DSM Diagnostic Criteria: Disorders of Depression

I.

Introduction:

Depression is a common problem in healthcare. Among adults in the United States,

almost 10% of the population is depressed over a period of one year. Depression
accounts for a large number of people who visit the healthcare system and are
hospitalized. In addition, depression can be deadly. Almost 40,000 deaths occur every
year due to suicide which is most often related to depression (Center for Disease
Control, 2013).
Despite its prevalence it is still considered under diagnosed and under treated. Often
times, this is due to the social stigma surrounding mental illness; people are often
ashamed to discuss it with their health team and the health team is often reluctant to
inquire about mood with their patients.
II.

General Definition:

Depression is more than feeling sad. Everyone has days when they are sad, but
depression is a persistent feeling of sadness that disrupts life for the person afflicted and
their loved ones.
III.

Causes of Depression and Risk Factors:

A. Neurotransmitters
B. Family History
C. Substance Abuse
D. Presence of Other Psychiatric Disorders E. Environment
F. Other Risk Factors -

IV.

Depressive Disorders:

A. Major Depressive Episode -

B. Persistent Depressive Disorder (Dysthymic Disorder) -

C. Other types of depression 1.

2.
3.
4.
5.
V.

Bipolar Depression
Substance-Induced Depressive Disorder
Postpartum Depression
Seasonal Affective Disorder
Psychotic Depression
Assessment:

A. Symptoms of Major Depressive Episode Depression presents differently in different individuals. The Diagnostic and Statistical

Manual of Mental Disorders, Fifth Edition (DSM-5) uses specific criteria when
formulating a diagnosis. A common mneumonic to help nurses remember the classical
signs and symptoms of major depressive episode is
SIG-E-CAPS
S Sleep disturbances either not sleeping enough or excessive sleep
I Loss of interest in activities that the individual used to find enjoyable (anhedonia)
G Guilt or feeling worthless or helpless
E Low energy or fatigue
C Concentration problems
A Appetite disturbances either eating too much or too little
P Psychomotor retardation or agitation
S Suicidal thoughts or attempts
B. Screening Tools 1.
2.
3.
4.

Hamilton Rating Scale for Depression

Beck Depression Inventory
Zung Self-Assessment Scale
Geriatric Depression Scale

Care of the Patient Experiencing Depression

I. Interventions:

A. Provide for the safety of the patient and others.

B. Continually assess for suicide potential and remain aware of suicide potential at all
times (See below).
C. Begin a therapeutic relationship by using therapeutic communication and spending
non-demanding time with the patient.
D Encourage the patient to verbalize and describe emotions.
E. Promote completion of ADLs by assisting the patient as necessary.
F. Establish adequate hydration and nutrition.
G. Promote adequate sleep and rest.
H. Encourage the patient in activities.
I. Work with the patient to manage medications and side effects (See below).
J. Psychotherapy, Group Therapy, Cognitive-Behavioral Therapy (CBT)
K. Electroconvulsive Therapy (ECT) (See below).
L. Transcranial Magnetic Stimulation (TMS) (See below).

II.

Antidepressant Medication:

A. Action - Directly affect the chemistry of the brain by increasing neurotransmitters

primarily serotonin, norepinephrine, and dopamine.

B. First Generation Medications

1. Tricyclic Antidepressants (TCAs)

2. Monoamine Oxidase Inhibitors (MAOIs)

C. Second Generation Medications
1. Selective Serotonin Reuptake Inhibitors (SSRIs) -

2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)-

D. Others

E. Antidepressant Medication Table

Class

Medication

Side Effects/Issues

TCAs

Amitriptyline, Doxepin,
Imipramine

narrow therapeutic range,

anticholinergic, orthostatic
hypotension, arrhythmia,
sedation, sexual
dysfunction, sweating,
weight gain

MAOIs

Phenelzine,
Tranylcypromine

hypertensive crisis related

to drug-drug interactions
and food-drug interactions
(tyramine free diet),
sedation, sexual
dysfunction, blurred vision,
tachycardia, serotonin
syndrome

SSRIs

Citalopram, Escitalopram,
Paroxetine, Fluoxetine,
Sertraline

nausea, diarrhea,
headache, anxiety upon
initiation or dose increase,
sexual dysfunction,

sweating,
sedation/agitation
SNRIs

Venlafaxine, Duloxetine

same as SSRIs, increased

blood pressure, increased
heart rate, liver toxicity
(duloxetine)

Others

Mirtazapine, Trazodone,
Bupropion

less sexual dysfunction

than other classes,
sedation/agitation,
appetite changes

F. Overview of Medications
1. All take 6-12 weeks for full effect
2. According to available literature all are equally effective
3. Choice based on past response, target symptoms, drug interactions, and cost
4. All have FDA warning for increased suicidality in patients < 24 years of age

VI.

Electroconvulsive Therapy (ECT):

A. Action

B. Nursing Considerations -

VII.

Transcranial Magnetic Stimulation (TMS):

A. Action

B. Nursing Considerations

VIII.

Evaluation:
The patients response to interventions is evaluated based on the attainment of
desired outcomes. The nurse compares the patients clinical symptoms as initially
seen when entering treatment with symptoms exhibited following completion of
the care plan. Input from all healthcare team members as well as the patient and
the patients family members is important.

Safety Considerations: Care of the Patient Experiencing Suicidal Ideation

I.

Introduction:
A person who thinks about suicide often experiences deep sadness and personal
pain. Thoughts of suicide may occur when a person cannot handle the pain they feel
or feel they are not able to cope with the demands of their life. The feel hopeless,
helpless, and trapped. Suicide is often a way of trying to end this pain. Facts about
suicide in the United States:
A. The Joint Commission established in 2015 that a National Patient Safety Goal is
to identify patients at risk for suicide.
B. More than 32,000 people commit suicide each year.
C. One person commits suicide every 16 minutes.
D. Suicide is the 3rd leading cause of death in young people ages 15-24.

E. Males are 4 times more likely to die from suicide than females.
F. Females attempt suicide 3 times more than males.
G. White males commit almost 20% of all suicides.
H. Suicide rates are highest among Americans over the age of 65.
I.

More than 50% of all suicides are completed by using firearms.

J. Most people who commit suicide suffer from one or more mental illnesses.

II.

Risk Factors for Suicide:

A. Elderly males over the age of 65
B. Young males between ages 15-24
C. Drug and alcohol abusers
D. Those who lack social support
E. People with mental illness

F. Those who suffer from chronic illness, chronic debilitation, and chronic pain
congestive heart failure (CHF), stroke, multiple sclerosis (MS), chronic
obstructive lung disease (COPD), seizure disorders, and malignant neoplasms
for example.
G. People who are divorced, widowed, or have never married
H. People who have experienced a major loss
I.

Those who have a family history of suicide

J. People with a previous suicide attempt

K. People with access to firearms
L. Victims of sexual abuse or assault

III.

Assessment
Suicide is considered more preventable than any other cause of death. A patients
degree of suicidality can change quickly and unpredictably so assessment for suicide

risk is an ongoing process, not a single event. Information is obtained from both the
patient and those close to the patient.
A. Regard all behaviors and comments about suicide as serious B. A common mneumonic to help nurses remember the classical signs and
symptoms of warning signs for suicide is IS PATH WARM
I Ideation
S- Substance Abuse
P Purposelessness
A Anxiety
T Trapped
H Hopelessness
W Withdrawal
A Anger
R Recklessness
M Mood changes
C. Screening Tools

1.
2.
3.
4.

Columbia Suicidal Severity Rating Scale

Sad Persons Assessment Scale
Beck Hopelessness Scale
Linehans Reasons or Living Inventory

D. Dont be afraid to ask your patients the following:

1.
2.
3.
4.
5.
6.

IV.

What worries do you have?

Have you had thoughts that life is not worth living?
Do you want to die?
Do you have a specific plan to end your life? If so, what is your plan?
What keeps you from acting out your plan?
Have you attempted suicide before? If so, how?

Nursing Diagnosis:
First and foremost, the priority nursing diagnosis is Risk for Violence: Self-Directed.
In order to provide interventions for our patients, we must help to keep our patients
free of self-inflicted harm and alive.

V.

Interventions:

A. Establishing a therapeutic relationship during the assessment process is crucial

B. Demonstrate an attitude of acceptance, empathy, and support
C. Encourage the patient to verbalize negative feelings
D. Assessment is critical (see above)
E. Suicide prevention measures
1. Primary Prevention
2. Secondary Prevention
3. Tertiary Prevention
F. Safety of environment
G. Treat depression and/or other mental illnesses
H. Teach and encourage healthy coping skills
I.

Suicide precautions

J. Hospitalization, seclusion, and restraint

VI.

Evaluation
Evaluation is an ongoing process that considers the patients progress in attaining
expected outcomes as stated in the inpatient or outpatient plan of care.

CACA
MACARECCARE OF THE PATIENT
WHO IS MANIC