Depression

Depression

Chapter 15

Objectives

  • By the end of this class the student will be able to:

    • Compare and contrast major depression and dysthymia (PDD).

    • Describe the key differential diagnosis for Major Depressive Disorder (MDD).

    • Create care plans for patients with depression using evidence-based practices.

    • Formulate teaching plans for patients taking monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), serotonin/norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs).

    • Describe the actions, side effects, and nursing considerations for SSRIs, SNRIs, tricyclic antidepressants, and MAOIs.

    • Describe the signs and symptoms of serotonin syndrome as well as the usual interventions to correct this problem.

    • Identify indications for the use, procedure, and patient education for both electro-convulsant therapy (ECT) and transcranial magnetic stimulation (TMS).

Key Terms

  • Anergia

  • Anhedonia

  • Deep brain stimulation

  • Dysthymia/Persistent Depressive Disorder (PDD)

  • Electroconvulsive therapy (ECT)

  • Light therapy

  • Major depressive disorder (MDD)

  • Psychomotor agitation

  • Psychomotor retardation

  • Rapid transcranial magnetic stimulation

  • Vagus nerve stimulation

  • Vegetative signs of depression

Possible Causes of Depressive Symptoms

  • Patients with some neurological disorders:

    • Stroke

    • Alzheimer’s Disease

    • Up to 40% of patients may exhibit depressive symptoms.

  • Withdrawal from substances of abuse (e.g., cocaine).

  • Stressors/Life events.

  • Rule out medical conditions through:

    • Complete physical exam and mental status examination.

    • Medication review.

    • Laboratory tests including:

    • Complete Blood Count (CBC) with differential,

    • Thyroid tests,

    • Electrolytes.

Medical Conditions Associated with Depressive Symptoms

  • Endocrine diseases: Hypothyroidism, Addison's disease, or Cushing's disease.

  • Metabolic disorders: Electrolyte imbalances (e.g., hypokalemia, hyponatremia).

  • Deficiency states: Severe anemia.

  • Infections: AIDS, encephalitis, sexually transmitted diseases (STDs), tuberculosis (TB).

  • Cardiovascular Disease: Coronary artery disease (CAD), congestive heart failure (CHF), myocardial infarction (MI).

  • Malignant disease.

  • Neurological disorders: Epilepsy, chronic pain, Parkinson’s disease.

Substance Use Disorders Associated with Depressive Symptoms

  • Intoxication and withdrawal from:

    • Alcoholism

    • Nicotine dependence

    • Δ9-Tetrahydrocannabinol (THC)

    • Opiate and psychostimulant abuse and dependence.

Medications Associated with Depressive Symptoms

  • Medications including:

    • Clonidine

    • Diuretics

    • Hydralazine

    • Methyldopa

    • Propranolol

    • Reserpine

    • Oral contraceptives

    • Steroids

    • Isotretinoin.

Diagnostic Criteria for MDD

  • A person must meet 5 or more of the following criteria during the same 2-week period, representing a change from previous functioning.

  • At least one of the symptoms must be either depressed mood or loss of interest/pleasure:

    • Depressed mood.

    • Markedly diminished interest or pleasure.

    • Significant weight loss or weight gain.

    • Insomnia or excessive sleeping (hypersomnia).

    • Psychomotor agitation or retardation.

    • Fatigue or loss of energy.

    • Feelings of worthlessness or excessive guilt.

    • Diminished ability to think or concentrate.

    • Thoughts of death (not just fear of dying), suicidal ideation.

  • Symptoms cause significant distress or impairment.

  • Not caused by illicit substances/medication or another medical condition.

Assessment of Depression

  • Mood and affect

    • Anxiety, worthlessness, guilt, helplessness, anger, irritability.

    • May not make eye contact, exhibit flat affect.

  • Thought content and processes

    • Slow thinking, rumination on faults, indecisiveness, delusional thinking.

  • Physical signs and symptoms

    • Anergia, psychomotor retardation, psychomotor agitation, "vegetative" signs of depression, sleep pattern changes.

  • Characteristic communication styles

    • Monotone speech, requires more time to respond.

SIGECAPS (Symptom Checklist)

  • Depressed mood + SIGECAPS:

    • Sleep changes

    • Interest (loss)

    • Guilt

    • Energy (loss)

    • Concentration issues

    • Appetite changes

    • Psychomotor retardation

    • Suicidal thoughts.

  • 5 or more symptoms over a period of 2+ weeks.

Depressive Disorders Across the Life-Span

  • Children and adolescents:

    • More likely to exhibit anxiety and somatic symptoms.

    • Decreased interaction with peers; avoidance of play and recreational activities.

    • More irritable mood rather than sad; higher risk of suicide.

  • Older adults:

    • Commonly associated with chronic illness; symptoms may be confused with those of dementia or stroke.

    • Suicide rates peak in middle age with a second peak at age 75.

Risk Factors for Depression

  • History of previous depressive episodes.

  • Family history of depressive disorders, particularly in first-degree relatives.

  • History of suicide attempts or family suicide history.

  • Membership in the LGBTQ community.

  • Female gender.

  • Age 40 years or younger.

  • Experienced postpartum period.

  • Chronic medical illnesses.

  • Lack of social support.

  • Negative life events, especially early trauma.

  • Active alcohol or substance use disorder.

  • History of sexual abuse.

Differences Between MDD and PDD

Major Depressive Disorder (MDD)

  • Depressed mood in nearly all activities for at least 2 weeks.

  • May include suicidal ideation (SI).

  • Impairment in functioning is severe; patient may have psychotic features.

  • Symptoms may include anorexia (poor appetite).

Persistent Depressive Disorder (PDD) (Dysthymia)

  • Less acute, chronic condition that can last for years; hospitalization is rare.

  • Symptoms are less severe than MDD.

  • Patients may show patterns of overeating.

Dysthymia (Persistent Depressive Disorder)

  • Requires fewer than 5 out of 9 symptoms.

  • Treatment often involves therapy ± medications.

  • Symptoms include feelings of hopelessness, low energy, low self-esteem over a duration of 2+ years, sleep disturbances, changes in appetite, and difficulties in decision-making.

Neurobiology of Depression and the Impact of Antidepressants

  • The imbalance of neurotransmitters such as serotonin and norepinephrine is thought to contribute to depression in certain brain areas.

  • Key Areas of the Brain Involved:

    • Prefrontal Cortex (PFC): Regulates executive functions, emotional control, and memory.

    • Limbic System: Comprises the amygdala, hypothalamus, and hippocampus; regulates emotions, physical and sexual drives, and the stress response as well as memory and learning processing.

    • Anterior Cingulate Cortex (ACC): Manages motivation, focus, and appropriate emotional reactions.

    • Various pathways can affect mood and emotional behavior, including the Serotonergic and Noradrenergic Pathways.

Medications for Depression

  • Common Classes of Antidepressants Include:

    • SSRIs: Selective serotonin reuptake inhibitors.

    • SNRIs: Serotonin/norepinephrine reuptake inhibitors.

    • NaSSAs: Noradrenergic and specific serotonergic antidepressants.

    • TCAs: Tricyclic antidepressants.

    • MAOIs: Monoamine oxidase inhibitors.

    • Atypical antidepressants.

  • All medications show similar efficacy, with choices influenced by safety profiles and side effects.

  • All have delayed responses and are associated with a discontinuation syndrome and a Black Box Warning for the risk of suicide.

Patient Problem and Drug Examples

  • Patient's Problems:

    • Fatigue

    • Insomnia

    • Sexual dysfunction

    • Chronic pain

  • Examples of Medications:

    • Fluoxetine (SSRI).

    • Mirtazapine (NaSSA).

    • Bupropion (Atypical).

    • Duloxetine (SNRI) or TCAs.

Neurotransmitters and Their Roles

  • Norepinephrine: Influences anxiety, alertness, concentration, energy, attention, impulse control, and irritability.

  • Serotonin: Affects mood, pleasure, motivation/drive, and cognitive function.

  • Dopamine: Manages obsessions, compulsions, memory, appetite, sex drive, and aggression.

Brain Functioning in Major Depression

  • Brain scans demonstrate less activity in a depressed brain compared to a normal brain.

Assessment Tools for Depression

  • Common Assessment Tools Include:

    • Beck Depression Inventory

    • Hamilton Depression Scale

    • Geriatric Depression Scale

    • Zung’s Self-Rating Depression Scale

    • Patient Health Questionnaire (PHQ-9)

    • Edinburgh Postnatal Depression Scale (EPDS)

    • Suicidal assessment for ideation related to harm to oneself or others.

PHQ-9 Assessment Questions

  • Respondents rate how often they have been bothered by symptoms over the past two weeks on a scale:

    • 0 = Not at all

    • 1 = Several days

    • 2 = More than half the days

    • 3 = Nearly every day

  • Nine Questions Include:

    1. Little interest or pleasure in doing things (e.g., hobbies, social activities)

    2. Feeling down, depressed, or hopeless

    3. Trouble falling or staying asleep, or sleeping too much

    4. Feeling tired or having little energy

    5. Poor appetite or overeating

    6. Feelings of failure or that you have let yourself or your family down

    7. Trouble concentrating on activities like reading or watching television.

    8. Moving or speaking slowly, or being so fidgety that others could notice.

    9. Thoughts that you would be better off dead, or of hurting yourself in some way.

Assessment Guidelines

  • Evaluate the patient’s risk of suicide or harm to others.

  • Determine if the depression is primary or secondary to another disorder.

  • Assess for a history of depression.

  • Assess support systems and triggering events.

  • Complete a psychosocial assessment.

Nursing Care Plans for Depression

  • Include issues such as:

    • Ineffective Coping

    • Low Self Esteem

    • Despair

    • Depressed Mood

    • Hopelessness

    • Helplessness

    • Risk for Suicide

    • Risk for Self-Mutilation

    • Self-Care Deficit

Ineffective Coping Interventions

  • Allow patients to express feelings.

  • Assess current and past coping skills.

  • Identify triggers and help problem solve.

  • Teach new coping skills as needed.

  • Role-play difficult situations and facilitate social support through inpatient and outpatient groups.

  • Assessment indicators: Poor decision-making, self-critique statements.

  • Goal: Patient will cope more effectively with issues by discharge.

Interventions for Low Self-Esteem

  • Reinforce patient's positive abilities and provide opportunities for success on the unit.

  • Teach assertiveness skills and establish achievable goals.

  • Use Cognitive Behavioral Therapy (CBT) to reframe negative thoughts.

  • Assessment indicators include negative statements and feelings of guilt/shame.

  • Goal: Patient will express positive feelings about themselves.

Therapy Interventions

  • Employ various communication techniques.

  • Health teaching and promotion, milieu therapy.

  • Psychotherapy interventions include:

    • Cognitive Behavioral Therapy (CBT)

    • Interpersonal therapy (IPT)

    • Problem-solving therapy (PST)

    • Cognitive Behavioral Therapy for Insomnia (CBT-I)

    • Dialectical Behavioral Therapy (DBT)

    • Mindfulness-Based Cognitive Therapy

    • Group therapy.

Strengths Exploration

  • Recognizing and utilizing personal strengths contributes to overall well-being.

  • Key strengths include but are not limited to:

    • Wisdom, empathy, creativity, perseverance, optimism.

    • Identify and explore new ways to leverage strengths.

Medication Therapy

  • Patient education is key to ensure safe medication administration.

  • Both patients and families need education on actions, side effects, and precautions of medications.

  • Recognize that most antidepressants take multiple weeks to show effectiveness.

  • Elderly patients often receive lower doses due to sensitivity to side effects.

  • Only 50% of patients may respond positively to the first medication prescribed.

SSRIs (Selective Serotonin Reuptake Inhibitors)

  • First-line treatment for depression.

  • Function by blocking the reuptake of serotonin, leading to increased availability in the synaptic cleft.

  • SSRIs exhibit fewer side effects than TCAs, improving patient compliance.

  • Common Side Effects:

    • Sexual dysfunction (25% of patients)

    • Headaches/dizziness (10% of patients).

  • Serious Side Effect: Serotonin syndrome characterized by hypertension, tachycardia, hyperpyrexia, and agitation.

  • Representative Drugs:

    • Fluoxetine (Prozac)

    • Paroxetine (Paxil)

    • Sertraline (Zoloft)

SNDIs & SNRIs (Serotonin/Norepinephrine Disinhibitors and Reuptake Inhibitors)

  • Serve as second-line treatments.

  • Can augment the effects of SSRIs.

  • Common examples include:

    • SNRIs: Duloxetine (Cymbalta), Venlafaxine (Effexor)

    • SNDIs: Mirtazapine (Remeron).

TCAs (Tricyclic Antidepressants)

  • Used less commonly; effective but associated with numerous side effects.

  • Function by blocking the reuptake of norepinephrine and serotonin.

  • Common Side Effects:

    • Anticholinergic effects, tachycardia, postural hypotension.

    • Drowsiness (typically administered at night).

  • Serious Side Effects:

    • Cardiotoxic effects including dysrhythmias and heart block.

  • Representative Drugs:

    • Amitriptyline (Elavil)

    • Imipramine (Tofranil)

    • Nortriptyline

    • Clomipramine.

  • Immediate medical attention required for urinary retention or severe constipation.

MAOIs (Monoamine Oxidase Inhibitors)

  • Effective but require careful management.

  • Function by preventing monoamine oxidase from breaking down norepinephrine and serotonin.

  • Serious Side Effect: Risk of hypertensive crisis due to tyramine in certain foods.

  • Representative Drugs:

    • Phenelzine (Nardil)

    • Tranylcypromine (Parnate).

  • Key Patient Education: Avoid other over-the-counter drugs that may cause hypertension (e.g. Sudafed).

Other Treatments for Depression

  • ECT (Electroconvulsive Therapy):

    • Indications for Use:

    • Failure of drug therapy

    • Patients with acute suicidality

    • Those with psychotic symptoms.

    • No absolute contraindications, but caution in patients with head trauma, seizure disorders, or brain tumors.

    • Procedure includes the application of electrodes to the scalp to generate seizures; requires anesthesia for safety.

  • Other Medical Therapies:

    • Transcranial Magnetic Stimulation (TMS): Uses a halo of magnets to modify electrical activity of the cerebral cortex (50% effectiveness observed in studies).

    • Vagus Nerve Stimulation: A surgically implanted device sends mild signals to the vagus nerve, stimulating brain regions involved in mood (40% effectiveness).

    • Deep Brain Stimulation: Electrodes implanted into the brain stimulate the subcallosal cingulate to improve mood.

    • Light Therapy: Used for Seasonal Affective Disorder (SAD), shown to alleviate depression symptoms.

Therapeutic Approaches

  • Talk Therapy: Most effective therapeutic approach, with Cognitive Behavioral Therapy (CBT) focusing on reframing thoughts.

  • Exercise: Can be as effective as talk therapy; empowers patients and promotes goal-oriented action.

  • Combination of medications and talk therapy is often recommended for optimal results.

Cognitive Distortions

  • Definition: Cognitive distortions are irrational or biased thought patterns contributing to negative emotions and behaviors, particularly in depression and anxiety.

  • Common Cognitive Distortions Include:

    • All-or-Nothing Thinking: Viewing situations in extremes without considering middle grounds (Ex: "If I don't get this promotion, I'm a total failure.").

    • Overgeneralization: Drawing broad conclusions from a single negative event (Ex: "I didn’t do well on this test, therefore I'm always going to fail.").

Case Studies on Depression

  • Part 1: Leo, a 14-year-old boy on SSRI treatment exhibiting euphoric behavior and the desire to give away personal belongings raises concern about possible mania or suicidal ideation. Assessment required regarding mood swings post-medication initiation.

  • Part 2: Positive behavior shifts to self-destructive tendencies; priority assessments by the school nurse are needed, addressing safety and communication with Leo’s parents about the signs and interventions.

  • Part 3: Mental status assessment reveals Leo’s suicidal thoughts, educational safety plans, and implications regarding SSRIs need to be thoroughly discussed with family to ensure oversight and support.

Biochemical Factors in Depression

  • The following areas of the brain are implicated in emotional and mood regulation:

    • Limbic System: Emotional alterations.

    • Hypothalamus: Mood regulation.

    • Prefrontal Cortex: Influences mood and problem-solving abilities.

    • Hippocampus: Associated with memory and feelings of worthlessness or hopelessness.

    • Amygdala: Linked to anxiety and motivation.

Other Theories on Depression

  • Cognitive Theory: Describes a triad of negative beliefs contributing to depression, encompassing negative views of self, the world, and beliefs about the future.

  • Learned Helplessness: Indicates an individual’s perception of negative events as their fault, leading to a state of powerlessness.

  • Diathesis-Stress Theory: Suggests a combination of biological predisposition and environmental stressors can lead to the onset of depression.