Major Depressive Disorder (MDD)

• Mood disorders are also known as affective disorders.
• These include psychiatric disorders like depression and bipolar disorder.
• All demographics are susceptible to depressive episodes.
• Some individuals are more susceptible to depressive episodes than others.

Major Depressive Disorder (MDD)

• One of the most common psychiatric disorders
• Occurs in women at a 2:1 ratio compared to men
• Affects approximately 1 in 8 adults
• Characterized by a persistently depressed mood for a minimum of 2 weeks.
• The length of this episode may vary for each individual
• If untreated, 20% of cases become chronic.
• MDD is characterized by depressed mood with emotional, cognitive, physical, and behavioural symptoms.
• Diagnosis may include specifiers for the most recent episode of depression.
• Specifiers include psychotic, melancholic, atypical, or catatonic features.
• Postpartum or seasonal features such as seasonal affective disorder (SAD) are also specifiers.

Other Depressive Disorders

• Disruptive mood dysregulation disorder.
• Persistent depressive disorder (dysthymia).
• Premenstrual dysphoric disorder.
• Substance/medication-induced depressive disorder.
• Depressive disorder due to another medical condition.

Epidemiology

• Depression is a leading cause of disability.
• Lifetime prevalence is 11.3%.
• Higher rates are found in lower-income, unemployed, unmarried, or divorced people.
• Average onset is between ages 15 and 45.
• Rates of diagnoses in children is rare and levels typically rise in the early teen years.
• Disruptive mood dysregulation disorder is also seen in children.
• Depression is not a normal part of aging.
• Risk of depression increases as health deteriorates.
• 1% to 5% of older persons will experience depression if living in the community.
• 11.5% of hospitalized older persons and 13.5% of those requiring homecare may experience depression.
• Subsyndromal depression can also manifest.

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
• Substance use, anxiety, and personality disorders
• Chronic or disabling medical conditions

Etiology: Biological Factors

• Genetic predisposition
• Biochemical factors like serotonin and norepinephrine levels
• Stressful life events and losses
• Hormonal imbalances in the hypothalamic-pituitary-adrenal axis
• Inflammation
• Diathesis-stress model

Etiology: Psychological Factors

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

Assessment Tools

• Beck Depression Inventory
• Hamilton Depression Rating Scale
• Zung Self-Rating Depression Scale
• Geriatric Depression Scale
• The Patient Health Questionnaire-9

Assessment SIGECAPS

• Clinicians use the mnemonic SIGECAPS for assessment:
• S: Sleep
• I: Interest
• G: Guilt
• E: Energy
• C: Concentration
• A: Appetite
• P: Psychomotor Activity
• S: Suicidal Thoughts

Assessment of Suicide Potential

• Clinicians assess suicide potential looking for factors like:
  • Feelings of depression and associated details.
  • Thoughts that occur when feeling depressed.
  • Thoughts of taking one's own life.
  • The existence of a suicide plan.
  • A means to carry out the plan.
  • Factors that might prevent the person from carrying out the plan.

Key Assessment Findings

• Anhedonia
• Psychomotor agitation
• Psychomotor retardation
• Vegetative signs of depression

Areas to Assess

• Affect, thought processes, mood, and feelings
• Cognitive changes and anger
• Physical behaviour, communication, and religious beliefs
• Spirituality

Nursing Diagnoses

• Prioritize risk for suicide.
• Hopelessness, ineffective coping, and social isolation
• Spiritual distress
• Self-care deficit

Outcomes Identification

• Focus on a recovery model.
• Focus on patient strengths.
• Treatment goals mutually developed to address patient's personal needs and values.

Planning

• Planning should be focused on patient's phase of depression, particular symptoms, and personal goals.

Implementation: Three Phases

• Acute phase (6 to 12 weeks)
• Continuation phase (4 to 9 months)
• Maintenance phase (1 year or more)
• Counselling and communication, health teaching/promotion, and self-care activities
• Teamwork and safety are crucial in milieu management

Implementation: Pharmacological Interventions

• Selective Serotonin Reuptake Inhibitors (SSRIs) as first-line therapy
  • Be aware of indications, adverse reactions, and potential for Serotonin Syndrome
• Tricyclic Antidepressants (TCAs) can have neurotransmitter effects
  • Consider indications, adverse/toxic effects, drug interactions, contraindications, and patient/family teaching
• Monoamine Oxidase Inhibitors (MAOIs) have neurotransmitter effects
  • Review adverse/toxic effects and be aware of interactions with specific drugs and foods
  • Be aware of contraindications

Box 13.3 – Serotonin Syndrome: Symptoms and Interventions

• Symptoms include hyperactivity, restlessness, tachycardia, and cardiovascular shock
• Other symptoms are fever, elevated blood pressure, altered mental states, irrationality, mood swings and seizures
• Myoclonus, incoordination, tonic rigidity, abdominal pain, diarrhea, bloating, and apnea
• Interventions include removing offending agents and initiating symptomatic treatment.
• Treatments are serotonin receptor blockade, cooling blankets, dantrolene or anticonvulsants.
• Artificial ventilation and paralysis may be required if severe.

Other Interventions for Depression

• Biological interventions such as electroconvulsive therapy (ECT).
• Transcranial magnetic stimulation, nerve and vagus nerve stimulation.
• Psychological interventions include Cognitive Behavioural Therapy (CBT).
• Interpersonal therapy (IPT), time-limited focused psychotherapy, behavioural therapy, and group therapy.

Complementary, Alternative, and Integrative Approaches

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

Evaluation

• Suicidal ideation, intake, sleep pattern
• Personal hygiene and grooming, self-esteem and social interaction.
• Care plan is revised when indicators are not met.

Post Partum Onset

• Indicates onset within 4 weeks after childbirth.
• Psychotic features are common.
• Severe ruminations or delusional thoughts about the infant signify increased risk of harm to the infant.

Post-Partum Psychosis

• Women who experience severe postpartum psychosis within 2 weeks of giving birth have a four times greater chance of conversion to bipolar disorder.
• Giving birth may trigger the first symptoms of bipolar disorder.
• Hormonal changes and sleep deprivation are precipitants.
• Estrogen's role in bipolar disorder is under review.
• Childbirth is 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.
• Selective estrogen receptor modulators (e.g., tamoxifen) have also been shown to produce antimanic effects.
• Further research is required.