Chapter 14

Depressive Disorders

Disruptive Mood Dysregulation Disorder

• Constant and severe irritability and anger

• Individuals between the ages of 6-18 with an onset before age 10

• Temper tantrums with verbal/behavioral outbursts out of proportion to the situation occur at least 3 times per week

• Can maintain control in certain settings, but need to exhibit symptoms in at least two settings — school, home, w/ peers

• 0.8-3.3%, more common in males, and more common in children than teens

• Management is symptomatic and problem-focused; antidepressants may be used; CBT, parent training

Persistent Depressive Disorder

• formerly dysthymia

• Low-level depression occurs most of the day, for the majority of days

• Depressive feelings last at least 2 years in adults and 1 year for kids/teens

• At least two of the following: decreased appetitie, overeating, insomnia, hypersomnia, low energy, poor self-esteem, difficulty thinking, hopelessness

• Social & occupational distress

• Onset usually in teenage years

• 1.5-3.3%, more common among women; 50% go undiagnosed

• psychotherapy, CBT, SSRIs, SNRIs, TCAs

Premenstural Dysphoric Disorder

• A cluster of symptoms that occur in the last week before ethe onset of a woman’s period

• Causes problems severe enought to interfere with the ability to work or itneract with others

• Mood swings, irritability, depression, anxiety, feeling overwhelmend, difficulty concentratiing

• Phsyical: lack of energy, overeating, hypersomnia or insomnia, breast tenderness, bloating, weight gain

• Symptoms decrease significantly or disappear with onset of menstruation

• 2-6% of mensturating women

• Symptoms cease after meonpause, may return with HRT

• Regular exercise, good diet, sufficient sleep, acupuncture, light therapy, relaxation therapy, SSRIs, diuretics

Substance/Medication-Induced Depressive Disorder

• Result of prolonged use of or withdrawal from drugs / alcohol

• Depressive symptoms last longer that the expected length of physiological effects, intoxication or withdrawal of the substance

• Would not experience depressive symptoms in the absence of durg or alcohol use or withdrawal

• Symptoms appear within 1 month of use — once substance is removed, depressive symptoms usually last a few days - several weeks

• 0.25%

• Medications associated with this disorder inclue antiviral, cardiovascular, retinoic acid derivatives, antidepressants, anticonvulsants, anti migraine, antipsychotics, hormonal agents, smoking cessation agents and immunological agents

Depressive Disorder due to Another Medical Condition

• May be caused by disorders that affet the body’s systems or from long-term illnesses that cause ongoing pain

• Strokes, Parkinson's disease, Huntington's disease, alzheimer's disease, TBI, Cushing disease, hypothyroidism, HIV, DM, cancer, infection & autoimmune problems are clearly associated or often linked with depressive disorders

Major Depressive Disorder

• One of the most common psychiatric disorders — 7% of the population

• Characterized by a persistently depressed mood lasting for a minimum of 2 weeks

• Other symptoms: markedly diminished interest or pleasure in all or some activities, significant weight loss or gain, insomnia or hypersomnia nearly every day, psychomotor agitation, fatigue, feeling of worthlessness, diminished thinking & concentration, recurrent thoughts of death & suicidal ideation

• Never been a manic or hypomanic episode

• Length of depressive episode may be 5-6 months

• About 20% of cases become chronic (last more than 2 years)

• People experience recurrent episodes 50% of the time within the first year and 85% within their lifetime

Bereavement Exclusion

• Clinicians were once advised against diagnosing a person with depression in the first 2 months following a significant loss

• Rationale follows: normal mourning could be labeled pathological, a psychiatric diagnosis could result in a lifelong label; unnecessary medications might be prescribed

• Now, according to the DSM-5 a diagnosis of MDD can now be given in the first 2 months following the death of a one or other loss — delaying treatment can adversly affect prognosis

Comorbidities

• A depressive syndrome fequently accompanies other psychiatric problems

  • Schizophrenia, substance use, eating disorders, schizoaffective disorder, and borderline personality disorder

• Combination of anxiety & depression is one of the most common pscyhiatric presentation

Risk Factors for Depressive Disorders

• Female gender

• Adverse childhood experiences

• Stressful life events

• first-degree family members with MDD

• Neuroticism

• Other comorbid disorders

• Chronic or disabling medical conditions

• Biochemical (NT — serotonin & norepi) deficiencies

Anergia

• An abnormal lack of energy

• May result in psychomotor retardation (movements are extremely slow, facial expressions are decreased, gaze is fixed)

Anhedonia

• Inability to feel pleasure or absence of happiness in aspects of life that once made the person happy

• Social: disinterest in interaction with others — isolation

• Phsyical: inability to experience physical pleausres — eating, touching, sex

Vegetative Signs of Depression

• Alterations in thsoe activites necessary to support phsyical life & growth

• Eating, elimination, sleeping & sex

Affect

• Outward representation of a person’s internal state and is an objective finding based on the nurse’s assessment

• Feelings of hopelessness and despair are reflected in the person’s affect

• Congruent or incongruent with mood

• Types:

  • Constricted: reduction in the range and intensity of normal expression

  • Blunted (shallow): more severe than constricted and represents a significant decrease in emotional reactivity

  • Flat: no or nearly no emotional expression or reactivity

Poverty of Thought

• Thinking that is so severely impacted

• Responses may be slow or absent

• Repeat questions or comments in order to prompt a respoonse

Medications

• SSRIs: increase serotonin levels

• SNRIs: increase serotonin & norepinephrine levels

• Esketamine (ketamine): new, NMDA receptor antagonist, approved for treatment-resistant depression — Schedule III drug

• SARIs: serotonin antagonists and reuptake inhibitors

• NDRI: norepinephrine dopamine reuptake inhibitors

• Noradrengergic and Specific Serotnergic Antidepressant (NaSSA)

• Tricycyclic Antidepressants (TCAs)

• Brexanolone (Zulresso): first and only FDA-approved medication specifically for postpartum depression (Schedule IV), neuroactive steroid, influences GABA-A receptors, admin over a 60 hr (2.5 day) IV inufsion

Serotonin Syndrome

• Rare & life-threatening event associated with SSRIs

• thought to be related to overactivation of the central serotonin receptors caused by either too high a dose or interactions with other drugs

• ab pain, d, sweating, fever, tachy, HTN, delirium, myoclonus, increased motor activity, irritability, hostility, mood change

• Severe: hyperpyrexia, cardiovascular shock, death

• risk high when SSRI given with a MAOI (also a serotonin enhancing agent)

Brain Stimulation Therapies

• Electroconvulsive Therapy (ECT): highly effective somatic treatment, two or three treatments per week

• Repetitive Transcranial Magnetic Stimulation (rTMS): noninvasive treatment modality, MRI-strength magnetic pulses to stimulate focal areas of the cerebral cortex, mildly treatment-resistant depression, 5 days a week for 4-6 weeks

• Vagus Nerve Stimulation (VNS): pacemaker-like device is implanted surgically into the left chest wall, delivers pulses for 30 seconds every 5 minutes, 24 hours a day, takes several weeks to work

• Deep Brain Stimulation (DBS): treatment whereby electrodes are surgically implanted into specific areas of the brain to stimulate those regions identified as underactive in depression; invasive but reversible; Parkinson’s, MDD, treatment-resistant OCD

Light Therapty

• first-line treatment for SAD (subtype of MDD “with seasonal patterns” +)

• Influence of light on melatonin — maintains and shifts biological rhythms, exposure to light suppresses the nocturnal secretion of melatonin — therapeutic effect

• 30-35 minutes of exposure daily to a 10,000 lux light source w/ morning exposure the best