What is major depressive disorder?
What does MDD look like?
Risk Factors
- History of depression – Previous episode of depression, postpartum depression, depression during pregnancy
- Previous postpartum depression with psychosis is linked to 30-50% increased risk of recurrence at subsequent delivery
- Family history of depressive disorder – Twin studies show that MDD is more common among 1st degree biological relatives than among the general population.
- Lack of social supports
- Stressful life events
- Current substance use
- Medical comorbidity
- Economic difficulties
Differential Diagnosis
- Bipolar disorder; manic episodes with irritable mood or mixed episodes
- Adjustment disorder with depressed mood
- Depressive disorder due to another medical condition
- Obstructive sleep apnea
- Substance/medication-induced depressive/bipolar disorder
- Oral contraceptives
- Corticosteroids
- Attention-deficit/hyperactivity disorder
- Normal sadness
- Grief/loss
- Other conditions that may be a focus of clinical attention
- Thyroid or adrenal dysfunction, or hypothyroidism
- Neoplasms
- Stroke
- Vitamin deficiencies, such as of folic acid (B9)
How is MDD investigated?
- Labwork: complete blood count (CBC), iron studies, liver function tests, TSH, vitamin B12, vitamin D, zinc, calcium, magnesium, phosphate
- Polysomnography
- Electroencephalogram (EEG)
| Screening/Scale | Rater | Description |
| Beck Depression Inventory (BDI) | Client | 21 questions with multiple choice answers to measure the severity of depression; for ages 13+ |
| Patient Health Questionnaire (PHQ-9) | Client | 9 questions to screen for presence and severity of depression |
| Hamilton Rating Scale for Depression (HAM-D/HDRS) | Clinician | 17 to 29 dimensions scored on a 3- or 5-point scale; should not be used for diagnosis |
| Montgomery–Åsberg Depression Rating Scale (MADRS) | Clinician | 10-item questionnaire to diagnose severity of mood disorders |
| Quick Inventory of Depressive Symptomatology (QIDS-C) | Clinician | 16-item rating of depressive symptoms; clinician version |
| Quick Inventory of Depressive Symptomatology (QIDS-SR) | Client | 16-item rating of depressive symptoms; client version |
| Geriatric Depression Scale (GDS) | Clinician/client | 30 questions (15 questions in the short version) with “yes” and “no” responses |
How is MDD treated?
The experience of major depressive disorder is variable, thus there is no one-size-fits-all approach to treatment. Nonpharmacological approaches should be offered first, as they are the least invasive. Plus, psychotherapy can help prevent illness recurrence in the long run. However, there is evidence that psychotherapy and pharmacotherapy used in conjunction is more effective than either one used alone.
Goals of treatment
- Reduce or control symptoms, and eliminate signs and symptoms of the depressive syndrome, if possible
- Improve occupational and psychosocial functioning as much as possible
- Reduce the likelihood of relapse and recurrence
First-generation antidepressants:
- Monoamine oxidase inhibitors (MAOI)
- Tricyclic antidepressants
Second-generation antidepressants:
- Selective serotonin reuptake inhibitors (SSRI)
- Selective norepinephrine reuptake inhibitors (SNRI)
- Norepinephrine dopamine reuptake inhibitors (NDRI)
- Serotonin modulator and stimulators
Special Considerations
Children & Teenagers
From around the age of 8, children begin to experience and express symptoms of depression that similarly to adults, allowing for diagnosis using the same, or slightly modified, criteria used for adults.
Some signs of depression seen in youth may include:
- Age 3 and younger: feeding problems, tantrums, lack of playfulness, lack of emotional expression, failure to thrive, delays in speech, delays in gross motor development
- Ages 3-5: accident proneness, phobias, aggression, excessive self-reproach for minor infractions
- Ages 6-8: vague physical complaints, aggression, clinging to parents and avoiding new people or challenges, lagging behind in academics and social skills when compared to peers
- Ages 9-12: morbid thoughts, excessive worrying; may reason that they are depressed because they have disappointed their parents; lack of interest in playing with friends
- Teenagers: Inappropriately expressed anger, aggression, running away, delinquency, social withdrawal, sexual acting out, substance abuse, restlessness, apathy, low self-esteem, sleeping or eating disturbances, psychosomatic complaints
Although non-pharmacological treatment options, such as CBT, should be first considered for children and teenagers, fluoxetine (Prozac) is the first line antidepressant for depression in youth. Fluoxetine has FDA approval for treatment of pediatric depression, and it has a long half-life, which means there’s a lesser concern for withdrawal risk if the child is non-adherent to the medication. Escitalopram (Lexapro, Cipralex) has also been approved by the FDA in 2009 for treatment of MDD in youth ages 12-17.
Older Adults
Diagnosis can be made using the criteria used for adults, but special attention should be placed on the role of other medical or neurocognitive causes. Symptoms such as anhedonia, psychomotor slowing, changes in sleep, fatigue, and changes in weight and/or appetite could be attributed to another condition.
Risk factors: medical comorbidities, white matter abnormality, low education level, polypharmacy, psychosocial stressors, being single or a widower, and increased age
Nursing Management
Causes & Behaviors:
- Depressed mood
- Feelings of hopelessness and worthlessness
- Anger
- Misinterpretations of reality
- Suicidal ideation, plan, and available means
Interventions:
- Conduct ongoing suicide risk assessment
- Routinely check on the client (e.g. q15minute checks)
- Environmental checks to ensure it is free of things the client can use to harm themselves (e.g. pills, ropes/cords, plastic bags, sharp objects)
- Form a no-suicide contract with the client and/or formulate a safety plan with them for when they are in crisis
References
[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.
[3] Bracht, T., Linden, D., & Keedwell, P. (2015). A review of white matter microstructure alterations of pathways of the reward circuit in depression. Journal of affective disorders, 187, 45–53. https://doi.org/10.1016/j.jad.2015.06.041
[4] Otte, C., Gold, S. M., Pennin, B. W., Pariante, C. M., Etkin, A., Fava, M., Mohr, D. C. & Schatzberg, A. F. (2016). Major depressive disorder (Primer). Nature Reviews: Disease Primers, 2(1).
[5] Rogers, D. & Pies, R. (2008). General medical drugs associated with depression. Psychiatry, 5(12), 28–41.
[6] Sözeri-Varma G. (2012). Depression in the elderly: clinical features and risk factors. Aging and disease, 3(6), 465–471.
[7] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.