98 Major depression

Overview/pathophysiology

Major depression is one of the mood disorders, a category of disorders characterized by profound sadness or apathy, irritability, or elation. These disorders rank among the most serious and poorly diagnosed and treated of the health problems in the United States. Major depression is defined as an illness characterized by either depression or the loss of interest in nearly all activities. The symptoms must be present for at least 2 wk. At least four other symptoms must be present from the following list: changes in appetite or weight, sleep, and psychomotor activity; feelings of worthlessness and guilt; difficulty concentrating or making decisions; and recurrent thoughts of death or suicidal ideation, plans, or attempts.

Major depression affects emotional, cognitive, behavioral, and spiritual dimensions. Depression may range from mild-to-moderate states to severe states with or without psychotic features. Major depression can begin at any age, although it usually begins in the mid-20s and 30s. The risk factors for depression include prior history of depression, family history of depression, prior suicide attempts, female gender, age of onset younger than 40 yr, postpartum period, medical comorbidity, lack of social support, stressful life events, personal history of sexual abuse, and current substance abuse. There are many theories to explain causation of depression. Research supports influence of the following factors: sleep disturbance; effects of pharmacologic substances, including many of the antihypertensive, steroidal, cardiovascular, and antipsychotic medications; neuronal factors that involve injury or malfunction of the brain, such as stroke, Parkinson’s disease, and deficiencies in neurotransmitters; endocrinologic factors, such as thyroid dysfunction; genetic factors; and psychodynamic factors.

Health care setting

Primarily primary care settings, that is, offices of private psychiatrist, psychologist, or psychiatric nurse practitioner or clinics with occasional brief acute care hospitalization for very severe depression, especially if there is serious suicide threat.

Assessment

The assessment of major depression involves much more than an assessment of mood. It is a holistic disorder that results in changes in self-attitude (feelings of self-worth), as well as vital sense (sense of physical well-being) and spiritual sense.

Feelings, attitudes, and knowledge:

Negative feelings expressed include sadness, lack of joy and happiness about anything, shame, humiliation, fear of reprisals if others find out about depression, denial, anger, fear of experiencing a relapse, and fear of passing the disorder on to children.

Signs of low mood:

Withdrawal from activities that once provided pleasure, as well as from social interactions; negativism expressed in excessive skepticism and stubborn resistance to suggestions, orders, or instructions from others; and unhappiness expressed in persistent sadness or frequent crying.

Signs of lowered self-attitude:

Self-deprecating, guilty, or self-blaming comments are common, as well as expressions of hopelessness.

Signs of decreased vital sense:

A depressed person may neglect personal appearance or let assignments, tasks, and projects slide. Decreased energy is very common, with the depressed person complaining of fatigue and difficulty getting activities started, especially in the early morning hours. A decreased ability to concentrate makes it difficult for individuals to think through a problem. The inability to make choices becomes apparent even with simple decisions that were previously made routinely.

Spiritual issues:

Depression carries with it many negative experiences, such as marital and family problems, divorce, and unemployment, which contribute to the downward spiral of self-appraisals. Depression can lead to a crisis in faith in self, others, life, and ultimately God. This loss of faith and hope contributes significantly to the risk of suicide.

Additional signs:

Some depressed individuals experience decreased appetite leading to weight loss. Others experience an increase in appetite and weight. A change in sleep pattern is characteristic of depression, with many depressed individuals awakening in the early morning hours between 2 am and 6 am, whereas others experience a need for excessive sleep and have difficulty awakening. A decline in sexual interest and activity is characteristic of depressed individuals.

Suicidality:

Suicide assessment is critical with depressed patients and includes questions to determine the presence of suicidal ideation and the lethality of any plan. Essential questions to ask include:

• Have you thought of hurting yourself?

• Are you presently thinking about hurting yourself?

• If you have been thinking about suicide, do you have a plan?

• What is the plan?

• Have you thought about what life would be like if you were no longer a part of it?

A previous history of suicide attempts combined with depression places the patient at high risk in the present for attempting suicide. A patient whose depression is lifting is at higher risk for suicide than a severely depressed individual. The improvement may result in an increase in energy. This increased energy is not enough to make the patient feel good or hopeful, but it is enough to carry out a suicidal plan.

Diagnostic tests

Although there are physical changes such as abnormal sleep electroencephalograms (EEGs) that coincide with sleep disturbances, sleep EEGs are not used to diagnose depression. The diagnosis of depression is made through history, interview of patient and family, and observation of verbal and nonverbal behaviors. A number of effective scales are available to quantify the degree of depression, such as the Zung Self-Rating Depression Scale, the Beck Depression Inventory, and the Geriatric Depression Scale. The SAD PERSONS scale for suicide assessment is an easy-to-use scale.

Nursing diagnosis:

Deficient knowledge

related to unfamiliarity with causes, signs and symptoms, and treatment of depression

Desired Outcome: By discharge (if inpatient) or after 4 wk of outpatient treatment, patient and significant other verbalize accurate information about at least two of the possible causes of depression, four of the signs and symptoms of depression, and use of medications, psychotherapy, and/or electroconvulsive therapy (ECT) as treatment.

ASSESSMENT/INTERVENTIONS	RATIONALES
Assess patient’s and significant other’s knowledge about depression and its causes.	Depression is a physiologic disorder caused by the interplay of many factors such as stress, loss, imbalance in brain chemistry, and genetics. Many people believe that depression is caused by character weakness. This belief contributes to the stigma experienced by the person suffering with depression and interferes with seeking treatment.
Inform patient and significant other about the major symptoms of depression.	Many people believe depression equates with sadness and fail to recognize the many other signs and symptoms that make this a holistic disorder. These include sadness and loss of interest in normal activities, plus at least four of the following: changes in appetite or weight, sleep, or psychomotor activity; feelings of worthlessness and guilt; difficulty concentrating or making decisions; recurrent thoughts of death or suicidal ideation, plans, or attempts. If the depressed individual displays sadness through irritability, the conclusion that depression is present may be missed, and consequently, necessary treatment may be delayed or avoided entirely.
Inform patient and significant other that depression is treatable.	Medications are usually indicated for treatment. They do not solve the stressors or problems that may have precipitated the depression, but they provide the energy to deal with these issues. Antidepressants or psychotherapy or a combination of both generally relieves the symptoms of depression in weeks.
Inform patient and significant other about ECT if this is appropriate.	Many antidepressant drugs take 3 wk or more to lift the mood. In the meantime, ECT may be used to achieve more rapid results and may provide necessary protection for the suicidal patient. Patient and significant other/family may fear ECT. This intervention provides an opportunity for education that presents ECT as a positive treatment alternative.

Nursing diagnosis:

Hopelessness

related to losses, stresses, and basic symptoms of depression

Desired Outcome: By discharge (if inpatient) or by the end of 4 wk of outpatient treatment, patient verbalizes feelings and acceptance of life situations over which he or she has no control, demonstrates independent problem-solving techniques to take control over life, and does not demonstrate or verbalize suicidality.

ASSESSMENT/INTERVENTIONS	RATIONALES
Assess individual signs of hopelessness. Assess unhealthy behaviors used to cope with feelings.	This helps focus attention on areas of individual need. These signs may include decreased physical activity, social withdrawal, and comments made by patient that indicate hopelessness and despair. Patient may have tried to overcome feelings of hopelessness with harmful and ineffective behaviors (e.g., withdrawal, substance abuse, avoidance). Recognizing these behaviors provides an opportunity for change.
Encourage patient to identify and verbalize feelings and perceptions.	The process of identifying feelings that underlie and drive behaviors enables patients to begin taking control of their lives.
Express hope to patient in a low-key manner.	Patient may feel hopeless, but it is helpful to hear positive expressions from others.
Help patient identify areas of life that are under his or her control.	Patient’s emotional state may interfere with problem solving. Assistance may be required to identify areas that are under his or her control and to have clarity about options for taking control.
Encourage patient to assume responsibility for own self-care, for example, setting realistic goals, scheduling activities, and making independent decisions.	Helping patient set realistic goals increases feelings of control and provides satisfaction when goals are achieved, thereby decreasing feelings of hopelessness.
Help patient identify areas of life situation that are not within his or her ability to control. Discuss feelings associated with this lack of control.	Patient needs to recognize and resolve feelings associated with inability to control certain life situations before acceptance can be achieved and hopefulness becomes possible.
Encourage patient to examine spiritual supports that may provide hope.	Many people find that spiritual beliefs and practices are a great source of hope.
Conduct a suicide assessment to determine level of suicide risk.	High risk will necessitate hospitalization.
Teach patient about crisis intervention services such as suicide hotlines and other resources.	It is vital to provide patients with resources for support and safety when thoughts and feelings about suicide become difficult to manage.
Administer antidepressant medication or teach importance of taking medication as prescribed (for additional interventions, see Risk for Suicide).	Suicidal thinking is a symptom of depression that is ameliorated through appropriate medication.

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