Chapter 16

Depressive Disorders

Copyright ©2019 F.A. Davis Company

 Epidemiology
• 6.7% of persons aged 18 or older had at least one major depressive
episode in the previous year.
• Gender prevalence
• Depression is more prevalent in women than in men by about 2 to 1.
• Age
• Lifetime prevalence of depressive disorders is higher in those aged 45 years or
younger.
 Epidemiology
• Social class
• There is an inverse relationship between social class and the report of
depressive symptoms.
• Race and culture
• No consistent relationship between race and affective disorder has been
reported.
• Problems have been encountered in reviewing racial comparisons.
Epidemiology

• Seasonality
• Affective disorders are more prevalent in the winter and in the fall.
• Marital status
• Single and divorced people are more likely to experience depression than are married
persons or persons with a close interpersonal relationship (differences occur in various age
groups).
 Types of Depressive Disorders
• Major depressive disorder
• Characterized by depressed mood
• Loss of interest or pleasure in usual activities
• Symptoms present for at least 2 weeks
• No history of manic behavior
• Cannot be attributed to use of substances or another medical condition
Types of Depressive
Disorders Persistent
depressive disorder
• Sad or “down in the dumps”
(dysthymia)
• No evidence of psychotic symptoms
• Essential feature is a chronically
depressed mood for
• Most of the day
• More days than not
• At least 2 years
Types of Depressive
Disorders Premenstrual
dysphoric disorder
• Depressed mood
• Anxiety
• Mood swings
• Decreased interest in activities
• Symptoms begin during the 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.
 Types of Depressive
Disorders
• Substance- or medication-induced
depressive disorder
• Considered to be the direct result of
physiological effects of a substance
• Depressive disorder associated with
another medical condition
• Attributable to the direct physiological
effects of a general medical condition
 Predisposing 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.
 Predisposing Factors to
• Neuroendocrine disturbances
Depression
• Possible failure within the hypothalamic-pituitary-adrenocortical axis
• Possible diminished release of thyroid-stimulating hormone
 Predisposing Factors to
• Physiological influences
Depression
• Medication side effects
• Neurological disorders
• Electrolyte disturbances
• Hormonal disorders
• Nutritional deficiencies
• Other physiological conditions
• The role of inflammation
 Predisposing Factors to
• Psychoanalytical Depression:
theory Psychosocial
Theories
• A loss is internalized and becomes directed against the ego.
• Learning theory
• Learned helplessness: The individual who experiences numerous failures learns
to give up trying.
 Psychosocial
• Object loss theory Theories
• 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.
• Cognitive theory Psychosocial Theories
• 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
Developmental Implications

• Childhood depression
• Symptoms
• < Age 3: Feeding problems, tantrums, lack of playfulness and
emotional expressiveness
• Ages 3 to 5: Accident proneness, phobias, excessive self-
reproach
• Ages 6 to 8: Physical complaints, aggressive behavior,
clinging behavior
• Ages 9 to 12: Morbid thoughts and excessive worrying
• Precipitated by a loss
• Focus of therapy: Alleviate symptoms and strengthen coping
skills
• Parental and family therapy
Developmental
Implications: Adolescence
• Symptoms include
• Anger, aggressiveness
• Running away
• Delinquency
• Social withdrawal
• Sexual acting out
• Substance abuse
• Restlessness, apathy
• 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
Treatment

• Treatment with
• Supportive psychosocial intervention
• Antidepressant medication

NOTE: All antidepressants carry a Food

and Drug Administration 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
• Psychotherapies
Postpartum depression

• May last for a few weeks to several

months
• Associated with hormonal changes,
tryptophan metabolism, or cell
alterations
• Treatments
• Antidepressants and psychosocial
therapies
• Symptoms include
• Fatigue/Irritability
• Loss of appetite
• Sleep disturbances
• Loss of libido
• Concern about inability to care for
infant
Transient depression
• Symptoms at this level of the continuum are not necessarily dysfunctional.
• Affective: The “blues”
• Behavioral: Some crying
• Cognitive: Some difficulty getting mind off of one’s disappointment
• Physiological: Feeling tired and listless
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
 Moderate depression
• Symptoms associated with dysthymic disorder
• Affective: Helpless, powerless
• Behavioral: Slowed physical movements, slumped posture, limited
verbalization
• Cognitive: Retarded 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: prevalent delusional thinking, with
delusions of persecution and somatic
delusions; confusion; suicidal thoughts
• Physiological: a general slow-down of the
entire body
 Diagnosis/Outcome
Identification
• Risk for suicide related to
• Depressed mood
• Feelings of worthlessness
• Anger turned inward on the self
• Misinterpretations of reality
• 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
• Powerlessness related to
• Complicated grieving process
• Lifestyle of helplessness
Criteria for Measuring Outcomes: Client

• Has experienced no physical harm to self

• Discusses 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
• Expresses personal satisfaction and support from spiritual practices
Outcomes: Client
• Interacts willingly and appropriately with others
• Is able to maintain reality orientation
• Is able to concentrate, reason, and solve problems
 Planning/Implementation
• Risk for suicide
• Be direct.
• Maintain close observation at irregular intervals.
• Encouraging verbalizations of honest feelings.
• Complicated grieving
• Develop a trusting relationship with the client.
• Encourage the client to express emotions.
• Communicate that crying is acceptable.
Client/Family Education

• Nature of the illness

• Stages of grief and symptoms associated with  Support
each stage
• What is depression? services
• Why do people get depressed?
• What are the symptoms of depression? • Suicide
• Management of the illness
• Medication management
hotline
• Assertive techniques • Support
• Stress-management techniques
• Ways to increase self-esteem groups
• Electroconvulsive therapy
• Legal/financ
ial
assistance
 Evaluation
• Has self-harm to the client been avoided?
• Have suicidal ideations subsided?
• Does the client know where to seek assistance outside of the hospital
when suicidal thoughts occur?
• Has the client discussed the recent loss with the staff and family
members?
Treatment Modalities

• Individual
psychotherapy
• Group therapy
• Family therapy
• Cognitive therapy
Electroconvulsive therapy

• Mechanism of action: Thought to

increase levels of biogenic amines
• Side effects: Temporary memory loss
and confusion
• Risks: Mortality; permanent memory
loss; brain damage
• Medications: Pretreatment medication;
muscle relaxant; short-acting anesthetic
Treatment Modalities

• Repetitive transcranial magnetic

stimulation
• Vagal nerve stimulation and deep brain
stimulation
• Light therapy
 Psychopharmacology
• Psychopharmacology
• Tricyclics
• Selective serotonin reuptake inhibitors
• Monoamine oxidase inhibitors (M A O I’s)
• Heterocyclics
• Serotonin-norepinephrine reuptake inhibitors
• Atypical
• St. John’s Wort
 Client/Family Education
• Continue to take medication for 4 weeks.
Related to Antidepressants
• Do not discontinue medication abruptly.
• Report sore throat, fever, malaise, yellow skin, bleeding, bruising,
persistent vomiting or headaches, rapid heart rate, seizures, stiff neck,
and chest pain to physician.
 Client/Family Education
Related to Antidepressants
• Avoid foods and medications high in tyramine
when taking M A O I’s. These include
Smoked and processed
meats Beef or chicken
Aged cheese liver
Wine; beer Canned figs
Chocolate; colas Caviar
Coffee; tea Raisins
Pickled herring
Sour cream; yogurt Yeast products
Soy sauce Broad beans
Cold remedies
Diet pills
Antidepressants:
Background
Assessment
• Indications Data
• Dysthymia, major depressive
disorder, depression associated
with organic disease, alcoholism,
schizophrenia, intellectual disability,
depressive phase of bipolar
disorder, and depression
accompanied by anxiety
Antidepressants:
Background
•Assessment
Action Data
• Increase concentration of
norepinephrine, serotonin, and/or
dopamine in the body either by blocking
their reuptake by the neurons (tricyclics,
tetracyclics, S S R I’s, SNRI’s) or by
inhibiting the release of monoamine
oxidase inhibitors (M A O I’s).
 Antidepressants:
Drug Interactions
with S S R I’s
Interacting Drugs Adverse Effects

Buspirone (BuSpar), T C A’s (especially Serotonin syndrome

clomipramine), selegiline (Eldepryl), Saint
John’s Wort

M A O I’s Hypertensive crisis

Warfarin, NSAID’s Increased risk of bleeding

Alcohol, benzodiazepines Increased sedation

Antiepileptics Lowered seizure threshold

Antidepressants:
Drug Interactions
with Tricyclic
Interacting Drugs Adverse Effects

M A O I’s High fever, convulsions, death

Saint John’s Wort, tramadol (Ultram) Seizures, serotonin syndrome

Clonidine (Catapres), epinephrine Severe hypertension

Acetylcholine blockers Paralytic ileus

Alcohol and carbamezipine (Tegretol) Blocks antidepressant action, increases sedation

Cimetidine (Tagamet), bupropion (BuSpar) Increased T C A blood levels, increased side effects
Antidepressants:
Drug Interactions
with M A O I’s
Interacting Drugs

S S R I’s, T C A’s, atomoxetine (Strattera), duloxetine

(Cymbalta), dextromethorphan (an ingredient in many
Adverse Effects

Serotonin syndrome

cough syrups), venlafaxine (Effexor), St. John’s Wort,

ginkgo

Morphine and other narcotic pain relievers, Hypotension

antihypertensives

All other antidepressants, pseudoephedrine, Hypertensive crisis (these side effects can occur
amphetamines, cocaine cyclobenzaprine (Flexeril), even if taken within 2 weeks of stopping M A O
dopamine, methyldopa, levodopa, epinephrine, I’s)
buspirone (BuSpar)

Buspirone (BuSpar) Psychosis, agitation, seizures

Antidiabetics Hypoglycemia

Tegretol Fever, hypertension, seizures

Quick Quiz
An individual experienced the death
of a parent 2 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. Post-trauma syndrome related
to parent’s death
B. Anxiety (severe) related to
parent’s death
C. Coping, ineffective related to
parent’s death
D. Grieving, complicated related
to parent’s death
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 4 weeks.
C. Long-term use may result in
physical dependence.
D. Tricyclics should not be given
with anti-anxiety agents.
Quick Quiz
An individual experienced the death
of a parent 2 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. Post-trauma syndrome related
to parent’s death
B. Anxiety (severe) related to
parent’s death
C. Coping, ineffective related to
parent’s death
D. Grieving, complicated related
to parent’s death
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 4 weeks.
C. Long-term use may result in
physical dependence.
D. Tricyclics should not be given
with anti-anxiety agents.
Quick Quiz

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.
Quick Quiz

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.