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Mood (Affective) Disorder
Nabina Paneru
Terminology
• Emotion: It is an intense feeling that people experience that are directed at someone or something.
• Affect: Which is shrot, lived emotional response to an ideas or an event.
• Mood: is an internal emotional state of an individual Which is sustained and pervasive and sustained
emotional response that may influence a person’s behavior and perception of the world. Mood can be
normal, elevated or depressed. E.g. depression, joy,eletion, anger and anxiety.
• Mania: Alteration in mood that is expressed by feeling of elation characterized by over activities, mood
changes, self important activites/ideas.
Mood disorder
• A mood state of a normal individual fluctuates between mild depressions to mild
elation for brief periods depending on many factors. It is only when the mood
swing is excessive in severity and duration and when it interferes with a person’s
day to day activities that it becomes a mood disorder.
• Mood disorders are a group of clinical conditions characterized by a loss of that
sense of control and subjective experience of great distress.
Contd.
• People with this diagnosis have an abnormal mood characterized by:
– Depression
– Mania, or
– Both symptoms in alternating fashion
• The abnormal mood may or may not impair the person’s social or
occupational functioning
Classification:
According to ICD-10 the classification of mood disorder is as following:
• Manic/hypomanic episodes
• Depressive episode
• Bipolar mood/affective episode
– Bipolar I disorder
– Bipolar II disorder
• Persistent Mood disorder (including cyclothymic and dysthymia)
• Recurrent depressive episode
• Persistent mood disorders
• Other mood disorders
• Unusually and persistently elevated, expansive, or irritable mood that
is distinctly different from the person’s non-manic state
• Marked impairment, requires hospitalization
Characterstics:
• Elevated expansive or irritable mood
• Increase psychomotor activity
• Increase pressure of speech e.g. joyful, playful, joking, teasing,
speaking loudly, flight of ideas
Hypomania
Hypomania is a less severe form of mania. Hypomania is a mood that many don't
perceive as a problem. It actually may feel pretty good. He/she have a greater sense
of well-being and productivity. However, for someone with bipolar disorder,
hypomania can evolve into mania -- or can switch into serious depression.
• Less severe variant of mania; no need of hospitalization.
Depressive episode
• Major depressive disorder (Unipolar) is characterized by depressed mood or loss
of interest in usual activities, and somatic symptoms may be evident without any
hypomanic or manic states: the patient is either depressed or average in mood, but
experiences no mania. Change in appetite and sleep patterns are common.
Bipolar disorder
• Bipolar disorder is characterized by manic or hypomanic states: the
patient is either depressed, euthymic (normal in mood), or
hypomanic/manic.
Bipolar I: Is defined as having a clinical course of one or more manic
episodes and sometimes, major depressive episodes (a complete set of
mania symptoms occurs during the course of the disorder).
Contd..
Bipolar II: Bipolar disorder characterized by episodes of major depression and
hypomania rather than mania is known as bipolar II disorder ( the episodes of manic
like symptoms do not quite meet the diagnostic criteria for a full manic syndrome).
Persistent Mood Disorder
• Dysthymia: refers to clinically significant major depressive symptoms somewhat
milder, that are present for 2 years or more but do not reach the threshold (with
respect to severity and/or number of symptoms) for major depression. There is no
evidence of psychotic symptoms.
Contd.
• Cyclothymias: is a chronic mood disturbance of at least a 2 year duration involving
numerous episodes of hypomania and depressed mood of insufficient severity or
depressive symptoms do not reach the threshold for diagnosis of a major depressive
episode.
Epidemiology
Type Lifetime prevalence (%)
Major Depressive Episode 5-17 (12)
Bipolar disorder 0.3 – 1.5
Dysthymic disorder 3 – 6 (5)
Minor Depressive Disorder 10
Full unipolar spectrum 2.0 – 2.5
Full bipolar spectrum 2.6 – 7.8
Cyclothymia 0.5 – 6.3
Hypomania 2.6 – 7.8
Sadock and Sadock, 2004
Mood disorders affect about 10% of the population
Contd.
• According to gender
- In bipolar disorder, the prevalence in males and females is equal
- Two fold greater prevalence of major depressive disorder in women than in men
- Manic episodes are more common in men.
Contd.
• According to age
- The onset of bipolar disorder is earlier than that of major depressive disorder
- The mean age of onset of bipolar disorder is 17 to 27 years
- The mean age of onset for major depressive disorder is 20 and 50 (mean age – 40
years). But the incidence of major depressive disorder may be increasing among
people younger than 20 years of age.
Contd.
• According to marital status
- Seen in persons without close interpersonal relationship or in those who are divorced
or separated.
Etiology
• Idiopathic
Contd.
Etiology
Biological Theories:
a. Genetic Theory
b. Biochemical Theories
c. Alterations in hormonal regulation
Sociological
Theory
Psychosocial Theories
a. Psychoanalytic theory
b. Behavioral theory
c. Cognitive theory
Contd.
1. Biological Theories
a. Genetic theories:
- The lifetime risk for the first degree relative of patient with bipolar disorder is 25%
- The lifetime risk for the children of one parent with disorder is 27% and of both parents with
mood disorder is 74%
- concordance rate for mood disorder in the monozygotic (MZ) twins of 70 to 90 percent
compared with the same-sex dizygotic (DZ) twins of 16 to 35 percent.
Biological Theory Contd.
b. Biochemical Theories
Serotonin
• Depletion of serotonin:
precipitate depression
Biochemical Theories Contd.
Gamma –
Aminobutyric acid
(GABA)
- Has an inhibitory
effect on mesocortical
and mesolimbic
systems
Decreased plasma,
CSF and brain GABA
levels in depression
Contd.
c. Alterations in hormonal regulation
Stimulated by dopamine and Nor epinephrine and inhibited by
somatostatinGrowth Hormone
• Decreased CSF somatostatin = depression
• Increased CSF somatostatin = mania
Released by serotonin and inhibited by dopamineProlactin
• A blunted prolactin response to various serotonin (depression)
Thyroid Stimulating
hormone
• About one fourth depressed people have a reduced thyroid
stimulating hormone
Etiology contd.
2. Psychosocial Theories
According to Freud depression results due to loss of a
loved object, and fixation in the oral sadistic phase of
development. In this model, mania is viewed as denial
of depression (Mania represents the reaction formation
to depression).
According to this model,
depression is conditioned by
repeated loses in the past.
According to this theory
depression is due to negative
cognition.
Etiology Contd.
3. Sociological Theory:
a. Life Events and Environmental Stress
• – One theory : stress = long-lasting changes in the brain's biology = alter the
functional states of various neurotransmitter and intraneuronal signaling systems =
loss of neurons and an excessive reduction in synaptic contacts.
• high risk of undergoing subsequent episodes even without an external stressor.
– losing a parent before age 11,
– loss of a spouse
– Unemployment
Sociological Theory Contd.
b. Personality Factors
– Persons with certain personality disorders may be at greater risk for depression
• OCD,
• histrionic,
• Borderline
– antisocial or paranoid personality disorder can use projection and other externalizing
defense mechanisms to protect themselves from their inner rage.
– Recent stressful events are the most powerful predictors of the onset of a depressive
episode.
Depression
Depression is a common psychiatric disorder, characterized by a
persistent lowering of mood, loss of interest in usual activities and
diminished ability to experience pleasure.
Epidemiology
Epidemiology of Depression
Incidence (yr) 1/100 men and 3/100 women
Prevalence 2-3/100 men and 5-10/100 women
Lifetime risk
Lifetime suicide rate (depression)
10-20%
15%
Age 40 – mean age, 50% occur before age 40
Sex 2:1 women/men
Marital Status Persons without close interpersonal relationships or
in those who are divorced or separated
Family history Approx. 10 – 13% risk for first-degree relatives
Monozygotic concordance rate higher than
dizygotic but ratio not as high as seen in bipolar
Etiology
• Exact cause of depression is still unknown. However most probable theories of
developing the depression are as follows:
A. Bio physiological
1. Genetic: The disorder is 1.5 to 3 times more common among first degree
relatives.
2. Reduction in Biogenic Amines: Norepinephrine, serotonin and dopamine.
3. Alterations of Hormonal Regulation: Elevated levels of serum cortisol and
decreased levels of thyroid stimulating hormone.
4. Thyroid Axis Activity: An elevated basal thyroid – stimulating hormone (TSH)
level.
Biophysiological contd.
5. Alterations of Sleep Neurophysiology: Depression is associated with a premature loss
of deep sleep and an increase in nocturnal arousal.
6. Immunological Disturbance/ Physiological Conditions: Depressive disorders are
associated with electrolyte disturbances, hormonal disturbances, nutritional
deficiencies, and with certain physical disorders.
7. Medication Side Effects: Anxiolytics, antipsychotics, and sedative – hypnotics,
antihypertensive medications such as propranolol and reserpine have been known to
produce depressive symtoms.
Contd.
B. Psychosocial Factors: Life events and Environmental Stress
C. Cognitive Theory: According to this, depression results from
cognitive distortions, anger turned inward.
D. Behavioral Theory: The learned helplessness: Following
numerous failures, the individual feels helpless to succeed at any
endeavor and therefore gives up trying. This “learned helplessness”
is viewed as a predisposition to depressive illness.
Diagnostic Criteria
1. Depressed mood
2. Loss of interest or pleasure
3. Decreased energy or increased
fatigability (Psychomotor
retardation)
Cardinal
Symptoms
1. Reduced confidence or self – esteem
2. Reduced concentration
3. Ideas of guilt or unworthiness
4. Pessimistic thoughts
5. Ideas of self harm (death or suicide)
6. Disturbed sleep: waking in the
morning 2 hours before the usual time
7. Diminished appetite: Change in
weight
Other/
Somatic
Symptoms
Contd.
4 s/s (2+2), continue most
activities
5/6 s/s (2+3/ or 4), difficulties to
continue activities
7 s/s (3+4), unlikely can function,
somatic s/s usually present,
psychotic s/s might be present
Other characteristics:
- Depression worse in the morning
- Marked loss of libido
- Subjective poor memory
- Menstrual and sexual disturbances
- Vague physical symptoms such as
fatigue, aching discomfort,
constipation etc.
Categories
Mild Depression Moderate Depression
Severe Depression
Clinical Features
All from diagnostic criteria plus following:
• The affect: sadness, dejection, helplessness and hopelessness. Gloomy outlook, pessimistic
and feeling of worthlessness.
• Speech: Decreased rate and volume of speech
• Delusions or hallucinations and catatonic features (mute, not bathing, soiling)
• Thought: negative views of world and themselves, suicidal ideation
• Concentration: may be impaired and forgetfulness
• Social participation is diminished
Treatment
• Pharmacological treatment
- Antidepressants, anxiolytics
• Electroconvulsive therapy
- Treatment of choice for psychotic depression, depression refractory to
pharmacotherapy and for acutely suicidal.
- Patients with recurrent depression will need either prophylactic medication or
maintenance ECT
- Side effects include temporary short term memory loss
Contd.
• Family Therapy: to reduce or modify stressors
• Group interventions: useful for mild to moderate cases of depression.
Helps by optimizing socialization, venting feelings, exploring and
establishing coping mechanisms, establishing personal goals, thus
reducing isolation and hopelessness.
Contd.
• Psychotherapeutic interventions:
- Cognitive therapy: address systematic errors in the client’s thinking that maintain negative
cognitive processing. It aims at correcting such cognition by examining logically and
replacing them with new cognitive and behavioral responses.
- Behavioral therapy: activity scheduling, social skill training, decision making techniques, self
– control therapy.
- Interpersonal therapy: emphasized on social functioning and interpersonal relationships. The
goal of therapy is to understand the social context of current problems based on earlier
relationships and managing current interpersonal problems.
Contd.
• Suicidal assessment and management
Nursing Management
• Assessment
- Have you had thoughts about death or about killing yourself?
- How persistent was the thoughts?
- Have you formulated a plan? What is it?
- Have you actually rehearsed or practiced how you would kill yourself?
- Do you thick you would really do it? Have you told anyone?
- Do you tend to be impulsive or can you resist the impulse to do this?
- What have stopped you doing this?
- Have you heard voices telling you to hurt or kill yourself?
- History or previous attempt especially the degree of intent.
- Family history of depression or suicide
Nursing diagnosis with interventions
1. Risk for suicide related to anger turned inward/or, irrational feelings
of guilt/ or depressed mood/ or hopelessness/ or hallucinations/ or
delusional thinking.
• Ask client directly: “Have you thought about harming yourself in any way?
• Create a safe environment for the client. Remove all potentially harmful objectives.
• Formulate a short term verbal or written contract with the client that he or she will
not harm self during specific period.
• Maintain close observation of client. Place in room close to nurse’s station: do not
assign to private room.
• Make records at frequent, irregular intervals (especially at night, toward early
morning, at change of shift, or other predictably busy time or staffs.
• Encourage client to express angry feelings within appropriate limits. Provide safe
method of hostility release.
• Identify community resources that client may use as support system, and from
whom he or she may request help if feeling suicidal.
2. Social Isolation/Impaired social Interaction related to unresolved
grief/ or altered thought processes (delusional thinking/ or fear of
rejection or failure of the interaction.
• Spend time with client
• Develop a therapeutic nurse client relationship through frequent, brief contacts and an
accepting attitude. Show unconditional positive regard.
• Encourage client to take as much responsibility as possible for own self – care practices.
• Help client to recognize and focus on strengths and accomplishments.
• Help client set realistic goals.
• Encourage participation in social activities and provide positive reinforcement.
3. Disturbed thought process related to impaired cognition fostering
negative perception of self and the environment.
• Do not argue or deny the belief
• Use the techniques of consensual validation and seeking clarification.
• Reinforce and focus on reality. Talk about real events and real people.
• Give positive reinforcement as client is able to differentiate between reality – based
and nonreality – based thinking.
• Teach client to intervene, using thought – stopping techniques, when irrational or
negative thoughts prevail.
4. Imbalanced nutrition less than body requirement related to liability
to ingest food because of depressed mood, loss of appetite, energy level
too low to meet own nutritional needs, ideas of self – destruction.
• Ensure high fiber diets to prevent constipation. Encourage client to increase fluid
consumption and physical exercise.
• Weigh client daily.
• Determine client’s likes or dislikes.
• Administer vitamin and mineral supplements and stool softeners or bulk extenders, as
ordered by physician.
• Stay with client during meals.
• Explain the importance of adequate nutrition and fluid intake.
5. Insomnia related to depression or repressed fears.
• Keep strict records of sleeping patterns.
• Discourage sleep during day.
• Administer antidepressants medication on bedtime.
• Assist with measure that may promote sleep, such as warm, non stimulating drinks, light snacks, warm baths,
back rubs, relaxation exercises, and soft music.
• Limit intake of caffeinated drinks such as tea, coffee and colas.
• Administer sedative medications as ordered.
• Some depressed clients may use excessive sleep as an escape. For them limit time spent in a room. Plan
stimulating diversionary activities on daily schedule.
• Depressed people are more likely to engage in behaviors that contribute to poor health such as smoking, limited
or no exercise, poor eating habit and are likely to have greater difficulty managing their co-morbid conditions.
Mood disorder and depression

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Mood disorder and depression

  • 2. Terminology • Emotion: It is an intense feeling that people experience that are directed at someone or something. • Affect: Which is shrot, lived emotional response to an ideas or an event. • Mood: is an internal emotional state of an individual Which is sustained and pervasive and sustained emotional response that may influence a person’s behavior and perception of the world. Mood can be normal, elevated or depressed. E.g. depression, joy,eletion, anger and anxiety. • Mania: Alteration in mood that is expressed by feeling of elation characterized by over activities, mood changes, self important activites/ideas.
  • 3. Mood disorder • A mood state of a normal individual fluctuates between mild depressions to mild elation for brief periods depending on many factors. It is only when the mood swing is excessive in severity and duration and when it interferes with a person’s day to day activities that it becomes a mood disorder. • Mood disorders are a group of clinical conditions characterized by a loss of that sense of control and subjective experience of great distress.
  • 4. Contd. • People with this diagnosis have an abnormal mood characterized by: – Depression – Mania, or – Both symptoms in alternating fashion • The abnormal mood may or may not impair the person’s social or occupational functioning
  • 5. Classification: According to ICD-10 the classification of mood disorder is as following: • Manic/hypomanic episodes • Depressive episode • Bipolar mood/affective episode – Bipolar I disorder – Bipolar II disorder • Persistent Mood disorder (including cyclothymic and dysthymia) • Recurrent depressive episode • Persistent mood disorders • Other mood disorders
  • 6. • Unusually and persistently elevated, expansive, or irritable mood that is distinctly different from the person’s non-manic state • Marked impairment, requires hospitalization Characterstics: • Elevated expansive or irritable mood • Increase psychomotor activity • Increase pressure of speech e.g. joyful, playful, joking, teasing, speaking loudly, flight of ideas
  • 7. Hypomania Hypomania is a less severe form of mania. Hypomania is a mood that many don't perceive as a problem. It actually may feel pretty good. He/she have a greater sense of well-being and productivity. However, for someone with bipolar disorder, hypomania can evolve into mania -- or can switch into serious depression. • Less severe variant of mania; no need of hospitalization.
  • 8. Depressive episode • Major depressive disorder (Unipolar) is characterized by depressed mood or loss of interest in usual activities, and somatic symptoms may be evident without any hypomanic or manic states: the patient is either depressed or average in mood, but experiences no mania. Change in appetite and sleep patterns are common.
  • 9. Bipolar disorder • Bipolar disorder is characterized by manic or hypomanic states: the patient is either depressed, euthymic (normal in mood), or hypomanic/manic. Bipolar I: Is defined as having a clinical course of one or more manic episodes and sometimes, major depressive episodes (a complete set of mania symptoms occurs during the course of the disorder).
  • 10. Contd.. Bipolar II: Bipolar disorder characterized by episodes of major depression and hypomania rather than mania is known as bipolar II disorder ( the episodes of manic like symptoms do not quite meet the diagnostic criteria for a full manic syndrome).
  • 11. Persistent Mood Disorder • Dysthymia: refers to clinically significant major depressive symptoms somewhat milder, that are present for 2 years or more but do not reach the threshold (with respect to severity and/or number of symptoms) for major depression. There is no evidence of psychotic symptoms.
  • 12. Contd. • Cyclothymias: is a chronic mood disturbance of at least a 2 year duration involving numerous episodes of hypomania and depressed mood of insufficient severity or depressive symptoms do not reach the threshold for diagnosis of a major depressive episode.
  • 13. Epidemiology Type Lifetime prevalence (%) Major Depressive Episode 5-17 (12) Bipolar disorder 0.3 – 1.5 Dysthymic disorder 3 – 6 (5) Minor Depressive Disorder 10 Full unipolar spectrum 2.0 – 2.5 Full bipolar spectrum 2.6 – 7.8 Cyclothymia 0.5 – 6.3 Hypomania 2.6 – 7.8 Sadock and Sadock, 2004 Mood disorders affect about 10% of the population
  • 14. Contd. • According to gender - In bipolar disorder, the prevalence in males and females is equal - Two fold greater prevalence of major depressive disorder in women than in men - Manic episodes are more common in men.
  • 15. Contd. • According to age - The onset of bipolar disorder is earlier than that of major depressive disorder - The mean age of onset of bipolar disorder is 17 to 27 years - The mean age of onset for major depressive disorder is 20 and 50 (mean age – 40 years). But the incidence of major depressive disorder may be increasing among people younger than 20 years of age.
  • 16. Contd. • According to marital status - Seen in persons without close interpersonal relationship or in those who are divorced or separated.
  • 18. Contd. Etiology Biological Theories: a. Genetic Theory b. Biochemical Theories c. Alterations in hormonal regulation Sociological Theory Psychosocial Theories a. Psychoanalytic theory b. Behavioral theory c. Cognitive theory
  • 19. Contd. 1. Biological Theories a. Genetic theories: - The lifetime risk for the first degree relative of patient with bipolar disorder is 25% - The lifetime risk for the children of one parent with disorder is 27% and of both parents with mood disorder is 74% - concordance rate for mood disorder in the monozygotic (MZ) twins of 70 to 90 percent compared with the same-sex dizygotic (DZ) twins of 16 to 35 percent.
  • 20. Biological Theory Contd. b. Biochemical Theories Serotonin • Depletion of serotonin: precipitate depression
  • 21. Biochemical Theories Contd. Gamma – Aminobutyric acid (GABA) - Has an inhibitory effect on mesocortical and mesolimbic systems Decreased plasma, CSF and brain GABA levels in depression
  • 22. Contd. c. Alterations in hormonal regulation Stimulated by dopamine and Nor epinephrine and inhibited by somatostatinGrowth Hormone • Decreased CSF somatostatin = depression • Increased CSF somatostatin = mania Released by serotonin and inhibited by dopamineProlactin • A blunted prolactin response to various serotonin (depression) Thyroid Stimulating hormone • About one fourth depressed people have a reduced thyroid stimulating hormone
  • 23. Etiology contd. 2. Psychosocial Theories According to Freud depression results due to loss of a loved object, and fixation in the oral sadistic phase of development. In this model, mania is viewed as denial of depression (Mania represents the reaction formation to depression). According to this model, depression is conditioned by repeated loses in the past. According to this theory depression is due to negative cognition.
  • 24. Etiology Contd. 3. Sociological Theory: a. Life Events and Environmental Stress • – One theory : stress = long-lasting changes in the brain's biology = alter the functional states of various neurotransmitter and intraneuronal signaling systems = loss of neurons and an excessive reduction in synaptic contacts. • high risk of undergoing subsequent episodes even without an external stressor. – losing a parent before age 11, – loss of a spouse – Unemployment
  • 25. Sociological Theory Contd. b. Personality Factors – Persons with certain personality disorders may be at greater risk for depression • OCD, • histrionic, • Borderline – antisocial or paranoid personality disorder can use projection and other externalizing defense mechanisms to protect themselves from their inner rage. – Recent stressful events are the most powerful predictors of the onset of a depressive episode.
  • 26. Depression Depression is a common psychiatric disorder, characterized by a persistent lowering of mood, loss of interest in usual activities and diminished ability to experience pleasure.
  • 27. Epidemiology Epidemiology of Depression Incidence (yr) 1/100 men and 3/100 women Prevalence 2-3/100 men and 5-10/100 women Lifetime risk Lifetime suicide rate (depression) 10-20% 15% Age 40 – mean age, 50% occur before age 40 Sex 2:1 women/men Marital Status Persons without close interpersonal relationships or in those who are divorced or separated Family history Approx. 10 – 13% risk for first-degree relatives Monozygotic concordance rate higher than dizygotic but ratio not as high as seen in bipolar
  • 28. Etiology • Exact cause of depression is still unknown. However most probable theories of developing the depression are as follows: A. Bio physiological 1. Genetic: The disorder is 1.5 to 3 times more common among first degree relatives. 2. Reduction in Biogenic Amines: Norepinephrine, serotonin and dopamine. 3. Alterations of Hormonal Regulation: Elevated levels of serum cortisol and decreased levels of thyroid stimulating hormone. 4. Thyroid Axis Activity: An elevated basal thyroid – stimulating hormone (TSH) level.
  • 29. Biophysiological contd. 5. Alterations of Sleep Neurophysiology: Depression is associated with a premature loss of deep sleep and an increase in nocturnal arousal. 6. Immunological Disturbance/ Physiological Conditions: Depressive disorders are associated with electrolyte disturbances, hormonal disturbances, nutritional deficiencies, and with certain physical disorders. 7. Medication Side Effects: Anxiolytics, antipsychotics, and sedative – hypnotics, antihypertensive medications such as propranolol and reserpine have been known to produce depressive symtoms.
  • 30. Contd. B. Psychosocial Factors: Life events and Environmental Stress C. Cognitive Theory: According to this, depression results from cognitive distortions, anger turned inward. D. Behavioral Theory: The learned helplessness: Following numerous failures, the individual feels helpless to succeed at any endeavor and therefore gives up trying. This “learned helplessness” is viewed as a predisposition to depressive illness.
  • 31. Diagnostic Criteria 1. Depressed mood 2. Loss of interest or pleasure 3. Decreased energy or increased fatigability (Psychomotor retardation) Cardinal Symptoms 1. Reduced confidence or self – esteem 2. Reduced concentration 3. Ideas of guilt or unworthiness 4. Pessimistic thoughts 5. Ideas of self harm (death or suicide) 6. Disturbed sleep: waking in the morning 2 hours before the usual time 7. Diminished appetite: Change in weight Other/ Somatic Symptoms
  • 32. Contd. 4 s/s (2+2), continue most activities 5/6 s/s (2+3/ or 4), difficulties to continue activities 7 s/s (3+4), unlikely can function, somatic s/s usually present, psychotic s/s might be present Other characteristics: - Depression worse in the morning - Marked loss of libido - Subjective poor memory - Menstrual and sexual disturbances - Vague physical symptoms such as fatigue, aching discomfort, constipation etc. Categories Mild Depression Moderate Depression Severe Depression
  • 33. Clinical Features All from diagnostic criteria plus following: • The affect: sadness, dejection, helplessness and hopelessness. Gloomy outlook, pessimistic and feeling of worthlessness. • Speech: Decreased rate and volume of speech • Delusions or hallucinations and catatonic features (mute, not bathing, soiling) • Thought: negative views of world and themselves, suicidal ideation • Concentration: may be impaired and forgetfulness • Social participation is diminished
  • 34. Treatment • Pharmacological treatment - Antidepressants, anxiolytics • Electroconvulsive therapy - Treatment of choice for psychotic depression, depression refractory to pharmacotherapy and for acutely suicidal. - Patients with recurrent depression will need either prophylactic medication or maintenance ECT - Side effects include temporary short term memory loss
  • 35. Contd. • Family Therapy: to reduce or modify stressors • Group interventions: useful for mild to moderate cases of depression. Helps by optimizing socialization, venting feelings, exploring and establishing coping mechanisms, establishing personal goals, thus reducing isolation and hopelessness.
  • 36. Contd. • Psychotherapeutic interventions: - Cognitive therapy: address systematic errors in the client’s thinking that maintain negative cognitive processing. It aims at correcting such cognition by examining logically and replacing them with new cognitive and behavioral responses. - Behavioral therapy: activity scheduling, social skill training, decision making techniques, self – control therapy. - Interpersonal therapy: emphasized on social functioning and interpersonal relationships. The goal of therapy is to understand the social context of current problems based on earlier relationships and managing current interpersonal problems.
  • 38. Nursing Management • Assessment - Have you had thoughts about death or about killing yourself? - How persistent was the thoughts? - Have you formulated a plan? What is it? - Have you actually rehearsed or practiced how you would kill yourself? - Do you thick you would really do it? Have you told anyone? - Do you tend to be impulsive or can you resist the impulse to do this? - What have stopped you doing this? - Have you heard voices telling you to hurt or kill yourself? - History or previous attempt especially the degree of intent. - Family history of depression or suicide
  • 39. Nursing diagnosis with interventions
  • 40. 1. Risk for suicide related to anger turned inward/or, irrational feelings of guilt/ or depressed mood/ or hopelessness/ or hallucinations/ or delusional thinking. • Ask client directly: “Have you thought about harming yourself in any way? • Create a safe environment for the client. Remove all potentially harmful objectives. • Formulate a short term verbal or written contract with the client that he or she will not harm self during specific period. • Maintain close observation of client. Place in room close to nurse’s station: do not assign to private room. • Make records at frequent, irregular intervals (especially at night, toward early morning, at change of shift, or other predictably busy time or staffs. • Encourage client to express angry feelings within appropriate limits. Provide safe method of hostility release. • Identify community resources that client may use as support system, and from whom he or she may request help if feeling suicidal.
  • 41. 2. Social Isolation/Impaired social Interaction related to unresolved grief/ or altered thought processes (delusional thinking/ or fear of rejection or failure of the interaction. • Spend time with client • Develop a therapeutic nurse client relationship through frequent, brief contacts and an accepting attitude. Show unconditional positive regard. • Encourage client to take as much responsibility as possible for own self – care practices. • Help client to recognize and focus on strengths and accomplishments. • Help client set realistic goals. • Encourage participation in social activities and provide positive reinforcement.
  • 42. 3. Disturbed thought process related to impaired cognition fostering negative perception of self and the environment. • Do not argue or deny the belief • Use the techniques of consensual validation and seeking clarification. • Reinforce and focus on reality. Talk about real events and real people. • Give positive reinforcement as client is able to differentiate between reality – based and nonreality – based thinking. • Teach client to intervene, using thought – stopping techniques, when irrational or negative thoughts prevail.
  • 43. 4. Imbalanced nutrition less than body requirement related to liability to ingest food because of depressed mood, loss of appetite, energy level too low to meet own nutritional needs, ideas of self – destruction. • Ensure high fiber diets to prevent constipation. Encourage client to increase fluid consumption and physical exercise. • Weigh client daily. • Determine client’s likes or dislikes. • Administer vitamin and mineral supplements and stool softeners or bulk extenders, as ordered by physician. • Stay with client during meals. • Explain the importance of adequate nutrition and fluid intake.
  • 44. 5. Insomnia related to depression or repressed fears. • Keep strict records of sleeping patterns. • Discourage sleep during day. • Administer antidepressants medication on bedtime. • Assist with measure that may promote sleep, such as warm, non stimulating drinks, light snacks, warm baths, back rubs, relaxation exercises, and soft music. • Limit intake of caffeinated drinks such as tea, coffee and colas. • Administer sedative medications as ordered. • Some depressed clients may use excessive sleep as an escape. For them limit time spent in a room. Plan stimulating diversionary activities on daily schedule. • Depressed people are more likely to engage in behaviors that contribute to poor health such as smoking, limited or no exercise, poor eating habit and are likely to have greater difficulty managing their co-morbid conditions.

Editor's Notes

  1. Pervasive: spreading widely throughout an area or a group of people. Elation: great happiness and exhilaration
  2. Elation: great happiness
  3. Hypomania is a state of increased energy, exhilaration, and irritability commonly associated with bipolar disorder. Hypomania: A condition similar to mania but less severe.
  4. Somatic: relating to the body, especially as distinct from the mind. Somatic symptom disorder is characterized by an extreme focus on physical symptoms — such as pain or fatigue — that causes major emotional distress and problems functioning. You may or may not have another diagnosed medical condition associated with these symptoms, but your reaction to the symptoms is not normal.
  5. Euthymia is defined as a normal, tranquil mental state or mood. It is often used to describe a stable mental state or mood in those affected with bipolar disorder that is neither manic nor depressive, yet is distinguishable from healthy controls.
  6. dysthymic : a mood disorder characterized by chronic mildly depressed or irritable mood often accompanied by other symptoms (such as eating and sleeping disturbances, fatigue, and poor self-esteem) — called also dysthymic disorder.
  7. Cyclothymia, also known as cyclothymic disorder, is a mental disorder that involves numerous periods of symptoms of depression and periods of symptoms of hypomania.[3] These symptoms, however, are not sufficient to be a major depressive episode or a hypomanic episode.[3] Symptoms must last for more than one year in children and two years in adults.[3]
  8. Concordance: agreement or consistency.
  9. HPA: Hypothalamic pituitary adrenal axis Neurocognitive: denoting or relating to the neural processes and structures involved in cognition. NMDA receptor: The N-methyl-D-aspartate receptor is a glutamate receptor
  10. Neurons send what are known as electrochemical signals. Once a neuron has been stimulated by some sort of stimulus, it generates an electric potential that travels down the length of the cell. ... This is the 'chemical' part of electrochemical. The primary class of signaling molecules are called neurotransmitters.
  11. Histrionic personality disorder is one of a group of conditions called "Cluster B" or "dramatic" personality disorders. People with these disorders have intense, unstable emotions and distorted self-images. For people with histrionic personality disorder, their self-esteem depends on the approval of others and does not arise from a true feeling of self-worth. They have an overwhelming desire to be noticed, and often behave dramatically or inappropriately to get attention. The word histrionic means "dramatic or theatrical. Borderline: characterized by a long-term pattern of unstable relationships, distorted sense of self, and strong emotional reactions.[4][5][10] Individuals often engage in self-harm and other dangerous behavior.[4] Those affected may also struggle with a feeling of emptiness, fear of abandonment, and detachment from reality.[4
  12. Cortisol is the main hormone involved in stress and the fight-or-flight response. This is a natural and protective response to a perceived threat or danger. Increased levels of cortisol result in a burst of new energy and strength.
  13. Assignment: Stage of sleep
  14. Aching: having an ache in a part of one's body.
  15. Dejection: a sad and depressed state; low spirits. Gloomy: dark or poorly lit, especially so as to appear depressing or frightening.
  16. Refractory: resistant to a process of stimulus, stubborn or unmanageable
  17. Optimize: make the best or most effective use of  Venting: When you vent, you let something out
  18. ;L
  19. Foster: encourage the development of Consenual Validation refers to the agreement of two or more perspectives on reality. This is when two or more separate individuals agree on observed events. For instance, when police investigate a car accident they speak to as many witnesses as they can to understand the series of events involved.  Prevail: persuade (someone) to do something. Intervene: take part in something so as to prevent or alter a result or course of events.
  20. Liability: a person or thing whose presence or behaviour is likely to put one at a disadvantage. Bulk extender: a substance added to another substance, as to paint or food, to increase its volume or bulk: to add cereal and soy protein to hamburger as extenders.
  21. Repressed: (of a thought or desire) kept suppressed and unconscious in one's mind.