major depression

1. Major Depression

2. overview

4. Major depression Depressed mood on a daily basis for 2 weeks or longer A syndrome of persistent sad, dysphoric mood accompanied by disturbances in sleep and appetite, lethargy, and an inability to experience pleasure (anhedonia) About 15% of the general population experiences a major depression episode at some time in their lives About 6-8% of patients in care settings meet the diagnostic criteria for this disorder Often undiagnosed; patients commonly receive inadequate treatment

6. may occur sporadically, increasing in frequency as the patient grows older

8. GENDER CUE Gender plays a significant role in clinical depression Males have a 5% to 12% lifetime risk factor Females have a 10% to 25% risk factor One cause for this difference is the link between rates of depression and levels of sex hormones

9. Key mechanisms in the initiation of depression in women: Changes in gonadal hormones caused by puberty, menses, pregnancy Disturbances in the hypothalamic-pituitary-gonadal (HPG) axis Effects of neuromodulators such as serotonin Changes in estrogen and progesterone levels (as well as changes in the HPG axis) are associated with pregnancy and delivery These factors may underlie postpartum depression

10. Pathophysiology and etiology

12. Unclear relationship between psychological stress, negative life events, and onset of depression Genetic, Familial, Biochemical, Physical, Psychological, Social Causes In many patients, the history identifies a specific personal loss or severe stress that probably interacts with a person's predisposition to provoke major depression Risk of unipolar depression increases with the number of occurrences About 50-60% of persons who have a first episode experience at least 2 more episodes

13. Primary sites of defects in unipolar depression: neural networks of the prefrontal cortex and the basal ganglia A decreased rate of the brain's glucose metabolism in the caudate nuclei and frontal lobes in depressed patients returns to normal with recovery Involvement of the serotonin system and neuroendocrine systems Changes in the hypothalamic-pituitary-adrenal regulation system represent an adaptive deregulation of the stress response

16. There may also be differences in biological rhythms changes in the patient's circadian rhythm various neurochemical and neurohormonal factors Differentiate major depression from depression that occurs in response to a specific event or has a recognizable organic basis Many physical disorders are associated with secondary depression metabolic disturbances: hypoxia and hypercalcemia endocrine disorders: diabetes and Cushing's disease

17. Neurologic diseases: Parkinson's, Alzheimer's disease Cancer (especially of the pancreas) Viral & bacterial infections: influenza, pneumonia Cardiovascular disorders: heart failure Pulmonary disorders: chronic obstructive lung disease Musculoskeletal disorders: degenerative arthritis GI disorders: irritable bowel syndrome Genitourinary problems: incontinence Collagen vascular diseases: lupus Anemias

18. Drugs prescribed for medical and psychiatric conditions and commonly abused substances can also precipitate secondary depression Antihypertensives Psychotropics Antiparkinsonian drugs Opioid and nonopioid analgesics Numerous cardiovascular medications Oral antidiabetics Antimicrobials Steroids Chemotherapeutic agents Cimetidine Alcohol

20. complications

21. Major depression can profoundly alter social, family, and occupational functioning Suicide: most serious complication of major depression resulting when the patient's feelings of worthlessness, guilt, and hopelessness are so overwhelming that he no longer considers life worth living

22. ALERT If specific plans for suicide are uncovered or if significant risk factors exist: previous history profound hopelessness concurrent medical illness substance abuse social isolation Refer the patient to a mental health specialist for immediate care Nearly 15% of patients with untreated depression commit suicide most of these patients sought help from a physician within 1 month of their deaths

23. Assessment findings

25. Patients with endogenous depression experience a profound loss of pleasure in all enjoyable activities Duration: a full month to 1 or more years During assessment interview patient: may complain of feeling “down in the dumps” may express doubts about his self-worth or ability to cope may simply appear unhappy and apathetic The patient often notices that symptoms are worse in the morning

26. Common symptoms: Difficulty concentrating or thinking clearly Distractibility Indecisiveness Severe states of major depression: Delusions of persecution or guilt Severe affective disorder may effectively immobilize the patient of all functions Take special note if the patient reveals suicidal thoughts, a preoccupation with death, or previous suicide attempts

28. ASSESSMENT TIP Be alert for signs of suicide Assess the patient's risk of suicide by using direct questioning Patients are often reluctant to verbalize these thoughts without prompting

29. Psychosocial history May reveal life problems or losses that can account for the depression Medical history May implicate a physical disorder or the use of prescription, nonprescription, or illegal drugs that can cause depression Patient may report: Increase or a decrease in appetite Sleep disturbances (insomnia or early awakening) A lack of interest in sex Constipation or diarrhea

31. Other signs: Agitation (hand wringing or restlessness) Psychomotor retardation (slowed speech) In a minority of patients, the severity of depression may progress to psychotic symptoms Seasonal pattern of depression Seasonal affective disorder Particular in women Anergy, fatigue, weight gain, hypersomnia, and episode carbohydrate craving The prevalence increases with distance from the equator Mood improvement can be accomplished with light exposure therapy

33. CULTURAL TIP External manifestations of depression can differ in various cultures Some individuals become stoic when depressed Others outwardly express their depression The core symptoms remain the same

34. Diagnostic criteria

35. DSM-IV-TR At least 5 of the following symptoms during the same 2-week period and represent a change from previous functioning One of these symptoms must be either depressed mood or loss of interest in previously pleasurable activities restlessness or feeling keyed up or on edge depressed mood (irritable mood in children & adolescents) most of the day, nearly every day, as indicated by either subjective account or observation by others a markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

36. significant weight loss or weight gain (>5% of the patient's body weight in a month) when not dieting or a change in appetite nearly every day insomnia or hypersomnia nearly every day psychomotor agitation or retardation nearly every day fatigue or loss of energy nearly every day feelings of worthlessness & excessive or inappropriate guilt nearly every day diminished ability to think or concentrate or indecisiveness, nearly every day recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or suicide attempt or a specific plan for committing suicide The symptoms aren't due to a mixed episode

37. The symptoms aren't due to a medical condition or the effects of a medication or other substance The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning The symptoms aren't better accounted for by bereavement Psychological tests such as the Beck Depression Inventory can be used to determine the onset, severity, duration, and progression of depressive symptoms Toxicology screening may suggest a drug-induced depression

38. management

39. Patients may receive treatment in acute inpatient psychiatric hospitals community in an outpatient program Decision about treatment setting is made according to the severity of the patient's illness, with primary concern being the risk of self-harm (suicide) as well as the presence of symptoms that are severely disabling Inpatient treatment is directed toward drug management and supportive psychotherapy using milieu management

41. Amitriptyline (Elavil, Endep)

42. Clomipramine (Anafranil)

43. Desipramine (Norpramin, Pertofrane)

44. Doxepin (Adapin, Sinequan)

45. Imipramine (Tofranil, Tofranil-PM, Janimine, SK-pyramine)

46. Nortriptyline (Aventyl, Pamelor)

47. Protriptyline (Vivactil)

49. Mirtazapine (Remeron)

50. Bicyclic Agent

51. Venlafaxine (Effexor)

52. Selective Serotonin Reuptake Inhibitors (SSRIs)

53. Citalopram (Celexa)

54. Escitalopram (Lexapro)

55. Fluoxetine (Prozac)

56. Paroxetine (Paxil)

57. Sertraline (Zoloft)

58. Fluvoxamine (Luvox)

59. Monoamine Oxidase Inhibitors (MAOIs)

62. Tranylcypromine (Parnate)

63. Pargyline (Eutonyl)

64. Selegiline (Eldepryl, Deprenyl)

65. Dibenzoxazepine Agent

66. Amoxapine (Asendin)

67. Unicyclic Agent

68. Bupropion (Wellbutrin)

69. Triazolopyridine Agent

70. Trazodone (Desyrel)

71. Phenylpiperazine Agent

73. ECT may be used to treat severe depression that is unresponsive to antidepressant drugs Ultraviolet light therapy may be recommended for depression that occurs during fall and winter months (seasonal affective disorder) Complementary and alternative treatments Use of herbal supplements (St. John's wort) Discuss with health care provider due to the potential for drug interactions

76. identifying and challenging the accuracy of the patient's negative thought patterns

81. Anxiety Chronic low self-esteem Disturbed sleep pattern Dysfunctional grieving Fatigue Impaired home maintenance Impaired social interaction Ineffective coping Ineffective role performance Risk for other-directed violence Risk for self-directed violence Social isolation Spiritual distress

84. Key outcomes

85. The patient will verbalize strategies to reduce anxiety demonstrate verbally and behaviorally a decrease in negative self-evaluation use support groups and other resources to work through the grieving process resume normal sleep patterns verbalize the importance of adequate rest periods comply with medication regimen

86. The patient will engage in social interactions with others develop effective coping behaviors maintain roles and responsibilities to the fullest extent possible (won't) harm others make a verbal contract not to harm himself while in the facility maintain family and peer relationships verbalize the importance of inner resources

88. Nursing interventions

90. To prevent the patient from becoming isolated, try to spend some time with him each day Avoid long periods of silence, which tend to increase anxiety Share your observations of the patient's behavior with him “You're sitting all by yourself, looking very sad. Is that how you feel?” Because the patient may think and react sluggishly, try to speak slowly and allow ample time for him to respond Avoid feigned cheerfulness, but don't hesitate to laugh with the patient and point out the value of humor

92. Encourage the patient to talk about and write down his feelings Show him he's important by listening attentively and respectfully, preventing interruptions, and avoiding judgmental responses Provide a structured routine (noncompetitive activities) to build the patient's self-confidence and encourage interaction with others Urge him to join group activities and to socialize Reassure the patient that he can help ease his depression by: expressing his feelings

93. participating in pleasurable activities improving grooming and hygiene Record all observations of and conversations with the patient because they're valuable for evaluating his response to treatment While caring for the patient's psychological needs, don't forget his physical needs If he's too depressed to take care of himself, help him with personal hygiene Encourage him to eat, or feed him, if necessary If he's constipated, add high-fiber foods to his die Offer small, frequent meals

94. Encourage physical activity and fluid intake Offer warm milk or back rubs at bedtime to improve sleep Assume an active role in initiating communication Plan activities for when the patient's energy levels are highest If the patient has been prescribed an antidepressant, monitor for evidence of seizures Some antidepressants significantly lower the seizure threshold Recognize that it may take several weeks for the antidepressants to produce an effect

95. CULTURAL TIP Members of some cultures, such as Arab Americans, don't acknowledge depression Encourage the patient to discuss his condition, and give the patient permission to feel depressed

96. ALERT Ask the patient if he thinks of death or suicide Such thoughts signal an immediate need for consultation and assessment Failure to detect suicidal thoughts early may encourage the patient to attempt suicide The risk of suicide increases as the depression lifts

97. Patient teaching

98. Teach the patient about his depression Emphasize that effective methods are available to relieve his symptoms Help him to recognize distorted perceptions, and link them to his depression When the patient learns to recognize depressive thought patterns, he can consciously begin to substitute self-affirming thoughts If the patient has been prescribed an antidepressant, stress the need for compliance and review adverse reactions

99. For drugs that produce strong anticholinergic effects (amitriptyline, amoxapine) suggest sugarless gum or hard candy to relieve dry mouth Many antidepressants are sedating (amitriptyline, trazodone); warn the patient to avoid activities that require alertness, including driving and operating mechanical equipment Caution the patient taking a TCA to avoid drinking alcoholic beverages or taking other central nervous system depressants during therapy

102. Pickled herring, liver, canned figs, raisins

103. Bananas, avocados, chocolate, soy sauce,

104. Fava beans, yeast extracts, meat tenderizers,

107. Suicide prevention guidelines

110. Remove dangerous objects Remove such objects as belts, razors, suspenders, light cords, glass, knives, nail files, and clippers from the patient's environment Consult with staff Recognize and document both verbal and nonverbal suicidal behaviors Keep the physician informed Share data with all staff Clarify the patient's specific restrictions Assess risk and plan for observation Clarify day and night staff responsibilities and frequency of consultation

111. Observe the suicidal patient Be alert when the patient is using a sharp object (shaving), taking medication, or using the bathroom (to prevent hanging or other injury) Assign the patient to a room near the nurses' station and with another patient Continuously observe the acutely suicidal patient Maintain personal contact Help the suicidal patient feel that he's not alone or without resources or hope Encourage continuity of care and consistency of primary nurses Building emotional ties to others is the ultimate technique for preventing suicide.

112. Learning activity

115. http://nurseRD.blogspot.com www.authorstream.com/reynel89/Nursing www.slideshare.net/reynel89/slideshows THANK YOU!Have a nice day : ) - RDG