Major Depression Nursing Care Management

Major depression (clinical depression) is a persistent, pervasive low mood: sadness, hopelessness, and loss of interest in things the patient used to enjoy, lasting 2 weeks or longer. On the floor your first concern is always the same. Suicide is the most serious complication and occurs in nearly 15% of patients with untreated depression, and the risk climbs as the mood starts to lift and energy returns before judgment does.

What is Major Depression?

Major depression is a mood disorder, a disturbance in the regulation of mood, behavior, and affect that goes well beyond normal fluctuation. Also called unipolar major depression, it is a persistently sad mood lasting 2 weeks or longer, paired with guilt, helplessness or hopelessness, poor concentration, sleep disturbance, lethargy, appetite loss or weight gain, anhedonia, loss of mood reactivity, and thoughts of death.

Statistics and Incidences

During 2009 to 2012, 7.6% of Americans aged 12 and over had depression. It was more common in females than males, and most common in adults aged 40 to 59. In 2015, an estimated 16.1 million adults aged 18 or older in the United States had at least one major depressive episode in the past year.

Pathophysiology

The pathophysiology is not clearly defined. Current evidence points to a complex interaction between neurotransmitter availability and receptor regulation and sensitivity. Disturbed central nervous system serotonin (5-HT) activity appears to be an important factor, supported by the efficacy of selective serotonin reuptake inhibitors (SSRIs). Norepinephrine, dopamine, glutamate, and brain-derived neurotrophic factor are also implicated. In late-onset depression, age-related and disease-related brain changes combine with physiologic vulnerability and psychosocial adversity to disrupt the functional circuitry of emotion regulation.

Causes

Genetic, biochemical, physical, psychological, and social factors all contribute.

• Genetic. Two to three times more common in people with a first-degree relative who has the disorder.
• Biological. Primary defect sites at the prefrontal cortex and basal ganglia. May involve serotonin, neuroendocrine, and hypothalamic-pituitary-adrenal (HPA) regulation, and abnormal cortisol levels.
• Psychosocial. The relationship between psychological stress, stressful life events, and onset is real but not fully defined.
• Pharmacologic. Some prescribed drugs cause depression, including antihypertensives, psychotropics, antiparkinsonian drugs, oral antidiabetics, steroids, and chemotherapeutic agents.

Clinical Manifestations

Symptoms per DSM-IV-TR criteria:

• Depressed mood. Sadness, dejection, helplessness, hopelessness.
• Anhedonia. Decreased attention to and enjoyment of previously pleasurable activities.
• Weight changes. Unintentional change of 5% or more in a month.
• Sleep changes. Insomnia or hypersomnia.
• Agitation or psychomotor retardation. Often a general motor slowdown.
• Fatigue. Weakness and very low energy for activities of daily living (ADLs).
• Worthlessness or guilt inappropriate to the situation, sometimes delusional.
• Difficulty thinking, focusing, and making decisions.
• Hopelessness, helplessness, and suicidal ideation.

Assessment and Diagnostic Findings

• Beck Depression Inventory to determine symptom onset, severity, duration, and progression.
• Dexamethasone suppression test showing failure to suppress cortisol secretion (high false-negative rate).
• Toxicology screening to identify drug-induced depression.
• Diagnosis confirmed when DSM-V-TR criteria are met.

Medical Management

• Psychotherapy. Evidence-based options include behavioral therapy, cognitive therapy, cognitive behavioral analysis system of psychotherapy, interpersonal psychotherapy, problem-solving therapy, and self-management or self-control therapy.
• Electroconvulsive therapy. Highly effective for depression.
• Stimulation techniques. Transcranial magnetic stimulation (TMS) is FDA-approved for adults who have failed at least 4 adequate medication and/or ECT regimens.

Pharmacologic Management

Medications are the primary treatment and work best combined with therapy. They modify the activity of the relevant neurotransmitter pathways.

• SSRIs. First-line. Raise brain serotonin. Fluoxetine, sertraline, escitalopram.
• SNRIs. Target serotonin and norepinephrine. Venlafaxine, duloxetine.
• TCAs. Effective but less used due to side effects. Influence serotonin and norepinephrine. Amitriptyline, nortriptyline.
• MAOIs. Used when other drugs fail. Affect multiple neurotransmitters. Require dietary restrictions and carry interaction risk.
• Atypical: bupropion. Affects norepinephrine and dopamine. Useful when sexual side effects limit other antidepressants.
• NMDA receptor antagonist: ketamine. Rapidly acting, used in treatment-resistant depression under controlled settings.
• Combination therapy. Different antidepressant classes, or an antidepressant plus a mood stabilizer, in severe or treatment-resistant cases.

Nursing Management

Nursing Assessment

• Subjective. Inability to cope or ask for help, sleep disturbance and fatigue, chemical use, muscular or emotional tension, poor appetite.
• Objective. Lack of goal-directed behavior, inadequate problem solving, decreased use of social support, inability to meet roles or basic needs, and self-destructive behavior (overeating, smoking, drinking, overuse of prescribed or OTC medications, illicit drug use).

Nursing Diagnosis

• Ineffective Coping related to situational or maturational crises.
• Hopelessness related to long-term stress.
• Fatigue related to stress and anxiety.

Planning and Goals

Determine the degree of impairment, assess coping abilities, help the client deal with the current situation, meet psychological needs, and promote wellness.

Nursing Interventions

• Meet physical needs first. Assist with self-care and hygiene, encourage eating, offer warm milk or a back rub at bedtime for sleep. Plan activities for when energy peaks.
• Initiate communication. Share your observations of the patient's behavior, speak slowly and give ample time to respond, encourage talking and journaling, and provide a structured routine with noncompetitive activities.
• Avoid feigned cheerfulness, but do not be afraid to laugh with the patient and use humor.
• Educate. Explain that expressing feelings and engaging in pleasurable activity ease depression, and that effective symptom relief exists.
• Help the patient recognize distorted perceptions and connect them to the depression.
• Ask directly about death or suicide. A yes signals an immediate need for consultation and assessment. Remember that suicide risk rises as the depressed mood lifts.
• Stress medication compliance and review adverse effects.

Therapeutic Communication Techniques

How you talk to a depressed patient is part of the treatment. Five techniques carry the most weight:

• Drop "I think" and "You should." Advice like "just stay positive" implies the patient chose to feel this way and leaves them feeling inadequate or resentful. Instead, ask the patient to describe how the problem feels, then offer facts and services that fit. Protect their decision-making.
• Acknowledge the pain. Build trust through understanding and acceptance. When the patient shares anger, worry, or anxiety, name the feeling and encourage more, without judging it.
• Stay neutral. Do not approve or disapprove of what the patient shares. Approval sets your values as the standard and may push the patient to fake agreement. Disapproval imposes your beliefs, intimidates, and damages the relationship.
• Use silence. Not every disclosure needs a reply. Silence slows the conversation and gives the patient time to reflect and collect their thoughts, and it is a good moment to read nonverbal cues.
• Let the patient pick the topic. Do not lead with the first thing you notice. A broad opening shows you are interested in what matters to them right now, and it opens the door to explore their thinking.

Evaluation

• Accurately assesses the current situation.
• Identifies ineffective coping behaviors and their consequences.
• Verbalizes awareness of own coping abilities and feelings congruent with behavior.
• Meets physiologic needs through appropriate expression of feelings, identification of options, and use of resources.

Discharge and Home Care Guidelines

Address long-term needs and actions, the available support system, specific referrals made, and who is responsible for each action.

Documentation Guidelines

Record all observations and conversations with the patient. They are valuable in evaluating response to treatment.

Pediatric Considerations

In children, major depression is a persistently sad or irritable mood with disturbed sleep and appetite, lethargy, and an inability to express pleasure, lasting at least 2 weeks to be clinically significant. Depressed children and adolescents lose interest in activities that used to please them and are at increased risk for substance abuse and suicidal behavior. Psychotic symptoms are rare in children, unlike in adults. Instead, they tend to show anxiety symptoms (reluctance to meet people) and physical symptoms (aches and pains).

Nursing care tips for children:

• Structure and maintain a safe environment.
• Monitor closely for dangerous or self-destructive behavior.
• Make an agreement with the child to seek out a staff member whenever they feel desperate or suicidal.
• Teach the child to talk things out rather than act them out.
• Help the child talk about problems and stressors and express feelings openly.
• Provide physical outlets for energy and aggression (sports, music, art).
• Help identify supportive people and teach the child how to talk to them about feelings and needs.