NURSING 3PA2 Study Guide - Final Guide: Psychomotor Agitation, Dysthymia, Cyclothymia

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NURSING 2PF3 Module 6: Depression
MODULE 6: ALTERATIONS IN MENTAL HEALTH – DEPRESSION
Alterations in mental health
Mood disorders are disorders of emotion and include mania and depression.
Depressive disorders: are commonly divided into two categories
1. Major depressive disorder: characterized by a persistent unpleasant mood. DSM-IV criteria for
diagnosis include the presence of 5 of more of the following symptoms during a two week period –
and these symptoms must represent a change from previous functioning:
- Depressed mood
- Anhedonia (inability to experience pleasure)
- Feelings of worthlessness or excessive guilt
- Psychomotor agitation or retardation, insomnia or hypersomnia, decreased libido
- Change in weight or appetite
- Thoughts of death or suicidal ideation
2. Dysthymia: characterized by chronic mild depressive symptoms
- Low self-esteem, sleep and energy problems, and appetite disturbances
- At risk for development of major depression and other psychiatric disorders, including substance
abuse disorders
3. Bipolar depression:
-Manifestations of mania include decreased need for food and sleep, labile mood, irritability,
racing thoughts, high distractibility, rapid and pressured speech, inflated self-esteem, and
excessive involvement with pleasurable activities
-Cyclothymia mood fluctuates between mild elation and depression to severe delusional mania
which may begin abruptly
-The more frequently a person has a shift in mood, cycling into either mania or depression, the
easier it becomes to have another episode
-The better the control of the illness and the fewer cycles an individual has, the better his or her
quality of life is likely to be
Additionally, there are several sub-classifications of depression
-Depression with melancholic features: refers to when depression is worse in the morning
-Atypical depression: refers to depression which becomes worse as the day progresses
-Depression with psychotic features: involves the presence of delusions or hallucinations
-Depression with catatonic features: term used to describe expression when symptoms include
excessive mobility or motoric immobility
-Postpartum specifier: describes depression which occurs within 6 weeks after childbirth
-Chronic specifier: describes depression where symptoms persist for 2 or more years.
Several medical illnesses such as diabetes, heart disease, autoimmune disorders, and pain are
common co-morbid diagnoses
Statistics
Mood disorders are highly under-diagnosed and under-treated. The incidence of depression seems to
be increasing
Average onset of bipolar disorder is the mid-to late twenties, and for depression, the mid-thirties;
however the age of onset of both disorders has been decreasing
Mood disorders are thought to occur with equal prevalence among races, although it is more
frequently misdiagnosed as schizophrenia among non-white populations. Depression is among the
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NURSING 2PF3 Module 6: Depression
leading cause of disability worldwide with approximately 8% of adults experiencing major
depressive episodes at some time in their lives
- 10% of Canadians are affected by mood disorders
-Nearly 1 in 5 people will experience a major depressive episode at some point in their lives
-About 1% of the population are affected by bipolar disorder
Gender considerations: the prevalence of major depression in women is double the prevalence in
men. In contrast, the prevalence of bipolar disorder is the same in both sexes. Clinical considerations:
Why are more women diagnosed with depression?
-The true neurobiological basis for the increased prevalence in women is unknown but it is
thought to be related to differences in hormonal statuses, or stress response systems or between
sexual differences in brain areas.
-It is thought to due in part to the fact that women are more likely to recognize mental health
issues and seek medical attention. Finally, In men, depression is often masked as somatic
complaints such as migraines, back pain or irritable bowel syndrome and therefore, is often not
recognized
Sadly, it is estimated that suicide is the cause of death in 15% of individuals with major depressive
disorder.
Risk Factors and Etiology of Depression
The etiology of depression is multi-factorial and involves dynamic interplay between genetic
predisposition, environment, life history, development, and biological challenges. Currently, it is believed
that major depressive disorders arise from the complex interaction of genes and environmental factors.
Much of the research in the past 40 years has focused on deficits of neurotransmitter systems.
Genetic-Environment Interaction
Major depression is more common among first-degree relatives than the general population. Family,
twin, and adoption studies suggest a hereditary component to the etiology of mood disorders
Twin studies suggest that the hereditability for depression is ~31-42%, but that there is a substantial
contribution of environmental effects unique to individuals of 58-67%
Gene–environment interactions seem to predict a person’s risk for major depressive disorder better
than genes or environment alone.
Several environmental risk factors for depression have been identified: childhood emotional,
physical, and sexual abuses; prior episode of depression; family history of depressive disorder; lack
of social support; stressful life event; current substance abuse; economic difficulties. Environmental
stressors can trigger the HPA axis causing depression. It is believed that the way a person interprets
their environment and thinks about themselves can induce and perpetuate depressive symptoms
-Psychodynamic factors: Negative beliefs about self, environment, future that can induce and
perpetuate depressive symptoms
-Behavioural factors: Decrease in pleasurable activities that result in depression and a further
restriction of activity decreasing the likelihood of experiencing pleasurable activities and
intensifying a mood disturbance
-Developmental factors: Parenting (either a loss or lack of supportive parenting) can delay or
prohibit the realization of appropriate developmental milestones
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NURSING 2PF3 Module 6: Depression
-Family distress: Disruption in family dynamics involving maladaptive circular patterns in family
interactions that contribute to the onset of depression in family members
-Social factors: Adverse or traumatic life events especially the loss of an important human
relationship or role in life that is followed by a depression
Clinical considerations: Why is determining the cause of depression so difficult? The brain is
extremely complex! The average adult brain is about 3 pounds and contains ~100 billion neurons
and 10-50 trillion neuroglia which support the nerve cells in the brain. On average, each neuron
forms 1000 synapses with other neurons; thus there about 1000 trillion synapses in the brain.
Genetic Polymorphisms
Genetic polymorphisms can predispose individuals to major depressive disorders through their
effects on genes which help control the metabolism of neurotransmitters and their receptors, the
number of particular types of neurons and their synaptic connections, intracellular transduction of
neuronal signals, and the speed of which all of these change in response to environmental stressors.
The serotonin transporter gene is the most studied in major depressive disorder
-The serotonin transporter gene contains a polymorphism that gives rise to two different alleles –
long and short. The short allele slows down the synthesis of the serotonin transporter and is
thought to reduce the speed at which serotonin neurons can adapt to changes in their
stimulation. This subsequently leads to the dysregulation of serotonin which has been implicated
in depression
Brain Derived Nerotropic Factor (BDNF) is a growth factor that has an important role in birth,
survival and maturation of brain cells and neuronal growth during development. It is also thought to
be important for the synaptic changes that occur throughout a person’s life.
-Specifically,
1. BDNF activates DNA binding factors that stimulate the genes involved in serotonin function,
including genes for the serotonin transporter and tryptophan hydrolysis (serotonin
synthesizing gene).
2. Activation of serotonin receptors stimulates the expression of the BDNF gene
3. The cyclic process promotes outgrowth, synapse formation, and survival of serotonin
neurons, and eventual innervations of multiple brain regions during brain development.
-The ability of the serotonin system to adapt and change in response to various stimuli continues
to be influenced by BDNF throughout life. BDNF may be the link between stress, neurogenesis,
and hippocampus atrophy in depression. It is thought to be related to multiple psychiatric
disorders
-In non-depressed persons, BDNF is found in high concentrations in the brain. However,
individuals diagnosed with major depressive disorder have lower levels of BDNF in the
hippocampus and the prefrontal cortex, and in the serum. Clinical considerations: BDNF is not
generally assessed in a clinical setting and is not considered a diagnostic measure.
-A polymorphism in the gene that codes for BDNF has been identified (val/met genotype). This
polymorphism affects the intracellular transport and secretion of BDNF. Specifically, individuals
with the met allele have increased vulnerability to depression
oHave a small hippocampus at birth, hippocampal activity at rest, hippohypercampal
activity during learning, at relatively poor hippocampus dependent memory function
oHippocampus is significant to depression because it is believed to modulate the
cognitive aspects of depression such as memory impairments, and feelings of
hopelessness, guilt, doom, suicide ideation
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