Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.

1. By:Isha Thapa Magar
Nursing Instructor

2. Introduction
Major depression is classified under mood
disorders which are characterized by
disturbances in the regulation of mood,
behavior, and affect that go beyond the normal
fluctuations that most people experience.
 Major depression is a syndrome of a persistently
sad mood, lack of interest and enjoyment and
lack of energy; lasting at least two (2) weeks or
longer.

3. It is accompanied by other problems like
feelings of guilt, helplessness,
or hopelessness, poor concentration, sleep
disturbances, lethargy, appetite loss or weight
gain, anhedonia, loss of mood reactivity, and
thoughts of death.

4. The key features (Typical Symptoms) of the
depressive disorders are:
i. Low mood
ii. Reduced energy
iii. Loss of interest or enjoyment.
Other common symptoms include poor
concentration, reduced self-confidence, guilty
thoughts, pessimism, ideas of self-harm or
suicide, disturbed sleep and altered Appetite.
• Suicide is the most serious complication of major
depression. It occurs in nearly 15% of patients
with untreated depression.

5. Incidence
• About 6% of general population suffers from
it.
• The life-time risk of depression in males is 8-
12% and in females is 20-26%.
• Females are more prone to depression as
compared to males.
• The average age for onset of depression is
between 20 to 40 years.

6. Etiology
Exact cause of depression is unknown
Genetic Factors:
• The occurrence of depression is positively
related to the family history (affected persons
have shown that patient.
• Siblings and children of severe depression
patients have a 10-15% risk for depression as
against 1-2% in the general population
children

7. • 50-75% of children are likely to get depression
if both parents are suffering of from
depression.
• Monozygotic twins – 53%
• Dizygotic twins- 28%
Biochemical factors:
• Decrease amines (norepinephrine and
serotonin, dopamine) are related to
depression.

8. Neuroendocrine Disturbances:
• Hypersecretion of cortisol results in
depression.
• Diminished thyroid stimulating hormone (TSH)
is observed in approximately 25 % of
depressed persons.

9. Physiological Influences:
1. Medication side effects:
• Certain drugs such as antipsychotics, sedative
hypnotics, certain antihypertensive
medications such as propranolol and
reserpnine, steroids (e.g. Prednisone and
cortisone), have been known to produce
depressive symptoms.

10. 2. Electrolyte disturbances:
• Excessive levels of sodium bicarbonate,
potassium, calcium and deficits in magnesium
and sodium produce symptoms of depression.
3. Hormonal Disturbance:
• Depression is associated with dysfunction of
the adrenal cortex and is commonly observed
in both Addison's disease and Crushing's
syndrome.

11. • Other endocrine conditions such as
hypoparathyroidism, hyperparathyroidism,
hypothyroidism, hyperthyroidism may result
in symptoms of depression.
• Imbalance of the estrogen and progesterone
has been implicate in the predisposition to
premenstrual depression disorder.

12. 4. Nutritional Deficiencies:
• Deficiencies in Vitamins B1, Vitamin B2, Vitamin
B12, niacin, Vitamin C, iron, folic acid, zinc,
calcium and potassium may produce symptoms
of depression.
5. Medical condition such as infection (hepatitis),
degenerative neurological disorders such as
alzheimers disease, strokes in the frontal part of
the brain.
•

13. Cognitive theory
• According to this theory depression is due to
negative cognitions which includes:
- Negative expectations of the environment
- Negative expectations of the self
- Negative expectations of the future

14. Sociological theory
• Stressful life events such as the loss of parent
or spouse, financial hardship, illness,
perceived or real failure, and midlife crisis etc
are factors contributing to the development of
a mood disorders.
• Certain populations of people including the
poor, single persons, or working mothers with
young children seem to be more susceptible
than others to mood disorders.

15. Clinical Features

16. Depressed Mood
• Sadness of mood
• loss of interest
• Loss of pleasure in almost all activities present
throughout the day.
• Social withdrawal
• Decreased ability to function in occupational and
interpersonal areas and decreased involvement
in previously pleasurable activities.
• In severe depression, there may be complete
anhedonia (inability to experience pleasure).

17. Depressive Ideation/Cognition
• Sadness of mood is usually associated with
pessimism, which can result in three common
types of depressive ideas. These are:
- Hopelessness (there is no hope in the future).
- Helplessness (no help is possible now)
- Worthlessness (feeling of inadequacy and
inferiority)
• Guilt-feelings.

18. • The other features are difficulty in thinking,
difficulty in concentration, indecisiveness,
slowed thinking, subjective poor memory, lack
of initiative and energy. Often there are
ruminations (repetitive, intrusive thoughts)
with pessimistic ideas.
• In severe cases, delusions of nihilism (e.g.
'world is coming to an end', 'my brain is
completely dead', 'my intestines have rotted
away') may occur.

19. Psychomotor Activity
• In younger patients (<40 year old), retardation
is more common and is characterized by
slowed thinking and activity, decreased energy
and monotonous voice.
• In a severe form, the patient can become
stuporous (depressive stupor).

20. Physical Symptoms
• Multiple physical symptoms such as heaviness
of head, vague body aches, stomach pain,
constipation common in the elderly
depressives and depressed patients from the
developing countries.
• Hypochondriacal
• Complaints of reduced energy and easy
fatigability.

21. Biological Functions
• Disturbance of biological functions is common
with insomnia.
• Increased sleep
• loss of appetite and weight
• Weight gain and loss of sexual derive.
• When the disturbance is severe, it is called
melancholia (somatic syndrome).

22. Psychotic features
• About 15-20% of depressed patients have
psychotic symptoms such as delusions,
hallucination, grossly inappropriate behavior
or stupor.
Suicidal thought is most common in
depression.

23. Classification

24. F32 Depressive episode
F32.0 Mild depressive episode
F32.1 Moderate depressive episode
F32.2 Severe depressive episode without
psychotic symptoms
F32.3 Severe depressive episode with
psychotic symptoms
F32.8 Other depressive episodes
F32.9 Depressive episode, unspecified

25. 1. Unipolar depression (major
depression)
It is characterized by depressive symptoms in
the absence of a history of mania or
hypomania.
Unipolar depression may present as mild,
moderate, and severe depression without
psychotic symptoms and severe depression
episode with psychotic symptoms.

26. i. Mild depression
• Depressed mood, loss of interest and enjoyment,
and increased fatigability are usually regarded as
the most typical symptoms of depression, and at
least two of these, plus at least two of the other
symptoms such as reduced concentration and
attention, reduced self-esteem and self
confidence, disturbed sleep, diminished
appetitie; ideas or act of suicide.
• Minimum duration of the whole episode is about
2 weeks.
• A person with a mild episodes is probably capable
of continuing with the majority of their activities.

27. ii. Moderate depression
• At least two to the three most typical symptoms
(depressed mood, loss of interest and enjoyment,
and reduced energy leading to increased
fatigability and diminished activity) should be
present, plus at least four and six of the
additional symptoms noted for mild depressive
episode.
• Minimum durations of the whole episodes are
about 2 weeks.
• A person with a moderate episode will probably
have difficulties continuing with their ordinary
activities.

28. iii. Severe depression
a. In severe depressive episode without
psychotic symptoms
b. In severe depressive episode with
psychotic symptoms

29. a. In severe depressive episode without psychotic
symptoms
• In severe depression the individual will have all
three of the typical and eight other symptoms
with severe intensity such as loss of self-esteem,
guilt feelings, worthlessness. Suicidal thoughts
and acts are common, and a number of somatic
symptoms are present without psychotic
symptoms.
• The depressive episodes should usually last at
least 2 weeks.
• During a severe depressive episodes it is very
unlikely that the sufferer will be able to continue
with social, work or domestic activities.

30. b. Severe depressive episode with psychotic
symptoms
• A severe depressive episode which meet the
criteria given for severe depression without
psychotic symptoms and in which delusion,
hallucination, or depressive stupor are
present.

31. 2. Recurrent Depressive Disorder
• Recurrent disorder is characterized by
recurrent of unipolar depression at least two
depressive episode.

32. 3. Persistent Mood Disorder
(Cyclothymia and Dysthmia)
• Persistent Mood disorders are characterized
by persistent mood symptoms that last for
more than 2 years (1 year in children and
adolescents) but are less severe than major
depressive disorder and bipolar mood
disorder.
• It consists of two types of depression disorder;
(i) Cyclothymia and (ii) Dysthmia

33. • It consists of two types of depression disorder;
(i) Cyclothymia and (ii) Dysthmia
• If the symptoms consist of persistent mild
depression, the disorder is called as dysthymia
and if symptoms consist of persistent
instability of mood between mild depression
and mild elation, the disorder is called as
cyclothymia.

34. 4. Other depressive disorders
Seasonal depression:
- Which is characterized by the onset of a
depressive illness during the winter months,
when there is less natural sunlight.
- The depression generally lifts during spring
and summer season.

35. Postpartum depression:
- Postpartum depression is depression that
occurs soon after having a baby, usually peak
in 3 to 7 days and characterized by labile
mood and affect, crying, spells sadness,
insomnia and anxiety.

36. Diagnosis

37. 1. History Taking
2. Mental status Examination
3. DSM Criteria for identifying for Major
Depressive Disorders
a. Five ( or more) of the following symptoms
been present during the same 2 week period
and at least one of the symptoms is either (i)
depressed mood or (2) loss of interest or
pleasure

38. i. Depressed mood most of the day, nearly every
day.
Note: In children and adolescents, can be irritable
mood.
i. Markedly diminished interest or pleasure in all,
or almost all, activities most of the day, nearly
every day.
ii. Significant weight loss when not dieting or
weight gain or a decrease or increase in
appetite nearly every day.
Note: In children, consider failure to make
expected weight gains.

39. iv. Insomnia or hypersomnia nearly everyday.
v. Psychomotor agitation or retardation nearly
every day.
vi. Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional)
nearly every day.
vii. Diminished ability to think or concentrate
nearly everyday.

40. viii. Recurrent thoughts of death (not just fear of
dying ) recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific
plan for committing suicide.
b. There has never been a manic episode, a
mixed episode, or a hypomanic episode that
was not substance or treatment induced or
caused by the direct physiological effects of a
general medical condition.

41. c. The symptoms cause clinically significant
distress or impairment in social, occupational
or other important areas of functioning.
d. The symptoms are not due to the direct
physiological effects of a substance (e.g. a
drug of abuse or a medication) or a general
medical condition (e.g hypothyroidism).

42. Treatment

43. 1. Antidepressants
• Antidepressants are the treatment of choice
for a vast majority of depressive episodes.
• The usual starting dose is about 75-100mg of
imipramine .
• The clinical improvement is assessed after
about two weeks. In case of non-
improvement, the dose can usually be
increased up to 300mg of imipramine.

44. 2. Electro- convulsive Therapy (ECT)
The indications for ECT in depression include:
– Severe depression with suicidal risk.
– Severe depression with stupor, severe
psychomotor retardation or somatic syndrome.
– Severe treatment refractory depression.
– Delusional depression (psychotic features)
– Presence of significant antidepressant side-
effects or intolerance to drugs.

45. • In most clinical situations, usually 6-8 ECTs are
needed, given three times a week. When six
ECTs are administered, the usual pattern in
three ECTs in the first week, two in the second
week and one in the third week.
• However, improvement is not sustained after
stopping the ECTs. Therefore, antidepressants
are often needed along with ECTs, in order to
maintain the improvement achieved.

46. 3. Lithium
• It has also been used in treatment of
depression with less success.

47. 4. Antipsychotics
• Antipsychotics are an important adjunct in the
treatment of mood disorder.
• The commonly used drugs include
risperidone, olanzapine, haloperidol.

48. 5. Other Mood stabilizers
i. Lamotrigine:
- Lamotrigine is particularly effective for
bipolar depression and is recommended by
several guidelines.
ii. T3 and T4 as adjuncts for the treatment of
rapid cycling mood disorder and resistant
depression.

49. 6.Psychosocial Treatment
1. Cognitive Behavior Therapy
• Cognitive Behaviors Therapy aims at correcting
depressive negative (ideations) such as
hopelessness, worthlessness, helplessness and
pessimistic ideas, and replacing them with new
cognitive and behavioral responses.
• CBT is useful in mild to moderate, non-bipolar
depression and can be used with or without
somatic treatment.

50. 2. Interpersonal Therapy
• Interpersonal Therapy (IPT) attempts to
recognize and explore interpersonal stressors,
role disputes and transitions, social isolation
or social skills deficits, which act as
precipitants for depression.
• It is useful in the treatment of mild or
moderate unipolar depression, with or
without antidepressants.

51. 3. Psychoanalytic Therapy
• The short-term psychoanalytic
psychotherapies aim at changing the
personality itself rather than just ameliorating
the symptoms.
• These techniques are however helpful in the
treatment of selected patients (such as
dysthymic disorder, depression co-morbid
with personality disorders, or depression with
history of childhood loss/child abuse).

52. 4. Behaviour Therapy
• This includes the various short-term
modalities such as social skills training;
problem solving techniques, assertiveness
training, self-control therapy, activity
scheduling and decision-making techniques.
• It can be useful in mild cases of depression or
as an adjunct to antidepressants in moderate
depression.

53. 5.Group Therapy
• Group psychotherapy can be useful in mild
cases of depression.
• It is a very useful method of psychoeducation
in both recurrent depressive disorder and
bipolar disorder.

54. 6. Family and Marital therapy
• These therapies can however help decrease
the intrafamilial and interpersonal difficulties,
and to reduce or modify stressors, which may
help in a faster and more complete recovery.

55. Nursing Management

56. Nursing Diagnosis
• Potential risk of self-directed violence related to
depressed mood, feelings of worthlessness and
anger directed inward on the self.
• 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.
• Powerlessness related to dysfunctional grieving
process, life-style of helplessness, evidenced by
feelings of lack of control over life situations, over
dependence on others to fulfill needs.

57. • Self-esteem disturbance related to learned
helplessness, impaired cognition, negative
view of self, evidenced by expression of
worthlessness, sensitivity to criticism,
negative and pessimistic outlook.
• Altered sleep and rest, related to depressed
mood and depressive cognitions evidenced by
difficulty in falling asleep, early morning
awakening, verbal complaints of not feeling
well-rested.

58. • Altered nutrition less than body requirements
related to depressed mood, lack of appetite or
lack of interest in food, evidenced by weight
loss, poor muscle tone, pale conjunctiva, poor
skin turgor.
• Self-care deficit related to depressed mood,
feelings of worthlessness, evidenced by poor
personal hygiene and grooming

59. Nursing Intervention
• Assess if there is any tendency, create a safe
environment for the patient. Remove all
potentiality harmful objects from patient's access
(e.g. sharp object, belts, glass items, alcohol).
• Institute safety precautions for suicide risk as per
institutional policy.
• Give the prescribe drug in time.
• Supervise closely during meals and medication
administration. Promote fluid and food intake
and maintain intake and output chart.

60. • Encourage more fluid intake, roughage diet
and green leafy vegetables.
• Provide emotional support (i.e. empathic,
support, listening, encourage expression of
feeling), support adaptive coping, encourage
pleasant reminiscences.
• Record patient's weight regularly.
• Do not allow the patient to put the bolt on his
side of the door bathroom or toilet. Encourage
the patient to express his feelings.

61. • Allow the patient to take decisions regarding
own care.
• Ensure a quiet and peaceful environment
when the patient is preparing for sleep.
• Do not allow the patient to sleep for long
time during the day. A night use measures
that may promote sleep, such as warm drinks
(milk), music therapy.

62. • Provide non-intellectual activities (e.g.
cleaning and physical exercise). Encourage
daily participation in relaxation therapies,
pleasant activities, music therapy.
• Monitor and document to medication and
other therapies, re-administer depression
screening tool.

63. • Provide information regarding the illness and
treatment.
- Depression is for more common than you
might think
- Depression can occur without any obvious
external cause. It can occur biochemical
imbalance.
- For you treatment, you are not alone, there
are your family , your friends and your doctor
and his team.

64. - Take your medicines carefully and regularly.
- Never take less or more than the prescribed
does. Never skip a dose. Expect improvement
not earlier than 14 days.
- Other information's regarding the drug.
- Continue the drug for at least four weeks after
the patient return to normal. Then reduce the
dose over 2-3 weeks gradually.