DEPRESSIVE EPISODE
DEPRESSION
It is a world widespread mental health problem affecting many people. The lifetime risk of depression in males is 8-12% and females it is 20-26%. The highest incidence of depressive symptoms has been indicated in individuals without close interpersonal relationships and in persons who are divorced or separate. Depression often is associated with a variety of medical problems.
DEFINATION
• .
A mental health disorder characterised by persistently depressed mood or loss
of interest in activities, causing significant impairment in daily life.
• .
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.(APA)
Classification
of depression
1. Depressive episode
2. Mild depressive episode
3. Moderate depressive episode
4. Sever depressive episode without
psychotic symptoms
5. Sever depressive episode with
psychotic symptoms
6. Other depressive episode- Atypical
depression
7. Depressive episode unspecified
8. Recurrent depressive disorder
Etiology
Biologic
theories
The etiology
of depression has been biologically attributed to alterations in Neurochemical,
genetic, endocrine and circadian rhythm function
a. Neurochemical theories
Finding suggest that when levels of
norepinephrine and serotonin are decreased and dysregulation of acetylcholine GABA.
b. Genetic theories
Ø Major depressive disorders occur more
often in first degree relatives than they do in the general population
Ø Studies of identical twins show that
when one twin is diagnosed with major depression, the other twin has greater
than 70% chance of developing it.
c. Endocrine theories
Normally the hypothalamic –
pituitary- adrenal axis a system that mediates the stress response. However in
some depressed people this system malfunctions and creates cortisol, thyroid
and hormonal abnormalities.
d. Circadian rhythm
These are responsible for
the daily regulation of weak-sleep cycles, and hormonal secretion. These
changes might be caused by medication, nutritional deficiency, physical or
psychologically illness, hormonal fluctuations.
e. Changes in brain
anatomy
Loss of neurons in the
frontal lobes, cerebellum and basal ganglia has been identified in depression.
f.
Psychological theories
According to Freud
(1957) depression is result due to loss of a “loved object” and fixation in the
oral sadistic phase of development. In this model mania is viewed as a denial
of depression.
g. Behavioral theory
This theory of depression
phenomena to the experience of uncontrollable events. According to this model
depression is conditioned by repeated losses in the past.
h. Cognitive theory
According to this theory
depression is due to negative cognition which includes
Ø Negative expectation of the
environment
Ø Negative expectation of the self
Ø Negative expectation of the future
These cognitive
developments arise out of a defect in cognitive development and cause the
individual to feel inadequate, worthless and rejected by others.
i.
Sociological theory
Stressful life events for example
death, marriage, finical loss and onset of disease conditions probably have a
formative effect.
Transactional
model of stress/ adaption
According to this
depression occurs as a combination of predisposing factors, past experiences
and existing condition, inadequate coping skills and other psychological
conditions.
Clinical
features
Depressive episode is
characterized by the following features, which should last for at least two
weeks in order to make a diagnosis.
1. Depression mood
Sadness of mood
or loss of interest and loss of pleasure in almost all activities, present
throughout the day.
2. Depressive cognitions
Hopeless,
helplessness, worthlessness, unreasonable guilt and self blame over trivial
matters in the past.
3. Suicidal thoughts
Ideas of
hopelessness are often accompanied by the thought that life is no longer worth
living and that death had come as a welcome release. These gloomy
preoccupations may progress to thoughts of and plans for suicide.
4. Psychomotor activity
The
retarded patients think walks and acts slowly. Slowing of thoughts is reflected
in the patient’s speech, questions are often answered after a long delay and in
a monotonous voice. In older patients agitation is common with marked anxiety,
restlessness and feelings of uneasiness.
5. Psychotic features
Some
patients have delusions and hallucination. These are often mood congruent. Some
patients experience delusions and hallucination that are not clearly related to
depressive themes, for example delusion of control. The prognosis then appears
to be much worse.
Symptoms
of depression
1. Decreased in appetite or weight
2. Depression being worst in the morning
3. Psychomotor retardation
Other symptoms
1. Difficulty in thinking and
concentration
2. Subjective poor memory
3. Menstrual or sexual disturbances
4. Fatigue
5. Constipation
Diagnosis
1. Mental status examination
2. Hamilton rating scale for
depression to assess severity and
prognosis
3. Physical examination
4. CT scan
5. MRI
Treatment
1. Psychopharmacology
a. Antidepressant such as
Ø Unicyclic depressants (Bupropein)
Ø Bicyclic depressant (Fluoxetine)
Ø Tricyclic depressants (Imipramine)
Ø Tetracyclic depressant
(Inaprotilline)
b. MAOIs (mono amine oxidase) inhibitors like
Phenelzine
2. Physical therapies
Ø Electro convulsive therapy- severe
depression with suicidal risk is the most important indicated for ECT.
Ø Light therapy – sometimes called as
phototherapy involves exposing the patient to an artificial light source during
winter months to relieve seasonal depression.
3. Psychosocial treatment
Ø Psychotherapy – it is based on
psychoanalytic interventions helping patients gain insight into the cause of
their depression.
Ø Cognitive therapy – it aims at
correcting the depressive negative cognitions like hopelessness, helplessness
and behavioral responses.
Ø Supportive psychotherapy- various
techniques are employed to support the patient. They are ventilation,
occupational therapy, relaxation and other activity therapies.
Ø Group therapy- is useful for mild
cases of depression. In group therapy negative feelings such as anxiety, anger,
guilt and emotional growth is improved through expression of their feelings.
Ø Family therapy – is used to decrease
interpersonal difficulties and to reduce or modify stressors, which may help in
faster and more complete recovery.
Ø Behavioral therapy- it includes
social skills training, problem solving techniques, self control therapy,
activity scheduling and decision making techniques.
Nursing
management
1. High risk for violence
related to depressed mood
Ø Create safe environment in the ward
Ø Remove the all dangerous things such
as sharp blades, scissors, glass pieces and rope etc.
Ø Don’t leave the patient alone
Ø Don’t talk about suicide near to
patient
Ø Contact with staff members is
encouraged
Ø Close observation is required
Ø Encourage the patient to explore
his/her feelings
2. Dysfunctional griefing
related to loss
Ø Assess the stage of fixation in grief
process
Ø Encourage patient to do simple
activities
Ø Allow patient to take his own
decision
Ø Encourage the patient to verbalize
and express his/her feelings
3. Self esteem disturbance
related to negative views
Ø Accept patient as he/she is
Ø Help the patient to identify the
positive points
Ø Provide the reinforcement to patient
Ø Keep the self help strategies simple
4. Altered communication
process related depression
Ø Use active friendly approach
Ø Introduce one patient to other
patients
Ø Encourage patient to talk about their
problems
Ø Encourage to express their feelings
of anger and tension
5. Altered sleep and rest
related to disease condition
Ø Provide quiet and peaceful
environment
Ø Give sedatives as ordered by doctor
Ø Provide comfortable measures
6. Altered nutrition less
then body requirement related to depressed mood
Ø Ask like and dislike of the patient
Ø Maintain intake and output chart
Ø Encourage patient to include
different food items in their diet
Ø Check weight regularly
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