Major Depressive Disorder

Description

• A mood disorder may include symptoms of depressed mood, feelings or hopelessness and helplessness, decreased interest in usual activities, disinterest in relationship with others or cycles of depression and mania.
• Depression is often concurrent with other psychiatric diagnoses. Almost have of clients with major depressive disorders have histories of non-mood psychiatric disorders.
• A high incidence exists for persons with chronic illness or prolonges hospitalization or institutional care.

Risk Factors

1. Biological factors – brainchemicals
2. Family genetics – parent with depression, child 10-13% risk of depression.
3. Gender – higher rate for women
4. Age – often less than 40 when begins
5. Marital status – more frequently single, widowed
6. Season of year – Seasonal Affective Disorder (SAD) occurs when client experiences recurrent depression that occurs annually at the same time.
7. Psychological influences – low self-esteem, unresolved grief.
8. Environmental factors – lack of social support, stressful life events.
9. Medical co-morbidity – clients with chronic or terminal illness, postpartum, and current substance abuse are especially prone to becoming depresses.

Signs and Symptoms

1. Sexual disinterest
2. Suicidal and homicidal ideations
3. Decrease in personal hygiene
4. Tearfulness, crying, and melancholy
5. Altered thought process; difficulty concentrating, self-destructive behavior.
6. Loss of energy or restlessness
7. Anhedonia or loss of pleasure
8. Gain or loss of weight
9. Anger, self-directed
10. Psychomotor retardation or agitation
11. Insomnia or hypersomnia
12. Feelings of hopelessness, worthlessness, and helplessness.

Medical Diagnosis

A number of tests should be conducted to diagnose major depression:

• Beck Depression Inventory is a psychological test used to determine symptom onset, severity, duration, and progression.
• Dexamethasone suppression test showing failure to suppress cortisol secretion in depressed patients (although test has high false-negative rate).
• Toxicology screening suggesting drug-induced depression.
• Diagnosis is confirmed if DSM-V-TR criteria is met.

Nursing Diagnoses

• Risk for violence, self-directed or directed at others
• Impaired verbal communication
• Decisional conflict
• Altered role performance
• Hopelessness
• Deficit in diversional activity
• Fatigue
• Sel-care deficit
• Altered thought processes
• Self-esteem
• Anxiety

Medical Management

Medications are the primary treatment for major depression. Ideally, medications should be combined with various therapies. Drugs generally work by modifying the activity of relevant neurotransmitter pathways.

• Antidepressants are classified according to class:
• The first-line treatment for patients with depression because these drugs lack the most of disturbing effects of TCAs and MAOIs. Examples include citalopram (Celexa), paroxetine (Paxil), and sertraline (Zoloft).
• Generally used as second-line agents for patients with major depressive disorder. Example include venlafaxine (Effexor)
• Atypical antidepressants. Their mechanism of action is not clearly understood. Some examples include bupropion (Wellbutrin) and mirtazapine (Remeron). They are used as second-line agents too.
• An older class of antidepressants. Some examples include amitriptyline (Elavil) and amoxapine (Asendin).
• May be prescribed for patients with atypical depression (e.g. depression marked by increased appetite and sleep). Rarely used today because of high risk for adverse effects like hypertensive crisis and dangerous interactions with foods and medications.
• Improve treatment outcome by helping patient cope with low self-esteem and self-demoralization.
• Electroconvulsive therapy. To treat severe depression.

Therapeutic Nursing Management

1. Safe environment
2. Psychological treatment
   • Individual psychotherapy – long –term therapeutic approach or short term solution-oriented, may focus on in-depth exploration, specific stress situations, or problem solving.
   • Behavioral therapy – modifying behavior to assist in reducing depressive symptoms and increasing coping skills.
   • Behavioral contacts – focus on specific client problems and need to help the client resolve them.
3. Social treatment
   • Milieu therapy – incorporates day to day living experiences in a therapeutic environment to expect changes in perception and behavior.
   • Family therapy – aimed at assisting the family cope with the client’s illness and supporting the client in therapeutic ways.
   • Group therapy – focuses on assisting clients with interpersonal communication, coping, and problem-solving skills.
4. Psychopharmacologic and Somatic treatments
   • Administer antidepressant medications
   • Continued assessment by monitoring client’s mental health status is critical, particularly interms of agitation and suicidal ideation.
   • Electroconvulsive therapy

Nursing Interventions

1. Priority for care is always the client’s safety.
2. Use of behavioral contacts. Use this technique to meet outcomes relating to “no self-harm” or no suicidal ideation or plan.
3. Assess regularly for suicidal ideation or plan.
4. Observe client for distorted, negative thinking.
5. Assist client to learn and use problem solving and stress management skills.
6. Avoid doing too much for the client, as this will only increase client’s dependence and decrease self-esteem.
7. The nurse’s role in the physical care of the client experiencing major depressive disorder is to provide assessment and interventions related to appropriate nutrition, fluids, sleep, exercise, and hygieme, and to provide health education.
8. Explore meaningful losses in the client’s life.
9. Help the client and family to identify the internal and external indicators of major depressive disorder.

[mtouchquiz 776 title=off]

Risk for self-directed violence: At risk for behaviors in which an individual demonstrates that he/she can be physically, emotionally, and/or sexually harmful to self.

Risk factors

• Anhedonia, helplessness, hopelessness
• Loneliness
• Social isolation
• Severe personality disorder/ depression/ psychosis, substance abuse

Possibly evidenced by

• Previous attempts of violence.
• Suicidal plan (clear, specific, lethal method and available means).
• Suicidal behavior (attempts, ideation, plan and available means).
• When depression begins to lift, clients may have energy to carry out suicidal plan.

Desired Outcomes

• Patient will seek help when experiencing self-destructive impulses.
• Patient will have a behavioral manifestation of absent depression.
• Patient will have satisfaction with social circumstances and achievements of life goals.
• Patient will identify at least two-three people he/she can seek out for support and emotional guidance when he/she is feeling self-destructive before discharge.
• Patient will not inflict any harm to self or others.
• Patient will identify support and support groups with he/she is in contact within one month.
• Patient will state that he/she wants to live.
• Patient will start working on constructive plans for the future.
• Patient will demonstrate compliance with any medication or treatment plan within the next two weeks.
• Patient will demonstrate alternative ways of dealing with negative feelings and emotional stress.

Spiritual Distress

Spiritual Distress: Impaired ability to experience and integrate meaning and purpose in life through a person’s connectedness with self, others, art, literature, music, nature, or a power greater than oneself.

May be related to

• Chronic illness of self or others.
• Death or dying of self or others.
• Lack of purpose in life.
• Life changes.
• Pain.
• Self-alienation.
• Sociocultural deprivation.

Possibly evidenced by

• Expresses intense feelings of guilt.
• Expresses feelings of hopelessness and helplessness.
• Expresses being abandoned by or having anger towards God.
• Expresses concern with meaning of life/death or belief systems.
• Expresses lack of hope, meaning, or purpose in life, forgiveness of self, peace, serenity, acceptance.
• Inability to pray.
• Inability to express previous state of creativity (e.g., writing, drawing, singing).
• Inability to participate in religious activities
• Lack of interest in art.
• Questions meaning of own existence.
• Refuses interaction with families, friends or religious leaders.
• Searching for a spiritual source of strength.

Desired Outcomes

• Patient will feel the connectedness with others to share thoughts, feelings, and beliefs.
• Patient will feel the connectedness with the inner self.
• Patient will participates in spiritual rites and passages.
• Patient will discuss with nurse two things that gave his or her life meaning in the past within 3 days.
• Patient will talk to a nurse or a spiritual leader about spiritual conflicts and concern within 3 days.
• Patient will keep a journal tracking thoughts and feelings for one week.
• Patient will state that he/she feels a sense of forgiveness.
• Patient will state that he/she wants to participate in former creative activities.
• Patient will state that he/she gained comfort from previous spiritual practices.

Chronic Low Self-Esteem: Long standing negative self-evaluation/feelings about self or self-capabilities.

• Biochemical/neurophysiological imbalances.
• Feelings of shame and guilt.
• Impaired cognitive self-appraisal.
• Repeated past failure.
• Unrealistic expectation of self.

Possibly evidenced by

• Evaluates self as unable to deal with events.
• Inability to recognize own achievement.
• Negative view of self and abilities.
• Repeated expression of worthlessness.
• Rejection of a positive feedback.
• Self-negating verbalizations.

Desired Outcomes

• Patient will express belief in self.
• Patient will maintain self-esteem.
• Patient will demonstrate a zest for life and ability to enjoy the present.
• Patient will identify one or two strengths by the end of the day.
• Patient will identify two unrealistic self-expectations and reformulate more realistic life goals with nurse by the end of the day.
• Patient will identify three judgemental terms (e.g., “I am lazy”) client uses to describe self and identify objective terms to replace them (e.g., ” I do not feel motivated to).
• Patient will keep a daily load and identify on a scale of 1 to 10 (1 being the lowest, 10 being the highest) feelings of guilt, shame, self-hate.
• Patient will report decreased feelings of guilt, shame and self-hate by using a scale of 1 to 10 (1 being the lowest, 10 being the highest).
• Patient will demonstrate the ability to modify unrealistic self-expectations.
• Patient will give an accurate and nonjudgmental account of four positive qualities as well as identify two areas he or she wishes to improve.

Impaired Social Interaction: Insufficient or excessive quantity or ineffective quality of social exchange.

May be related to

• Altered thought processes.
• Anergia (lack of energy and motivation).
• Feelings of worthlessness.
• Fear of rejection.
• Lack of support system.
• Self-concept disturbance.

Possibly evidenced by

• Dysfunctional interaction with family, peers, and/or others.
• Family reports change of style or patterns of interaction.
• Verbalized discomfort in social situations.
• Remains feelings of seclusion, avoids contact with others and lacks eye contact.

Desired Outcomes

• Patient will identify feelings that lead to poor social interactions.
• Patient will interact with family/friends/peers.
• Patient will participate in certain community social activities (e.g.,leisure activity, church member).
• Patient will participate in one activity by the end of the day.
• Patient will discuss two-three alternative ways to take when feeling the need to withdraw.
• Patient will identify two-three personal behaviors that might discourage others from seeking contact.
• Patient will eventually voluntarily attend individual/group therapeutic meetings within a therapeutic milieu (community or hospital).
• Patient will verbalize that he/she enjoys interacting with others in activities and one-on-one interactions to the extent they did before becoming depressed.
• Patient will state and demonstrate progress in the resumption of sustaining relationships with friends and family members within one month.

Disturbed Thought Processes: A state in which individual experiences a disruption in cognitive operations and activities.

May be related to

• Biologic/medical factors.
• Biochemical/neurophysical imbalances.
• Persistent feelings of extreme guilt, fear or anxiety.
• Prolong grief reaction.
• Overwhelming life circumstances.
• Severe anxiety or depressed mood.

Possibly evidenced by

• Decreased problem-solving abilities.
• Hypovigilance.
• Impaired ability to grasp ideas or orders thoughts.
• Impaired attention span/easily distracted.
• Impaired insight.
• Impaired judgment, perception, decision making.
• Inaccurate interpretation of the environment.
• Memory problems/deficits.
• Negative ruminations.

Desired Outcomes

• Patient will process information and makes appropriate decisions.
• Patient will accurately recall recent and remote information.
• Patient will exhibit organized thought process.
• Patient will identify two goals he or she wants to achieve from treatment, with aid of nursing intervention, within 1 to 2 days.
• Patient will discuss with nurse two irrational thoughts about self and others by the end of the first day.
• Patient will reframe three irrational thoughts with the nurse.
• Patient will remember to keep appointments, attend activities, and attend to grooming with minimal reminders from others within 1 to 3 weeks.
• Patient will identify negative thoughts and rationally counter them and/or reframe them in a positive manner within 2 weeks.
• Patient will show improved mood as demonstrated by the Beck Depression Inventory.
• Patient will give examples showing that short-term memory and concentration have improved to usual levels.
• Patient will demonstrate an increased ability to make appropriate decisions when planning with the nurse.

Self-Care Deficit: Impaired ability to perform or complete bathing/hygiene, dressing/grooming, feeding or toileting activities for oneself.

May be related to

• Anergia (Decreased or lack of motivation).
• Perceptual or cognitive impairment.
• Severe anxiety.
• Severe preoccupation.

Possibly evidenced by

• Awakening earlier or later than desired.
• Body odor/hair unwashed and unkempt.
• Constipation related to lack of exercise, roughage in diet, and poor fluid intake.
• Consuming insufficient food or nutrients to meet minimum daily requirements.
• Decreased ability to function secondary to sleep deprivation.
• Inability to organize simple steps in hygiene and grooming.
• Persistent insomnia or hypersomnia.
• Weight loss.

Desired Outcomes

• Patient will groom and dress appropriately with help from a nursing staff and/ or family.
• Patient will regain more normal elimination pattern with aid of foods high in roughage, increased fluid intake, and exercise daily (also with the aid of medications).
• Patient will sleep between 4 to 6 hours with aid of nursing measures and/or medications.
• Patient will gain 1 pound a week with encouragement from family, significant others, and/or staff if significant weight loss is noted.
• Patient will demonstrate progress in the maintenance of adequate hygiene and be appropriately groomed and dressed (shave/makeup, clothes clean and neat).
• Patient will experience normal elimination with the aid of diet, fluids, and exercise within 3 weeks.
• Patient will sleep between 6 to 8 hours per night within one month.
• Patient will gradually return to weight consistent for height and age or baseline before illness.