Unit 2- Major Depressive Disorder

●      Major depressive disorder

Pathophysiology

Major Depressive Disorder (MDD) also called clinical depression is when a client experiences a severe depressed mood, loss of enjoyment in life, low energy & few other critical signs and symptoms. Everything is low & slow, it is thought to be from low levels of neurotransmitters within the brain, more specifically a dysregulation of serotonin and norepinephrine

·       Dopamine, Ach, GABA, and glutamate also involved


Etiology

Biological factors:

•       Family history- when depression runs in the family, we will see at an earlier age of onset, more comorbidity, and more recurrence of illness

•       Genetic factors are less involved in late onset

 

     Biochemical 

Stressful life events- Early life experiences such as harsh or abusive parenting during childhood could make a person more psychologically sensitive to rejection and more biologically sensitive to stress.

·       A wide range of later life events including separations, job loss, loss of self esteem, death of someone important, extreme poverty are implicated.

 

Diathesis-stress model

            The stress-diathesis model of depression is a biopsychosocial theory that explains depression as environmental, interpersonal, and life-events perspective, combined with biological vulnerability or predisposition (diathesis).

            Psychosocial stressors and interpersonal events can trigger neurophysiological and neurochemical changes in the brain.

  Stressful events can cause brain changes that can lead to depression in a vulnerable brain.

Early life trauma can lead to neurotransmitter depletion. This can lead to neuronal damage and depression later in life.

 

 

Other theories:

                 Alterations in Hormonal Regulation- Many severely depressed patients have high blood levels of cortisol, caused by chronic stress.

            Depressed persons display hyperactivity in the HPA (hypothalamus, pituitary gland, and Adrenal glands) axis.

 

     Inflammatory Process

     Psychological factors

 

                  Cognitive theory- According to cognitive behavioral theory, depressed people think differently than non-depressed people

             Depressed people view themselves, their environment, and the future in a negative, pessimistic light.

             As a result, depressed people tend to misinterpret facts in negative ways and blame themselves for any misfortune that occurs.

            Cognitive Behavioral Therapy (CBT) teaches clients how to identify and change distorted thinking

 

     

Learned helplessness:

·       A state in which people conclude that unpleasant or aversive stimuli cannot be controlled

·       A view of the world that become so ingrained that they cease trying to remedy the aversive circumstances, even if they actually can exert some influence


Signs & Symptoms

  • Frequent napping during the day

  • Aggressive behavior changes

  • Difficulty concentrating

  • Anhedonia- Withdrawn from activities that would otherwise bring the client joy

  • Insomnia

  • Slower speech

  • Anergia

 

Risk Factors:

·       Family history of mood disorders

·       A serious medical condition

·       A chronic disability

·       The lack of a support system

·       A history of abuse/trauma

·       Early loss of significant other

·       Poverty

·       Loss of employment/humiliation

·       Alcohol/substance use

·       Postpartum period

●      Persistent depressive disorder (Dysthymia)

●      Suicidal behavior


Medical Management

     Medications

1.     Selective serotonin reuptake inhibitors (SSRIs)

2.     Atypical antidepressants (non SSRIs)

3.     Tricyclic antidepressants (TCAs)

4.     Monoamine oxidase inhibitors (MAOIs)

Psychotherapies

·       Interpersonal: focuses on difficulties in relationships and role this plays in depression

·       Cognitive Behavioral Therapy (CBT) is particularly effective for mild and moderate depression, restructure negative thought patterns

·       CBT is goal oriented, time limited with client actively engaged

·       Mindful based cognitive therapy – present moment awareness,  disengage from ruminative thoughts

  • Cognitive Reframing- In this phase the client learns to identify ineffective responses or thought processes to the disorder or phobia. Once identified, the client then learns to work through the initial response and transition to a more manageable response. This phase teaches the client how to identify the less productive thought, belief, or attitude. Once identified, the client learns techniques to change the initial response to a more productive or manageable response.

  • Self Observation- In this phase the client implements self-observation to identify triggers and responses to situations and events.


Electroconvulsive therapy (ECT)

  • The procedure is explained and informed consent is obtained.

  • A short acting general anesthetic is used to allow the patient to be asleep during the short procedure.

  • The induction of electrical activity on the scalp to create a generalized seizure to treat depression.

  • ECT is an alternative treatment for clients who are unresponsive to antidepressants and cognitive behavior interventions.

  • Seizures are induced in the client to treat clinical depression, schizophrenia, and bipolar disorder

ECT Preprocedure Interventions:

  • With hold food and fluids for 6 hours before

  • Stop anticonvulsant medication

  • Remove dentures and contact lenses

  • Have a cardiac monitor, crash cart, O2, and suction ready

  • Have O2 and suction ready


Potential Adverse Reactions of ECT:

  • The patient may be confused and disoriented

  • Headache , muscle soreness, and nausea

  • Short term memory deficits for the first few hours to weeks after.


·       Transcranial magnetic stimulation

·       Vagus nerve stimulation

·       Deep brain stimulation


    Other treatments:


·       Light therapy- first line treatment for seasonal affective disorder, adjunct for other depressions; 30 to 45 minutes daily; light boxes shield UV

·       St. John’s Wort- mild to moderate depression; thought to increase serotonin, norepinephrine, dopamine in the brain.  Should not be taken with other medications. Risk of Serotonin Syndrome.

·       Exercise- increases serotonin, endorphins, dampens hypothalamic–pituitary–adrenal (HPA) axis, effective and few side effects

 

Nursing Care

·       Assessment: Monitor mood, sleep, appetite, energy, and suicidal ideation

·       Therapeutic Communication: Be empathetic, nonjudgmental, and supportive

·       Education:

o   Teach about the chronic nature of dysthymia and the importance of ongoing treatment

o   Stress medication adherence and regular follow-up

o   Discuss side effects and when to report them

o   Encourage self-monitoring (journaling, mood apps)

·       Safety: Assess for suicide risk and implement safety plans if needed

·       Collaboration: Work with interdisciplinary teams (psychiatrists, therapists, social workers)

·       Support Systems: Encourage involvement of family and community resources


Interventions

  • Encourage the client to particiapte in group activities

  • Offer to help the client get out of bed and dressed

  • Sit with the client

  • Communicate with client in a simple language and direct communication