This document defines mood disorders and provides information on depressive disorders specifically. It discusses the classification, definition, epidemiology, types, diagnostic criteria and predisposing factors of depressive disorders. Major depressive disorder and persistent depressive disorder are explained in detail. The clinical features, diagnosis, treatment modalities and nursing management of depressive disorders are also summarized.

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

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
A.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
1. Depressed mood most of the day, nearly every day
2. Markedly diminished interest or pleasure in all or
almost all, activities most of the day.
3. 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.
C. 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:-
A. 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.
B. 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
A. 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.
B. 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 B1,B6,B12, 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:-
I. Psychopharmacology:-
Antidepressant:-
Selective serotonin reuptake inhibitors(SSRI) Ex:-
Sertraline, fluoxetine
Tricyclic Antidepressant (TCAs) ,Ex:- Amitriptyline,
Imipramine
Mono Amine oxidase inhibitors(MAOIs), Ex:- Isocarboxazid

40. II. Physical therapy:-
ECT, Light therapy
III. 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.