Download Uncovering Major Depressive Disorder

Uncovering
Major Depressive Disorder
By Rosita Rodriguez, ANP-BC,
NP-C, MSN, DNP(c)
Nursing made Incredibly Easy!
July/August 2009
2.3 ANCC contact hours
Online: 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

Medical comorbidity

Stressful situations

Past suicide attempt

Female gender

Lack of support system


Prior episodes of
depression
Onset before age 40


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 norepinephrinedopamine 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