DEPRESSION Note Taking Outline
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Incidence and Prevalence
NIMH --Depression Rate:
 7.1% in women/Postpartum Depression
 3.5% in men
 6.7 % of US adult population in a given year
Age of onset- anytime, highest in 20’s
 Highest prevalence: ages 25-44
Hospital admits: 10 to 15% are depressed
Many Forms of Depression
SELECTED DISORDERS
 DSM Depressive Disorders
 Major Depressive Disorder (MDD)
 “Specifiers” include severity, recurrence and features e.g. with psychotic
features, postpartum onset, with anxiety, etc.
 Dysthymia (DSM V- Persistent Depressive Disorder)
 Depressive Disorder, Not Otherwise Specified (NOS)
 Has
characteristics of depression but does not fit exact criteria for the above
Criteria for Major Depressive Disorder
5 of the following 9 Symptoms > 2 weeks:
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Depressed Mood
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Anhedonia (or Apathy)
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Significant change in weight
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Insomnia or hypersomnia
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Increased or decreased psychomotor activity
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Fatigue or energy loss
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Feelings of worthlessness or guilt
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Diminished concentration or indecisiveness
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Recurrent death or suicidal thoughts
Dysthymia (Persistent Depressive Disorder)
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Chronic disorder
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
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Never free of symptoms for 2 months
Symptoms of Depression
 Alterations in Activity
 Psychomotor agitation
 Tired; poverty of speech
 Poor hygiene
 W eight loss or gain
 Insomnia or hypersomnia
 Uninterrupted self-defeating ruminations
 Altered Social Interactions
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Poor social skills
Withdrawn, prefer isolation
 Alterations of Cognition
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Inability to concentrate
Confusion
Easily distracted
Problems with thinking ideas and problem solving
Delusions
 Delusion of Persecution:
 e.g. For a moral or ethical mistake
 Somatic Delusions
 e.g. “I am full of cancer”
 Alterations of Affect
Low-self esteem
Worthlessness
 Guilt
 Anxiety
 Hopelessness
 Helplessness
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Alterations of a Physical Nature
 Somatic Complaints
 Preoccupation with their bodies
 Panic Attacks in 15% to 30% of people with MDD
 Alterations of Perception: Usually Mood Congruent
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Hallucinations
 E.g. Voices accusing or blaming of self
Depression Model and Theories
 Unified Model of Mood Disorders
 Genetic Vulnerability
 Developmental Events
 Physiological Stressors
 Psychosocial Stressors
 Any of these can start the cycle of disturbed neurochemistry
Neurochemical Theories of Depression
 Serotonin and Norepinephrine
 Level is 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 Theory
 Elevated levels of corticotropin-releasing hormone
 Elevated pituitary release of andreno-corticotropic hormone
 Early life exposure to overwhelming trauma
Circadian Rhythm Theory:
 Alterations in biorhythms may result from:
 Medications
 Nutritional deficiencies
 Physical illness
 Wake-sleep cycles
 Hormonal fluctuations
Psychological Theories of Depression
 Psychoanalytic Theory: Freud-depression is anger turned on the self; “overactive
superego”
 Interpersonal Theory: Sullivan:-(for more information see Chap 4, p. 41-42) problems
in the areas of neglect, abuse, rejection, loss
 Behavioral Theory-The way you act affects people’s response
 learned helplessness, hopelessness, and being unassertive
 Cognitive Theory : Very commonly used treatment modality
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Beck-Depression based on distorted thinking patterns
Ellis-Concept of negative. self talk and catastrophising
 Core beliefs = how you think about your situation
 Identify self-defeating thoughts, beliefs
 Change beliefs and you will change behavior
(Review p. 35, 43-45)
Treatment Efficacy in Depression
 Depression very treatable disease
 Episodes usually last 6 to 9 weeks
 Endogenous: no identifiable trigger or event-- medications and psychotherapy
 Exogenous: identifiable event(s) or stressor(s)-- counseling/psychotherapy may be
enough to resolve symptoms
Nursing Dx For Depressive Disorders
Potential for Violence: directed at self,
or Risk for Suicide
 Alteration in Nutrition: Less than body requirements
 Sleep pattern disturbance
 Self care deficit
 Alterations in perception:Hallucinations
 Alteration in thought process: Delusions
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Nursing Care and Milieu Management
Safety First: The milieu or environment should keep the client safe
 Check all clients every 15 minutes
 Locked environment
 Remove all harmful, sharp items
Balance Sleep/activity
 Assess hours of sleep
 Encourage exercise/Walking
 Relaxation exercises
 Medication as needed for sleep or agitation
Monitor and Provide Adequate Nutrition
 Observation of client during meals
 Record intake and weight
 Vital signs
 Lab work
 Decrease Isolation
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Approach is firm and direct
Reasonable limits on isolative behavior
 Listen and Acknowledge Negative Feelings
Interventions for Other Issues
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Anger: writing, discussing, and exercise
Agitated depression: walk with patient
Simple, structured activities best in early treatment (why?)
Group Therapies
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Assertiveness training
Coping Skills
Grief group
Art therapy
Insight oriented psychotherapy (outpatient)
Family therapy
Nurse-Client Communication
Establish trust
 Show sincere concern
Assess client’s negative self talk
Provide another point of view
 Do not attempt to reason
 Don’t reinforce delusions
May be resistant to come to 1-1
Active listening, non-directive 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
Medications for Depression
Antidepressants
 Tricyclics (TCAs)
 Serotonin re-uptake Inhibitors /SSRIs
 Monoamine Oxidase Inhibitors (MAOIs)
 Atypical/Novel Antidepressants
 Misc. agents
 Atypical Antipsychotics
 Psychostimulants (e.g. amphetamines)
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 St. John’s W ort (hypericum)--herbal remedy (described on p. 584-585)
Comparison of Modes of Action TCAs and SSRIs
 Tricyclics: a) non-selectively inhibit reuptake, b) increase receptivity to serotonin and
norepinephrine
 SSRI’s: Selective inhibition of serotonin reuptake  fewer side effects
Antidepressant
Side Effect Profiles
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TCAs
 Dry mouth
 Blurred vision
 Constipation
 Sedation
  appetitewt gain
 Postural hypotension
 Cardiac effects
 Can be cardiotoxic
 EKG prior to starting
 Slow onset 2-4 weeks
 Overdose potential
 SSRIs
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Nausea
Nervousness, anxiety
Insomnia
Sexual dysfunction
Headache
Slow onset 2-4 weeks
 This length of time is a consideration if client is suicidal
Low OD risk
Client Teaching: Managing Common 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
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Tricyclics may be supplied one week at a time
Monoamine Oxidase Inhibitors (MAOIs)
Inhibit enzyme that breaks down serotonin and norepinephrine
Non-Selective (older) and Selective types
Usually last choice of pharmacotherapy
Side Effects of MAOIs
 MAOIs can cause very serious hypertensive crisis
 Client must be instructed not to drink red wine, eat cheese, yogurt anything aged.
Tyramine is chemical ingredient.
 Check with MD before taking any new meds. many drug-drug interactions and
adverse effects
Atypical Antidepressants
 Prevent reuptake of specific neurotransmitters, e.g.
 Serotonin and Norepinephrine (SNRI)
 Norepinephrine and Dopamine (NDRI)
or are
 Receptor Antagonists - increase activity of neurotransmitters
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Side Effects of Atypicals
trazodone/Desyrel- Usually used for sleep: rare side effect: priapism
buproprion/W ellbutrin: seizures at high doses, irritability, decreased appetite,
worsening of tics
venlafaxine/Effexor: Nausea, agitation, headache and increase in blood pressure
mirtazapine/Remeron: Sedation, increased appetite
Serotonin Syndrome
A potentially fatal syndrome
Too much serotonin
Results from: Combination of serotonin containing therapies
 e.g. Serotonin Reuptake Inhibitors combined with:
 Prescribed:
 Tricyclic Antidepressants
 Monoamine Oxidase Inhibitors
 Lithium
 Over the Counter Medications:
 Cough and cold meds.
 Diet drugs
 St. John’s W ort
 Other: LSD, Ecstasy
 Symptoms:
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CNS-confusion
Agitation
Hypomania
Myoclonus
Tremor
Hyperreflexia
Autonomic signs
 Fever
 Tachycardia OR bradycardia
 Hypertension OR hypotension
 Diaphoresis, diarrhea
 Severe dehydration can be fatal
Other Medications for Depression
 Used in conjunction with an antidepressant for treatment of variants of depression
e.g. agitated-type depression, or for treating anxiety, psychosis or severe cognitive
symptoms
Somatic Therapy: Electroconvulsive Therapy (ECT)
 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
 Treatment series of 6-10 times, Spaced several days apart
 Under supervision of anesthesiologist
 Pre-op: Give atropine, barbiturate, muscle relaxant
 Procedure: Induction of controlled seizure via electrical current
 Monitor LOC, orientation, vitals, resp. before return to unit/home
 Side effects- short term memory loss
 Initially: memory of events immediately prior to the procedure
 Client may have immediate relief of Depression
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