1. 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.comwww.nursingcenter.com © 2009 by Lippincott Williams & Wilkins. All world rights reserved.

2. 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

3. 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

4. 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

5. 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

6. 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)

7. Neurotransmitters Out of Balance

8. 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

9. 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

10. Medical Conditions Associated with Depression  Cerebrovascular accident  Cognitive impairment disorders (dementia)  Diabetes  Cancer  Coronary artery disease  Chronic fatigue syndrome  AIDS

11. Medications that May Cause Depression  Hormones  Cardiovascular drugs  Psychotropic medications  Anti-inflammatory and anti-infective drugs  Anti-ulcer medications

12. 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

13. Somatic Complaints that May Signal Depression  Headache  Backache  Abdominal pain  Fatigue  Malaise  Anxiety  Decreased desire or problems with sexual functioning

14. 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?

15. 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

16. 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

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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