Depression

DEPRESSION

CASE REPORT

  • Patient Profile: M.M is a 20-year-old woman working part-time at an after-school program.

  • History of Mental Health:

    • Depressed mood and anxiety since age 12

    • Engaged in self-harm (cutting) with a razor blade

    • Head banging and one previous suicide attempt (overdose in 2019)

  • Emergency Presentation:

    • Self-presented to the emergency department (ED) after self-activating EMS following therapist's recommendation for worsening suicidal ideation over the last two weeks.

    • Reported recent self-mutilation with 8-10 new horizontal incisions.

EPIDEMIOLOGY

  • Statistics:

    • Approximately 21.0 million adults in the U.S. have experienced at least one major depressive episode.

    • Prevalence higher in females (10.3%) compared to males (6.2%).

    • Young adults (aged 18-25) show the highest prevalence at 18.6% (NIH, 2021).

DEPRESSION PREVALENCE RATES

Past Year Data (2021)

  • U.S. Adults:

    • Male 18-25: 18.6%

    • Female 18-25: 10.3%

    • Varied prevalence rates across different age groups and racial/ethnic backgrounds.

MAJOR DEPRESSIVE DISORDER

  • Diagnosis Criteria:

    • Minimum of 5 symptoms (SIG: Energy CAPsules) experienced for at least 2 weeks:

      • Sleep disorder (increased/decreased)

      • Interest deficit (anhedonia)

      • Guilt (feelings of worthlessness/hopelessness)

      • Energy and Concentration deficits

      • Appetite disorder (increased/decreased)

      • Psychomotor agitation or retardation

      • Suicidality

POTENTIAL CAUSES FOR DEPRESSION

  • Factors Influencing Depression:

    • Abuse

    • Age (elderly, isolation, lack of social support)

    • Certain medications (e.g. isotretinoin, interferon-alpha, corticosteroids)

    • Conflicts (family/friends)

    • Death or loss

    • Gender (twice as likely in women)

    • Genetics (family history)

    • Major life events, serious illness, substance abuse

TREATMENT GOALS

  • Primary Objectives:

    • Ensure safety and assess suicide risk.

    • Aim to reduce or control symptoms, possibly eliminate depressive signs.

    • Improve occupational and psychosocial function.

    • Reduce relapse and recurrence likelihood.

DEPRESSIVE DISORDERS ACROSS THE LIFE-SPAN

  • Children and Adolescents:

    • Present anxiety and somatic symptoms.

    • Increased irritability, decreased peer interaction, high suicide risk.

  • Older Adults:

    • Often associated with chronic illness.

    • Suicide risk increases in middle age and peaks at age 75.

NURSING ASSESSMENT

Key Components

  • Assessment Areas:

    • History of present illness, general appearance, motor behavior (retardation/agitation).

    • Mood and affect (anhedonia).

    • Thought process (rumination, suicide thoughts) and sensorium (impaired memory).

    • Judgment and insight, self-concept (worthlessness), and physiological considerations.

Depression Rating Scales

  • Utilized Instruments:

    • Self-rating: Patient Health Questionnaire (PHQ-9).

    • Clinician rating: Hamilton Rating Scale for Depression.

Comprehensive Assessment

  • Components:

    • Medical history, medication review, physical examination.

    • Assess neurovegetative symptoms (appetite, sleep disturbance, energy fatigue).

OUTCOME IDENTIFICATION & INTERVENTION

  • Goals for Patients:

    • Safety from self-injury.

    • Capability to independently conduct daily living activities.

    • Achieve balance in rest, sleep, and activity.

    • Engagement in social and occupational activities.

    • Medication compliance.

KAPLAN QUESTIONS

Example Scenario

  • Client Interaction: A nurse finds a crying client expressing self-hate and defeat.

  • Best Response: “You seem to be in pain, so I will stay with you for a while.”

ANTIDEPRESSANTS

  • Considerations:

    • Initial efficacy within 1-3 weeks; maximal response may take up to 12 weeks.

    • FDA warning for increased suicidal tendencies during early treatment.

    • Safety concerns regarding self-harm potential as energy improves.

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

Common Agents

  • Fluoxetine, Sertraline, Fluvoxamine, Paroxetine, Citalopram, Escitalopram

Common Side Effects

  • Adverse Effects:

    • Agitation, nausea, diarrhea, headache, blurred vision, dry mouth, sexual dysfunction, insomnia, sweating.

SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)

  • Examples:

    • Desvenlafaxine, Duloxetine, Levomilnacipran, Venlafaxine

Side Effects

  • Adverse Effects:

    • Nausea, headache, nervousness, sweating, insomnia, hypertension, sexual dysfunction.

TRICYCLIC ANTIDEPRESSANTS

Common Medications

  • Amitriptyline, Nortriptyline, Clomipramine, Imipramine, Doxepin

Management Considerations

  • Administer at bedtime to mitigate daytime sedation, monitor orthostatic hypotension.

  • Risks: Cardiac toxicity, sodium bicarbonate is standard care for TCA poisoning.

ANTICHOLINERGIC EFFECTS

  • Mnemonics:

    • Hot as a hare (increased temperature)

    • Blind as a bat (dilated pupils)

    • Dry as a bone (dry mouth/eyes)

    • Red as a beet (flushed face)

    • Mad as a hatter (delirium)

MONOAMINE OXIDASE INHIBITORS

Common Drugs

  • Isocarboxazid, Phenelzine, Tranylcypromine, Selegiline

Risks

  • Rarely used due to potential for hypertensive crisis from dietary tyramine.

  • Symptoms include severe headache, confusion, tachycardia, nausea, vomiting, stroke, and death.

  • Preventive Measures: Avoid aged meats, bananas, fermented foods.

ATYPICAL ANTIDEPRESSANTS

  • Example: Bupropion (Wellbutrin)

Advantages and Disadvantages

  • Pro: No weight gain, no sexual dysfunction, aids smoking cessation.

  • Con: Lowers seizure threshold; not suitable for patients with eating disorders or seizure history.

Side Effects

  • Insomnia, agitation, weight loss, nausea, dry mouth.

SEROTONIN SYNDROME

  • Onset: Often within 72 hours of treatment.

  • Symptoms: Altered mental status, fever, excessive sweating, incoordinated movements.

  • Risks: Concurrent use of MAOIs and SSRIs, which may lead to death if untreated.

DRUG INTERACTIONS

  • SSRIs and MAOIs: Risk of serotonin syndrome; requires a 14-day wash-out period.

OTHER MEDICAL TREATMENTS

  • Therapies:

    • Electroconvulsive therapy (ECT)

    • Psychotherapy (especially Cognitive Behavioral Therapy) focusing on cognitive distortions.