Copyright © 2014. F.A. Davis Company Depressive Disorders Chapter 25

Copyright © 2014. F.A. Davis Company

Depressive DisordersDepressive DisordersChapter 25Chapter 25


IntroductionIntroduction

• Depression is the oldest and one of the most frequently diagnosed psychiatric illnesses.

• Transient symptoms are normal, healthy responses to everyday disappointments in life.


• Pathological depression occurs when adaptation is ineffective.

• Mood is also called affect. • Depression is an alteration in mood that is

expressed by feelings of sadness, despair, and pessimism.

Introduction Introduction (cont.)(cont.)


Historical PerspectivesHistorical Perspectives

• Many ancient cultures believed in the supernatural or divine origin of mood disorders.

• Hippocrates believed that melancholia was caused by an excess of black bile, a heavily toxic substance produced in the spleen or intestine, which affected the brain.


EpidemiologyEpidemiology

• During their lifetimes, about 21

percent of women and 13 percent of men will become clinically depressed.


• Gender Prevalence– Depression is more prevalent in women

than in men by about 2 to 1.

Epidemiology Epidemiology (cont.)(cont.)


• Age – Depression is more common in young women

than in 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

– No consistent relationship between race and affective disorder has been reported.

– One recent survey revealed:• Depression is more prevalent in whites than blacks.• Depression is more severe and disabling in blacks.• Blacks are less likely to receive treatment than whites.



• Marital Status– Single and divorced people are more likely

to experience depression than married persons or persons with a close interpersonal relationship (differences occur in various age groups).



• Seasonality: Affective disorders are more prevalent in the spring and in the fall.



Types of Depressive DisordersTypes of Depressive Disorders

• Major Depressive Disorder– Characterized by depressed mood– Loss of interest or pleasure in usual activities– Symptoms have been present for at least 2

weeks– No history of manic behavior– Cannot be attributed to use of substances or

another medical condition


• Persistent Depressive Disorder (Dysthymia)– Sad or “down in the dumps”– No evidence of psychotic symptoms– Essential feature is a chronically depressed

mood for:• Most of the day • More days than not • For at least 2 years

Types of Depressive Disorders Types of Depressive Disorders (cont.)(cont.)


• Premenstrual Dysphoric DisorderEssential features:– Depressed mood– Anxiety – Mood swings – Decreased interest in activities– Symptoms begin during week prior to menses,

start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses



• Substance-Induced Depressive Disorder– The depression is considered to be the direct

result of physiological effects of a substance.

• Depressive Disorder Associated with Another Medical Condition– The depression is attributable to the direct

physiological effects of a general medical condition.



Predisposing Factors to DepressionPredisposing Factors to Depression

• Biological Theories– Genetics

• Hereditary factor may be involved.– Biochemical influences

• Deficiency of norepinephrine, serotonin, and dopamine has been implicated.

• Excessive cholinergic transmission may also be a factor.


• Neuroendocrine Disturbances

– Possible failure within the hypothalamic-pituitary-adrenocortical axis

– Possible diminished release of thyroid-stimulating hormone

Predisposing Factors to Depression Predisposing Factors to Depression (cont.)(cont.)


• Physiological Influences– Medication side effects– Neurological disorders– Electrolyte disturbances– Hormonal disorders– Nutritional deficiencies– Other physiological conditions



• Psychosocial Theories– Psychoanalytical theory

• A loss is internalized and becomes directed against the ego.

S. Freud



• Psychosocial Theories (cont.)

– Learning theory• Learned helplessness

—The individual who experiences numerous failures learns to give up trying.



• Psychosocial Theories (cont.)– 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.



• Psychosocial Theories (cont.)– 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 Depression is likely related to multiple

factors, including genetic, biochemical and psychosocial.



Developmental Implications Developmental Implications

• Childhood Depression– Symptoms

• Younger than age 3: feeding problems, tantrums, lack of playfulness and emotional expressiveness

• Ages 3 to 5: prone to accidents, phobias, excessive self-reproach

• Ages 6 to 8: physical complaints, aggressive behavior, clinging behavior

• Ages 9 to 12: morbid thoughts and excessive worrying


• Childhood Depression (cont.)– Precipitated by a loss– Focus of therapy: Alleviate symptoms and

strengthen coping skills– Parental and family therapy

Developmental Implications Developmental Implications (cont.)(cont.)


• Adolescence– Symptoms include:

• Anger, aggressiveness• Running away• Delinquency• Social withdrawal• Sexual acting out• Substance abuse• Restlessness, apathy



• Adolescence (cont.)

– 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.)

– 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.



• Senescence– Bereavement overload– High percentage of suicides among elderly– Symptoms of depression often confused with

symptoms of neurocognitive disorder.

• 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

– Symptoms include:• Fatigue, irritability• Loss of appetite• Sleep disturbances• Loss of libido• Concern about inability to care for infant

– Treatments• Antidepressants and psychosocial therapies



• Transient Depression– Symptoms at this level of the continuum not

necessarily dysfunctional • Affective: the “blues”• Behavioral: some crying• Cognitive: some difficulty getting mind off of

one’s disappointment• Physiological: feeling tired and listless

Nursing Process: AssessmentNursing Process: Assessment


• Mild Depression– Symptoms of mild depression are identified by

clinicians as those associated with normal grieving

• Affective: anger, anxiety• Behavioral: tearful, regression • Cognitive: preoccupied with loss• Physiological: anorexia, insomnia

Nursing Process: Assessment Nursing Process: Assessment (cont.)(cont.)


• Moderate Depression

– Symptoms associated with dysthymia:• Affective: helpless, powerless• Behavioral: sluggish physical movements, slumped

posture, limited verbalization• Cognitive: slow thinking processes, difficulty with

concentration• Physiological: anorexia or overeating, sleep

disturbance, headaches



• Severe Depression– Includes symptoms of major depressive

disorder and bipolar depression• Affective: feelings of total despair, worthlessness,

flat affect• Behavioral: psychomotor retardation, curled-up

position, absence of communication• Cognitive: irrelevant delusional thinking with

delusions of persecution and somatic delusions, confusion, suicidal thoughts

• Physiological: a general slow-down of the entire body



• Risk for suicide related to:

– Depressed mood – Feelings of worthlessness– Anger turned inward on the self– Misinterpretations of reality

Diagnosis/Outcome IdentificationDiagnosis/Outcome Identification


Nursing DiagnosisNursing Diagnosis

• Complicated grieving related to:

– Real or perceived loss – Bereavement overload


• Low self-esteem related to:

– Learned helplessness– Feelings of abandonment by significant

others– Impaired cognition fostering negative view

of self

Nursing Diagnosis Nursing Diagnosis (cont.)(cont.)


• Powerlessness related to:

– Complicated grieving process– Lifestyle of helplessness



• 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



• Social isolation/impaired social interaction related to:– Developmental regression– Egocentric behaviors– Fear of rejection or failure of the interaction



• Disturbed thought processes related to:

– Withdrawal into self– Underdeveloped ego– Punitive superego– Impaired cognition fostering negative

perception of self or environment



• Imbalanced nutrition less than body requirements

• Insomnia • Self-care deficit• All related to depressed mood



Nursing DiagnosesNursing Diagnoses

1. An individual experienced the death of a parent two years ago. This individual has not been able to work since the death, cannot look at any of the parent’s belongings, and cries daily for hours at a time. Which nursing diagnosis most accurately describes this individual’s problem?

A. Posttrauma syndrome R/T parent’s deathB. Anxiety (severe) R/T parent’s deathC. Coping, ineffective, R/T parent’s deathD. Grieving, complicated, R/T parent’s death


Nursing Diagnoses Nursing Diagnoses (cont.)(cont.)

• Correct answer: D– The excessive reactions the individual continues

to exhibit such as daily crying, the inability to return to work, and the inability to look at parent’s belongings after a two-year period, are indicative of dysfunctional or complicated grieving. This individual’s grieving response has arrested in the anger stage, is being turned inward on the self, and is manifested by symptoms of depression.


• 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

Criteria for Measuring OutcomesCriteria for Measuring Outcomes


• The Client (cont.):

– 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

Criteria for Measuring Outcomes Criteria for Measuring Outcomes (cont.)(cont.)


Planning/ImplementationPlanning/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


• Nursing interventions (cont.)

– 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

Planning/Implementation Planning/Implementation (cont.)(cont.)


Client/Family EducationClient/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?


• Management of the Illness– Medication management– Assertive techniques– Stress-management techniques– Ways to increase self-esteem – Electroconvulsive therapy

Client/Family Education Client/Family Education (cont.)(cont.)


• Support Services

– Suicide hotline– Support groups– Legal/financial assistance

Client/Family Education Client/Family Education (cont.)(cont.)


• Evaluation of the effectiveness of nursing interventions is measured by fulfillment of the outcome criteria.

Nursing Process: EvaluationNursing Process: 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?

Nursing Process: Evaluation Nursing Process: Evaluation (cont.)(cont.)


• 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?

• Have obsessions with and idealization of the lost object subsided?

• Is anger toward the lost object expressed appropriately ?

• Does client set realistic goals for self?



• Is the client 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 ModalitiesTreatment Modalities

• Individual Psychotherapy• Group Therapy• Family Therapy• Cognitive Therapy• Electroconvulsive Therapy• Transcranial Magnetic Stimulation• Light Therapy


• Psychopharmacology– Tricyclics (TCAs)– SSRIs– MAO inhibitors– Heterocyclics– SNRIs

Treatment Modalities Treatment Modalities (cont.)(cont.)


• Psychopharmacology (cont.)

– 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

Treatment Modalities Treatment Modalities (cont.)(cont.)


Psychopharmacology Psychopharmacology (cont.)(cont.)

– Contraindications/Precautions

• Contraindicated in known hypersensitivity (all), 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


– Interactions (with tricyclics)• Increased effects of tricyclics with bupropion,

cimetidine, haloperidol, SSRIs, and valproic acid• Decreased effects of tricyclics with rifamycin,

carbamazepine, and barbiturates• Hyperpyretic crisis, convulsions, and death can occur

with MAOIs• Hypertensive crisis can occur with clonidine• Decreased effects of levodopa and guanethidine• Potentiation of pressor response with direct-acting

sympathomimetics



– Interactions (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)



– Interactions (SSRIs)• Toxic, sometimes fatal, reactions have occurred with

concomitant use of MAOIs. • Increased effects of SSRIs with cimetidine, L-

tryptophan, and lithium• Concomitant use of SSRIs may increase effects of

hydantoin, tricyclic antidepressants, benzodiazepine, beta-blockers, carbamazepine, clozapine, haloperidol, phenothiazine, St. John’s wort, sumatriptan, sympathomimetics, theophylline, and warfarin.

• Concomitant use of SSRIs may decrease effects of buspirone and digoxin.

• Serotonin syndrome can occur with concurrent use of other drugs that increase serotonin.



2. When teaching about the tricyclic group of antidepressant medications, which information should the nurse include?

A. Strong or aged cheese should not be eaten while taking this group of medications.

B. The full therapeutic potential of tricyclics may not be reached for four weeks.

C. Long-term use may result in physical dependence.D. Tricyclics should not be given with antianxiety

agents.



• Correct answer: B– A client needs to be advised that it may take

several weeks for tricyclic medications to reach their full therapeutic effect and for relief of symptoms to be noted.



– Side effects• May occur with all chemical classes:

– Dry mouth, sedation, nausea– Discontinuation syndrome with abrupt withdrawal

• Most commonly occur with tricyclics and heterocyclics: – Blurred vision, constipation, urinary retention,

orthostatic hypotension, reduction of seizure threshold, tachycardia, arrhythmias, photosensitivity, weight gain



– Side effects (cont.)• Most commonly occur with SSRIs and SNRIs:

– Insomnia, agitation, headache, weight loss, sexual dysfunction, serotonin syndrome

• Most commonly occur with MAOIs:– Hypertensive crisis– Application site reactions (transdermal system)

• Miscellaneous side effects:– Priapism (with trazadone)– Hepatic failure (with nafazodone)



• 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.



• Avoid foods and medications high in tyramine when taking MAOIs. These include:

• Broad beans• Smoked and processed

meats• Soy sauce• Beef or chicken liver• Cold remedies• Canned figs• Diet pills

• Aged cheese• Caviar• Wine; beer• Raisins• Chocolate; colas• Pickled herring• Coffee; tea• Yeast products• Sour cream; yogurt



1. A client has been diagnosed with major depression. The psychiatrist prescribes paroxetine (Paxil). Which of the following medication information should the nurse include in discharge teaching?

A. Do not eat chocolate while taking this medication.B. The medication may cause priapism.C. The medication should not be discontinued

abruptly.D. The medication may cause photosensitivity.



• Correct answer: C– Antidepressants such as paroxetine must be

tapered and not stopped abruptly. All classifications of antidepressants have varying potentials to cause discontinuation syndromes. Abrupt withdrawal from SSRIs, such as paroxetine, may result in dizziness, lethargy, headache, and nausea.


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Copyright © 2014. F.A. Davis Company Depressive Disorders Chapter 25