Depressive disorders

CHAPTER 14


Depressive disorders


Mallie Kozy and Margaret Jordan Halter



Objectives



1. Compare and contrast major depressive disorder and dysthymic disorder.


2. Explore disruptive mood dysregulation disorder and its impact on children.


3. Describe the symptoms of premenstrual dysphoric disorder.


4. Discuss the complex origins of depressive disorders.


5. Assess behaviors in a patient with depression in regard to each of the following areas: (a) affect, (b) thought processes, (c) feelings, (d) physical behavior, and (e) communication.


6. Formulate five nursing diagnoses for a patient with depression, and include outcome criteria.


7. Name unrealistic expectations a nurse may have while working with a patient with depression, and compare them to your own personal thoughts.


8. Role-play six principles of communication useful in working with patients with depression.


9. Evaluate the advantages of the selective serotonin reuptake inhibitors (SSRIs) over the tricyclic antidepressants (TCAs).


10. Explain the unique attributes of two of the unconventional antidepressants for use in specific circumstances.


11. Write a medication teaching plan for a patient taking a tricyclic antidepressant, including (a) adverse effects, (b) toxic reactions, and (c) other drugs that can trigger an adverse reaction.


12. Write a medication teaching plan for a patient taking a monoamine oxidase inhibitor, including foods and drugs that are contraindicated.


13. Write a nursing care plan incorporating the recovery model of mental health.


14. Discuss the use of electroconvulsive therapy (ECT) for depressive disorders.




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To be a nurse is to work with patients with depression. Depression can exist along or in conjunction with other disorders and illnesses. Depression can present differently in different populations and different age groups, and depression can be manifested on a continuum from mild to severe. One thing is consistent—depression results in significant pain and suffering that disrupts social relationships, performance at school or on the job, and the ability for a person to live a full and happy life. Depression also has a negative impact on physical well-being and the course of other medical diagnoses. This chapter includes basic information and therapeutic tools that will facilitate the care of patients with depression.




Clinical picture


According to the National Institute of Mental Health (NIMH, 2012b), major depressive disorder is one of the most common mental disorders, affecting approximately 13 million adults annually in the United States. Major depressive disorder, disruptive mood dysregulation disorder, dysthymic disorder, premenstrual dysphoric disorder, substance-induced depressive disorder, and depressive disorder not elsewhere classified are all disorders included in the category of depressive disorders in the Diagnostic and Statistical Manual, fifth edition (DSM-5) (American Psychiatric Association, 2013).


Major depressive disorder, or major depression, is characterized by a persistently depressed mood lasting for a minimum of two weeks. Children tend to be irritable rather than depressed. It may be a single episode or recurrent (more than one) episode. The depressed mood is accompanied by a lack of interest in previously pleasurable activity, also known as anhedonia (an “without” + hedone “pleasure”); fatigue; sleep disturbances; changes in appetite; feelings of hopelessness or worthlessness; persistent thoughts of death or suicide; an inability to concentrate or make decisions; and a change in physical activity (Wasserman, 2011).


While we tend to label anyone with a depressed mood as having depression, in actuality the diagnosis of major depression involves a cluster of symptoms. Not only does the patient have a depressed mood or anhedonia (inability to feel happy), but also additionally at least five of the other eight symptoms listed above. The patient will complain of problems with family members, friends or co-workers; fear of failing at school; or worries that his or her job performance has declined. In severe cases the patient may not be able to perform basic activities of daily living such as bathing, dressing, or preparing food.


Sleep disturbances might involve insomnia, or the inability to sleep. Sometimes people have trouble falling asleep; other times the patient may fall asleep quickly only to awaken after a few hours unable to return to sleep until it is time to get up for the day. Early morning awakening, known as terminal insomnia, is a red flag for depression. Sometimes the opposite can occur, and people are completely exhausted and sleep too much, as many as 12 to 16 hours a day. We refer to this symptom as hypersomnia.


Appetite changes also vary in individuals experiencing depression. Appetite loss is common, and sometimes patients can lose up to 5% of their body weight in less than a month. Other patients find they eat more often and complain of weight gain.


Feelings of guilt and worthlessness are sometimes hard to discern in patients with depression. As a nurse listens to a patient talk, he or she will hear phrases such as “I never seem to do anything right,” “I was never a good parent,” or “it’s my fault that project at work failed.” For a patient with major depression, these thoughts tend to occur over and over again and are difficult for the patient to stop. These thoughts can fuel the insomnia and the fatigue that accompanies depression.


Patients with depression will sometimes complain of an inability to think or make decisions. They will say that they can’t concentrate at work, are easily distracted while they try to study, or they can’t make up their mind what to wear or what to eat. For these patients, these difficulties represent a change in functioning. In some cases, especially for hospitalized patients, these symptoms can be severe. Some patients cannot concentrate long enough to complete tasks at work or attend class. Others find it so difficult to make decisions that they cannot get dressed or select, plan or prepare a meal.


Physical activity is also affected in major depression. Normally we think of depressed patients as having psychomotor retardation, a reduction in the amount of physical activity. This type of symptom results in less motor movement; patients tend to stay in bed or sit in one spot most of the day. When they do move, they move more slowly and posture is frequently stooped with the head down; however, patients with major depression may also have psychomotor agitation. When this occurs, the patient appears restless, changes position often, and may wring his or her hands and fidget. He or she also may pace up and down the hall. This is not goal-directed activity, and the patient does not feel energized. While many symptoms of major depression are subjective and must be described by the patient, psychomotor retardation and psychomotor agitation are visible signs to family members, friends, co-workers, and the nurse caring for the patient.


In depression a person can be abnormally preoccupied with death. This may be exhibited in the patient by fantasizing about his or her funeral or having recurring dreams about death. It is not uncommon for patients with depression to become suicidal. Suicidal thoughts may be relatively mild and fleeting. For other individuals, suicidal thoughts are quite serious or persistent and involve a plan. Suicidal thoughts, especially those in which the patient has a plan and the means to carry it out, represent an emergency requiring immediate intervention by the nurse (refer to Chapter 25) Suicidal thoughts are a major reason for hospitalization for patients with major depression.


Major depression can occur just once in a patient’s lifetime or it can remit and recur. In bipolar disorder, patients may also experience depression that remits and recurs; however, patients with major depression differ from patients with bipolar disorder in that they experience no episodes of mania or hypomania (refer to Chapter 13).


Grief versus depression: People experiencing a significant loss can exhibit feelings and behaviors similar to depression. They may cry frequently, feel hopeless about the future, have disruptions in eating and sleeping, and lose pleasure in everyday activities. They may even temporarily lack interest in caring for themselves and neglect normal hygiene. At what point does grief become pathological, result in a diagnosis of depression and require intervention? This is a controversial question and one that is not easily answered.


Until recently, someone was not diagnosed with depression in the first two months following a significant loss. This was called a bereavement exclusion. There was a concern that the normal process of bereavement might be rendered pathological, resulting in a diagnostic label, unnecessary treatment and loss of dignity for the bereaved. Although controversial, a diagnosis of depression can now be given in the first two months following death of a loved one or other loss. The reason for the change is that grief, like other stressors, can result in depression. For some people, waiting two months for an official diagnosis of major depression may delay treatment and adversely affect prognosis. Further research and education about grief is needed in order to clarify diagnostic categories and prevent overdiagnosis of depression in the presence of grief (Shear et al., 2011).


Depressive disorders are classified according to symptoms or the situations under which they occur.


Disruptive mood dysregulation disorder relates to children between the ages of 6 and 18 and refers to situations in which a person has frequent temper tantrums resulting in verbal or behavioral outbursts out of proportion to the situation; in addition, others would describe the person’s persistent mood between outbursts as irritable (Stringaris, 2011). A couple of things should be considered when considering whether the temper tantrums constitute disruptive mood dysregulation disorder. Temper tantrums are not unusual at certain developmental stages, and some other illnesses, such as autism, exhibit temper tantrums. For that reason, this diagnosis is given for the first time only to children between the ages of 6 and 18 who do not have other medical or mental health diagnoses that could account for the tantrums.


Dysthymic disorder occurs when feelings of depression persist consistently for at least two years. Children, adolescents, and adults may have this problem. The symptoms are difficult for the patient to live with and bring about social and occupational distress, but they are usually not severe enough to require hospitalization (Wasserman, 2011). Because the onset of dysthymic disorder is usually in teenage years, patients will frequently express that they have “always felt this way” and that being depressed seems like a normal way of functioning (NIMH, 2012b). It is not uncommon for people with this low-level depression to also have periods of full-blown major depressive episodes.


Premenstrual dysphoric disorder refers to a cluster of symptoms that occur in the last week prior to the onset of a woman’s period. Symptoms include physical discomfort and emotional symptoms similar to major depression that are severe enough to interfere with the ability of a woman to work or interact with others. Symptoms decrease significantly or disappear with the onset of menstruation. The prevalence for Premenstrual Dysphoric Disorder is 2.5% to 5.5 % (Wasserman, 2011).


Substance-induced depressive disorder applies when symptoms of a major depressive episode arise as a result of prolonged drug or alcohol intoxication or as the result of withdrawal from drugs and alcohol. The person with this diagnosis would not experience depressive symptoms in the absence of drug or alcohol use or withdrawal (Niciu et al, 2009).


Depressive disorder associated with another medical condition can be the result of changes that are directly related to certain illnesses such as kidney failure, Parkinson’s disease, and Alzheimer’s disease however, the symptoms that result from medical diagnoses or that result from the use of certain medications are not considered major depressive disorder.



Epidemiology


Depression is the leading cause of disability in the United States. The most comprehensive statistics in the United States are from 2008. At that time the prevalence of depression was 6.7% for adults and 8.3% for children ages 12 to 17 (NIMH, 2012b). This means that at least 1 in every 20 people in the United States suffers from depression. This results in a significant loss of productivity (Beck et al., 2011) in addition to the more personal individual and family distress.


Because symptoms vary by age and circumstance, depression in children, until recently, has been underrecognized. We now know that even infants can display symptoms of depression (Jacobs & Taylor, 2009). With this understanding, we are just beginning to get a realistic view of the epidemiology of depression in children. Children and adolescents between 13 and 18 years of age have an 11.2% prevalence of depression, and 3.3% have a severe form of the illness (National Institute of Mental Health [NIMH], 2012a). If the first episode of depression occurs in childhood or adolescence, the likelihood of recurrence is high (Jacobs & Taylor, 2009), setting the stage for recurrent depression.


Although depression in older adults is common, it is not a normal result of aging. The risk of depression in the elderly increases as health deteriorates. It is estimated that about 1-5% of older adults living in the community have depression. This number rises to 11.5% of hospitalized older adults and 13.5% for those requiring home care (NIMH 2012a). Many older adults suffer from subsyndromal depression, in which they experience many, but not all, of the symptoms of a major depressive episode; these individuals have an increased risk of developing major depression. A disproportionate number of older adults with depression are likely to die by suicide (NIMH, 2012b). There are discrepancies in diagnosis and treatment along cultural and socioeconomic lines in older adults. For older adults, fewer African Americans (4.2%) are diagnosed with depression than whites (6.4%) or Hispanics (7.2%); however, only 63% of African American and Hispanic patients received treatment, while 73% of whites received treatment. Hispanic and African Americans are more likely to identify economic barriers to receiving treatment (NIMH, 2012a). Older individuals suffering from depression are at risk for being untreated, and this is especially true for minorities.



Comorbidity


A depressive syndrome frequently accompanies other psychiatric disorders, such as anxiety disorders, schizophrenia, substance abuse, eating disorders, and schizoaffective disorder. People with anxiety disorders (e.g., panic disorder, generalized anxiety disorder, obsessive-compulsive disorder) commonly have depression, as do people with personality disorders, particularly borderline personality disorder (Joska & Stein, 2008). The combination of anxiety and depression is perhaps one of the most common psychiatric presentations. Symptoms of anxiety occur in an average of 70% of cases of major depression. Some clinicians believe that mixed anxiety and depression should be a stand-alone diagnosis and be treated as a distinct entity.


The incidence of major depression greatly increases with the occurrence of a medical disorder, and people with chronic medical problems are at a higher risk for depression than those in the general population. Depression often develops secondary to a medical condition and may also be secondary to use of substances such as alcohol, cocaine, marijuana, heroin, and even anxiolytics and other prescription medications (Table 14-1). Depression can also be a consequence of bereavement and grief.




Etiology


Although many theories attempt to explain the cause of depression, many psychological, biological, and cultural variables make identification of any one cause difficult; furthermore, it is unlikely there is a single cause for depression. The high variability in symptom manifestation, response to treatment, and course of the illness supports the supposition that depression may result from a complex interaction of causes. For example, genetic predisposition to the illness combined with childhood stress may lead to significant changes in the central nervous system (CNS) that result in depression; however, there seem to be several common risk factors for depression, listed in Box 14-1 (Sadock & Sadock, 2008).



BOX 14-1   


PRIMARY RISK FACTORS FOR DEPRESSION




From Joska, J. A., & Stein, D. J. (2008). Mood disorders. In R. E. Hales, S. C. Yudofsky, & G. O. Gabbard (Eds.), Textbook of psychiatry (5th ed., pp. 457-504). Washington, DC: American Psychiatric Publishing



EVIDENCE-BASED PRACTICE


Depression in Adolescent Mothers


Meadows-Oliver, M., & Sadler, L. (2010). Depression among adolescent mothers enrolled in a high school parenting program. Journal of Psychosocial Nursing, 48(12), 34-41. doi: 10.3928/02793695-20100831-04.








Biological factors



Genetic

Twin studies consistently show that genetic factors play a role in the development of depressive disorders. Various studies reveal that the average concordance rate for mood disorders among monozygotic twins (twins sharing the same genetic material) is about 37%. That is, if one twin is affected, the second has a 37% chance of being affected as well (Joska & Stein, 2008). Increased heritability of mood disorders is associated with an earlier age of onset, greater rate of comorbidity, and increased risk of recurrent illness (Lahoff, 2010). It is likely that multiple genes are involved, each one having a small but substantial role in the development and severity of depression. For instance, certain genetic markers seem to be related to depression when accompanied by early childhood maltreatment or a history of stressful life events (Smoller & Korf, 2008). In this case, there is no gene directly related to the development of the mood disorder; there is a genetic marker associated with depression in the context of stressful life events.


One of the more important aspects of understanding the role of genetics in relation to mental illness such as major depression may be in pharmacological treatments. Understanding genetic influences on the role of the transport of certain neurotransmitters, such as serotonin, across synapses will make it much easier to prescribe effective medical treatment of depression based on individual genetic patterns.



Biochemical

The brain is a highly complex organ that contains billions of neurons. There is much evidence to support the concept that many CNS neurotransmitter abnormalities may cause clinical depression. These neurotransmitter abnormalities may be the result of genetic or environmental factors or other medical conditions, such as cerebral infarction, Parkinson’s disease, hypothyroidism, acquired immunodeficiency syndrome (AIDS), or drug use.


Two of the main neurotransmitters involved in mood are serotonin (5-hydroxytryptamine [5-HT]) and norepinephrine. Serotonin is an important regulator of sleep, appetite, and libido; therefore, serotonin-circuit dysfunction can result in sleep disturbances, decreased appetite, low sex drive, poor impulse control, and irritability (Joska & Stein, 2008). Norepinephrine modulates attention and behavior. It is stimulated by stressful situations, which may result in overuse and a deficiency of norepinephrine. A deficiency, an imbalance as compared to other neurotransmitters, or an impaired ability to use available norepinephrine can result in apathy, reduced responsiveness, or slowed psychomotor activity.


Research suggests that depression results from the dysregulation of a number of neurotransmitter systems beyond serotonin and norepinephrine. The dopamine, acetylcholine, and GABA systems are also believed to be involved in the pathophysiology of a major depressive episode (Sadock & Sadock, 2008). Glutamate is a common neurotransmitter with a number of different functions. Glutamate increases the ability of a nerve fiber to transmit information (NIMH, 2012d); therefore, a deficit in glutamate can interfere with normal neuron transmission in the areas of the brain that affect mood, attention, and cognition. Research is just beginning to understand the role of glutamate in depression.


Stressful life events, especially losses, seem to be a significant factor in the development of depression. Norepinephrine, serotonin, and acetylcholine play a role in stress regulation. When these neurotransmitters become overtaxed through stressful events, neurotransmitter depletion may occur. Research indicates that stress is associated with a reduction in neurogenesis, which is the ability of the brain to produce new brain cells. One of the antidepressants is associated with increasing these new cells (Anacker et al., 2011).


At this time, no single mechanism of depressant action has been found. The relationships among the serotonin, norepinephrine, dopamine, acetylcholine, GABA, and glutamate systems are complex and need further assessment and study; however, treatment with medication that helps regulate these neurotransmitters has proved empirically successful in the treatment of many patients. Figure 14-1 shows a positron emission tomographic (PET) scan of the brain of a woman with depression before and after taking medication. Refer to Chapter 3 for further discussion of brain imaging and depression.


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FIG 14-1  Positron emission tomographic (PET) scans of a 45-year-old woman with recurrent depression. The scan on the left was taken when the patient was on no medication and very depressed. The scan on the right was taken several months later when the patient was well, after she had been treated with medication for her depression. Note that her entire brain, particularly the left prefrontal cortex, is more active when she is well. (Courtesy Mark George, MD, Biological Psychiatry Branch, National Institute of Mental Health.)


Alterations in hormonal regulation

Although neuroendocrine findings are as yet inconclusive, the neuroendocrine characteristic most widely studied in relation to depression has been hyperactivity of the hypothalamic-pituitary-adrenal cortical axis. People with major depression have increased urine cortisol levels and elevated corticotrophin-releasing hormone (Joska & Stein, 2008). Dexamethasone, an exogenous steroid that suppresses cortisol, is used in the dexamethasone suppression test (DST) for depression. Results of this test are abnormal in about 50% of people with depression, which indicates hyperactivity of the hypothalamic-pituitary-adrenal cortical axis; however, the findings may also be abnormal in people with obsessive-compulsive disorder (OCD) and other medical conditions. Significantly, patients with major depression with psychotic features are among those with the highest rates of non suppression of cortisol on the dexamethasone suppression test.


Depression rates are almost equal for males and females in the years preceding puberty and in older adults; this has led to more research into the effect of hormones on depression in women. The results are inconclusive in humans; however, evidence is beginning to demonstrate a relationship with estrogen levels and neurological changes associated with depression. Recent studies have found that estradiol, a form of estrogen, affects receptors sensitive to serotonin in the areas of the brain responsible for mood in rats. Additional research has demonstrated that declines in the levels of estrogen around menstruation and menopause create changes in nerve structures in the brain, called dendritic pruning, that are associated with depression (Accortt et. al, 2008). As the relationships between sex hormones such as estrogen in women and testosterone in males are better understood, more effective therapies may be developed.



Inflammatory processes

Inflammation is the body’s natural defense to physical injury. There is growing evidence that inflammation may be the result of psychological injury as well. Researchers have focused in on two important blood components related to inflammation, C-reactive protein and interleukin-6. In young females with a history of adversity, depression is accompanied by elevations in these blood components, but not in children without a history of adversity (Miller & Cole, 2012). Adversity in life may compromise resilience and place children at risk for depression and other disorders.


While we do not believe that inflammation causes depression, research indicates that it does play a role (Krishnadas & Cavanagh, 2012). Support for this belief includes that about a third of people with major depression have elevated inflammatory biomarkers in the absence of a physical illness. Also, people who have inflammatory diseases have increased risk of major depression. Finally, people treated with cytokines to enhance immunity during cancer treatment develop major depression at a high rate.



Diathesis-stress model

The diathesis-stress model of depression takes into account the interplay between genetic and biological predisposition toward depression and life events. The physiological vulnerabilities such as genetic predispositions, biochemical makeup, and personality structure are referred to as a diathesis. The stress part of this model refers to the life events that impact individual vulnerabilities. This explains why two persons exposed to relatively similar events may respond differently. One person may demonstrate resilience and another may develop depression (Seriani, 2011).


Biochemically, the diathesis-stress model of depression is believed to work this way. Psychosocial stressors and interpersonal events trigger neurophysical and neurochemical changes in the brain. Early life trauma may result in long-term hyperactivity of the CNS corticotropin-releasing factor (CRF) and norepinephrine systems, with a consequent neurotoxic effect on the hippocampus, which leads to overall neuronal loss. These changes could cause sensitization of the CRF circuits to even mild stress in adulthood, leading to an exaggerated stress response (Gillespie & Nemeroff, 2005).



Psychological factors



Cognitive theory

In cognitive theory, the underlying assumption is that a person’s thoughts will result in emotions. If a person looks at life in a positive way, the person will experience positive emotions, but negative interpretation of life events can result in sorrow, anger, and hopelessness. Cognitive theorists believe that people may acquire a psychological predisposition to depression due to early life experiences. These experiences contribute to negative, illogical, and irrational thought processes that may remain dormant until they are activated during times of stress (Beck & Rush, 1995). Beck found that persons with depression process information in negative ways, even in the midst of positive factors. He believed that automatic, negative, repetitive, unintended, and not-readily-controllable thoughts perpetuate depression. Three assumptions constitute Beck’s cognitive triad:



For a nursing student working with depressed patients, two things need to be understood. A patient will not immediately respond when the student offers a positive perspective to the patient. This may frustrate the student; however, the patient can learn over time to identify and disrupt the negative feedback loop that contributes to depression. Coming to realize that one has an ability to interpret life events in positive ways helps a person recognize that he or she has an element of control over emotions and therefore depression.




Application of the nursing process




Assessment


There is a consensus that major depression goes unrecognized and underdiagnosed in the general population, but specifically in minority populations and in older adults. According to Louch (2009), less than half of depressed patients seek medical help. Of those who present for treatment only half are accurately diagnosed. Yet research suggests that early treatment for depression can result in improved outcomes. Nurses at both the generalist and advanced practice level are frequently in the position to screen and assess for signs of depression, facilitating early and appropriate treatment.



General assessment


Assessment tools

Numerous standardized depression-screening tools that help assess the type and severity of depression are available, including the Beck Depression Inventory, the Hamilton Depression Scale, the Zung Depression Scale, and the Geriatric Depression Scale. The Patient Health Questionnaire-9 (PHQ-9), a short inventory that highlights predominant symptoms seen in depression, is presented here because of its ease of use (Figure 14-2) in primary care and community settings. It is important to note that self-screening tools such as the PHQ-9 have been validated, meaning they screen for depression with 91% accuracy, providing a valuable tool for the nurse (Gilbody, Richards & Barkham, 2007). Use of these tools during multiple encounters with a patient also allows the nurse to follow changes in the patient’s symptoms and depression severity over time.


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FIG 14-2  A, Patient Health Questionnaire-9 (PHQ-9). B, Scoring the PHQ-9. (Copyright © 2005 by Pfizer, Inc. Developed by Drs. Robert L. Spitzer, Janet B. Williams, Kurt Kroenke, and colleagues.)

The website www.depression-screening.org, sponsored by the National Mental Health Association (NMHA), enables people to take an online confidential screening test for depression and find reliable information on the illness (Live your life, 2009).



Assessment of suicide potential

The patient should always be evaluated for suicidal or homicidal ideation. About 15% of people with clinical depression commit suicide (Brendel et al., 2008). Risk for suicide in patients with major depression is increased in the presence of the following symptoms: severe hopelessness, overuse of alcohol, recent loss or separation, a history of past and serious suicide attempts, and acute suicidal ideation. Approaching initial suicide assessment might include the following statements or questions:



Refer to Chapter 25 for a detailed discussion of suicide, critical risk factors, warning signs, and strategies for suicide prevention. Also see Case Study and Nursing Care Plan 14-1.



14-1      CASE STUDY AND NURSING CARE PLAN


Depression


Ms. Glessner is a 35-year-old executive secretary. She has been divorced for 3 years and has two sons, 11 and 13 years old. She is brought into the emergency department (ED) by her neighbor. She has superficial slashes on her wrists and is bleeding. The neighbor shared that Ms. Glessner’s sons are visiting their father for the summer. Ms. Glessner reports that she has been depressed for as long as she can remember, yet she has become more and more despondent since terminating a 2-year relationship with a married man 4 weeks ago. After this relationship ended, she became withdrawn and despondent. Ms. Glessner is about 20 pounds overweight, and her neighbor states that Ms. Glessner often stays awake late into the night, drinking by herself and watching television. She sleeps through most of the day on the weekends.


After receiving treatment in the ED, Ms. Glessner is seen by a psychiatrist. The initial diagnosis is dysthymic disorder with suicidal ideation. A decision is made to hospitalize her briefly for suicide observation and evaluation for appropriate treatment.


The nurse, Carrie, admits Ms. Glessner to the unit from the ED.


Nurse: Hello, Ms. Glessner, I’m Marcia Ward. I’ll be your primary nurse.


Ms. Glessner: Yeah …. I don’t need a nurse, a doctor, or anyone else. I just want to get away from this pain.


Nurse: You want to get away from your pain?


Ms. Glessner: I just said that, didn’t I? Oh, what’s the use? No one understands.


Nurse: I would like to understand, Ms. Glessner.


Ms. Glessner: Look at me. I’m fat …. ugly …. and no good to anyone. No one wants me.


Nurse: Who doesn’t want you?


Ms. Glessner: My husband didn’t want me …. and now Jerry left me to go back to his wife.


Nurse: You think because Jerry went back to his wife that no one else could care for you?


Ms. Glessner: Well …. he doesn’t anyway.


Nurse: Because he doesn’t care, you believe that no one else cares about you?


Ms. Glessner: Yes ….


Nurse:Who do you care about?


Ms. Glessner: No one …. except my sons …. I do love my sons, even though I don’t often show it.


Nurse: Tell me more about your sons.


Carrie continues to speak with Ms. Glessner. Ms. Glessner talks about her sons with some affect and apparent affection; however, she continues to state that she does not think of herself as worthwhile.



Self-assessment


Carrie, a registered nurse, is aware that when patients have depression, they can be negative, think life is hopeless, and be hostile toward those who want to help. When Carrie was new to the unit, she withdrew from patients with depression and sought out patients who appeared more hopeful and appreciative of her efforts. The unit coordinator was supportive of Carrie when she was first on the unit. Carrie, along with other staff, went to in-service education sessions on working with patients with depression and was encouraged to speak up in staff meetings about the feelings many of these patients evoked in her. As a primary nurse, she was assigned a variety of patients. She found that as time went on, with the support of her peers and the opportunity to speak up at staff meetings, she was able to take what patients said less personally and not feel so responsible when patients did not respond as fast as she would like.


After 2 years, she had had the experience of seeing many patients who seemed hopeless and despondent upon admission respond well to nursing and medical interventions and go on to lead full and satisfying lives. This also made it easier for Carrie to understand that even though the patient with depression may think life is hopeless and may believe there is nothing in life to live for that change is always possible.







Implementation


Ms. Glessner’s plan of care is personalized as follows:




















































SHORT-TERM GOAL INTERVENTION RATIONALE EVALUATION



GOAL METBy the end of the second day, Ms. Glessner states she really did not want to die, she just couldn’t stand the loneliness in her life. She states that she loves her sons and would never want to hurt them.
 
 
 
 

GOAL METBy discharge, Ms. Glessner states that she is definitely going to try cognitive-behavioral therapy. She also discusses joining a women’s support group that meets once a week in a neighboring town.
 

 
 

 
 

 


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Key assessment findings

A depressed mood and anhedonia are the key symptoms in depression. Almost 97% of people with depression have anergia (lack of energy or physical passivity). Anxiety, a common symptom in depression, is seen in about 60% to 90% of patients with depression.


When people experience a depressive episode, their thinking is slow, and their memory and concentration are usually negatively affected. They also dwell on and exaggerate their perceived faults and failures and are unable to focus on their strengths and successes. A person with major depression may experience delusions of being punished for committing bad deeds or being a terrible person. Feelings of worthlessness, hopelessness, guilt, anger, and helplessness are common.


Psychomotor agitation may be evidenced by constant pacing and wringing of hands. The slowed movements of psychomotor retardation, however, are more common. Somatic complaints (headaches, malaise, backaches) are also common. Vegetative signs of depression (change in bowel movements and eating habits, sleep disturbances, and disinterest in sex) are usually present. In primary care, people with major depression experience chronic pain at a rate of 66% and disabling pain at a rate of 41%, compared to 43% and 10%, respectively, of those who do not have depression (Arnow et al., 2006).



Areas to assess





Feelings

Guilt is a common accompaniment to depression. A person may ruminate over present or past failings. In severe depression extreme guilt can assume psychotic proportions (see “Thought Processes” above).


Helplessness is demonstrated by a person’s inability to solve problems in response to common concerns. In severe situations helplessness may be evidenced by the inability to carry out the simplest tasks (e.g., grooming, doing housework, working, caring for children) because they seem too difficult to accomplish. With feelings of helplessness come feelings of hopelessness, which are particularly correlated with suicidality (Beck et al., 2006). Even though most depressive episodes are time limited, people experiencing them believe things will never change. This feeling of utter hopelessness can lead people to view suicide as a way out of constant mental pain. Hopelessness, one of the core characteristics of depression and risk factors for suicide, is a combined cognitive and emotional state that includes the following attributes:



Anger and irritability are natural outcomes of profound feelings of helplessness. Anger in depression is often expressed inappropriately through hurtful verbal attacks, physical aggression toward others, or destruction of property, and anger may be directed toward the self in the form of suicidal or otherwise self-destructive behaviors (e.g., alcohol abuse, substance abuse, overeating, smoking). These behaviors often reinforce feelings of low self-esteem and worthlessness.



Physical behavior

Lethargy and fatigue may result in psychomotor retardation, in which movements are extremely slow, facial expressions are decreased, and gaze is fixed. The continuum of psychomotor retardation may range from slowed and difficult movements to complete inactivity and incontinence. Psychomotor agitation, in which patients constantly pace, bite their nails, smoke, tap their fingers, or engage in some other tension-relieving activity, may also be observed. At these times, patients commonly feel fidgety and unable to relax.


Grooming, dress, and personal hygiene may be markedly neglected. People who usually take pride in their appearance and dress may be poorly groomed and allow themselves to look shabby and unkempt. They may neglect to bathe, change clothes, or engage in other basic self-care activities.


Change in sleep patterns is a cardinal sign of depression. Often, people experience insomnia, wake frequently, and have a total reduction in sleep, especially deep-stage sleep (Sadock & Sadock, 2008). One of the hallmark symptoms of depression is waking at 3 or 4 am and then staying awake or sleeping for only short periods. The light sleep of a person with depression tends to prolong the agony of depression over a 24-hour period. For some, sleep is increased (hypersomnia) and provides an escape from painful feelings. In any event, sleep is rarely restful or refreshing.


Changes in bowel habits are common. Constipation is seen most frequently in patients with psychomotor retardation. Diarrhea occurs less frequently, often in conjunction with psychomotor agitation or anxiety.


Interest in sex declines (loss of libido) during depression. Some men experience impotence, and a declining interest in sex often occurs among both men and women, which can further complicate marital and social relationships.


Vegetative signs of depression refer to alterations in those activities necessary to support physical life and growth (eating, sleeping, elimination, sex). For example, changes in eating patterns are common. About 60% to 70% of people with depression report having anorexia; however, overeating and weight gain may occur.

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  3. Sleep-wake disorders
  4. Biological basis for understanding psychiatric disorders and treatments

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Feb 3, 2017 | Posted by in NURSING | Comments Off on Depressive disorders

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