7.11 Depression

Depression is a mood disorder that is a common mental illness in the United States and throughout the world. Depression is different from the usual mood fluctuations and short-lived emotional responses to everyday life stressors. When it is recurrent with moderate or severe intensity, depression can become a serious health condition. People affected with depression suffer emotionally, often resulting in poor functioning at work, school, or in social relationships. Depression often affects relationships and family functioning because people with depression often withdraw from social interactions. At its worst, depression can lead to suicide.^[1] See Figure 7.6^[2] for an artist’s depiction of depression.

According to the DSM-5-TR, signs and symptoms of depression are listed in Table 7.11a.^[3]

Table 7.11a. Signs and Symptoms of Depression

Other types of depression include seasonal affective disorder and postpartum depression. Seasonal affective disorder (SAD) is a specific type of depression that includes mood changes and symptoms similar to depression. The symptoms usually occur during the fall and winter months, especially in northern latitudes, when there is less sunlight. Symptoms usually improve with the arrival of spring. SAD is more than just “winter blues.” The symptoms can be distressing and overwhelming and can interfere with daily functioning.

Depression that occurs after delivery of a baby is called postpartum depression. Postpartum depression includes feelings of extreme sadness, anxiety, and exhaustion that may make it difficult for new mothers to complete daily care activities for themselves and/or for their babies. Untreated postpartum depression is not only a problem for the mother’s health and quality of life but can also affect the well-being of the baby. Severe postpartum depression can lead to postpartum psychosis, a medical emergency. Women who have postpartum psychosis may have delusions (thoughts or beliefs that are not true), hallucinations (seeing, hearing, or smelling things that are not there), mania (a high, elated mood that often seems out of touch with reality), paranoia, and confusion. Women who have postpartum psychosis are at risk for harming themselves or their child and should receive help as soon as possible by calling 911 or taking the mother to the nearest emergency room.

Assessment (Recognizing Cues)

Nurses recognize and document signs and symptoms of depression. If depression has not been previously diagnosed, or a client is experiencing worsening signs and symptoms of depression, these assessments should be communicated to the provider.

According to the DSM-5-TR, a mental health professional diagnoses depression if the client demonstrates five or more of the signs or symptoms previously discussed in Table 7.11a. Symptoms must be observed most of the day, on most days, over the previous two weeks, and represent a change from previous functioning. At least one of the symptoms must be either depressed mood or loss of interest or pleasure, and signs/symptoms exhibited cannot be attributable to physiological effects of a substance or another medical condition.^[4]

Nurses may also be involved in administering a screening tool for depression at their agency to determine if clients need further evaluation for depression. A common screening tool for depression is called PHQ-9.

Depression in Children and Adolescents

Every child, adolescent, and adult feels sad occasionally. However, some children may exhibit signs of depression such as feeling sad, hopeless, or disinterest in things they previously enjoyed. When a child appears withdrawn or sad for two or more weeks, they may be diagnosed with a depressive disorder. Examples of behaviors observed in children and adolescents with a depressive disorder are much the same as adults shown in the table above. Some additional considerations for children are the following:

• Difficulty paying attention
• Feeling useless
• Engaging in self-injury or self-destructive behavior
• Exhibiting physical complaints, such as frequent headaches or stomachaches
• Using alcohol or drugs as a way of trying to feel better
• Appearing unmotivated or acting out, which others may label as “lazy” or a “troublemaker”

It is important to ask children and adolescents who are withdrawn or sad about thoughts of suicide or self-harm. Adolescents may perceive a single disappointment (such as a relationship break-up) as so catastrophic they feel suicidal or begin to hurt themselves.

If a child or adolescent is suspected to have undiagnosed depression, a nurse or school counselor can refer them to a mental health professional to conduct a comprehensive assessment and plan effective treatments.

Treatments for Depression

Depression is one of the most treatable mental disorders. Treatments for depression can include medications, psychotherapy, and other medical treatments. Nursing interventions focus on screening for suicidal ideation and implementing safety interventions and encouraging effective coping strategies.

Medications

Providers may prescribe antidepressants to help balance neurotransmitters and improve the client’s mood. There are several classes of antidepressants, including selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), norepinephrine and dopamine reuptake inhibitors (NDRIs), serotonin antagonist and reuptake inhibitors, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). SSRIs are typically prescribed as first-line treatment because they cause fewer and milder side effects than other types of antidepressants. Clients whose symptoms do not respond to antidepressant medication may be prescribed a different class of antidepressant medications or additional antipsychotic or anticonvulsant medications.^[5]

New medications, such as intranasal esketamine, may be prescribed for people with treatment-resistant depression. Intranasal esketamine acts rapidly, typically within a couple of hours, to relieve depression symptoms. People who use esketamine usually continue taking an oral antidepressant to maintain the improvement in their symptoms.^[6]

Psychotherapy

Psychotherapy may be used alone for treatment of mild depression or in combination with antidepressant medications for moderate to severe depression. Psychotherapy may involve the individual and/or their family members to help address issues within these close relationships. Additionally, group therapy brings people with similar disorders together in a supportive environment to learn how others cope in similar situations.

Two effective types of psychotherapy for depression are cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT). Review information about CBT and DBT in the “Psychotherapy” section of this chapter.

If a child or adolescent is diagnosed with depression, treatment may also include behavioral therapy with the child and their family members in collaboration with the child’s school. Behavioral interventions reward desired behaviors and reduce maladaptive coping behaviors. For example, the point or star system may be used where the child receives points or stars for desired behaviors, and then specific privileges are awarded based on the points or stars earned each day. Rewards have been shown to increase desired behavior.

Other Treatments

Electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) are medical procedures that may be used to treat severe depression that does not respond to psychotropic medications or psychotherapy. Read more information about these procedures in the “General Treatments for Mental Health Conditions” section.

Seasonal affect disorder (SAD) may be treated with light therapy. Light therapy involves sitting near a special lamp for at least 30 minutes upon awakening. This lamp produces a very bright, full-spectrum light that mimics outdoor light. Research indicates this light helps balance serotonin levels and improves SAD symptoms.^[7]

Some people use natural products, including vitamin D and the herbal dietary supplement St. John’s wort, for depression. However, research is ongoing, and these products have not been approved by the FDA. Dietary supplements and natural products can limit the effectiveness or interact with prescribed medications, so clients should be advised to consult with their health care provider before using them.^[8]

Nursing Interventions

Nurses screen clients with depression for suicidal ideation and promptly implement safety interventions for those at risk. Review information about suicide screening and safety interventions in the “Suicide Screening and Safety Interventions” section of this chapter.

Nurses also implement interventions that address the physiological effects elated to depression such as nutrition, sleep and rest, elimination, and self-care deficits. See common nursing interventions related to these physiological effects in Table 7.11b.

Table 7.11b. Nursing Interventions Targeting Physiological Effects Related to Depression

Health Teaching

In addition to teaching clients about the symptoms of depression, prescribed medications, and other treatments, nurses teach clients about using stress management and healthy coping strategies to manage emotional responses.

Stress management techniques include engaging in regular physical exercise, selecting healthy food choices, setting personal and professional boundaries, and maintaining a healthy social support network. Additional stress management strategies include the techniques of grounding, unhooking, acting on our values, being kind, and making room. Emotion-focused coping refers to strategies used to manage one’s emotional responses, such as participating in mindfulness, meditation, or yoga; using humor and jokes; seeking spiritual or religious pursuits; breathing exercises; and seeking social support.^[9] Review additional information about these strategies in the “Applying the Nursing Process to Promote Healthy Coping” in the “Mental Health Concepts” chapter.