Happiness and unhappiness are appropriate responses to life events. When sadness, grief, or elation is extremely intense and the mood unduly prolonged, a mood disorder may be the cause. It’s important to understand that individuals who are going through depression are often in substantial pain, experiencing severe suffering, and have intolerable sadness.

In MDD, a severely depressed mood, usually recurrent, causes clinically significant distress or impairment in social, occupational, or other important areas of the person’s life. The depressed mood can be distinguished from the person’s usual functioning and might occur suddenly or gradually. Major depression is basically a depression that is thought to involve changes in receptor neurotransmitter relationships in the limbic system, prefrontal cortex, hippocampus, and amygdala. The primary neurotransmitters involved with depression are serotonin and norepinephrine, although dopamine is also related to depression. Genetic factors and biochemical and brain scans also reveal anomalies in some individuals suffering from depression.

People with major depression may have other problems, such as:

• Seasonal affective disorder (SAD)—most prominent during certain seasons (e.g., winter or summer); SAD is more prevalent in climates with longer periods of darkness in a 24-hour cycle

• Catatonic features—for example, peculiarities of voluntary movement, motor immobility, purposeless motor activity, echolalia, or echopraxia

• Melancholic features—severe symptoms, loss of feelings of pleasure, worse in morning, early morning awakening, significant weight loss, excessive feelings of guilt

• Postpartum onset—within 4 weeks of delivery

Persistent depressive disorder (dysthymia) is characterized by less severe, usually chronic depressive symptoms that have been present for a longer period of time (e.g., 2 years or longer). The symptoms of persistent depressive disorder are very similar to those of major depression, which makes an accurate diagnosis difficult. Although the symptoms and functional impairment are not as severe with persistent depressive disorder (dysthymia) as they are in MDD, symptoms can cause significant distress or impairment in major areas of the person’s life. Individuals with dysthymia are usually able to function at work and in social situations, but not often at optimal levels. There are no psychotic symptoms in people with a persistent depressive disorder.

• Diminished interest in or pleasure in almost all activities (anhedonia)

• Vegetative Signs: Alterations in eating, sleeping, activity level (fatigue), and libido

• Feelings of worthlessness or guilt

• Difficulty with concentration, memory, and making decisions

• Recurrent thoughts of death and/or self-harm

• Apathy, low motivation, and social withdrawal

• Irritability

• Excessive emotional sensitivity

• May complain of pain, such as backache or headache, that does not seem to have a physical cause

• The patient has taken drugs or alcohol

• Medical conditions are present

2. Always evaluate the patient’s risk for harm to self or others. Overt hostility is highly correlated with suicide.

The section that identifies specific nursing diagnoses, goals, and interventions is useful when working with depressed patients and targeting discrete problems. However, the following overall guidelines are important throughout the nurse’s work with depressed patients.

2. Note that the instillation of hope is a key tool for recovery.

3. Enhance the patient’s sense of self by highlighting past accomplishments and strengths.

4. Whether in the hospital or in the community:

• Monitor and intervene to help patient maintain adequate nutrition, hydration, and elimination.

• Monitor and intervene to help provide adequate balance of rest, sleep, and activity.

• Monitor and record increases/decreases in symptoms and which nursing interventions are effective.

• Involve the patient’s support system, and find supports for patient and family members in the community that are appropriate to their needs.

5. The dysfunctional attitude or learned helplessness and hopelessness seen with depressed individuals can be alleviated through cognitive therapy or other psychotherapeutic interventions.

The following section offers key nursing diagnoses, goals, and nursing interventions that can help nurses and other clinicians when planning care for a depressed individual/patient.

• Satisfaction with social circumstances and achievement of life goals

• Seeks help when experiencing self-destructive/other-destructive impulses

• Positive changes in quality of life (e.g., ability to work, intimate relationships, social relationships, and enjoyment of life have improved significantly).

Patient will:

• Identify supports and support groups with whom he or she is in contact within 1 month

• State that he or she wants to live

• Start working on constructive plans for the future

• Demonstrate adherence with any medication or treatment plan within 2 weeks

Patients will:

• Identify at least two people he or she can call for support and emotional guidance when he or she is feeling self-destructive before discharge

• Show willingness to work on a medical/treatment plan that is congruent with their cultural values and future goals.

Assessment findings/diagnostic cues:

• Processes information, and makes appropriate decisions

• Increased ability to problem solve

• Increased ability to meet role expectations

Patient will:

• Demonstrate an increased ability to make appropriate decisions when planning with nurse or clinician by (date)

• Identify negative thoughts and rationally counter them and/or reframe them in a positive manner within 2 weeks

Patient will:

• Identify two goals he or she wants to achieve from treatment, with aid of nursing intervention, within 1 to 2 days

• Discuss with nurse two irrational thoughts about self and others by the end of the first day

• Reframe three irrational thoughts with nurse/practitioner by (date)