Depression: Depressive Moods and Suicidal Behavior

DEPRESSION

Overview of Depressive Moods and Suicidal Behavior

MOOD AND DEPRESSION

  • Mood:

    • Definition: A pervasive and sustained emotion that colors one’s perception of the world and influences functioning.

  • Affect:

    • Expression of mood characterized by:

    • Blunted: Diminished expressiveness.

    • Bright: Cheerful and expressive.

    • Flat: Absence of emotional expression.

    • Inappropriate: Discrepancy between affect and situation.

    • Labile: Rapid changes in emotional expression.

  • Depression:

    • Definition: A condition where a sad, irritable, or empty mood is present along with somatic (physical) and cognitive changes that hinder functioning.

DEPRESSIVE DISORDERS OVERVIEW

Depressive Disorders Across the Life-Span

  • Children and Adolescents:

    • More prone to exhibit anxiety symptoms.

    • Increased risk of suicide, peaking during mid-adolescence.

  • Older Adults:

    • Often undetected or inadequately treated.

    • Commonly associated with chronic illness; symptoms may be mistaken for dementia or strokes.

    • Estimated 8% to 20% prevalence in this population.

    • Suicide rates peak in middle age, with a second peak in individuals aged 75 and older.

MAJOR DEPRESSIVE DISORDER

Epidemiology

  • Prevalence in the U.S.:

    • 10.4% within a 12-month period.

    • Lifetime prevalence of 20.6%.

  • Age Correlation:

    • Individuals aged 18 to 29: 3× higher prevalence compared to those aged 60 and older.

    • Twice as common in females than males (females: 13.3%, males: 7.2%).

  • Recurrence:

    • More than 50% of individuals recovering from an initial depression episode will experience another episode within 5 to 10 years.

  • Co-occurring Disorders:

    • Coupled with other psychiatric and substance-related disorders.

    • Linked to chronic medical conditions, especially endocrine disorders, cardiovascular disease, and neurological disorders.

CASE STUDY: MARIA

  • Profile:

    • Age: 45 years old, high school teacher.

    • Complaints: Persistent fatigue and frequent headaches lasting three weeks.

    • Personal Life: Divorced, lives with two teenage children.

    • Emotional State: Feels emotional numbness; overwhelmed by daily responsibilities; loss of interest in teaching and daily activities.

    • Physical Changes: Irregular eating habits; 10-pound unintentional weight loss over two months.

    • Suicidal Ideation: Admits to thoughts of wishing she wouldn’t wake up, denies active suicidal intent.

  • Medical History: Hypertension and seasonal allergies.

MAJOR DEPRESSIVE DISORDER

Clinical Course

  • Diagnosis (DSM 5-TR):

    • Criteria for diagnosis includes: One or more of the following moods for at least two weeks: depressed mood or loss of interest or pleasure (anhedonia).

    • Must also include at least four out of the following seven additional symptoms:

    • Disruption in sleep.

    • Appetite (or weight) changes.

    • Concentration difficulties.

    • Changes in energy.

    • Psychomotor agitation or retardation.

    • Excessive guilt or feelings of worthlessness.

    • Suicidal ideation.

MAJOR DEPRESSIVE DISORDER

Risk Factors for Depression

  • Previous episodes of depression.

  • Family history of depressive disorders.

  • Lack of social support and coping abilities.

  • Presence of life stressors or environmental challenges.

  • Current substance use or abuse.

  • Coexisting medical and/or mental illness.

MAJOR DEPRESSIVE DISORDER

Theoretical Perspectives

Social Theories

  • Family Factors: Influence on depressive symptoms.

  • Environmental Factors: Environmental contributions to the disorder.

Psychological Theories

  • Psychodynamic Factors: Emotional and psychological processes.

  • Behavioral Factors: Behavioral patterns contributing to depression.

  • Cognitive Factors: Thoughts and belief systems influencing mood.

  • Developmental Factors: Impact of development stages on depression.

Biologic Theories

  • Genetics: Hereditary factors.

  • Neurobiologic Hypotheses: Brain and neurotransmitter involvement.

  • Neuroendocrine Factors: Hormonal and biological processes affecting mood.

OTHER DEPRESSIVE DISORDERS

  • Persistent Depressive Disorder (Dysthymia): Symptoms lasting two years in adults, one year in children/adolescents.

  • Premenstrual Dysphoric Disorder: Severe mood symptoms associated with menstrual cycles, including irritability and temper outbursts.

  • Disruptive Mood Dysregulation Disorder: Characterized by severe irritability and mood swings prior to the age of 10.

RECOVERY-ORIENTED CARE FOR PERSONS WITH DEPRESSIVE DISORDERS

Goals of Treatment

  • Reduce or control symptoms, with the aim to eliminate signs of depressive syndrome.

  • Improve occupational and psychosocial functioning.

  • Reduce likelihood of relapse and recurrence via recovery-oriented strategies.

  • Therapeutic Approaches:

    • Cognitive therapies.

    • Interpersonal therapies.

    • Combination therapies involving both medication and therapy.

    • Alternative therapies (e.g., lifestyle modifications).

EVIDENCE-BASED NURSING CARE OF PERSONS WITH DEPRESSIVE DISORDER

Mental Health Nursing Assessment

  • Focus on physical consequences and psychosocial aspects.

  • Recognize that symptoms can mimic medical conditions or medication side effects.

  • The mental health nurse may provide holistic care, especially when others focus solely on medical aspects.

CASE STUDY: MARIA’S ASSESSMENT

Data Collected

  • Symptoms: Persistent fatigue and headaches for the past three weeks.

  • Emotional State: Feels emotionally numb and overwhelmed; loss of interest in daily activities; irregular eating habits; lost 10 pounds.

  • Thoughts: Wishing to not wake up; denies active suicidal ideation.

Physical Health History

  • Hypertension and seasonal allergies.

Nursing Assessment

  • Ensure medical causes are ruled out; reconcile medication history.

  • Conduct Mental Status Exam (MSE) and risk assessment for suicidality/self-harm.

  • Utilize rating scales like Beck Depression Inventory and PHQ-9 (Maria scored 18).

  • Assess substance use and evaluate sleeping and functioning conditions.

CASE STUDY: MARIA’S NURSING DIAGNOSIS

  • Risk for Suicide: Related to feelings of hopelessness, emotional numbness, and passive suicidal ideation, as evidenced by statements such as “sometimes wishes she wouldn’t wake up,” withdrawal from activities, and PHQ-9 score of 18.

  • Disturbed Sleep Pattern: Related to depressive symptoms and emotional overwhelm, as evidenced by reports of difficulty sleeping, fatigue, and low energy.

  • Imbalanced Nutrition: Less than body requirements due to decreased appetite and emotional distress, as evidenced by unintentional weight loss and irregular eating habits.

EVIDENCE-BASED NURSING CARE OF PERSONS WITH DEPRESSIVE DISORDER

Therapeutic Relationships

  • Built on culturally competent interventions and strategies.

  • Nurse's availability during crises and vigilance regarding danger to self/others.

  • Provide education about the illness, treatment goals, and encouragement regarding progress.

  • Set realistic goals and monitor progress in a supportive framework.

MEDICATIONS FOR DEPRESSION

Classes of Antidepressants

  • SSRIs (Selective Serotonin Reuptake Inhibitors)

  • SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)

  • NDRIs (Norepinephrine-Dopamine Reuptake Inhibitors)

  • Tricyclic Antidepressants

  • MAOIs (Monoamine Oxidase Inhibitors)

Black Box Warning and Safety

  • Serotonin Syndrome:

    • Cause: Excessive intrasynaptic serotonin due to certain medication combinations increasing CNS serotonin levels.

    • Symptoms: Changes in mental status, agitation, ataxia, myoclonus, hyperreflexia, fever, shivering, diaphoresis, diarrhea.

    • Treatment: Assessment of all medications/supplements, discontinue any causative substances:

    • Mild symptoms: Supportive treatment with propranolol and lorazepam.

    • Moderate/Severe symptoms: Hospitalization, vital sign monitoring, fluids, antipyretics, and cooling measures.

MENTAL HEALTH NURSING INTERVENTIONS

Psychosocial Interventions

  • Therapeutic Interactions: Encourage realistic goal-setting, and promote engagement in social activities.

  • Enhancing Cognitive Functioning: Strategies include thought stopping, positive self-talk, and cognitive-behavioral therapy (CBT).

  • Behavioral Interventions: Activity scheduling, social skills training, and problem-solving assistance.

Psychoeducation

  • Teach patients about symptoms and involve family in education.

  • Develop a support system and stress management strategies.

  • Encourage physical activity, healthy eating, and adequate sleep.

Collaborative Care

  • Emphasize interdisciplinary team involvement for comprehensive care.

OTHER SOMATIC THERAPIES

  • Electroconvulsive Therapy (ECT): Effective for treatment-resistant depression.

  • Light Therapy: Used for Seasonal Affective Disorder (SAD).

  • Repetitive Transcranial Magnetic Stimulation (rTMS):

    • Procedure involves stimulating the brain with magnetic fields enough to depolarize neurons across synapses without anesthesia.

    • Typically requires 20 to 30 sessions lasting 37 minutes each over a span of 4 to 6 weeks.

CASE STUDY: MARIA’S PLAN

  • Immediate referral to mental health professionals for evaluation and therapy due to passive suicidal ideation and depression severity.

  • Educate on sleep hygiene, including limiting caffeine and establishing a proper sleep schedule.

  • Encourage small, frequent meals with nutrient-dense snacks to combat low appetite.

CASE STUDY: MARIA’S IMPLEMENTATION

  • Provide education on Major Depressive Disorder (MDD) symptoms and progression.

  • Teach coping strategies: routine building, gratitude exercises, mindfulness, journaling, sleep hygiene, physical endeavors, goal-setting.

  • Encourage engagement in Cognitive Behavioral Therapy (CBT) and support groups.

  • Reinforce adherence to medications and non-pharmacological approaches.

  • Collaborate with providers for medication management, include antidepressants and mood stabilizers, with attention to side effects and efficacy evaluation.

  • Promote ongoing safety assessments regarding suicidal ideation/self-harm behavior due to heightened risk as improvement occurs.

CASE STUDY: MARIA’S EVALUATION

  • Referral results: Maria has received outpatient mental health treatment for four weeks and actively participates in both individual and group therapy with medication management.

  • Progress Indicators:

    • Reports improved depression, energy, appetite, interest in activities, and sleep quality.

    • Current PHQ-9 score is 14, indicating moderate depression.

CASE STUDY: MARIA’S EVALUATION

Indicators of Progress

  • Reduction in depressed mood and passive suicidal ideations.

  • Increased energy, improved appetite, less anhedonia (loss of interest), improved sleep quality.

  • Successfully utilizing adaptive coping strategies and therapy participation.

If Outcomes Not Met:

  • Re-evaluate stressors, symptoms, and barriers to recovery.

  • Increase frequency of therapy sessions and assess current therapeutic modalities.

  • Consider medication adjustments or necessary elevation in care level.