mood disorders depression

depressive disorders

•Disturbance in psychological, physiological, and social functioning

symptoms of depressive disorders

•Wide range of symptoms with disturbance in daily patterns

•Sleep, appetite, ADL’s, weight, attention, memory, libido

•Impulse control, suicidal ideation, social withdraw

•Physical Symptoms: H/A, Stomachache, muscle tension

transient depression

•a normal reaction to loss

•Sadness directly attributable to a situation or disappointment -reactive or secondary depression

depressive disorder

•sad mood can be related to external events or not

•Symptoms range from dissatisfaction with life to sudden and abrupt changes in function that suppress or take away the will to live

incidence and prevalence of depression

•Major Depression most common illness of any type (Medical or Psychiatric).

•Affects all ages and backgrounds

•Major Depression affects 14.8 million people aged 18 years or older (6.7% of the population)

•Average age: 32 years old

depression age groups

•1-2% of pre-puberty children and 3-8% of adolescents are depressed at any point in time.

•Depression is major health problem for elderly

•3.5% in the community, up to 15-20% in nursing home

•Depression in the older adult difficult to dx. d/t co-morbid physical diseases (heart, DM)

•Due to social limitation, losses, physical limits, HCP frequently conclude incorrectly that depression is a normal consequence of getting old.

depression Frequently accompanies other psychiatric disorders:

•    Schizophrenia

•    Substance Abuse

•    Eating disorders

•    Anxiety disorders

•    Personality disorders

risk factors

•Higher in women than men

•Past episodes of depression

•Family history

•Stressful life event

•Current substance use

•Medical illness

•Limited social supports

etiology

•Combination or interaction of:

•Genetics- increased risk if first degree relatives suffer from depression, neurotransmitters (deficiency in biogenic amines), dopamine, norepinephrine & serotonin 

•Environment

•Individual Life History

•Development

•Neurobiological

•Irregularities in the thyroid are seen as especially important in relation to Major Depressive Disorder

•Unknown

areas of the brain affected by depression

1. thalamus

2. amygdala

3. cingualte gyrus

4. prefrontal cortex

amygdala depressed people

responsible for negative feelings displays overactivity in depressed people

thalamus depression

associated w changes in emotion and is known to stimulate the amygdala

displays increased levels of activity in depressed individuals

cingulate gyrus depression

increased activity with depression

area helps associate smells and sights with pleasent memories of past emotions

it also takes part in the emotional rxn to pain and regulation of aggression

prefrontal cortex and depression

help regulate emotion, people w depression have decreased activity in this section of the brain

•Major Depressive Disorder:

•Potential for pain and suffering in all aspects of life

•Affects children, teenagers, adults & elderly

•Depressed mood or inability to feel pleasure from previously enjoyed activities

•Four of these seven symptoms must be present: Suicidal Ideations, disruptions in sleep, disruptions in appetite/ weight, disruption in concentration, disruption in energy level, Psychomotor agitation/ retardation, or excessive guilt/ feelings of worthlessness.

•Symptoms may include psychotic, catatonic,
melancholic features

•Over a minimum 2 weeks

•Persistent Depressive Disorder (Dysthymia):

•Chronic depressed mood

•> 1 year for children and adolescents

•> 2 years for adults and elderly

•Symptoms include poor appetite or over eating, insomnia or excessive sleep, low energy, fatigue, low self esteem, poor concentration, difficulties making decisions and feelings of hopelessness

MDD must haves:

•depressed mood or loss of interest

•Average length of time 4-12 months

persistent depressive disorder (dysthymia) s/s

• Less severe sx than MDD.  Presents as life long struggle against depression, chronic negativity & irritability

•Average more days than not with s/s for at least 2 yrs.

PPD

•Post Partum Depression- more serious and persistent lasting weeks or months after end of pregnancy, can emerge any time during the 1st year after childbirth

•Higher incidence with previous psych history

•Untreated can become dangerous for family and affected individual

•HCP need to screen for and is treatable

•Obvious in some women where other clients may not as readily share their feelings

assessment tools

•Beck Depression Inventory

•Hamilton Depression Scale

•Geriatric Depression Scale

•Zung Depression Scale

•

•SAFETY FIRST

Always assess suicidal risk, ideation and intent

key symptoms w assessment

•Depressed mood

•Anhedonia- without pleasure

•Anxiety

•Psychomotor agitation or retardation

•Somatic complaints

•Vegetative state- physical and mental inactivity

areas to assess

•Mood- subjective report of clients emotional state that impacts current life situation

•Affect- emotional tone the client projects-- physical appearance, posture, mood, eye contact, speech, withdrawn, blunted & flat

•Thought processes- Insight & judgment, decision making, memory & concentration & delusions

•Feelings- anxiety, hopeless, helpless, guilt, anger & listless

•Physical Behaviors- hygiene and grooming, sleep patterns, appetite, bowel habits, libido & anorexia

•Communication- maybe soft spoken, mute, cadence, rate, response time

nursing diagnosis

•Mood- subjective report of clients emotional state that impacts current life situation

•Affect- emotional tone the client projects-- physical appearance, posture, mood, eye contact, speech, withdrawn, blunted & flat

•Thought processes- Insight & judgment, decision making, memory & concentration & delusions

•Feelings- anxiety, hopeless, helpless, guilt, anger & listless

•Physical Behaviors- hygiene and grooming, sleep patterns, appetite, bowel habits, libido & anorexia

•Communication- maybe soft spoken, mute, cadence, rate, response time

interventions

•Mood- subjective report of clients emotional state that impacts current life situation

•Affect- emotional tone the client projects-- physical appearance, posture, mood, eye contact, speech, withdrawn, blunted & flat

•Thought processes- Insight & judgment, decision making, memory & concentration & delusions

•Feelings- anxiety, hopeless, helpless, guilt, anger & listless

•Physical Behaviors- hygiene and grooming, sleep patterns, appetite, bowel habits, libido & anorexia

•Communication- maybe soft spoken, mute, cadence, rate, response time

communication

•conveying information through verbal and nonverbal behaviors. Sending and receiving messages

therapeutic communication

nurse demonstrates empathy, effective communication skills, and responds to client’s thoughts, needs and concerns

nontherapeautic communication

•nurse responds in ways that cause defensive feelings, misunderstood, controlled, minimized, alienated, discouraged from expressing self, thoughts, feelings

therapeutic communication techniques

Giving Broad Openings

Paraphrasing

Offering General Leads

Reflecting Feelings

Voicing Doubts

Clarifying

Placing Events in time Sequence

Giving Information

Encouraging formulation of Plan

Testing Discrepancies

non therapeutic communication techniques

Social Responding

Asking Closed Ended Questions

Changing the Subject

Belittling

Making Stereotyped comments

Offering False Reassurance

Moralizing

Interpreting

Advising

Challenging

Defending

listening

•Focus on ALL behaviors that the client express

•Watch for clients verbal and non-verbal communication

•Requires energy, concentration, specific skills to ask the right questions and allows the client the time to determine content and level of disclosure

active listenig involves

•Maintaining eye contact

•Close proximity

•Projecting a relaxed environment

•Focus on what the client says, interpret interactions and respond objectively

•Remember use non-verbal's when communicating with a client

Confronting and Setting Limits

•Skill of pointing out in a caring way discrepancies between what the client does and says

•Describe the behavior that is inconsistent or confusing

•Offer at least two possible interpretations of the behavior

•Ask for feedback

self disclosure

•Personal information only if therapeutic purpose- generally not a good idea

•Use self disclosure to help client open up not to meet your needs

•Keep disclosure brief

•Do not imply your experience is the same as the client

•Only disclose the situations you have mastered

•Do not use to discuss painful situations

•Curb your talk about yourself

•Needs to be appropriate and comfortable

•Monitor nonverbal behaviors to see if the client is receptive

treatments

•Provide Safety

•Psychotherapy and Medications- Most effective combination to treat depressive disorders

•Group Therapy/Counseling

•Family Therapy/involvement

•ECT

•Cognitive Behavioral Therapy

•Social Skills Training & Milieu Therapy

SSRIs: Selective Serotonin Reuptake Inhibitors (ex: Prozac, Zoloft)

•First generation serotonergic agents which are considered first line drugs for depression, unless patients medical history or condition warrants use of a different medication

•Generally have fewer side effects than other antidepressants, but do have side effects such as nausea, headache and loss of libido

•They have minimal anticholinergic or cardiotoxic side effects

•One possible lethal reaction to SSRIs is Serotonin Syndrome.  This typically follows use of SSRIs, TCAs, tryptophan, dextromethorphan or meperidine alone or with a monoamine oxidase inhibitor (MAOIs)

•Serotonin Syndrome can also be seen with use of the popular herbal medication, St. John’s wort

•SARIs and SNRIs are also other common first line drugs

serotonin syndrome S/S

•Confusion & disorientation

•Mania & restlessness

•Rigidity

•Diaphoresis

•Tremors

•Coma even could rarely lead to death

treatment serotonin syndrome

•Stop all serotonergic drugs, give anticonvulsants if ordered or possibly a serotonin antagonist

atypical antidepressants

•Considered safer than TCA’s or MAOI’s

•Second line antidepressants

•Examples: trazodone or Remeron

tricyclic antidepressants

•Before SSRIs and Atypical antidepressants, Tricyclic antidepressants (TCA’s) were the first line drugs for depression.  Example: Elavil

•Not used frequently any more due to cardiotoxic effects and a narrow therapeutic window.  Not used with suicidal patients

•Current uses are when patients have been unsuccessful on SSRIs or Atypical antidepressants or have documented past success with TCA’s

•TCA’s can be used for patients whom also have certain GI disorders such as peptic ulcer disease

Monoamine Oxidase Inhibitors (MAOIs):

•Not used frequently since development of SSRIs. Example: Nardil

•May be used to treat atypical depression or for patients not showing responses to other antidepressants

•MAOIs increase tyramine.  Need to educate patients taking MAOIs to not eat foods high in tyramine.  These foods include yogurt, aged cheeses, beef or chicken liver, canned meats, fish, sausage, avocado, eggplant, alcoholic beverages, chocolate and meat tenderizer.  High levels leads to hypertensive crisis

counseling

•Help client identify and question cognitive distortions

•Encourage activities that improve self-esteem

•Encourage exercise

•Encourage supportive relationships

•Provide referrals for spiritual interventions when needed

family therapy

•Assessment, intervention and evaluation of family functional and dysfunctional patterns of behavior

•Need to examine interactions between parents and children

•Goal is to help family members identify and change behaviors that maintain depression and dependence among family members.

electroconvulsive therapy

•Electroconvulsive Therapy (ECT)- used if psychopharmacology and all other tx’s are ineffective

•Produces seizure- thought to modify neurotransmissions

•Few long term side effects

•Can cause memory loss, confusion lasting a few weeks or months after series complete

electroconvulsive therapy usage

•Short acting anesthesia and muscle-paralyzing agents used

•No absolute contraindications, but some conditions pose risk: recent MI, CVA or intracranial mass. 

•ECT not usually used for these clients unless need is compelling.

•Additional high risk consent and skill required for these clients

ECT Useful for:

•Major Depression and Bipolar Disorders, especially when psychotic features present

•Depression with psychomotor retardation or stupor

•Rapid Cycling Bipolar Disorder

•Schizophrenia (especially catatonic)

•Schizoaffective Syndromes

•Pregnant psychotic clients

•Clients with Parkinson’s

nursing care w electroconvulsive therapy

•Routine pre and post anesthesia care

•May need to orient client after awakening

•Provide supportive care for memory loss (may last for a few weeks; occasionally does not recover)

•Inform that this is not a permanent cure

•Watch for falls as patients are a high fall risk after procedure

cognitive behavioral therapy

•Common treatment for depressive disorders

•Completed in group or individual setting.

•Goal is to help clients identify and correct distorted, negative and catastrophic thinking, therefore relieving symptoms.

•Hope is to work actively with clients to change faulty though patterns.

milieu therapy

•Supportive group activities

•Protection from suicide intent

•Assertiveness training

•Assistance with grooming and hygiene

•Brief and frequent interpersonal contacts

•Ensure adequate nutrition

•Prevent constipation

•Discourage daytime sleep

self assessmnet of the nurse

•Unrealistic expectations for outcomes

•Understanding of depression as a systemic illness with a complex interaction of causes and is treatable

•Depressed clients can cause feelings of depression, frustration, anger & hopelessness

•Nurses need to care for themselves as well as the client

health teaching

•Teach client and family that depression is a legitimate illness

•Teach signs & symptoms

•Review medications

•Relaxation techniques

•Appropriate humor

outcome criteria

•Teach client and family that depression is a legitimate illness

•Teach signs & symptoms

•Review medications

•Relaxation techniques

•Appropriate humor