illness.
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Epidemiology
 Gender prevalence – Woman > men
 Age
 Social class (inverse relationship)
 Race and culture
 Marital status
 Seasonality
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Types of Depressive Disorders
 Major depressive disorder (MDD)
• Characterized by depressed mood for at least 2 weeks
• May describe feelings of sadness, discouragement,
hopelessness
• Loss of interest or pleasure in usual activities
• May describe somatic complaints or increased anger, no
manic behavior
• Cannot be attributed to use of substances or another
medical condition
• Single episode or recurrent
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Depressive Disorder
Web Link: Major Depressive Disorder
Web Link: Symptoms of Major
Depressive Disorder
Web Link: Signs of Major Depressive
Disorder
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Types of Depressive Disorders
 Persistent depressive disorder (dysthymia)
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Sad or “down in the dumps” for most days
Symptoms less severe than MDD
No evidence of psychotic symptoms
Essential feature is a chronically depressed
mood for
‒ Most of the day
‒ No more than two months symptom free
‒ At least 2 years
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Types of Depressive Disorders
 Premenstrual dysphoric disorder (PMDD)
 Substance- or medication-induced
depressive disorder
 Depressive disorder associated with
another medical condition
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Predisposing Factors to Depression
 Etiology unclear
 Multiple causations
• Genetics
• Biochemical
• Psychosocial
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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
 Physiological influences
• Medication side effects
• Neurological disorders
• Electrolyte disturbances
• Hormonal disorders
• Nutritional deficiencies
• Other physiological conditions
• The role of inflammation
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Predisposing Factors to Depression
 Neuroendocrine disturbances
• Possible failure within the hypothalamic-pituitaryadrenocortical axis
• Possible diminished release of thyroid-stimulating
hormone
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Predisposing Factors to Depression:
Transactional Model of Stress and Adaptation
 Recognizes the combined effect of genetic,
biochemical, and psychosocial influences on
an individual’s susceptibility to depression
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Developmental Implications
 Senescence
• Bereavement overload
• High percentage of suicides among elderly
• Symptoms of depression often confused with
symptoms of neurocognitive disorder
• Treatment
‒ Antidepressant medication
‒ Electroconvulsive therapy
‒ Psychotherapies
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Nursing Process/Assessment
 Transient depression
• Symptoms at this level of the continuum are not
necessarily dysfunctional
‒ Affective: Sadness, dejection, having “ 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
 Mild depression
• Symptoms of mild depression are identified by
clinicians as those associated with normal
grieving
‒ Affective: Denial of feelings, anger, anxiety, guilt, helplessness,
hopelessness, sadness, despondency
‒ Behavioral: Tearful, regression, restlessness, agitation,
withdrawal
‒ Cognitive: Preoccupied with loss, self-blame, ambivalence,
blaming others
‒ Physiological: Anorexia or overeating, insomnia or hypersomnia,
aches and pains
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Nursing Process/Assessment
 Moderate depression
• Symptoms associated with dysthymic disorder
‒ Affective: Sadness, dejection, helpless, powerless, hopelessness, low
self-esteem, gloomy outlook
‒ Behavioral: Slowed physical movements, slumped posture, limited
verbalization, self-destructive behavior
‒ Cognitive: Retarded thinking processes, difficulty
with concentration, obsessive and repetitive thoughts, pessimism
and negativism, suicidal ideation
‒ Physiological: Anorexia or overeating, sleep disturbance, aches and
pains, decreased libido, low energy level, fatigue and listlessness
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Nursing Process/Assessment
 Severe depression
• Includes symptoms of major depressive disorder
and bipolar depression
‒ Affective: Feelings of total despair, worthlessness,
flat affect, emptiness, apathy, loneliness
‒ Behavioral: Psychomotor retardation, curled-up position, absence
of communication, no personal hygiene, social isolation
‒ Cognitive: Prevalent delusional thinking, with delusions of
persecution and somatic delusions; confusion; suicidal thoughts,
hallucinations
‒ Physiological: General slow-down of the entire body
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Nursing Process: Diagnosis/Outcome
Identification
 Risk for suicide
behavior
 Maladaptive grieving
 Low self-esteem
 Powerlessness
 Spiritual distress
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 Social isolation
 Disturbed thought
processes
 Imbalanced
nutrition less than
body requirements
 Insomnia
 Self-care deficit
Connection Check
An individual experienced the death of a parent 2 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. Post-trauma syndrome related to parent’s death
B. Anxiety (severe) related to parent’s death
C. Coping, ineffective related to parent’s death
D. Grieving, complicated related to parent’s death
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Criteria for Measuring Outcomes: Client
 Has experienced no physical harm to self
 Discusses loss with staff and family members
 Expresses hopefulness
 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: Client
 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
 Eats a well-balanced diet
 Sleeps 6 to 8 hours
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Planning/Implementation
 Patient will:
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Remain free from injury
Refrain from attempts to injure self or others
Participate in recreational activities
Comply with treatment regimen
Articulate steps to feeling better, before
beginning to feel better
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Planning/Implementation
 Low self-esteem/self-care deficit
• Be accepting of the client.
• Encourage the client to recognize areas of change.
• Encourage independence in the performance of activities
of daily living.
 Powerlessness
• Encourage the client to take responsibility.
• Help the client set goals.
• Help the client identify areas of their life that they can
and cannot control.
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Client/Family Education
 Nature of the illness
 Management of the illness
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Medications
Assertiveness techniques
Stress management techniques
Ways to increase self-esteem
ECT therapy
 Support services
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Evaluation
 Has self-harm to the client been avoided?
 Have suicidal ideations subsided?
 Does the client know where to seek assistance
outside of the hospital when suicidal thoughts occur?
 Is client able to resume normal activity patterns and
meet functional needs appropriately?
 Does client express hopefulness for the future?
 Has the client discussed the recent loss with the staff
and family members?
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Treatment Modalities
 Individual psychotherapy
 Group therapy
 Family therapy
 Cognitive therapy
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Treatment Modalities
 Electroconvulsive therapy
• Mechanism of action: Thought to increase levels of
biogenic amines
• Side effects: Temporary memory loss and
confusion
• Risks: Mortality (0.002%), permanent memory
loss, no evidence of brain damage
• Medications: Pretreatment medication, muscle
relaxant, short-acting anesthetic
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Treatment Modalities
 Repetitive transcranial magnetic stimulation
 Vagal nerve stimulation and deep brain
stimulation
 Light therapy
Light therapy
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Transcranial magnetic stimulation
Treatment Modalities
 Psychopharmacology
• Antidepressant medications
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Tricyclics
Selective serotonin reuptake inhibitors (SSRIs)
Monoamine oxidase inhibitors
Heterocyclics
Serotonin-norepinephrine reuptake inhibitors (SNRIs)
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Psychopharmacology
Classes of Antidepressant Medication
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Psychopharmacology
Imipramine (Tofranil)
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Therapeutic class: Antidepressant
Pharmacologic class: Tricyclic antidepressant
Action: Blocks the reuptake of serotonin and norepinephrine. Used for major depression or nocturnal
enuresis in children. Can be used for pain, anxiety disorders, withdrawal symptoms.
Administration alert: Paradoxical diaphoresis (sweating);anticholinergic affects; abrupt discontinuation
may cause withdrawal symptoms.
Pharmacokinetics: Onset less than 1 hour; peak 1-2 hours PO; 30 min IM; duration variable
Adverse effects: Sedation, drowsiness, blurred vision, dry mouth, cardiovascular symptoms
(dysrhythmias, heart block, hypertension), photosensitivity. May increase risk for suicidal thinking and
behavior, especially in children, adolescents and young adults with psychiatric disorders. Not for
pediatric patients.
Contraindication: Recovering from MI, bundle branch conduction, narrow-angle glaucoma, chronic
kidney disease, hepatic impairment.
Drug-drug interactions: CNS depressants, Cimetidine (toxicity), oral contraceptives, Disulfam, antithyroid
agents (agranulocytosis), phenothiazines, sympathomimetics, methylphenidate, phenytoin (less
effective). MAOIs (neuroleptic malignant syndrome).
Lab tests: Altered blood glucose tests, elevation of serum bilirubin and alkaline phosphatase.
Pregnancy class: C
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Treatment Modalities
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Psychopharmacology
Sertraline (Zoloft)
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Therapeutic class: Antidepressant
Pharmacologic class: Selective serotonin reuptake inhibitor (SSRI)
Action: Inhibits the reuptake of serotonin. Enhancement of mood and improvement of
affect observed after several weeks.
Administration: Give in morning; abrupt discontinuation can result in withdrawal
symptoms
Pharmacokinetics: Onset 2-4 wk.; peak unknown; duration variable
Adverse effects: agitation, insomnia, headache, dizziness, somnolence, fatigue, weight
gain, sexual dysfunction. Serotonin syndrome (SES) buildup of serotonin in the body
leading to confusion, anxiety, restlessness, hypertension, tremors, sweating, hyperpyrexia
or ataxia. May increase risk for suicidal thinking and behavior, especially in children,
adolescents and young adults with psychiatric disorders. Not for pediatric patients.
Drug-drug interactions: Avoid highly-protein bound medications, such as digoxin and
warfarin (toxicity and increase in blood concentration). MAOIs (neuroleptic malignant
syndrome).
Pregnancy class: C
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Treatment Modalities
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Selective serotonin reuptake inhibitors (SSRIs):
Sertraline
 Serotonin Syndrome
• Life-threatening emergency d/t excess
serotonin.
• Caused by combining with other drugs
that increase serotonin or by giving SSRIs
too close to discontinuation of MAOIs, St.
Johns Wort.
• S & S: HR & BP ↑, agitation, sweating,
hyperthermia, CV collapse, coma, seizures
 Discontinuation Syndrome
• Caused from abrupt discontinuation of
drug (flu like syndrome). Taper over weeks
before discontinuation.
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Psychopharmacology
Phenelzine (Nardil)
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Therapeutic class: Antidepressant
Pharmacologic class: Monoamine oxidase inhibitor (MAOI)
Action: Irreversible inhibition of MAO – intensifies the effects of norepinephrine an adrenergic synapses.
Manage symptoms of depression not responsive to safer medications, panic disorders.
Administration alert: Washout period of 2-3 weeks before introducing other drugs; abrupt discontinuation
may cause rebound hypertension.
Pharmacokinetics: Onset 2 weeks; peak variable; duration 48-96 hours.
Adverse effects: Constipation, dry mouth, orthostatic hypotension, insomnia, nausea, loss of appetite. May
increase heart rate and neural activity (delirium, mania, anxiety, convulsions). Severe hypertension may
occur when consuming foods containing tyramine. May increase risk for suicidal thinking and behavior,
especially in children, adolescents and young adults with psychiatric disorders. Not for pediatric patients.
Contraindication: Hypersensitivity, cardiovascular or cerebrovascular disease, renal or hepatic impairment,
pheochromocytoma..
Drug-drug interactions: Many drugs. Avoid concurrent use of TCAs and SSRIs, opioids, sympathomimetics,
caffeine
Lab tests: Slightly false elevation in serum bilirubin.
Pregnancy class: C
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Treatment Modalities
Monoamine oxidase inhibitors (MAOIs)
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Avoid food with a high concentration of tyramine or
dopamine: hypertensive crisis
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Client/Family Education Related to
Antidepressants
 Continue to take medication for 4 weeks
 Do not discontinue medication abruptly
 Report sore throat, fever, malaise, yellow skin,
bleeding, bruising, persistent vomiting or
headaches, rapid heart rate, seizures, stiff
neck, and chest pain to physician
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Connection Check
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 4 weeks.
C. Long-term use may result in physical dependence.
D. Tricyclics should not be given with antianxiety agents.
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Connection Check
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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Depressive Disorders Takeaway
Take a moment to reflect on what you learned
during this module and write down # key
takeaways to share with your peers.
What was your muddiest point (most unclear
or confusing concept) during this module?
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