Uncovering Major Depressive Disorder

By Rosita Rodriguez, ANP-BC, NP-C, MSN, DNP(c)Nursing made Incredibly Easy! July/August 20092.3 ANCC contact hoursOnline: www.nursingcenter.com

© 2009 by Lippincott Williams & Wilkins. All world rights reserved.

Major Depressive Disorder (MDD)

Leading cause of disability in the U.S. for people ages 15 to 44

Effects 14.8 million Americans (6.7% of the U.S. population) age 18 and older each year

Estimated 2 million Americans over age 65 have a depressive disorder

Median age onset is 32

Definition

Characterized by at least 2 weeks of a depressive mood and 4 or more of the following characteristics:• Significant weight loss or gain• Sleep difficulties• Psychomotor agitation• Fatigue• Suicidal thoughts• Inability to concentrate• Feelings of sadness, worthlessness or guilt

These symptoms must be present almost every day for at least two weeks, and not caused by bereavement, illness, or substance abuse

Subtypes

Psychotic depression: severe depressive illness with psychosis, such as delusions or hallucinations

Postpartum depression: when a new mother is diagnosed with depression within 1 month after delivery

Seasonal affective disorder (SAD): depressive illness during winter months when less natural sunlight is present

Dysthymic Disorder

Also known as dysthymia

Less severe, long-term form of depression

Symptoms last most of the day, on most days, for 2 years or longer

People with dysthymia may experience major depression over their lifetimes

Pathophysiology

Exact cause is unknown, but there are several theories

Norepinephrine and serotonin are deficient

Deficiency in serotonin reuptake sites (as found on autopsy)

Hypersecretion of cortisol

Hypothyroidism (especially women)

Circadian rhythm changes (evidenced by abnormal sleep patterns in these patients)

Defective gene on chromosome 4 (patients with this gene are 26 times more likely to be hospitalized for severe depression/attempted suicide)

Neurotransmitters Out of Balance

Other Theories

Kindling: environmental stressors activate internal physiologic stress responses; with reoccurring event, takes less to activate depression

Inward anger and aggression over a significant loss

Negative cognitive patterns developed over time

Risk Factors

Family history

Stressful situations

Female gender

Prior episodes of depression

Onset before age 40

Medical comorbidity

Past suicide attempt

Lack of support system

History of physical or sexual abuse

Current substance abuse

Medical Conditions Associated with Depression

Cerebrovascular accident

Cognitive impairment disorders (dementia)

Diabetes

Cancer

Coronary artery disease

Chronic fatigue syndrome

AIDS

Medications that May Cause Depression

Hormones

Cardiovascular drugs

Psychotropic medications

Anti-inflammatory and anti-infective drugs

Anti-ulcer medications

Depression in Older Adults

Older adults are at increased risk for MDD but may be overlooked as symptoms may present differently

More medical conditions may cause depressive symptoms or medications may have adverse reactions that can cause depression

Highest suicide rate is in men age 85 and older

Somatic Complaints that May Signal Depression

Headache

Backache

Abdominal pain

Fatigue

Malaise

Anxiety

Decreased desire or problems with sexual functioning

Assessing Patients with Depression

The following are questions you can ask your patient who has been diagnosed with depression:

• Can you describe what your depression feels like to you? How long have you felt this way?• How would you rate your feeling of depression on a scale of 1 to 10, with 10 being the worst depression?• What activities or things in your life give you pleasure?• Do you sleep excessively or have difficulty sleeping?• Have you lost weight recently or do you have a poor appetite?• Have you experienced any losses or changes in your life?• Are you experiencing thoughts of suicide? Do you have a specific suicide plan?

Evaluating for Depression

Medical history, including alcohol and substance abuse

Physical exam, including mental status exam

Thorough medication history

Family, social, and occupational history

Recent illnesses

Current stress

Characteristics of MDD

Physiologic responses • Altered appetite (increased or decreased)• Altered sleep patterns (hypersomnia or insomnia)

Cognitive responses • Indecisiveness• Reduced concentration and attention span

Emotional responses • Sadness or despondency• Anger, agitation, or resentfulness• Guilt or feelings of worthlessness• Hopelessness or helplessness• Apathy

Characteristics of MDD

Behavioral responses

• Poor personal hygiene• Psychomotor retardation• Decreased motivation• Anhedonia• Frequent complaints and demands• Lack of spontaneity• Lack of exercise• Fatigue• Somatic complaints• Restlessness and undirected activity

Suicide Risk Factors

Previous suicide attempt

Organized plan

Alcohol or substance abuse

Presence of thought disorder

Lack of support system

Unmarried, divorced, or widowed

Presence of physical illness (especially chronic)

Pharmacologic Treatment

Selective serotonin reuptake inhibitors (SSRIs): often first-line medication

Serotonin-norepinephrine reuptake

inhibitors (SNRIs): increase availability of serotonin and

epinephrine

Tricyclic antidepressants: block serotonin reuptake

Other medications include a norepinephrine-dopamine reuptake inhibitor, a noradrenergic and specific serotonergic antidepressant, and monoamine oxidase inhibitors

Nonpharmacologic Treatment

Psychotherapy: includes cognitive, behavior, psychodynamic, and group therapy; alone or in combination with medication is considered an important treatment component

Electroconvulsive therapy (ECT): for patients with severe medication resistant depression

Patient Teaching

Teach him about MDD, including:• The nature of the illness• Symptom identification and management (including signs and symptoms of relapse) • Treatment recommendations, including information about prescribed medication and its expected effects • Long-term self-management

Make sure he understands that taking medication as prescribed is important and that antidepressants may not have an immediate effect; it may take 2 to 4 weeks or longer for him to experience a noticeable improvement in his mood

Teach him the importance of continuing treatment and not to abruptly stop taking his medication, even if he feels better

Teaching for Family

Don’t try to cheer up the patient; be accepting of his current mood

Be supportive and encourage the patient by assuring him that his mood will improve with treatment

Encourage maintaining regular activities with rest

Take talk about suicide seriously; contact the healthcare provider if this occurs