( Topic: Depression 1

Depression
By m. Zubair Khan
Lecturer Kmu
Depression

Everyone occasionally feels blue or sad, but these feelings are usually fleeting (short live)
and pass within a couple of days. When a person has a depressive disorder, it interferes
with daily life, normal functioning, and causes pain for both the person with the disorder
and those who care about him or her. Depression is a common but serious illness, and
most who experience it need treatment to get better.

Race: Depression is less common in the black population.

Sex: MDD is diagnosed more commonly in women, with a prevalence twice that
observed in men. In pre-pubertal children, boys and gin's are affected equally.

Different forms of depression

There are several forms of depressive disorders. The most common are major depressive
disorder and dysthymic disorder.

Major depressive disorder:

It is also called major depression, is characterized by a combination of symptoms that

interfere with a person's ability to work, sleep, study, eat, and enjoy one’s-pleasurable
activities. Major depression is disabling and prevents a person from functioning normally.
An episode of major depression may occur only once in a person's lifetime, but more
often, it recurs throughout a person's life. They call the more severe, short-lasting type
major depression.

Dysthymic disorder

It is also called dysthymia, is characterized by long-term (two years or longer) but less
severe symptoms that may not disable a person but can prevent one from functioning
normally or feeling well/ People with dysthymia may also experience one or more
episodes of major depression during their lifetimes

Psychotic depression:

This occurs when a severe depressive illness is accompanied by some form of psychosis,
such as a break with reality, hallucinations, and delusions.

Postpartum depression,

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This is diagnosed if a new mother develops a major depressive episode within one month
after delivery. It is estimated that 10 to 15 percent of women experience postpartum
depression after giving birth.

Seasonal affective disorder (SAD):

This is characterized by the onset of a depressive illness during the winter months, when
there is less natural sunlight. The depression generally lifts during spring and summer

Bipolar disorder

It is also called manic-depressive illness, is not as common as major depression or

dysthymia. Bipolar disorder is characterized by cycling mood changes-from extreme
highs (e.g., mania) to extreme lows (e.g., depression).
Depression incusions in DSM 5:
Grief:
Dominant affect is feelings of emptiness and loss
Dysphoria occurs in waves, vacillates with exposure to reminders and decreases with
time
Capacity for positive emotional experiences
Self-esteem preserved
Fleeting thoughts of joining deceased
Major Depression
Dominant affect is depressed mood
Persistent dysphoria that is accompanied by self-critical preoccupation and negative
thoughts about the future
Limited capacity to experience happiness or pleasure
Worthlessness clouds esteem
Suicidal ideas about escaping life versus joining a loved one
Disruptive mood dysregulation disorder:
Essential feature: Severe temper outbursts with underlying persistent angry or irritable
mood
– Temper outburst frequency: Three or more time a week
– Duration: Temper outbursts and the persistently irritable
mood between outbursts lasts at least 12 months
– Severity: Present in two settings and severe in at least one
– Onset: Before age 10 but do not diagnose before age 6. Can not diagnose for the first
time after age 18.
– Common rule-outs:
Bipolar disorder, intermittent explosive disorder, depressive disorder, ADHD, ASD,
separation anxiety disorder
Persistant depressive disorder: (formerly dysthymia)

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Essential feature: Depressed mood plus at least two other depressive symptoms
• Duration: The symptoms persist for at least two years (one year for children and
adolescents)
• May include periods of major depressive episodes (double depression)
• Rule outs: Be sure it is not due to another psychotic disorder, substance, medication or
medical condition

Premenstrual dysphoric disorder: (PMDD):

Essential feature: Significant affective symptoms that emerge in the week prior to menses
and quickly disappear with the onset of menses
Symptom threshold: At least five symptoms which include marked affective lability,
depressed mood, irritability, or tension
Duration: Present in all menstrual cycles in the past year and documented prospectively
for two menstrual cycles
Impairment: Clinically significant distress or impairment
Rule outs: An existing mental disorder (e.g., MDD), another medical condition (e.g.,
migraines that worsen during the premenstrual phase) or substance or medication use

Cause for depression

There is no single cause for depression. Many factors play a role including genetics,
environment, life events, medical conditions, and the way people react to things that
happen in their lives.

Genetics

Research shows that depression runs in families and that some people inherit (comes
into) genes that make it more likely for them to get depressed. Not everyone who has the
genetic makeup (structure) for depression gets depressed, though. And many people who
have no family history of depression have the condition. So although genes are one
factor, they aren't the single cause of depression

Life Events

The death of a family member, friend, or pet can go beyond normal grief (sorrow) and
sometimes lead to depression. Other difficult life events, such as when parents divorce,
separate, or remarry, can trigger depression. Even events like moving or changing schools
can be emotionally challenging enough that a person becomes depressed.

Family and Social Environment

For some people, a negative, stressful, or unhappy family atmosphere can affect their
self-esteem and lead to depression. This can also include high-stress living situations such
as poverty; homelessness; and violence in the family, relationships, or community.

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Substance use and abuse:

It also can cause chemical changes in the brain that affect mood — alcohol and some
drugs are known to have depressant effects. The negative social and personal
consequences of substance abuse also can lead to severe unhappiness and depression.

Medical Conditions

Certain medical conditions can affect hormone balance and therefore have an effect on
mood. Some conditions, such as hypothyroidism, are known to cause a depressed mood
in some people.

Illnesses often co-exist with depression

Depression often co-exists with other Illnesses. Such illnesses may precede (lead) the
depression, causes It, and/or be a consequence of It. It is likely that the mechanics behind
the intersection (junction) of depression and other Illnesses differ for every person and
situation. Regardless, these other co-occurring illnesses need to be diagnosed and treated.

Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive

disorder, panic disorder, social phobia and generalized anxiety disorder, often accompany
depression. People experiencing PTSD are especially prone to having co-occurring
depression.

Alcohol and other substance abuse or dependence may also co-occur with depression. In
fact, research has indicated that the co-existence of mood disorders and substance abuse
is pervasive among the U.S population.

Depression also often co-exists with other serious medical illnesses such as heart disease,
stroke, cancer, HIV/aids, diabetes, and Parkinson's disease. Studies have shown that
people who have depression in addition to another serious medical illness tend to have
more severe symptoms of both depression and the medical illness, more difficulty
adapting to their medical condition, and more medical costs than those who do not have
co-existing depression. Research has yielded increasing evidence that treating the
depression can also help improve the outcome of treating the co-occurring illness.

Pathophysiology;

Research indicates that depressive illnesses are disorders of the brain. Brain-imaging
technologies, such as magnetic resonance imaging (MRI). Have shown that the brains of
people who have depression look different than those of people without depression. The
parts of the brain responsible for regulating mood, thinking, sleep, appetite and behavior
appear to function abnormally. In addition, important neurotransmitters-chemicals that
brain cells use to communicate-appear to be out of balance.

Symptoms of Depression

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 People with depressive illnesses do not all experience the same symptoms. The
severity, frequency and duration of symptoms will vary depending on the Individual
and his or her particular Illness,
 Persistent sad, anxious or "empty" feelings
 Feelings of hopelessness and/or pessimism (distrust)
 Feelings of guilt, worthlessness (un-importance) and/or helplessness
 Irritability, restlessness
 Loss of Interest In activities or hobbles once pleasurable. Including sex
 Fatigue and decreased energy
 Difficulty concentrating, remembering details and making decisions
 Insomnia, early-morning wakeful ness, or excessive sleeping
 Overeating or appetite loss
 Thoughts of suicide, suicide attempts
 Persistent aches or pains, headaches, cramps or digestive, problems that do not ease
even with treatment

Diagnostic evaluation

 Lab Studies
No diagnostic laboratory tests are available for diagnosis of MOD. Based on the
clinical history and physical findings, focused laboratory studies are useful in
excluding potential medical illnesses that may present as MOD.

 CT scan or MRI of the brain

 EEG
 Lumbar puncture for VDRL, Lyme antibody, cell count, chemistry, and protein
electrophoresis

Medical Treatment:

 Antidepressants work to normalize naturally occurring brain chemicals called

neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work
on the neurotransmitter dopamine. Scientists studying depression have found that
these particular chemicals are involved in regulating mood, but they are unsure of the
exact ways in which they work.

 Tile newest and most popular types of anti-depressant medications are called selective
serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), citalopram
(Celexa), sertraline (Zoloft) and several others. Serotonin and norepinephrine re
uptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and
duloxetine (Cymbalta). SSRIs and SNRIs are more popular than the older classes of
antidepressants, such as Tricyclic-named for their chemical structure-and monoarnine
oxidase inhibitors (MAOIs) because they tend to have fewer side affects. However,

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medications affect everyone differently-no one-size-fits-all approach to medication

exists therefore, for some people, Tricyclic or MAOIs may be the best choice.

 Sometimes stimulants, anti-anxiety medications, or other medications are used in

conjunction with an antidepressant, especially if the patient has a co-existing menial
or physical disorder. However, neither anti-anxiety medications nor stimulants are
effective against depression when taken alone, and both should be taken only under a
doctor's close supervision.

Nursing consideration

For all classes of antidepressants, patients must take regular doses for at least three to
four weeks before they are likely to experience a full therapeutic effect. They should
continue taking the medication for the time specified by their doctor, even if they are
feeling better, in order to prevent a relapse (deterioration) of the depression. Medication
should be stopped only under a doctor's supervision. Some medications need to be
gradually stopped to give the body time to adjust. Although antidepressants are not habit-
forming or addictive, abruptly (suddenly) ending an antidepressant can cause withdrawal
symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent
depression, may need to stay on the medication indefinitely. (for indefinite period)

Side effects of medication

 The most common side effects associated with SSRIS and SNRIs include:
 Headache-usually temporary and will subside.
 Nausea-temporary and usually short-lived
 Insomnia and nervousness (trouble falling asleep or waking often during the night)-
may occur during the first few weeks out often subside over time or it the dose is
reduced.
 Agitation (feeling jittery (nervous)).
 Sexual problems-both men and women can experience sexual problems including
reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an
orgasm.
 Tricyclic antidepressant also can cause side effects Including:
 Dry mouth-it is helpful to drink plenty of water, chew gum, and dean teeth dally.
 Constipation-It Is helpful to eat mote bran cereals, prunes, fruits, and vegetables.
 Bladder problems-emptying the bladder may be difficult, and the urine stream may
not be as strong as usual. Older men with enlarged prostate conditions may be more
affected. The doctor should be notified if it is painful to urinate.
 Sexual problems-sexual functioning may change and side effects are similar to those
from SSRIs.
 Blurred vision-often passes soon and usually will not require a new corrective lenses
prescription.
 Drowsiness during the day-usually passes soon, but driving or operating heavy
machinery should be avoided while drowsiness occurs. The more sedating

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antidepressants are generally taken at bedtime to help sleep and minimize daytime
drowsiness.

Diet

Dietary restrictions are necessary only when prescribing MAOIs. Foods high in tyramine,
which can produce a hypertensive crisis in the presence of MAOIs, should be avoided
These foods include soy sauce, sauerkraut, aged chicken or beef liver, aged cheese, faya
beans, air-dried sausage and similar meats, pickled or cured meat or fish, overripe fruit,
canned figs, raisins, avocados, yogurt, sour cream, meat tenderizer, yeast extracts, caviar,
and shrimp paste. Beer and wine also should be avoided.

Activity

Physical activity and exercise contribute to recovery from MOD. Patients should be
counseled regarding stress reduction.

Psychotherapy

Several types of psychotherapy-or "talk therapy"-can help people with depression.

Electroconvulsive Therapy

For cases in which medication and/or psychotherapy does not help alleviate a person's
treatment-resistant depression, electroconvulsive therapy (ECT) may be useful.

Nursing Diagnosis

Hopelessness, related to long-term stress

Powerlessness, related to lack of ability to exert control.
Self-care deficit, related to lack of concern
Sleep pattern disturbance related to internal stress

Complications

Medical:

Completed suicides number more than 30,000 per year in the United States. Other
adverse outcomes may arise from attempts at self-injury, untreated medical conditions, or
physical decline due to inanition. Medical and surgical prognosis and recovery also are
affected adversely by concurrent MOD.

Psychosocial:

MOD, particularly when chronic or untreated, can contribute to unemployment or failure

in school, social isolation, substance abuse, and marital/family dysfunction.

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Prognosis

With appropriate treatment 70-80% of individuals with MOD can achieve a significant
reduction in symptoms, although as many as 50% of patients may not respond to the
initial treatment trial.
Untreated at 1 year, 40% of individuals with MOD will continue to meet criteria for the
diagnosis, while an additional 20% will have a partial remission. Partial remission and/or
a history of chronic MOD are risk factors for recurrent episodes and treatment resistance.

Patient Education

Education plays an important role in the successful treatment of MOD Patients should be
aware of the rationale behind the choice of treatment, potential adverse effects, and
expected results. The involvement of the patient in the treatment plan can enhance
medication compliance and referral to counseling. Over the long term, patients also may
become aware of signs of relapse and may seek treatment early.

For excellent patient education resources, visit eMedicine's Depression Center. Also, see
eMedicine's patient education Article Depression.

Conclusion

Depression doesn't mean a person is "crazy." Depression (and the suffering that goes with
it) is a real and recognized medical problem. Just as things can go wrong in all other
organs of the body, things can go wrong in the most important organ of all: the brain.
Luckily, most people who get help for their depression go on to enjoy life and feel better
about them

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The END

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