Mood Disorders: Depression

Chapter 15

NUR203 Psychiatric Nursing: Assessment

and Management of Mental Health
NUR222 Nursing III: Psychiatric Nursing

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Depression

It is impossible to convey adequately

the personal pain and suffering
experienced by an individual going
through a severe depressive episode. A
races, all ages, and both genders are
susceptible to depressive episodes,
although some individuals are more
vulnerable than others. Depression is
an umbrella term variety of disorders
that range from mildly to moderately to
severely disabling. Depression is a
syndrome rather than disease, while
disease is specific condition
characterized by common underlying
cause, consistent physical traits, a
syndrome a collection of
signs/symptoms known to appear 2
together, but without a single known
Depression and Chronicity

In terms of chronic conditions seen in

medical practice, depression is
secondary only to hypertension.

Approximately 16.5% of people older

than age 18 in the United States
will have a major depressive
disorder in their lifetime.

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 Prevalence and Co-Morbidity
ple with co-occurring chronic medical problems, (e.g., hypertension, backache, diabetes, hea
roblems, arthritis) are at a higher risk for depression than those in the general population.

ression is often secondary to a

medical condition.
MARY RISK FACTORS FOR DEPRESSION:
of prior episodes of depression.
ily hx of depression disorder, especially in first degree relatives.
of suicide attempts or family hx of suicide.
mber of LGBTQ .
ale gender.
40 years or younger.
partum period.
onic medical illness.
ence of social support.
ative, stressful life events, early trauma.
ve alcohol or substance use disorder.
of sexual abuse.
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Prevalence and Co-Morbidity (Cont.)
Depression is second only to chronic hypertension.

Women are 70% more likely to experience depression than men more likely to
seek help.

Older adults (65 years and older) with an MDD or PDD are often:
▪ Underdiagnosed or misdiagnosed because they are less likely to seek
help from mental health professionals. Suicide is high in this age group.
Two key symptoms that distinguish late-life depressive disorders in
older adults: 1. complaints of sadness are less prominent. 2. Excessive
concern with physical health compared with those who are younger.

Depression frequently accompanies other psychiatric disorders.

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Children and Adolescents
Children as young as 3 years of age have been diagnosed with MDD with an inciden
those underage 12yr old. Depression in children/adolescents may be different. Ch
symptoms: irritability, physical complaints, decline school performance, social wi
puberty girls are twice to develop depression. Adolescent symptoms: mask depre
sulking, being negative, grouchy, getting in trouble at school, feel misunderstood,
others, running away from home.

MDD is said to occur in as many as 18% preadolescents (probably low estimate —thi
often underdiagnosed)

High recurrence rate in this population, prevalence rate of depression individuals 18

3x higher than in individuals 60 years or older.

Early recognition and treatment helpful in decreasing recurrence

Girls more vulnerable than boys

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Older Adults
Depression among older adults (65 or older) is approximately 6% to 9% for
MDD and 17% to 18% for PDD.

Disproportionate number of depressed older Americans die by suicide.

Often associated with chronic illness.

Underdiagnosed and misdiagnosed.

Refer to Chapter 28 for more on depression in older adults.

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 Theory
Biological Theories

▪ Genetic factors
• Twin studies – Monozygotic twins sharing the same genetic constitution twin is
chance being affected. The percentage for DIZYGOTIC twins different genetic co
• Adoption studies -

▪ Biochemical factors
• Serotonin and norepinephrine are two major neurotransmitters involved in depr
Theory states that depression is thought to involve changes in neurotransmitter relatio
1. Limbic system- emotional alterations
2. Hypothalamus - mood regulation
3. Prefrontal cortex- decreased mood , problems concentrating.
4. Hippocampus – memory impairments, feeling of worthlessness, hopelessness/gui
5. Amygdala – anxiety/reduced motivation

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Theory (Cont.)
Psychosocial Theories

▪ The stress–diathesis model of depression

▪ Learned helplessness
▪ Cultural considerations

Cognitive Theory
▪ Beck’s cognitive triad:
1. Negative, self-deprecating view of self
2. Pessimistic view of the world
3. Belief that negative reinforcement will continue

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Positron-emission tomography (PET) scan: A 45-year-old woman with
recurrent depression with no medication (left). Same patient treated with
medication (right). The entire brain, particularly the left prefrontal cortex, is
more active after recovery.

Image courtesy Mark George, MD, NIMH

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Subtypes Observed in Major Depressive Disorder
▪ Psychotic features

▪ Melancholic features

▪ Atypical features

▪ Catatonic features

▪ Postpartum onset

▪ Seasonal affective disorder (SAD)

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 Diathesis Stress Model Biological Model

▪ Environmental ▪ Genetic – Depression gene

▪ Interpersonal ▪ Biochemical

▪ Life events combined with ▪ Alterations in hormonal

biological predisposition regulation
(diathesis)

▪ Psychologic stressors that trigger

brain changes – Neurotransmitters
become overtaxed

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Assessment of a depressed individual’s behaviors in
each of the following areas:

Affect

Thought processes

Feelings

Physical characteristics

Communication

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Communication
Communication Techniques: See Tables 15-3, 15-4.

Communication Guidelines:

Person with depression may speak and comprehend very slowly.

Extreme depression—Person may be mute.

Nurses—Are uncomfortable with silence.

Sitting with a patient in silence is a valuable intervention.

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Nursing Diagnoses
Nursing diagnoses can be numerous. Individuals with depression are always
evaluated for the risk of suicide.

Other common diagnoses include:

▪ Disturbed thought processes
▪ Chronic low self-esteem
▪ Imbalanced nutrition
▪ Constipation
▪ Disturbed sleep pattern
▪ Ineffective coping
▪ Spiritual distress
▪ Disabled family coping

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Pharmacologic Therapy

For persons with depression but without

psychotic features, a
combination of specific psychotherapies
(e.g., cognitive-behavioral therapy [CBT],
interpersonal therapy [IPT]) and
antidepressant therapy may be superior to
either psychotherapy or
psychopharmacologic treatment alone.

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Quick Question
Mrs. Chauncey, 80 years old, is taking a selective serotonin reuptake inhibitor
(SSRI) and Tylenol PM daily plus other medications. She has multiple, vague
somatic complaints. This morning she complains of a “stomach ache” and
“gas.” What is your best initial nursing response?
A. Tell her to increase her water intake.

B. Perform a digital rectal examination for impaction.

C. Document the complaint of abdominal pain.

D. Assess bowel sounds in all four quadrants.

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Answer and Rationales
A. An increase in water intake may be an excellent intervention for an older
patient as long as no fluids are restricted and no swallowing problems are
evident.

B. A digital rectal examination without further assessment is inappropriate

and can be traumatic for the patient.

C. Documenting a patient’s complaint is appropriate as long as the

intervention and evaluation are also completed and documented.

D. Assessing bowel sounds is the best initial response. Older adults are at risk
for constipation, and some medications can cause constipation. Mrs.
Chauncey is taking an SSRI and Tylenol PM, which contains
diphenhydramine.

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Nursing Process
Assessment

▪ Self-assessment

▪ Unrealistic expectations of self

▪ Feeling what the patient is feeling

▪ Assessment tools

▪ Assessment of suicide potential

▪ Key assessment findings

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Nursing Process (Cont.)
Areas to assess

▪ Affect

▪ Thought processes

▪ Mood

▪ Feelings

▪ Physical behavior

▪ Communication

▪ Religious beliefs and spirituality

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▪ Affect- defined as the observable response to a person’s behavior

▪ Anhedonia (inability to find meaning or pleasure in existence, decreased

concentration and diminished libido.
Assessment of Suicide Potential Areas to Assess
▪ Anergia- reduction lack of energy
▪ Anxiety- common symptom associated with depression, seen in 60%-90% depress
patients.

▪ Feelings of:
• Worthlessness- unrealistic evaluation of self worth, reflect low self esteem,
statement e.g I am no good. Guilt- commonly seen with depression, statements
e.g, I have caused terrible pain and now I’m paying for it..Helplessness – evidence
by believing that everything , even unusual task is too difficult to accomplish,
during a depress period , some people believe things will never change , can lead
to consider suicide, as a way to escape constant mental pain. Hopelessness- one of
the core characteristics of depression/suicide, results in negative expectations for
the future/loss of control for future outcomes.
• Anger and irritability- natural outcomes of profound feelings of helplessness,
anger in depression often expressed inappropriately through destruction of
property, hurtful verbal attacks, physical aggression toward others.

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Pharmacologic Therapy
Target symptoms include the following:

▪ Sleep disturbance
▪ Appetite disturbance (decreased or increased)
▪ Fatigue

▪ Decreased sex drive

▪ Psychomotor retardation or agitation

▪ Diurnal variations in mood (often worse in the morning)

▪ Impaired concentration or forgetfulness

▪ Anhedonia (loss of ability to experience joy or pleasure)
Anosognosia – Denial of unawareness of one’s NEUROLOGICAL DEFECT.

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Pharmacologic Therapy (Cont.)
Tricyclic antidepressants (TCAs)

▪ Neurotransmitter effects – Increase norepinephrine & serotonin

▪ FULL AFFECT not felt for 4 to 8 weeks

▪ Indications - Lethargic patients, family hx of positive response to TCAs

▪ Adverse effects – Anticholinergic effects

▪ Contraindications – Recent MI, narrow-angle glaucoma, hx of seizures.

“Start low, go slow.”

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Pharmacologic Therapy (Cont.)
Antidepressants

▪ SSRIs
• First-line therapy
• Indications – Depression & anxiety disorders.
• Adverse reactions – agitation, insomnia, tremor, tension headache
• Potential toxic effects – Serotonin syndrome, Lung hypertension in
pregnancy

▪ Serotonin syndrome
• Rare and life-threatening event
• Risk greatest when SSRI is administered in combination with monoamine
oxidase inhibitor (MAOI)
• Sxs: abdominal pain, diarrhea, sweating, fever, tachycardia,
hypertension, delirium, muscle spasms, irritability

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Pharmacologic Therapy (Cont.)
MAOIs

▪ Neurotransmitter effects – Prevent breakdown of norepinephrine,

serotonin, & dopamine
▪ Indications – Atypical depression, MDD, panic disorder, social phobia,
GAD, OCD, PTSD, & bulimia
▪ Adverse and toxic effects – HTN crisis –SYMPTOMS: SEVERE
HEADACHE,INCREASING CHEST PAIN, INCREASING
SOB,DIAPHORESIS/ANXIETY,MENTAL STATUS CHANGES,
NAUSEA/VOMITING
▪ Interactions
• Drugs: Avoid over-the-counter (OTC) medications.
• Food: Avoid foods containing tyramines. AVACADOS, FRUITS
ESPECIALLY OVERRIPE BANNAS/BANANAS PEELS,MEATS THAT
ARE FERMENTED,SMOKED, AGED SPOILED MEATS,LIVER UNLESS
VERY FRESH, SAUSAGES,PEPPERONI,FISH, SMOKED
SALMON,MILK PRODUCTS,FOODS WITH YEAST, SOME IMPORTED
BEERS, SOME WINES, PROTEIN DIEATARY SUPPLEMENTS,SOUPS 25
WITH PROTEIN EXTRACT, SHRIMP PASTE/SOY SAUCE.
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Case Study
Part 1: Leo, a 14-year-old adolescent, is administered an SSRI 2 weeks earlier
after a psychiatrist diagnosed him with MDD. This morning Leo comes to
the kitchen and hugs his parents and tells them that he feels “awesome.”
They note he has a stack of X-Box games under his arm. When they ask,
“What are you going to do with those?” He replies, “I’m going to give them
to Jimmy.” After Leo leaves for school, his parents talk about how happy
they are that Leo is getting better.

Based on what you have studied regarding SSRIs, what is your assessment of
Leo’s “top of the world” mood?

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Case Study (Cont.)

Part 2: Leo’s parents receive a call from the school. At lunch break, Leo walked
to a bridge near his school and was found on the water side of the railing
staring into the water. The principal coaxed Leo back and then drove him to
school. The school nurse is caring for Leo in the clinic.

You are the school nurse. What are your priority assessments and
interventions with Leo? What do you tell the parents? What do you ask
the parents? What do you include in your documentation?

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Case Study (Cont.)

Part 3: Leo is admitted to the community mental health center for a 72-hour
observation. His admitting mental status assessment reveals that his thought
content includes the following: “I probably wouldn’t have jumped, but I
started feeling like I just wanted it all to go away!”

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Electroconvulsive Therapy (ECT)
Procedure description- done under general anesthesia which small electric currents
are passed through the brain, intentionally triggering seizures. Is one of the
most effective treatment – resistant depression/major depression with psychotic
symptoms, pts with life threatening psychiatric symptoms. ECT is safe/effective
can achieve 70%-90% remission rate in depress pts within 1-2 weeks. Procedure
explain to pt, obtain informed consent, short acting general
anesthetic{methohexital sodium} used to allow pt to sleep during short
procedure, NUEROMUSCULAR blocking agent{ SUCCINYCHOLINE
CHLORIDE} IS USED TO LESSEN THE POTENTIAL SIDE EFFECTS OF
INDUCE SEIZURE. {GLYCOPYRROLATE} may be used to lessen secretions/
modulate vagul response to the procedure.
Potential adverse reactions: Patient may be confused/disoriented , pt may complain
of headache, muscle soreness/nausea, short term memory deficits. ECT – once a
week to once a month may help decrease relapse rates for patients with
recurrent depression. Can be perform both INPATIENT/OUTPATIENT.

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Somatic Treatments Electroconvulsive Therapy (Cont.)
Electroconvulsive therapy (ECT) is indicated if the:

▪ Patient is suicidal or homicidal.

▪ Agitation or stupor is extreme.

▪ Life-threatening illness is a result of the refusal of foods or fluids.

▪ History includes a poor drug response or a good ECT response.

▪ Standard medical treatment has no effect.

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rve stimulation
Somatic FDA approved adjunctive,
Treatments long- term
and Other treatment for pts with treatment- resi
Treatments
ally implanting a device called {PULSE GENERATOR} similar to pacemaker into the upper
cted by a wire to the left vagus nerve.
generator is stimulated electrical impulses are transmitted to areas of the brain that affect m
ressive symptoms.
nscranial magnetic stimulation (rTMS)- noninvasive electromagnetism to deliver an electric
omagnet coil is placed against scalp near the forehead , the electromagnet is painless deliver
cells in the region of the brain. Requires 30-60 min series treatment sessions to be effective.
al side effects such as headaches, scalp discomfort, lightheadedness that tend to resolve qu

apy- one method to treat seasonal affective disorder, Full spectrum wavelength light is the

wort- { hypericum perforatum} OTC whole plant product with antidepressant properties n
ul drug interactions that can result in toxic effects on the liver.

ylmethionine (SAMe)- OTC dietary supplement found to be effective as an adjunct treatmen

nt to other treatment.

ort – PEER GROUP AND SUPPORT GROUPS ARE IMPORTANT in helping people with d
se feelings of isolation provide a buffer against stressful events, increase health information
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Critical Thinking Question
Mrs. Chauncey, 80 years of age, complains of stomach pain and is now mute
and staring out of her window. She is refusing food. Which of the following
interventions are appropriate? Select all that apply.

A. Give her privacy, and close her door.

B. Speak with her, although she may not answer.

C. Continue to offer her food and fluids.

D. Regularly assess vital signs and skin turgor.

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Answer and Rationales
A. Isolating Mrs. Chauncey is inappropriate. You need to be aware that older
adults may experience increased depression while hospitalized. Although
frail, Mrs. Chauncey may have energy to harm herself, even superficially.

B. Sitting with Mrs. Chauncey and speaking to her lets her know you are
available.

C. You are legally and ethically responsible to offer patients regular food and
fluids whether they accept them or not.

D. Vital signs are an important regular assessment, as well as skin turgor

assessment. The older adult who is depressed is at risk for dehydration and
possible hypotension.

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Critical Thinking Question
Mrs. Chauncey receives a visit from her priest. He runs out of her room and
then pulls the nurse assistant back into her room. Mrs. Chauncey is cutting her
left wrist (superficially) with the 5 x 7 glass from a framed photo of a
grandchild. She is taken to the emergency department, where her wrist is
bandaged. Her daughter and son-in-law are notified. As her nurse, which of
the following statements help clarify what has taken place?

A. “Don’t worry, I think your mom is just confused.”

B. “Your mom has been more withdrawn over the last few
days.”

C. “I am very concerned that your mom is suicidal.”

D. “When your mom’s priest arrived, he found her cutting her

wrist with the glass from a framed photo.”

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Critical Thinking Question
A. This statement offers false reassurance.

B. Although true, this statement does not give the family a clear picture of the
events.

C. You may suspect suicidal ideation, but until Mrs. Chauncey is further
assessed, you should not state your suspicions.

*D. This statement is a clear representation of what has actually happened.

Once the family members understand this, then dialog related to care
options can begin.

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