Mental Health Nursing: Clinical Principles and Practice

Introduction

Among the various psychiatric disorders, major depression or unipolar depression, is a very common condition. The prevalence of major depression has been found to be 10% to 25% in females, while it is around 5% to 12% in males. However, this condition often goes undetected or untreated clinical condition. It not only interferes with the day to day functioning of the affected person but also causes considerable stress to the family and caregivers.

The exact mechanism of major depression is poorly understood. Although many go undetected and are not treated adequately, many effective treatment modalities are now available. In addition to the various modalities of treatment, the nurse also has an important role to play. The aim of this essay is to define major depression, enumerate its etiology and treatment strategy and elaborate the role played by nurses in major depression. A critical review of literature is also made.

Major depressive disorder

Major depression can be defined as “a clinical syndrome lasting at least 2 weeks, during which the patient experiences either depressed mood or anhedonia plus at least five of the following symptoms: depressed mood most of the day, nearly every day; markedly diminished interest or pleasure in most activities most of the day; significant weight loss or gain or appetite disturbance; insomnia or hypersomnia; psychomotor agitation or retardation; inappropriate guilt; diminished ability to think or concentrate, or indecisiveness; or recurring thoughts of death, including suicidal ideation” (Snow, Lascher, Mottur-Pilson, 2000, p.3.)

Etiology

The exact etiology is not known, but genetic and environmental factors are thought to contribute (The Merck Manuals, 2009). About 50 % of the cause is considered to be due to heredity. First-degree relatives of depressed patients commonly have depression (The Merck Manuals, 2009). “A functional polymorphism in the promoter region of the serotonin transporter (5-HT T) gene was found to moderate the influence of stressful life events on depression” (Caspi et al 2003). A study has confirmed the presence of a specific predisposition gene to major depression at 12q22-q23.2 (Abkevich et al 2003).

Among other causes, psychosocial factors also are considered to be a cause. Major stressors in life like loss of a loved one, separation etc are implicated. But these cause severe depression mostly in those who are predisposed to a mood disorder (The Merck Manuals, 2009.)

Introverted people with an anxious tendency are more susceptible to depression, since they lack the social skills, which are required in adjusting to pressures in life. Major depression is also more common in those having other mental disorders (The Merck Manuals, 2009.)

There is a female preponderance in developing major depression, although the exact reason is not clear. Some possible reasons, which have been put fort include: thyroid dysfunction, endocrine changes during menstruation and menopause, after delivery (postpartum depression), heightened response or greater exposure to daily stresses and higher levels of monoamine oxidase (The Merck Manuals, 2009.)

Seasonal affective disorder is a condition where depression occurs during certain seasons like autumn or severe winter. Some of the different physical disorders, which are associated with major depression include: thyroid disorders, stroke, AIDS, Parkinson’s disease, multiple sclerosis, adrenal gland disorders, and brain tumors (benign and malignant) (The Merck Manuals, 2009).

Drugs, which are implicated in causing major depression includes: interferon, reserpine, corticosteroids, some β-blockers, abuse of alcohol, amphetamines, and due to the withdrawal effect of drugs (The Merck Manuals, 2009)

Other theories for major depression includes; abnormal regulation of catecholaminergic, cholinergic, and serotonergic neurotransmission. Neuroendocrine dysregulation of the 3 axes (hypothalamic-pituitary-adrenal, hypothalamic-pituitary-thyroid, and growth hormone) (The Merck Manuals, 2009)

Treatment

The therapies that have proven to be effective for depressive disorders includes: pharmacotherapy, psychotherapy, electroconvulsive therapy and other treatment.

Pharmacotherapy – these includes tricyclic antidepressants (first and second-generation), heterocyclics, and monoamine oxidase inhibitors. The newer classes of antidepressants include selective serotonin reuptake inhibitors (SSRIs).

Other drugs include herbal remedies like St. John’s wort, GABA mimetic agents, 5-HT1a receptor agonists, dopamine reuptake inhibitors, serotonin and noradrenaline reuptake inhibitors, selective norepinephrine reuptake inhibitors, reversible inhibitors of monoamine oxidase, 5-HT2 receptor antagonists, and dopamine antagonists (Snow, Lascher, Mottur-Pilson, 2000).

The newer antidepressants (especially SSRIs) are believed to be more efficacious, have lesser adverse effect profiles, and tolerated better by patients (Snow, Lascher, Mottur-Pilson, 2000).

Recommendations have been made that in the case of primary care patients with acute major depression or dysthymia, treatment with either SSRIs or tricyclic antidepressants should be considered. Since a short-term relapse can occur, its prevention is by continuing the antidepressant at the initial dose for at least four months after recovery or improvement in symptoms.

If still the patient does not show much of a response at 6 weeks, then the treatment should be reconsidered and changed (Snow, Lascher, Mottur-Pilson, 2000).

Psychotherapy among the most promising psychosocial intervention for the treatment of depression, cognitive therapy appears to be the best. It seems to be at least as effective to other interventions and may reduce the risk of symptoms returning after the therapy has been stopped (Hollon, Shelton, Davis, 1993.)

“Cognitive therapy is a treatment process that helps patient’s correct false self-beliefs that lead to certain moods and behaviors” (Rupke, Blecke, Renfrow, 2006 ). Cognitive therapy is based on the principle that a mood is preceded by a thought, both of which are related to the physical reaction, environment and subsequent behavior of a person.

Based on this principle, therefore, a person can change their mood, behavior, and physical reaction by changing a current thought. First, the patient is taught to accept that some of their interpretation and perception of reality may not be true and that these are the ones that cause negative thoughts. In the next step, the patient is taught to recognize negative thoughts and find out other thoughts that are more realistic.

The patient then has to make a decision as to which is supported by evidence- the negative thought or the alternative thought. With progress in the cognitive therapy, the focus is more “on reframing deeply held or “core” beliefs about self and the world” (Rupke, Blecke, Renfrow, 2006, p.2).

Positive reinforcement for the patient is obtained by scheduling pleasurable activities, mainly with other people. Giving “graded tasks, homework and acting out difficult behavioral situations” are some of the other CBT techniques (Rupke, Blecke, Renfrow, 2006.)

ECT  electroconvulsive therapy (ECT) is a widely used and efficient treatment method. It is used for various psychiatric conditions, especially affective disorders, which are resistant to medication, psychotherapy and other treatment (Chamberlin, Tsai, 1998).

However, despite the efficacy of this method, many cognitive side effects are known to occur after ECT like anterograde and retrograde memory disturbances, acute confused state, interictal disorientation and postictal delirium (Durr, Golden, 1995). Therefore, although ECT is considered to be a safe and effective treatment, its use is limited. The use of succinylcholine (to modify convulsive motor effects), continuous oxygenation, and brief-pulse stimuli has made it more acceptable; however, the major concern is the occurrence of short-term cognitive effects (Bailine et al, 2000.)

Other treatment – some studies have shown that in the treatment of patients with major depression, exercise has a comparable effect to that of antidepressant medication (Blumenthal et al, 2007). Even though antidepressant treatment or cognitive therapy have been shown to be effective by themselves, a combination treatment with both is more effective (Shamsaei et al, 2008.)

In the past few decades, neurostimulation techniques are increasingly being considered as an augmentation alternative for treatment-resistant depression. Thus, another alternative strategy is to combine antidepressants with neurostimulation therapies (electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS)).

The first-line of treatment for major depressive disorder, according to recent meta-analyses have been SSRIs-escitalopram and sertraline. However, large pragmatic trials and other meta-analyses have not observed these findings. Hence, at present, there is no clear-cut evidence on the superiority of any specific antidepressant drug. Therefore, the emphasis should be on being aware of the adverse effects, and pharmacological interactions of antidepressant treatment and tailoring it according to the need of the patient. In addition, the cost-effectiveness of the drug and switching to other options, adding an additional antidepressant or titrating the dose should also be considered (Brunoni, Fraguas, Fregni, 2009.)

Critical review of literature

The efficacy of antidepressant drugs has been subject to much debate. The critical reviews point out the problems in study methodology, inconsistency in the literature and the lack of evidence that increasing antidepressant medication has on the burden of depressive disorders (Greenberg & Fisher, 1997; Antonuccio et al, 1999; Moncrieff, 2001). There is no consistent pointer as to what biochemical pathway is affected by antidepressants. It has also been argued that many studies are mainly done to “obtain regulatory approval, to introduce new medications, or to showcase particular advantages of newer drugs after regulatory approval” and thus, “form an inadequate basis for an evidence-based medicine assessment of antidepressant effectiveness” (Thase, 2008).

However, a systematic review and meta-analysis by Cipriani et al 2010, shows that sertraline is favored over other antidepressive agents both in terms of efficacy and acceptability.

Considering all evidences, the argument questioning the efficacy and tolerability of antidepressants seem to be stronger. However, when combined with other forms of therapy, antidepressants definitely have a role to play in the treatment of major depression.

Female preponderance in depressive illness has also been subject to debate. Some studies report that, in females, rather than a greater number of longer duration of episodes, there is a higher first-onset depression (Kessler et al 1993; Wilhelm et al, 1997) while others show a female preponderance in recurrent and chronic depression (Stefansson et al, 1994). Many other studies (Romans et al, 2007) have shown a female preponderance in their studies. Thus, this finding appears to be quite strong.

Role of the nurse

Nurses are in an ideal position to treat patients with MDD due to many reasons. Since they have a lot of direct contact with the patient, they are in a unique position to develop a strong and consistent therapeutic relationship. As a direct result of this direct contact, they are “exposed to a greater sampling of a patient’s behavior that can lead to faster detection of disorders” (Buckwalter, Gerdner, Kohout, 1999). Lastly, nurses are able to provide the best care for individual patients because they are able to coordinate services and service providers (Buckwalter, Gerdner, Kohout, 1999). Three specific techniques from cognitive-behavioral strategies have been described (Buckwalter, Gerdner, Kohout, 1999).

Brief Therapy

Although 10 sessions of cognitive behavioral therapy (CBT) can effectively control MDD, it can be cut down to 6 sessions, and even by 3 sessions (2 meetings 1 week apart followed by a third session 3 months later), according to recent evidence. A sustained improvement over a period of one year has been shown by this brief cognitive-based treatment (Emery, 2000, p.240.)

Behavioral activation

In order to minimize treatment time, a course of therapy that zeroes in on some of the active ingredients of CBT has been described (Lejuez et al, 2001). Although 10-12 sessions have been recommend by them in total, subsequent sessions can be for just 15 to 30 minutes or less. This can be conducted over the telephone also, if required (Lejuez et al, 2001).

The therapy described by Lejuez et al, 2001 aims “to identify environmental factors that are maintaining the depression and the factors that limit pleasurable activity, and then gradually increase that positive activity to not only increase one’s pleasure, but one’s sense of control as well” (Lejuez et al, 2001.)

Guided self-management: psychoeducation and bibliotherapy

Psychoeducation involves educating the patient about MDD by the therapist or the nurse. It has been found that depression in caregivers of patients with dementia have been successfully reduced by means of psychoeducation by nurses (Buckwalter, Gerdner, Kohout, 1999.)

In addition to psychoeducation, bibliotherapy can also be useful. Bibliotherapy is “a form of treatment where patients are provided a manual to work on nearly autonomously, nurses can provide the support and direction that the patient may need to maintain focus” (Scogin, Hamblin, Beutler, 1987.)

Nursing interventions include: providing a safe environment for the client, continually assess the clients potential for suicide, and observe the client closely, especially under the following circumstances: after antidepressant medication begins to raise the clients mood, during unstructured time on the unit or times when the number of staff on the unit is limited, after any dramatic behavioral change (Schultz, Sheila, Videbeck, 2009, p.140.)

The client is reoriented to person, place and time as indicated. Adequate time is spent with the client. Initially, the same staff members are assigned to work with the client whenever possible. When approaching the client, it is preferable to use a moderate, level tone of voice. It is better to avoid being overtly cheerful. When interacting with the client, silence and active listening is used. When first communicating with the client, simple, direct sentences have to be used. Too many questions are not asked. The client is encouraged to ventilate their feelings (verbal and nonverbal), freely. The client is taught about problem-solving process. Positive feedback is provided frequently. A regular routine is maintained (Schultz, Sheila, Videbeck, 2009, p.150.)

The patient can be encouraged to participate in individual and group therapy and encouraged to interact with others. It is important to document observations and significant conversations. It is wise to plan activities for the patient when their energy levels are the highest. The adverse effects of medications, functioning level and the response to treatment have to be regularly monitored (Kowalak, 2008, p.85.)

Conclusion

Major depression is a common psychiatric disorder with a poorly defined etiology. Various causes like heredity, psychosocial factors, personality type, drugs, physical disorders and other theories have been put forth. Pharmacotherapy, psychotherapy, electroconvulsive therapy, combination therapy and other treatment like exercise have all been found to be beneficial. A critical review of literature shows that there is some debate on the efficacy of increasing antidepressant medication and the theory about female preponderance. Nurses play an important role in the management of this disorder since they are uniquely placed in the care of the patient. Three specific techniques from cognitive-behavioral strategies have been described, which can be practiced by advanced nurses; brief therapy, behavioral activation and guided self-management.

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