Patan Academy of Health Sciences

School of Nursing and Midwifery

Lalitpur Nursing Campus
Sanepa, Lalitpur

Presentation on
DEPRESSION

Submitted to: Submitted by:

Respected Madam, Isha Bhusal
Associate professor Jagriti Thapa
Shova Laxmi Bajracharya MN 1st Year
 DEPRESSION

Mood/Mood disorder-
Introduction
Mood is a pervasive and sustained feeling tone that is experienced internally and that influences
a person’s behavior and perception of the world. Mood can be normal, elevated or depressed.
Affect is the external, behavioral expression of mood. It may be appropriate, inappropriate, blunt
and flat.

ICD-10 - Depressive episode

F32 Depressive episode
F32.0Mild depressive episode
F32.1 Moderate depressive episode
F32.2 Severe depressive episode without psychotic symptoms
F32.3 Severe depressive episode with psychotic symptoms
F32.8 Other depressive episodes
F32.9 Depressive episode, unspecified
F33 Recurrent depressive disorder

Depression - Introduction
The term depression was derived from Latin verb deprimere, "to press down". From the
14th century, "to depress" meant to subjugate or to bring down in spirits. An alteration in mood
expressed by feelings of emotional sadness, despair, and pessimism.
A very common, highly treatable, and oldest psychiatric illness that affects physical, mental and
emotional well-being./everyday activities as affects how people think about things and feel about
themselves.

Definition
Major depressive disorder (MDD) (also known as clinical depression, major depression, unipolar
depression, unipolar disorder or recurrent depression) is a mental disorder characterized by
episodes of all-encompassing low mood accompanied by low self-esteem and loss of interest or
pleasure in normally enjoyable activities that persists for at least two weeks.
It is a disabling condition that adversely affects a person's family, work or school life, sleeping
and eating habits, and general health.

Prevalence
Depression is a common mental disorder. Globally, more than 264 million people of all ages
suffer from depression. Depression is a leading cause of disability worldwide and is a major
contributor to the overall global burden of disease. More women are affected by depression than
men. At its worst, depression can lead to suicide. Close to 8,00,000 people die due to suicide
every year. Suicide is the second leading cause of death in 15-29-year-olds. (WHO Fact Sheet)
The lifetime risk for major depression is 7% to 12% for men and 20% to 30% for women.
Among women, rates peak between adolescence and early adulthood. (Stuart GW,2013)
Epidemiology of Depression in adolescence
Major depression affects approximately 4% to 8% of adolescents. Within 5 years of the onset
of major depression, 70% of depressed youths will experience a recurrence. Depression in
young people often co-occurs with other mental disorders, most often anxiety, disruptive
behavior, or substance use disorders. As many as 5% to 10% of adolescents will complete
suicide within 15 years of their initial episode of major depression. Although adolescent
depression is twice as common among girls as boys, between the ages of 15 and 19 years, the
male suicide rate is five times that of the female rate.

Epidemiology of Depression in Elderly

Unipolar depression occurs in 7% of the general older population and it accounts for 5.7%
among those over 60 years old. (2017,WHO)

Risk factor
Gender:
 Common in women, (Pregnancy and new motherhood are at high risk). While depression is
the leading cause of disability for both males and females, the burden is 50% higher for
females than males (WHO,2008).
 Economic disadvantages, that is, poverty.
 Social disadvantages, such as low education.
 Genetics: If someone in the family has this disorder, two to three times more likely to
develop depression at some point in the life.
 Exposure to violence
 Being separated or divorced
 Other chronic illness: with neurological, cardiovascular conditions such as stroke,
Parkinson's disease, or multiple sclerosis, cancer

Types of Depression
A. Major depressive disorder:
This (unipolar depression) requires at least 2 weeks of depression/loss of interest and 4 additional
depressive symptoms, with one or more major depressive episodes.

The following specifiers may be used to further describe the depressive episode:
Single Episode or Recurrent: This specifier identifies whether the individual has
experienced prior episodes of depression.
Mild, Moderate, or Severe: These categories are identified by the number and severity of
symptoms.
With or Without Psychotic Features:
Impairment of reality testing is evident. The individual experiences hallucinations and/or
delusions.
With Catatonic Features: This category identifies the presence of psychomotor
disturbances, such as severe psychomotor retardation, with or without the presence of waxy
flexibility or stupor or excessive motor activity.
Waxy Flexibility
With Melancholic Features:
This is a typically severe form of major depressive episode. Symptoms are exaggerated.
extreme despair and guilt. There is a loss of interest in all activities. Depression is regularly
 worse in the morning.
Chronic: This classification applies when the current episode of depressed mood has been
evident continuously for at least the past 2 years.
With Seasonal Pattern
This diagnosis indicates the presence of depressive symptoms during the fall or winter
months. This disorder has previously been identified in the literature as seasonal affective
disorder (SAD).
With Postpartum Onset: This specifier is used when symptoms of major depression occur
within 4 weeks postpartum.

B. Dysthymic disorder:
A mood disturbance with characteristics similar to, if somewhat milder than, those ascribed to
major depressive disorder. There is no evidence of psychotic symptoms.

Diagnostic Criteria
According to DSM-V-TR a major depressive disorder occurs without a history of manic, mixed
or hypomanic episode and must last at least 2 weeks.

A. At least five (or more) of the following symptoms have been present during the same 2 week
period and represent a change from previous functioning; at least one of the symptoms is either;
depressed mood or loss of interest or pleasure

Others are:
changes in appetite and weight,
changes in sleep
psychomotor retardation
changes in activity, lack of energy/fatigue,
feeling of guilt, worthlessness
problems thinking and making decisions,
Recurrent thoughts of death or suicide.

Note: Following Is A Mnemonic For Easy Recall And Review Of The DSM-IV Criteria
For Major Depression Or Dysthymia (SIGECAPS):
Sleep (increase/decrease)
Interest (diminished)
Guilt/low self esteem
Energy (poor/low)
Concentration / attention (poor)
Appetite (increase/decrease)
Psychomotor (agitation/retardation)
Suicidal ideation

Diagnostic Classification of Depression (ICD: 10)

The following symptoms should have been present during the 2-week period:
 A. Cardinal Symptoms
1. Depressed mood to a degree that is definitely abnormal for the individual, present for most of
the day and almost every day, largely uninfluenced by circumstances, and sustained for at least
2 weeks (persistent and consistent);
2. Loss of interest or pleasure
3. Decreased energy or increased fatigability

B. Additional Symptoms
1. Reduced confidence or self-esteem
2. Reduced concentration:
3. Ideas of guilt and unworthiness: Unreasonable feeling of self-reproach
4. Pessimistic thoughts
5. Ideas of self-harm: Recurrent thoughts of death or suicide, or any suicidal behavior
6. Disturbed sleep
7. Diminished appetite:

C. Psychotic Features
1.Delusion
 Nihilistic delusion
 Delusion of guilt
 Delusion of control
 Delusions of poverty
2. Hallucination (Mood congruent)

D. Somatic Syndrome
 Waking in the morning 2 hours or more before the usual time
 Depression worse in the morning
 Objective evidence of marked psychomotor retardation or agitation (remarked on or reported
by other people)
 Marked loss of appetite
 Weight loss (5% more of body weight in the past month)
 Marked loss of libido

Types of depression, according to diagnostic features of ICD 10

Criteria for diagnosis Mild Moderate Severe depression
depression depression
A 1. Depressed mood At least 2 of At least 2 of At least 3 of “Cardinal signs”
(Cardinal 2. Loss of interest or “Cardinal “Cardinal
signs) pleasure signs” signs”
3. Decreased energy or
increased fatigability
B 1. Reduced confidence or At least 2 of At least 4 of At least 4 of “Additional
(Additional self-esteem “Additional “Additional symptoms”
symptoms) 2. Reduced concentration: symptoms” symptoms” (somatic s/s usually present,
3. Ideas of guilt and psychotic s/s like delusion,
 unworthiness: hallucination, depressive
Unreasonable feeling of stupor might be present.)
self-reproach
4. Pessimistic thoughts
5. Ideas of self-harm:
Recurrent thoughts of
death or suicide, or any
suicidal behavior
6. Disturbed sleep
7. Diminished appetite

C Duration At least of 2 At least of 2 At least of 2 weeks or less if

weeks weeks the symptoms are particularly
severe intensity requiring
hospitalization.
D Daily activities and social Some Considerable Unlikely to perform except to
activities difficulty in difficulty in a very limited extent.
performance performance
and usually
distressed by
symptoms

▪ Mild depression: 4 s/s (2cs+2as), continue most activities

▪ Moderate depression: 6 s/s (2cs+4as), difficulties to continue activities
▪ Severe depression: 7 s/s (3cs+4as), unlikely can function, somatic s/s usually present,
psychotic s/s might present
(cs: Cardinal signs, as: additional symptoms)

Causes of Depression

Biological
Causes of Depression
❖ Biological
❖ Physiological
❖ Psychosocial

❖ Biological
a. Genetic theories
The disorder is 1.5 to 3 times more common among first-degree relatives of individuals (APA,
2000). (Approximately 10-13% risk for first-degree relatives). Monozygotic concordance rate
higher than dizygotic. Studies of identical twins show when one twin is diagnosed with major
depression, the other twin has a greater of 70% chance of developing it. (Townsend MC, 2011)

b. Biochemical:
Research findings suggests that depression results when levels of Norepinephrine and
serotonin decrease and dysregulation of acetylcholine and GABA occurs.

c. Neuroendocrine disturbances:
Elevated levels of serum cortisol and decreased levels of thyroid stimulating hormone have
been associated with depressed mood in some individuals.

❖ Physiological influences
a. Medication side effects:
A number of drugs can produce a depressive syndrome as a side effect. Common ones include
anxiolytics, antipsychotics, and sedative-hypnotics.
Antihypertensive medications such as propranolol and reserpine have been known to produce
depressive symptoms.

b. Medical conditions
With certain disorder such as cardiovascular accident, systemic lupus erythematosus, hepatitis,
diabetes mellitus and brain tumors. Agitated depression may be part of the clinical picture
associated with Alzheimer’s disease, Parkinson’s disease, multiple sclerosis.

c. Electrolyte Disturbances
Excessive levels of sodium bicarbonate, potassium or calcium can produce symptoms of
depression, as can deficits in magnesium and sodium.

d. Hormonal Disturbances
Depression is associated with dysfunction of the adrenal cortex. Other endocrine conditions that
may result in symptoms of depression include hypoparathyroidism, hyperparathyroidism,
hypothyroidism and hyperthyroidism. An imbalance of the hormones estrogen and progesterone
has been implicated in the predisposition to premenstrual dysphoric disorder.

e. Nutritional Deficiencies
Deficiencies in vitamin B1 (thiamine), vitamin B6 (pyridoxine), vitamin B12, niacin, vitamin C,
iron, folic acid, zinc, calcium, and potassium (Schimelpfening, 2009).

❖ Psychosocial Factors

e. Social: Poverty and social isolation are associated with increased risk. Child abuse (physical,
emotional, sexual, or neglect), disturbances in family functioning, severe marital conflict or
divorce, death of a parent, stressful life events connected to social rejection are additional risk
factors.
a. Psychoanalytical:
Freud observed that melancholia occurs after the loss of a loved object. Various aspects of
personality and its development appear to be integral to depression, with negative emotionality
as a common precursor. Also correlated with adverse events, coping mechanism. In addition, low
self-esteem and self-defeating or distorted thinking are related to depression.
Attachment theory: predicts a relationship between depressive disorder in adulthood and the
quality of the earlier bond between the infant and the adult caregiver. In particular, it is thought
that "the experiences of early loss, separation and rejection by the parent or caregiver (conveying
the message that the child is unlovable) may all lead to insecure internal working models.

Social cognitive theory: depressed individuals have negative beliefs about themselves, based on
experiences of failure, observing the failure of social models and their own somatic and
emotional states including tension and stress.

b. Cognitive:
Beck and colleagues (1979) proposed that depressive illness occurs as a result of impaired
cognition, which foster a negative evaluation of self by the individual. Outlook for the future is
one of pessimism and hopelessness. American psychiatrist Aaron T. Beck, He proposed that
three concepts underlie depression: a triad of negative thoughts composed of cognitive errors
about oneself, one's world, and one's future.

c. Learning theory:
This theory (Seligman, 1973) proposes that depressive illness is predisposed by the individual’s
belief that there is a lack of control over his or her life situations. It is thought that this belief
arises out of experiences that result in failure (either perceived or real).

d. Object Loss Theory:

As a result of having been abandoned by, or otherwise separated from, a significant other during
the first 6 months of life. Some researchers suggest that loss in adult life afflicts people much
more severely in the form of depression if the subjects have suffered early childhood loss.

e. Social:
Poverty and social isolation are associated with increased risk. Child abuse (physical, emotional,
sexual, or neglect), disturbances in family functioning, severe marital conflict or divorce, death
of a parent, stressful life events connected to social rejection are additional risk factors.

Diagnosis
 Psychological tests- Beck depression inventory, Hamilton rating scale for depression to
assess severity and prognosis
 Dexamethasone suppression test showing failure to supress cortisol secretions in depressed
patients
 Toxicology screening suggesting drug induced depression
 Based on ICD-10 or DSM-IV-TR criteria

MANAGEMENT
The three most common treatments for depression are psychotherapy, medication and
electroconvulsive therapy.

Anti-Depressants treatment guideline

First episode—Treat for 4-6 month at same dosage then tapper [so total 9 month]; If stopped
quickly—50% cases will have it again.
If two or more episode in recent past & significant functional impairment was seen—treat for 2
years [As continuing the treatment have the absolute risk of depressive relapse] & then
reevaluate.
Of those patient who have 1 episode of major depression, 50-85% will have 2 nd & of these 80-
90% will go to have a third.

Psychopharmacology: antidepressants, anxiolytics

Antidepressant Medications

1. SSRIs (Selective Serotonin Reuptake Inhibitors) —the class of choice for initial therapy
due to effectiveness and lower risk or side effects.
Citalopram: 20-40 mg/day
Escitalopram: 10-20 mg/day
Fluoxetine: 20-80 mg/day
Paroxetine: 10-50 mg/day
Sertraline: 25-200 mg/day

2.SNRIs- Serotonin-Norepinephrine Reuptake Inhibitors

Venlafaxine :75-375 mg/day
Duloxetine: 40-60 mg/day

3. Tricyclic antidepressants
Amitriptyline: 50-300 mg/day
Imipramine: 30-300 mg/day
Nortriptyline :30-100 mg/day
Protriptyline :15-60 mg/day
Trimipramine :50-300 mg/day

4.NaSSAs ( Nor-adrenergic and Specific Serotonergic Antagonists)

Mirtazapine: 15-45 mg/day

5. NorEpinephrine and Dopamine reuptake inhibitors

Bupropion : 200-450 mg/day

6.SARI (Serotonin antagonists and reuptake inhibitors)

Nefazodone : 200-600 mg/day
Trazodone : 150-600 mg/day

7. MAOIs- Mono-amine Oxidase Inhibitors

Phenelzine (Nardil) : 45-90 mg/day
Tranylcypromine (Parnate) : 30-60 mg/day
Isocarboxazid (Marplan) : 25-60 mg/day

Electroconvulsive Therapy
Treatment of choice for psychotic depression, depression refractory to pharmacotherapy,
catatonic depression and for the acutely suicidal.
Patients with recurrent depression will need either prophylactic medication or maintenance ECT.
Side effects include temporary memory loss and confusion.

Other brain stimulation therapies

Other more recently introduced types of brain stimulation therapies used to treat severe
depression; Light therapy and repetitive transcranial magnetic stimulation (rTMS).
These methods are not yet commonly used, but research has suggested it.

Psychotherapy
1.Cognitive behavioral therapy (CBT) currently has the most research evidence for the
treatment of depression in children and adolescents, and CBT and interpersonal psychotherapy
(IPT) are preferred therapies for adolescent depression.

2.Family interventions: Family therapy is used to decrease intrafamilial/interpersonal

difficulties and to reduce or modify stressors, which may help in faster and more complete
recovery.

3.Group interventions/ group therapy: Group therapy is useful for mild to moderate cases of
depression. 

4.Supportive Care
SPEAK approach: Schedule, Pleasurable activities, Exercise, Assertiveness, Kind thoughts
about oneself
Areas the physician can encourage the patient to develop in order to combat depression.
Single drug therapy only effective in 50-60% of patients. Drug therapy should be combined with
supportive psychotherapy, whether with the identifying physician, a referred mental health
specialist, or group therapy. Patient’s morale is improved by provoking, strengthening
expectations of help and hopefulness, realistic goals are set and patient is guided regarding daily
schedule and appointment. Ongoing education and feedback are provided regarding patient’s
illness, prognosis and treatment.

Prognosis
Nearly 40% of depressed with episodic course improve in 3 months, 60% in 6 months & 80%
improve within a period of one year.15-20% of patient develops a chronic course of illness,
which may last for two or more years.
Good prognostic factors are: Acute/abrupt onset, typical clinical features, good response to
treatment.
Poor prognostic factors are:- Slow onset, comorbidity, severe or ongoing chronic stressor, poor
social support & unfavourable environment, or mood incongruent, psychotic features, poor
response to treatment.

Follow-up
Patient should have a minimum of 3 follow-up visits in the first 12 weeks of treatment.
Patients with co-morbidity should also be followed by their doctor even if psychotherapy has
been referred—this improves outcome and decreases patients’ feelings of abandonment. Patient
should be aware that it takes at least 4-6 weeks for antidepressants to start taking effect. If one
drug proves unsuccessful after 4-6 weeks or side effects are unbearable, try switching to a
different class. Once symptoms are controlled, medication should be continued for at least 6
months to prevent relapse. Follow up appointments should be at least every 3-6 months.
Psychotherapy should also be continued, preferably as long as the patient is taking medication.

Application of the nursing process to Depressive Disorder/Nursing Management

Assessment
Assessing the history to determine any previous episodes of depression, treatment, and client’s
response to treatment including the family history of mood disorders, suicide, or attempted
suicide and mental status examination.
▪ General appearance and motor behavior
▪ Mood and affect
▪ Thought process and content
▪ Sensorium and intellectual process
▪ Insight and judgement
▪ Self-concept
▪ Roles and relationship
▪ Physiologic and self-care consideration

Nursing diagnosis
Nursing diagnosis commonly established for the client with depression include the following:
1. Risk for self-directed violence related to feeling of worthlessness.
2. Powerlessness related to dysfunctional grieving process as evidenced by feelings of lack of
control over life situations.
3. Low Self-Esteem related to negative view of self as evidenced by expression of
worthlessness.
4. Imbalanced nutrition: less than body requirements related to lack of appetite as evidenced by
weight loss.
5. Self-Care Deficit related to depressed mood as evidenced by poor personal hygiene.
6. Disturbed Sleep Pattern related to depressive moods and depressive cognitions as evidenced
by difficulty in falling asleep.
7. Impaired Social Interaction related to depressive cognitions as evidenced by unable to
interact with others.

Goals/Outcome
1. The patient will not injure himself or herself.
2. The patient will be able to take control of life situations.
3. The patient will be able to verbalize positive aspects about self and attempt new activities
without fear of failure.
4. The patient will establish a balance of adequate nutrition, hydration, and elimination.
5. The patient will independently carry out activities of daily living (showering, changing
clothing, grooming).
6. The patient will establish a balance of rest, sleep, and activity.
7. The patient will socialize with staff, peers, and family/friends.
8. The patient will return to occupation or school activities.
9. The patient will comply with antidepressant regimen.

Intervention

1. PROVIDING FOR SAFETY

 If a patient has suicidal ideation, measures to provide a safe environment are necessary. If he
has a suicide plan, the nurse asks additional questions to determine the lethality of the intent
and plan.
 Create a safe environment for the patient. Remove all potentially harmful objects, for
example (sharp objects, belts, glass items, alcohol, etc.)
 Do not leave the patient alone. Close observation is required.
 Encourage the patient to express his feelings, including anger.
Suicide assessment
 Have you had thoughts about death or about killing yourself?
 How persistent was the thoughts?
 Have you formulated a plan? What is it?
 Have you actually rehearsed or practiced how you would kill yourself?
 Do you think you would really do it? Have you told anyone?
 Do you tend to be impulsive or can you resist the impulse to do this?
 What have stopped you doing this?
 Have you heard voices telling you to hurt or kill yourself?
 History of previous attempt especially the degree of intent.
 Family history of depression or suicide

2. PROMOTING A THERAPEUTIC RELATIONSHIP

 Patients may be unable to sustain a long interaction, so several shorter visits help the nurse
to assess status and to establish a therapeutic relationship.
 Allow patient to take decisions regarding own care.
 Be accepting of patient and spend time with him, even though pessimism and negativism
may seem objectionable.
 Encourage patient to recognize areas of change and provide assistance toward his effort.
 Teach assertiveness & coping skills.

3. IMPROVING NUTRITIONAL STATUS

 Closely monitor the patient’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 or liquid diet frequently that is nourishing.
 Record the patient’s pattern of bowel elimination.
 Encourage more fluid intake, roughage diet and green leafy vegetables.

4. PROMOTING ACTIVITIES OF DAILY LIVING AND PHYSICAL CARE

▪ Allow patients to participate in their self-care activities. It promotes independence and
provides dynamic assessment data about psychomotor abilities.
▪ Promoting sleep may include the short-term use of a sedative in the evening.
▪ Encourage patient to remain out of bed and active during the day to facilitate sleeping at
night.
▪ It is important to monitor the number of hours patient sleep as well as if they feel refreshed
on awakening.

5. USING THERAPEUTIC COMMUNICATION

▪ Encourage to describe in detail how they are feeling. Sharing the burden with other can
provide some relief.
▪ At these times the nurse can listen attentively, encourage clients, and validate the intensity of
their experience.
▪ As patient begins to improve, the nurse can help them to learn or rediscover more effective
coping strategies such as talking to friends, spending leisure time to relax, taking positive
steps to deal with stressors, and so forth.

6. MANAGING MEDICATIONS
▪ Assess paradoxical suicide risk, ensure they are not saving the medication in attempt to
commit suicide.
▪ At discharge, careful assessment of suicide potential is important.
▪ Management of side effects is important. Patients and family must learn how to manage the
medication regimen.
▪ Education promotes compliance. Clients should know how often they need to return for
monitoring and diagnostic tests.

7. PROVIDING CLIENT AND FAMILY TEACHING

▪ Teach about the illness of depression and its nature.
▪ Teach the patient and family about the benefits of therapy and follow-up appointments.
▪ Teach the action, side effects, and special instructions regarding medication.
▪ Teach about stress-management technique, ways to increase self-esteem.
▪ Teach about support services like support groups, Legal/financial assistance.
 
Evaluation
Evaluation is done based on achievement of individual patient outcomes. It is essential that
clients feel safe and are not experiencing uncontrollable urges to commit suicide. Participation in
therapy and medication compliance produces more favorable outcomes for clients with
depression.

References
● Stuart GW. Principles and Practice of Psychiatric Nursing. 10 th edition. Missouri: Mosby
Publishers; 2013.
● Townsend M C Psychiatric mental health nursing- concepts of care. 5 th edition. Philadelphia:
F.A Dais company; 2011.
● Reddemma S. A guide to mental health and psychiatric nursing. New Delhi: 4 th edition.
Jaypee Brothers: Medical Publishers (P) Ltd;2016.
● Ahuja N. A short textbook of psychiatry.7 th edition. India: Jaypee Brothers Medical
Publishers (P) Ltd; 2011.
● Dailey MW, Saadabadi A. Hypomania Checklist: A systematic review. perspective
psychiatry care. [Internet];2021 [cited April 1]. Available from:
https://pubmed.ncbi.nlm.nih.gov/31066059/
● Sekhon S, Gupta V. What are the types of bipolar disorder? National library of medicine
[Internet];2021 [cited May 1]. Available from: https://pubmed.ncbi.nlm.nih.gov/32644337/
● World Health Organization. [Internet]. 2021. [cited on May 15]. Available from:
https://www.who.int/mental_health/mhgap/evidence/psychosis/q7/en/
● Healthline. [Internet].2021. [cited on May 15]. Available from:
https://www.healthline.com/health/mania#Diagnosis