depression. incidence and prevalence n nimh --depression rate: 7.1% in women/postpartum depression...
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Depression
Incidence and Prevalence
NIMH --Depression Rate:• 7.1% in women/Postpartum Depression• 3.5% in men• 5.8% overall
Age of onset- anytime, highest in 20’s• Highest Prevalence-ages 25-44. • General Hospital adm. 10 to 15% depressed
– Box 29-3 page 380
Depression is a Type of Mood Disorders
Depressive Disorders• Major Depression
Disorder (MDD)• Dysthymic Disorder• Depressive
Disorder NOS
Bipolar Disorders (also considered a mood disorder)• Bipolar I• Bipolar II• Mixed episode• Cyclothymia• Bipolar spectrum
Symptoms of Major Depressive Disorder
5 of the following 9 Symptoms-2 weeks Depressed Mood Anhedonia Significant change in weight Insomnia or hypersomnia Increased or decreased psychomotor activity Fatigue or energy loss Feelings of worthlessness or guilt Diminished concentration or indecisiveness Recurrent death or suicidal thoughts
Symptoms of Major Depressive Disorder
One of the of the criteria must be:
• Depressed Mood
• Anhedonia
Dysthymic Disorder
A Disorder of Chronicity Depressed mood at least 2 years for more days
than not (>50% of the time) 2 or more of the following
• Poor Appetite or overeating• Insomnia or hypersomnia• Fatigue or low energy• Low self-esteem• Poor concentration• Feelings of hopelessness
Never free of symptoms for 2 months
Symptoms of Depression
Hopelessness Alterations in Activity
• Psychomotor agitation• Tired; poverty of speech• Poor hygiene• Weight loss or gain• Insomnia or hypersomnia• Uninterrupted self-defeating ruminations
Altered Social Interactions• Poor social skills• Withdrawn prefer Isolation
Symptoms of Depression
Alterations of Cognition• Inability to concentrate• Confusion• Easily distracted• Problems with thinking ideas and problem solving
Alterations of Affect• Affect is outwardly demonstrated emotion
– Low-self esteem– Worthlessness– Guilt– Anxiety– Hopelessness
Symptoms of Depression
Alterations of a Physical Nature• Somatic Complaints• Preoccupation with their bodies• Panic Attacks in 15% to 30% of people
with MDD
Symptoms of Depression
Alterations of Perception• Delusions and Hallucinations–Delusion of Persecution:
• For a moral or ethical mistake
–Somatic Delusions• They are full of cancer
–Nihilistic Delusions• Fears of death
Depression
Unified Model of Mood Disorders• Genetic Vulnerability• Developmental Events• Physiological Stressors• Psychosocial Stressors
This model believes that any of these can start the cycle of disturbed neurochemistry
Neurochemical Theories
Serotonin and Norepinephrine• Altered at the
receptor site• Receptor
sensitivity changes• The cells they
activate have lost the capacity to respond
Genetic Theories
Depression, major correlation, but not clear
Two thirds of twins are concordant for MDD if one or both parents have MDD
Endocrine
Elevated levels of corticotrophin releasing hormone
Elevated pituitary release of andreno-corticotropic hormone
Early live exposure to overwhelming trauma
Circadian Rhythm
Medications Nutritional deficiencies Physical illness Wake-sleep cycles
Etiology/psychosocial/depression
Freud believed depression was anger turned on the self; overactive superego
Sullivan-problems in the interpersonal areas of neglect, abuse, rejection, loss
Cognitive theories• Beck-Depression based on distorted thinking
patterns• Ellis-Concept of neg. self talk and
catastrophising
Psychosocial Cont.
Behavioral Theories- Believes that the way you act effects peoples response• Seligman- Developed theory of learned
helplessness, hopelessness and being unassertive
Loss theory• Bowlby-Loss during childhood predisposes
you to depression, esp. another loss
Cognitive Theory
How we think about our situation Aims at symptom removal by
identifying and correcting silent assumptions
Silent assumption: going to school is something I am doing for me.
Treatment Efficacy
Depression very treatable disease Episodes usually last 6 to 9 weeks Endogenous compared to
Exogenous depression
Treatment Efficacy
• Endogenous means from within– The client can not describe a specific event that
exacerbated the depression.• Exogenous means from without
– There is a specific event that triggers the depression• Loss of a loved one• Surgery• Retirement
• Psychotherapy may be enough for exogenous– Group Therapy for Grief
• Combination is best for endogenous– Medications– Individual or Group psychotherapy
Nursing Dx
Alteration in Nutrition: Less that body requirements
Sleep pattern disturbance Self care deficit Alterations in perception:Hallucinations Alteration in thought process:Delusions Potential for Violence: directed at self
Issues for Nurses with depressed Patients
Safety First: The milieu or environment should keep the client safe• Check all clients every 15 minutes• Locked environment• Remove all harmful items
– Mirrors, pocket knifes, razors, shoelaces, hangers Insomnia• Assess hours of sleep• Encourage exercise/Walking• Use relaxation Tapes• Medication as needed for sleep
Weight Loss - Anorexia
Observation of client during meals Record weight weekly• Can be recorded more frequently
Record amount eaten Assess client• Vital signs• Lab work
– A low albumin level or total protein will let you know the client is not eating well
Decrease Isolation
Approach is firm and direct “It is time for our 1-1 or Art Class or
Coping Skills Group” Listen and Acknowledge negative
feelings• If client has made suicide attempt,
important acknowledge their feeling. You do not agree with it but you let them know you heard it.
Other Issues
Anger: Use activities such as writing, discussing, and exercise
Agitated depression: May want to walk with patient
Simple, structured activities best in early treatment• A one page work sheet on feelings• An expressive drawing
– These are also activities that can be used to encourage communication about feelings
– Should be easy to complete and structured so the client is successful
Group Therapies
Assertiveness training Coping Skills Grief group Art therapy Insight oriented psychotherapy
Communications and Supportive Therapy
Establish trust Assess client’s negative
self talk• Ruminations
Provide another point of view
May be resistant to come to 1-1
Active listening, non-directive style
Cognitive Therapy Strategy
Have client list 3 negative thoughts about self• This must be limited in
number or could initiate rumination
Have client list 3 positive qualities about self• Talk with client about
positive qualities Goal to begin to replace
negative thinking with more positive thoughts
Family therapy
Depression of parent is very difficult for children• There may be role reversal and depersonalization of the
child– Child takes on care of younger children– Child tries to “cheer up parent”– Child tries to be prefect– Child acts out in order get attention (becomes a lightening
rod for the family) Client may feel like victim and want to change
family relationships (described in your book as feeling like “a doormat”
Marital relationship may need renegotiating• Client who is depressed may be taking on too much
responsibility
Treatment/Medications
Antidepressants• Tricyclics• Serotonin re-uptake Inhibitors /SSRI• Monoamine Oxidase inhibitors• Atypical Antipsychotic
Side Effect Profiles
TCA’S• Dry mouth• Blurred vision • Constipation• Sedation• Wt gain• Postural hypotension• Cardiac effects
– Can be cardiotoxic– EKG prior to starting
• Dizziness• Slow onset 2 weeks
SSRI’S• Nausea• Nervousness• Insomnia• Sexual dysfunction• headache• Low addiction potential• Slow onset 2 weeks
– This length of time is a consideration if client is suicidal
Managing Medication Side Effects
Orthostatic Hypotension• Teach the patient to rise slowly
Insomnia• Schedule dose early in day
Dry mouth• Hydrate• Hard candy or gum
Drowsiness• Schedule dose at night
Cardiac effects• Tricyclics may be supplied one week at a time
Serotonin Syndrome
A potentially fatal syndrome Too much serotonin Results from: Combination of Therapy
• Serotonin Reuptake Inhibitors used in combination with:• Prescribed:
– Tricyclic Antidepressants– Monoamine Oxidase Inhibitors– Lithium
• Over the Counter Medications:– Robitussin – Cold medications
• Other– LSD, Ecstasy
Serotonin Syndrome
Too much serotonin Symptoms:
• CNS-confusion• agitation • Hypomania• Myoclonus• Tremor• Hyperreflexia
Autonomic signs• Fever• tachycardia OR bradycardia• hypertension OR hypotension• Diaphoresis, diarrhea• severe dehydration can be fatal
Serotonin Syndrome
Side Effects of MAO’s
MAO’s can cause very serious hypertensive crisis
Client must be instructed not to drink red wine,eat cheese, yogurt any thing aged. Tyramine is chemical.
Also, pt must not take any medications without checking with their MD.
AVOID
Atypicals
Trazodone-Desyrel Nefazadone-Serzone Bupropion-Wellbutrin SR • (increases availability of dopamine
not serotonin)
Venlafaxine-Effexor XR Duloxetine/Cymbalta Mirtazapine-Remoran
Side Effects of Atypicals
Trazodone/Desyrel- Usually used for sleep: rare side effect; priapism
Nefazadone/Serzone: taken off the market because of liver toxicity
Wellbutrin: seizures at high doses, irritability, decreased appetite, worsening of tics
Effexor: Nausea, agitation, headache and increase in blood pressure
Remoran: Sedation, increased appetite
Electroconvulsive therapy
Beneficial for for Clients with• Severe Depression• Depression that is resistive to treatment with medications• Older adults
– Renal disease or Liver disease• Blood serum levels of medication increases
ECT seems to balance dopamine and serotonin • Procedure- Administer barbiturate, muscle relaxant, • Side effects- short term memory loss
– Initially: memory of events immediately prior to the procedure• Treatment 6-10 times
– Spaced several days apart After Treatment
• Client may have immediate relief of Depression