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Not just feeling blue: Major depressive disorder

Davis, Charlotte BSN, RN, CCRN; Lockhart, Lisa MHA, MSN, RN, NE-BC

doi: 10.1097/01.NME.0000521805.31528.75
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Nurses may encounter patients experiencing depression in acute care hospitals, long-term-care facilities, and outpatient areas, not only on behavioral health units.

Nurses may encounter patients experiencing depression in acute care hospitals, long-term-care facilities, and outpatient areas, not only on behavioral health units.

Charlotte Davis is a Surgical-Trauma ICU Nurse Educator at Ocala Regional Medical Center in Ocala, Fla., a Clinical Adjunct Faculty Member at Clayton State University in Morrow, Ga., and the Clinical Editor of Nursing made Incredibly Easy!Lisa Lockhart is the Emergency Services Director at KentuckyOne Health, Saint Joseph Health System, in Lexington, Ky., and a Nursing made Incredibly Easy! Editorial Board Member.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

Get connected to www.NursingMadeIncrediblyEasy.com. See page 30.

World Mental Health Day, October 10

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Major depressive disorder (MDD), also known as clinical depression, is a profound depressed mood that persists for longer than 2 weeks, severe enough to cause noticeable problems in the patient's ability to maintain personal relationships, meet work or school obligations, and participate in previously enjoyable social activities.

According to the World Health Organization, more than 300 million people are affected by depression. The National Institute of Mental Health (NIMH) indicated in 2015 that 15.7 million American adults over age 18, or 6.7% of the population, have experienced at least one depressive episode in the past year. And this number is expected to increase, with an estimated projection of 46 million adults in the United States being diagnosed with a depressive disorder by 2050. This increase is predicted to be more prevalent in adults ages 65 and older.

Children experience depression, too, with an estimated 3 million American adolescents ages 12 to 17, or 12.5% of the population in this age range, having at least one major depressive episode in the past year, according to the NIMH. It's estimated that only 36% to 44% of children and adolescents with depression receive treatment.

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What it looks like

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, indicates that MDD is present when the patient experiences five or more of the following criteria nearly every day during a 2-week period:

  • depressed mood most of the day (reported by the patient or others)
  • loss of interest in previously enjoyable daily activities
  • fatigue and loss of energy
  • significant weight loss (greater than 5% in 1 month) or change in appetite
  • feelings of worthlessness or excessive/inappropriate guilt (may be delusional)
  • insomnia or hypersomnia
  • change in activity (psychomotor agitation or retardation)
  • reduced ability to think or concentrate, or increased indecisiveness
  • recurrent thoughts of death, suicidal ideation, or a suicide plan.

In children, symptoms may include:

  • sadness or worry
  • clinginess
  • irritability
  • aches and pains
  • refusing to attend school
  • being underweight.

In adolescents, symptoms may include:

  • sadness
  • irritability or anger
  • negative feelings or feelings of worthlessness or being misunderstood
  • self-harm
  • poor performance or attendance at school
  • alcohol or substance use
  • eating or sleeping too much
  • loss of interest in normal activities, including avoiding social interaction.

For older adults, symptoms may be more subtle, such as memory difficulties, changes in personality, fatigue or sleep difficulties, loss of appetite, and a reluctance to socialize.

Common risk factors include:

  • family history of bipolar disorder, depression, suicide, or alcohol or substance abuse
  • personality traits, including dependence, low self-esteem, pessimism, or being self-critical
  • new acute or chronic illness diagnosis, such as cancer, stroke, chronic pain, or heart disease
  • recent or traumatic stressful event, such as the death of a loved one, sexual or physical abuse, or financial hardship
  • history of other mental health disorders, such as anxiety disorder, eating disorders, or posttraumatic stress disorder
  • being lesbian, gay, bisexual, transgender, or intersex in an unsupportive situation
  • current alcohol or substance abuse
  • certain medications, such as antihypertensive drugs or hypnotics.

The exact cause of MDD is unknown, but physical or chemical changes to the brain, hormone changes, and/or genetics are believed to play a role.

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The patient interview

Depression may go unrecognized by healthcare providers, the patient's support network, and even the patient him- or herself, especially in children and patients over age 65. When conducting an interview with a patient who you suspect may have MDD, obtain subjective data from the patient and objective data from your observations and reports from family or friends. Assess the patient for possible acute causes of depression, such as grieving, medication use, or an existing comorbidity.

The patient may present with a disheveled appearance. His or her posture may be slumped; his or her facial expression may display a flat, dull affect or be frowning or sad; and there may be evidence of crying (reddened or swollen eyes). You may notice agitation or avoidance of eye contact. Make note of the patient's verbal responses; there may be a lack of engagement in the interaction or surroundings. The patient may seem withdrawn or show signs of isolation, such as a lack of humor. This may be indicative of low self-esteem. Other signs may include impulsive overeating, drinking or substance abuse, fighting or displays of aggression, or antisocial behavior. Observe and check for any physical complaints; patients with depression often experience physical symptoms, such as constipation, anorexia, headache, insomnia, hypersomnia, weight gain or loss, or a general feeling of malaise.

Use a depression screening tool to document the severity of the patient's depression from mild to severe or suicidal. Depression screening tools may include both objective and subjective data. A common focus is how the depression is affecting the patient's daily social functioning and quality of life. The following are the most common depression screening tools:

  • Beck Depression Inventory
  • Center for Epidemiologic Studies Depression Scale and the Center for Epidemiologic Studies Depression Scale for Children
  • Cornell Scale for Depression in Dementia
  • Geriatric Depression Scale
  • Hamilton Depression Rating Scale
  • Major Depression Inventory
  • Patient Health Questionnaire
  • Zung Self-Rating Depression Scale.
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Therapeutic options

Treatment for MDD depends on its severity and existing comorbidities, and usually centers on pharmacologic and behavioral therapies.

Many types of antidepressant medications are available that vary in mechanism of action. Patients will often be placed on different medications until they achieve the right type and dosage for maximum efficacy. The following medications are commonly utilized:

  • selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, sertraline, citalopram, and escitalopram (often the first type of medication prescribed because it's safe and has fewer adverse reactions)
  • serotonin-norepinephrine reuptake inhibitors, such as duloxetine, venlafaxine, desvenlafaxine, and levomilnacipran
  • norepinephrine-dopamine reuptake inhibitors, such as bupropion
  • atypical antidepressants, such as vortioxetine and vilazodone
  • tricyclic antidepressants, such as imipramine, nortriptyline, amitriptyline, doxepin, trimipramine, desipramine, and protriptyline (this type of medication may cause adverse reactions, so it isn't generally prescribed unless the patient doesn't respond to other treatment)
  • monoamine oxidase inhibitors, such as tranylcypromine, phenelzine, isocarboxazid, and selegiline (typically prescribed only when other medications haven't worked because this type of medication can have serious adverse reactions and requires a strict diet due to potential interactions with certain foods and medications).

The prescribing provider may recommend combining two antidepressants or adding other medications, such as mood stabilizers, antipsychotics, or antianxiety agents.

Psychotherapy, or talk therapy, includes cognitive behavioral therapy and behavioral activation therapy. The benefits of psychotherapy include assisting the patient with adjusting to a crisis or other current difficulty; helping him or her identify negative beliefs and behaviors, and replace them with healthy, positive ones; allowing the patient to learn how to set realistic short- and long-term goals, and develop the ability to tolerate and accept distress using healthier behaviors in a safe environment; and encouraging the patient's exploration of relationships and experiences, the development of positive interactions with others, and the ability to proactively cope and find solutions to gain a sense of satisfaction and control in his or her life.

Brief behavioral therapy is a type of therapy often utilized for children with MDD or anxiety. During a session, the child is encouraged to engage in activities that he or she finds interesting but difficult, such as social functions. In a recent study, 56.8% of children who participated in pediatric-based behavioral therapy showed improvement as compared with 28.2% of children who were referred to outpatient community mental healthcare.

Some patients may require more aggressive treatment options when pharmacologic and behavioral therapies have failed, such as electroconvulsive therapy (ECT), during which electrical currents are used to impact the function of neurotransmitters, and transcranial magnetic stimulation, during which magnetic pulses are used to stimulate nerve cells involved in mood regulation.

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What you can do

Educate your patient and his or her caregivers regarding the goals of prescribed therapies and the potential adverse reactions of medications, which may include worsening behavior or suicidal thoughts. Provide the patient and family with directions for whom to contact if his or her condition worsens. When implementing a holistic care plan for the patient with MDD, explore whether he or she has the means to adhere to the recommended behavioral therapy and medication regimen. Many patients may need supportive services, such as a social worker consult, to help them identify community programs that can assist with medication costs or transportation to and from therapy sessions. And remember that the patient's family needs support, too, as they care for him or her.

Many antidepressant medications predispose patients to electrolyte imbalances, such as hypernatremia and hypokalemia. Inform the patient and his or her family that stopping medication may create withdrawal symptoms, such as nausea, vomiting, headache, and seizures; instruct patients not to stop taking their prescribed medication without consulting the healthcare provider.

Offer the patient a safe environment to openly discuss his or her feelings and concerns. Encourage the patient to verbalize his or her thoughts, even if they're feelings of anger or shame. Take care not to convey your own personal thoughts, ideas, or beliefs and remain nonjudgmental. Body language should encourage communication. For example, maintain eye contact and don't fold your arms, rather clasp your hands in front. Communication should consist of open-ended questions and restatement to clarify the patient's statements. Encourage patients to verbalize feelings, thoughts, and concerns by asking them to clarify what they feel is contributed to their current mental health state. Listen carefully, convey empathy, and don't rush the patient or finish sentences for him or her.

Evaluate the patient's supportive relationships because increasing healthy social interactions with friends and family can help him or her stabilize MDD. Ask the patient if he or she has spiritual support, such as a member of the clergy, cultural advisor, life coach, or spiritual advisor. Encourage the patient to engage in hobbies or social activities that interest him or her. Therapeutic activities should be limited in such a way as to not affect the patient emotionally. For example, avoid watching movies that may involve violence; instead, engage in a relaxing activity such as progressive relaxation or reminiscence therapy.

Evaluate the patient for the potential for self-harm or suicidal ideation. If the patient verbalizes a desire to self-harm or expresses suicidal ideation, stay with him or her, maintain close proximity, and call for assistance from another staff member. The highest priority is patient safety. Ensure that a team member is with the patient at all times until a psychiatric risk assessment has been completed.

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Wellness, optimized

As our population continues to live longer with chronic illnesses, we'll continue to see more patients with MDD. With detailed screening, we can help patients experiencing depression return to an optimal level of wellness.

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did you know?

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A recent study found that utilizing video talk therapy sessions for older veterans with MDD was at least as effective as in-person treatment delivery. The study randomized 241 veterans ages 58 and older with MDD to receive either same-room psychotherapy or telemedicine. Both groups received the same kind of treatment: behavioral activation, a talk therapy that emphasizes reinforcing positive behaviors. The team found that telemedicine-delivered psychotherapy produced similar outcomes to in-person treatment.

Source: Egede LE, Acierno R, Knapp RG, et al. Psychotherapy for depression in older veterans via telemedicine: a randomised, open-label, non-inferiority trial. Lancet Psychiatry. 2015;2(8):693-701.

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cheat sheet

MDD diagnostic criteria

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Five or more of the following criteria nearly every day during a 2-week period:

  • depressed mood most of the day (reported by the patient or others)
  • loss of interest in previously enjoyable daily activities
  • fatigue and loss of energy
  • significant weight loss (greater than 5% in 1 month) or change in appetite
  • feelings of worthlessness or excessive/inappropriate guilt (may be delusional)
  • insomnia or hypersomnia
  • change in activity (psychomotor agitation or retardation)
  • reduced ability to think or concentrate, or increased indecisiveness
  • recurrent thoughts of death, suicidal ideation, or a suicide plan.
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Bonus content

Head to www.NursingMadeIncrediblyEasy.com for additional resources.

Suicide: A growing public health concern

http://journals.lww.com/nursingmadeincrediblyeasy/Abstract/2017/07000/Suicide__A_growing_public_health_concern.5.aspx

Compassionate care for teens who self-injure

http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2017/03000/Compassionate_care_for_teens_who_self_injure.8.aspx

Recognizing depression across the lifespan

http://journals.lww.com/nursingmadeincrediblyeasy/Abstract/2013/05000/Recognizing_depression_across_the_lifespan.6.aspx

Is ECT an option for your patient with severe depression?

http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2013/05000/Is_ECT_an_option_for_your_patient_with_severe.7.aspx

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consider this

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While working on a busy medical-surgical unit, you note changes in one of your peers, Sonya, who's always been known as the friendly clinical expert on your unit. She was actually the first person to welcome you when you started your job 3 years ago with a smile, enthusiasm, and a wealth of knowledge. In the past, Sonya always offered assistance to peers during times of heavy admissions and transfers, and shared her clinical opinion when anyone encountered a perplexing patient event. She's also always been the top choice to precept new employees because of her expansive knowledge base and infectious personality.

Lately, though, you see that Sonya is often short tempered with peers. She's unable to offer assistance because she's struggling to complete her job duties on time. You notice that she's started making lists of her job duties and crossing them off as she completes them; an obvious effort to increase her sense of organization. When staff members approach Sonya for assistance with clinical questions, she seems unfocused and unable to provide help. She's also volunteered to work during all of the upcoming holidays.

On her most recent shift, you find Sonya in the supply room and it looks like she's been crying. When you ask her if she's okay, she quickly responds that she's fine. You suspect that Sonya is depressed and it's affecting her ability to function professionally. You share your concerns and observations with your manager, who schedules time to meet with Sonya and explore what's changed.

Sonya's spouse died 5 months ago and she returned to work 2 months ago. Your manager makes a referral to employee assistance so that Sonya can get the support she needs.

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on the web

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American Academy of Child and Adolescent Psychiatry:www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Depression_Resource_Center/Home.aspx

American Psychiatric Association:https://www.psychiatry.org/patients-families/depression/what-is-depression

American Psychological Association:www.apa.org/topics/depression

Anxiety and Depression Association of America:https://www.adaa.org/

CDC:https://www.cdc.gov/mentalhealth/basics/mental-illness/depression.htm

National Alliance on Mental Illness:https://www.nami.org/Learn-More/Mental-Health-Conditions/Depression

National Institute of Health Senior Health:https://nihseniorhealth.gov/depression/aboutdepression/01.html

National Institute of Mental Health:https://www.nimh.nih.gov/health/topics/depression/index.shtml

World Health Organization:www.who.int/mediacentre/factsheets/fs369/en

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REFERENCES

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC: American Psychiatric Association; 2013.
    Anxiety and Depression Association of America. Treatment. https://http://www.adaa.org/understanding-anxiety/depression/treatment.
      CDC. Depression in the U.S. household population, 2009-2012. https://http://www.cdc.gov/nchs/data/databriefs/db172.htm.
        Egede LE, Acierno R, Knapp RG, et al Psychotherapy for depression in older veterans via telemedicine: a randomised, open-label, non-inferiority trial. Lancet Psychiatry. 2015;2(8):693–701.
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