CASE PRESENTATION ON DEPRESSION.pptx for nurses

(notable loss or gain unrelated to dieting).
Sleeping too little or too much.
Decreased energy or increased tiredness or fatigue
Increase in purposeless physical activity (e.g., inability to sit still, pacing, handwringing) or slowed movements or speech that are severe enough to be observable by others.
Feeling worthless or excessively guilty.
Difficulty thinking or concentrating, forgetfulness, and/or difficulty making minor decisions.
Thoughts of death, suicidal ideation, or suicide attempts.
It is normal to experience moments of sadness or feeling “down in the dumps” or the blues as part of the human experience. However, a diagnosis of depression requires that the above symptoms occur for most of the day, nearly every day, for more than two weeks, along with a clear change in day-to-day functioning (e.g., in work/school performance, personal relationships, and hobbies). Fortunately, depression is very treatable.

1. CASE PRESENTATION ON SEVERE DEPRESSIVE EPISODE PRESENTED TO, Mr. Ravindra Vikhe Sir Assistant Professor, CEMH, INHS Asvini , Colaba PRESENTED BY, Seema Ankush Kondhalkar PBDPN Student CEMH, INHS Asvini , Colaba

2. Book Picture and Patient Picture of disorder Depression D epression is a mood disorder that causes a persistent feeling of sadness of mood and loss of interest . C lassification of depression according to ICD 10 Code Category In Patient F32 Depressive episode F32.0 Mild depressive episode F32.1 Moderate depressive episode F32. 2 Severe depressive episode without psychotic symptoms Present F32.3 Severe depressive episode with psychotic symptoms F32.8 Other depressive episodes- atypical depression F32.9 Depressive episode unspecified F33 Recurrent depressive disorder

3. Severe Depressive E pisode S evere Depressive E pisode - in severe episode of depression the central features are low mood ,lack of enjoyment( a nhedonia) negative thinking and reduce energy all of which lead to decrease social and occupational functioning G eneral appearance – the patient appearance is characterise by dress and grooming may be neglected the facial features are characterized by a turning downwards of the corner of the mouth and by vertical furrowing of the centre of the brow Mood – sadness of mood

4. Continue… Depressive cognition- Negative thoughts- worthlessness P essimism Guilt Helplessness H opelessness Psycho motor changes – P sycho motor retardation B iological symptoms- disturbance in biological drive (Also called melancholic ,somatic or vegetative)

5. Psychotic depression Depressive episodes become more severe severity increasing with loss of function in social and occupational spheres. Inattention to basic hygiene and nutrition. Psychomotor retardation and hallucination, delusion in which case the disorder is referred as a psychotic depression.

6. E tiology Book picture Patient picture Genetic causes- Depressive disorders occur more in first degree relative then do in the general population Studies of identical twin shows that when one twin is diagnose with major depression The Other twin has a greater than 70% of developing it Personality- certain personalities like premorbid anxiety is associated with depression Present Precipiting factors – recent life events- peer victimization through bullying se fresh start life events example establishing a new relationship or starting occupational educational course

7. Continue… Book picture Patient picture Vulnerability factors and life difficulties Poor social support, lack of intimacy associated with increase depression mechanism of action is Un clear Patient is having distorted perception of degree of intimacy Biological theories- Neurochemical-decreased level of serotonin and norepinephrine and dysfunction of acetylcholine and GABA. Endocrine theories -malfunction of hypothalamic pitutory adrenal axis creates cortisol ,thyroid and hormonal abnormalities .

8. Continue… Book picture In patient Circardian Rhythm theories -changes in circadian cycle are at risk of depression. Changes in brain anatomy- loss of neuron in the frontal cortex, cerebellum and basal ganglia Psychoanalytic theory-fixation in oral sadistic phase of development.in this mania is viewd as denial of depression Cognitive theory-negative cognition ,negative expectation from self,environment and future individual feel worthless and rejected by others Present in patient

9. Clinical manifestation As per book In patient Depressed mood - Hadness of mood or loss of interest and loss of pleasure in almost all activities present throughout the day Depressive cognitions - Hopelessness a feeling of no hope in future due to pessimism ,helplessness the patients feel that no help is possible and inferiority ,unreasonable guilt and self blame over trivial matter past Psycho motor activity - Retarded thought reflected in patient speech agitatin is common with mark anxiety restlessness uneasiness. Suicidal thoughts - Hopelessness are accompanied by thought of life is no longer worth living and that death had come as a welcome release. this gloomy preoccupation progress to thought of and plan of suicide present Psychotic features - Delusion and hallucination Other features - Difficulty in thinking and concentration, poor memory, spontaneous crying present Somatic symptoms - Decreased appetite, diurnal variation, pervasive lack of interest, psychomotor restlessness present

10. I nvestigation As per book In patient Physical examination Done,no any abnormalities Psychiatric evaluation –MSE, History taking Mse and history collection finding of suggestive case of severe depression Lab test - include blood test to check thyroid profile ,complete blood count renal function and liver function Complete blood count- platelate -2.76lakh/ cumm HB 15.9 g/dl wbc - 4900 /mm total Billrubin 0.9 mg/dl SGOT – 22 U /L SGOT – 39 U/L Alkaline Phospate 64 U/L RFT – Sodium 143 meq /dl Potasium – 4.2 meq /dl Creatinine – 0.6 mg/dl GGT -19 Vitamin D3 – 14.33 mg/dl

11. Continue… As per book In patient Thyroid Profile T3 – 118.1 mg/ml T4 -8.93mca /dl TSH – 1.15 mIu /L Sr. Amylase 87 U/L Lipase- 71 u/l Total Cholestrol 148mg/dl HDL 39 mg/dl HDL 94 mg/dl Trigylceride 73 mg/dl Urine - routine – Microscopy NAD Chest X-Ray – Normal ECG – Normal HIV, HBSAg , HCV - negative Psychological test- becks depression inventory Patient score is 34/63 suggestive of severe depression MRI And CT Scan Few tiny fair hyperintense foci seen in white matter o bilateral frontal lobe-suggestive of ichmic foci.

12. Diagnostic criteria as per ICD - 10 A Depressed mood Loss of interest and enjoyment Reduced energy and decresed activity B Reduced concentration Reduced self esteem and confidence Ideas of guilt and unworthiness Pessimistic thoughts Ideas of self harm Disturbed sleep Diminished appetite

13. Continue.. Mild depressive episode – at least two of A and at two of B Moderate depressive episode - at least two of A and at three of B Severe depressive episode - at least three of A and at four of B In Patient – Patient full fill all Symptoms of diagnostic criteria for severe depressive episode

14. The Epidemiology of Depressive D isorders The 12-Month prevalence of major depressive in the community is around 2-5% The lifetime rate in different studies vary considerably (in the fung 4-30%) and the figure probably lies in the range 10-20% The mean age of onset is 27 years Rate of depressive are about twice as high in the women as in men, across different cultures. Rates high in unemployed and divorce. Major depressive has high comorbidity with other disorders, particularly anxiety disorders and substance missuse .

15. Prognostic Factors The best predictor of the future course is the history of previous episode not surprisingly , the risk of recurrence is much higher in individuals with history of several previous episodes. Other factors that predict a higher risk of future episodes include the following : Incomplete symptomatic remission Early age of onset Poor social support Poor physical health Comorbid substance misuse Comorbid personality disorder

16. Continue… The various factors particularly previous pattern of recurrent and extent current remission have important implications for the se of longer term maintenance treatments in many patients depressive disorders are best conceptualised as chronic relapsing condition that require an integrated long term treatment approach

17. M anagement AS per book In Patient Psycharmacology - major categories of anti depressant- 1) selective serotonin reuptake inhibitors(SSRIs)- citalopram,fluoxetine , sertraline Tricyclic anti depressant (TCAs)- amitriptyline , clomipramine imipramine Monoamine Oxidase inhibitor – Isocrboxazid , phenepine Tablet sertraline(100mg)BD Tablet clonazepam(0.5mg)HS Lithium as a sole treatment - may have antidepressant efficacy suggested by placebo-controlled trial. Lithium in combination with antidepressants -can produce useful therapeutic effectswhen added with antidepressant in resistant patient Tablet lithium carbonate (300)mg TDS

18. Continue… AS per book In Patient Physical therapies- 1)Electroconvulsive therapy – severe depression with suicidal risk indication 2)Light therapy - winter month to relieve seasonal depression 3)Repetitive transcranial magnetic stimulation and vagus nerve stimulation - affect brain function by stimulating nerve that are direct extensions of the brain influencing brain activity increase release of neurotransmitters and downregulate beta adrenergic receptors

19. Continue… As per Book In Patient Psychosocial treatment- 1)psychotherapy-to developed insight 2)Cognitive therapy-correcting depressive negative cognition 3)Supportive psychotherapy-relaxation and other activities therapy 4)Group therapy 5)Family therapy 6)Behaviour therapy-social skill training , assertiveness training, Decision making techniques, activity schedule Cognitive behaviour therapies supportive therapy including relaxation techniques JPMR technique coping skill training Family therapy

20. Nursing management Nursing assessment- S hould focus on judging the activiity of the disorder including the risk of suicide Identifying the possible causes the social resources available to the patient and effects of the disorder on other people. S uicide in every depress patient there is much more in presence of following factors 1) more than 40 years of age 2) male sex,unmarried,widow or divorced 3) Early stages of depression 4) Written or verbal communication of sucide intent or plan

21. Continue… 5) Early stage of depression 6) recovery from depression at the peak of depression the patient is usally either too depressed or to redarded to comit suicide 7) period of three month from recovery the nurse should inquire about patient work family life social activities depressive delusion and patient act on them

22. Nursing diagnosis High risk of self directed violence related to depressive mood feeling of worthlessness helplessness as evidence by previous attempt of violence suicidal plan low self esteem related to learn helplessness ,negative view of self as evidence by expression of worthlessness disturbed thought process related to severe anxiety o r depress mood as evidence by impaired attentions span impaired social interaction related to feeling of worthlessness as evidence by remains feeling of seclusion, avoid contacts with other Altered sleep and rest related to depressed mood as evidence by difficulty in falling asleep verbal complaints of not well resting

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