Depressive Disorders

Depressive Disorders

Instructor Details

  • Tony Dharmaraj

  • RN, MSN, Assistant Professor

  • Course: NRSG 217

  • Text: Halter 8th Edition Depressive Disorders

Trigger Warning

  • Discussion on depression and suicide.

  • Acknowledgment that the topic can be triggering.

  • Encouragement for students to take breaks as needed and reach out for further conversation.

Overview of Depressive Disorders

  • Major Depressive Disorder (MDD) with specifiers:

    • With or without psychotic features

  • Other types of depression include:

    • Persistent Depressive Disorder

    • Postpartum Depression

    • Premenstrual Dysphoric Disorder

    • Substance/Medication Induced Depression

    • Depressive Disorder due to another medical condition

Learning Objectives

  • Define the concept of depression.

  • Differentiate between DSM-5 depressive diagnoses and recognize major symptoms.

  • Review the criteria for Major Depressive Disorder based on DSM-5.

  • Discuss signs/symptoms, nursing diagnoses, and expected outcomes for patients with depression.

  • Identify guidelines for communication with severely depressed or self-isolating clients.

  • Review different classes of antidepressant medications:

    • SSRIs, SNRIs, MAOIs, TCAs

  • Discuss serotonin syndrome: risks and causes.

  • Explore Cognitive Behavioral Therapy.

  • Review Electroconvulsive Therapy (ECT).

  • Discuss holistic forms of treatment for depression.

Common Comorbidities

  • Anxiety Disorders (70%)

  • Psychotic Disorders

  • Substance Use Disorders (often as a coping mechanism)

  • Eating Disorders

  • Personality Disorders

  • Noted that these will be addressed in future lectures.

Definition of Depression

  • Often referred to as Major Depressive Disorder (MDD) or clinical depression.

  • Defined as a mood disorder that significantly impacts functioning and is a leading cause of disability (according to ATI Ebook).

  • Affects mood, feelings, and attitudes, resulting in notable changes in normal functioning (social, occupational, self-care).

Risk Factors for Depression

  1. Genetic: Higher chances if a first-degree relative has depression.

  2. Hormonal: Sudden hormonal shifts can trigger depression.

  3. Biochemical: Involvement of neurotransmitters:

    • Serotonin, norepinephrine, and dopamine are critical.

  4. Diathesis-Stress Model: A combination of genetic predisposition and life stressors can trigger depression.

Major Depressive Disorder (Clinical Depression) Diagnosis

  • Must exhibit at least 5 out of 9 symptoms nearly every day for a minimum of 2 weeks, with at least one of the following:

    • Depressed mood

    • Low energy (anergia)

    • Low interest/pleasure in activities (anhedonia)

    • Weight change (5% of body weight over 1 month)

    • Sleep disturbances (insomnia or hypersomnia)

    • Psychomotor agitation or retardation

    • Feelings of worthlessness or guilt

    • Decrease in concentration

    • Thoughts of death or suicide (plans or attempts)

Additional Criteria for Major Depressive Disorder

  • Symptoms must cause impairment in social or occupational functioning.

  • Episode is not attributable to a medical condition.

  • No history of manic or hypomanic episodes (indicative of Bipolar Disorder).

Depression Assessment Criteria

  • Assessment tool: N (SIGE CAPS):

    • S: Sleep disturbances

    • I: Loss of Interest in pleasurable activities

    • G: Feelings of Guilt

    • E: Decreased Energy

    • C: Decreased Concentration

    • A: Changes in Appetite

    • P: Psychomotor functions

    • S: Suicidal ideations.

Postpartum Depression

  • Begins within 4 weeks after childbirth.

  • Safety risks for both mother and baby.

  • Potential causes include hormonal changes (estrogen and progesterone) and lifestyle changes.

  • This condition can also occur in men.

Persistent Depressive Disorder (Dysthymia)

  • Milder form of depression with at least 3 clinical findings.

  • Can evolve into Major Depressive Disorder later in life.

  • Early onset often during childhood or adolescence.

  • Duration: at least 2 years for adults; 1 year for children.

Premenstrual Dysphoric Disorder (PMDD)

  • Linked to the luteal phase of the menstrual cycle (7-10 days before menstruation).

  • Symptoms include mood swings, irritability, depression, anxiety, difficulty concentrating, anergia, sleep disturbances, and physical symptoms like bloating.

  • Impairs daily functioning and interactions.

  • Symptoms generally subside with the onset of menstruation.

  • Prevalence: affects 2-6% of menstruating individuals.

Substance/Medication-Induced Depressive Disorder

  • Depression symptoms tied to substance use or withdrawal.

Seasonal Affective Disorder (SAD)

  • Depressive episodes correlated with seasonal changes, predominantly in winter.

  • Light Therapy is a common treatment, theorized to enhance neurochemicals related to mood.

Client Care for Depression

Acute Phase

  • Severe clinical findings, potential need for inpatient care due to self-harm risk.

  • Goals include:

    • Ensuring client is not a danger to themselves.

    • Supporting participation in self-care.

    • Providing resources for outpatient safety.

Continuation Phase

  • Care focuses on medication and psychotherapy.

  • Goals are aimed at preventing relapse.

Maintenance Phase

  • Aims for remission of symptoms. Focus on preventing future depressive episodes.

  • Important considerations include medication duration, therapy necessity, and coping with inevitable sadness without triggering clinical depression.

Additional Risk Factors

  • Higher incidence in females (ratio 2:1).

  • Age: particularly prevalent in those aged 18-25.

  • Chronic medical conditions with poor prognosis increase risk.

  • Individuals identifying as multiracial are at heightened risk.

  • Older adults (age >65) face increased depression risk as health declines.

Expected Findings for Major Depressive Disorder (MDD)

  1. Anergia

  2. Anhedonia

  3. Anxiety

  4. Psychomotor agitation/retardation

  5. Vegetative symptoms: changes in appetite and bowel habits, sleep disturbances.

Additional Findings

  • Slowed speech and delayed responses.

  • Poor grooming and lack of hygiene.

  • Social isolation due to low energy.

Screening Tools for Depression

  • Hamilton Depression Scale

  • Beck Depression Inventory

  • Geriatric Depression Scales

  • Zung Self-Rating Depression Scale

  • Patient Health Questionnaire-9 (PHQ-9)

Nursing Care for Clients with Depression

  1. Suicide Risk: Regularly assess and implement safety precautions.

  2. Self-Care: Monitor client’s ability to perform activities of daily living (ADLs); encourage participation regardless of their motivation level to foster independence with ADLs.

  3. Communication: Set aside dedicated time with the client:

    • Use concise directions and break tasks into manageable increments to avoid overwhelming the client.

    • Allow sufficient response time to client questions.

Treatment Options

Pharmacological Treatments

  • SSRIs (Selective Serotonin Reuptake Inhibitors)

  • SNRIs (Serotonin Norepinephrine Reuptake Inhibitors)

  • MAOIs (Monoamine Oxidase Inhibitors)

  • TCAs (Tricyclic Antidepressants)

Non-Pharmacological Treatments

  • Dietary modifications

  • Regular exercise

  • Psychotherapy, e.g., Cognitive Behavioral Therapy (CBT)

  • Electroconvulsive Therapy (ECT)

Neurotransmitters Involved in Depression

  • Function: Signaling molecules (dopamine, serotonin, norepinephrine) involved in neuronal communication; critical for regulating mood, attention, sleep, and cognition.

  • The quantity of neurotransmitters in the synaptic cleft is theorized to affect depression symptoms.

Dopamine

  • Impacts attention, motivation, and pleasure.

  • Excess: leads to mania; Deficiency: results in low energy and depression.

Serotonin

  • Regulates sleep, mood, pain perception, temperature, and libido.

  • Deficiency: leads to irritability, sleep issues, loss of appetite; Excess: can result in increased aggression or serotonin syndrome.

Norepinephrine

  • Influences alertness and the "fight or flight" response.

  • Deficiency: brings dullness and low energy; Excess: can result in anxiety and hyper-alertness.

Selective Serotonin Reuptake Inhibitors (SSRIs)

  • First-line treatment for Major Depressive Disorder.

  • Generic names include fluoxetine, sertraline, citalopram.

  • Mechanism of Action: Inhibits serotonin reuptake, increasing availability in the synaptic cleft.

  • Common Side Effects: Gastrointestinal issues (nausea/vomiting), agitation, anxiety, sleep disturbances, sexual dysfunction, headaches.

  • Adverse Effects: Serotonin syndrome and discontinuation syndrome (details will follow).

SSRI Usage Education

  • Expect 4-6 weeks for optimal effects.

  • Improvement often first noted through increased self-care engagement.

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

  • Generic names include duloxetine, venlafaxine.

  • Mechanism of Action: Inhibits reuptake of both serotonin and norepinephrine.

  • Common Side Effects: Similar to SSRIs, generally better tolerated than SSRIs.

  • Adverse Effects: May exacerbate anxiety, cause sweating; caution is advised for patients with hypertension.

Tricyclic Antidepressants (TCAs)

  • Generic name: amitriptyline (Elavil).

  • Mechanism of Action: Inhibits the reuptake of norepinephrine and serotonin.

  • Notably also blocks histamine leading to sedative effects.

TCA Side Effects

  • Contributes to sedation; potential for anticholinergic effects (e.g., dry mouth, constipation).

  • Patient Education: Encourage chewing sugarless gum, consuming high-fiber foods, and increasing hydration to mitigate side effects.

  • Adverse Effects: Serious cardiovascular issues, such as dysrhythmias and tachycardia, especially in older adults and those with cardiac disease.

Monoamine Oxidase Inhibitors (MAOIs)

  • Generic name: Phenelzine (Nardil).

  • Mechanism of Action: Increases serotonin, norepinephrine, and dopamine availability.

  • Common Side Effects: Dry mouth, nausea, diarrhea, constipation, insomnia, drowsiness.

  • Adverse Effects: Risk of hypertensive crisis.

Education for MAOI Patients

  • The need for a tyramine-free diet to avoid hypertensive crises.

  • Foods containing tyramine to avoid: aged cheeses, processed meats, alcoholic beverages, certain bean and soy products, bananas, chocolate, avocados, etc.

Hypertensive Crisis

  • Can occur 15-90 minutes after ingestion of contraindicated foods/substances.

  • Early Signs: Anxiety, flush, severe headache; may escalate to severe fever, seizures, coma.

  • Considered a medical emergency: stop medication and seek immediate help.

Serotonin Syndrome

  • Occurs when combining multiple antidepressants or taking more than prescribed doses.

  • Symptoms may develop within hours of increased serotonin levels: high temperature, excessive sweating, confusion, agitation, dilated pupils, headache, blood pressure changes, rapid heartbeat, nausea, diarrhea.

  • Management: Stop the offending medication and seek immediate medical assistance.

Serotonin Withdrawal Syndrome (not fatal)

  • Symptoms emerge 2-5 days post abrupt cessation of medication.

  • Symptoms include:

    • F: Flu-like symptoms (headache, anxiety)

    • I: Insomnia (with vivid dreams)

    • N: Nausea/vomiting

    • I: Imbalance (vertigo/dizziness)

    • S: Sensory disturbances

    • H: Hyperarousal (anxiety, agitation)

  • Requires a gradual tapering of the medication for safety.

Study Tips for Psychotropics

  • Understand which neurotransmitter is manipulated by each medication.

  • Focus on studying by medication class and recognize differences, unless specified otherwise.

  • Use provided templates for organizing class information effectively.

Treatment Options Recap

Pharmacological

  • SSRIs, SNRIs, MAOIs, TCAs

Non-Pharmacological

  • Diet, Exercise, Psychotherapy (CBT), and ECT.

Exercise as Treatment

  • Releases endorphins and neurotransmitters; may help relax tense muscles.

  • Recommendation: exercise 20 minutes, 3 times per week.

Dietary Recommendations

  • Emphasize less processed foods, more fruits and vegetables, and omega-3 fatty acids (found in fish oil and marine algae).

  • Depressed individuals often have lower levels of DHA and EPA.

Herbal Supplement: St. John's Wort

  • Commonly used to treat depression and anxiety; acts on neurotransmitters.

  • Notes on usage: available over-the-counter in the U.S.; not FDA-approved; risk of serotonin syndrome when combined with other antidepressants.

Light Therapy

  • First-line treatment for Seasonal Affective Disorder (SAD); helps boost mood-related neurotransmitters.

  • Possible side effects include headaches and jitteriness.

Electroconvulsive Therapy (ECT)

  • Indicated for drug-resistant depression.

  • Induces controlled seizures.

  • Safety considerations include the use of anesthetic and paralytic drugs prior to ECT, potential for retrograde amnesia, and fall risk post-procedure.

Cognitive Behavioral Therapy (CBT)

  • Developed by Aaron Beck; focuses on negative thought patterns common in depression.

  • Goal: identify and challenge negative thoughts, replace them with positive and rational thinking.

  • Addresses cognitive distortions leading to misinterpretations and pessimism in patients.