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Depression /Reading and Sharing

Depression is the most common psychiatric disorder in the general population and the most common mental health condition seen primary care. Depression is a mental disorder that affects the emotion, cognition, behavior, and physically. Thus, it interferes with the daily life of the patient. 1 out of 10 adults experience one or more episode during their lifetime. Common complaints presented to the office are lack of interest in pleasurable activities, insomnia, digestive problems, and unexplained chronic aches and pains.  As there are many forms of depression, treatment varies depending on the specific diagnosis. Type of depression may include: major depression, single versus recurrent episode (mild, moderate and severe with or without psychotic features); persistent depressive disorder (dysthymia), postpartum depression, seasonal affective disorder (SAD), bipolar disorder, and premenstrual dysphoric disorder. Most depression is associated with other physical or mental disorders (Cash & Glass, 2017).

The lifetime prevalence of a major depressive disorder (MDD) according to Dunphy, Winland-Brown, Porter, & Thomas (2015), is 16.5% with a 6.7% 12- month prevalence rate. They further state that the prevalence of depression in adults older than 65 years-old can be as high as 40% hospitalized and nursing home patients and as high as 30% in community-dwelling elders or in adults living with chronic medical conditions. Dunphy et al. (2015), believes that once a person experiences a depressive episode, they may be at risk for a recurrence. They further state that 50% of these individuals go on to experience a recurrence; after two episodes, their chances of another recurrence are an 80% chance.

Women have a two or threefold higher rate of self-reported depression compared to men. In the elderly, major depression diagnosis is approximately 3 to 5% living in the community, 15 to 20% in the institutional setting, and 13% living in the nursing homes.  Interesting to note is the fact that only 10 to 25% with depression come to seek treatment with the providers.

The pathophysiology of persistent depression disorder is unknown, but it is believed that an alteration in serotonin and noradrenergic systems and dopamine (DA) have been demonstrated in different forms of chronic depression (Hellerstein, 2018). Dunphy et al. (2015), believes that there is a correlation between the hypersecretion of cortisol and depression. They further state that approximately 5% to 10% of all patients with depression have a coexisting thyroid disorder, have a genetic factor, and that psychosocial life events may precede to a mood disorder. Thus, history of childhood emotional, physical, and/or sexual abuse may contribute to adult-onset depression (Ferri, 2018).

Most patients with depression are complaining of unexplained, unrelated symptoms and patients are not aware that what they are experiencing is depression (Connor, Gaynes, Burda, Soh, & Whitlock, 2013. Therefore, during physical examination and history taking, these are the signs and symptoms to watch for:

  1.  Vegetative status- trouble in sleeping, appetite, and weight; changes in appearance with poor grooming and hygiene, loss of energy, decreased interest in sex, psychomotor retardation; and poor eye contact, staring down, flat affect.
  2.   Impulse control- suicidal or homicidal ideation needs to be addressed asap with counselling and safety precaution in place.
  3.   Behavioral-depressed mood, irritability, and anxiety; and isolation, fatigability and anhedonia wherein the patient is unable to find satisfaction from pleasurable activities.
  4.   Cognitive-increase sense of guilt, low self-esteem, worthlessness, attention span difficulties, poor frustration tolerance, mild paranoia, psychosis, and memory or concentration problems.
  5.   Physical symptoms-digestion issues like nausea, constipation, diarrhea, fatigue, physical aches and pains, unexplained recurrent headaches, backaches, or stomachaches, increased muscle tension, and mitigating pain that disappears when depression lifts (Cash & Glass, 2017).

Considering the numerous unexplained signs and symptoms presented by the patient with depression, a provider may start with these diagnostics tests and mental state screening: CBC with differentials, CMP, thyroid panel, liver profile, Vitamin D25 hydroxy, Vitamin B12, FSH/LH level, blood alcohol level, urine drug screen, and CT/MRI if needed.  In assessing the mental health, depression screening tools like Beck Depression Inventory Scale, Geriatric Depression Scale (GADS), and PHQ-2 and/or PHQ-9, is utilized in the clinical setting. Treatment of depression starts with keeping the patient from self-harm and treating the physical and laboratory findings. If there is a hormonal issue, then a replacement will be ordered. Some patients need dietary changes to avoid insomnia or digestive symptoms (Cash & Glass, 2017).

According to Cash & Glass (2017), education of a depressed patient and their family will include taking of the medication as prescribed with emphasis on side effects and that it takes 3-4 weeks before the medication takes full effect. Exercise daily for 20-30 minutes is encouraged as it promotes energy and enhance feeling of well-being. Next, 7-8 hours of sleep is needed and address it accordingly if it is a problem. Avoidance of caffeine products, exercise close to sleeping time, and watching TV late at night needs to be discussed. Counselling either with a psychologist or psychiatrist, and/or attending a group psychotherapy should be considered as another option. During this time, patient is highly encouraged to enhance interpersonal relationships and build self-esteem, with their friends and family. Instruct to call anytime if patient needs to express self-harm or harm to others feeling and other worsening symptoms if it occurs before the next visit.  In contrast, of patient is feeling better, educate in continuing the medication, activities and related resources for the next six months or so, to prevent relapse of depression.

If pharmacologic intervention is needed, the drug of choice is the SSRI antidepressants like the Celexa, Zoloft, Paxil, Lexapro, Effexor or Cymbalta. Individual considerations will be taken for different patients. For example, the elderly can have the Paxil or Zoloft instead of the TCAs, as it has short half-lives and can be withdrawn quickly; TCAs should not be prescribed for patient who had recent acute myocardial infarction, Cymbalta or Effexor should only be 50% for patients with hepatic impairment. Reminding the patient that the full effect takes 3-4 weeks before a visible change can happen. The patient will have to be on the trial medication for 6-8 weeks to measure the progress. Next, confirming that patient is taking correctly or as prescribed is needed before concluding that it is ineffective. These antidepressant therapy is usually continued for 6 months to one year or up to 5 years if needed, since there is a risk of depression recurrence. Remind the patient that the medication needs to be tapered off and not just stopped abruptly.  Finally, the MAO inhibitors could only be prescribed by a psychiatrist patient education in case patient would ask for this drug (Collins-Bride, Saxe, Duderstadt & Kaplan, 2017).

In conclusion, the follow-up in 1-2 weeks is necessary to assess the status, drug effectiveness, and adverse reactions.  Patients tend to become suicidal after the depression as they have more energy to carry out the idea. Thus, every visit means assessing the patient for suicidality. Then, increase to 2-4 weeks after checking the progress. If with positive change, a monthly visit is appropriate. However, if suicidal or homicidal behavior is strong, immediate psychiatrist referral for possible emergency admission is needed. Co-management or physician consult is needed for continuing psychotherapy. And, if patient fails to respond to the prescribed antidepressant for 1-2 months, a psychiatrist should be consulted (Ferri, 2018).

 

References:

Cash, J. C. & Glass, C.A. (2017). Family practice guidelines. (4th ed.). New York, NY: Springer Publishing Company.

Collins-Bride, G.M., Saxe, J.M., Duderstadt, K.G., & Kaplan, R. (2017). Clinical guidelines for advance practice nursing (3rd ed.). Burlington, MA: Jones & Bartlett Learning.

Connor, E., Gaynes, B. N., Burda, B. U., Soh, C., & Whitlock, E. P. (2013). Screening for and treatment of suicide risk relevant to primary care: A systematic review for the U.S. Preventive Services Task Force. Annals of Internal Medicine158(10), 741-754. doi:10.7326/0003-4819-158-10-201305210-00642

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). In Primary care: The art and science of advanced practice nursing (4th ed., pp. 313-318). Philadelphia, PA: F.A. Davis Company.

Ferri, F. (2018). 2018 Ferri’s clinical advisor. Philadelphia, PA: Elsevier.

Hellerstein, D. (2018). Persistent depressive disorder Etiology – Epocrates online. Retrieved fromhttps://online.epocrates.com/diseases/80524/Persistent-depressive-disorder/Etiology

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