Jeff

Chapter 27:Depressive Disorders ;(

Depressive disorders are associated with

1. disturbed psychological functioning
2. physiologic
3. social functioning

symptoms include:
1. disturbances in daily patterns ( sleep, weight, libido, appetites)
2. disturbances in cognition( thinking, memory)
3. impulse control ( suicide, homicide)
4. behavior ( lack of pleasure, fatigability)
5. physical symptoms( things are hurt physically):: headache, stomachache, muscle tension

Reaction to loss, death or loved, being fired, being in debt is called “Reactive or secondary
depression”

Depressive disorder= sad mood that has been caused by something or be unrelated to anything
at all. RISK FOR SUICIDE ACCOMPANIES DEPRESSIVE DISORDER, so this demands
PRIORITY attention

bipolar disorders - are alterations in mood, switches from mania( high energy, elevated mood) to
depression.

OVERVIEW OF DEPRESSIVE ILLNESS

Depression affects all ages and backgrounds.
Dysthymia - chronic mild depression, affects 1.5 of U.S. population.
depression is difficult to diagnose b/c they have physical diseases (heart diasease, diabetes)
and healthcare professionals think incorrectly that depression is a normal consequence.

Risk factor for depression:

1. Gender: higher in women than men
2. prior episode of depression
3. family history
4. stressful life event
5. substance use
6. medical illness
7. few social supports

ETIOLOGY : depression results from a combo of things, GENES, ENVIRONMENT, LIFE

history, DEVELOPMENT, NEUROBIOLOGIC MAKEUP.

GENETIC FACTORS:
studies show that if first degree relatives(parents,children, siblings) had depression you have an
increased risk.

Physiologic factors:
Areas of brain are affected in depressive disorders
1. Biogenic Amines:
hypothesis shows that depression results from deficiency of amines( neurotransmitters
synthesized in nerve). The MONOamines in depression are NOREPINEPRHRINE (NE),
DOPAMINE (DA), SEROTONIN (5-HT. Disturbances in mood result when theres too much
concentrations or too little of NOREP, DOPAMINE and SEROTONIN.

2. Psychoneuoendocrine and Immune Relationships:

Hypothalamic pituitary adreanal axis (HPA) is conisdered the stress axis. HPA interacts with
endocrine and CNS.

Hypothamalamus interacts with CNS through corticotropin releasing hormone(CRH)

CRH → adrenal medulla → secretes catecholamines and cortisol
(catecholamines and cortisol regulate endorcrine and immune system)
a. people exposed to traumatic, stressful and unstable situations are more likely to
develop problems with mood because over stimulation of HPA pathways and
endocrine system

3.Psychological Factors
psychodynamic theories postulate that clients with depression have unexpressed and
unconscious anger about feeling helpless or dependent on others. Can’t express anger, so
anger turns inward, believe that this begins in childhood

LEARNED HELPLESSNESS
a. learned helplessness- People who believe that they have no influence or feel ineffective on
factors that cause their suffering
b. behaviors like being passive, negative expectations, feeling helpless, hopeless and
powerless pose people to develop to mood disorders. ( these are also symptoms of major
depression)

COGNITIVE FACTORS
a. theorists believe that depression is a manifestation of errors in thinking and unrealistic
attitudes about self and world.
b. thinking wrong about self, negative view about achieving goals, unable to experience
pleasure

SIGNS AND SYMPTOMS/DIAGNOSTIC CRITERIA

depressive illnesses can be categorized in various ways, depending on symptoms, severity and
persistence
a. Major Depressive Disorder: depressed mood or loss of interest or inability to derive pleasure
from previously enjoyed activities. Recurrent thoughts of suicide, decrease or increase appetite,
inability to concentrate, difficulty making decisions, worthlessness and self blame, decrease
energy, motor disturbance, disturbed sleep, substance abuse, social withdrawal.
-Symptoms have to be present most of the day everyday for at least 2WEEKS and cause
significant distress or impair functioning.
-major depressive episodes last several weeks to several months

b.Dysthymic Disorder: mild depressive ilness in which symptoms, like poor appetite or
overeating, insomnia or excessive sleep, low energy, faitgue, low self esteem, pooer
concentration and difficulty making decisions are chronic but LESS SERVE than major
depression. In an attempt to escape negative self-esteem, self depreciation, emptiness, low
energy, fatigue and pessimism, they may FOCUS on work, spend lots of money, egnage in
extreme sexual behavior or become preoccupied with religion.
-ppl with this become accustomed to the disorder and do not recognize symptoms as abnormal.

c. Postpartum Depression: (PPD)

-lasts for weeks or months after pregnancy ends
-evolves after delivery til first year after childbirth
-untreated PPD, is treatable through mechanisms similar to those of depressive disorders

IMPLICATIONS AND PROGNOSIS

-treatable
-mangament is more effective if it is started early and prevents recurrence
-replapses are common
-if condiiton remains unadressed, pt at RISK FOR SUICIDE

INTERDISCIPLINARY GOALS AND TREATMENT

-interdisciplinary approach to long term management is most effective
-a combo of psychotherapy and meds are effective together
-psychopharmaologic + somatic therapy like electroconvulsive therapy are used for pt with
refractory depression

Cognitive BEHAVIORAL THERAPY

-can be done individually or in group settings
goal is help pt identify and correct distorted, negative, catastrophic thinking, thereby relieving
symptoms.
- Modify maladaptation through homework assignments, structured schedules and other
techniques.

Psychopharmacology
- antidepressants are drug of choice for depressive disorders ( including depressive phase of
bipolar disorder)
- students are encouraged to read results of STAR*d( sequenced treatment alternatives to
relieve depression) studies fro lastest data regarding antidepressant therapy
- pt get antidepressants for moderate or severe symptoms of depression, significant impairment
in social or occupational functioning as result of depression or suicidal ideation.
- are indicated for people have a positive response to them, negative response to
psychotherapeutic interventions, recurrent depressive episodes, family history of depression
and client preference for drug therapy
-antidepressant therapy is a long term process, requiring patience from client and clinician, trail
and error
-Tricyclic antidepressants are potenitally lethal
-antidepressants can precipitate mania in ppl with bipolar disorder and activate latent psychosis
in susceptible clients.

SELECTIVE SEROTONIN REUPTAKE INHIBITORS AND RELATED DRUGS

- selective serotoning reuptake inhibitors (SSRIs)
-reuptake inhibitors (SARIs)
-Serotonin norepinephrine reputake inhibitors (SNRIs)
those 3 are considred first line drugs for depression
-SSRIs have fewer side effects than other antidepressants, affect GI, CNS (headache,
nervousness, anxiety light headedness) loss of libido
-lethal reaction to SSRIs is serotonin syndrome, which happens after use of (SSRIs, TCAs,
TRYPTOPHAN, DEXTROMEHTORPHAN, or meperidine) THIS RESULTS IN
HYPERACTIVITY in 5-HT(serotonin levels) and leads to serotonin syndrome.
-IF client switches from fluoxetine to an MAOI, provider should have WASHOUT period for 5
weeks (half life of fluoxetine) before beginning of MAOI. If client is switching from MAOI to
Fluoxetine the provider should allow washout of at least 2weeks.

NOVEL (atypical) ANTIDEPRESSANTS

- second line antidepressants
-trazodone
-mirtazapine
-bupropion

CYCLIC ANTIDEPRESSANTS
- TCAs used when SSRIs and novel antidepressants have been ineffective
- Tcas are used cautiously in clients who are hypersensitive to any tricyclic drugs and taking
MAOIs have had recent heart attack or lactating.
- also pre existing cardio vascular diosrder, closed angle glaucoma, symptomatic begign
prostatic hypertrophy, constipation, seizure disorder impaired hepatic or renal function or bipolar
disorder

Monoamine Oxidase INHIBITORS

- used to treat atypical depression or depression in clients who do not experience response to
other drugs.
- MAOIs increase levels of TYRAMINE, if they eat tyramine foods, MAOI will accumulate and
lead to hypertensive crisises. this requires immediate medical intervention

SOMATIC AND ITERGRATIVE INTERVENTIONS

- used for depressive disorders
-Electroconvulsive therapy (ECT) is used when clients have depression and fail to respond to
medications and other modalities.
-involves application of small dose of electricity to brain to induce seizure and alleviate
depressive symptoms.
-ECT can cuase memory impairment can be mild or severe.
-PHOTOTHERAPY is effective for clients with symptoms of depression associated with
seasonal pattern ( related to lack of light and decreased melatonin production)

NURSING PROCESS
- assessment
a. safety is priority for clients with depression.
b. suicide is primary concern for clients with depression
c. factors that increase client’s risk for suicide inlude expression of current thoughts or
plans about suicide, active mental illness ( severe depression, psychosis), substance
abuse, history of suicidal attempts or behaviors, formulation of plan
ask questions like
“ when you feel depressed, what do you think about?”
“do you ever think about taking your own life?”
“do you have a plan for committing suicide?”
“would anything prevent you from killing yourself?”

d. violence risk - agitated, angry or despairing may turn feelings outward

e. mental status examination - pt’s behavior, symptoms, medications, needs and other
environmental factors
f. physiologic stability - physiologic integrity and function, avoid eating, have difficulty
sleeping and experience other physicologic consequences of inability to engage
in self care. weight loss or gain is a sign of depression. sleep disturbances

DIAGNOSIS
-risk for suicide
-risk for violence
-ineffective health maintenace
-impaired social interaction
- disturbed thought processes
-ineffective therapetuic regimen management

OUTCOME + PLANNING
1. client will reamin safe w/o harm
2. client will remain safe w/o harm to others
3. client will have adquate food and fluid intake, maintain balance rest, sleep and activity
4. client will engage in appropriate socoical behavior
5. client will maintain medication regimen, taking medications

IMPLeMENTATION
1. protecting client from suicide
a. assess client’s risk for suicide. If at risk, nurses immediately place him or her on
suicide precautions with frequent or continuous one to one observations and
reassessment.

b. Restrict the client to unit based activities and remove dangerous objects (belts, glass,
ties, razors)

c. look for bathroom for safety because that is most common area for successful suicide
completion

d. build therapeutic relationship, increases likelihood client will convey suicidal thoughts

e. Suicidal ideation resolves when medication begins working, RISK FOR SUICIDE
INCREASES WITHIN first 2 to 3weeks after starting antidepressant
medication
2. Managing the Potential for Violence
a. assess client’s level of violence, and if necessary place client on violence precautions
b. establish geographic boundaries ( room restriction or half hall restriction)
c. clients will have as needed medictions
d. reduce stimuli and opportunites for interaction with other clients in environment
3.Maintaing Physical Health and Personal Hygiene
a. Monitor food and fluide intake and assess weight, vital signs, and laboratory values
b. balance rest with activity
4.Enhancing thought process
a. client with depression, encourage sitting in environment, with minimal contact with
others
b. if anxiety is extreme, limit client’s interaction and contacts with low stimulus
environment in client’s room.
c. relaxation exercises, imagery and progressive muscle relaxation may help.
5. Encouraging Treatment and medication Adherence
a. provide info about prescribed medication and needed aftercare, such as frequency of
laboratory testing, discharge planning and follow up visits.
b. teach clients prescribed CLOZAPINE, importance of monitoring for
AGRANULOCYTOSIS
c. teach importance of taking medication with relpase prevention.
EVALUATION
1. fewer suicidal thoughts
2. no self harm or acting aggressively
3.client ingest adequate calories and fluids
4. participate appropriately in milieu activities
5. client expresses positive sense of self worth
6. client adheres to therapeutic regimen and discusses importance of doing so