DEPRESSION

INTRODUCTION

  • Depression is categorized as a mood disorder, one of the most prevalent psychiatric disorders with a lifetime prevalence of nearly 17%.

  • Notably, it is observed that major depressive disorder (MDD) has a twofold higher prevalence in women compared to men.

  • Contributing factors to this disparity potentially include:
      - Hormonal differences
      - Effects of childbirth
      - Different psychosocial stressors faced by men and women
      - Behavioral models like learned helplessness.

EPIDEMIOLOGY

  • The average age of onset for major depressive disorder is approximately 40 years.
      - 50% of patients see their first symptoms between the ages of 20 and 50.
      - MDD may begin in childhood or later in life, with increasing incidence noted among individuals under 20 years of age.

  • A higher prevalence is primarily observed in individuals with poor interpersonal relationships, and those who have experienced divorce or separation.

  • No significant correlation is identified between socioeconomic status and the likelihood of developing major depressive disorder.

LEARNING OBJECTIVES

  • At the conclusion of this lecture, students should be able to:
      1. Define depression according to DSM-IV-TR.
      2. Identify the signs and symptoms of depression.
      3. List the four types of depression.
      4. Describe the causative and contributing factors of depression.
      5. Outline medical treatment options for depression.
      6. Formulate nursing management strategies for depression through a nursing care plan.

DEFINITION

  • According to DSM-IV-TR:
      - A major depressive disorder is characterized by the absence of any history of manic, mixed, or hypomanic episodes.
      - A major depressive episode must persist for at least 2 weeks.
      - Individuals typically display at least four of the following symptoms:
        - Changes in appetite and weight
        - Changes in sleep patterns and activity levels
        - Lack of energy
        - Feelings of guilt
        - Difficulties in thinking or decision-making
        - Recurring thoughts of death or suicide (Sadock 2007).

SIGNS AND SYMPTOMS

  • The impact of depression encompasses profound changes across various life domains including:
      - Mood
      - Motivation
      - Cognitive processes
      - Physical and motor functions.

  • The characteristic features of major depressive episodes per DSM-IV-TR include:
      - Depressed mood
      - Loss of pleasure or interest in usual activities
      - Sleep disturbances
      - Changes in appetite
      - Psychomotor retardation or agitation
      - Loss of energy
      - Feelings of worthlessness and excessive guilt
      - Cognitive difficulties like indecision and problem-solving
      - Recurrent thoughts of death or suicide.

TYPES OF DEPRESSION

  1. Reactive Depression
       - Common type triggered by external events (e.g., loss of a loved one or disasters).
       - Often unresponsive to physical therapies such as medications or electroconvulsive therapy (ECT).
       - Does not exhibit genetic determination, cyclic recurrence, and is typically milder than endogenous depression.

  2. Endogenous Depression
       - Arises from unknown internal processes rather than specific external triggers.
       - Typically cyclical in nature and responsive to drugs and ECT.
       - Potential contributing factors include hormonal and genetic predisposition. Symptoms are typically more severe than reactive depression.

  3. Bipolar Depression
       - Characterized by alternating episodes of depression and mania.
       - Mania manifests as extreme elation and excitement, contrasting the depressive states.

  4. Uni-polar Depression
       - Refers to major depressive episodes without any manic episodes observed.

CAUSES AND CONTRIBUTING FACTORS

  • The etiology of depression is multifactorial and potentially involves:
      - Genetic influences
      - Biological irregularities (specifically involving neurotransmitters)
      - Environmental stressors.

  • Biochemical causes have been identified, particularly indicating abnormalities in neurotransmitter levels.
      - Serotonin is a key biogenic amine neurotransmitter associated with depression, notably influenced by selective serotonin reuptake inhibitors (SSRIs), e.g., fluoxetine (Prozac).

  • Dopamine activity:
      - Reduced in depressive states but increased during manic episodes.
      - Certain drugs, like tyrosine, amphetamine, and bupropion (Wellbutrin), may alleviate depressive symptoms by enhancing dopamine levels.
      - Theories propose dysfunction in the mesolimbic dopamine pathway and hypoactivity of the D1 receptor in depression.

ADDITIONAL RISK FACTORS

  • Hormonal alterations

  • Heredity

  • Personality traits such as negative thinking, worry, and low self-esteem.

  • Stressful life events and environmental challenges, including life changes like pregnancy which may induce postpartum depression.

  • Co-occurring medical conditions e.g., heart disease, diabetes, hormonal disorders, and cancer can increase depression risk.

  • Substance abuse: While traditionally viewed as a maladaptive coping mechanism for depression, it is now recognized that substance abuse can also precipitate depression.

MEDICAL TREATMENT OF DEPRESSION

MILD DEPRESSION

  • Psychotherapy is recommended including:
      - Psychological assessment and therapy to gauge depressive levels.
      - Cognitive Behavioral Therapy (CBT) focuses on identifying and replacing maladaptive thoughts with adaptive ones.
      - Psychoeducation for patient and family regarding treatment adherence and follow-ups.
      - Environmental manipulation and supportive therapy may be beneficial.

MODERATE DEPRESSION

  • Antidepressants such as:
      - Amitriptyline: Starting at 75 mg nightly with maximum of 150 mg daily.
      - Fluoxetine (Prozac): Dosing begins at 20 mg daily, potentially increased up to 60 mg.
      - Imipramine dosage mirrors that of amitriptyline.

SEVERE DEPRESSION WITH SUICIDAL IDEAS

  • Comprehensive assessment of suicide intent is essential:
      - Inquiry into thoughts of self-harm or methods planned.
      - High-risk assessments may lead to hospitalization under monitoring conditions.

  • Medications include:
      - Higher doses of Amitriptyline, Imipramine, and Fluoxetine.

PSYCHOTHERAPY

  • Types of therapy include:
      - Cognitive Behavioral Therapy (CBT)
      - Behavior Therapy
      - Interpersonal Therapy
      - Structured Problem-solving approaches.

SUICIDE OBSERVATION AND MANAGEMENT

  • For patients with suicidal ideation:
      - Inpatient admission for close monitoring may be necessary.
      - Safety protocols include removing harmful objects from the patient’s environment.
      - Establish regular observation routines based on the individual’s risk level.

NURSING CARE PLAN

  • A detailed nursing diagnosis for depression leads to distinct goals and interventions, emphasized by the identification and assessment of risks including:
      - Risk of suicide
      - Low self-esteem
      - Social isolation
      - Imbalanced nutrition
      - Implementation of systematic interventions aimed at fostering positive communication, assuring safety, and incorporating psycho-social therapies.

SUMMARY AND CONCLUSIONS

  • Depression leads to profound changes in a person's life, notably affecting mood, motivation, cognitive abilities, and overall lifestyle.

  • Understanding the multifaceted nature of depression, along with its biochemical underpinnings, is crucial for developing comprehensive treatment plans that encompass medical, psychological, and nursing care strategies.

  • An effective nursing management framework focusing on specific care plans can facilitate recovery monitoring and intervention efficacy assessment.

ASSIGNMENT

  • Task: Utilizing a nursing care plan, identify three physical problems likely encountered by a depressed patient, alongside their respective nursing management strategies.

  • Due Date: /03/2017 at 16:00.

REFERENCES

  • American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC.

  • Townsend, C. (2006). Psychiatric Mental Health Nursing, Concepts Of Care In Evidence-Based Practice, 5th edition. F.A. Davis Company, Switzerland.

  • Sadock et al. (2007). Kaplan and Sadock Synopsis of Psychiatry; Behavioural sciences/clinical psychiatry. 10th edition, Lippincott Williams & Wilkins, China.

  • Treatment protocol and guidelines for common mental disorders (2011). Clinical policies and guidelines, Chainama Hills College Hospital, Lusaka, Zambia.

  • Videbek, S. (2011). Psychiatric mental health nursing. 5th edition. Wolters Kluwer Health, Lippincott Williams & Wilkins, China. ISBN: 978-1-60547-861-6.