MAJOR DEPRESSION/DYSTHYMIC DISORDER
DSM-IV
DEPRESSIVE DISORDERS
296.xx Major depressive disorder
296.2x Single episode
296.3x Recurrent
300.4 Dysthymic disorder
311 Depressive disorder NOS
A disturbance of mood, characterized by a full or partial depressive syndrome, or loss of interest or pleasure in usual activities and pastimes with evidence of interference in social/occupational functioning.
ETIOLOGICAL THEORIES
Psychodynamics
Psychoanalytical theory focuses on an early unsatisfactory parent/child relationship, with an unresolved grieving process. This results in the individual remaining fixed in the anger stage of the grieving process and turning it inward on the self. The ego remains weak, while the superego expands and becomes punitive.
Cognitive theory projects a belief that depression occurs as a result of impaired cognition, fostering a negative evaluation of self through disturbed thought processes. The individual is pessimistic and views self as inadequate and worthless and life as hopeless.
Learning theorists propose that depressive illness arises out of the individual’s having experienced numerous failures (either real or perceived). A feeling of inability to succeed at any endeavor ensues. This “learned helplessness” is viewed as a predisposition to depressive illness. The behavioral model states that the cause of depression is in the person-behavior-environment interaction. Although people are seen as capable of exercising control over their behavior, they are not totally free of environmental influence.
Biological
A family history of major affective disorders may exist in individuals with depressive disorders. Recently it has been found that the disease has a genetic marker, as shown by numerous studies that support the involvement of heredity in depressive illness.
Biochemical factors (e.g., electrolyte imbalances) appear to play a role in depressive illness. An error in metabolism results in the transposition of sodium and potassium within the neuron. Another theory implicates the biogenic amines norepinephrine, dopamine, and serotonin. The levels of these chemicals are deficient in individuals with depressive disorders. Controversy remains as to whether these biochemical changes cause the depression or whether they are caused by the illness. In recent years, a common form of major depression called seasonal affective disorder (SAD) has been identified. Recurring each year, starting in fall or winter and ending in spring, the symptoms are largely typical of depression, with some atypical symptoms (excessive sleep, increased appetite, and weight gain). This disorder is believed to be caused by the decreased availability of sunlight and is related to circadian cycles, which are set by each individual’s internal biological clock. Circadian cycles are more precisely adjusted and coordinated by the alternation of darkness and light.
Impaired seratonergic transmission has also been investigated as a cause of depression (indolamine hypothesis). It has been shown that multiple regions of the brain in depressed clients lack metabolic responsivity, suggesting a generalized subresponsivity of the serotonergic system. Additionally, current research suggests that infection with the Borna disease virus (BDV) may be linked to some cases of major depression and other severe mood disorders.
Family Dynamics
Object loss theory suggests that depressive illness occurs if the person is separated from or abandoned by a significant other during the first 6 months of life. The bonding process is thereby interrupted, and the child withdraws from people and the environment.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
Fatigue, malaise, decreased energy level, lethargy
Sleep disturbances (e.g., insomnia) occur in 90% of cases—either anxiety insomnia (with difficulty falling asleep) or depressive insomnia (with early morning awakening, accompanied by painful ruminations); also hypersomnia (with restlessness and feeling unrefreshed, particularly in SAD)
May report feeling best early in the morning, then continually feeling worse as the day progresses (dysthymia); or the opposite may be true (especially in severe depression)
Ego Integrity
Feelings of worthlessness: self-derogatory statements, expressions of guilt, or exaggeration of minor inadequacies; may assume delusional proportions with presentations of unrealistic evidence of self-worth/intense focus on self (e.g., feeling oneself responsible for major tragedies and catastrophes or persecuted for a failure)
Morbid sadness; actual loss or life stressor perceived as a loss (e.g., retirement, job loss, divorce, illness, aging); may or may not see connection between perceived losses and onset of depression
Feelings of helplessness, hopelessness, powerlessness, pessimism, irritability, excessive anger
Elimination
Constipation and urinary retention may be present
Food/Fluid
Decreased/increased appetite accompanied by significant change in weight (average gain of 10 pounds in SAD)
Hygiene
Inattention to personal care needs, unkempt appearance
Possible body odor
Posture may be bent/slouched (defeated-looking)
Neurosensory
Dejected or sad mood, with loss of interest/enjoyment in usual activities
Depressed mood for most of day, for more days than not, for at least 2 years (dysthymia), or with intermittent symptom-free periods, for at least 2 months (recurrent)
Expressed sadness, dejection, not caring about anything, not seeing any future for self; tending to sigh and be tearful
Irritability, headache
Psychotic features with prominent delusions and/or hallucinations (major depression)
Psychomotor Retardation: May present either a “slow motion” picture, with slowed speech and latencies (long pauses before responding), decreased amount of speech, and slowed body movements; or agitation, featuring constant, rapid, purposeless movements (severe depression)
Thinking characterized by poor concentration and decreased memory, indecision, suicidal ideation
Safety
Thoughts of suicide/wanting to die possibly occurring frequently throughout the illness; may range in severity from indifference about the consequences of behavior (e.g., lack of cooperation with medical treatment, or dangerous driving), to wishing it were “over” or for death, to specific suicide plans and attempts
Sexuality
Disinterest in sexual activities, and/or impotence
Women affected almost twice as often as men, primarily during the childbearing years of late 20s to early 30s and again in the postmenopausal years of late 40s to early 50s
Social Interactions
Participation diminished, difficulty starting activities, withdrawal (e.g., housebound or remains in a single room/bed)
Teaching/Learning
Family history of depression; high rates of alcoholism/other drug abuse
DIAGNOSTIC STUDIES
(The several biochemical alterations in depression are not, by themselves, indicative of depression but, combined with clinical observation, may indicate best pharmacological response.)
Thyroid-Stimulating Hormone Response to Thyrotropin-Releasing Hormone: Decreased level suggests depression.
Dexamethasone-Suppression Test (DST) (an indirect marker of melancholia): Postdexamethasone cortisol levels exceeding 5 g/dl indicate abnormal/positive result and can be used to predict effectiveness of antidepressants.
EEG Sleep Profile: This shows reduced latency of rapid eye movement (REM) sleep.
CBC, Blood Glucose, Electrolytes, Renal/Liver Function Tests: These identify abnormalities contributing to or resulting from depression.
Other medical tests that may be included:
Platelet Monoamine Oxidase Activity (MAO): Increased.
Biogenic Amines (Especially Norepinephrine and Serotonin Levels): Decreased (clients with low serotonin levels are 10 times more likely to commit suicide within a year).
a-Acid Glycoprotein: Inhibitor of serotonin transporter is elevated.
Urinary 3-Methoxy-4-Hydroxyphenylglycol (MHPG): If low, indicates decreased norepinephrine output.
Cerebrospinal Fluid Level of 5-Hydroxytryptamine (5HIAA): Reduced.
Minnesota Multiphasic Personality Inventory (MMPI): Scale 2 consistently
elevated.
Wechsler Adult Intelligence Scale-Revised (WAIS-R): Overall performance score significantly lower than verbal score.
Rorschach Test: Long reaction times, chromatic color responses diminished.
Thematic Apperception Test (TAT): Short, stereotyped responses/simple descriptions of cards.
Zung (or Similar) Depressive Scale (ADS): Self-report reflecting affective, psychic, somatic characteristics of depression.
NURSING PRIORITIES
1. Promote physical safety with special focus on suicide prevention.
2. Provide for client’s basic needs, promoting highest possible level of independent functioning.
3. Provide experience/interactions that enhance self-esteem, sense of personal power.
4. Support client/family participation in follow-up care/community treatment.
5. Provide information about condition, prognosis, and treatment needs.
DISCHARGE GOALS
1. Suicidal ideation/self-violent behaviors absent.
2. Physiological stability achieved with responsibility for self demonstrated.
3. Client expressing feelings appropriately with some optimism and hope for the future.
4. Client/family participating in follow-up care/community treatment.
5. Condition, prognosis, and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.
DSM-IV
DEPRESSIVE DISORDERS
296.xx Major depressive disorder
296.2x Single episode
296.3x Recurrent
300.4 Dysthymic disorder
311 Depressive disorder NOS
A disturbance of mood, characterized by a full or partial depressive syndrome, or loss of interest or pleasure in usual activities and pastimes with evidence of interference in social/occupational functioning.
ETIOLOGICAL THEORIES
Psychodynamics
Psychoanalytical theory focuses on an early unsatisfactory parent/child relationship, with an unresolved grieving process. This results in the individual remaining fixed in the anger stage of the grieving process and turning it inward on the self. The ego remains weak, while the superego expands and becomes punitive.
Cognitive theory projects a belief that depression occurs as a result of impaired cognition, fostering a negative evaluation of self through disturbed thought processes. The individual is pessimistic and views self as inadequate and worthless and life as hopeless.
Learning theorists propose that depressive illness arises out of the individual’s having experienced numerous failures (either real or perceived). A feeling of inability to succeed at any endeavor ensues. This “learned helplessness” is viewed as a predisposition to depressive illness. The behavioral model states that the cause of depression is in the person-behavior-environment interaction. Although people are seen as capable of exercising control over their behavior, they are not totally free of environmental influence.
Biological
A family history of major affective disorders may exist in individuals with depressive disorders. Recently it has been found that the disease has a genetic marker, as shown by numerous studies that support the involvement of heredity in depressive illness.
Biochemical factors (e.g., electrolyte imbalances) appear to play a role in depressive illness. An error in metabolism results in the transposition of sodium and potassium within the neuron. Another theory implicates the biogenic amines norepinephrine, dopamine, and serotonin. The levels of these chemicals are deficient in individuals with depressive disorders. Controversy remains as to whether these biochemical changes cause the depression or whether they are caused by the illness. In recent years, a common form of major depression called seasonal affective disorder (SAD) has been identified. Recurring each year, starting in fall or winter and ending in spring, the symptoms are largely typical of depression, with some atypical symptoms (excessive sleep, increased appetite, and weight gain). This disorder is believed to be caused by the decreased availability of sunlight and is related to circadian cycles, which are set by each individual’s internal biological clock. Circadian cycles are more precisely adjusted and coordinated by the alternation of darkness and light.
Impaired seratonergic transmission has also been investigated as a cause of depression (indolamine hypothesis). It has been shown that multiple regions of the brain in depressed clients lack metabolic responsivity, suggesting a generalized subresponsivity of the serotonergic system. Additionally, current research suggests that infection with the Borna disease virus (BDV) may be linked to some cases of major depression and other severe mood disorders.
Family Dynamics
Object loss theory suggests that depressive illness occurs if the person is separated from or abandoned by a significant other during the first 6 months of life. The bonding process is thereby interrupted, and the child withdraws from people and the environment.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
Fatigue, malaise, decreased energy level, lethargy
Sleep disturbances (e.g., insomnia) occur in 90% of cases—either anxiety insomnia (with difficulty falling asleep) or depressive insomnia (with early morning awakening, accompanied by painful ruminations); also hypersomnia (with restlessness and feeling unrefreshed, particularly in SAD)
May report feeling best early in the morning, then continually feeling worse as the day progresses (dysthymia); or the opposite may be true (especially in severe depression)
Ego Integrity
Feelings of worthlessness: self-derogatory statements, expressions of guilt, or exaggeration of minor inadequacies; may assume delusional proportions with presentations of unrealistic evidence of self-worth/intense focus on self (e.g., feeling oneself responsible for major tragedies and catastrophes or persecuted for a failure)
Morbid sadness; actual loss or life stressor perceived as a loss (e.g., retirement, job loss, divorce, illness, aging); may or may not see connection between perceived losses and onset of depression
Feelings of helplessness, hopelessness, powerlessness, pessimism, irritability, excessive anger
Elimination
Constipation and urinary retention may be present
Food/Fluid
Decreased/increased appetite accompanied by significant change in weight (average gain of 10 pounds in SAD)
Hygiene
Inattention to personal care needs, unkempt appearance
Possible body odor
Posture may be bent/slouched (defeated-looking)
Neurosensory
Dejected or sad mood, with loss of interest/enjoyment in usual activities
Depressed mood for most of day, for more days than not, for at least 2 years (dysthymia), or with intermittent symptom-free periods, for at least 2 months (recurrent)
Expressed sadness, dejection, not caring about anything, not seeing any future for self; tending to sigh and be tearful
Irritability, headache
Psychotic features with prominent delusions and/or hallucinations (major depression)
Psychomotor Retardation: May present either a “slow motion” picture, with slowed speech and latencies (long pauses before responding), decreased amount of speech, and slowed body movements; or agitation, featuring constant, rapid, purposeless movements (severe depression)
Thinking characterized by poor concentration and decreased memory, indecision, suicidal ideation
Safety
Thoughts of suicide/wanting to die possibly occurring frequently throughout the illness; may range in severity from indifference about the consequences of behavior (e.g., lack of cooperation with medical treatment, or dangerous driving), to wishing it were “over” or for death, to specific suicide plans and attempts
Sexuality
Disinterest in sexual activities, and/or impotence
Women affected almost twice as often as men, primarily during the childbearing years of late 20s to early 30s and again in the postmenopausal years of late 40s to early 50s
Social Interactions
Participation diminished, difficulty starting activities, withdrawal (e.g., housebound or remains in a single room/bed)
Teaching/Learning
Family history of depression; high rates of alcoholism/other drug abuse
DIAGNOSTIC STUDIES
(The several biochemical alterations in depression are not, by themselves, indicative of depression but, combined with clinical observation, may indicate best pharmacological response.)
Thyroid-Stimulating Hormone Response to Thyrotropin-Releasing Hormone: Decreased level suggests depression.
Dexamethasone-Suppression Test (DST) (an indirect marker of melancholia): Postdexamethasone cortisol levels exceeding 5 g/dl indicate abnormal/positive result and can be used to predict effectiveness of antidepressants.
EEG Sleep Profile: This shows reduced latency of rapid eye movement (REM) sleep.
CBC, Blood Glucose, Electrolytes, Renal/Liver Function Tests: These identify abnormalities contributing to or resulting from depression.
Other medical tests that may be included:
Platelet Monoamine Oxidase Activity (MAO): Increased.
Biogenic Amines (Especially Norepinephrine and Serotonin Levels): Decreased (clients with low serotonin levels are 10 times more likely to commit suicide within a year).
a-Acid Glycoprotein: Inhibitor of serotonin transporter is elevated.
Urinary 3-Methoxy-4-Hydroxyphenylglycol (MHPG): If low, indicates decreased norepinephrine output.
Cerebrospinal Fluid Level of 5-Hydroxytryptamine (5HIAA): Reduced.
Minnesota Multiphasic Personality Inventory (MMPI): Scale 2 consistently
elevated.
Wechsler Adult Intelligence Scale-Revised (WAIS-R): Overall performance score significantly lower than verbal score.
Rorschach Test: Long reaction times, chromatic color responses diminished.
Thematic Apperception Test (TAT): Short, stereotyped responses/simple descriptions of cards.
Zung (or Similar) Depressive Scale (ADS): Self-report reflecting affective, psychic, somatic characteristics of depression.
NURSING PRIORITIES
1. Promote physical safety with special focus on suicide prevention.
2. Provide for client’s basic needs, promoting highest possible level of independent functioning.
3. Provide experience/interactions that enhance self-esteem, sense of personal power.
4. Support client/family participation in follow-up care/community treatment.
5. Provide information about condition, prognosis, and treatment needs.
DISCHARGE GOALS
1. Suicidal ideation/self-violent behaviors absent.
2. Physiological stability achieved with responsibility for self demonstrated.
3. Client expressing feelings appropriately with some optimism and hope for the future.
4. Client/family participating in follow-up care/community treatment.
5. Condition, prognosis, and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.
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