Major Depressive Disorder (MDD)

• Depressive disorders are covered in Week 7, addressing Mental Health and Crisis Management Theory

Introduction to Mood Disorders

• Mood disorders called affective disorders
• Mood disorders are a group of psychiatric disorders including depression and bipolar disorder
• All ethnicities, cultures, ages, socioeconomic groups, education levels, and geographic areas are susceptible to depressive episodes
• Some individuals are more susceptible to depressive episodes

Clinical Picture: Major Depressive Disorder (MDD)

• MDD is one of the most common psychiatric disorders

• MDD affects women more than men in a 2:1 ratio

• Approximately 1 in 8 adults experience MDD

• Key characteristics of MDD:

  • Persistently depressed mood for a minimum of 2 weeks, though the length can vary
  • Depressed mood experienced most of the day, nearly every day, indicated by subjective report (sadness, emptiness, hopelessness) or observation by others (tearfulness); in children and adolescents, can be irritable mood
  • Markedly diminished interest or pleasure in activities most of the day, nearly every day
  • Significant weight loss when not dieting or weight gain (a change of more than 5% of body weight in a month) or decrease or increase in appetite nearly every day; consider failure to make expected weight gain in children
  • Insomnia or hypersomnia nearly every day
  • Psychomotor agitation or retardation nearly every day, observable by others
  • Fatigue or loss of energy nearly every day
  • Feelings of worthlessness or excessive or inappropriate guilt nearly every day
  • Diminished ability to think or concentrate or indecisiveness nearly every day
  • Recurrent thoughts of death, suicidal ideation, suicide attempt, or a specific plan for suicide

• 20% of MDD cases become chronic

• Depressed mood in MDD impairs with Emotional, Cognitive, Physical, and Behavioural symptoms

• The diagnosis for MDD may include one of the following specifiers to describe the most recent episode of depression:

  • Psychotic features: presence of disorganized thinking, delusions, hallucinations
  • Melancholic features: endogenous depression (severe apathy, weight loss, profound guilt)
  • Atypical features: dominant vegetative symptoms (overeating, oversleeping)
  • Catatonic features: non-responsiveness (paralyzed, withdrawal)
  • Postpartum onset: 4 weeks after childbirth, severe ruminations about the infant
  • Seasonal features (seasonal affective disorder [SAD]): episodes begin in fall or winter, hyperinsomnia, overeating, weight gain

Other Depressive Disorders

• Disruptive mood dysregulation disorder features severe and recurrent temper outbursts inconsistent with the developmental level, alongside constant and severe irritability and anger
• Persistent depressive disorder (dysthymia) involves feelings of depression most of the day, along with changes in appetite, sleep, and energy.
• Premenstrual dysphoric disorder presents as a cluster of symptoms the week before the onset of the menstrual period, including mood swings, irritability, depression, anxiety, and feeling overwhelmed
• Substance or medication-induced depressive disorder results from prolonged use or withdrawal from drugs and alcohol, appearing within 1 month of use
• Depressive disorder due to another medical condition is caused by disorders that affect the body's systems or from long-term illness that causes ongoing pain, examples include Parkinson's, Huntington's, Alzheimer's, TBI, Cushing disease, hypothyroidism, cancer, HIV

Epidemiology

• Depression is a leading cause of disability
• Lifetime prevalence of depression is 11.3%
• Higher prevalence rates are observed in lower income, unemployed populations, and unmarried or divorced individuals
• The average onset of depression is between 15 and 45 years of age
• The rate of depression in Canada is shown in Figure 13.1
• Depression can be diagnosed in children as young as 3, though it is rare
• Levels of depression rise in the early teen years
• Disruptive mood dysregulation disorder may also be diagnosed
• Depression is not a normal part of aging
• The risk of depression increases as health deteriorates
• 1% to 5% of older persons living in the community experience depression
• Rates rise to 11.5% for hospitalized older persons and 13.5% for those requiring homecare
• Suicide and subsyndromal depression is also a risk among this population

Risk Factors for Depression

• Female gender
• Early childhood trauma
• Stressful life events
• Family history of depression, especially in first-degree relatives
• High levels of neuroticism
• Other disorders such as substance use, anxiety, and personality disorders
• Chronic or disabling medical conditions

Etiology: Biological Factors

• Twin studies consistently show genetic factors play a role in depressive disorders
• Concordance rate for MDD among monozygotic (identical) twins is nearly 50%: if one twin is affected, the second has about a 50% chance of being affected
• Serotonin dysfunction results in sleep disturbances, decreased appetite, low sex drive, poor impulse control, and irritability
• Norepinephrine deficiency results in apathy, reduced responsiveness, or slowed psychomotor activity
• Stressful life events, especially losses, can contribute to depression
• Hormonal imbalances, particularly involving the hypothalamic-pituitary-adrenal axis and hyperactivity, play a role
• Research indicates inflammation plays a role, with about 1/3 of people with major depression having elevated inflammatory biomarkers; people with inflammatory diseases have increased risk; people treated with cytokines develop major depression
• The diathesis-stress model is also relevant

Etiology: Psychological Factors

• Cognitive theory
• Beck's Cognitive Triad
• Learned helplessness

Nursing Assessment: Assessment Tools

• Beck Depression Inventory
• The Hamilton Depression Rating Scale
• Box 13.2
• Zung Self-Rating Depression Scale
• Geriatric Depression Scale
• The Patient Health Questionnaire - 9, and Figure 13.3

Nursing Assessment: SIGECAPS

• Clinicians use the mnemonic SIGECAPS to guide their assessment
  • Sleep
  • Interest
  • Guilt
  • Energy
  • Concentration
  • Appetite
  • Psychomotor activity
  • Suicidal thoughts

Nursing Assessment: Suicide Potential

• Inquire on reported feelings of depression
• Inquire on thoughts going through mind
• Determine if the patient has thoughts on taking their own life?
• Determine if the patient has a suicide plan, means to carry it out, and if there is anything that prevent them from carrying out plan?

Nursing Assessment: Key Findings

• Anhedonia: loss of interest
• Psychomotor agitation: pacing and wringing hands
• Psychomotor retardation: slowed movements
• Vegetative signs of depression: changes in bowel movement, sleep disturbances

Nursing Assessment: Areas to Assess

• Affect: outward presentation of a person's internal state of being observed by nurse based on assessment: posture, expression conveys emotion, lack of eye contact
• Mood: patient's subjective experience of sustained emotions or feelings
• Feelings: worthlessness, guilt, helplessness, hopelessness, and anger; Anhedonia
• Cognitive changes
• Physical behaviour
• Communication
• Religious beliefs and spirituality
• Areas to consider when assessing children and adolescents, as well as older persons Self-assessment: unrealistic expectations or feeling what the patient is feeling

Nursing Diagnosis

• Safety is always the highest priority
• Risk for suicide
• Hopelessness
• Ineffective coping
• Social isolation
• Spiritual distress
• Self-care deficit
• Table 13.2 identifies signs and symptoms experienced in depression and offers potential nursing diagnoses

Nursing Process: Outcomes Identification

• Recovery model
• Focus on patient's strengths
• Treatment goals mutually developed
• Based on patient's personal needs and values
• Table 13.3 presents outcome criteria from the Nursing Outcomes Classification (NOC)

Nursing Process: Planning

• Geared towards specific phases of depression, paticular symptoms, and patient's personal goals

Nursing Process: Implementation

• Three phases: Acute phase (6 to 12 weeks), Continuation phase (4 to 9 months), and Maintenance phase (1 year or more)
• Counselling and communication
• Health teaching and health promotion
• Promotion of self-care activities
• Milieu management: Teamwork and safety

Nursing Process: Implementation Pharmacological Interventions

• Selective serotonin reuptake inhibitors (SSRIs)
  • First-line therapy
  • Indications
  • Adverse reactions
  • Potential toxic effects (Serotonin syndrome)

Serotonin Syndrome

• Symptoms: Hyperactivity or restlessness, Tachycardia, cardiovascular shock, Fever, hyperpyrexia, Elevated blood pressure, Altered mental states (delirium), Irrationality, mood swings, hostility, Seizures status epilepticus, Myoclonus, incoordination, tonic rigidity, Abdominal pain, diarrhea, bloating, and Apnea death
• Interventions: Remove offending agents, Initiate symptomatic treatment, Serotonin receptor blockade with cyproheptadine, methysergide, propranolol, Cooling blankets, chlorpromazine for hyperthermia, Dantrolene, diazepam for muscle rigidity or rigours, Anticonvulsants, Artificial ventilation, and Paralysis

Nursing Process: Implementation Pharmacological Interventions: Tricyclic antidepressants (TCAs)

• Neurotransmitter effects
• TCAs block the reuptake of norepinephrine (NE) and serotonin (5-HT), increasing their levels in the synaptic cleft.
• Histamine (H1) receptors: sedation, weight gain
• Muscarinic cholinergic receptors and Alpha-1 adrenergic receptors
• Indications
• Toxic effects
  • Narrow therapeutic index, Cardiotoxicity: prolonged QT interval, arrhythmias, Seizures, CNS depression → coma, respiratory depression, Anticholinergic toxicity: "hot as a hare, dry as a bone, blind as a bat, red as a beet, mad as a hatter"
• Adverse drug interactions, including
  • MAOIs or SSRIs: risk of serotonin syndrome
  • Alcohol, benzodiazepines: additive CNS depression Patient and family teaching: 2-4 weeks to see full therapeutic effect, Do not stop abruptly, avoid alcohol and other CNS depressants, keep out of reach of children due to overdose risk and report symptoms of irregular heartbeat

Nursing Process: Implementation Pharmacological Interventions: Monoamine oxidase inhibitors (MAOIs)

• MAOIs inhibit the enzyme monoamine oxidase, which breaks down neurotransmitters, increasing mood and emotional regulation
• Adverse/toxic effects include hypertensive crisis and serotonin syndrome
• Drug and Food interactions include risks for serotonin syndrome and food that contains tyramine such as aged cheese and fermented food

Other Interventions for Depression

• Biological interventions such as Electroconvulsive therapy (ECT), Transcranial magnetic stimulation, Nerve stimulation including Vagus nerve stimulation

• and Advanced-practice interventions

• Psychological interventions

  • Cognitive behavioral therapy (CBT)
  • Interpersonal therapy (IPT)
  • Time-limited focused psychotherapy
  • Behavioral therapy
  • Group therapy

• Complementary approaches

  • Light therapy
  • St. John's Wort
  • Exercise

Nursing Process: Evaluation

• Suicidal ideation
• Intake
• Sleep pattern
• Personal hygiene and grooming
• Self-esteem
• Social interaction
• The care plan is revised when indicators are not met.

Postpartum Depression

• Onset within 4 weeks after childbirth
• Psychotic features accompany this depression
• Severe ruminations or delusional thoughts about the infant can signify increased risk of harm to the infant
• Women who experience a severe postpartum psychosis within 2 weeks of giving birth have a four times greater chance of subsequent conversion to bipolar disorder (Perry et al., 2020)
• Giving birth may act as a trigger for the first symptoms of bipolar disorder
• The precipitant may be hormonal changes and sleep deprivation
• The role of estrogen in bipolar disorder is also under review
• Childbirth is known to be associated with the onset of mood and anxiety disorders
• Estrogen studies have shown that people with postpartum psychosis have very low levels of estrogen and improve after estrogen replacement therapy (Meinhardet al., 2014)
• Selective estrogen receptor modulators (e.g., tamoxifen) have also been shown to produce antimanic effects
• Further research in this area is required