Major Depressive Disorder  1. Represents a change in previous function  2. Symptoms cause clinically significant, social, occupational, or other important arras of functioning (e.g...)  3. FIVE or more of :the following occur nearly very day for most waking over the same 2-week period ◦ a) Depressed mood most of the day, nearly every day ◦ b) Anhedonia ◦ c) Significant weight loss or gain (more than 5% of body weight on one month) ◦ d) Insomnia or hypersomnia

◦ e) Increased or decreased motor activity ◦ f) anergia (fatigue or loss of energy) ◦ g) feelings of worthlessness or inappropriate guilt (may be delusional) ◦ h) decreased concentration or indecisiveness ◦ i) recurrent thoughts of death or suicidal ideation (with or without plan)

Primary Risk Factors for Depression

Neurological: (e.g. epilepsies, Parkinson’s disease, multiple sclerosis, Alzheimer’s) Infectious or inflammatory: AIDS Cardiac disorders: ischemic heart disease, cardiomyopathies Endocrine: hypothyroidism, diabetes, parathyroid disorders Inflammatory disorders: collagen-vascular diseases, irritable bowl syndrome, chronic liver disorders

 Central nervous system depressants: alcohol, barbiturates, benzodiazepines, clonidine  Central nervous system medications: amatadine, bromocryptine, levodopa, phenothyazines, phenytoin  Psychostimulants: amphedamines  Systemic medications: corticosteroids, digoxin, dilitazem, enapranil, reserpine, thiaziodes, vincristine

Intervention

 Help the patient question underlying assumptions and beliefs and consider alternate explanations to problems.  Rationale: Reconstructing a healthier and more hopeful attitude about the future can alter a depressed mood.

 Work with the patient to identify cognitive distortions the encourage negative self- appraisal.  Rationale: Cognitive distortions reinforce a negative, inaccurate perception of self and world ◦ For example:  Overgeneralizations  Rationale: the patient takes one fact or event and makes a general rule out of it (“He always…”; “I never…”)  Self-blame  Rationale: The patient consistently blames self for everything perceived as negative.

◦ Further examples:  Mind reading  Rationale: The patient assumes others don’t like him or her, without any real evidence that assumptions are correct.  Discounting of positive attributes  Rationale: The patient focuses on the negative

 Encourage activities that can raise self- esteem.  Identify the need for (a) problem solving skills, (b) coping skills, (c) assertiveness skills.  Rationale: Many people with depression do not have a range of problem solving and coping skills. Increasing social, family, and job skills can change negative self- assessment.  Note social determinants of health barriers  Encourage exercise, such as running and/or weight lifting (**in the context of barriers)  Rationale: Exercise can improve self-concept and potentially shift neurochemical balance.  Note social determinants of health barriers

 Encourage formation of supportive relationships, such as through support groups, therapy, and peer support.  Rationale: Such relationships reduce social isolation and enable the patient to work on personal goals and relationship needs.  Note social determinants of health barriers  Provide information referrals, when needed, for religious or spiritual information (e.g., readings, programs, tapes, community resources).  Rationale: Spiritual and existential issues may be heightened during depressive episodes; many people find strength and comfort in spirituality or religion.  Note social determinants of health barriers

Assumptions of brief Therapy: Along with the central philosophy, SFBT makes several assumptions that nurses can use to guide their interactions with the client: Change is inevitable and constantly occurring. Focusing on the positive, the solution and the future facilitate change. The client is the “expert.” It’s not necessary to assess or diagnose the problem before being able to help.

 Only a small change may be necessary.  No problems happen all the time.  Individuals have the strengths and resources that they need to change.  There are many ways to look at a situation. None is more correct than the others.

Two client examples: nutrition during pregnancy; addiction to alcohol 1. Useful questions at initial contact During the initial contact, these typical questions invite the client to describe his or her problems and goals:  “What brings you here today?”  “How can I help?”  “What would need to happen here today in order for you to know it was a good idea to come?”

 2. Pre-session change questions Another kind of question is one that seeks to outline any pre-session change that may have occurred. For example: ◦ “What has been different or better since you made the decision to come here today?” ◦ This question recognizes that the client is already making an effort toward positive change by asking for help.

 3. The Miracle Question  One of the most powerful techniques developed by Berg and de Shazer (2001) is The miracle question: “Suppose that tonight, while you are asleep, a miracle happens. As a result of this miracle, all of the problems that brought you here today are gone. But, because you were sleeping, you don’t know a miracle has happened and the problems are now solved. What is the first thing you will notice that will tell you something is different?” The miracle question is an effective tool because it helps clients set goals even when they are in crisis and feel stuck. Framed as unrealistic, the miracle question helps the client feel less threatened about expressing what he or she wants

 4. The Scaling Questions  “On a scale of 1 to 10 (10 means that you_____, and 1 means that you_____,where are you now?”  “Realistically, where on the scale do you want to be?”  “What would you need to do in order to move up one point on the scale?”

 Brief or Solution-focused therapy is a whole field of therapeutic knowledge  However, these basic principles and techniques are essential for nursing, no matter where you eventually practice