Depression

Objectives
Recognize DSM-IV-TR criteria

Recognize terminology for depressive d/os

Major depressive d/o and dysthymic d/o Theories of depression Nursing interventions Suicide and depression Family and cultural considerations

Criteria of MDD
At least 5 out of the 9 criteria, one must be a

depressed mood or anhedonia over a min 2-wwek period: Depressed mood Anhedonia or apathy Significant change in weight Sleep disturbances Changes in psychomotor activity Fatigue or loss of energy Feelings of worthlessness, guilt Difficulty concentrating, staying focused Suicidal thoughts

Symptoms of depression
Apathy

sadness,
Sleep disturbances Hopelessness

Helplessness
Worthlessness Guilt Anger (fatigue, decreased libido, psychomotor agitation,

passiveness, crying)

Subcategories of MDD
Atypical depression

Melancholic depression
Postpartum depression Psychotic depression Seasonal affective disorder (SAD) Dysthymic disorder

Behavior symptomatic of depression

Objective signs

Alterations in activities Alterations in social interactions Alteration of affect Alteration of cognition Alterations of a physical nature Alterations of perceptions

Subjective signs

Etiology of depression
Biologic theories

Genetic theories
Endocrine theories Cardiac rhythm theories Psychologic theories of depression

Drugs that may induce depression

Analgesics Anticonvulsants Antihypertensives Antiinflammatory agents Antiparkinsonian agents Antituberculosis agents Cardiovascular agents Psychotropic and CNS agents Miscellaneous

Medical Illnesses associated with Depression

CNS disorders

Collagen vascular diseases

Infections Neoplastic disorders Toxic-metabolic disturbances Other

Special Considerations
Working with children and adolescent pts

Working with older adults

Cultural, age, gender variables

Antidepressant Medications
Tricyclics (TCAs)
imipramine)
(amitriptyline, doxepin, desipramine,

Selective Serotonin Reuptake Inhibitors (SSRIs) (Prozac, Paxil, Zoloft, Luvox)

Serotonin-Norepinephrine Reuptake

Inhibitors (SNRIs) (effexor, serzone) Monoamine Oxidase Inhibitors (MAOIs)

(Nardil, Parnate): low tyramine diet to prevent hypertensive crisis

Others

(wellbutrin, trazadone)

Serotonin Syndrome
SSRIs+MAOIs= FATAL! Mental status changes, headache Restlessness/agitation Myoclonus Hyperreflexia Diaphoresis Shivering, tremors Ataxia

Hypertensive Crisis
(food-drug interaction, drug-drug interaction)

Headache, stiff neck

Nausea, vomiting
Sweating Dilated pupils, photophobia Tachycardia, bradycardia Sudden nosebleed Chest pain

Antidepressant Therapy Pointers

Lag time before symptoms improve

Monitor for increased suicidal tendencies

Monitor for cheeking and hoarding Monitor VS Observe for signs of early toxicity Monitor sexual side effects of SSRIs Be aware of drug-drug and drug-food

interactions

Treatment Focus
Safety

Support
Structure

Activity schedule Sample assignments Pleasure and mastery

Symptom Management

Milieu Management

Useful NANDA Diagnoses

Anxiety Impaired verbal communication Ineffective coping Grieving, anticipatory/dysfunctional Hopelessness Risk for injury Self-care deficit Social isolation Risk for self-directed violence Spiritual distress Disturbed sleep pattern

Suicide: Risk Factors

Hopelessness General medical illness Severe anhedonia Male Caucasian or Native American Living alone Prior suicide attempts Under 60 or elderly Unemployed/financial problems

Suicide Assessment
Ask about suicidal ideation (does not increase

suicidal behavior, provides a sense of relief and information) Assess

Is there a concrete plan? How lethal is the method? Agitation and severe anxiety are warning signs of suicide in bipolar patients Successful response to antidepressants can provide enough energy for depressed pts to commit suicide

Depression: Interventions
Accept pt, focus on strengths

Reinforce efforts to make decisions

For severe indecision, nurse makes decision Never reinforce hallucinations/delusions Accept anger Spend time with withdrawn patient Provide activities designed for success

Milieu Interventions
Opportunity to experience accomplishments and

receive positive feedback Help avoid embarrassment Supportive group activities Assertiveness training Assistance with grooming and hygiene Brief and frequent interpersonal contacts Assistance with nutrition and sleep Monitor and promote night-time sleep Discourage day-time sleep

Life Supporting Measures

Nutrition

Sleep
Activities of Daily Living

Bathing Grooming Mobility

Support Systems
Connect patient to existing and new support

systems

Family Friends Community agencies

Immediate Support
Build trust

Help with ADLs

Provide choices Implement cognitive learning techniques

Becks Cognitive Framework

Irrational beliefs produce irrational emotions

and behaviors Change involves changing beliefs in order to change feelings and behaviors Change is a process of rational thinking

Cognitive Interventions: 5 steps

Invite pt to participate in a specific activity within own

capabilities If pt refuses, emphasize importance of stating reason for not accepting the invitation Work together to evaluate validity of pts reasons Test validity of pts ideas by asking the pt to participate in the activity After a successful experience help the pt recognize how a favorable outcome contradicts the pts negative predictors

Example:
PT: no. I dont want to get washed up for

dinner. Itll take too much out of me. I just dont have the energy. Ill feel a whole lot worse than I do now. RN: Youre afraid youll feel more tired as a result of getting washed up. Im just wondering.would you be willing to do an experiment with me?

Example:
PT: Oh, I dont know, what is it? RN: Id like you to go to the sink with me. Id

like you to test out what it would feel like for you to just splash some water on your face.
PT: That doesnt sound very good to

mebut I suppose I could do that.

Hopeless Thinking Pattern:

PT: No. I dont want to get out of bedIm

too weaktoo tired. I need the rest. It wont do any good to get up; Ill just feel worse. Whats the use? RN: You seem convinced that you will feel worse if you get out of bed. Youve been in bed for a while nowhas the rest helped you feel any better? PT: NoIll just feel more tired. I just dont have any energy anymore.

Hopeless Thinking Pattern:

RN: One thing you know for sure then is that

you will likely not feel better continuing resting in bed. It is always possible you could feel worse getting up, but do you know that for sure? PT: No, I guess not

Hopeless Thinking Pattern:

RN: One of the things we have learned from

ptrs is that even though it is hard to get started, moving around does tend to give you a lift; that is, you may feel more energy as you walk around. Lets both see what happens when you dangle your feet off the edge of the bed.

Tunnel Vision (Funneling)

Viewing only one aspect to the exclusion of everything else. PT: No, I dont want to go swimming. I have a terrible looking suit. It really doesnt fit me very well and I just look awful in it. I couldnt stand for anybody to see me in it. RN: Suppose you had a suit you liked or suppose you werent very concerned about what others would think about your suit. Would be some things about swimming that you would enjoy?

Tunnel Vision (Funneling)

PT: Yes. It would be really nice to cool offI

do like the nice cool temperature of the water. It would probably feel good to get some exercise, too.