Depression

Depression

Chapter 25 - Overview

  • Focus on Major Depressive Disorder (MDD) and associated concepts

Objectives

  • Describe symptoms and course of Major Depressive Disorder (MDD)
  • Identify diagnostic criteria for MDD
  • Recognize differences in presentation across age groups: children, adolescents, older adults
  • Apply nursing assessments and interventions
  • Explain treatment options including medications, Electroconvulsive Therapy (ECT), and psychotherapy
  • Prioritize safety and suicide risk assessment

Definition of Depression

  • A mood disorder characterized by:
    • Persistent sadness
    • Loss of interest (anhedonia)
    • Low energy
    • Impaired concentration
    • Sleep and appetite changes
  • When symptoms interfere with daily functioning, it is classified as a depressive disorder

Major Depressive Disorder (MDD) Criteria

  • Diagnostic criteria require:
    • Duration of symptoms: ≥ 2 weeks of depressed mood and/or loss of interest
    • Plus ≥ 5 additional symptoms (from specified categories such as sleep, appetite, etc.)
  • Course of illness: episodes typically last 4–6 months; conditions can recur and may worsen over time

Symptoms of Depression (using SIGECAPS)

  • Sleep changes: insomnia or hypersomnia
  • Interest decrease: notably in activities once enjoyed
  • Guilt/worthlessness feelings: persistent negative self-evaluation
  • Energy decrease: fatigue and loss of energy
  • Concentration difficulties: marked indecision or inability to focus
  • Appetite changes: increase or decrease in food intake leading to weight changes
  • Psychomotor agitation/retardation: observable restlessness or slowed movements
  • Suicidal thoughts: ideation or plans regarding self-harm

Risk Factors for MDD

  • Personal or family history of depression
  • Lack of social support: feeling isolated or without community
  • Poor coping skills: difficulties in managing stress
  • Substance use: can exacerbate mood disorders
  • Medical illnesses: chronic conditions that affect mental health
  • Environmental stressors: such as trauma or significant life changes
  • More prevalent in women; typically emerges between ages 18–29

Neurotransmitters and Depression

  • Depression is associated with dysregulation of specific neurotransmitters:
    • Serotonin
    • Norepinephrine
    • Dopamine

Special Populations

Children

  • Symptoms may manifest as:
    • Irritability and crankiness
    • Hyperactivity: often mistaken for other behavioral issues
    • School avoidance: high reluctance to attend or participate
    • Somatic complaints: reporting physical symptoms like stomach aches or headaches
    • Declining academic performance

Adolescents

  • Common features include:
    • Substance use: can be a coping mechanism for pain
    • Eating disorders: disturbances in eating habits
    • Risky or impulsive behaviors
    • Social withdrawal: isolating from peers and activities

Older Adults

  • Presenting symptoms often involve:
    • Somatic complaints: physical manifestations that may be overlooked
    • Cognitive changes: issues with memory and confusion
    • Higher suicide risk after age 65
    • Often underdiagnosed, leading to inadequate treatment

Seasonal Affective Disorder (SAD)

  • Characterized by depressive symptoms triggered by seasonal changes (often winter)
  • Treatment options include:
    • Light therapy: exposure to artificial light to alleviate symptoms
    • Antidepressants: medications to manage symptoms
    • Psychotherapy: counseling to address feelings and behaviors
    • Vitamin D supplementation: if deficiency is present

Disruptive Mood Dysregulation Disorder (DMDD)

  • Presents as chronic irritability and severe temper outbursts
  • Diagnosis must occur before age 10
  • Treatment options primarily include:
    • Psychotherapy
    • Sometimes antidepressants, stimulants, or antipsychotics

Overview of MDD Treatment

  • Options for MDD treatment include:
    • Antidepressants
    • Psychotherapy (especially Cognitive Behavioral Therapy - CBT)
    • Electroconvulsive Therapy (ECT)
    • Transcranial Magnetic Stimulation (TMS)
    • Ketamine/Esketamine: emerging treatments
  • Best outcomes often found with a combined therapy approach

Selective Serotonin Reuptake Inhibitors (SSRIs)

  • First-line treatment; examples include:
    • Sertraline
    • Escitalopram
    • Citalopram
  • Key points:
    • Generally have fewer side effects
    • Taken in the morning (to reduce insomnia)
    • Effects generally take 2–4 weeks to manifest
    • Risk of serotonin syndrome if mismanaged

SSRIs Nursing Teaching Points

  • Do not abruptly stop: Risk of discontinuation syndrome, which includes symptoms like gastrointestinal upset, dizziness, and sensory disturbances
  • Monitor for increased anxiety, agitation, and suicidality in early weeks of treatment
  • Report issues such as sexual dysfunction, insomnia, or GI disturbances to provider

Tricyclic Antidepressants (TCAs)

  • Examples include:
    • Amitriptyline
    • Imipramine
  • Key points:
    • Often taken at night due to sedative properties
    • Known for strong anticholinergic effects
    • Takes 6–8 weeks for full effect
    • Not recommended for clients with suicidal ideation due to high lethality in overdose

Monoamine Oxidase Inhibitors (MAOIs)

  • Examples include:
    • Phenelzine
    • Selegiline
    • Isocarboxazid
  • Key points:
    • Must avoid tyramine-rich foods (risk of hypertensive crisis), e.g., aged cheeses, cured meats, beer, etc.
    • Requires a 2-week washout period when switching medications
    • Typically reserved for treatment-resistant depression

Tyramine-Rich Foods to Avoid

  • Aged cheeses
  • Cured or aged meats
  • Fermented foods: e.g., sauerkraut, tofu
  • Alcohol products: beer, wine
  • Overripe fruits

Atypical Antidepressants

  • Bupropion:
    • Increases norepinephrine and dopamine levels
    • Has mild stimulating effects; recommended to take in the morning
    • Contraindications: seizure disorders and eating disorders

Common Antidepressant Side Effects

  • Weight gain
  • Orthostatic hypotension
  • Sexual dysfunction
  • Gastrointestinal symptoms: Nausea, vomiting, diarrhea
  • Fatigue (especially common in TCAs)
  • Tremors (usually resolve after a period of adjustment)
  • Blurry vision (may improve with adjustment)
  • Headaches (often improves after some time)

Antidepressants + Safety Considerations

  • Monitor for increased energy combined with ongoing hopelessness → indicates increased suicide risk
  • When switching to MAOIs, always follow with a 2-week washout period
  • Report symptoms of serotonin syndrome immediately if SSRIs are being used
  • MAOIs require immediate intervention for severe headaches that may occur

Serotonin Syndrome

  • Caused by excess serotonin in the body typically from combinations of medications (e.g., SSRI + MAOI or St. John's Wort)
  • Symptoms include:
    • Agitation
    • Fever and sweating
    • Tachycardia
    • Hyperreflexia
    • Tremors
    • Rigidity
  • Severe cases can progress to coma or death

Electroconvulsive Therapy (ECT)

  • Indications for ECT:
    • Severe depression
    • Suicidal urgency
    • Treatment-resistant depression
  • Benefits include rapid relief from symptoms; short-term memory loss is a significant concern for patients

ECT Procedure & Recovery

  • Can be performed as outpatient or inpatient treatment
  • Involves short duration anesthesia
  • Typically involves 12–15 treatments
  • Post-treatment side effects can include:
    • Confusion
    • Headache
    • Temporary memory impairments

Nursing Care for ECT

Before ECT

  • Ensure client is NPO (nothing by mouth) after midnight
  • Remove dentures and jewelry
  • Obtain baseline vital signs
  • Ensure consent has been obtained

After ECT

  • Monitor airway and vital signs closely
  • Reorient the client as necessary post-procedure
  • Implement fall precautions due to potential disorientation
  • Provide short-term memory support as needed

Transcranial Magnetic Stimulation (TMS)

  • A non-invasive therapy option using magnetic pulses to stimulate specific areas of the brain
  • Patient remains awake during the procedure
  • Treatment involves daily sessions for 4–6 weeks

Ketamine / Esketamine

  • Known for rapid reduction in depressive symptoms
  • Administration: via clinic as a nasal spray or intravenous (IV) infusion
  • Indication: for treatment-resistant depression
  • Avoid usage in patients with substance use disorders, psychosis, or during pregnancy

Psychotherapy (Cognitive Behavioral Therapy - CBT)

  • CBT focuses on:
    • Identifying and reframing:
      • All-or-nothing thinking
      • Catastrophizing
      • Overgeneralizing
      • Minimization
  • Aims to help clients build coping skills and challenge distorted thought patterns

Nursing Assessment: History

  • Important questions include:
    • Previous depressive episodes: history is crucial for diagnosis
    • Medications tried: to avoid duplication or adverse effects
    • Suicidal behavior: assess risk levels
    • Family history of mental illness: genetic influence consideration
    • Substance use: correlation with mood disorders

Common Screening Tools

  • PHQ-9: frequently used for depression assessment
  • Geriatric Depression Scale (GDS): tailored for older adults
  • Columbia Suicide Severity Rating Scale (C-SSRS): focused on suicide risk evaluation

Physiologic Assessment

  • Key areas of assessment include:
    • Appetite and weight changes
    • Sleep patterns: focusing on initial, middle, and terminal insomnia
    • Energy level: assessing fatigue or hyperactivity
    • Sexual functioning
    • Somatic complaints: reporting of physical symptoms

Mental Status Exam: Overview

  • Evaluating components include:
    • Appearance and behavior
    • Mood and affect
    • Thought processes and content
    • Cognition: orientation, memory evaluation
    • Judgment and insight

Suicide Risk Assessment

  • Directly inquire about:
    • “Are you thinking about harming yourself?”
    • “Do you have a plan?”
    • “Do you have access to the means to harm yourself?”
  • Priority of assessment: Ensure the client's safety

Suicide & Age-Related Considerations

  • Important predictors of suicide attempts in children and adolescents include:
    • Bullying
    • Unsafe home environment
    • Depression
    • Emotional trauma
    • Alcohol abuse (particularly in young adults)

Nursing Interventions for Suicide Ideation

  • Ensure immediate safety: Primary concern
    • Maintain 1:1 observation; ensure client is within arm’s length
    • Remove all potential hazards (e.g., sharp objects, cords, belts, toxic substances)
    • Place client in a safe environment (e.g., using paper scrubs, avoiding private rooms)
    • Keep the room free of ligature risks to prevent self-harm

Nursing Diagnoses for Clients with Depression

  • Risk for self-harm
  • Hopelessness
  • Imbalanced nutrition
  • Sleep pattern disturbance
  • Self-care deficit
  • Social isolation

Nursing Interventions

  • Provide therapeutic communication to foster trust
  • Encourage small, realistic goals to boost self-efficacy
  • Promote establishment of routine: sleep, nutrition, and activities of daily living (ADLs)
  • Ensure safety practices including 1:1 observation and hazard removal
  • Provide medication education and monitoring throughout treatment

Expected Outcomes for Clients

  • Clients will:
    • Remain safe
    • Perform ADLs independently
    • Show improvement in sleep and appetite
    • Engage socially with others
    • Identify and utilize coping strategies
    • Adhere to treatment regimen
    • Recognize early warning signs of worsening mood

Suicide & Crisis Lifeline

  • Dial 988: A resource for free and confidential emotional support available 24/7.