Depression

Kshirabdhi Tanaya
MHN Tutor,SUM nursing college,SOA DTU ,BBSR

1. MOOD DISORDER PRESENTED BY: Kshirabdhi Tanaya MHN Tutor,SUM nursing college,SOA DTU ,BBSR

2. DEFINITION : mood disorders are characterized by a disturbance of mood, accompained by a full or partial manic or depressive syndrome, which is not due to any orther physical or mental disorder.

3. CLASSIFICATION: F30 - Manic Episode F31 - Bipolar Affective Disorder F32 - Depressive Episode F33 - Recurrent Depressive Disorder F34 - Persistent Mood Disorder ( cyclothymia and dysthymia ) F38 – other mood disorders F39 – unspecified mood disorder

4. DEPRESSIVE DISORDER

5. HISTORICAL PERSPECTIVE

6. DEFINITION: Depression is a period of intense sad mood and other physical symptoms that exists nearly everyday for at least two weeks, and those symptoms include sleep disturbances, disturbances in appetite and weight, energy, concentration and physical activity and may entertain thoughts of death or suicide.

7. CLASSIFICTION: F32 - Depressive episode F32.0 - Mild depressive episode F32.1 - MODORATE depressive episode F32.2 - Severe depressive episode without psychotic symptoms F32.3- severe depressive episode with psychotic symptoms F32.8 - Other depressive episodes- Atypical depression F32.9- depressive episode, unspecified F33 - Recurrent depressive disorder

8. EPIDEMIOLOGY: Age and gender: Depressive disorder is higher in women than it is in men by almost 2 to 1. Women experience more depression than men beginning at about age 10 and continuing through middle life. The gender difference is less pronounced in age between 44 and 65. But after 65 women are more likely to be depressed than man.

9. Social class : Hudson (2005) reported that depression have most commonly been found to be outcomes of low socioeconomic status. Marital status : Marriage had a protective effect against major depression only in the oldest age category (65+). Being never married was associated with increased risk of major depression in the 40 to 64 years age group and 65+ age group . Seasonality: Two prevalent period of seasonal involvement include spring (march, April and may) and the fall (September, October, and November)

10. TYPES OF DEPRSSIVE DISORDER: Major depressive disorder Persistent depressive disorder ( dysthymia ) Premenstrual dysphoric disorder Substance/ medication induced depression Depressive disorder due to another medical condition

11. MAJOR DEPRESSIVE DISORDER Diagnostic criteria according to DSM -5 5 or more of the following symptoms have been present during the same 2-week period and represents a change from previous functioning atleast one of the symptoms is either 1- depressed mood 2- loss of interest or pleasure Depressed mood most of the day, nearly every day Markedly diminished interest or pleasure in all or almost all, activities most of the day. Significant weight loss when not dieting or weight gain or decreased or increased appetite.

12. 4. Insomnia and hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day 6.Fatigue or loss of energy nearly every day 7. Feeling of worthlessness or excessive or inappropriate guilt nearly every day 8. Diminished ability to think or concentrate nearly every day 9. Recurrent thoughts of death

13. B. The symptoms cause clinically significant distress or impairment in social, occupational and other important areas of functioning. The episode is not attributable to the physiological effects of a substance or another medical condition. Responses to a significant loss may include the feeling of intense sadness, insomnia, poor appetite and weight loss which may resemble a depressive episode. D. The occurrence of the major depressive episode is not better explained by schizophrenia, schizo affective disorder, schizophrenic form disorder, delusional disorder, and other specified or unspecified schizophrenia and other psychotic disorder. E. There has never been a manic episode or a hypomanic episode

14. PERSISTENT DEPRESSIVE DISORDER (DYSTHYMIA) Diagnostic criteria according to DSM -5:- Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. In children mood can be irritable and duration must be at least 1 year. Presence, while depressed, of 2/ more of the following Poor appetite or over eating Insomnia or hypersomnia Low energy or fatigue Low self esteem Poor concentration or difficulty in making decision Feeling of hopelessness. C. During the 2 year period of disturbance, the individual has never been without the symptoms in criteria A and B for more than 2 months at a time.

15. D. Criteria for major depressive disorder may be continuously present for 2 years. E. There has never been a manic or hypomanic episode and the criteria has never ben met for cyclothymic disorder. F. The disturbances is not better explained by schizophrenia, schizo affective disorder, schizophrenic form disorder, delusional disorder,and other specified or unspecified schizophrenia and other psychotic disorder. G. The episode is not attributable to the physiological effects of a substance or another medical condition. H. The symptoms cause clinically significant distress or impairment in social, occupational and other important areas of functioning

16. Premenstrual dysphoric disorder In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses and become minimal or absent in the week post menses. One or more of the following symptoms must be present : Marked affective liability Marked irritability, anger or increased interpersonal conflicts. Marked depressed mood, feelings of hopelessness or self deprecating thoughts. Marked anxiety, tension, feelings of being keyed up

17. C.One or more of the following symptoms must additionally be present to reach a total of five symptoms when combined with symptoms from criteria B above. Decreased interest in usual activities Subjective difficulty in concentration. Lethargy, easy fatigability or marked lack of energy..

18. Marked changes in appetite, overeating or specific food cravings Hypersomnia or insomnia. A sense of being overwhelmed or out of control. Physical symptoms such as breast tenderness or swelling, joint or muscle pain etc D. The symptoms are associated with clinically significant distress or interferences with work, social activities, decreased productivity and efficiency at work, school or home. E. Criteria A should be confirmed by perspective daily rating during at least two symptomatic cycle F. The episode is not attributable to the physiological effects of a substance or another medical condition.

19. Substance/ medication induced depression The depressed mood is associated with intoxication or withdrawal from substances such as alcohol, amphetamines, cocaine, hallucinogens, opiods , phencyclidine like substances, sedatives, hypnotics and they cause clinically significant distress or impairment in social, occupational and other important area of functioning. A number of medication has been known to evoke mood symptoms. Classification include anesthetics, analgesics, anticholinergics , anticonvulsants, antihypertensives , antiparkinsonian , oral contraceptives, muscle relaxants, steroids, psychotropic drugs .

20. According to ICD10 CLASSIFICATION:- 1-Mild Depression Symptoms at the mild level of depression are following: ■ Affective: anger, anxiety, guilt, helplessness, hopelessness, sadness. ■ Behavioral : tearfulness, regression, restlessness, agitation, withdrawal. ■ Cognitive: self- blame, ambivalence , blaming others. ■ Physiological : anorexia or overeating, insomnia or hypersomnia , headache, backache, chest pain.

21. 2-Moderate Depression Dysthymia , which include the following: ■ Affective: dejection, helplessness, powerlessness , hopelessness; pessimistic outlook; low self-esteem; difficulty experiencing pleasure in activities. ■ Behavioral : slowed speech; limited verbalizations, possibly consisting of ruminations about life’s failures, decreased interest in personal hygiene and grooming.

22. ■ Cognitive: difficulty in concentrating and attention; obsessive and repetitive thoughts, verbalizations and behavior reflecting suicidal ideation. ■ Physiological: anorexia or overeating; insomnia or hypersomnia ; decreased libido; headaches; backaches; chest pain; abdominal pain; low energy level; fatigue.

23. Severe Depression Severe depression ,include the following: ■ Affective: hopelessness, and worthlessness; flat (unchanging) affect, feelings of emptiness; apathy; loneliness; sadness; inability to feel pleasure. ■ Behavioral : psychomotor retardation so severe or psychomotor behavior manifested by rapid, agitated, purposeless movements; no personal hygiene and grooming; social isolation is common.

24. Cognitive: with delusions of persecution and somatic delusions; confusion,an inability to concentrate; hallucinations, self-blame and thoughts of suicide. ■ Physiological: sluggish digestion, constipation, and urinary retention; amenorrhea; diminished libido; anorexia; weight loss; difficulty falling asleep and awakening very early in the morning.

25. PREDISPOSING FACTOR: BIOLOGICAL THEORIES: GENETICS: A genetic link has been suggested but definite mode of genetic transmission has not identified yet. Twin studies Study of Monozygotic twins indicate that recurrent major depression is approximately 37%. Family studies: Major depression is more common among first degree biological relatives of people with the disorder than among the general population.

26. BIOCHEMICAL INFLUENCE : Biogenic Amines: Depression may be related to deficiency of neurotransmitters norepinephrine , serotonin and dopamine. Historically the biogenic amine hypothesis of mood disorders grew out of the observation that reserpine , which depletes the brain amines, was associated with the development of depressive syndrome. Tryptophan, the amino acid precursor of serotonin, has been shown to enhance the efficacy of antidepressant medications Cholinergic transmission is thought to be excess in depression and inadequate in mania.

27. NEUROENDOCRINE DISTURBANCES: Hypothalmic - Pitutary - Adenocorticoid axis: In client who are depressed the normal system of hormonal inhibition fails, resulting in a hyper secretion of cortisol . This elevated serum cortisol is the basis for dexamethasone suppression test that is some thing is used to determine if an individual has somatically treatable.

28. Hypothalmic - pitutary - thyroid Axis: Thyrotroponin releasing factor (TRF) from the hypothalamus stimulates the release of thyroid stimulating hormones from the anterior pituitary gland. In turn , TSH stimulates the thyroid gland. Diminished TSH response to administered TRF is observed in approximately 25% of depressed person. This laboratory test has potential for identifying the client at high risk for affective illness.

29. PHYSIOLOGICAL INFLUENCES: Depressive symptoms as a consequences of a non mood disorder or as adverse effect of medication is called as secondary depression. It may be related to Medication side effects: A number of drugs, either alone or in combination with other medication can produce depression Example:- antipsychotics, analgesics, anxiolytic and sedatives and hypnotics. Antihypertensive medication : Propranolol and reserpine Others : steroid, hormones, sedatives, antibacterial,antifungal , antineoplastic,antiulcer .

30. NEUROLOGICAL DISORDER: CVA Brain tumor particularly in the area of temporal lobe. Agitated depression may be associated with Alzheimer’s disease, Parkinson’s disease and Huntington’s disease, and multiple sclerosis patient. Electrolyte disturbances: Excess level of sodium bicarbonate or calcium can produce symptoms of depression. Deficit in sodium and magnesium Excess of potassium and depletion of potassium

31. Hormonal disturbances: Depression is associated with dysfunction of adrenal cortex and is commonly observed in both addison’s disease and cushing syndrome. Hypoparathyroidism , hyperparathyroidism, hypothyroidism, hyperthyroidism. Imbalance in oestrogen and progesterone is the predisposition to premenstrual dysphoric disorder. Nutritional deficiencies: Deficiency of vitamin B 1 ,B 6 ,B 12 , niacin, C, folic acid, zinc, ca, potassium may produce depression.

32. PSYCHOSOCIAL THEORY: Psychoanalytic theory: According to freud depression results due to loss of a loved object and fixation in the oral sadistic phase of development. Behavioral theory: According to this model, depression is conditioned by repeated losses in the past.

33. Cognitive theory: According to this theory depression is due to negative cognitions. Which includes : Negative expectation of the environment. Negative expectation of the self Negative expectation of the future. These cognitive distortion is due to defect in cognitive development and the individual feels inadequate, worthless, and rejected by others.

34. Object loss theory: The theory of object loss suggest that depressive illness occurs as a result of having been abandoned by or otherwise separated from significant other during the first 6 month of life. This absence of attachment , which may be either physical or emotional, leads to feeling of helplessness and despair that contribute to lifelong pattern of depression in response to loss.

35. CLINICAL FEATURES :- In depression the classical triad symptoms are: Depressed mood Slowed / retarded thinking Psychomotor retardation

36. OTHER FEATURES INCLUDES:- Suicidal ideas Psychotic features like: hallucination and delusion, in delusion (nihilistic delusions, delusion of guilt etc.). Somatic symptoms: (decrease appetite/weight, early morning awakening, lack of reactivity to pleasurable stimuli).

37. Psychomotor retardation Difficulties in thinking and concentration Poor memory Vague physical symptoms such as fatigue, aching discomfort, constipation etc .

38. DIAGNOSIS:- Psychological test Dexamethasone suppression test showing failure. Toxicology screening suggesting drug induced depression. Based on ICD 10 criteria.

39. Treatment modalities:- Psychopharmacology:- Antidepressant:- Selective serotonin reuptake inhibitors(SSRI) Ex:- Sertraline , fluoxetine Tricyclic Antidepressant (TCAs) ,Ex:- Amitriptyline , Imipramine Mono Amine oxidase inhibitors(MAOIs), Ex:- Isocarboxazid

40. Physical therapy:- ECT, Light therapy Psychosocial treatment:- Psychotherapy, Cognitive therapy Group therapy Family therapy Behavior therapy

41. Nursing management:- NURSING ASSESSMENT:- Nursing assessment should focus on judging the severity of the disorder including the risk of suicide, identifying the possible causes, the social resources available to the patient, and the effects of the disorder on other people.

42. Nursing diagnosis High-risk of self directed violence related to depressed mood, feelings of worthlessness and anger directed inward on the self. INTERVENTIONS: Ask the patient directly “have you thought about harming yourself in any ways”. Create a safe environment for the patient.

43. The patient should be placed near the nursing station. Do not allow the patient to put the bolt on his side of the door of bathroom/ toilet. Close observation is required when the patient is recovering from disease. Encourage the patient to express his feelings, including anger.

44. Powerlessness related to dysfunctional grieving process, lifestyle of helplessness, evidenced by feeling of lack of control over life situations, overdependence on others to fulfill needs. INTERVENTIONS:- Allow the patient to take decisions regarding own care. Encourage the patient to verbalize feelings about areas that are not in his ability to control. Ensure that goals are realistic and that patient is able to identify life situations that are realistically under his control.

45. Dysfunctional grieving related to real or perceived loss, bereavement, evidenced by denial of loss, inappropriate expression of anger, inability to carry out activities of daily living. INTEERVENTIONS:- Be accepting the patient and spend time with him. Explore feelings of anger and help patient direct them towards the intended object or person. Provide simple activities which can be easily and quickly accomplished.