Chapter 13: Depressive Disorders

Chapter 13: Depressive Disorders

Depression = mood (affective) disorder

Widespread issue, ranks high among causes of disability

Suicide Risk in Clients with Depression

• Increased risk if any of the following are present:

  • Family or personal history of suicide attempts

  • Comorbid anxiety disorder or panic attacks

  • Comorbid substance use disorder or psychosis

  • Poor self-esteem

  • Lack of social support

  • Chronic medical condition

(Rationale: These factors worsen prognosis and increase suicide vulnerability.)

Prognosis vs Diagnosis

Prediction of the course of a disease, including treatments and results

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The identification of a disease

Common Comorbidities with Depressive Disorders

Anxiety Disorders

• Present in ~70% of clients with depression

• Worsens prognosis (↑ suicide risk, ↑ disability)

Psychotic Disorders

• Example: Schizophrenia

Substance Use Disorders

• Often used to self-medicate or relieve depressive symptoms

• Leads to worsening of overall mental health

Eating Disorders

Personality Disorders

Depressive Disorders Recognized by the DSM-5-TR

Major Depressive Disorder (MDD)

• Single or recurrent episodes of unipolar depression (not mania)

• Must include ≥ 5 symptoms for ≥ 2 weeks, nearly every day, most of the day:

  • Depressed mood

  • Sleep disturbance (insomnia or hypersomnia)

  • Indecisiveness

  • Decreased concentration

  • Suicidal ideation

  • Psychomotor changes (↑ or ↓ activity)

  • Anhedonia (inability to feel pleasure)

  • Weight change (>5% in 1 month, ↑ or ↓)

Specifiers (DSM-5-TR):

• Psychotic features – hallucinations/delusions (e.g., voices, belief in fatal illness)

• Postpartum onset – within 4 weeks of childbirth, may include delusions → risk of harm to infant

Seasonal Affective Disorder (SAD)

• Depression that occurs seasonally (commonly in winter due to less daylight)

• First-line treatment: Light therapy

Persistent Depressive Disorder (Dysthymia)

• Milder form of depression, early onset (childhood/adolescence)

• Duration: ≥ 2 years in adults, ≥ 1 year in children

• At least 3 depressive symptoms

• May progress into major depressive disorder

Premenstrual Dysphoric Disorder (PMDD)

• Depression associated with luteal phase of menstrual cycle

• Prevalence: 2–6% of menstruating clients

• Symptoms: severe mood swings, irritability, anxiety, depression, poor concentration, fatigue, overeating, hypersomnia/insomnia, breast tenderness, bloating, weight gain

• Treatment: Exercise, diet changes, relaxation therapy

Substance/Medication-Induced Depressive Disorder

• Depression caused by substance use or withdrawal (e.g., alcohol, drugs, toxins, medications)

Client Care for Major Depressive Disorder (MDD)

(Mirrors the phase of the client’s disease)

Acute Phase

• Duration: 6–12 weeks

• May require hospitalization

• Goal: Reduce depressive symptoms

• Nursing: Assess suicide risk, implement safety precautions (including 1:1 observation if needed)

Continuation Phase

• Duration: 4–9 months

• Goal: Prevent relapse

• Methods: Education, medication therapy, psychotherapy

Maintenance Phase

• Duration: Can last for years

• Goal: Prevent future depressive episodes

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

a

“Care during the continuation phase focuses on treating continued manifestations of MDD.”

b

“The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks.”

c

“The client is at greatest risk for suicide during the first weeks of an MDD episode.”

d

“Medication and psychotherapy are most effective during the acute phase of MDD.”

c “The client is at greatest risk for suicide during the first weeks of an MDD episode.”

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The focus of the continuation phase is relapse prevention.

Treatment of manifestations occurs during the acute phase of MDD. The maintenance phase of treatment for MDD can last for 1 year or more.

Medication therapy and psychotherapy are used during the continuation phase to prevent relapse of MDD.

Depressive Disorders Risk Factors

Most significant: Family history & personal history of depression

Gender: Twice as common in females

Age: Common in clients >65 (can mimic dementia → memory loss, confusion, agitation)

Neurotransmitter imbalances:

• ↓ Serotonin → affects mood, sleep, sexual behavior, appetite, pain perception

• ↓ Norepinephrine → affects attention & behavior

• Other neurotransmitters: dopamine, acetylcholine, GABA, glutamate

Other Risk Factors

• Stressful life events

• Medical illness

• Postpartum period

• Comorbid anxiety or personality disorder

• Comorbid substance use disorder

• Early-life trauma

Depressive Disorders Expected Findings

Anergia (low energy)

Anhedonia (loss of pleasure)

Anxiety

Sluggishness (most common) or inability to relax

Vegetative signs:

• Eating changes (↓ appetite in MDD, ↑ in dysthymia/PMDD)

• Bowel changes (constipation common)

• Sleep disturbances

• ↓ sexual interest

Somatic complaints: fatigue, GI changes, pain

Physical Assessment Findings

• Sad appearance with blunted affect

• Poor grooming, poor hygiene

• Psychomotor retardation (slowed movement, slumped posture)

• May also show psychomotor agitation (restlessness, pacing, tapping)

• Social isolation, little/no interaction

• Speech changes: slowed, minimal, delayed responses, sighing

Depressive Disorders Screening Tools

Hamilton Depression Scale

Beck Depression Inventory

Geriatric Depression Scale (short form)

Zung Self-Rating Depression Scale

Patient Health Questionnaire-9 (PHQ-9)

A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression?

Select all that apply.

a

Male sex

b

History of chronic bronchitis

c

Recent death in client’s family

d

Family history of depression

e

Personal history of panic disorder

b History of chronic bronchitis

c Recent death in client’s family

d Family history of depression

e Personal history of panic disorder

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Females are twice as likely as males to experience a depressive disorder.

A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect?

a

Wide fluctuations in mood

b

Report of a minimum of five clinical findings of depression

c

Presence of manifestations for at least 2 years

d

Inflated sense of self-esteem

c Presence of manifestations for at least 2 years

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Wide fluctuations in mood are associated with bipolar disorder.

MDD contains a minimum of five clinical findings of depression.

A decreased, rather than inflated, sense of self-esteem is associated with persistent depressive disorder.

Depressive Disorders Patient-Centered Care

Milieu Therapy

• Suicide risk: Assess and implement safety precautions

• Self-care: Monitor ADLs, encourage independence

• Communication strategies:

  • Spend time with client, even if they don’t speak

  • Use observations instead of direct questions (↓ anxiety)

    • Example: “I noticed you attended group today” vs. “Did you enjoy group?”

  • Use short, simple, concrete directions (client may struggle to focus/comprehend)

  • Allow extra time for responses (delayed processing common)

Maintenance of a Safe Environment

• Provide structured, supportive, therapeutic environment

Counseling – Focus Areas

• Problem-solving skills

• Coping abilities

• Cognitive restructuring (change negative → positive thinking)

• Self-esteem building

• Assertiveness training

• Use of community resources

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse’s priority?

a

Placing the client on one-to-one observation

b

Assisting the client to perform ADLs

c

Encouraging the client to participate in counseling

d

Teaching the client about medication adverse effects

a Placing the client on one-to-one observation

The greatest risk for a client who has MDD and comorbid anxiety is injury due to self-harm.

Depressive Disorders Psychopharmacological Therapies (STaMiNa)

General Teaching for All Antidepressants

• Do not discontinue suddenly (risk of withdrawal)

• Therapeutic effect = delayed, may take weeks

• Avoid hazardous activities (sedation risk)

• Report suicidal thoughts immediately

• Avoid alcohol while on antidepressants

Tricyclic Antidepressants (TCA)

Example: Amitriptyline

• Change positions slowly (↓ orthostatic hypotension risk)

• Reduce anticholinergic effects: chew sugarless gum, eat high-fiber foods, ↑ fluids (2–3 L/day)

Monoamine Oxidase Inhibitors (MAOI)

Example: Phenelzine

• Avoid tyramine foods (risk of hypertensive crisis) → ripe avocados, figs, fermented/smoked meats, liver, aged cheese, some beer/wine, protein supplements

• Avoid all other meds (OTC, herbal, etc.) unless cleared by provider (drug interaction risk)

Atypical Antidepressants

Example: Bupropion

• Monitor for: headache, dry mouth, GI distress, constipation, ↑ HR, nausea, restlessness, insomnia

• Notify provider if adverse effects become intolerable

• Monitor food intake/weight (appetite suppression possible)

• Contraindicated in clients with seizure risk

SSRIs (Selective serotonin reuptake inhibitors): Paroxetine, Sertraline, Fluoxetine, Escitalopram, Fluvoxamine

SNRI (Serotonin norepinephrine reuptake inhibitor): Venlafaxine

Antidepressants (STaMiNA)

Antidepressants enhance my STAMINA

• S

  • SSRIs (Selective serotonin reuptake inhibitors): Paroxetine, Sertraline, Fluoxetine, Escitalopram, Fluvoxamine

  • SNRI (Serotonin norepinephrine reuptake inhibitor): Venlafaxine

• T

  • Tricyclic antidepressants: Amitriptyline, Imipramine

• M

  • MAOI (Monoamine oxidase inhibitor): Phenelzine

• N

  • NaSSA (Noradrenergic & specific serotonergic antidepressant): Mirtazapine

• A

  • Atypical Antidepressants (Bupropion)

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Taper

Takes weeks for full effects

No ETOH or hazards (sedation risk)

Report suicidal thoughts

Nursing Evaluation of Medication Effectiveness (All Antidepressants)

Less anxiety, improved mood, improved memory

Normal sleep pattern

Improved participation in social & occupational activities

Better coping with stressors

Ability to perform ADLs

Increased well-being

Depression Disorders Alternative or Complementary Therapies

St. John’s Wort

• Herbal product (not FDA regulated), sometimes used for mild depression

• Adverse effects: photosensitivity, skin rash, rapid HR, GI distress, abdominal pain

• Interactions:

  • Alters metabolism of many medications

  • Can cause serotonin syndrome if taken with SSRIs or other antidepressants

  • Avoid foods with tyramine

Light Therapy

• First-line for Seasonal Affective Disorder (SAD)

• Inhibits nocturnal melatonin secretion

• Exposure: face to 10,000-lux light box, 30 min/day (once or split into 2 doses)

Therapeutic Procedures

• Electroconvulsive Therapy (ECT):

  • Used for clients unresponsive to other treatments

  • Requires monitoring before and after by trained nurse

• Transcranial Magnetic Stimulation (TMS):

  • Uses MRI-strength magnetic pulses to stimulate focal brain areas

  • For treatment-resistant depression

• Vagus Nerve Stimulation (VNS):

  • Implanted device stimulates vagus nerve

  • For resistant depression

• Deep Brain Stimulation (DBS):

  • Electrodes implanted in brain to stimulate underactive regions

  • Reserved for clients who failed multiple other therapies

  • Requires postoperative nursing care

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Interprofessional Care

• Cognitive-Behavioral Therapy (CBT): Identifies & changes negative thoughts/behaviors

• Interpersonal Therapy (IPT): Improves personal relationships contributing to depression

• Other supports: group therapy, family therapy

Client Education

• Continuation → Maintenance phase:

  • Review symptoms & relapse warning signs with client/family

  • Reinforce adherence to medication & therapy

  • 30 minutes of exercise 3–5x/week improves symptoms and prevents relapse

  • Even short exercise intervals can be beneficial (adjunct therapy for MDD)

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine Which of the following findings should the nurse report to the provider as indications of serotonin syndrome?

Select all that apply.

a

Hypothermia

b

Hallucinations

c

Muscular flaccidity

d

Diaphoresis

e

Agitation

b Hallucinations

d Diaphoresis

e Agitation

Selective Serotonin Reuptake Inhibitors (SSRIs) (-xetine, -pram) Action / Use

Inhibit serotonin reuptake → more serotonin remains at junction of neurons.

Do not block dopamine or norepinephrine uptake.

Can cause CNS stimulation (e.g., insomnia).

Long half-life → takes up to 4 weeks for therapeutic effect.

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General

• First-line treatment for panic disorder and trauma-/stressor-related disorders.

Paroxetine

• GAD

• Panic disorder (reduces frequency/intensity of attacks; prevents anticipatory anxiety)

• OCD (reduces serotonin-driven obsessions/compulsions)

• Social anxiety disorder

• PTSD

• Depressive disorders

• Adjustment disorders

• Associated dissociative disorder manifestations

Sertraline

• Panic disorder, OCD, social anxiety disorder, PTSD

Citalopram

• Panic disorder, OCD, GAD, PTSD, social anxiety disorder

Escitalopram

• GAD, OCD, panic disorder, PTSD, social anxiety disorder

Fluoxetine

• Panic disorder, social anxiety disorder, OCD, PTSD

Fluvoxamine

• OCD, GAD, social anxiety disorder, PTSD

Selective Serotonin Reuptake Inhibitors (SSRIs) (-xetine, -pram) Contraindications / Compllications

Pregnancy: Paroxetine = Category D (others lower risk).

Contraindicated with MAOIs or TCAs.

Avoid alcohol use while on SSRIs.

Use cautiously in clients with:

• Liver/renal dysfunction

• Seizure disorders

• GI bleeding history

Use cautiously in bipolar disorder (risk of mania).

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Early Adverse Effects

• First few days/weeks: Nausea, diaphoresis, tremor, fatigue, drowsiness.

• Client Education:

  • Report adverse effects.

  • Take as prescribed.

  • Usually subside.

  • Avoid driving if sedation occurs.

Later Adverse Effects

• After 5–6 weeks: Sexual dysfunction (impotence, delayed/absent orgasm, decreased libido), weight gain, headache.

• Client Education: Report sexual dysfunction (may be managed with dose changes, drug holidays, or switching meds).

Weight Changes

• Weight loss early → weight gain with long-term therapy.

• Nursing Actions: Monitor weight.

• Client Education: Balanced diet, regular exercise.

Gastrointestinal Bleeding

• Risk ↑ with history of GI bleed, ulcers, or anticoagulant use.

• Client Education: Report GI bleeding signs (dark stools, coffee-ground emesis).

Hyponatremia

• Likely in older adults taking diuretics

Serotonin Syndrome (2–72 hrs after start; can be lethal)

• Confusion, agitation, poor concentration, hostility

• Disorientation, hallucinations, delirium

• Seizures → status epilepticus

• Tachycardia → CV shock

• Labile BP

• Diaphoresis

• Fever → hyperpyrexia

• Incoordination, hyperreflexia

• Nausea, vomiting, diarrhea, abdominal pain

• Coma, death (severe cases)

Client Education: Observe for symptoms; withhold medication and notify provider immediately.

Bruxism

• Grinding/clenching teeth (usually during sleep).

• Nursing Actions:

  • Report to provider (may change med class).

  • Treat with buspirone or mouth guard.

Withdrawal Syndrome

• Sensory disturbances, anxiety, tremor, malaise, unease.

• Client Education:

  • Taper slowly; avoid abrupt discontinuation.

Until I reached a point in my life where like oh you and I are nurse want to help you OK this is something that I can cause the girl was talking the same hobbies same hobbies and same upbringing is not no it’s work all

SNRI vs SSRI Complications

Headache, nausea, agitation, anxiety, dry mouth, sleep disturbances

Hyponatremia (esp. older adults on diuretics)

Anorexia / Weight loss

Hypertension

Sexual dysfunction

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First few days/weeks: Nausea, diaphoresis, tremor, fatigue, drowsiness.

After 5–6 weeks: Sexual dysfunction (impotence, delayed/absent orgasm, decreased libido), weight gain, headache.

• Weight loss early → weight gain with long-term therapy.

GI Bleed

Hyponatremia (esp. older adults on diuretics)

Serotonin Syndrome (2-72 hrs after start, lethal)

Bruxism (teeth grinding/clenching)

Withdrawal (Taper)

Selective Serotonin Reuptake Inhibitors (SSRIs) (-xetine, -pram) Interactions / Admin

TCAs, MAOIs, St. John’s Wort → ↑ risk of serotonin syndrome.

• Discontinue MAOIs 14 days before starting SSRI.

• Discontinue fluoxetine 5 weeks before starting MAOI.

• Avoid concurrent TCA/St. John’s Wort use.

Warfarin → displacement → ↑ bleeding risk.

• Nursing Actions: Monitor PT/INR, assess for bleeding, dosage adjustment may be needed.

TCAs + Lithium → ↑ levels of both.

• Client Education: Avoid concurrent use.

NSAIDs + Anticoagulants → ↑ bleeding risk (platelet suppression).

• Client Education: Monitor for bleeding (bruising, hematuria), notify provider.

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Take with food to minimize GI upset.

Take in morning to reduce sleep disturbances.

Daily dosing required to establish plasma levels.

May take up to 4 weeks to achieve therapeutic effects.

Selective Serotonin Reuptake Inhibitors (SSRIs) Meds

Prototype Medication

• Paroxetine

Other Medications

• Sertraline

• Citalopram

• Escitalopram

• Fluoxetine

• Fluvoxamine

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) (-loxetine, -faxine) Action / Use

Inhibit reuptake of serotonin and norepinephrine (minimal dopamine inhibition).

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Major depression

Panic disorder

Generalized anxiety disorder (GAD)

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) (-loxetine, -faxine) Contraindications / Complications

Pregnancy Risk: Category C.

Contraindicated with MAOIs.

Duloxetine contraindicated in hepatic disease or heavy alcohol use.

Client Education

• Avoid abrupt discontinuation.

• Avoid alcohol.

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Headache, nausea, agitation, anxiety, dry mouth, sleep disturbances

Hyponatremia (esp. older adults on diuretics)

• Nursing Action: Monitor sodium levels.

Anorexia / Weight loss

• Nursing Action: Monitor weight.

• Client Education: Maintain balanced diet, exercise.

Hypertension

• Nursing Action: Monitor blood pressure.

Sexual dysfunction

• Nursing Action: Report issues (can manage with dose change, med holiday, or switching meds).

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) (-loxetine, -faxine) Interactions / Admin

MAOIs & St. John’s Wort → risk of serotonin syndrome.

• Nursing Action: Discontinue MAOIs 14 days before starting SNRI.

• Client Education: Avoid St. John’s Wort.

CNS Depressants (alcohol, opioids, antihistamines, sedatives/hypnotics) → ↑ CNS depression.

• Nursing Action: Avoid concurrent use.

NSAIDs & Anticoagulants → ↑ risk of bleeding.

• Client Education: Monitor for bleeding (bruising, hematuria), notify provider.

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Duloxetine contraindicated in hepatic disease or heavy alcohol use.

Client Education:

• Avoid abrupt cessation.

• May take with food.

• Take daily to maintain therapeutic plasma levels.

• Takes up to 4 weeks for therapeutic effect.

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) Meds

Prototype Medication

• Venlafaxine

Other Medication

• Duloxetine