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Chapter 25: Depressive Disorders
Exam 2 Nursing 260 Mental Health Lansing Community College Townsend 8th edition
Terms in this set (53)
A pervasive and sustained emotion that may have major influence on a person perception of the world
depression, joy, elation. anger, anxiety
Emotional reaction associated with an experience
1) An alteration in mood that is expressed by feelings of sadness, despair, and pessimism.
2) Loss of interest in usual activities and somatic complaints.
3) Changes in appetite and sleep patterns.
When does pathological depression occur?
when adaptation is ineffective.
Severe form of depressive disorder, symptoms are exaggerated and interest in virtually all activities is lost.
Age and Gender
Higher in women, 2:1 less difference between 44-65, post 65 women increase
Inverse relationship between social class and depressive symptoms. Hudson reports, most commonly occurring in low socioeconomic backgrounds
Race and Culture
No consistent relationship between race and disorder. More cases for whites, but more severe in blacks and are less likely to be treated
Marriage equals positive effects against depression. Single and divorced people are more likely to experience depression
Affective disorders are more prevalent in the spring and in the fall.
Types of Depressive Disorders:
Major Depressive Disorder
1) Depressed mood
2) Loss of interest or pleasure in usual activities.
3) Impaired social and occupational functioning
4) Lasts for at least 2 weeks
5) No history of manic behavior
6) Symptoms not due to substances or general medical condition
7) Diagnosis is ID'd by degree (mild, moderate, severe) and if there is psychotic, catatonic (unresponsive) or melancholic features
Types of Depressive Disorders:
Persistent Depressive Disorder (Dysthymia)
1) Milder that MDD.
2) Mood is sad or "down in the dumps"
3) No evidence of psychotic symptoms
4) Chronic, lasts most of the day, more days than not, for 2 years
5) ID'd as early onset (before 21) or late onset (21 or older)
Types of Depressive Disorders:
Premenstrual Dysphoric Disorder
1) Depressed mood, excessive anxiety, mood swings, decrease interest in activities during week prior to menses and shortly after. 2) Become minimal or absent after postmenses
Types of Depressive Disorders:
Substance/Medication-Induced Depressive Disorders
The depression is considered to be the direct result of physiological effects of a substance.
Types of Depressive Disorders:
Depressive Disorder Due to Another Medical Condition
1) The depression is attributable to the direct physiological effects of a general medical condition.
2) Also, medical condition causes distress or impariment in social, occupational or other areas.
Genetics and depression
Genetic link has been suggested, but definitive mode of transmission has yet to be proven
Suggest strong genetic factors of affective illness
-monozygotic twins indicate heritability of major depression 37%
More common among first-degree biological relatives with the disorder than general population.
Biological children of parents with mood disorders are at increased risk for development of disorders
Biochemical Influences on depression
1) Deficiency of norepinephrine, serotonin, and dopamine has been implicated.
--->Diminished supply inhibits transmission of impulses, causing failure of cells to fire or become charged.
2) Excessive cholinergic transmission may also be a factor.
---> It is thought that there is an imbalance between this and biogenic amines
Physiological Influences on depression
Depressive symptoms that occur as a consequence of a non-mood disorder or as an adverse effect of a medication
Medication side effects
--Side effects on CNS
--Excessive sodium bicarbonate or calcium, potassium can create symptoms of depression
--Imbalance of estrogen and progesterone
--Dysfunction of adrenal cortex, hypo/hyperparathyrodism, hypo/hyperthroidism.
--B1 (thiamine) B6 (pyridoxine) B12, niacin, C, Iron, folic acid, zinc, calcium, potassium
Psycho-social Theories of depression
Melancholia; A loss is internalized and becomes directed against the ego.
After experiencing numerous failures the individual abandons any further attempt to succeed , imposing a feeling of lack of control
Object Loss Theory
1) Experiences loss of significant other during first 6 months of life
2) Feelings of helplessness and despair
3) Early loss or trauma may predispose client to lifelong periods of depression.
1) Primary depression is cognitive rather than affective.
2) Three cognitive distortions that serve as the basis for depression:
** Negative expectations of environment
** Negative expectations of self
** Negative expectations of the future
The Transactional Mode
Recognizes combined effect of genetic, biochemical, and psychosocial influences on an individual's susceptibility to depression
Alter mood by changing the way one thinks, controlling negative thought distortions that lead to pessimism, lethargy, procrastination, and low self-esteem.
Focuses on changing automatic thoughts including personalizing, all or nothing, mind reading and discounting positives
Up to age 3
Signs may include feeding problems, tantrums, lack of playfulness, and emotional expressiveness, failure to thrive, or delays in speech and gross motor development
Common symptoms include accident proneness, phobias, aggressiveness, and excessive self-reproach for minor infractions
Vague physical complaints and aggressive behavior may cling to parents and avoid new people and challenges, may la behind their classmates in social skills and academic competence
Morbid thoughts and excessive worrying, may reason that it is because they have disappointed their parents in some way, may be a lack of interest in playing with friends
Commonly Precipitated by a loss
May be harder to recognize due to "normal adjustments" during this age group.
inappropriately expressed anger, aggressiveness, running away, delinquency, social withdrawal, sexual acting out, substance abuse, restlessness, and apathy, loss of self-esteem, sleeping/disturbances, psychosomatic complatins
Indicator that differentiates depression from typical stormy adolescence behavior
A visible manifestation of behavioral change that lasts for several weeks
What is the most common precipitant to adolescent suicide?
Perception of abandonment by parents or close friends.
Depression treatment in children and adolescents
1) Supportive psychosocial intervention
2) Antidepressant medication
Antidepressants in children and adolescents
All antidepressants carry an FDA black-box warning for increased risk of suicidality in children and adolescents.
Prozac and Lexipro
The only pharm management approved for teens. Other SSRIs and SNRIs have not been approved
Senescence (older adults)
Depression is most common psychiatric disorder in the elderly
1) Bereavement overload
2) High percentage of suicides among elderly
3) Often misdiagnosed as neurocognitive disorder (NCD) when in fact it is depression
What are three treatments of depression in the elderly patient?
1) Antidepressant medication
2) Electro convulsive therapy
3) Psychosocial therapies
1) May last for a few weeks to several months.
2) Associated with hormonal changes, tryptophan metabolism, or cell alterations
Loss of appetite
Loss of libido
Concern about inability to care for infant
Antidepressants and psychosocial therapies
Transient Depression assessment
Symptoms at this level of the continuum not necessarily dysfunctional
some difficulty getting mind off of one's disappointment
feeling tired and listless
Mild Depression Assessment
Symptoms of mild depression are identified by clinicians as those associated with normal grieving
preoccupied with loss
Moderate Depression assessment
Symptoms associated with dysthymia:
sluggish physical movements, slumped posture, limited verbalization
slow thinking processes, difficulty with concentration
anorexia or overeating, sleep disturbance, headaches
Severe Depression Assessment
Includes symptoms of major depressive disorder and bipolar depression
feelings of total despair, worthlessness, flat affect
psychomotor retardation, curled-up position, absence of communication
irrelevant delusional thinking with delusions of persecution and somatic delusions, confusion, suicidal thoughts
a general slow-down of the entire body
Depression nursing diagnoses
Risk for suicide r/t
1) Depressed mood
2) Feeling of hopelessness and worthless
3) Anger turned inward on the self
4) Misinterpretation of reality;
Complicated grieving r/t
2) Preoccupation with loss
3) Self blame
4) Grief a voidance,
Low self-esteem r/t
1) Learned helplessness
2) Guilt and shame
3) Hypersensitivity to criticism
4) Feelings of abandonment by significant others
5) Impaired cognition fostering negative view of self
1) Complicated grieving process
2) Lifestyle of helplessness
3) Dependence of others to fulfill needs
Spiritual distress r/t
1) Complicated grieving process over loss of valued object evidenced by anger toward God
2) Questioning meaning of own existence, inability to participate in usual religious practices
Social isolation r/t
1) Developmental regression
2) Egocentric behaviors
3) Fear of rejection
4) Dysfunctional interaction with others
5) Discomfort in social situations.
Disturbed thought process r/t
1) Withdrawal into self
2) Underdeveloped ego
3) Punitive superego
4) Impaired cognition fostering negative perception of self or environment
Imbalanced nutrition less than body required
Criteria for measuring outcomes for 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
• 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
Nursing interventions are aimed at
1. Maintaining patient safety
2. Assisting patient through grief process
3. Promoting increase in self-esteem
4. Encouraging patient self-control and control over life situation
5. Helping patient to reach out for spiritual support of choice
6. Assistance in confronting anger that has been turned inward
7. Ensuring that needs related to nutrition, elimination, activity, rest, and personal hygiene are met.
8. Provide a daily structures program, encourage patient to participate. (Depressed patients need structure)
9. Identify recent accomplishments (depressed patients have low self-esteem and feelings of worthlessness.
Three topics for family education relating to depression
Nature of the illness
1) Stages of grief and symptoms associated with each stage
2) What is depression?
3) Why do people get depressed?
4) What are the symptoms of depression?
Management of the illness
1) Medication management
2) Assertive techniques
3) Stress-management techniques
4) Ways to increase self-esteem
1) Suicide hotline
2) Support groups
3) Legal/financial assistance
Evaluating for outcome achievement
• 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?
• 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?
• 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
Individual Psychotherapy treatment
Assessed to determine extent of illness, information provided, contract negotiated
Treatment focuses on helping resolve complicated grief reactions
Therapeutic Alliance is terminated with emphasis on reassurance, clarification of emotional states, improvement of communication, testing of perceptions, performance in interpersonal settings and interpersonal psychotherapy has been successful
After the acute phase is done, discuss issues in life that cause, maintain or arise out of having the disorder
Initiate/restore adaptive family functioning, combination of psych and pharm.
Depression is characterized by negative thoughts, the future is seen as hopeless
Goals - assist the patient in identifying dysfunction patterns of thinking
The inductions of grand mal seizure though electrical current to the brain, acutely suicidal patients and those with severe depression
Transcranial Magnetic Stimulation
Targets certain cells in the brain, involves the use of very short pulses of magnetic energy to stimulate nerve cells
15-25% of depressed people have a seasonal pattern, theory is it helps to depress melatonin to help with sleep and activation. Sits in front of box with eyes open, 10-15 minutes sessions progressing to 30-45 minutes. Side effects include headache, eye strain, nausea, irritability, photophobia, insomnia, and hypomania
Medications used in treatment in depression
inhibit re-uptake of serotonin and norepi, alpha 1 adrenergic antagonist
inhibits re-uptake of serotonin at presynaptic membrane ( the idea is that depression is caused by decreased levels of serotonin
1) This drug class is the last line of antidepressants but can help with phobias.
2) 2nd or 3rd line antidepressant
3) inhibits monoxamine oxidase--enzyme breaks down a lot of different NTM.
inhibit re-uptake of norepi, increases adrenergic transmission and is for treatment of depression and Generalized anxiety disorder
Common Side Effects of all Antidepressants
• Dry mouth
• Discontinuation syndrome
Tricyclic and Heterocyclic Side Effects
• Blurred Vision
• Urinary retention
• Orthostatic hypotension
• Reduction of seizure threshold
• Weight gain
SSRIs and SNRIs Side Effects
• Weight loss
• Sexual dysfunction
• Serotonin syndrome
MAOIs Side Effects
• Hypertensive Crisis
• Application site reactions (transdermal system)
Miscellaneous Side Effects
• Priapism- trazadone
• Hepatic failure- nefazodone
Avoid foods and medication high in _________ when taking MAOIS
Some tyramine containing foods.
cheese, wines, olives, dried meets, fruits, salami, yogurt, aged meats, nuts, processed foods
This drug has a very low threshold for toxicity
Medication/food interactions (TCAS)
- concurrent use with MAOIs may cause severe hypertension
-concurrent used with antihistamines and other anticholingeric agents may result in additive anticholingeric effects
- concurrent use with direct-acting sympathomimetics may result in increased effects of these medications
-concurrent use with alcohol, benzodiazepines, opioids, and antihistamines may result in additive CNS depression
• Therapeutic effect may not be seen for as long as 4 weeks
• Drowsiness or dizziness can occur.
• Do not discontinue use of the drug abruptly.
• Use sunblock when outside.
• Avoid smoking while taking tricyclic therapy, increases metabolism of tricyclics requiring an adjustment in dosage.
• Avoid drinking alcohol, potentiate the effects of each other.
• Pregnancy risks
syndrome that has s/s tachycardia, HTN, fever, confusion, restlessness, tremors, hyperreflexia. The treatments is to slow down and wait for s/s to subside
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