Depression University of Illinois at Chicago College of Nursing 1
Learning Objectives Upon completion of this session, participants will be better able to: 1. Recognize depression, its symptoms and behaviors 2. Discuss risk factors for depression 3. Utilize tools to assess depression 4. Identify treatments, outlook, and potential complications 5. Recognize the warning signs of suicide
What is depression? Depression is a medical illness in which a person has feelings of sadness, discouragement, lack of self-worth Influences an individual s mood, feelings, thoughts, behavior and physical health Different to normal episodes of feeling sad or blue ; depressive episodes last for weeks, months, or years Depression can be a life-long condition with periods of depression & remission Depression interferes with person s daily activities and overall quality of life NAMI, 2013
Incidence/Prevalence 25 million Americans experience major depressive disorder each year, but only half receive treatment (APA) 12-month prevalence of major depressive disorder is 7% in U.S. Prevalence varies by age group; incidence peaks in 20s More common in females than males Can occur at any age; risk rises after puberty NAMI, 2013; APA, 2013
Risk Factors Adverse childhood experiences Stressful life events Family history of depression Pattern of negative affect Other mental illness Substance use Chronic or disabling medical conditions (e.g. diabetes, morbid obesity, cardiovascular disease) APA, 2013
Causes May run in families (hereditary) May be a side effect of medication Changes within family (loss of income, family illness) Chronic pain and illness Difficulty getting around Frustration with memory loss Loss of a spouse or close friend Trouble adapting to a life change APA, 2013
Signs and Symptoms Depressed mood Loss of interest and/or isolation Weight loss or weight gain Increase or decrease in appetite Increase or decrease in sleep Increase or decrease in physical activity Fatigue or loss of energy Feelings of worthlessness Excessive or inappropriate guilt Excessive worry Decreased concentration Indecisiveness Recurrent thoughts of death Suicidal ideation Suicide attempts APA, 2013
Assessment Types of Depression Major depressive disorder Pervasive low mood that occurs most days Persists for at least two weeks Persistent depressive disorder (dysthymia) Persistent depressed mood for at least two years Symptoms are not absent for more than two months Premenstrual dysphoric disorder Mood symptoms present in the final week before the onset of menses, improve after the onset of menses, and become minimal or absent after menses APA, 2013
Assessment Features of Depression Depression may be classified with: Anxious distress Mixed features Some symptoms of mania or hypomania, but not enough to diagnose bipolar disorder Melancholic features Psychotic features Catatonia Peripartum onset During pregnancy or 4 weeks post-delivery Seasonal pattern APA, 2013
Assessment: Screening & Rating Tools Geriatric Depression Scale Short form: 15 questions http://counsellingresource.com/quizzes/geriatric-depression/ Long form: 30 questions http://psychology.wikia.com/wiki/geriatric_depression_scale RAND Corporation Self-Administered Depression Screener http://www.rand.org/health/surveys/screener.html Zung Self-Rating Depression Scale http://www.depression-help-resource.com/zung-depression-scale.pdf
Treatments Medications Antidepressants Antipsychotics Mood stabilizers Sleep medication Psychotherapy: individual, group, family therapy Psychosocial rehabilitation Diet, exercise, sleep Electroconvulsive therapy (ECT) Transcranial magnetic stimulation (TMS) Phototherapy --- Treatment of co-morbid conditions is also important (substance use, medical conditions, other mental illness) NAMI, 2013
Treatment Medications Antidepressants are most common treatment for depression; also used for other disorders such as anxiety disorders, sleep disturbance, and chronic pain Different classifications of antidepressants impact neurotransmitters in the brain differently e.g., SSRIs increase serotonin levels by preventing reuptake, while NDRIs act on dopamine and norepinephrine Antipsychotics are used to address psychosis, boost effects of antidepressants, or stabilize mood Mood stabilizers or anticonvulsants may be used in depression to help stabilize mood Mayo Clinic, 2018
Treatment Examples of Antidepressant Medications Selective serotonin reuptake inhibitors (SSRIs): e.g., fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), citalopram (Celexa), paroxetine (Paxil) Monoamine oxidase inhibitors (MAOIs): e.g., isocarboxazid (Marplan), phenelzine (Nardil) Tricyclic antidepressants (TCAs): e.g., amitriptyline (Elavil), clomipramine (Anafranil) Serotonin-norepinephrine reuptake inhibitors (SNRIs): e.g., venlafaxine (Effexor), duloxetine (Cymbalta) Others: e.g., bupropion (Wellbutrin) - NDRI, trazodone (Desyrel) - SARI Mayo Clinic, 2018
Treatment Examples of Other Medications Antipsychotics: o Typical antipsychotics: chlorpromazine (Thorazine), perphenazine (Trilafon), haloperidol (Haldol) o Atypical antipsychotics (second generation): olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), clozapine (Clozaril) Anticonvulsants: carbamazepine (Tegretol), valproic acid (Depakote), lamotrigine (Lamictal) Lithium
Management: Addressing Suicide Depression and treatment for depression place individuals at risk for suicide As symptoms start to improve, individuals may be at higher risk for suicide than at initial diagnosis (for example, due to increased energy) Be aware of member s history and stressors Suicidal ideation should be monitored closely Assess for thoughts, plan, intent, and access to means In the U.S., call the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) Use that same number and press "1" to reach the Veterans Crisis Line NIMH, 2018
Management Warning Signs of Suicide Suicidal ideation may require hospitalization Direct statements: I want to die, I wish I was dead, I m going to kill myself Indirect statements: My life isn t worth living Giving away belongings Pulling away from loved ones, isolation Long periods of depression with sudden increase of energy Take all suicidal statements seriously. Do not assume somebody is looking for attention NIMH, 2018
Management Intervention Strategies Assist member in identifying symptoms and how they may impact behavior o Help member make goals about behaviors to change and how to change them Educate family and involve in treatment plan when possible o Family can help identify symptoms, track behaviors, and give encouraging feedback Work on healthy lifestyle choices o Regular sleep, healthy eating, avoiding alcohol/drugs Help member identify treatment that works best for them NAMI, 2013
Management Intervention Strategies Encourage member to communicate with providers about medication side effects o Document side effects to help discussion on medication changes if needed Encourage member to take medication every day, as missing doses may lead to negative effects o Using pill boxes/bubble packs o Setting alarms, leaving notes, using a calendar Encourage member to discuss concerns with healthcare provider, assist in communication as needed NAMI, 2013
Prevention Depression can be challenging to prevent, but some strategies may help: Take steps to control stress, to increase resilience and boost self-esteem Reach out to family and friends, especially in times of crisis, to help you weather rough spells Get treatment at the earliest sign of a problem, to prevent depression from worsening Considering starting long-term maintenance treatment, to help prevent a relapse of symptoms Mayo Clinic, 2018
Member Education & Resources World Health Organization has produced helpful onepage handouts for patients & families: What you should know Parents worried about a child Peripartum depression Preventing adolescent depression Preventing depression while aging Suicide prevention/intervention http://www.who.int/campaigns/ world-health-day/2017/handouts-depression/en/
Member Education & Resources MedlinePlus (National Institutes of Health) has depression resources for both providers & patients Great selection of articles & handouts on specific depression-related topics https://medlineplus.gov/depression.html University of Wisconsin School of Medicine, Department of Family Medicine and Community Health includes patient handouts about complementary and nonpharmaceutical therapies https://www.fammed.wisc.edu/integrative/resources/ modules/depression/
References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (fifth ed.). Washington, DC: Author. National Alliance on Mental Illness. (2013). Depression. Retrieved from https://www.nami.org/learn-more/ Mental-Health-Conditions/Depression National Institutes of Mental Health. (2018). Depression. Retrieved from https://www.nimh.nih.gov/health/topics/depression/ Mayo Clinic. (2018). Depression (major depressive disorder). Retrieved from https://www.mayoclinic.org/ diseases-conditions/depression/symptoms-causes/ syc-20356007
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