Learning Outcome

After reviewing this module, the nurse will:

• Identify signs and symptoms of Major Depressive Disorder
• Implement nursing interventions related to the person with Major Depressive Disorder
• Analyze the role of the nurse caring for the person with Major Depressive Disorder in an interdisciplinary team

Introduction

Major Depressive Disorder (MDD) is a mental health disorder characterized by at least two weeks of persistently sad mood or loss of interest in activities (anhedonia), causing significant impairment in daily life functioning, accompanied by five or more symptoms including [1]:

• Depressed mood most of the time
• Loss of interest or pleasure in activities
• Feelings of worthlessness or excessive guilt
• Lack of energy
• Insomnia or hypersomnia
• Inability to concentrate or indecisiveness
• Decrease or increase in appetite
• Psychomotor retardation or agitation 
• Suicidal ideations

As per the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria, MDD is a subclassification under depressive disorders, which also include Disruptive Mood Dysregulation Disorder, Persistent Depressive Disorder (Dysthymia), Premenstrual Dysphoric Disorder, Substance/Medication-Induced Depressive Disorder, Depressive Disorder Due to Another Medical Condition, Other Specified Depressive Disorder and Unspecified Depressive Disorder. 

Nursing Diagnosis

Nursing diagnoses address responses to illness or disease. Nurses may identify that the following nursing diagnoses, in addition to others not mentioned, apply to the needs of people with MDD:

• Impaired Mood Regulation
• Chronic Sorrow
• Ineffective Coping
• Anxiety
• Hopelessness
• Fatigue
• Disturbed Sleep Pattern
• Sexual Dysfunction
• Social Isolation
• Risk for Suicide

Causes

MDD is considered to be caused due to a combination of biological, genetic, and psychosocial factors. According to cognitive theory, depression results from specific cognitive distortions present in persons susceptible to depression. The learned helplessness theory of depression connects depressive phenomena to the experience of uncontrollable life events.[2]

Risk Factors

MDD has been found to have the highest lifetime prevalence of any psychiatric disorder. The lifetime prevalence rate for MDD is 5 to 17 percent, with almost double in women than in men. The mean age of onset for MDD is about 40 years. Risk factors can be categorized into three broad groups: internal factors, external factors, and adverse life events. [1] Later in life, risk factors for depression include social isolation, death of a spouse, comorbidities, uncontrolled pain, insomnia, cognitive and functional impairments [1]. 

Assessment

It is important to first rule out any medical etiologies for depression. A general medical history along with family medical and psychiatric history, substance use history, medication history, social history should be evaluated, and a complete physical examination should be performed. A mental status examination is very helpful in recognizing a patient with Major Depressive Disorder. 

Evaluation

Laboratory studies including complete blood count with differential, comprehensive metabolic panel, lipid panel, TSH, Vitamin D and toxicology screening are done to rule out other causes of depression such as hypothyroidism, alcoholism, vitamin D deficiency etc.  Nearly 30% of people with substance abuse problems have major or clinical depression. Other tests may sometimes include:

• CT scan or MRI of the brain to rule out serious illnesses such as a brain tumor or dementia
• Electroencephalogram (EEG) to record electrical activity of the brain such as in epilepsy

In most medical office settings, the Patient Health Questionnaire-9 (PHQ9), a self-report instrument is commonly used to detect Major Depressive Disorder. In hospital settings, there are different scales such as Hamilton Rating Scale for Depression (HAM-D) used to detect depression in patients. PHQ-9 is a 9-item self-administered diagnostic screening and severity tool based on current diagnostic criteria for major depression. HAM-D is a multiple choice questionnaire that may be used to rate the severity of a patient's depression. One of the other popular scales used is Beck Depression Inventory (BDI) which is a 21-question multiple-choice self-report that measures the severity of depression symptoms and feelings.

Medical Management

Medications such as:

1. Selective serotonin reuptake inhibitors (SSRIs) such as citalopram, escitalopram, fluoxetine, paroxetine, sertraline, and vilazodone
2. Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine, venlafaxine, desvenlafaxine, and levomilnacipran
3. Atypical antidepressants such as bupropion, mirtazapine, nefazodone, trazodone and vortioxetine
4. Tricyclic antidepressants such as imipramine, nortriptyline, amitriptyline, doxepin, trimipramine, desipramine, and protriptyline
5. Monoamine oxidase inhibitors (MAOIs) such as tranylcypromine, phenelzine, isocarboxazid, and selegiline 
6. Other medications such as mood stabilizers or antipsychotics may be added to an antidepressant to enhance antidepressant effects.

Psychotherapy can be used alone or with other treatments. 

Brain stimulation such as electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS) are also used for patients with treatment-resistant depression that have failed to improve with the use of several different anti-depressant medications. 

Nursing Management

Nurses often perform initial interviewing of a patient in both inpatient and outpatient settings and ask patients questions about their medical history, medication history, and in many facilities are required to screen patients for self-harm or intent to harm others. Patients or their families may share with nurses that they are feeling down or depressed. Nurses have the opportunity to notify the healthcare team to assess the patient's mental health further. The nurses can also provide support and education on MDD. If a patient expresses suicidal ideations, the nurse should stay with the patient and notify a healthcare provider. The patient should not be left alone. 

When To Seek Help

People with MDD should seek help anytime they are having thoughts of hurting themselves or others, if they are considering stopping their treatments, if side effects become unmanageable, or if their symptoms are worsening. 

Coordination of Care

An interdisciplinary approach is essential for the effective and successful treatment of MDD. Primary care physicians and psychiatrists, along with nurses, therapists, social workers, and case managers, form an integral part of these collaborated services. In the majority of cases, primary care is the first setting where individuals with MDD present mostly with somatic complaints. Depression screening in primary care settings is very imperative. The regular screening of the patients using depression rating scales such as PHQ-9 can be very helpful in the early diagnosis and intervention, thus improving the overall outcome of MDD. Suicide screening at each psychiatric visit can be helpful to lower suicide incidence. Since patients with MDD are at increased risk of suicide, close monitoring, and follow-up by mental health workers becomes necessary to ensure safety and compliance with mental health treatment. The involvement of families can further add to a better outcome of the overall mental health treatment. Meta-analyses of randomized trials have shown that depression outcomes are superior when using collaborative care as compared with usual care.[3]

Health Teaching and Health Promotion

Patient education has a profound impact on the overall outcome of major depressive disorder. Since MDD is one of the most common psychiatric disorders causing disability worldwide and people in different parts of the world are hesitant to discuss and seek treatment for depression due to the stigma associated with mental illness, educating patients is very crucial for their better understanding of the mental illness and better compliance with the mental health treatment. Family education also plays an important role in the successful treatment of MDD. Psychoeducation plays a significant role in improving patient compliance and medication adherence. Recent evidence also supports that lifestyle modification, including moderate exercises, can help to improve mild-to-moderate depression. [4]

Nurses can also provide education about the side effects and expected treatment response when patients are prescribed anti-depressant medications. Important points of education include:

• Initially, it takes 2 - 4 weeks to see improvement in symptoms; do not discontinue the medication unless you have talked to your provider
• Notify the provider or go to the hospital immediately for suicidal thoughts
• Side effects may include tiredness, sexual dysfunction, weight gain, dry mouth, nausea, and more
• Do not stop taking anti-depressants abruptly for any reason. Discuss with provider; tapering off medication may be required to avoid withdrawal symptoms

Discharge Planning

Discharge planning should focus on treatment adherence, side effects of treatments, educating the patient and their family about when to seek help, and coordinating appropriate follow up care.

Pearls and Other issues

MDD is one of the most prevalent mental health disorders and causes of disability in the United States. Risk factors for MDD include internal factors, external factors, and adverse life events. Treatments for MDD include medications, psychotherapy, lifestyle modifications, and brain stimulation therapies. Nurses play an important role in the interdisciplinary team with screening and recognizing the signs and symptoms of MDD, making referrals to healthcare team members, and providing education about the disease and the medications prescribed.