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Major Depression

“Mom, I’m not afraid of the dark, perhaps that’s part of the problem. Mom says I thought the problem was that you can’t get out of bed. I can’t, anxiety holds me a hostage inside of my house inside of my head. Mom says where anxiety came from. Anxiety is the cousin visiting from out of town that depression felt obligated to invite to the party. Mom, I am the party, only I’m a party I don’t want to be at.” – Sabrina Benaim, Explaining My Depression to My Mother: A Conversation

Description

Major depression is classified under mood disorders which are characterized by disturbances in the regulation of mood, behavior, and affect that go beyond the normal fluctuations that most people experience.
  • Also called as unipolar major depression, major depression is a syndrome of a persistently sad mood lasting two (2) weeks or longer.
  • It is accompanied by other problems like feelings of guilt, helplessness, or hopelessness, poor concentration, sleep disturbances, lethargy, appetite loss or weight gain, anhedonia, loss of mood reactivity, and thoughts of death.
  • Suicide is the most serious complication of major depression. It occurs in nearly 15% of patients with untreated depression.

Statistics and Incidences

During 2009-2012, 7.6% of Americans aged 12 and over had depression.
  • Depression was more prevalent among females than males and among adults aged 40-59 than those of other age groups.
  • In 2015, an estimated 16.1 million adults aged 18 or older in the United States had at least one major depressive episode in the past year.

Pathophysiology

The underlying pathophysiology of major depressive disorder has not been clearly defined.
  • Current evidence points to a complex interaction between neurotransmitter availability and receptor regulation and sensitivity underlying the affective symptoms.
  • Clinical and preclinical trials suggest a disturbance in central nervous system serotonin (5-HT) activity as an important factor.
  • Other neurotransmitters implicated include norepinephrine, dopamine, glutamate, and brain-derived neurotrophic factor.
  • The role of CNS 5-HT activity in the pathophysiology of major depressive disorder is suggested by the therapeutic efficacy of selective serotonin reuptake inhibitors (SSRIs).
  • An integrative model of late-onset depression posits that age-related brain changes and disease-related changes coupled with physiologic vulnerabilities and psychosocial adversity, lead to disruptions in the functional circuitry of emotion regulation.

Causes

Genetic, biochemical, physical, psychological, and social factors are linked to major depression.
  • Genetic factor. Two-three times more common in people with first-degree relative with the disorder.
  • Biological factors. Primary defect sites at prefrontal cortex and basal ganglia. It may also involve serotonin, neuroendocrine, and hypothalamic-pituitary-adrenal (HPA) regulation systems. May also be associated with abnormal cortisol levels.
  • Psychosocial factors. There is an unclear relationship between psychological stress, stressful life events, and depression onset.
  • Pharmacologic factors. Prescribed drugs for certain medical and psychiatric conditions can cause depression. Some of these medications include antihypertensives, psychotropics, antiparkinsonian drugs, oral antidiabetics, steroids, and chemotherapeutic agents.

Clinical Manifestations

Symptoms of a major depressive disorder according to DSM-IV-TR diagnostic criteria:
  • Depressed mood. The affect of a depressed person is one of sadness, dejection, helplessness, and hopelessness.
  • Anhedonism. There is decreased attention to and enjoyment from previously pleasurable activities.
  • Weight changes. Unintentional weight change of 5% or more in a month.
  • Change in sleep pattern. Sleep disturbances are common, either insomnia or hypersomnia.
  • Agitation or psychomotor retardation. A general slowdown of motor activity commonly accompanies depression.
  • Tiredness. Physically there is evidence of weakness and fatigue-very light energy to carry on with the activities of daily living (ADLs).
  • Worthlessness or guilt inappropriate to the situation (probably delusional).
  • Difficulty thinking, focusing, and making decisions.
  • Hopelessness, helplessness, and/or suicidal ideations.

Assessment and Diagnostic Findings

A number of tests should be conducted to diagnose depression.
  • Beck Depression Inventory is a psychological test used to determine symptom onset, severity, duration, and progression.
  • Dexamethasone suppression test showing failure to suppress cortisol secretion in depressed patients (although test has high false-negative rate).
  • Toxicology screening suggesting drug-induced depression.
  • Diagnosis is confirmed if DSM-V-TR criteria is met.

Medical Management

A wide range of effective treatments is available for major depressive disorder.
  • Psychotherapy. There are a number of evidence-based psychotherapeutic treatments for adults with major depressive disorder such as behavioral therapy, cognitive therapy, cognitive behavioral analysis system of psychotherapy, interpersonal psychotherapy, problem-solving therapy, and self-management or self-control therapy.
  • Electroconvulsive therapy. Electroconvulsive therapy is a highly effective treatment for depression.
  • Simulation techniques. Transcranial magnetic stimulation (TMS) is approved by the FDA for use in adults patients who have failed to respond to at least 4 adequate medication and/or ECT treatment regimens.

Pharmacologic Management

Medications are the primary treatment for major depression. Ideally, medications should be combined with various therapies. Drugs generally work by modifying the activity of relevant neurotransmitter pathways.
  • Antidepressants are classified according to class:
  • The first-line treatment for patients with depression because these drugs lack the most of disturbing effects of TCAs and MAOIs. Examples include citalopram (Celexa), paroxetine (Paxil), and sertraline (Zoloft).
  • Generally used as second-line agents for patients with major depressive disorder.
  • Example include venlafaxine (Effexor)
  • Atypical antidepressants. Their mechanism of action is not clearly understood. Some examples include bupropion (Wellbutrin) and mirtazapine (Remeron). They are used as second-line agents too.
  • An older class of antidepressants. Some examples include amitriptyline (Elavil) and amoxapine (Asendin). May be prescribed for patients with atypical depression (e.g. depression marked by increased appetite and sleep). Rarely used today because of high risk for adverse effects like hypertensive crisis and dangerous interactions with foods and medications.

Nursing Management

These are the nursing responsibilities for taking care of patients with major depression:

Nursing Assessment

  • Subjective cues. Include verbalization of inability to cope or ask for help, sleep disturbance and fatigue, abuse of chemical agents, and reports of muscular or emotional tensions, and lack of appetite.
  • Objective cues. Include lack of goal-directed behavior or resolution of problem; inadequate problem solving, decreased use of social support, inability to meet role expectations/basic needs, and destructive behavior toward self (e.g. overeating, smoking/drinking, overuse of prescribed/OTC medications, and illicit drug use)

Nursing Diagnosis

  • Ineffective Coping related to situational or maturational crises
  • Hopelessness related to long-term stress
  • Fatigue related to stress and anxiety

Planning and Goals

Main article: 6 Major Depression Nursing Care Plans

  • To determine degree of impairment
  • To assess coping abilities and skills
  • To assist client to deal with current situation
  • To provide for meeting psychological needs
  • To promote wellness

Nursing Interventions

  • Provide for patient’s physical needs. Assist with self-care and personal hygiene. Encourage patient to eat. Give warm milk or back rubs at bedtime to improve sleep.
  • Plan activities for times when the patient’s energy level peaks.
  • Assume active role in initiating communication. This can be done by sharing observation of patient’s behavior, speaking slowly and allowing ample time for him to respond, encouraging him to talk and write down feelings, and by providing a structured routine which may include noncompetitive activities.
  • Avoid feigned cheerfulness, but don’t hesitate to laugh with him and point out the value of humor.
  • Educate patient about depression. Explain that depression can be eased by expressing feelings and engaging in pleasurable activities. Emphasize that there are effective methods available for relief of symptoms.
  • Help patient recognize distorted perceptions and link them to his depression.
  • Ask patient whether he thinks about death or suicide. Signal an immediate need for consultation and assessment. Risk of suicide is higher with lifting of depressed mood.
  • Stress the need for medication compliance. Review adverse effects with the patient.

Evaluation

  • Patient’s ability to assess current situation accurately.
  • Patient’s ability to identify ineffective coping behaviors and consequences.
  • Verbalization of awareness of own coping abilities and of feelings congruent with behavior.
  • Meet physiological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.

Discharge and Home Care Guidelines

  • Long-term needs and actions to be taken
  • Support system available, specific referrals made, and who is responsible for actions to be taken.

Documentation Guidelines

  • Record all observations and conversations with the patient because these are valuable in evaluating his response to treatment.

Practice Quiz: Major Depression

Quiz time about the topic! For more practice questions, visit our NCLEX practice questions page.

Text Mode

Text Mode: All questions and answers are given on a single page for reading and answering at your own pace. Be sure to grab a pen and paper to write down your answers.

Questions

1. Which patient would the nurse expect to prepare for ECT? A. A female patient with dysthymic disorder B. An elderly male with major depressive disorder and a history of stroke C. A middle-age, female patient with major depression and an immediate risk of suicide. D. A female patient with depression and hypomania due to cyclothymic disorder 2. How long should a depressive episode last for it to be considered for diagnosis? A. 7 days B. more than 10 days C. 2 weeks D. 3-4 weeks 3. Which antidepressive drug class is associated with severe food and medication interactions? A. MAOIs B. SSRIs C. SNRIs D. TCAs 4. The following are correct nursing interventions for patients with major depression, except: A. Painting B. Newspaper reading C. Scrabble D. Music therapy 5. The most serious complication of depression? A. Social isolation B. Suicide C. Physical deformities D. Stroke Answers and Rationale 1. Answer: C. A middle-age, female patient with major depression and an immediate risk of suicide. ECT may be used to treat major depression as well as certain psychotic disorders, particularly in situations of severe depression when psychotherapy and medications have been ineffective, when ECT poses a lower risk than other treatments do, or when the patient is at an immediate risk for suicide. 2. Answer: C. 2 weeks. Major depression is a syndrome of a persistently sad mood lasting 2 weeks or longer. 3. Answer: A. MAOIs. This is the reason why this drug class is rarely used. 4. Answer: C. Scrabble. Noncompetitive activities should be promoted for these patients. 5. Answer: B. Suicide. It occurs in 15% of untreated cases.

References

  1. Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR)
  2. Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
  3. Straight A’s in Psychiatric & Mental Health Nursing: A Review Series

External Links & Further Reading

  1. Depression – National Institute of Mental Health – provides up to date information about Major Depression.
  2. Psychiatric Mental Health Nursing Success: A Q&A Review Applying Critical Thinking to Test Taking (Davis’s Success) – great if you’re reviewing for the NCLEX.

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