Major Depressive Disorder

Notes

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.

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Nursing Care Plan

Risk For Self-Directed Violence

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.
Nursing Interventions Rationale
Identify the level of suicide precautions needed. If there is a high-risk, does a hospitalization requires? Or if there is a low risk, will the client be safe to go home with supervision from a family member or a friend? For example, does client:

  • Admit previous suicide attempts.
  • Abuse any substances.
  • Have no peers/friends.
  • Have any suicide plan.
A client with a high-risk will require a constant supervision and a safe environment.
Contact the family, arrange for crisis counseling. Activate links to self-help groups. Clients need a network of resources to help diminish personal feelings of helplessness, worthlessness, and isolation.
Check for the availability of  required supply of medications needed. Normally, a suicidal client’s medical supply should be limited to 3-5 days.
Encourage clients to express feelings (anger, sadness, guilt) and come up with alternative ways to handle feelings of anger and frustration. Clients can learn alternative ways of dealing with overwhelming emotions and gain a sense of control over his/her life.
If, hospitalized, follow unit protocols.  There are different measures for the suicidal client in either the hospital, clinic, and community.
Implement a written no-suicide contract. Reinforces action the client can take when feeling suicidal.

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.
Nursing Interventions Rationale
Assess what spiritual practices have offered comfort and meaning to the client’s life when not ill. Evaluates neglected areas in the person’s life that, if reactivated, might add comfort and meaning during a painful depression.
Encourage client to write a  journal expressing thoughts and reflections daily. This will help in identifying important personal issues and one’s thought and feelings surrounding spiritual issues. Writing a journal is a good way to explore deeper meanings in life.
If the client is unable to write, provide a tape recorder. Often speaking aloud helps a person clarify thinking and explore issues.
Discuss with the client what has given comfort and meaning to the person in the past. When depressed, clients usually are having a hard time searching for meaning in life and reasons to go on when feeling hopelessness and despondent.
Suggest that the spiritual leader affiliated with the facility contact the client. Spiritual leaders are familiar in dealing spiritual distress and can offer comfort to the client.
Provide information on referrals, when needed, for religious or spiritual information (e.g., readings, programs, tapes, community resources). When hospitalized, spiritual tapes and readings can be useful; when the client is in the community, client might express other needs.

Chronic Low Self-Esteem

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.
Nursing Interventions Rationale
Teach visualization techniques that can help the client replace negative self-images with more positive images and thought. To promote a healthier and more realistic self-image by helping the client choose more positive thoughts and actions.
 Encourage the client to participate in a group therapy where the members share the same situations/feelings that they have.  To minimize the feelings of isolation and provide an atmosphere where positive feedback and a more realistic appraisal of self are available.
Evaluate client’s need for assertiveness training tools to pursue things he or she wants or needs in life. Arrange for training through community-based programs, personal counseling, literature etc.  Low self-esteem individuals often have feelings of unworthiness and have difficulty determining their needs and wants.
Role model assertiveness. Clients can follow examples/role models.
Involve the client in activities that he or she wants to improve by using problem-solving skills. Assess and evaluate the need for more teaching in this area. Feelings of low self-esteem can interfere with usual problem-solving abilities.
Work with the client to identify cognitive distortions that encourage negative self-appraisal. For example:

  1. Discounting positive attributes.
  2. Mind reading.
  3. Overgeneralizations.
  4. Self-blame.
Cognitive distortions reinforce negative, inaccurate perception of self and the world.

  1. Focus on negative qualities.
  2. Assuming others “do not like me”. for example, without any real evidence that assumptions are correct.
  3. Taking one fact or event and making a general rule out of it. (“He always”, I never”).
  4. Consistent self-blame for everything perceived as negative.

Impaired Social Interaction

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.
Nursing Interventions Rationale
Initially, provide activities that require minimal concentration (e.g., drawing, playing simple board games). Depressed people lack concentration and memory. Activities that have no “right or wrong” or “winner or loser” minimizes opportunities  for the client to put himself/herself down.
Involve the client in gross motor activities that call for very little concentration (e.g.,walking). Such activities will aid in relieving tensions and might help in elevating the mood.
When the client is at the most depressed state, Involve the client in one-to-one activity. Maximizes the potential for interactions  while minimizing anxiety levels.
Eventually involve the client in group activities (e.g., group discussions, art therapy, dance therapy). Socialization minimizes feelings of isolation. Genuine regard for others can increase feelings of self-worth.
Eventually maximize the client’s contacts with others (first one other, then two others, etc.). Contact with others distracts the client from self-preoccupation.
Refer the client and family to self-help groups in the community. The client and the family can gain tremendous support and insight from people sharing their experiences.

Disturbed Thought Processes

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.
Nursing Interventions Rationale
Determine the client’s previous level of cognitive functioning (from client, family, past medical records). Establishing a baseline data  allows for evaluation of client’s progress.
Use simple, concrete words. Slowed thinking and difficulty concentrating impair comprehension.
Allow the client to have plenty of time to think and frame responses. Slowed thinking necessitates time to formulate a response.
Allow more time than usual for the client to finish usual activities of daily living (ADL) (e.g.,eating, dressing). Usual tasks might take long periods of time; demands that the client hurry only increase anxiety and slow down ability to think clearly.
Help the client to postpone important major life decision making. Making rational major life decision requires optimal psychophysiological functioning.
While the client is severely depressed, minimize client’s responsibility. Decreases feelings of guilt, anxiety and pressure.
Help the client identify negative thinking/thoughts. Teach the client to reframe and/or refute negative thoughts. Negative ruminations add to feelings of hopelessness and are part of a depressed person’s faulty thought processes. Intervening in this process helps in healthier and more useful outlook in life.
Help client and family structure an environment that can help re-establish set schedules and predictable routines during severe depressions. A fairly and non-demanding repetitive routine is easier to both follow and remember.

Self-Care Deficit

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.
Nursing Interventions Rationale
Bathing and/or Hygiene Self-Care Deficit:
  • Encourage the use of soap, washcloth, toothbrush, shaving equipment, make-up etc.
Being clean and well groomed can temporarily increase self-esteem.
  • Give step-by-step reminders such as “Brush the teeth “Clean the outer surfaces of your upper teeth, then your lower teeth. . .”
Slowed thinking and difficulty concentrating make organizing simple tasks difficult.
Constipation
  • Monitor intake and output, especially the bowel movements.
Most of the depressed clients are constipated. If this problem is not addressed, it can lead to fecal impaction.
  • Encourage the intake of nonalcoholic and noncaffeinated fluids, 6 to 8 glasses a day.
Fluids can help prevent constipation.
  • Offer fiber-rich foods and periods of exercise.
Roughage and exercise stimulate peristalsis and help evacuation of fecal material.
  • Evaluate the need for laxatives and enemas.
 These prevent the occurrence of fecal impaction.
Disturbed Sleep Pattern
  • Provide rest periods after activities.
Fatigue can intensify feelings of depression.
  • Encourage relaxation measures in the evening (e.g., drinking warm milk, back rub, or tepid bath).
These measures induce sleep and relaxation.
  • Encourage the client to get up and dress and to stay out of bed during the day.
Minimize sleep during the day increases the likelihood of sleep at night.
  • Reduce environmental and physical stimulants in the evening; Provide decaffeinated coffee, soft music, soft lights and quiet activities.
Decreasing caffeine and epinephrine levels increases the possibility of sleep.
Imbalanced Nutrition
  • Weight the client weekly and observe the eating patterns of the client.
Give the information needed for revising the intervention.
  • Encourage eating with others.
Increases socialization, decrease focus on the food.
  • Serve foods or drinks the client likes.
Clients are more likely to eat foods they like.
  • Encourage small, high-calorie, and high-protein snacks and fluids frequently throughout the day and evening if weight loss is noted.
Minimize weight loss, constipation, and dehydration.
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