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Life's everyday disappointments, resolves on own.
Transient depression
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"it takes more effort" to accomplish things
Mild depression
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Multiple symptoms start to impair one's ability to get things done.
Moderate depression
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Very symptomatic making it impossible to accomplish ADL's
Severe depression
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Major depressive disroder (MDD)
Axis I
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In MDD symptoms persist for how long and include depressed mood and loss of interest in pleasure and activities and 4 of the following?
2 weeks.
- Increase or decrease in appetite 5% weight change
- Increase or decrease in sleep
- Psychomotor agitation or retardation
- Fatigue and loss of energy
- Decreased ability to think or concentrate
- Recurrent thought of suicide - hopeless, helpless
- Worthlessness or inappropriate guilt - delusional
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Usually occurs in fall and winter months characterized by hypersomnia, overeating, carb-cravings and weight gain.
Seasonal affective disorder (SAD)
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Symtoms occur within 4 weeks of delivery affecting 1-% of new mothers. Postpartum psychosis may occur.
Postpartum depression
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Develops within three weeks of delivery - progresses from fatigue and sadness to loss of touch with reality and includes psychosis.
- Postpartum psychosis
- (psychotic features can occur with a major depression disorder)
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A type of "low level" depression.
Dysthymia
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Person experiences at least 2 of the symptoms of MDD.
Dysthymia
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Little or no impact on social and occupationsl functioning.
Duration of at least 2 years in adults and one year in children and adolscents.
Dysthymia
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Statistics about depression:
- 1:6 chances
- Affects women twice as often
- Tendency to reoccur
- May affect up to 15% of elderly
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What may cause depression?
Genetics - may make a person more vulnerable to depression and the actual illness is triggered by outside sources.
Hormones and the hypothalmic pituitary adrenal axis - increased cortisol levels such as with the "stress response" release become chronically elevated.
Chemical imbalance - deficits in norepinephrine and serotonin or difficulties with these chemicals at the synaptic level
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According to Dr. Freud...
He observed that "melancholia" (sadness or depression) occurs after the loss (perceived loss) of a loved object.
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According to Aaron T. Beck...
- Theory states that depression is due to cognitive disorders in susceptible people.
- Early influences and experiences caused their outlook to magnify negative events, traits, and expectations.
- Dr. Beck is widely regarded as the father of cognitive therapy
- Also developed several "tools" to assess depression including the Beck Depression Inventory
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Medical illnesses/medications account for up to 10-15% of mood disorders such as
- Hypothyroidism
- Hyperthyroidism
- Heart attack survivors
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Additional medical conditions that may cause mood disorders:
- CVA
- Dementia
- Cancer
- Chronic fatigue
- AIDS
- Degenerative neurological conditions such as Parkinsons
- Lupus
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Additional medications that may cause mood disorders:
- Betablockers
- Calcium channel blockers
- Benzodiazepines
- Anti ulcer drugs
- Hormones (oral contraceptives)
- Glucocorticoids
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How is depression diagnosed?
- May present as medical problem such as headache, stomach ache, sexual problems, lack of energy, trouble sleeping.
- Primary care providers often rely on "screening tools" or questionnaires when they suspect depression
- Lab studies: CBC, VDRL (syphilis), thyroid panel, CMP, EKG, UA, AIDS
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The depressed individual may remain under the care of their primary care provider if they respond well to the first medication prescribed and if they get frequent follow up
Mild depression is often treated by the PCP
Refer to specialist for more complicated cases.
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When to see a specialist or therapist:
Recovery is quicker - relapse is less likely if the patient receives an antidepressant in conjunction with therapy.
- Cognitive behavioral therapy
- interpersonal psychcotherapy
- Psychodynamic therapy
- Group of family therapy
- Light therapy
- ECT
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Depression and the elderly:
- Bereavement overload - grief accumulates.
- Depression vs. dementia
- White males over the age of 85 have the highest suicide rates in the US.
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Represents a medical and mental health emergency and is the most serious complication of depression
Also requires inpatient management until stable.
Suicide
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Treatment for mood disorders:
- Psychopharmacology - hospitalization
- Mood stabilizers such as lithium and anti seizure medications
- Anti-psychotic drugs
- Antidepressants
- Anti-anxiety medications
- Forms of psychotherapy
- Group and family therapy
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Nursing process for the depressed patient:
- At risk for self harm
- Anxiety
- Chronic low self esteem
- Sleep disorder
- Nutritional imbalances
- Hopelessness
- Dysfunctional grieving
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Nursing interventions for the depressed patient:
- Acceptance
- Suicide precautions
- Promote sleep, nutrition and ADLS
- Avoid excessive cheerfulness
- Promote social interactions
- Deal with delusions
- Teach about MDD and medication issues
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Be prepared to deal with common negative cognitions:
- Overgeneralizations
- All or nothing like thinking
- Should have, could have
- Labeling
- Fortune telling
- A world view that places them in unattractive incompetent hopeless setting.
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Family Education focus:
- Address knowledge deficits
- Explain the disorder and treatment
- Emphasize follow up
- Crisis management and prevention
- Acceptance
- Avoid secondary gain
- family therapy and respite issues
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Community based care:
- Support groups such as NAMI for families and patients
- Primary detection of disorders
- Consider role of co-occuring substance abuse issues
- Medication compliance and affordability issues
- Role of social rehab instead of physical rehab
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Self-awareness issues for nurses dealing with MDD:
- "I hope this mood isn't contagious - I think I'll just avoid Mr Jones it's too much"
- "He's just hopeless - so negative and incompetent "Mr Jones, if I were you I'd just pull myself up by my bootstraps and get a grip on all of this..."
- When Mr. Jones doesn't like my suggestions, I feel incompetent and unprofessional
- What's your nursing goal with Mr. Jones?
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