Mood Disorders –

Depression
 Introduction

• Depression is the oldest and most frequently

described psychiatric illness.

• Transient symptoms are normal, healthy responses to

everyday disappointments in life.

• Pathological depression occurs when adaptation is

ineffective.
 Epidemiology

• Approximately 9.5 million persons reported a

depressive episode in 2008.
• During their lifetime, about 21% of women and
13% of men will become clinically depressed.
• Gender prevalence
• Depression is more prevalent in women than in men by
about 2 to 1.
• Age
• Depression more common in young women than young
men.

• The gender difference is less pronounced between ages

44 and 65, but after age 65, women are again more likely
to be depressed than men.
• Social class: there is an inverse relationship between
social class and report of depressive symptoms

• Race and culture: no consistent relationship between

race and affective disorder has been reported; one
recent survey revealed
• More prevalent in whites than blacks
• Depression is more severe and disabling in blacks
• Blacks are less likely to receive treatment than whites
• Seasonality: affective disorders are more prevalent in the
spring and in the fall

• Marital status: single and divorced people

more likely to experience depression than
married persons or persons with a close
interpersonal relationship (differences
occur in various age groups)
 Types of Depressive Disorders

• Major depressive disorder

• Dysthymic disorder
• Premenstrual dysphoric disorder
• Mood disorder due to a general
medical condition
• Substance-induced mood
disorder
 Major depressive disorder

• Characterized by depressed mood

• Loss of interest or pleasure in usual activities

• Social and occupational functioning impaired for at least 2 weeks

• No history of manic behavior

• Cannot be attributed to use of substances or a general medical condition

 Dysthymic disorder

• Sad or “down in the dumps”

• No evidence of psychotic symptoms

• Gloomy, flat affect, pessimistic outlook on their life

• Essential feature is a chronically depressed mood for

• Sad mood most of the day
• More days than not
• For at least 2 years
Premenstrual dysphoric disorder

• Depressed mood
• Anxiety
• Mood swings
• Decreased interest in activities
• Symptoms begin during week prior to
menses and subside shortly after onset of
menstruation
 Biological theories

• Genetics: hereditary factor may be involved

• Biochemical influences: deficiency of norepinephrine,

serotonin, and dopamine has been implicated
Neuroendocrine disturbances

• Possible failure within the hypothalamic-pituitary-

adrenocortical axis

• Possible diminished release of thyroid- stimulating

hormone
 Physiological influences

• Medication side effects

• Neurological disorders
• Electrolyte disturbances
• Hormonal disorders
• Nutritional deficiencies
• Other physiological conditions
 Psychosocial theories

• Psychoanalytical theory
• Mourning
• Melancholia

• Learning theory
• Learned helplessness
• Repeated failure to control life,
leading to feelings of helplessness
and dependence on others
• A possible predisposition to depression
• Object loss
• Experiences loss of significant other during first 6 months of life
• Feelings of helplessness and despair
• Early loss or trauma may predispose client to lifelong periods of
depression
• Cognitive theory: views primary disturbance in depression as
cognitive rather than affective
• Three cognitive distortions that serve as the basis for depression
• Negative expectations of the environment
• Negative expectations of the self
• Negative expectations of the future
 The transactional model

• It is most likely that depressive disorder is caused by a

combination of factors

• Genetic

• Biochemical

• Psychosocial
 Developmental Implications

• Childhood depression

• Adolescence

• Senescence

• Postpartum depression
 Childhood depression

• Symptoms
• Under age 3: feeding problems, tantrums, lack of playfulness and
emotional expressiveness
• Ages 3 to 5: accident proneness, phobias, excessive self-reproach
• Ages 6 to 8: physical complaints, aggressive behavior, clinging
behavior
• Ages 9 to 12: morbid thoughts and excessive worrying
• Precipitated by a loss
• Focus of therapy: alleviate symptoms and strengthen coping skills
• Parental and family therapy
 Adolescence

• Symptoms include
• Anger, aggressiveness
• Running away
• Delinquency
• Social withdrawal
• Sexual acting out
• Substance abuse
• Restlessness; apathy
• Best clue that differentiates depression from normal
stormy adolescent behavior
• A visible manifestation of behavioral change that lasts
for several weeks
• Most common precipitant to adolescent suicide:
• perception of abandonment by parents or
close peer relationship
• Adolescence (cont’d)
• Treatment with
• Supportive psychosocial intervention
• Antidepressant medication

NOTE: All antidepressants carry an FDA black box

warning for increased risk of suicidality in children and
adolescents. Prozac is the most common antidepressant
(SSRI) for children and adolescents.
 Senescence

• Bereavement overload
• High percentage of suicides among elderly
• Symptoms of depression often confused with
symptoms of dementia
• Treatment
• Antidepressant medication
• Electroconvulsive therapy
• Psychosocial therapies
 Postpartum depression

• May last for a few weeks to several months

• Associated with hormonal changes, tryptophan metabolism,
or cell alterations
• Treatments: antidepressants and psychosocial therapies
• Symptoms include
• Fatigue
• Irritability
• Loss of appetite
• Sleep disturbances
• Loss of libido
• Concern about inability to care for infant
 Transient depression

• Symptoms at this level of the continuum not necessarily

dysfunctional
• Affective: the “blues”
• Behavioral: some crying
• Cognitive: some difficulty getting mind off one’s disappointment
• Physiological: feeling tired and listless
• Cognitive: some difficulty getting mind off one’s
disappointment
• Physiological: feeling tired and listless
 Major Depression

• Symptoms of mild depression are identified by clinicians

as those associated with normal grieving
• Can be a single episode or recurrent with varied levels of
severity in symptoms.
• Some milder symptoms;
• Affective: anger, anxiety
• Behavioral: tearful, regression
• Cognitive: preoccupied with loss
• Physiological: anorexia, insomnia
 Moderate depression

• Symptoms associated with dysthymic disorder

• Affective: helpless, powerless
• Behavioral: slowed physical movements,
slumped posture, limited verbalization
• Cognitive: retarded thinking processes, difficulty with
concentration
• Physiological: anorexia or overeating, sleep disturbance,
headaches
 Severe depression

• Includes symptoms of major depressive disorder

• Affective: feelings of total despair, worthlessness, flat affect
• Behavioral: psychomotor retardation, curled-up position,
absence of communication, unable to find pleasure in activities
• Cognitive: prevalent delusional thinking, may have delusions of
persecution and somatic delusions; confusion; suicidal thoughts
• Physiological: a general slow-down of the entire body
• Poor adls, disheveled
• * Think of the video
 Diagnosis/Outcome
Identification
• Risk for suicide related to

• Depressed mood
• Feelings of worthlessness
• Anger turned inward on the self
• Misinterpretations of reality
 Nursing Diagnosis

• Complicated grieving related to

• Real or perceived loss

• Bereavement overload
 Nursing Diagnosis (cont’d)

• Low self-esteem related to

• Learned helplessness
• Feelings of abandonment by significant others
• Impaired cognition fostering negative view of self
• Powerlessness related to
• Complicated grieving process
• Lifestyle of helplessness
 Nursing Diagnosis (cont’d)

• Spiritual distress related to

• Complicated grieving process over loss of valued object
evidenced by anger toward God, questioning meaning of
own existence, inability to participate in usual religious
practices.
 Nursing Diagnosis (cont’d)

• Social isolation/impaired social interaction related

to
• Developmental regression
• Egocentric behaviors
• Fear of rejection or failure of the interaction
 Nursing Diagnosis (cont’d)

• Disturbed thought processes related to

• Withdrawal into self
• Underdeveloped ego
• Punitive superego
• Impaired cognition fostering negative perception of self
or environment
 Nursing Diagnosis (cont’d)

• Imbalanced nutrition less than body requirements

• Insomnia
• Self-care deficit
• All related to depressed mood
 Criteria for Measuring
Outcomes
• The client
• Has experienced no physical harm to self
• Discusses the loss with staff and family members
• No longer idealizes or obsesses about the lost entity
• Sets realistic goals for self
• Attempts new activities without fear of failure
• Is able to identify aspects of self-control over life
situation
• Expresses personal satisfaction and support from spiritual
practices

• Interacts willingly and appropriately with others

• Is able to maintain reality orientation

• Is able to concentrate, reason, and solve problems

 Planning/Implementation

• Nursing interventions are aimed at

• Maintaining client safety
• Assisting client through grief process
• Promoting increase in self-esteem
• Encouraging client self-control and control over life situation
• Helping client to reach out for spiritual support of choice
• Assistance in confronting anger that has been turned inward on the
self
• Ensuring that needs related to nutrition, elimination, activity, rest, and
personal hygiene are met
• Some institutions are using a case management
model to coordinate care.

• In case management models, the plan of care may

take the form of a critical pathway.
 Client/Family Education

• Nature of the illness

• Stages of grief and symptoms associated with each stage
• What is depression?
• Why do people get depressed?
• What are the symptoms of depression?
• Have other organic causes for behavior been ruled out?
Client/Family Education cont’d

• Management of the illness

• Medication management
• Assertive techniques
• Stress-management techniques
• Ways to increase self-esteem
• Electroconvulsive therapy
Client/Family Education cont’d

• Support services
• Suicide hotline
• Support groups
• Legal/financial assistance
 Nursing Process/Evaluation

• Evaluation of the effectiveness of nursing

interventions is measured by fulfillment of the
outcome criteria.
 Evaluation
• Has self-harm to the client been avoided?
• Have suicidal ideations subsided?
• Does the client know where to seek assistance outside the
hospital when suicidal thoughts occur?
• Has the client discussed the recent loss with the staff and
family members?
• Is he or she able to verbalize feelings and behaviors
associated with each stage of the grieving process and
recognize own position in the process?
 Evaluation cont.

• Have obsession with and idealization of the lost

object subsided?
• Is anger toward the lost object expressed
appropriately ?
• Does client set realistic goals for self?
 Evaluation cont.

• Is he or she able to verbalize positive aspects about

self, past accomplishments, and future prospects?
• Can the client identify areas of life situation over
which he or she has control?
 Treatment Modalities

• Individual psychotherapy
• Group therapy
• Family therapy
• Cognitive therapy
• Electroconvulsive therapy
• Transcranial magnetic stimulation
• Light therapy
 Psychopharmacology

• Tricyclics
• SSRIs
• MAO inhibitors
• Heterocyclics
• SNRIs
• Action
• TCAs, heterocyclics, SSRIs, SNRIs
• Block reuptake of norepinephrine, serotonin, and/or dopamine
• MAOIs
• Inhibit monoamine oxidase, an enzyme known to inactivate norepinephrine,
serotonin, and dopamine
Tricyclics

• Page 485
• Most common you may see;
• Amitriptyline (Elavil)
• Imipramine (Tofranil)
nortriptyline (Pamelor)
• Doxepin
 Side effects of Tricyclics
• Dry mouth
• Sedation
• Nausea
• Discontinuation syndrome (Abrupt withdrawal with all classes of
antidepressants)
• Constipation
• Urinary retention
• Reduce the seizure threshold
• Tachycardia and arrhythmias
• Townsend page 489
 SSRI

• Most common
• Celexa (Xitalopram)
• Lexapro (Fluvoxamine)
• Paxil (Paroxetine)
• Zoloft (Sertraline)
• Fluoxetine (Prozac)* Used with kids
 SSRI
• Dry mouth
• Sedation
• Nausea
• Discontinuation syndrome (Abrupt withdrawal with all classes of
antidepressants)
• Can be toxic or fatal if used with MAOIs
• Serotonin syndrome if using more than one SSRI at the same time
• Weight gain
• Sexual dysfunction
• Townsend, page 487
Contraindications/precautions

• Contraindicated in known hypersensitivity (SSRIs,

MAOIs, tricyclics); acute phase of recovery from
myocardial infarction; angle-closure glaucoma
(tricyclics); and concomitant with MAOIs (TCAs,
heterocyclics, SSRIs, SNRIs)

• Caution with elderly or debilitated clients; clients with

hepatic, cardiac, or renal insufficiency; psychotic
clients; clients with benign prostatic hypertrophy; and
those with history of seizures (tricyclics, MAOIs)
 Interactions
• Interactions (with MAOIs)
• Hypertensive crisis with amphetamines, methyldopa, levodopa,
dopamine, epinephrine, norepinephrine, reserpine, vasoconstrictors,
or foods with tyramine
• Hypertension, hypotension, coma, convulsions, and death with narcotic analgesics
• Additive hypotension with antihypertensives
• Additive hypoglycemia with antihyperglycemic agents
• Potentially fatal reactions with all other antidepressants, carbamazepine, buspirone,
sympathomimetics, tryptophan, dextromethorphan, CNS depressants, and
amphetamines (avoid use within 2 weeks of each other)

• DIET considerations, no cheese, wine or yeast. See chart on page 488 for specific
foods you may want to know about to help patients fill out menu choices.
• Client/family education related to antidepressants
• Therapeutic effect may not be seen for as long as 4
weeks
• Do not discontinue use of the drug abruptly
• Avoid smoking and drinking alcohol
• Be aware of risks of taking antidepressants during
pregnancy
• If patients were or are suicidal, be watchful as they start to
feel better; depressive symptoms lighten as they may now
have enough energy to carry out a suicide.
Avoid foods and medications high in tyramine when
taking MAOIs, including

Aged cheese Caviar

Wine; beer Raisins
Chocolate; colas Pickled herring
Coffee; tea Yeast products
Sour cream; yogurt Broad beans
Smoked and processed meats Soy sauce
Beef or chicken liver Cold remedies
Canned figs Diet pills
 Concept map

• Frank, 56 is an engineer and father of three. He came home

from work one day and found his wife with their 22 year old
neighbor. He immediately asked his wife to leave the home
after 24 years of marriage. The wife agreed. Upon interview
john states “It is all my fault, I work 60 hours a week, I am
not as thin or attractive as I was in my prime.” “I should just
let my car run in the garage.” Frank has ben laying on the
couch for weeks, and will loose his job if he does not go to
work on Monday. Bills have not been paid and the kids are
not doing homework and have been missing sports activities.
• 4 signs and symptoms
• 4 nursing diagnoses
• 4 nursing actions
• ? Medicine???
• Outcomes
• [Link]
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