Chapter 14

Depressive Disorders
 Major Depressive Disorder
 Five (or more) of the following in 2-week period
 Weight (weight loss or gain) and appetite changes
 Sleep disturbances (insomnia or hypersomnia daily)
 Fatigue
 Worthlessness or guilt
 Loss of ability to concentrate
 Recurrent thoughts of death
 Psychomotor agitation/retardation daily
 PLUS—at least one symptom is also either
 Depressed mood most of the day (irritable mood
inchildren) or
 Loss of interest or pleasure (anhedonia)
 Recurrent thoughts of death/suicide ideation
Major Depressive Disorder (Cont.)

 Persistent for minimum 2 weeks to 6 months

 Chronic: Lasting more than 2 years
 Recurrent episodes common
 Symptoms cause distress or impaired function
 Episode not attributed to physiological effects
 Absence of a manic or hypomanic episode
 PTSD
 Substance use disorders
 Coexistence with bipolar disorder
 MDD “specifiers”
 Atypical depression = weight gain,
hypersomnia / hypersensitive to rejection
 Melancholic depression = anhedonia 100% of
time / guilt / often mistaken for dementia
 Postpartum depression = 10%-15% of new
mothers /
 Psychotic depression = delusion &
hallucinations
 Seasonal affective disorder = depressed in
winter
 Epidemiology

 Leading cause of disability in the United States

 Children and adolescents
 Older adults
 Comorbidity
 Combination of anxiety and depression is perhaps
one of the most common
 Other DSM 5 Depressive Disorders:
 Disruptive Mood Dysregulation Disorder
6-18 years old / started before age 10
 Chronic, sever irritability with outburst 3+ X week
 Persistent Depressive Disorder: Dysthymia
 Depressed over 50% of the time for 2 years or more + two
major symptoms
 Can function but interferes with daily interactions
 https://www.youtube.com/watch?v=3tJdULtYcLM
 Premenstrual Dysphoric Disorder
 Occurs before and during menstruation
 Dysphora mood swings an irritability
 Sense of lose of control
 Risk Factors
 Biological factors
 Genetic (first-degree family members)
 Biochemical
• Stressful life events
 Hormonal
 Inflammatory
 Diathesis-stress model
• Interplay between genetic and biological
 Risk Factors (Cont.)
 Female gender
 Adverse childhood experiences
 Stressful life events
 Other disorders, such as substance use, anxiety,
and personality disorders
 Chronic or disabling medical conditions
 Nursing Process: Assessment
 Assessment of suicidality
 Self-assessment
 Behavior/Affect: Anergia
 Mood: Depressed mood and anhedonia
 Emotions: Anxiety; feelings of worthlessness,
hopelessness, guilt, anger, helplessness
 Thoughts/Perceptions: delusions and/or
hallucinations
 Comorbidity: chronic pain (sometimes)
 Behavior Symptomatic of Depression
Objective:
 Alterations of activity = pace, OCD, “poverty of

speech” / no ADL
 Altered social interactions = social isolation

Subjective:
 Alterations of affect = low self esteem, guilt, Anxiety
 Alterations in cognition = can’t concentrate or make

decisions
 Alterations of Physical nature = pain, anorexia, sexual

dysfunction
 Alterations of perception = delusions and

hallucinations
 based on dying, guilt or sense of worthlessness
 Nursing Process

 Nursing diagnosis
 Risk for suicide—safety is always the highest priority
 Chronic low self-esteem
 Imbalanced nutrition
 Constipation
 Disturbed sleep pattern
 Ineffective coping
 Disabled family coping
 Nursing Process (Cont.)

 Outcomes identification
 Recovery model
 Focus on patient’s strengths
 Treatment goals mutually developed
 Based on patient’s personal needs and values
 Nursing Process (Cont.)

 Planning
 Geared toward
 Patient’s phase of depression
 Particular symptoms
 Patient’s personal goals
 Key Nursing Interventions

 Bolster self esteem / empathetic approach

 Reinforce efforts to make decisions
 For severe indecision, nurse makes decision
 Never reinforce hallucinations/delusions
 Encourage expression of feelings, anger
 Spend time with withdrawn patients
 Observe closely, encourage interaction
 Milieu Interventions

 Brief and frequent interpersonal contacts

 Supportive group activities
 Opportunity to experience accomplishment and
receive positive feedback
 Assertiveness training
 Assistance with grooming and hygiene
 Ensure adequate nutrition / Prevent constipation
 Monitor and promote nighttime sleep / Discourage
daytime sleep
 Nursing Process (Cont.)

 Communication Techniques
 Use simple, concrete words
 Allow time for a response
 Listen for covert messages
 Ask about suicide plans
 Avoid platitudes
 When a patient is silent:
 Avoid direct questions
 Make observations to reinforce reality
Antidepressant Treatment Strategies

 First-line agents: SSRIs, novel

antidepressants
 Second-line agents: TCAs
 Third-line agents: MAOIs
 Antidepressants
 Selective serotonin reuptake inhibitors (SSRIs)
 First-line therapy
 Rare risk of serotonin syndrome
 Fewer side effects: nausea, diarrhea, weight gain, sexual
dysfunction, antidepressant apathy syndrome
 Serotonin norepinephrine reuptake inhibitors (SNRIs)
 SSRIs may be tolerated better
 Tricyclic antidepressants
 Anticholinergic adverse reactions
 Monoamine oxidase inhibitors
 Effective for unconventional depression
 Serotonin Syndrome
 serotonin syndrome. This syndrome is thought to be related
to overactivation of the central serotonin receptors caused by
either too high a dose or interaction with other drugs. The
symptoms are many: abdominal pain, diarrhea, sweating,
fever, tachycardia, elevated blood pressure, altered mental
state (delirium), myoclonus (muscle spasms), increased
motor activity, irritability, hostility, and mood change. Severe
manifestations can induce hyperpyrexia (excessively high
fever), cardiovascular shock, or death.
 The risk of this syndrome seems to be greatest when an
SSRI is administered in combination with a second serotonin-
enhancing agent, such as a monoamine oxidase inhibitor
(MAOI). A patient should discontinue all SSRIs for 2 to 5
weeks before starting an MAOI.
 Antidepressant concerns

 Lag time before symptoms improve

 Monitor for increased suicidal tendencies
 Monitor for cheeking and hoarding
 Monitor vital signs
 Observe for signs of early toxicity
 Be aware of drug-drug and drug-food
interactions
 Other Treatments for Depression
 Integrative Medicine
 St. John’s wort
 Brain Stimulation Therapies
 ECT
 Repetitive ranscranial magnetic stimulation (rTMS)
 Vagus nerve stimulation (VNS)
 Deep brain stimulation (DBS)
 Light therapy
 Exercise
 St. John’s Wort

 Flower processed into tea or tablets

 Thought to increase serotonin, nerepinephrin,
and dopamine in the brain
 Useful in mild to moderate depression
 Electroconvulsive Therapy
 The most effective depression treatment
 Psychotic illnesses = second most common
indication
 ECT the primary treatment in
 Severe malnutrition, exhaustion, and dehydration due
to lengthy depression
 Safer than meds with certain medical conditions
 Delusional depression
 Failure of previous medication trials
 Schizophrenia with catatonia
 Repetitive Transcranial Magnetic
Stimulation
 Noninvasive
 Uses MRI-strength magnetic pulses to stimulate
focal areas of the cerebral cortex
 Presence of metal is main contraindication
 Adverse reactions
 Headache and lightheadedness
 No neurological deficits or memory problems
 Seizures rarely
 Most are mild and include scalp tingling and
discomfort at the administration site.
 Vagus Nerve Stimulation
 Originally used to treat epilepsy
 Decreases seizures and improves mood
 Electrical stimulation boosts the level of
neurotransmitters
 Side effects
 Voice alteration (nearly 60% of patients)
 Neck pain, cough, paresthesia, and dyspnea, which
tend to decrease with time
 Deep Brain Stimulation
 Surgically implanted electrodes (in the brain)
 Stimulates those regions identified as
underactive in depression
 More invasive than VNS
 Electrodes placed directly into the brain
 Light Therapy

 First-line treatment for seasonal affective

disorder (SAD)
 Efficacy due to influence of light on melatonin
 Effective as medication for SAD
 Negative effects: headache and jitteriness
 Exercise

 Biological, social, and psychological effects

 Increases serotonin availability
 Dampens HPA axis (thought to be overly active
in depression)
 Risk Factors of Suicide
Eight out of ten people considering suicide give
some sign of their intentions
 Hopelessness / General medical illness

 Severe anhedonia

 Male / Caucasian or Native American

 Living alone / Prior suicide attempts

 Elderly

 Unemployed/financial problems

 Giving away possessions / saying good-by

 Starting antidepressants
Indications someone may be at risk

• Threatening to hurt or kill oneself

• Seeking access to means
• Talking, writing, or posting on social media about death,
dying, or suicide
• Feeling hopeless
• Feeling worthless or a lack of purpose
• Acting recklessly or engaging in risky activities
• Feeling trapped
• Increasing alcohol or drug use
• Withdrawing from family, friends, or society
• Demonstrating rage and anger or seeking revenge
• Appearing agitated
• Having a dramatic change in mood
Indications someone may be at risk
• Threatening to hurt or kill oneself
• Seeking access to means
• Talking, writing, or posting on social media about death, dying, or
suicide
• Feeling hopeless
• Feeling worthless or a lack of purpose
• Acting recklessly or engaging in risky activities
• Feeling trapped
• Increasing alcohol or drug use
• Withdrawing from family, friends, or society
• Demonstrating rage and anger or seeking revenge
• Appearing agitated
• Having a dramatic change in mood
 Suicide prevention

 Talk with them about what you are

seeing…
 Ask directly if they want to kill or harm
themselves,
 Ask them what brought them to this point
 Ask if they have a plan
 What can make them safe for now?
 1800 273 TALK text 741741
 In the hospital -
 One to one – arm length at ALL times
 No harm contract / agreement