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Chapter 12 Mood Disorders: Depression

Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Concept of Depression • Individuals with depression experience great personal pain and suffering • Depression common to all ages, races, and both sexes • Vulnerability to depression can be related to genetics and life stressors Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Depressive Disorders: Prevalence and Comorbidity • Prevalence – Fourth leading cause of disability in U.S. – Lifetime prevalence of major depressive disorder is 16.6% • More common in women

• Comorbidity – Frequently with other psychiatric disorders • Anxiety disorders, schizophrenia, substance abuse, and eating disorders

– Increases with presence of medical disorder Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Depressive Disorders: Developmental Aspects • Children as young as age 3 have been diagnosed with depression • Adolescents have increased incidence – Often associated with substance abuse and antisocial behaviors

• Older adults (>65) increased incidence – Increased suicide rate occurs with depression in this age group Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Biological Theories Related to Depressive Disorders • Genetics – Twin and adoptive studies point to genetic factors

• Biochemical factors: multiple neurotransmitters (NT) may be involved – Monoamine NT (serotonin, noradrenaline) – Research focused on role of dopamine, acetylcholine, and GABA receptors – Stressful life events can deplete NTs Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Biological Theories Related to Depressive Disorders • Neuroendocrine factors – Hyperactivity of hypothalamic-pituitaryadrenal cortex axis implicated – Increased cortisol secretion • Dexamethasone suppression test (DST) helps determine cortisol oversecretion

• Imaging results – CT and MRI scans show ventricle enlargement, cortical atrophy, sulcal widening Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Other Theories Related to Depressive Disorders • Psychodynamic factors: stress-diathesis model – Early life trauma sensitizes stress pathways in brain, increasing vulnerability to depression

• Cognitive theory: Aaron Beck – Automatic negative thoughts (of self, future and the world) related to depression

• Learned helplessness: Martin Seligman – Individual’s perception of lack of control over stressful life events leads to depression Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Major Depressive Disorder (MDD)

• Manifested by emotional, cognitive, physical, and behavioral symptoms occurring nearly every day for at least a 2week period – Symptoms represent a change in functioning

Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Major Depressive Disorder (MDD)

• DSM-IV-TR diagnosis can include specifiers – Psychotic features; catatonic features; melancholic features; postpartum onset; seasonal affective disorder (SAD); atypical features

Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Major Depressive Disorder: Common Symptoms • Emotional and cognitive symptoms: depressed mood, feelings of worthlessness and guilt, anhedonia, hopelessness, decreased concentration, recurrent thoughts of death/suicide • Physical: weight gain or loss, insomnia or hypersomnia, increased or decreased motor activity, anergia, constipation Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Dysthymic Disorder: DD • Characterized by chronic depressive syndrome usually present for most of day, more days than not, for at least a 2-year period (APA, 2000b) – Not usually severe enough for hospitalization unless person becomes suicidal

• Onset is usually early childhood, teenage years, or early adulthood Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Nursing Process: Assessment Guidelines • Use any of the multiple standardized depression screening tools available • Evaluate patient for suicidal ideation • Determine presence of emotional, cognitive, and physical symptoms of depression • Determine presence of other medical conditions contributing to depression Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Nursing Process: Assessment Guidelines • Determine history/current support system • Ascertain recent “triggering event” related to loss • Determine cultural beliefs/spiritual practices related to mental health treatment Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Nursing Process: Diagnosis and Outcomes Identification • Common nursing diagnoses assigned – Risk for suicide, Hopelessness, Ineffective coping, Social isolation, Self-care deficit

• Outcomes identification – Important to include specific goals for patient safety and outcomes related to vegetative/physical signs of depression Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Nursing Process: Planning and Implementation • Planning – Geared toward specific phase of depression and particular symptoms exhibited

• Implementation – Focus interventions on specific symptoms with priority related to suicide prevention – Teach patient and family about symptoms of depression, treatment, and medication – Focus on predischarge counseling to alleviate tension on family system Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Communication Guidelines for Patient with Depression • Understand that patient may need more time to reply to communication – Silence/sitting with patient can be therapeutic – Allow time for patient to respond

• Make observations related to patient/situation or environment • Avoid platitudes • Listen carefully for covert messages and question directly about suicide Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Treatment for Depression • Milieu therapy – Structured hospital environment helpful – Follow protocol for suicide prevention

• Psychotherapy – Cognitive-behavioral (CBT) and interpersonal (IPT) therapies used

• Group therapy – Helps decrease feelings of isolation, hopelessness, helplessness and alienation Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Treatment for Depression: Antidepressant Medications • Advantage – Can help alter withdrawal, vegetative symptoms, activity level; improve self-concept

• Drawback – Can take 1-3+ weeks to note improvement

• Safety considerations – Concerns about relationship between use of antidepressant drugs and suicide; however, no conclusive evidence to support this Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Treatment for Depression: Tricyclic Antidepressants (TCAs) • Action: inhibit reuptake of norepinephrine and serotonin by presynaptic neurons • Dose: start low and gradually increase • Common adverse reactions – Dry mouth, blurred vision, constipation, and urinary retention – Sedation

• Potential dysrhythmias, hypotension, myocardial infarction Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Treatment for Depression: Selective Serotonin Reuptake Inhibitors (SSRIs) • Action: selectively block neuronal uptake of serotonin • Common adverse reactions – Agitation, anxiety, sleep disturbance, tremor, sexual dysfunction, headache, weight changes, nausea, diarrhea, dry mouth

• Potential toxic effect – Serotonin syndrome (SS): potentially fatal reaction when more than one antidepressant used Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Symptoms and Treatment of Serotonin Syndrome (SS) • Symptoms – Hyperactivity, severe muscle spasms, tachycardia leading to cardiovascular shock, hyperpyrexia, hypertension, delirium, seizures, coma, death

• Treatment – Stop offending agents – Provide respiratory, circulatory support in intensive care environment – Use medications to reverse excess serotonin: cyproheptadine, methysergide, propranolol 21 Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

Treatment for Depression: Newer Atypical Agents • Action: affect variety of NTs including those affecting serotonin and norepinephrine • Advantage – Can target unique populations of depressed individuals – Can be used to treat other conditions Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Treatment for Depression: Monoamine Oxidase Inhibitors (MAOIs) • Action: enhance NTs at synapse by preventing the enzyme monoamine oxidase from breaking them down • Common adverse reactions – Hypotension, sedation, insomnia, changes in cardiac rhythm, muscle cramps, sexual impotence, anticholinergic effects, weight gain

• Potential toxic reaction – Hypertensive crisis Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Hypertensive Crisis and MAOIs • Can occur when monoamine oxidase inhibition prevents the breakdown of tyramine, which is used by the body to make norepinephrine • Preventing hypertensive crisis involves maintaining a special diet (low tyramine) and avoiding medications that contain ephedrine/other psychoactive substances Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Treatment for Depression: Somatic Treatments • Electroconvulsive therapy (ECT) – Course of treatment: 2 or 3 treatments/week for total of 6 to 12 treatments – For patients not responding to antidepressants or for depression with psychosis – Potential adverse reactions • Initial confusion and disorientation on awakening from treatment • Memory deficits Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Treatment for Depression: Somatic Treatments • Vagus nerve stimulation: long-term implanted treatment device approved by FDA for patients with treatment-resistant depression – Action: not well understood, affects neurotransmitters implicated in depression – Device implanted in upper chest that sends electrical signals to left vagus nerve in the neck at regular intervals Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Treatment for Depression: Integrative Therapies • Light therapy – First-line treatment for seasonal affective disorder (SAD) – Action: suppresses nocturnal secretion of melatonin, which seems to have beneficial effect on depression

Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Treatment for Depression: Integrative Therapies • St. John’s wort – Plant with antidepressant properties – Not regulated by FDA – Research suggests effective in mild depression

• Exercise – Research indicates mood elevation and decreased depression occurs with moderate exercise Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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Nursing Process: Evaluation

• Evaluate short-term indicators and outcome criteria – Reduction in suicidal thoughts – Able to state alternatives to suicide – Decrease in severity of emotional, cognitive and vegetative/physical symptoms of depression Copyright © 2009 by Saunders, an imprint of Elsevier Inc.

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