DEPRESSIVE DISORDERS

Depressive disorders are characterized by a depressed mood that is severe enough or persistent enough to interfere with function and may presents as an absence of interest or pleasure (anhedonia), a loss of energy, feelings of guilt or low self-esteem, altered cognition, altered appetite, and disturbed sleep.

Depressive disorders can develop at any age. However, they most often occur in a person’s mid-teens, 20s, or 30s. Patients with depressive disorders make up as many as 30% of those cared for in primary care settings.

It is important to be aware that certain physical disorders can be the cause of a depressive disorder. These can include:

  • Thyroid disease
  • Adrenal gland disorder
  • Malignant or benign brain tumors
  • Stroke
  • AIDS
  • Parkinson’s disease
  • Multiple sclerosis

Depression may also be caused as a side effect of:

  • Medications (corticosteroids, some beta blockers, interferon)
  • Recreational drugs

Depression may weaken the immune system and cause increased susceptibility to illness. Individuals with depressive disorders also have increased risk for cardiovascular disorders, myocardial infarction, and stroke, thought to be due to elevated inflammatory cytokines and factors that increase blood clotting, and to decreased heart rate variability. In addition, depression can mimic medical illness (Coryell, 2022; MHA, 2022a; NIMH, 2022).

Signs and Symptoms of a Depressive Disorder

Subjective clues that an individual is experiencing depression include:

  • Verbalization of inability to cope or request help
  • Sleep disturbance and fatigue
  • Abuse of chemical agents
  • Reports of muscular or emotional tension or unexplained aches and pains
  • Persistent sadness or anxious mood
  • Preoccupation with thoughts of death

Objective clues may include:

  • Inability to concentrate or lack of ability to focus or stay focused
  • Lack of goal-directed behavior
  • Inadequate decision-making and problem-solving
  • Inability to meet role expectations or basic needs
  • Destructive behaviors toward the self, reckless behaviors
  • Expressed loss of interest in all activities and loss of motivation
  • Irritability, short-temperedness, or being obstinately silent
  • Expressions of being hopeless, helpless, or worthless
  • Disturbed sleep patterns, including insomnia, frequent awakening during the night, sleeping more than normal
  • Appetite changes, either binge eating or loss of appetite resulting in considerable weight loss or gain
    (Mayo Clinic, 2022; Tabangcora, 2022a)
SCREENING FOR DEPRESSION

Patients who present with signs and symptoms of depression should be screened. One depression screening tool that is accurate and easily administered is the Patient Health Questionnaire-2, also called the Two-Question Screen, used for adolescents, adults, and older adults. It consists of two questions:

  1. During the past two weeks, have you often been bothered by feeling down, depressed, or hopeless?
  2. During the past two weeks, have you often been bothered by having little interest or pleasure in doing things?

Responses may be dichotomous (yes/no), or scaled (0 to 3).

0 = No, not at all
1 = Yes, several days
2 = Yes, more than half the days
3 = Yes, nearly every day

A single “yes” response or a score ≥3 (out of a possible score of 0 to 6) indicates possible clinically significant depression. If positive, the test should be followed up with a more detailed screening (Williams & Nieuwsma, 2022).

Treatment for Depressive Disorders

Evidence-based treatment for depression includes the use of specific psychological therapies and/or pharmacologic agents. Patients who are being treated for a medical condition may have been taking an antidepressant medication or may be started on an antidepressant following screening and diagnosis while in a medical setting. It is important for clinicians to become aware of the contraindications, cautions, and side effects for these medications. Common types of antidepressants and examples include:

  • Tricyclics: amitriptyline, doxepin, imipramine (Tofranil), nortriptyline (Pamelor)
  • Monoamine oxidase inhibitors (MAOIs): isocarboxazid (Marplan), phenelzine (Nardil)
  • Selective serotonin reuptake inhibitors (SSRIs): citalopram (Celexa), fluoxetine (Prozac)
  • Serotonin norepinephrine reuptake inhibitors (SNRIs): venlafaxine (Effexor)
    (Tabangcora, 2022b)

How to Respond to and Care for a Patient with Signs and Symptoms of Depression

Current recommendations are to manage depression as a chronic condition. This requires follow-up of symptoms, side effects of medications, treatment compliance, and treatment modification as necessary to achieve the best outcome.

Patients who present with the signs and symptoms of depression should be carefully assessed for warning signs of suicide. Indications of suicidal thinking may include:

  • A clear or covert statement indicating that the patient may be considering suicide
  • Previous suicide or self-harm attempts
  • Saying good-byes (e.g., “I won’t need any more appointments.”)
  • Preoccupation with death or lack of concern about personal safety
    (Hildah, 2022)

Nursing management for a hospitalized patient with comorbid depressive disorder includes:

  • Monitoring the environment for safety
  • Engaging the patient in a therapeutic relationship
  • Using empathy when communicating with the patient
  • Encouraging self-care and offering direction if depression is severe
  • Using sleep hygiene measures to encourage sleep
  • Assisting patient to set realistic goals for the day and reviewing goal attainment
  • Reviewing and evaluating the patient’s coping strategies and support systems
  • Monitoring eating and encouraging nutritional intake
  • Monitoring medications for effectiveness and side effects
  • Including family in care if the patient wishes
    (Shand et al., 2022)

The central element of responding to the patient is the development of a quality therapeutic relationship. A therapeutic relationship requires exceptional communication skills, which include:

  • Trust: Critical to the relationship and requiring continual effort to maintain it
  • Respect: Recognizing each individual has inherent dignity, worth, and uniqueness
  • Professional intimacy: Providing physical care while being privy to the patient’s psychological, spiritual, and social history
  • Empathy: Understanding, validating, and confirming what the healthcare experience means to the patient
  • Power: Recognizing the unequal power relationship and not abusing it
    (CNO, 2020)
CASE

A Patient with Signs of Depression

Yolanda, a physical therapist, is making her fourth visit to Loren, a male patient who lives in Forest Park, an assisted-living facility. Loren is 78 years old and recovering from a stroke affecting his left side. He has been progressing well, and normally greets Yolanda with a smile, but today he simply opens the door for her without any greeting.

During the treatment session, Yolanda notes that Loren seems distracted and not his usual self. He appears to be tired and out of sorts. She begins a conversation with Loren in order to learn more about his condition.

Yolanda: “You don’t seem to be your usual self today.”

Loren: “Well, I’m kind of tired is all.”

Yolanda: “Are you not sleeping well?”

Loren: “Oh, I don’t know. Things get to me.”

Yolanda: “You’ve been through a lot lately. Perhaps this is affecting your sleep.”

Loren: “Oh, dear. I can’t sleep at all lately.”

Yolanda: “Tell me more about that.”

Loren: “Well, I wake up during the wee hours of the morning and just can’t get back to sleep.”

Yolanda: “What do you think about when you’re trying to get back to sleep?”

Loren: “Oh, I just lay awake, turn this way and that way, and think of all the mistakes I’ve made in my life.”

Yolanda: “That sounds very distressing.”

Loren: “Yes, it is.”

Yolanda: “Tell me …”

Discussion

Yolanda recognizes that sleep disturbances, especially early morning awakenings, are a major physical symptom of a depressive disorder and that Loren’s negative ruminations are also a problem. Her next step will be to inquire about other signs and symptoms of depression (e.g., changes in appetite, feelings of hopelessness, etc.) and then to inform Loren’s primary care provider about her findings. Yolanda will also watch for any indicators of suicidal thinking. This is especially important with older male patients like Loren who have comorbid health problems, since they have the highest rate of suicide.