DEPRESSION
DEPRESSION
According to the World Health Organization
(WHO), depression is a common mental disorder
characterized by a persistently low or depressed
mood and/or loss of pleasure or interest in
activities for long periods of time.
Under ICD 11 criteria it comes under 6A70
PREVALENECE
occurs in persons of all genders, ages, and
backgrounds.
higher in women than in men by almost 2 to 1.
Average age of onset is 20 and 40 years.
PREVALENECE
Higher incidence in women who are divorced or
separated.
Affecting about million people worldwide.
leading causes of disability worldwide.
CAUSES OF DEPRESSION
1. Genetic or Hereditary
depression is 1.5 to 3 times more common
among first-degree
The occurrence rate for monozygotic twins is
65%and for dizygotic twins is 15%
2. Neurochemical
deficiency of the neurotransmitters norepinephrine,
serotonin, and dopamine.
NOTE
Norepinephrine is a key component to deal with stressful
situations.increases alertness and attention.
Serotonin regulate functions, such as mood, anxiety,
thinking, cognition, appetite and circadian rhythm.
Dopamine influence over human mood, thought and
behaviour.
3. Endocrine theories
• Malfunction of hypothalamic
pituitary adrenal axis [HPA]
may lead to depression.
• HPA is a system that mediates
the stress response.
4. Circadian rhythm theories
Responsible for daily
regulation of wake-sleep
cycle.
Malfunction of circadian
rhythm may lead to
depression.
5.Changes in Brain anatomy
Loss of neurons in frontal lobe
and cerebellum has been
identified in depression
Cerebellum I-- plays a role in
some cognitive and emotional
processes.
6. Psychoanalytical theory
According to Freud, depression result due to loss of
loved object and fixation in oral phase of
development.
7.Behavioural theory
According to this theory depression is conditioned by
repeated loss in the past.
8.Cognitive theory
According to this theory depression is due to negative
cognition which includes
Negative expectation of the environment
Negative expectation of the self
Negative expectation of the future
9.Social theory
Stressful life events for example death , marriage,
financial loss , divorce may lead to depression.
10. Medications;
Some medication like beta blockers, corticosteroids , oral
contraceptives may precipitate depression.
NOTE-
Research suggests that corticosteroids lower
serotonin levels in the body.
estrogen and progesterone influence the activity of neurotransmitters gamma-
aminobutyric acid, serotonin and dopamine
SIGNS AND SYMPTOMS
Depressed mood:
Persistent sad, anxious, or "empty" feelings
loss of pleasure in almost all activities
Persistent sadness present throughout the day
Depressive cognitions:
Hopelessness ('no hope in future’)
helplessness (no help is possible),
worthlessness
unreasonable guilt and self-blame over matters in the past
Irritability, restlessness
SIGNS AND SYMPTOMS
Suicidal thoughts:
Patient feel life is no longer worth living
death had come as a welcome release.
Preoccupations with thought of suicide.
thoughts of and plans for suicide
Psychomotor activity:
Psychomotor retardation is frequent.
patient thinks, walks and acts slowly.
Slowing of thought is reflected in the patient's speech;
questions answered after a long delay
monotonous voice.
Marked anxiety, restlessness and feelings of uneasiness
SIGNS AND SYMPTOMS
Psychotic features:
delusions and hallucinations
nihilistic delusions (belief of being dead,
decomposed , having lost one's own internal organs
or even not existing entirely as a human being.),
delusions of guilt,
delusions of poverty,
delusion of control.
SIGNS AND SYMPTOMS
Somatic symptoms
Significant decrease in appetite or weight.
Early morning awakening, at least 2 or more hours before
the usual time
depression being worst in the morning.
Other Features
Difficulties in thinking and concentration.
Subjective poor memory.
Menstrual or sexual disturbances.
Vague physical symptoms such as fatigue, aching
discomfort, constipation, etc.
ICD 11 CLASSIFICATION
The presence of at least five of the following symptoms
occurring for most of the day, nearly every day, during a period
lasting at least 2 weeks is required for diagnosis.
At least one symptom from the affective cluster must be present.
Affective cluster
• Depressed mood as reported by the individual (e.g. feeling
down, sad) or as observed (e.g. tearful, defeated appearance)
• Markedly diminished interest or pleasure in activities,
ICD 11 CLASSIFICATION
Cognitive-behavioural cluster
• Reduced ability to concentrate and sustain attention on tasks.
• Beliefs of low self-worth or excessive and inappropriate guilt
that may be manifestly delusional
• Hopelessness about the future
• Recurrent suicidal ideation (with or without a specific plan), or
evidence of attempted suicide
ICD 11 CLASSIFICATION
Neurovegetative(those symptoms that are directly related
to the body ) cluster
• Significantly disrupted sleep or excessive sleep
• Significant change in appetite (diminished or increased).
• Psychomotor agitation or retardation
• Reduced energy, fatigue or marked tiredness following the
expenditure of only a minimum of effort
ICD 11 CLASSIFICATION
• The symptoms are not better accounted for by loss/suffering.
• The symptoms are not a manifestation of another medical
condition (e.g. a brain tumor), and are not due to the effects of a
substance or medication
• The mood disturbance results in significant impairment in
personal, family, social, educational, occupational or other
important areas of functioning.
CLASSIFICATION OF DEPRESSION
Depressive disorders include the following:
6A70 Single episode depressive disorder
6A71 Recurrent depressive disorder
6A72 Dysthymic disorder
6A73 Mixed depressive and anxiety disorder
6A7Y Other specified depressive disorder
6A7Z Depressive disorder, unspecified.
6A70 Single episode depressive disorder
The presence or a history of a single depressive episode.
There is no history of manic, mixed or hypomania episodes, which
would indicate the presence of a bipolar disorder.
Further classified into:
6A70.0 Single episode depressive disorder, mild
6A70.1 Single episode depressive disorder, moderate, without
psychotic symptoms
6A70.2 Single episode depressive disorder, moderate, with psychotic
symptoms
6A70.3 Single episode depressive disorder, severe, without psychotic
symptoms
6A70.4 Single episode depressive disorder, severe, with psychotic
symptoms
6A70.5 Single episode depressive disorder, unspecified severity
6A71 Recurrent depressive disorder
• A history of at least two depressive episodes which may include a current
episode, separated by several months without significant mood disturbance is
required for diagnosis. .
• There is no history of manic, mixed or hypomanic episodes, which would
indicate the presence of a bipolar disorder.
• Further classified into:
6A71.0 Recurrent depressive disorder, current episode mild
6A71.1 Recurrent depressive disorder, current episode moderate, without
psychotic symptoms
6A71.2 Recurrent depressive disorder, current episode moderate, with psychotic
symptoms
6A71.3 Recurrent depressive disorder, current episode severe, without
psychotic symptoms
6A71.4 Recurrent depressive disorder, current episode severe, with psychotic
symptoms
6A72 Dysthymic disorder
Persistent depressed mood (i.e. lasting 2 years or more), for most
of the day as reported by the individual (e.g. feeling down, sad)
or as observed (e.g. tearful, defeated appearance), is required for
diagnosis.
The depressed mood is accompanied by additional symptoms.
Examples include:
• markedly diminished interest or pleasure in activities
• reduced concentration and attention, or indecisiveness(unable to
decide, conclude, or resolve something)
• low self-worth, or excessive or inappropriate guilt
• hopelessness about the future
• disturbed sleep or increased sleep
• diminished or increased appetite
• low energy or fatigue.
During the first 2 years of the disorder, there has never been a 2-week
period during which the number and duration of symptoms were
sufficient to meet the diagnostic requirements for a depressive episode.
There have never been any prolonged symptom-free periods (e.g.
lasting 2 months or more) since the onset of the disorder.
There is no history of manic, mixed or hypomanic episodes, which
would indicate the presence of a bipolar or related disorder.
The symptoms are not a manifestation of another medical condition
(e.g. hypothyroidism), and are not due to the effects of a substance or.
withdrawal effects .
The symptoms result in significant distress or cause significant
impairment in personal, family, social, educational, occupational or
other important areas of functioning.
6A73 Mixed depressive and anxiety disorder
The presence of both depressive and anxiety symptoms for most
of the time during a period of 2 weeks or more is required for
diagnosis.
Depressive symptoms include depressed mood or markedly
diminished interest or pleasure in activities.
There are multiple anxiety symptoms, which may include feeling
nervous, anxious , not being able to control worrying thoughts,
fear that something awful will happen, having trouble relaxing.
Neither the depressive nor the anxiety symptoms –are sufficiently
severe, numerous or lasting to meet the diagnostic requirements
of another depressive disorder or an anxiety related disorder.
6A73 Mixed depressive and anxiety disorder
There is no history of manic or mixed episodes, which would
indicate the presence of a bipolar disorder.
The symptoms are not a manifestation of another medical
condition (e.g. hypothyroidism, hyperthyroidism), and are not
due to the effects of a substance or medication or withdrawal
effects.
The symptoms result in significant distress or significant
impairment in personal, family, social, educational, occupational
or other important areas of functioning.
DIAGNOSIS
History Collection
Mental Status Examination
ICD – 11 Criteria
MANAGEMENT
Management depends upon severity of depression
MILD DEPRESSION
Counselling
Frequent follow up
Patient improve no further treatment required
If not start antidepressant.
Counselling continue
Cognitive therapy:
Aims at correcting the depressive negative cognitions like
hopelessness,
worthlessness,
helplessness and
pessimistic ideas,
replacing them with new cognitive and behavioral responses.
Supportive psychotherapy:
Various techniques are employed to support the patient.
They are reassurance, ventilation, relaxation and other
activity therapies.
Group therapy:
useful for mild cases of depression.
In group therapy negative feelings such as anxiety anger,
guilt are recognized
emotional growth is improved through expression of their
feelings.
Family therapy:
used to decrease intrafamilial and interpersonal difficulties
to reduce or modify stressors, which may help in faster and
more complete recovery.
Behavior therapy:
It includes
social skills training,
problem solving techniques,
activity scheduling and
decision making techniques.
MANAGEMENT
MODERATE DEPRESSION
Antidepressant e.g. Imipramine, sertraline etc.
Psychotherapy
Group therapy
Family therapy
Behavioural therapy
Cognitive therapy
If psychotic symptoms is seen Antipsychotic medication
is prescribed.
MANAGEMENT
SEVERE DEPRESSION SEVERE DEPRESSION
Without psychotic feature With psychotic feature
Antidepressant Antidepressant
Psychotherapy Antipsychotic
Group therapy Psychotherapy
Family therapy Group therapy
Behavioural therapy Family therapy
Cognitive therapy Behavioural therapy
ECT Cognitive therapy
ECT
ANTI DEPRESSANTS
• Imipramine—25- 50 mg/ day
• Amitriyptaline – 25- 50 mg/ day
As a starting dose and Can be increased to 150
mg/ day.
ANTI PSYCHOTIC
• Risperidone
• Halopéridol
• Chlorpromazine
• Clozapine
• olanzapine
Course and Prognosis of Mood
An average depressive episode lasts for 4-9 months.
Good Prognostic Factors
Abrupt or acute onset
Well-adjusted premorbid personality
Good response to treatment
Poor Prognostic Factors
Recurrent depression
Co-morbid personality disorders or alcohol dependence
Chronic ongoing stress
Poor drug compliance
Marked hypochondriacal features
psychotic features
NURSING MANAGEMANT
ASSESSMENT
History [marked helplessness, hopelessness and
worthlessness]
MSE
Assess severity of symptoms
Assess suicidal tendency and attempts
Assess social resources available to the patient.
NURSING MANAGEMANT
DIAGNOSIS
Risk for suicide related to Depressed mood, feelings of
hopelessness and worthlessness.
Complicated grieving related to loss of object/loved one.
Low self-esteem related to helplessness, negative view
about self, feelings of abandonment by significant other.
NURSING MANAGEMANT
DIAGNOSIS
Impaired social interaction related to short
attention span, high level of distractibility and
labile mood.
Ineffective coping skills related to poor impulse
control.
Altered sleep and rest, related to depressed mood
and disturbed cognition .
NURSING MANAGEMANT
Imbalanced nutrition, less than body requirement related
to helplessness, hopelessness and worthlessness.
Self- care deficit related to depression as evidence by
monitoring the patient’s daily activities.
Ineffective individual coping related to symptoms
secondary to depressive.
NURSING MANAGEMANT
NURSING INTERVENTION
Risk for suicide
Ask the patient directly "Have you thought about harming yourself in
any way? If so, do you plan to do? Do you have the means to carry
out this plan?“
Create a safe environment for the patient.
Remove all potentially harmful objects from patient’s environment
(sharp objects, straps, belts, glass items, alcohol, etc.).
Supervise closely during meals and medication administration.
Formulate a short-term verbal or written contract that the patient will
NURSING MANAGEMANT
NURSING INTERVENTION
Risk for suicide
Do not leave the patient alone. Place the client near the
nursing station
Do not allow the patient to put the door of bathroom or toilet.
If the patient suddenly becomes unusually happy or gives any
other clues of suicide, special observation may be necessary.
Encourage the patient to express his feelings, including anger
Low self-esteem
Be accepting to patient and spend time, even though
negativism may be seem.
Focus on strengths and accomplishments and minimize
failures.
Provide simple and easily achievable activity.
Encourage the patient to perform activities without
assistance.
Teach coping skills.
Complicated grieving
Assess stage of fixation in grief process.
Be accepting to and spend time with patient.
Show empathy, care and unconditional, positive regard.
Explore feelings of anger and help patient direct them or
release them.
Provide simple activities which can be easily and quickly
accomplished.
Disturbed sleeping pattern
Plan daytime activities according to the patient's
interests,
Do not allow him to sit idle. Do not allow the patient to
sleep during the day.
Ensure a quiet and peaceful environment for sleep.
Provide comfort measures (back rub,, warm milk, etc.).
Give sedatives as prescribed.
Altered nutritional status
Closely monitor the client's food and fluid intake; maintain intake
and output chart.
Record patient's weight regularly.
Find out the likes and dislikes of the person before he was sick and
serve the best preferred food.
Serve small amounts of a light diet frequently that is nourishing.
Record the client's pattern of bowel elimination.
Encourage more fluid intake, roughage diet and green leafy
vegetables
Self- care deficit
Ensure that he takes his bath regularly.
Do not ask the patient's permission for a wash or bath.
Lead the patient to the action with positive suggestions,
e.g. "The water is ready, let me take you for a bath."
When the patient has taken care of himself, express
realistic appreciation.
Altered communication
Observe for non-verbal communication. The patient may say that he is
happy but looks sad. Point out this discrepancy in what he is saying and
actually feeling.
Use short sentences while asking question in simple and understandable
way.
Ask questions in such a way that the patient will have to answer in more
than one word.
Use silence appropriately without anxiety or discomfort.
Introduce the patient to another patient who is quiet and possibly
recovering from depression.
