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Chapter 25: Depressive Disorders Introduction (pg 495) Indy DONE ● Depression is the oldest and one of the most frequently diagnosed psychiatric illnesses. ● Transient symptoms are normal, healthy responses to everyday disappointments in life. ● Pathological depression occurs when adaptation is ineffective and the symptoms are significant enough to impair functioning. ● Mood is also called affect ○ Mood is a pervasive and sustained emotion that may have a profound influence on a person’s perception of the world. Examples include depression, joy, elation, anger and anxiety. ○ Affect is described as the external, observable emotional reaction associated with an experience. A flat affect describes the state of a person who lacks emotional expression and is often seen in severely depressed clients ● Depression is an alteration in mood that is expressed by feelings of sadness, despair, and pessimism. ○ There is a loss of interest in usual activities, and somatic symptoms may be evident. Changes in appetite, sleep patterns, and cognition are common. ● SPEAKER NOTES: ○ Symptoms of depression have been described almost as far back as there is evidence of written documentation. ○ An occasional feeling of sadness or downheartedness is common among healthy people and considered to be a normal response to everyday disappointments in life. Pathological depression occurs when adaptation is ineffective and the symptoms are significant enough to impair functioning. ○ Mood is a pervasive and sustained emotion that may have a major influence on a person’s perception of the world. Examples of mood include depression, joy, elation, anger, and anxiety. Affect is described as the external, observable emotional reaction associated with an experience. A flat affect describes someone who lacks emotional expression and is often seen in severely depressed clients. ○ Depression : An alteration in mood expressed by feelings of sadness, despair, and pessimism. There is a loss of interest in usual activities and somatic symptoms may be evident. Changes in appetite, sleep patterns, and cognition are common Historical Perspectives ● Many ancient cultures believed in the supernatural or divine origin of mood disorders. ● Hippocrates believed that melancholia was caused by an excess of black bile, a heavily toxic substance produced in the spleen or intestine, which affected the brain. ○ Melancholia is a severe form of depressive disorder in which symptoms are exaggerated and interest or pleasure in virtually all activities is lost.

Epidemiology (pg 495) ● Major depressive disorder (MDD) is one of the leading causes of disability in the United States. ● Disability posed by the disorder ● Research links depression to an increased risk for coronary artery disease. ● 6.6 percent of individuals aged 18 years and older had at least one major depressive episode in the past year. ● Age and gender ○ Depression is more prevalent in women than in men by about 2 to 1. ○ Depression is more common in young women than in young men. ○ The gender difference is less pronounced between ages 44 and 65 years, but after age 65, women are again more likely to be depressed than are men. ○ SPEAKER NOTES: ■ Research indicates that the incidence of depressive disorder is higher in women than it is in men by almost 2 to 1. The gender difference is less pronounced between ages 44 and 65, but after the age of 65, women are again more likely to be depressed than men. The construction of gender stereotypes, or gender socialization, promotes typical female characteristics, such as helplessness, passivity, and emotionality, which are associated with depression. In contrast, some studies have suggested that “masculine” characteristics are associated with higher self-esteem and less depression. ● Social class ○ There is an inverse relationship between social class and report of depressive symptoms. ● Race and culture ○ There is no consistent relationship between race and affective disorder. ○ Depression is more prevalent in whites than in blacks. ○ Depression is more severe and disabling in blacks. ○ Blacks are less likely to receive treatment than are whites. ○ SPEAKER NOTES: ■ Results of some studies have indicated an inverse relationship between social class and report of depressive symptoms. However, there has yet to be a definitive causal structure in the socioeconomic status-mental illness relationship. ■ Studies have shown no consistent relationship between race and affective disorder. One problem encountered in reviewing racial comparisons has to do with the socioeconomic class of the race being investigated. Sample populations of nonwhite clients are often predominantly lower socioeconomic class populations that are being compared with white populations from middle and upper social classes.

● Marital status ○ Single and divorced people are more likely to experience depression than are married persons or persons with a close interpersonal relationship (differences occur in various age groups). ■ In other words, marriage has a positive effect on psychological well-being compared to those who are single or do not have a close relationship with another person ● Seasonality ○ Affective disorders are more prevalent in the spring and in the fall but some clients have recurrent summer episodes ○ SPEAKER NOTES: ■ A number of studies have suggested that marriage has a positive effect on the psychological well-being of an individual. Other studies have suggested that marital status alone is not a valid indicator of risk for depression. Some of those studies have identified that age is an important variable in risk for depression among married and single individuals. ■ Studies exploring whether seasonality is a cause of depression have yielded varying results. Authors of one large study report that prevalence rates of depression with seasonal patterns have varied from 1 percent to 12 percent but in their study of 5549 patients from primary care settings, there was no evidence of seasonal patterns for major depressive disorder. Another study found that a small but significant peak in depression symptoms occurred in winter months but over 20 years of following those clients, the winter seasonal pattern was not stable. Types of Depressive Disorders (pg 497) ● Major depressive disorder ○ Characterized by depressed mood ○ Loss of interest or pleasure in usual activities, impaired social and occupational functioning ■ Termed “Anhedonia” ○ Symptoms present for at least 2 weeks ○ No history of manic behavior ■ If there is, it would be bipolar disorder ○ Cannot be attributed to use of substances or another medical condition ■ If patient has cancer and is depressed, that would be different ○ SPEAKER NOTES: ■ Major depressive disorder (MDD) is characterized by depressed mood or loss of interest or pleasure in usual activities. Evidence will show impaired social and occupational functioning that has existed for at least 2 weeks & 5 or more symptoms present, no history of manic behavior, and

symptoms that cannot be attributed to use of substances or a general medical condition. The diagnosis will also identify the degree of severity of symptoms (mild, moderate, or severe) and whether there is evidence of psychotic, catatonic, or melancholic features. ■ The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (APA, 2013) diagnostic criteria for major depressive episodes are presented in Box 25-1.

○ ● Dysthymic disorder (pg 499) ○ Sad or “down in the dumps” ○ No evidence of psychotic symptoms ○ Essential feature is a chronically depressed mood (or possibly an irritable mood in children or adolescents) for ■ Most of the day ■ More days than not ■ At least 2 years (1 year for children and adolescents) ○ SPEAKER NOTES: ■ Characteristics of persistent depressive disorder, or dysthymia, are similar and perhaps milder than MDD. There is no evidence of psychotic symptoms. The essential feature is a chronically depressed mood (or possibly an irritable mood in children or adolescents) for most of the day, more days than not, for at least 2 years (1 year for children and adolescents). The diagnosis is identified as early onset (occurring before age 21 years) or late onset (occurring at age 21 years or older).

■ The DSM-5 diagnostic criteria for persistent depressive disorder (dysthymia) are presented in Box 25-2.

○ ● Premenstrual dysphoric disorder (pg 499) ○ Depressed mood ○ Excessive Anxiety ○ Mood swings ○ Decreased interest in activities ○ Symptoms begin during the week prior to menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses. ○ SPEAKER NOTES: ■ The essential features of premenstrual dysphoric disorder include markedly depressed mood, excessive anxiety, mood swings, and decreased interest in activities during the week prior to menses, improving shortly after the onset of menstruation, and becoming minimal or absent in the week postmenses. ■ The DSM-5 diagnostic criteria for premenstrual dysphoric disorder are presented in Box 25-3.

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● Substance-induced depressive disorder ○ Considered to be the direct result of physiological effects of a substance ○ This disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. ○ The depressed mood is associated with intoxication or withdrawal from substances such as alcohol, amphetamines, cocaine, hallucinogens, opioids, phencyclidine-like substances, sedatives, hypnotics, or anxiolytics. ○ Speaker note: The depressed mood is associated with intoxication or withdrawal from substances such as alcohol, amphetamines, cocaine, hallucinogens, opioids, phencyclidine-like substances, sedatives, hypnotics, or anxiolytics. The symptoms meet the full criteria for a relevant depressive disorder. A number of medications have also been known to evoke mood symptoms including anesthetics, analgesics, anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian agents, antiulcer agents, cardiac medications, oral contraceptives, psychotropic medications, muscle relaxants, steroids, and sulfonamide ● Depressive disorder associated with another medical condition (pg 500) ○ Characterized by symptoms associated with a major depressive episode that are attributable to the direct physiological effects of a general medical condition ■ The depression causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. ○ SPEAKER NOTES: ■ Describe characteristics of depressive disorder associated with another medical condition. ■ This disorder is characterized by symptoms associated with a major depressive episode that are the direct consequence of another medical condition. The depression causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Predisposing Factors to Depression (pg 501) ● Biological theories ○ Genetics ■ Hereditary factor may be involved ● Affective illness has been the subject of considerable research on the relevance of hereditary factors ○ Biochemical influences ■ Depressive illness may be related to a deficiency of norepinephrine, serotonin, and dopamine has been implicated ■ Excessive cholinergic transmission may also be a factor ■ SPEAKER NOTES:

● The cause of depression is unclear, and no single theory or hypothesis offers a clear-cut explanation for the disease. Evidence continues to mount in support of multiple causations. ● Describe the biological theories of the causes of depression. ● A genetic link has been suggested in numerous studies of depression, but a definitive mode of genetic transmission has yet to be proven. Twin studies suggest a strong genetic factor in the etiology of affective illness including depressive disorders. Family studies have shown that major depression is more common among first-degree biological relatives of people with the disorder than among the general population. Further support for heritability as an etiological influence in depression comes from studies of the adopted offspring of affectively ill biological parents. ● Depressive illness may be related to a deficiency of the neurotransmitters norepinephrine, serotonin, and dopamine, at functionally important receptor sites in the brain. More recently, this hypothesis has been expanded to include another neurotransmitter, acetylcholine. Because cholinergic agents do have profound effects on mood, electroencephalograms, sleep, and neuroendocrine function, it has been suggested that the problem in depression and mania may be an imbalance between the biogenic amines and acetylcholine. ● Neuroendocrine disturbances ○ May play a role in the pathogenesis or persistence of depressive illness ○ This notion has arisen in view of the marked disturbances in mood observed with the administration of certain hormones or in the presence of spontaneously occurring endocrine disease (diminished release of TSH) ←IT'S REALLY HIGH LEVELS OF nonsense ○ SPEAKER NOTES: ■ Neuroendocrine disturbances may play a role in the pathogenesis or persistence of depressive illness. In clients who are depressed, the normal system of hormonal inhibition fails, resulting in a hypersecretion of cortisol. Thyrotropin-releasing factor (TRF) from the hypothalamus stimulates the release of thyroid-stimulating hormone (TSH) from the anterior pituitary gland. Diminished TSH response to administered TRF is observed in approximately 25 percent of depressed persons and appears to be associated with increased risk for relapse despite treatment with antidepressants. ● Physiological influences Cole done

○ Depressive symptoms that occur as a consequence of non-mood disorder or as an adverse effect of certain medications are called secondary depression. ■ Secondary depression may be related to medication side effects, neurological disorders, electrolyte or hormonal disturbances, nutritional deficiencies, and other physiological conditions ○ Medication side effects ■ Most common are those that have a direct effect on the central nervous system, such as anxiolytics, antipsychotics, sedative-hypnotics (including barbiturates and opioids), and anticonvulsant mood stabilizers. ○ Neurological disorders ■ Brain tumors, particularly in the area of the temporal lobe (this lobe deals with processing affect, and emotions), often cause symptoms of depression ■ CVAs (stroke) ○ Electrolyte disturbances ■ Excessive levels of sodium bicarbonate or calcium can produce symptoms of depression ■ Deficits in magnesium and sodium ■ Potassium is implicated as well ○ Hormonal disorders ■ Associated with dysfunction of adrenal cortex ● Addison’s disease ● Cushing’s syndrome ■ Hypoparathyroidism ■ Hyperparathyroidism ■ Hypothyroidism ■ Hyperthyroidism ■ Imbalance of progesterone and estrogen is implicated in the development of PMDD (premenstrual dysphoric disorder) ○ Nutritional deficiencies ■ B-vitamins, iron, zinc, calcium, potassium, omega-3 fatty acids, vitamin D ○ Other physiological conditions ■ SLE, cardiovascular diseases, CHF, MI, encephalitis, hepatitis, pneumonia syphilis, DM ○ SPEAKER NOTES: ■ A number of drugs, either alone or in combination with other medications, can produce a depressive syndrome. Most common among these drugs are those that have a direct effect on the central nervous system. ■ An individual who has suffered a cardiovascular accident (CVA), brain tumors, particularly in the area of the temporal lobe, Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease, or multiple sclerosis may display symptoms of depression.

■ Excessive levels of sodium bicarbonate or calcium can produce symptoms of depression, as can deficits in magnesium and sodium. Potassium is also implicated in the syndrome of depression. ■ Depression is associated with dysfunction of the adrenal cortex and is commonly observed in both Addison’s disease and Cushing’s syndrome. 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 (PMDD) although the exact etiology is unknown. ■ Deficiencies in proteins, carbohydrates, vitamin B1 (thiamine), vitamin B2 (riboflavin), vitamin B6 (pyridoxine), B9 (folate), vitamin B12, iron, zinc, calcium, chromium, iodine, lithium, selenium, potassium, and omega 3 fatty acids have all been associated with producing symptoms of depression. ■ Other conditions that have been associated with secondary depression include collagen disorders, such as systemic lupus erythematosus (SLE) and polyarteritis nodosa; cardiovascular disease, such as cardiomyopathy, congestive heart failure, and myocardial infarction; infections, such as encephalitis, hepatitis, mononucleosis, pneumonia, and syphilis; and metabolic disorders, such as diabetes mellitus and porphyria. ● Psychosocial theories ○ Psychoanalytic theory (Freud) ■ A loss is internalized and becomes directed against the ego. ■ Fail nursing school, we internalize the loss and become consumed in that loss and disappointment and become depressed ■ SPEAKER NOTES: Freud posited that melancholia occurs after the loss of a loved object, either actually by death or emotionally by rejection, or the loss of some other abstraction of value to the individual. Freud indicated that in melancholia, the depressed patient’s rage is internally directed because of identification with the lost object. Freud believed that the individual predisposed to melancholia experienced ambivalence in love relationships. ○ Learning theory ■ Learned helplessness ■ The individual who experiences numerous failures learns to give up trying. ■ SPEAKER NOTES: As a result of Seligman’s experiments with dogs, he theorized that learned helplessness predisposes individuals to depression

by imposing a feeling of lack of control over their life situation. He believed they become depressed because they feel helpless; they have learned that whatever they do is futile. ○ Object loss ■ Experiences loss of significant other during first 6 months of life ■ Feelings of helplessness and despair ■ Early loss or trauma may predispose client to lifelong periods of depression ■ Some researchers suggest that loss in adult life afflicts people much more severely in the form of depression if the individuals have suffered early childhood loss ■ SPEAKER NOTES: The theory of object loss suggests that depressive illness occurs as a result of having been abandoned by or otherwise separated from a significant other during the first 6 months of life. This absence of attachment, which may be either physical or emotional, leads to feelings of helplessness and despair that contribute to lifelong patterns of depression in response to loss. ○ Cognitive theory ■ Views primary disturbance in depression as cognitive rather than affective ■ the underlying cause of depression is from three cognitive distortions that serve as the basis for depression 1. Negative expectations of the environment 2. Negative expectations of the self 3. Negative expectations of the future ■ Theorists believe that depression is the product of negative thinking ■ Cognitive therapy focuses on helping the individual alter mood by changing the way he or she thinks ■ SPEAKER NOTES: Beck and colleagues proposed a theory suggesting that the primary disturbance in depression is cognitive rather than affective. The underlying cause of the depression is cognitive distortions that result in negative, defeated attitudes. These cognitive distortions arise out of a defect in cognitive development, and the individual feels inadequate, worthless, and rejected by others. Outlook for the future is one of pessimism and hopelessness. ○ Transactional model ■ No single theory or hypothesis exists to substantiate a clear-cut explanation for depressive disorder. ■ Evidence continues to mount in support of multiple causations.

■ The transactional model recognizes the combined effects of genetic, biochemical, and psychosocial influences on an individual’s susceptibility to depression. Develop...