depression (unipolar)

  1. Intro
    • one of the oldest and most frequently dx
    • transient symptoms are normal, healthy response to everyday life disappointment
    • Mood disorders, like depression also called Affective disorders which are pervasive alternation in emotions exhibited by long term sadness, agitation (esp in children), anger, guilt, or self doubt or bipolars periods of extreme elation
    • depression interferes with all aspects of life, work recreation and relationships
  2. More intro
    • pathological depression occurs when adaptions is ineffective, poor coping and lack of resources
    • the term mood is used interchangable with affect. however mood is subjectively reported and affect is objectively observed
    • Major depression is an alteration in mood that is expressed by feelings of sadness, despair and pessimism, it is ofeten accompanied by a sense of worthlessness and hopelessness (hard to change their mind)
  3. Historical & cultural perspectives
    • many ancient cultures believed in the supernatural or divine origin of mood disorders
    • hippocrates believed that melancholia was caused by an excess of black bile, a heavily toxic substance produced in the spleen or intestine, which affected the brain
    • many cultures still believe that depression occurs due to loss of harmony with environment or by evil spirits or as punishment for non-conformity to culture or religion
  4. Epidemiology
    • NIMH est. 16 million adults in the US experienced a depressive episode in 2015
    • 7% if the total adult population
    • makes up 3.7% of all US disability
    • left untreated could last for yrs
    • during their lifetime about 21% of women and 13% of men will become clinically depressed
  5. Epidemiology more
    • Gender prevalence
    • depression is prevalent in women than menĀ  2
    • to 1
    • women experience depression at an earlier age
    • gender socialization promotes female as more passive and helpless, which associates with depression
  6. Depression in men
    • men are less likely to admit to depression and healthcare providers are less likely to suspect it
    • nearly 4x as many men commit suicide
    • typically presents as irritable, angry, and discouraged
    • often masked by substance abuse or overworking
    • choose more lethal means to die ie gunshot
  7. Epidemiology
    • depression is more common in young women than young men. children depression is under-recognized and undertreated
    • the gender difference is less pronounced between the ages 44 and 65, women are again more likely to be more depressed
  8. epidemiology
    social class
    • social class
    • there is an inverse relationship between social class and report of depressive symptoms
    • higher class has more depression
    • race
    • no consistent relationship between race and affective disorder has been reported
    • one recent survey revealed:
    • - depression is more prevalent in whites than blacks
    • - depression is more severe and disabling in blacks
    • - blacks are less likely to received tx than whites
  9. epidemiology
    marital status
    • single and divorce people are more likely to experience depression than married persons or persons with a close interpersonal relationship (differ in various age groups)
    • esp true 37-49 yrs old group
  10. epidemiology
    • affective disorders are more prevalent in the spring and the fall
    • this pattern seems to parallell the seasonal pattern for suicide
    • theory is possible variation in serotonergic function or increase or decrease in social
    • - light therapy- serotonin and melatonin
  11. co-morbidities
    • anxiety disorders, approx 70%, pooer progonosis
    • psychotic disorders (schizo)
    • substance use disorders
    • personally disorders
  12. co-morbidities
    • anxiety disorders- approx 70%, poorer prognosis
    • ADHD
    • Conduct disorders- repetitive, persistent behavior where basic rights of others are violated, physical aggresion can also be seen (some psychologist believe this disorder is a precursor to anti-social personality disorder)
    • substance abuse- older children and adolescents
    • cd- anxious, irritable, aggression smashing things in school
    • can turn into antisocial disorder
  13. risk factors
    • fam hx
    • personal hx
    • female
    • over 65
    • stressful life events
    • NT deficiencies
    • medical illness
    • postpartum
    • poor social support network
    • co-morbid substance abuse
    • unmarried
  14. five types of depressive disorders
    • major depressive disorder
    • dysthymic disorder
    • premenstrual dysphoric disorder
    • substance induced depressive disorder
    • depressive disorder associated with another medical condition
    • uniqiness of each find a difference
  15. Major depressive disorder
    DSM criteria
    • must have a total of 5 symptoms for a least 2 weeks andmust be a chance from previous functioning
    • at least 1 symptom must be depressed mood or loss of interest/pleasure
    • no manic episode
    • not attributed to substance use
  16. Major depressive
    DSM criteria
    • significant weight loss/gain
    • insomnia/hypersomnia
    • psychomotor retardation/ agitated
    • fatigue or loss of energy nearly everyday
    • feelings of worthlessness/excessive guilt= coginitive
    • decrease ability to concentrate, collect thoughts- coginitive
    • recurrent thoughts of death/suicidal ideation (SI)
  17. Dysthymic disorders
    • chronic low level depression, most of the day, more days than not for at least 2 yrs and at least 2 or more of the following symptoms:
    • poor appetitie or overeating
    • insomnia/hypersomnia
    • low energy/fatigue
    • low self esteem
    • negative thinking/guilt
  18. dysthymic disorders
    • similar but much milder symptoms, sort like 'down in the dumps'
    • poor concentration/decision making
    • hopelessness
    • irritablity/anger
    • anhedonia (loss of pleasure)/withdrawal
    • no evidence of psychotic thinking- no mania
    • note this can develop into major depression
  19. premenstrual dysphoric disorder
    • depressed mood
    • anxiety
    • mood swings
    • decreased interest in activities
    • symptoms begin during week prior to menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week of post menses
    • tx birth control, anti-depressants
  20. other types of depressive disorders
    • substance-induced depressive disorder
    • - considered to be the direct result of physiological effects of a substance
    • - depressed mood assoc with intoxication or withdrawal
    • Depressive disorder Associated with another medical condition
    • - Attributable to the direct physiological effects of a general medical condition such as stroke, cancer or MI directly
  21. predisposing factors to depression
    biological theories
    • genetics
    • hereditary factor may be involved
    • affective disorders tend to run in families and a definite association has been scientifically established
    • twin sister
  22. predisposing factors
    biochemical influences
    • deficiency of norepinephrine, serotonin, and dopamine has been implicated
    • excessive cholinergic transmission may also be a factor (overdrive produce nuero-endocrine and behavioral features of melancholy
  23. predisposing factors
    neuroendocrine disturbances
    • possible failure within the hypothalamic-pituitary-adrencortical axis (feedback look regulates stress, digestion, immune status, energy and mood)
    • elevated glucocorticoid activity associated with the stress response and evidence of increased cortical secretion is apparant in about 40% of patient with depression (increase in inflammatory process)
  24. predisposing factors
    • possible dimishing release of thyroid-stimulating hormone (decrease body metabolism, fatigue, irritability, constipation, slow thinking, depressed mood)
    • hormonal disorders (cusing, addison or issues within adrenal cortex causing debilitating fatigue)
  25. predisposing factor
    physiological influences
    • medication side effects (steriods- could make you angry, estrogen, and sedative)
    • neurological disorders (tumors, cva)
    • electrolyte disturbances (incr Na, K)
    • nutritional deficiencies (vita b)
    • other physiological condition (SLE-lupus)
  26. Predisposing factors
    psychological theories
    • cognitive theory
    • - views primary disturbance in depression as cognitive rather than affective
    • - three cognitive distortation that serve as the basis for depression
    • * negative expectation of the environment
    • * negative expectations of the self
    • * negative expectation of the future
    • tx
    • cognitive therapy w/medications
    • chx mood and thought process then behavior will change
  27. developmental implications
    • childhood depression
    • adolescence
    • senescence
    • postpartum depression
    • - hormones
    • - young women
    • - intimacy v isolation
  28. developmental implications
    childhood depression
    symptoms ages
    • < age 3: feeding problems, tantrums, lack of playfulness and emotional expressiveness
    • age 3-5: accident proneness, phobias, excessive self-reproach,
    • ages 6-8- physical compliants, aggressive behavior, clinging behavior
    • ages 9-12: morbid thoughts and excessive worrying
    • children- anger
  29. developmental implications
    childhood depression
    • precipated by a loss (divorce loss of pet, death or even academic failure
    • focus of therapy- alleviate symptoms and strengthen coping skills
    • parental and fam therapy
  30. Developmental implications
    • anger, agressiveness
    • running away
    • delinquency
    • social withdrawal
    • sexual acting out
    • substance abuse
    • restlessness, apathy
  31. developemental implications
    • despression/suicide 2nd leading cause of death
    • best clue that differentiates depression from normal stormy adolescent behavior
    • - a visible manifestation of behavior change that last for several weeks (grades drop, skip classes, withdraws when they were very social)
    • most common precipitant to adolescent suicide
    • - perception of abandonment by parents or close peer relationship
  32. developmental implications
    • often not caught and when it is often untreated
    • treatment with
    • - supportive pyschosocial intervention
    • - antidepressants medication
    • note: all antidepressants carry a FDA black box warning for incr risk for suicide in children and adolescents. does not mean can't treat, but require very close monitoring
  33. developmental implications
    senescence (period of old age)
    • beveavement overload, physical and financial stressors and loneliness (support)
    • high percentage of suicide among elderly
    • symptoms of depression often confused with symptoms of neurocognnitive disorder
    • treatment
    • - antidepressant meds
    • - electroconvulsive therapy
    • - psychosocial therapies
  34. development implications
    postpartum depression
    • may last for a few weeks to several months
    • associated with hormonal changes, tryptophan (turkey, amino acid) metabolism or cell alteration
    • treatment
    • - antidepressants and psychosocial therapies
    • symptoms include
    • - fatigue and sleep disturbances
    • - irritability
    • - loss of appetite
    • - loss of libido
    • - concern about inability to care for infant
  35. continuum of depression
    • transcient
    • - life's everyday disappointments
    • Mild
    • - normal grieve response- loss of someone
    • moderate
    • - dysthymia
    • severe
    • - major depressive disorder
  36. nursing process assessment
    transcient depression
    • symptoms not necessarily dysfunctional
    • Affective- the blues
    • behavioral- sometimes crying
    • cognitive- some difficulties getting mind off disappointments
    • physiological- feeling tired and listless
    • (going to go away, last about a day, sad about disappointment)
  37. nursing process assessment
    mild depression
    • symptoms of this are identified by clinician as those associated with normal grieving
    • affective: anger, anxiety
    • behavioral- tearful, regression
    • cognitive: preoccupied with loss
    • physiological- insomnia, anorexia
  38. assessment
    moderate depression
    • symptoms associated with dysthymic disorder
    • affective: helpless, powerless
    • behavioral: slowed physical movements, slumped posture, limited verbalized
    • cogitive: retarded thinking process, difficulty with concentration
    • physiological: anorexia or overeating, sleep disturbances, headache
  39. assessment
    severe depression
    • symptoms associated with major depression
    • affective: feelings of total despair, worthlessness, flat affect
    • behavioral: psychomotor retardation, curled up (ball), 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
    • main suicide with this. vegative signs- noting eating, drinking, withdrawal
  40. starting the assessment
    • physiologic: r/o organic causes first
    • appetite
    • vital signs
    • hydration
    • sleep pattern changes
    • activity level
    • fatigue- energy level
    • constipation
    • weight loss
    • sex drive
  41. use diagnostic evaluation tools
    • rating scale- hamilton
    • ask how would you describe your mood
    • when did yous tart feeling like this
    • how is your appetite and sleep
    • what have you been doing to manage those feelings
    • how much of the day do you feel depressed
  42. prognosis of depression
    • with tx prognosis is favorable
    • can be with controlled with:
    • medication
    • psychotherapy
    • self-help strategies
    • - including excerise and proper nutrition
    • need for education, lifetime monitoring, maintenience tx
    • lack of adherence, resistance of symptoms may lead to some impairments in daily functioning for long periods of time (which can lead to relapse)
  43. planning/implementaion
    • maintaining pt safety (not making good decision, not eating, risk for suicide)
    • promoting increase in self esteem
    • ensuring needs, r/t nutrition, elimination, activity, rest and personal hygience are met
    • encouraging pt self control and control over life situation and helping pt to reach out for spirtual support of choice
    • assistance in confronting anger that has been turned inward towards self - trying to draw out reason
    • assisting client thru grieve process
    • set goals at their level
    • 1 day- lots of positive reinforcements
  44. examples of nx dx
    risk for suicide/self harm related
    • depressed mood
    • feelings of worthlessness/hopelessness
    • anger turned inward on the self
    • misinterupretation of reality
  45. interventions for risk of suicide/self harm
    • approach the pt calmly and non judgementally as this promotes trust n self worth
    • assess pt for thoughts of SI with or without a plan every shift periodically throughout the day
    • look for withdrawal, tearfulness, rumination
    • contract with the pt for no self harm
    • one to one supervision- cna/tech
    • keep environment free of safety hazards
  46. examples of nursing diagnosis
    complicated grieving r/t
    • real or percieved loss
    • bereavement overload (multiple losses, tragic events ie murder)
    • grief after loss last for more than six months occurs in waves
  47. intervention for complicated grieving
    • determine the stage of grieve
    • show empathy, concern, unconditional positive regard
    • encourage expression of anger (may be displaced)
    • communicate that crying is good
    • teach normal stages of grieve and feelings of guilt and anger toward the lost person
    • review relationship with lost person with support and sensitivity
    • encourage reaching out for spiritual support
  48. examples of nursing dx
    low self esteem r/t
    • learned helplessness
    • feelings of abandonment by significant others
    • impaired cognition fostering negative view of self
  49. intervention for low self esteem
    • encourage participation in activities, one task at a time- come to group
    • provide assertiveness training
    • help pt avoid embarassing themselves through socially runny nose etc
    • seek things they are strong at, art, music singing and encourage them to share this with you to help them feel accomplished
    • spend quality time with patient
  50. ex of nx dx
    powerlessness r/t
    • complicated grieving process
    • lifestyle of helplessness
  51. intervention of powerlessness
    • encourage pt to explore and verbalize feelings and perceptions
    • help pt identify reasons for feeling hopeless and powerless
    • listen actively, don't force group interaction
    • assist pts to identify helpful support people
    • help pt identify areas of life that are under own control
    • help search for available resources, teach problem- solving skills
  52. ex of nx of dx
    social isolation/impaired social interaction r/t
    • developmental regression
    • egocentric behaviors (turned inward)
    • fear of rejection or failure of the interation
    • poor social skills link directly to s/s of depression ie lack of focus, reduced interest in others, problems thinking so conversation are difficult use silence and wait
    • meds
  53. intervention for social isolation
    • spend time with pt
    • keep contact brief but frequent
    • accompany pt with brief activities
    • i know you feel like staying in bed but it is time for breakfast
    • my name is george and i am ur nurse today.i am going to sit with you for a few minutes. if you need anything or if you like to talk just let me know.
    • after time has past say i am going now, i'll back in a hour
  54. other nx dx
    imbalanced nutrition less than body requirements
    • insomonia
    • self- care deficit:
    • - all r/t depressed mood
    • - so important...need frequent planned nursing interventions, since they are too fatigued, manic, depressed, withdrawing etc
    • offer snacks
  55. nursing interventions for self care deficits
    • provide assistance with care as necessary after assessment
    • break care steps up into steps
    • provide for short rest periods
    • provide positive reinenforcement and recognition for completing activities
  56. nx intervention for altered nutrition/impaired sleep
    • access intake of food and fluids and wt
    • offer nutritionous finger food
    • high fiber, inc fluids (constipation accompanies depression)
    • esta a routine for sleep at night
    • avoid letting pts sleep for long periods of time during the day
    • insomnia avoid caffeine
  57. evaluation
    • has self harm to client been avoided
    • have SI subsided
    • does the pt know where to seek assistance outside the hosp when suicidal thoughts occur
    • has the client discuss the recent loss owith the staff and family members
    • is he or she able to verbalize feelings and behaviors associated with each stage of the grieving process and recognize own position in the process
  58. evaluation
    • have obession with the idealization of a the lost object subsided
    • is anger toward the lost object expressed appropriately
    • does client set realistic goals for self
    • is the client able to verbalize positive aspects of themselves, past accomplishments, and future prospects
    • can the client identify areas of life situation over which he or she has control
  59. client/family education
    nature of the illness
    • nature of the illness
    • stages of grief and symptoms associated with each stage
    • what is depression
    • why do people get depressed
    • what are the symptoms of depression
  60. client fam/education
    management of the illness
    • medication management
    • assertive techniques
    • stress-management techniques
    • ways to in self esteem
    • electroconvulsive therapy
  61. client/fam education
    support services
    • suicide hotline
    • support groups
    • legal financial assistance
  62. goals for discharge
    • decribe methods for minimizing stressors
    • discusses med knowledge
    • makes and keeps f/u appts
    • expresses guit and anger openly, directly, appropriately
    • engages significant others as support
    • structure life to include healthy activities'
    • identifies early s/s of the prodomal phase of the disorder
  63. goals for discharge
    • verbalizes plan for future (absence of suicidal thoughts or behavior)
    • verbalizes realistic perception of self, abilities
    • verbalizes realistic expectations for self others
    • sets realistic attainable goals
    • identifies stressors that may have negative influence and begins to modify them
    • discusses importance of seeking medical attention early, prior to deterioration in functioning occurs
  64. frequently
    • nurses often fail to recognize the severity of a pts symptoms, or depth to which depression can reach
    • nurses frequently equate depression with their own normal blues, the passing moods of sadness
    • they may say things that reveal lack of empahy and lack of approriate insight
  65. look in pp for examples of mistakes nx make
  66. two general principles
    • dont be overly happy- it makes them feel like you are belittling their feelings. adopt mutual emotional attitude, maintain and communicate confidence that they will feel better it takes time
    • working with depressed may lower your mood and make you feel down. it may cause you feel anxious/angry while caring for them. stay in touch with your feelings, use supervision/support from peers, change pt population if need be
Card Set
depression (unipolar)