Mental Health Chapter 16 PDF

Chapter 16 Depressive Disorders Copyright ©2019 F.A. Davis Company Introduction § Depression is the oldest and one of the most frequently diagnosed psychiatric illnesses. § Transient symptoms are normal, healthy responses to everyday disappointments in life. § Pathological depression occurs when ada...

Chapter 16 Depressive Disorders Copyright ©2019 F.A. Davis Company Introduction § Depression is the oldest and one of the most frequently diagnosed psychiatric illnesses. § Transient symptoms are normal, healthy responses to everyday disappointments in life. § Pathological depression occurs when adaptation is ineffective. § Mood is also called affect. § Depression is an alteration in mood that is expressed by feelings of sadness, despair, and pessimism. Copyright ©2019 F.A. Davis Company Historical Perspective § 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, that affected the brain. Copyright ©2019 F.A. Davis Company Epidemiology § 6.7% of persons aged 18 or older had at least one major depressive episode in the previous year. Copyright ©2019 F.A. Davis Company Epidemiology (continued_1) § Gender prevalence Depression is more prevalent in women than in men by about 2 to 1. § Age Lifetime prevalence of depressive disorders is higher in those aged 45 years or younger. Copyright ©2019 F.A. Davis Company Epidemiology (continued_2) § Social class There is an inverse relationship between social class and the report of depressive symptoms. § Race and culture No consistent relationship between race and affective disorder has been reported. Problems have been encountered in reviewing racial comparisons. Copyright ©2019 F.A. Davis Company Epidemiology (continued_3) § Marital status Single and divorced people are more likely to experience depression than are married persons or persons with a close interpersonal relationship (differences occur in various age groups). Copyright ©2019 F.A. Davis Company Epidemiology (continued_4) § Seasonality Affective disorders are more prevalent in the winter and in the fall. Copyright ©2019 F.A. Davis Company Types of Depressive Disorders § Major depressive disorder Characterized by depressed mood Loss of interest or pleasure in usual activities Symptoms present for at least 2 weeks No history of manic behavior Cannot be attributed to use of substances or another medical condition Copyright ©2019 F.A. Davis Company Types of Depressive Disorders (continued_1) § Persistent depressive disorder (dysthymia) Sad or “down in the dumps” No evidence of psychotic symptoms Essential feature is a chronically depressed mood for ‒ Most of the day ‒ More days than not ‒ At least 2 years Copyright ©2019 F.A. Davis Company Types of Depressive Disorders (continued_2) § Premenstrual dysphoric disorder Depressed mood Anxiety Mood swings Decreased interest in activities Symptoms begin during the week prior to menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses. Copyright ©2019 F.A. Davis Company Types of Depressive Disorders (continued_3) § Substance- or medication-induced depressive disorder Considered to be the direct result of physiological effects of a substance § Depressive disorder associated with another medical condition Attributable to the direct physiological effects of a general medical condition Copyright ©2019 F.A. Davis Company Predisposing Factors to Depression § Biological theories Genetics ‒ Hereditary factor may be involved Biochemical influences ‒ Deficiency of norepinephrine, serotonin, and dopamine has been implicated. ‒ Excessive cholinergic transmission may also be a factor. Copyright ©2019 F.A. Davis Company Predisposing Factors to Depression (continued_1) § Neuroendocrine disturbances Possible failure within the hypothalamic-pituitary-adrenocortical axis Possible diminished release of thyroid-stimulating hormone Neuroendocrine disturbances may play a role in the pathogenesis or persistence of depressive illness. In clients who are depressed, the normal system of hormonal inhibition fails, resulting in a hypersecretion of cortisol. Thyrotropin-releasing factor (TRF) from the hypothalamus stimulates the release of thyroid-stimulating hormone (TSH) from the anterior pituitary gland. Diminished TSH response to administered TRF is observed in approximately 25% of depressed persons and appears to be associated with an increased risk for relapse despite treatment with antidepressants. Copyright ©2019 F.A. Davis Company Predisposing Factors to Depression (continued_2) § Physiological influences Medication side effects Neurological disorders Electrolyte disturbances Hormonal disorders Nutritional deficiencies Other physiological conditions The role of inflammation Copyright ©2019 F.A. Davis Company § § § § § § § A number of drugs, either alone or in combination with other medications, can produce a depressive syndrome. Most common among these drugs are those that have a direct effect on the central nervous system. An individual who has suffered a cardiovascular accident (CVA), brain tumors, particularly in the area of the temporal lobe, Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease, or multiple sclerosis may display symptoms of depression. Excessive levels of sodium bicarbonate or calcium can produce symptoms of depression, as can deficits in magnesium and sodium. Potassium is also implicated in the syndrome of depression. Depression is associated with dysfunction of the adrenal cortex and is commonly observed in both Addison’s disease and Cushing’s syndrome. Other endocrine conditions that may result in symptoms of depression include hypoparathyroidism, hyperparathyroidism, hypothyroidism, and hyperthyroidism. An imbalance of the hormones estrogen and progesterone has been implicated in the predisposition to premenstrual dysphoric disorder (PMDD) although the exact etiology is unknown. Deficiencies in proteins, carbohydrates, vitamin B1 (thiamine), vitamin B2 (riboflavin), vitamin B6 (pyridoxine), B9 (folate), vitamin B12, iron, zinc, calcium, chromium, iodine, lithium, selenium, potassium, and omega-3 fatty acids have all been associated with producing symptoms of depression. Other conditions that have been associated with secondary depression include collagen disorders, such as systemic lupus erythematosus (SLE) and polyarteritis nodosa; cardiovascular disease, such as cardiomyopathy, congestive heart failure, and myocardial infarction; infections, such as encephalitis, hepatitis, mononucleosis, pneumonia, and syphilis; and metabolic disorders, such as diabetes mellitus and porphyria. Copyright ©2019 F.A. Davis Company Predisposing Factors to Depression: Psychosocial Theories § Psychoanalytical theory A loss is internalized and becomes directed against the ego. Freud posited that melancholia occurs after the loss of a loved object, either actually by death or emotionally by rejection, or the loss of some other abstraction of value to the individual. Freud indicated that in melancholia, the depressed patient’s rage is internally directed because of identification with the lost object. Freud believed that the individual predisposed to melancholia experienced ambivalence in love relationships. § Learning theory Learned helplessness: The individual who experiences numerous failures learns to give up trying. As a result of Seligman’s experiments with dogs, he theorized that learned helplessness predisposes individuals to depression by imposing a feeling of lack of control over their life situation. He believed they become depressed because they feel helpless; they have learned that whatever they do is futile. Copyright ©2019 F.A. Davis Company Predisposing Factors to Depression: Psychosocial Theories (continued_1) § Object loss theory Experiences loss of significant other during first 6 months of life Feelings of helplessness and despair Early loss or trauma may predispose client to lifelong periods of depression. Copyright ©2019 F.A. Davis Company Predisposing Factors to Depression: Psychosocial Theories (continued_2) § Cognitive theory Views primary disturbance in depression as cognitive rather than affective. Three cognitive distortions that serve as the basis for depression. ‒ Negative expectations of the environment ‒ Negative expectations of the self ‒ Negative expectations of the future Copyright ©2019 F.A. Davis Company Developmental Implications § Childhood depression Symptoms ‒ < Age 3: Feeding problems, tantrums, lack of playfulness and emotional expressiveness ‒ Ages 3 to 5: Accident proneness, phobias, excessive self-reproach ‒ Ages 6 to 8: Physical complaints, aggressive behavior, clinging behavior ‒ Ages 9 to 12: Morbid thoughts and excessive worrying Copyright ©2019 F.A. Davis Company Developmental Implications (continued_1) § Childhood depression (continued) Precipitated by a loss Focus of therapy: Alleviate symptoms and strengthen coping skills Parental and family therapy Copyright ©2019 F.A. Davis Company Developmental Implications (continued_2) § Adolescence Symptoms include ‒ Anger, aggressiveness ‒ Running away ‒ Delinquency ‒ Social withdrawal ‒ Sexual acting out ‒ Substance abuse ‒ Restlessness, apathy Copyright ©2019 F.A. Davis Company Developmental Implications (continued_3) § Adolescence (continued) Best clue that differentiates depression from normal stormy adolescent behavior ‒ A visible manifestation of behavioral change that lasts for several weeks. Most common precipitant to adolescent suicide ‒ Perception of abandonment by parents or close peer relationship Copyright ©2019 F.A. Davis Company Developmental Implications (continued_4) § Adolescence (continued) Treatment with ‒ Supportive psychosocial intervention ‒ Antidepressant medication NOTE: All antidepressants carry a Food and Drug Administration black-box warning for increased risk of suicidality in children and adolescents. Copyright ©2019 F.A. Davis Company Developmental Implications (continued_5) § Senescence Bereavement overload High percentage of suicides among elderly Symptoms of depression often confused with symptoms of neurocognitive disorder Treatment ‒ Antidepressant medication ‒ Electroconvulsive therapy ‒ Psychotherapies Copyright ©2019 F.A. Davis Company developmental implications of depression in senescence. § Depression is the most common psychiatric disorder of the elderly, who make up 13.1% of the general population of the United States. Symptoms of depression in the elderly are not very different from those in younger adults. Depressive syndromes in older adults are often confused by other illnesses associated with the aging process. Symptoms of depression are often misdiagnosed as neurocognitive disorder (NCD). § The most effective treatment of depression in the elderly individual is thought to be a combination of psychosocial and biological approaches. Antidepressant medications are administered with consideration for age-related physiological changes in absorption, distribution, elimination, and brain receptor sensitivity. Electroconvulsive therapy (ECT) is an important alternative for treatment of major depression in the elderly, especially considering the problematic side effects of antidepressants in this population. § Other therapeutic approaches include interpersonal, behavioral, cognitive, group, and family psychotherapies. Copyright ©2019 F.A. Davis Company Developmental Implications (continued_6) § Postpartum depression May last for a few weeks to several months Associated with hormonal changes, tryptophan metabolism, or cell alterations Treatments ‒ Antidepressants and psychosocial therapies Copyright ©2019 F.A. Davis Company Developmental Implications (continued_7) § Postpartum depression (continued) Symptoms include ‒ ‒ ‒ ‒ ‒ Fatigue/Irritability Loss of appetite Sleep disturbances Loss of libido Concern about inability to care for infant Copyright ©2019 F.A. Davis Company Nursing Process/Assessment § Transient depression Symptoms at this level of the continuum are not necessarily dysfunctional. ‒ Affective: The “blues” ‒ Behavioral: Some crying ‒ Cognitive: Some difficulty getting mind off of one’s disappointment ‒ Physiological: Feeling tired and listless Copyright ©2019 F.A. Davis Company Nursing Process/Assessment (continued_1) § Mild depression Symptoms of mild depression are identified by clinicians as those associated with normal grieving. ‒ ‒ ‒ ‒ Affective: Anger, anxiety Behavioral: Tearful, regression Cognitive: Preoccupied with loss Physiological: anorexia, insomnia Copyright ©2019 F.A. Davis Company Nursing Process/Assessment (continued_2) § Moderate depression Symptoms associated with dysthymic disorder ‒ Affective: Helpless, powerless ‒ Behavioral: Slowed physical movements, slumped posture, limited verbalization ‒ Cognitive: Retarded thinking processes, difficulty with concentration ‒ Physiological: Anorexia or overeating, sleep disturbance, headaches Copyright ©2019 F.A. Davis Company Nursing Process/Assessment (continued_3) § Severe depression Includes symptoms of major depressive disorder and bipolar depression ‒ Affective: feelings of total despair, worthlessness, flat affect ‒ Behavioral: psychomotor retardation, curled-up position, 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 Copyright ©2019 F.A. Davis Company Nursing Process: Diagnosis/Outcome Identification § Risk for suicide related to Depressed mood Feelings of worthlessness Anger turned inward on the self Misinterpretations of reality § Complicated grieving related to Real or perceived loss Bereavement overload Copyright ©2019 F.A. Davis Company Nursing Process: Diagnosis/Outcome Identification (continued_1) § Low self-esteem related to Learned helplessness Feelings of abandonment by significant others Impaired cognition fostering negative view of self § Powerlessness related to Complicated grieving process Lifestyle of helplessness Copyright ©2019 F.A. Davis Company Nursing Process: Diagnosis/Outcome Identification (continued_2) § Spiritual distress related to Complicated grieving process over loss of valued object evidenced by anger toward God, questioning meaning of own existence, inability to participate in usual religious practices Copyright ©2019 F.A. Davis Company Nursing Process: Diagnosis/Outcome Identification (continued_3) § Social isolation/Impaired social interaction related to Developmental regression Egocentric behaviors Fear of rejection or failure of the interaction Copyright ©2019 F.A. Davis Company Nursing Process: Diagnosis/Outcome Identification (continued_4) § Disturbed thought processes related to Withdrawal into self Underdeveloped ego Punitive superego Impaired cognition fostering negative perception of self or environment Copyright ©2019 F.A. Davis Company Other Nursing Diagnoses § Imbalanced nutrition less than body requirements § Insomnia § Self-care deficit All related to depressed mood Copyright ©2019 F.A. Davis Company Clicker Question 1 1. An individual experienced the death of a parent 2 years ago. This individual has not been able to work since the death, cannot look at any of the parent’s belongings, and cries daily for hours at a time. Which nursing diagnosis most accurately describes this individual’s problem? A. Post-trauma syndrome related to parent’s death B. Anxiety (severe) related to parent’s death C. Coping, ineffective related to parent’s death D. Grieving, complicated related to parent’s death Copyright ©2019 F.A. Davis Company Clicker Question Answer 1 Correct Answer: D The excessive reactions the individual continues to exhibit, such as daily crying, inability to return to work, and inability to look at parent’s belongings after a 2-year period, are indicative of dysfunctional or complicated grieving. This individual’s grieving response has arrested in the anger stage, is being turned inward on the self, and is manifested by symptoms of depression. Copyright ©2019 F.A. Davis Company Criteria for Measuring Outcomes: Client § Has experienced no physical harm to self § Discusses loss with staff and family members § No longer idealizes or obsesses about the lost entity § Sets realistic goals for self § Attempts new activities without fear of failure § Is able to identify aspects of self-control over life situation Copyright ©2019 F.A. Davis Company Criteria for Measuring Outcomes: Client (continued) § Expresses personal satisfaction and support from spiritual practices § Interacts willingly and appropriately with others § Is able to maintain reality orientation § Is able to concentrate, reason, and solve problems Copyright ©2019 F.A. Davis Company Planning/Implementation § Risk for suicide Be direct. Maintain close observation at irregular intervals. Encouraging verbalizations of honest feelings. § Complicated grieving Develop a trusting relationship with the client. Encourage the client to express emotions. Communicate that crying is acceptable. Copyright ©2019 F.A. Davis Company Planning/Implementation (continued_1) § Low self-esteem/self-care deficit Be accepting of the client. Encourage the client to recognize areas of change. Encourage independence in the performance of activities of daily living. Copyright ©2019 F.A. Davis Company Planning/Implementation (continued_2) § Powerlessness Encourage the client to take responsibility. Help the client set goals. Help the client identify areas of his or her life that they can and cannot control. Copyright ©2019 F.A. Davis Company Client/Family Education § 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? Copyright ©2019 F.A. Davis Company Client/Family Education (continued_1) § Management of the illness Medication management Assertive techniques Stress-management techniques Ways to increase self-esteem Electroconvulsive therapy Copyright ©2019 F.A. Davis Company Client/Family Education (continued_2) § Support services Suicide hotline Support groups Legal/financial assistance Copyright ©2019 F.A. Davis Company Evaluation § Has self-harm to the client been avoided? § Have suicidal ideations subsided? § Does the client know where to seek assistance outside of the hospital when suicidal thoughts occur? § Has the client discussed the recent loss with the staff and family members? Copyright ©2019 F.A. Davis Company Evaluation (continued_1) § Is he or she able to verbalize feelings and behaviors associated with each stage of the grieving process and recognize his or her position in the process? § Have obsession with, and idealization of, the lost object subsided? § Is anger toward the lost object expressed appropriately? § Does the client set realistic goals for self? Copyright ©2019 F.A. Davis Company Evaluation (continued_2) § Is the client able to verbalize positive aspects about self, past accomplishments, and future prospects? § Can the client identify areas of life situation over which he or she has control? Copyright ©2019 F.A. Davis Company Treatment Modalities § § § § Individual psychotherapy Group therapy Family therapy Cognitive therapy Copyright ©2019 F.A. Davis Company Treatment Modalities (continued_1) § Electroconvulsive therapy Mechanism of action: Thought to increase levels of biogenic amines Side effects: Temporary memory loss and confusion Risks: Mortality; permanent memory loss; brain damage Medications: Pretreatment medication; muscle relaxant; short-acting anesthetic Copyright ©2019 F.A. Davis Company Treatment Modalities (continued_2) § Repetitive transcranial magnetic stimulation § Vagal nerve stimulation and deep brain stimulation § Light therapy Copyright ©2019 F.A. Davis Company Treatment Modalities (continued_3) § Psychopharmacology Tricyclics Selective serotonin reuptake inhibitors Monoamine oxidase inhibitors (M A O I’s) Heterocyclics Serotonin-norepinephrine reuptake inhibitors Copyright ©2019 F.A. Davis Company Client/Family Education Related to Antidepressants § Continue to take medication for 4 weeks. § Do not discontinue medication abruptly. § Report sore throat, fever, malaise, yellow skin, bleeding, bruising, persistent vomiting or headaches, rapid heart rate, seizures, stiff neck, and chest pain to physician. Copyright ©2019 F.A. Davis Company Client/Family Education Related to Antidepressants (continued_1) § Avoid foods and medications high in tyramine when taking M A O I’s. These include Aged cheese Wine; beer Chocolate; colas Coffee; tea Sour cream; yogurt Copyright ©2019 F.A. Davis Company Smoked and processed meats Beef or chicken liver Canned figs Client/Family Education Related to Antidepressants (continued_2) § Avoid foods and medications high in tyramine when taking M A O I’s. These include (continued) Caviar Raisins Pickled herring Yeast products Broad beans Copyright ©2019 F.A. Davis Company Soy sauce Cold remedies Diet pills Pharmacogenomics § Between 30 and 50% of patients do not respond to first antidepressant prescription. § A study is needed to identify benefits of routine testing, cost effectiveness, and ability to provide timely results. Copyright ©2019 F.A. Davis Company Clicker Question 2 2. When teaching about the tricyclic group of antidepressant medications, which information should the nurse include? A. Strong or aged cheese should not be eaten while taking this group of medications. B. The full therapeutic potential of tricyclics may not be reached for 4 weeks. C. Long-term use may result in physical dependence. D. Tricyclics should not be given with anti-anxiety agents. Copyright ©2019 F.A. Davis Company Clicker Question Answer 2 Correct Answer: B A client needs to be advised that it may take several weeks for tricyclic medications to reach their full therapeutic effect and for relief of symptoms to be noted. Copyright ©2019 F.A. Davis Company Clicker Question 3 3. A client has been diagnosed with major depression. The psychiatrist prescribes Paroxetine (Paxil). Which of the following medication information should the nurse include in discharge teaching? A. Do not eat chocolate while taking this medication. B. The medication may cause priapism. C. The medication should not be discontinued abruptly. D. The medication may cause photosensitivity. Copyright ©2019 F.A. Davis Company Clicker Question Answer 3 Correct Answer: C Antidepressants such as paroxetine must be tapered and not stopped abruptly. All classifications of antidepressants have varying potentials to cause discontinuation syndromes. Abrupt withdrawal from S S R I’s, such as paroxetine, may result in dizziness, lethargy, headache, and nausea. Copyright ©2019 F.A. Davis Company