The presentation is about depression and how to manage a depressed patient.

1. DEPRESSION
MR MULUNDANO
BSc NRs-UNZA

2. OBJECTIVES
• By the end of this presentation students
should be able to :
1. Define depression
2. Describe the diagnostic criteria of
depression
3. Explain the
4. Outline the etiology of depression
5. Describe the management of depression

3. INTRODUCTION
• Most common single entity of mental
health problem that brings a person to
seek medical help
• The symptom is rarely presented
directly because pt is un aware that he
is depressed
• But common complaints are physical in
nature – fatigue, lack of interest, sleep
disturbance, appetite disturbance,
bowel disturbance, irritability, lack of
sexual interest or performance etc

4. INTRODUCTION
• When physical examination, lab results
and x-rays are negative but pt still has
complaints, depression may be the
cause.
• Depression can also be a major
symptom associated with other
diseases such as; diabetes, severe
anaemia, hypothyroidism, cancer of
the pancreas, neurological disorders.

5. DEFINITION
• A subjective mood disorder
characterized by persistent feelings of
sadness, discouragement, loneliness,
worthlessness and isolation lasting not
less than 2 weeks.
• Frequently manifested by unwarranted
crying spells, sluggishness of mental
activity and suicidal ideation.

6. Diagnostic criteria
• According to the Diagnostic and
Statistical Manual Fourth Edition
(DSM-IV), to diagnose major
depression, requires at least one
of the core symptoms:
oPersistent sadness or low mood
nearly every day, or
oLoss of interests or pleasure in
most activities.

7. • Plus some other 4 of the following
symptoms:
o Fatigue or loss of energy
o Worthlessness, excessive or inappropriate
guilt
o Recurrent thoughts of death, suicidal
thoughts, or actual suicide attempts
o Diminished ability to think/concentrate or
increased indecision
o Psychomotor agitation or retardation
o Insomnia/hypersomnia
o Changes in appetite and/or weight loss

8. CLASSIFICATION OF
DEPRESSION
1. Primary versus secondary
depression
• This distinction is based on the
proposed cause of the depressive
illness in an individual.
• Primary: the depression is not as a
result of any other medical or
psychological cause.

9. • Secondary: the depression has
been caused by a medical condition
(eg a disorder of the thyroid gland)
or psychiatric illness (eg
schizophrenia).
• There is little evidence that these
'types' of depression are really
different.

10. 2. Unipolar versus bipolar
depression(manic depression)
• This classification is based on the
course of the illness that an individual
experiences.
• If a patient has only ever had episodes
of depression, they are described as
having a unipolar affective disorder
(recurrent depressive illness).

11. • If a patient has had at least one
episode of elevated mood (mania) as
well as episodes of depression, they
are described as suffering from a
bipolar affective disorder (manic
depression). A few people only
experience episodes of mania. They
are also referred to as suffering from
bipolar affective disorder.

12. 3. Dysthymia (chronic mild
depression) versus depressive illness
• This distinction is based on the
severity and number of symptoms, and
the duration of the illness.
• Dysthymia is defined by the presence
of depressive symptoms for at least
two years.

13. A diagnosis of dysthymia rather than a
depressive illness is made because:
• < symptoms present to fulfil the
diagnostic criteria for a depressive
illness
• or symptoms are not present for the
majority of time but may come and go
for a few days at a time.

14. • There is less evidence that counselling or
psychotherapies work.
• Antidepressants may be of some help,
but they can take months (rather than
two to four weeks) to start working.

15. • People with dysthymia are at increased
risk of also developing a full-blown
depressive illness on top of their
ongoing depressive symptoms.
Sometimes called 'double depression',
meaning dysthymia plus a depressive
illness.
• If this happens, then treatment for the
depressive illness is especially
important to prevent a chronic full-blown
depressive illness developing.

16. 4. Depressive illness versus
depressive symptoms
• Everybody may experience low mood
from time to time, but this is different
from suffering from a depressive
illness.
• A depressive illness is diagnosed
when a person has a number of
depressive symptoms consistently
over a couple of weeks or more.

17. • According to the diagnostic criteria of
DSM and ICD, a depressive illness is
present if a person is suffering from a
certain number of specified symptoms.

18. Type of depression
• Psychiatrists and researchers once
categorized depression using a pair of
terms derived from Latin: endogenous
(meaning "from within”) and
exogenous ("from without").
• These names were intended to
indicate whether someone’s
depression came from internal causes
(such as genetics) or external causes
(like a stressful or traumatic event).

19. • Over the last few decades, however,
research has not provided sufficient
evidence in support of this theory.
• Today, depression formerly referred to
as “endogenous” is known as major
depressive disorder (MDD). The
current philosophy is that the same
types of treatment can be used for
MDD whether it is "endogenous or
exogenous."

20. Endogenous Depression
• Symptoms include;
–feelings of sadness,
worthlessness, guilt, and an
inability to enjoy normally
pleasurable things, changes in
appetite, sleep patterns, and
energy levels.

21. • If you have endogenous depression,
the world may seem like a dark and
sad place because that's how you feel
within yourself.

22. • Exogenous Depression
–Exogenous depression can look and
feel much like endogenous
depression.
–The difference is that these symptoms
come on after something happens in a
person's life. For example, a person
may feel persistently sad after the
death of a loved one or struggle with
guilt and feelings of worthlessness
after losing their job.

23. 1. Major depression
• Major depression is also known
as major depressive disorder, classic
depression, or unipolar depression. It’s
fairly common. People with major
depression experience symptoms
most of the day, every day.

24. It’s a severe form of depression that
causes symptoms such as:
– despondency, gloom, or grief
– difficulty sleeping or sleeping too much
– lack of energy and fatigue
– loss of appetite or overeating
– unexplained aches and pains
– loss of interest in formerly pleasurable
activities

25. –lack of concentration, memory
problems, and inability to make
decisions
–feelings of worthlessness or
hopelessness
–constant worry and anxiety
–thoughts of death, self-harm, or
suicide

26. • These symptoms can last weeks or
even months. Some people might
have a single episode of major
depression, while others experience it
throughout their life. Regardless of
how long its symptoms last, major
depression can cause problems in
your relationships and daily activities.

27. 2. Bipolar Affective Disorders (BAD)
• BAD are periods of prolonged and
profound depression alternate with
periods of excessively elevated and/or
irritable mood, known as mania.
• Bipolar I disorder is one or more manic
episodes with/without a history of one
or more depressive episodes.

28. • Bipolar II disorder is one or more depressive
episodes accompanied by at least one
hypomanic episode.
• A hypo manic episode is clearly different from
a ‘normal’ mood, but is not severe enough to
interfere with social or occupational
functioning, require admission to hospital, or
include psychotic features.
• Its features are similar to those of mania but
in a milder form.

29. • In order to be diagnosed with bipolar I
disorder, you have to experience an
episode of mania that lasts for seven
days, or less if hospitalization is
required. You may experience a
depressive episode before or following
the manic episode.

30. Other types
• Study also on;
–Seasonal affective disorder
–Perinatal and postpartum depression
–Premenstrual dysphoric disorder
– Persistent depressive disorder

31. Etiology of depression
• Alterations in circadian rhythm
functions
• Neurotransmitter deficiency
• Hormonal fluctuations and
interactions with neurotransmitters
• Genetic predisposition

32. • Adverse early life experiences,
intrapsychic conflicts or reactions to life
events.
• It could be due to traumatic experiences
in life like:
–Bereavement
–Failing an important exam
–Loosing important property
–Chronic illness

33. • Changes in the brain anatomy – atrophy
of a specific brain location e.g loss of
neurons in the frontal lobes, cerbellum
and basal ganglia.

34. Clinical features
• Loss of appetite
• Patient may be mute or monosyllabic (response
using just one word as opposed to providing
detailed explanation)
• Loss of libido
• Neglect of body hygiene
• Patient may avoid social contact
• Psychomotor retardation
• Poor concentration.

35. Clinical features
• Psychomotor retardation
• Sad facial expression
• Significant weight loss when not dieting
• Insomnia or hypersomnia
• Fatigue or loss of energy every day
• Feeling of worthlessness or inappropriate
guilt
• Diminished ability to concentrate
• Suicidal ideas

36. MANAGEMENT OF
DEPRESSION cont’d
• Management is divided into 2 parts.
1. Medical management
2. Nursing care

37. • Medical mgt
• Layout as follows;
– Aims
– Hxt
– Mental state examination
– Investigations
– Diagnosis
– Drug therapy
• Name of drug
• Dosage & route
• MOA
• S.E
• N.I

38. Medical management
• AIMS
• To establish an appropriate diagnosis
• To relieve signs and symptoms
• To prevent complications
• To rule out any other medical
conditions

39. Medical management
cont’d
• Hxt taking
– Presenting complaints
– Past medical hxt
– Social hxt
– Family hxt
– Mental state examination

40. • Investigations
• Investigations can be inversive and
non invasive
• Physical examination can be done to rule
out any medical cause of depression
focused on neurological and endocrine
systems.
• Urine and blood test for dexamethasone
suppression test.
• FBC-to rule out any serious infections that
may present or trigger symptoms of

41. • Investigations cont’d
• Polysomnographic assessement –
examinations of sleep patterns
esp in adults (REM latency
phase is shortened resulting into
frequent night and early morning
wakening)

42. • Investigations cont’d
• CT scan or MRI of the brain to rule out
serious illnesses such as a brain tumor
• Electrocardiogram (ECG) to diagnose
some heart problems
• Electroencephalogram (EEG) to record
electrical activity of the brain

43. Medical management
• Drug therapy
– Antidepressants can restore the
normal pattern of REM sleep e.g.
Imipramine, Amitriptyline 25mg to
75mg Bd.
– MAOIs were the first class
of antidepressants to be developed but
are less used. Isocarboxazid,
selegiline, Initial dose: 10 mg orally 2
times a day

44. –Side effects of MAOIs
• Fatigue, muscle aches,
nervousness, insomnia, reduced
libido, erectile dysfunction (ED)

45. • Selective serotonin reuptake inhibitors
(SSRIs) are the medications most
commonly prescribed for severe
depression. Examples of SSRIs
include:
– citalopram
– escitalopram
– fluoxetine
– paroxetine
– Sertraline
Look for dosages for SSRIs

46. Side effects antidepressants
• Dry mouth, nasal congestion, urinary
hesitancy, urinary retention, blurred
vision, constipation, sedation, ataxia,
confusion, orthostatic hypotension,
arrhythmias, tachycardia, palpitations,
decreased sweating, sexual dysfunction
(depressed libido, arousal, or orgasm)
• MAOIs – also hypertensive crisis related
to drug interactions
Electroconvulsive therapy can be done

47. Electroconvulsive therapy

48. • NOTE:
• STUDY ON ECT.
• Notes will be sent

49. NURSING CARE
1. AIMS
2. ENVIRONMENT
3. MAINTAINING SAFETY
4. THERAPEUTIC RELATIONSHIP
5. PSYCHOTHERAPY
6. ASSERTIVENESS TRAINING
7. NUTRITION
8. REST AND EXERCISE
9. SOCIAL THERAPY
10.GROUP THERAPY
11.FAMILY THERAPY
12.IEC

50. Aims
– To prevent injury and other complications
– To provide social support and promote
interaction
– To promote drug compliance

51. Environment
• I will nurse the patient close to the
nurses bay for close observation.
• I will Nurse patient in an
environment with others to promote
socialization
• I will make sure all items necessary
for the treatment of patient are
readily available

52. Maintaining safety
• I will make sure the environment is free of items
that the patient can use to hurt himself and/or
others.
• I will maintain close observation of the patient to
detect any dangers early.
• I will make sure all drugs are kept out of patients
reach to prevent any suicide by drug poisoning
• I will maintain close observations to ensure that
the client is really taking the medication and not
hoarding and later on use the medication to
commit suicide.
• A contract can also be signed with client to
ensure that the client does not take any action
meant to harm self or others.

53. ESTABLISHMENT OF A THERAPEUTIC
NURSE CLIENT RELATIONSHIP
• The nurse should develop a positive supportive
relationship with the client as quickly as possible
because most clients feel they do not deserve the
nurse’s time(feel worthless) and so will make excuses
or behave in such a way so as to discourage
interaction.
• I will introduce myself to the client and allow him to
introduce himself to me if he can, this will promote trust
once he knows who I am.
• I will use simple, concrete words and allow time for the
client to respond because clients concentration may be
impaired.
• I will spend short moments with patient even in silence
if not willing to speak, this is to enhance formation of a
therapeutic relationship.
• I will avoid making unnecessary promises that I can not
fulfil to prevent the patient from loosing trust in me.

54. • Pay attention to patients concerns and
avoid making promises you will not
fulfill
• Clarify all ideas and expectations from
interventions
• Communicate in a non discriminatory
manner.
• Always ask for permission before
carrying out any procedure.

55. Psychotherapy
• This is known as talking therapy. It gives the person
an opportunity to discuss and resolve problematic
issues in life.
• Educate the client in order to improve his
understanding and knowledge of his mental health
issues.
• Find out what the client would like to do about his
problem and encourage him to find a solution.
• Empathise with the patient and retain a non-
judgemental attitude.
• Always involve patient in his care and encourage
questions and give adequate responses.

56. NUTRITION
• I will give the patient small frequent meals
as they are easily tolerated by a depressed
client than large amounts of food when one
is anorexic.
• I will also offer high caloric and protein
fluids frequently during the day and evening
to prevent dehydration.
• I will pair patient with another patient during
meal times to motivate the client to feed.
• I sit with client during meal times in order to
help and motivate him to feed.

57. ELIMINATION
• Monitor intake and output,
especially bowel movements.
• Foods high in fibre as well as
exercises should be encouraged to
prevent constipation as it can occur
mainly due to under activity, even
faecal impaction can result.
• Fluids can also be encouraged for
the same reasons.

58. REST AND SLEEP
• Observe for insomnia or early morning
waking. It is important for the nurse to
provide rest periods after activity. Fatigue
can intensify feelings of depression.
• Encourage the client to stay out of bed
during the day so as to increase
likelihood of sleep during the night.
Furthermore, provide relaxation
measures during the evening and reduce
on environmental or physical stimulants.

59. Rest and sleep
Promote sleep by the following
measures;
– Discourage day time naps
– Encourage pt to participate in day time
activities avoid caffeinated drinks
– Assist pt have a warm bath at bed time
– If still cannot sleep give prescribed
sedative

60. HYGIENE
• If there is evidence of self neglect as is
common in most depressed clients,
the client needs to be helped on his or
her self care with regards to hygiene.
This can be done by providing
toiletries to the client as well as
keeping on reminding the client to
under take the tasks needed in this
area.

61. Social therapy
• During this therapy, the patient will be
involved in activities that will promote
interaction and discourage isolation.

62. Group therapy
• This kind of therapy is important for the
patient because it will promote
socialization and improve clients
knowledge about the condition. The
patient will also receive
encouragement from other clients with
the same condition.

63. Family therapy
• Family therapy is important because the
family is usually the primary care providal
and support system for the patient, therefore
as a nurse;
– Educate the family about the patient condition.
– Teach them on how to provide support to the
patient so as to maintain the desired mental
status.
– Respond to questions from the family in order to
alley anxiety.
– Provide reassurance to the family about
effectiveness of the patients treatment so as to
help boost their desire to help the patient.

64. SEXUALITY
• Assess and reassure the client of any
changes taking place in their sexual life
as a result of depression or
antidepressants. This will reduce on the
clients anxiety and assist to support
compliance to treatment(medication)

65. PHYSICAL ACTIVITIES
AND RECREATION
• While the client is severely depressed, one
to one activities are appropriate because
concentration is impaired, potential for
interaction is maximised, and anxiety levels
may be minimised.
• The nurse should use activities involving
gross motor activities which call for minimal
concentration i.e. taking a walk, making
beds with the nurse, setting up chairs etc.
• Physical activities are known to relieve
tension.

66. PHYSICAL ACTIVITIES
AND RECREATION
• For a severely depressed client, it is better
to provide activities that require very little
concentration e.g. simple card games;
looking through a magazine etc. this is so
because concentration and memory is
impaired in depression.
• Lastly, there is need to bring the patient into
contact with one other person and then into
a group of more than two. This distracts the
client from self preoccupations and provides
opportunities for spending time with other
people and activities based on reality.

67. PHYSICAL ACTIVITIES
AND RECREATION
It also raises the client’s self esteem
which in most cases is low.
• Group discussions, dance therapy and
art therapy can assist to achieve this.

68. PREPARATION FOR
DISCHARGE
• Clients preparation for discharge which
should have began in the initial phase
of clients admission to hospital should
be re-emphasised to client and his
family. This helps on improving on the
knowledge levels of the client and
family with regards to the illness and in
turn reduces on the anxiety and
relapses.

69. Specific nursing
• Altered nutrition less than body requirement
• Altered thought processes
• Impaired verbal communication
• Impaired physical mobility
• Sensory or perceptual alterations
• Sleep pattern disturbances
• Sexual dysfunction
• High risk for violence
• Social isolation

70. IEC
• To the family – teach them the
causes, symptoms and side effects of
drugs so that they watch over the pt
• Seek medical help pt has symptoms
• Family members should be tolerant to
the pt
• Give pt positive feed back
• Bring pt for follow-up care

71. COMPLICATIONS OF
MAJOR DEPRESSION
• Alteration in social, family and
occupational functioning
• Suicide

72. Questions
1. Explain why depression is common in
people with chronic illnesses? (10
marks)
2. State the difference between
endogenous and exogenous
depression(5 marks)
3. Explain the diagnostic criteria of
depression according to the DSM-IV-
TR criteria [5marks]

73. 4. Write the nursing care plan for a
patient with a Major depressive disorder.
[50 marks]
5. Discuss how you will prepare a patient
for electro convulsive therapy [30marks]
6. Identify 5 problems of a depressed
patient and write your nursing
interventions for each

74. ASSESSMENT
• Non-biological assessment – history and
standardized verbal and written
measurement scales
• Biologic assessment –
• urine and blood samples collected for
dexamethasone suppression test prior for
cortisol baseline data, then pt is given
dexamethasone injection then the cortisol
levels are monitored in 24 hours. If
suppressed below 5mcg/dl of blood then
may confirm depression

75. QUESTION
Q.The biologic assessment of depression
involves one of the following.
a.History taking using written measurement
scales
b.Polysomnographic assessement
c.Dexamethasone suppression test
d.None of the above

76. •THE END