Chapter14/Exam2

Overview of Depressive Disorders

  • General Characteristics: All depressive disorders share a cluster of symptoms, which include:

    • Feelings of sadness, emptiness, and irritability.

    • Somatic concerns, which refer to physical or bodily complaints.

    • Impairment of thinking processes.

  • Functional Impact: These disorders significantly impair an individual's ability to function in daily life.

Classification of Depressive Disorders

  • Major Depressive Disorder (MDD): The most prevalent form of depression.

  • Disruptive Mood Dysregulation Disorder (DMDD): Primarily diagnosed in the pediatric population.

  • Persistent Depressive Disorder: Previously known as dysthymia; characterized by chronic, low-level depression.

  • Premenstrual Dysphoric Disorder (PMDD): Symptoms occurring in the week before menstruation.

  • Substance/Medication-Induced Depressive Disorder: Depression resulting from use or withdrawal of substances.

  • Depressive Disorder due to Another Medical Condition: Resulting from physiological effects of a specific medical illness.

Disruptive Mood Dysregulation Disorder (DMDD)

  • Diagnosis Demographics: Typically diagnosed in children between the ages of 66 and 1818.

  • Key Symptoms:

    • Constant and severe irritability combined with anger.

    • Temper tantrums that are significantly out of proportion to the situation.

    • Tantrum frequency must occur at least 3× week−13 \times \text{ week}^{-1}.

  • Symptom Presence: Symptoms must be exhibited in at least two of the following settings: home, school, and with peers.

  • Management Strategies:

    • Symptomatic medications.

    • Cognitive Behavioral Therapy (CBT).

    • Parent training.

    • Facial expression recognition training.

Depression Symptoms Across the Lifespan

Childhood Depression

  • Ages < 3: Feeding problems, frequent tantrums, lack of playfulness, and lack of emotional expressiveness.

  • Ages 3 to 5: Proneness to accidents, development of phobias, and excessive self-reproach.

  • Ages 6 to 8: Physical (somatic) complaints, aggressive behavior, and clinging behavior.

  • Ages 9 to 12: Morbid thoughts and excessive worrying.

  • Precipitating Factors: Often precipitated by a loss.

  • Therapeutic Focus: Alleviation of symptoms and strengthening of coping skills, alongside parental and family therapy.

Adolescent Depression

  • Symptoms: Anger, aggressiveness, running away from home, delinquency, social withdrawal, sexual acting out, substance abuse, restlessness, and apathy.

  • Clinical Differentiation: The best clue to differentiate depression from normal "stormy" adolescent behavior is a visible manifestation of behavioral change that persists for several weeks.

  • Suicide Precipitants: The most common trigger for adolescent suicide is the perception of abandonment by parents or a close peer relationship.

Senescence (Biological Aging)

  • Bereavement Overload: The cumulative impact of multiple losses in the elderly.

  • High Risk: There is a high percentage of suicides among the elderly population.

  • Diagnostic Challenges: Symptoms of depression are often confused with symptoms of neurocognitive disorders (e.g., dementia).

  • Treatment Modalities: Antidepressant medication, Electroconvulsive therapy (ECT), and psychosocial therapies.

Persistent Depressive Disorder (Dysthymia)

  • Definition: Low-level depressive feelings occurring through most of each day, for the majority of days.

  • Duration Requirements:

    • Adults: At least 2 years2\,\text{years}.

    • Children and Adolescents: At least 1 year1\,\text{year}.

  • Diagnostic Criteria: Must include at least two of the following:

    • Decreased appetite or overeating.

    • Insomnia (difficulty sleeping) or hypersomnia (excessive sleeping).

    • Low energy or fatigue.

    • Poor self-esteem.

    • Difficulty thinking or concentrating.

    • Feelings of hopelessness.

Specific Depressive Subtypes

Premenstrual Dysphoric Disorder (PMDD)

  • Timing: A cluster of symptoms occurring in the last week prior to the onset of a woman's period.

  • Symptom Cluster: Includes mood swings, irritability, depression, anxiety, feeling overwhelmed, and difficulty concentrating.

  • Resolution: Symptoms decrease significantly or disappear entirely with the onset of menstruation.

Postpartum Depression

  • Duration: May last for a few weeks to several months.

  • Etiology: Associated with hormonal changes, tryptophan metabolism, or cell alterations.

  • Symptoms: Fatigue, irritability, loss of appetite, sleep disturbances, loss of libido, and significant concern about the inability to care for the infant.

  • Treatment: Antidepressants and psychosocial therapies.

Substance-Induced and Medical Condition Depression

  • Substance-Induced: The person experiences depressive symptoms only in the presence of drug/alcohol use or withdrawal; symptoms are absent otherwise.

  • Due to Medical Conditions: Depression associated with Cerebrovascular Accident (CVA), Parkinson’s disease, Huntington’s disease, Alzheimer’s disease, Traumatic Brain Injury (TBI), Cushing’s disease, hypothyroidism, arthritis, back pain, metabolic conditions, HIV, diabetes, infection, cancer, and autoimmune problems.

Major Depressive Disorder (MDD)

  • Diagnostic Criteria: Presence of five (or more) of the following symptoms during a 2-week2\text{-week} period:

    • Weight and appetite changes.

    • Sleep disturbances.

    • Fatigue.

    • Feelings of worthlessness or guilt.

    • Loss of ability to concentrate.

    • Recurrent thoughts of death.

    • Psychomotor agitation.

  • Mandatory Symptoms: At least one of the symptoms must be either:

    • Depressed mood.

    • Loss of interest or pleasure (Anhedonia).

  • Timeline and Severity:

    • Minimum duration for a standard episode: 2 weeks2\,\text{weeks} to 6 months6\,\text{months}.

    • Chronic MDD: Lasting more than 2 years2\,\text{years}.

    • Recurrent episodes are common.

  • Exclusions: Symptoms must cause distress or impaired function; episodes cannot be attributed to physiological effects of a substance or another medical condition; there must be an absolute absence of manic or hypomanic episodes.

Epidemiology and Risk Factors

  • Epidemiology: MDD is the leading cause of disability in the United States, affecting children, adolescents, and older adults.

  • Comorbidity: A combination of anxiety and depression is one of the most common clinical presentations.

  • Biological Risk Factors:

    • Genetic: Increased risk among first-degree family members.

    • Biochemical findings.

    • Stressful life events.

    • Hormonal and inflammatory factors.

  • Diathesis-Stress Model: Focuses on the interplay between genetic/biological vulnerabilities and environmental stress.

  • Other Risk Factors: Female gender, adverse childhood experiences, neuroticism, other mental disorders (substance use, anxiety, personality disorders), and chronic/disabling medical conditions.

Nursing Process: Assessment

  • Assessment Areas:

    • Suicidality: Always the priority.

    • Behavior/Affect: Checking for Anergia (lack of energy).

    • Mood: Depressed mood and Anhedonia (inability to feel pleasure).

    • Emotions: Anxiety, worthlessness, hopelessness, guilt, anger, and helplessness.

    • Thoughts/Perceptions: Monitoring for delusions and/or hallucinations.

    • Comorbidity: Assessing for chronic pain.

  • Self-Assessment for Nurses: Nurses should recognize that patients may reject advice or encouragement. Nurses must recognize unrealistic expectations for themselves, identify countertransference feelings, and understand the biological/genetic roles in MDD.

Nursing Process: Diagnosis and Planning

  • Nursing Diagnoses:

    • Risk for suicide (Highest priority/safety).

    • Chronic low self-esteem.

    • Imbalanced nutrition.

    • Constipation.

    • Disturbed sleep pattern.

    • Ineffective coping.

    • Disabled family coping.

  • Outcomes Identification: Utilization of the Recovery Model, focusing on patient strengths and mutually developed goals based on personal needs and values.

  • Implementation Phases:

    • Acute Phase: 6 to 12 weeks6\,\text{to } 12\,\text{weeks}.

    • Continuation Phase: 4 to 9 months4\,\text{to } 9\,\text{months}.

    • Maintenance Phase: 1 year1\,\text{year} or more.

Communication Techniques for Depressed Patients

  • General Strategies: Use simple, concrete words; allow sufficient time for a response; listen for covert messages; ask directly about suicide plans; avoid platitudes.

  • Techniques for Silent Patients: Make observations to reinforce reality and avoid using direct questions.

  • Evaluation: Tailored to the patient; focuses on self-care, thought processes, self-esteem, and social interactions.

Biological Treatment: Pharmacotherapy

  • Antidepressant Selection Factors: Symptom profile, side-effect profile (e.g., weight gain, sexual dysfunction), ease of administration, past response history, and safety considerations.

  • Drug Classes:

    • Selective Serotonin Reuptake Inhibitors (SSRIs): First-line therapy; requires monitoring for rare risk of Serotonin Syndrome.

    • Serotonin Norepinephrine Reuptake Inhibitors (SNRIs): Alternative to SSRIs; SSRIs may be better tolerated by some.

    • Tricyclic Antidepressants (TCAs): Known for anticholinergic adverse reactions.

    • Monoamine Oxidase Inhibitors (MAOIs): Effective for unconventional depression.

  • Newer Antidepressants:

    • Serotonin Antagonists and Reuptake Inhibitors (SARIs).

    • Norepinephrine Dopamine Reuptake Inhibitor (NDRI).

    • Noradrenergic and Specific Serotonergic Antidepressant (NaSSA).

  • Novel Medications:

    • Esketamine: An N-methyl-D-aspartate (NMDA) receptor antagonist.

    • Brexanolone (Zulresso): The first and only FDA-approved medication specifically for postpartum depression.

Brain Stimulation and Other Therapies

  • St. John’s Wort: Herbal treatment thought to increase serotonin, norepinephrine, and dopamine; useful for mild to moderate depression.

  • Electroconvulsive Therapy (ECT):

    • Considered the most effective treatment for depression.

    • Indications: Severe malnutrition/exhaustion/dehydration, delusional depression, medication failure, or schizophrenia with catatonia.

    • Procedure: Includes short-acting anesthetic and muscle relaxants. Mechanism involves increasing biogenic amines.

    • Side Effects: Temporary memory loss and confusion.

  • Repetitive Transcranial Magnetic Stimulation (rTMS):

    • Noninvasive; uses MRI-strength magnetic pulses to stimulate the cerebral cortex.

    • Contraindication: Presence of metal in the body.

    • Side Effects: Headache, lightheadedness, and scalp tingling.

  • Vagus Nerve Stimulation (VNS):

    • Electrical stimulation to boost neurotransmitters.

    • Side Effects: Voice alteration (approx. 60% of patients60\%\,\text{of patients}), neck pain, and dyspnea (shortness of breath).

  • Deep Brain Stimulation (DBS): Surgically implanted electrodes placed directly into underactive brain regions; more invasive than VNS.

  • Bright Light Therapy: First-line for Seasonal Affective Disorder (SAD). Mimics outdoor light to influence melatonin. Side effects include headache and jitteriness.

  • Exercise: Increases serotonin availability and dampens the HPA axis (Hypothalamic-Pituitary-Adrenal axis), which is often overactive in depression.

Advanced Practice Interventions

  • Psychological Therapies: Cognitive-Behavioral Therapy (CBT), Interpersonal Therapy (IPT), Time-limited focused psychotherapy, and Behavior therapy.

  • Group Therapy: Provided in clinical settings.

Questions & Discussion

  • Question: Which question would be a priority when assessing for symptoms of major depression?

    • Answer: "You look really sad. Have you ever thought of harming yourself?" (Prioritizing safety/suicidality).

  • Question: Jeff was just diagnosed with a major depressive disorder. Which medication is the health care provider most likely to start the patient on?

    • Answer: SSRI (First-line therapy).

  • Question: A patient with major depression walks and moves slowly. Which term should the nurse use to document this finding?

    • Answer: Psychomotor retardation.

  • Question: Which assessment finding in a patient with major depression represents a vegetative sign?

    • Answer: Hypersomnia (Vegetative signs involve basic physiological functions like sleep, appetite, and elimination).