Depression

INTRODUCTION:When the negative reactions to life`s situations become

repetitively intense and frequent we develop depression. Life throws up innumerable
situations, which we greet with both negative and positive emotions such as excitement,
frustration, fear, happiness, anger, sadness,joy.
Depression is prevalent among all age groups, in almost all walks of life.
Persons of any age—children or adults, may develop depression. Even minor
stress events can stir up depression depending on the personality type.

WHAT IS DEPRESSION:-Depression is a common mental disorder that presents with

depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed
sleep or appetite, low energy, and poor concentration. These problems can become
chronic or recurrent and lead to substantial impairments in an individual's ability to take
care of his or her everyday responsibilities. At its worst, depression can lead to suicide, a
tragic fatality associated with the loss of about 850 000 thousand lives every year
DEFINITION:- Depression is a type of affective psychosis illness. This illness is also
called as melancholia and is characterized by a triad of symptoms.
Along with this delusion of various types like somatic, poverty, sin and guilt, nihilistic
and paranoid are present.Patient may have feelings of hopelessness, helplessness and
powerlessness. Illusions hallucinations and suicidal ideation are also common.
EPIDEMIOLOGY….Prevalence of depression is higher in younger population
between the age of 20-40 years. From this population 14.4% persons are suffering from
major depression, 10.5% are from recurrent brief depression, 0.9% are suffering from
dysthymia, 3.3%from bipolar disorder, 1.3%from hypomania. So on a average 49% of all
these cases received treatment for affective disorder.
What causes Depression?
 BIOLOGICAL FACTORS:
1. Heredity- genetic predisposition is common, life time risk is noticed in first
degree relatives of the client. If one parent is suffers, 25% chances for children to
have the disorders, if both parents are suffering, 50-70% chances to occur in
children. Twins are more predisposed, higher percentage(40-70) is observed in
identical/monozygotic/uniovular twins than dizygotic twins(20%).
Neuro-physiological factors:Imbalance in excitatory and inhibitory processes may
predispose MDP.Obliteration of excitatory functions leads to mania, inhibitory functions
may lead to depression.
PHYSICAL FACTORS: viral infections. For example, hepatitis, mono nucleosis.
Biochemical factors…:-Imbalance in catecholamine
(norepinephrine,dopamine)levels or its functions obliterate results into MDP.If
catecholamine amounts increased mania will occur, decreased levels predispose for
depression. Deficiency in serotonin levels results in MDP. Increase serotonin leads to
depression. These deficits interface with transmission of nerve impulses
from one cell to another resulting in an affect.
Neuro-Hormonal Factors:- Decreased cortisol secretions; alteration in
hippocampus functions predisposes for MDP. Due to non-adrenergic receptors
dysfunction in nocturnal period, alteration in pineal gland hormonal secretion (melatonin
hormone) results into MDP(Excess secretion leads to mania; decreased secretions leads
to depression)
II) Social Factors:
 Stressfull life events,traumatic or unpleasent or disturbing life experience
 Social pressures -Rejection of children by parents
 Difficult or strained interpersonal relationships;interpersonal loss,interpersonal
role dispute or transition or deficits
 Sociocultural factors -Loss of loved one(real or symbolic)
 Financial difficulties -Unemployment,poor job opportunities
 Criticism and rejection
 Failure in life, defeat, hardship in scholastic environment
 Faulty interactions within the social environment
 Environmental stress -Uncontrollable events or factors
 Maladaptive behavior -Unhealthy comparison
 Parental influence -Trying to escape from reality.
III) Physiological Factors:-
 Feeling of helplessness, hopelessness, inadequate, worthlessness
 Premorbid personality pattern-ambitious, energetic, social, will not express hostile
feelings, endomorphic in their built, uncontrolable impulsive behaviour, lack of
energy, breakdown under stress, introversion, insecurity, tendency to worry
always, dependency, obsessionality.
 Psychoanalytical factors-hostility, loss, conflicts within the self, borderline
personality traits predisposes for depression
 Cognitive factors-faulty cognition, Beck has described cognitive triad which
predisposes for depression as:
-perceiving oneself as defective as demanding and punishing
-expecting failure, defeat and hardship
-negative cognitions,i.e.negative expectations of environment, self, future.
Others Causes….Certain medications used alone or in combination can cause side
effects much like the symptoms of depression.
 Use of Alcohol or other Drugs can lead to or worsen depression.
 Depression can also occur for no apparent reason!
medicines That Cause Depression:-
 The following drugs have been reported to cause depression in some patients.
Elderly people are particularly at risk.
 Accutane -- This drug treats severe acne.
 Alcohol -Antabuse -- -Anticonvulsants. -Barbiturates --
 Benzodiazepines -- -Beta-adrenergic blockers --
 Bromocriptine (Parlodel) -- -Calcium-channel blocker -Estrogens --
 Fluoroquinolone antibiotics -Interferon alfa -- .
 Norplant -- Opioids -- Statins -Zovirax --
Types of depression:- psychogenic depression
Neurotic depression -involutional depression
 PSCHYCHOTIC DEPRESSION: It is a type of depression which is caused due to
factors present within the individual. Cyclothymic or dysthymic personalities are more
prone to develop this type of depression
NEUROTIC DEPRESSION: It is a type of depression in which external stimuli
play a significant role in manifestation of disease.
DIFFERENCE BETWEEN PSYCHOTIC AND NEUROTIC DEPRESSION
PSYCHOTIC DEPRESSION NEUROTIC DEPRESSION
 Significant stress situation preceding  Significant stress situation preceding the attack is
the attack is absent or may be present in always present and in moderate to severe in intensity.
minor intensity.
 Biological factors like heredity,  Environmental factors are more important as
constituation etc.are more important as etiological factor.
etiological agents.
 Seen more commonly in persons with  More common in persons with anxious, inadequate,
psychlothymic temperament and obsessive personalities.
constable personalities.
 Insomnia of early morning type such  Insomnia of early night type that the patient finds
that patient wake up at 2 a.m or 3 a.m difficulty in falling asleep sleeps only after loosing
and cannot sleep afterwards. about in bed for long time.
 Diurnal variation of mood present.  Inverse diurnal variation is present.Patient feels more
Patient feels more sad in the morning sad in the evening than in the morning.
than in the evening.
 Patient feels sad while in group.  Patient feels better in group than alone.
 Suicidal tendencies are more common.  Suicidal tendencies are rare.
 Psychomotor retardation is more  Anxiety and agitation are more common.
common.
 Relapses are common in spite of Relapses are inadequate if adequately treated.
adequate treatment.
 ECT and antidepressants drugs are the Psychotherapy and case work are the principle
principle treatment psychotherapy andtreatment. Antidepressants and antianxiety drugs are also
case work are of only supportive value. usefull.ECT does not give satisfactory results.
INVOLUTION DEPRESSION
Is a type of depression which occurs at the age of 45-55 years. In females it is
associated with menopause. In addition to symptoms of depression these patients suffer
from: -Anxiety -Hypochondriasis -Paranoid reaction
Symptoms of Depression:-Vary from person to person
 3 key signs are sadness of mood, poverty of ideas and psychomotor retardation.
Illusions hallucinations, delusions of sin and guilt and suicidal ideation are
common.
SIGN AND SYMPTOMS
PHYSICAL SYMPTOMS:- These may include:
Sleep disturbances such as early morning waking, sleeping too much or insomnia
Lack of energy -Loss of appetite -Weight loss or gain
Unexplained headaches or backaches
Stomachaches, indigestion or changes in bowl habits
Vague aches and pain in body
Dryness of mouth -Constipation -Urinary frequency
Sexual disturbances like diminished sex desire or interest
Pain in chest
EMOTIONAL SYMPTOMS:- Loss of cheerfulness
Diminished enthusiasm -Loss of interest in activities
Crying spells -Lack of confidence or low self esteem
Unexplained fear -felling of guilt and sin
Ideas of worthlessness,uselessness,hopelessness
Suicidal ideas
PSYCHOLOGICAL SYMPTOMS:-Psychomotor retardation
Slowing down of physical and mental activities
Avoiding people and social responsibilities
Tendency to postpone activities
Cannot take decisions
Neglect of daily routine and work
Negativism and stupor
Impaired concentration
Forgetfulness
Delusions of various types like somatic, poverty, sin and guilt, nihilistic and paranoid
Illusions and hallucinations may also be present
Unexplained worries and anxiety
Changes in behavior and attitude:- These may include:
General slowing down
Neglect of responsibilities and appearance
Poor memory -Inability to concentrate
Suicidal thoughts, feelings or behaviors
Difficulty making decisions
Additional Signs include: Changes in feelings which may include:
Feeling empty -Inability to enjoy anything
Hopelessness -Loss of sexual desire
Loss of warm feelings for family or friends
Feelings of self blame or guilt
Loss of self esteem& Inexplicable crying spells, sadness or irritability
Management..

Psychotherapy:- This can help many depressed people understand themselves and
cope with their problems. For example:
Interpersonal therapy works to change relationships that affect depression
Cognitive-behavioral therapy helps people change negative thinking and behavior
patterns.
GROUP THERAPY: In mild depression cases group therapy is helpful to overcome
negative feelings and to develop good interpersonal skills, by enhancing emotional
growth and support.
TASKS AND GOALS OF THERAPY:- Since a depression reaction is by a loss of
self esteem so this involve following tasks:
 Where the patient is lonely the therapeutic task may be uncovered the factors that
prevent from achieving the kind of objects relationship that are necessary for
adequate self esteem.
 Helping the client to identify his needs.
 Identify the defence mechanism that tends to isolate the patient.
 Identification of self defeating pattern of relating to the members of opposite sex.
To achieve these goals needs a long period intensive therapy.
Medication:- Antidepressants can help ease the symptoms of depression and
return a person to normal functioning. Antidepressants are not habit forming.
 Sedatives : These are indicated if patient is agitated. For example:
-Meprobamate
1200-1600mg
 Tranquilizers are given to reduce anxiety. These are few Tranquilizers…
-Alprazolam 0.75-4mg/day
-Clonazepam 1.5-20mg/day
Neuroleptics :
1. Chlorpromazine HCL
25-50 mg Tds
Stimulants: to lift up the mood.

1. amphetamines (Adderall) 20-200 mg

2. Methylphenidate(Ritaline)
3. Dextraamphetamine(Dexadrine)
Antidepressants :
2. Selective serotonin reuptake inhibitor. For example, Fluoxetine (Prozac);
Citalopram (celexa).
3.Monoamine oxidase inhibitors(MAO inhibitors). For example,
Phenelzine(Nardil); Isocarboxazid(Marplan)
Drug treatment is indicated in mild to moderate degree of depression, patients
where ECT is contraindicated or uneffective. Addition to all these treatment ECT is also
effective in depression. In chronic cases surgery like prefrontal leucotomy is also
recommended.
Electro Convulsive Therapy:-About 6-8 ECT’s are given over a period of 2-3
weeks. Excellent results are in endogenous depression.
INDICATIONS:
1. Severe attacks
2. Suicidal and homicidal tendencies
3. Stupor
4. Poor response to other treatment.

PROGNOSIS
 It depends upon:
Duration of illness:- shorter the duration carries better prognosis.
Type of depression:- Exogenous depression has better and long term prognosis than
endogenous depression.
Personality:-Well adjusted and healthy personality carries better prognosis than
maladjusted and neurotic personalities.
Type of onset:- Acute onset carries better prognosis than gradual onset.
Precipitating factors:- Presence of precipitating factors carries better prognosis than
absence of precipitating factors.
Number of attacks:- Repeat attacks results in poor prognosis.
Family history: Family history of depression carries poor prognosis.

DEFENCE MECHANISM:

Withdrawal Reaction/Seclusiveness: In this, to reduce frustration, an individual will

withdraw himself from painfull stimuli or difficulty situations as he cannot face the
problems in real life.
Denial: It is a primitive mechanism.The individual refuses to accept or to face the reality.
He protects himself from unpleasent situations. Like certain individual do not accept the
death of beloved ones.
Avoidance : In avoidance the individual try to avoid the real situation or reality.
Introjection : Introjection is an act of identifying with other’s norms and values to
himself. It may lead to serious distorted adaptations when guilty feeling starts to function.
Retroflexion

Activities assigned to depressive clients….Activities which needs little

concentration should be assigned to depressive patients e.g.
1. Taking a walk
2. Making beds with nurses
3. Setting up chairs
4. Playing simple card games
5. Looking through a magazine
6. Drawing
7 Watching rain and squirrels
Later on involve in:
 Dance therapy
 Art therapy
 Group discussion
8. Cleaning windows, pans
9. Mopping, washing clothes
10. Folk dance
11. Playing cards
12. Visiting vegetables market
Approach for depressive client..
 As a health care professionals we should go with Persuasive approach for the
depressive client.
  Avoid
-excessive bright colors dresses
-same pace
DIET….
 High protein, high caloric.
 Supplementation with vitamins fortifications of food
 Serve from same trolley
 Sit with patient while he or she is eating
NURSING MANAGEMENT
I) NURSING DIAGNOSIS:Dysfunctional grieving related to real or perceived loss
as evidenced by denial of loss in appropriate expression of anger, obsession with lost
objects, inability to carry out ADL’s.

INTERVENTIONS RATIONALE
1. Assess the stage of fixation in 1. Accurate baseline data is required to plan accurate
grief process. care.

2. Develop trust, show empathy,Provide basis for therapeutic relationship.

caring and positive regard to patient.
3. Spend short period of timeFrequent short periods minimize anxiety.
with the patient throughout the day.
4. Teach normal behaviourTo prevent feelings of guilt generated by these responses.
associated with grieving.
Nursing diagnosis IISelf esteem disturbances R/T learned helplessness, feeling of
abandonment by significant others as evidenced by feelings of worthlessness,
hypersensitivity to slight or criticism, negative and passive outlook.

INTERVENTIONS RATIONALE
1. Be acceptive of patient andYour presence and interest overtime can reinforce that you
spend time with him even if client is notreview the patient as worthwhile.
speaking.
2. Focus on strength andContribute towards feelings of self worth.
accomplishments and minimize failure.
3. Encourge patient to attendSuccess and independence promote feelings of self worth.
group therapies that offer patient simple
method of accomplishment. encourage
patient to be independent
4. Teach assertiveness andServe to enhance self- esteem.
communication techniques.

Nursing diagnosis III

 Powerlessness R/Tdysfunctional grieving process as evidenced by feelings of
lack of control over live situation, over dependence of others to fulfill needs.
 INTERVENTIONS RATIONALE
1. Allow patient to participate inProviding patient with choices will increase his/her
goal setting and decision making regardingfeelings of control.
own care.
2. Ensure that goals are realistic andTo avoid further failure.
that the patient is able to identify areas of
life situations that are realistically under his
control.
3. Encourge patient to verbalizeVerbalization of unresolved issues helps the patient to
feelings about areas that are not within accept what cannot be changed.
his/her control.
Nursing diagnosis IVSpiritual distress R/T dysfunctional grieving over loss of
valued objects as evidenced by anger towards GOD, inability to participate in usual
religious practice.

INTERVENTIONS RATIONALE

1.Be accepting and non-Nurse’s presence and non-judgemental attitude increases

judgemental when patient eexpress angerpatients feelings of self worth and promote trust in
and bitterness towards GOD.Stay withrelationship.
the patient.
2. Ensure patient that he or she isPatient feels comfortable.
not alone when feeling inadequate in the
search for life’s answer.
3. Contact some spiritual leadersValidation of patient’s feelings gives a feeling of
of patient’s choice if he or she request. acceptability to patient.

4.Encourage patient to ventilatePatient may feel that he or she cannot live without lost
his or feelings R/T meaning of ownobject and by doing this patient may feel better.
existing in the face of current loss

FOLLOW THE FOLLOWING..

 See a doctor for a complete check up.

 Go to the counseling center and talk to a counselor.
 Talk things over with a friend, family member or a residential life staff member.
 Don’t expect too much of yourself
 Take a break
 Get some exercise
 Avoid extra stress and big changes

Things to do…
 Reduce or eliminate the use of alcohol or drugs
 Exercise or engage in some form of physical activity
 Eat a proper, well-balanced diet
 Obtain an adequate amount of sleep
 Seek emotional support from family and friends
 Focus on positive aspects of your life
 Pace yourself, modify your schedule, and set realistic goals
Things to Avoid….
 Don’t make long-term commitments or important decisions unless necessary
 Don’t assume things are hopeless
 Don’t engage in “emotional reasoning” (i.e.: because I feel awful, my life is
terrible)
 Don’t assume responsibility for events which are outside of your control
 Don’t avoid treatment as a way of coping
Intervening with a depressed friend..
 Be empathetic and understanding
 Avoid critical or shaming statements
 Challenge expressions of hopelessness
 Empathize with feelings of sadness, grief, anger and frustration
 Don’t argue about how bad things are
 Don’t insist that depression or sadness are the wrong feelings to be experiencing
 Don’t become angry even though your efforts may be resisted or rejected
 Advocate for their recovery from depression
 Emphasize that depression is treatable
 Seek consultation
 Encourage them to seek help, go with them to the counseling center.