Objective: NP students will gain a basic understanding on clinical management of Major depressive disorder; Application of Experiential Learning Technique will be applied in the learning cycle.
Depression is one of the most common primary care conditions that you will come across in your advanced nursing practice career. According to a Statistics Canada report released in 2012, 5.4% of the Canadian population aged 15 years and over reported symptoms that met the criteria for a mood disorder in the previous 12 months. Further, almost one in 8 adults identified symptoms that met the criteria for a mood disorder at some point during their lifetime. Studies have consistently documented higher rates of depression among women than among men: similarly, young adults (between 15-24), and older adults are higher risk of depression. Personal stressors, major life events, chronic diseases, and substance abuse are the other major risk factors (Government of Canada, 2019)
When you provide care for depressed individuals, it is imperative that you are familiar with appropriate diagnostic tools, pharmacological and non-pharmacological interventions, and personal, professional, and social support available for such individuals.
Now, you have entered in advanced practice with some basic knowledge on depression, complications, use of antidepressants, and conservative management strategies---that means, your ‘abstract conceptualization’is ready to be taken to the next level of learning cycle.
Pathophysiology of depression
In the second stage of learning cycle, you are actively participating in assessing, diagnosing, and managingdepressed patients under supervision. It may take several patient encounters for you to get enough knowledge, skill, and attitude to develop a concrete concept on depression management. Often, your supervisor may take you through this experience using a step by step approach -for e.g., you may start with history collection in the preliminary stage of your practicum; gradually, you will be introduced to assessment, diagnosing, and management stages of patient encounter until you are confident to independently manage clinical depression.
History Collection &Patient Assessment
Collect information pertaining to previous mental health history, hospitalization, history of violence, substance abuse, any use of antipsychotics/ antidepressants, family h/o mental illness, development history, any major life events, functional status, social support, risk for self or others, any concomitant medical conditions, use of drugs that may mimic depression etc. Assess patient’s general presentation, grooming, communication, any tic disorder, eye contact, judgement, hyperactivity, attention span.
You can start screening by asking the following two quick questions?
- Have you lost interest or pleasure in things you usually like to do?
- Have you felt sad, low, down, depressed or hopeless?
Additionally, determine if the patient meets DSM-V criteria of MDD by asking ‘SIGECAPS’ interview questions as below:
|S||Sleep disturbance (insomnia, hypersomnia)|
|I||Interest reduced (anhedonia)|
|G||Guilt and self-blame|
|E||Energy loss and fatigue|
|A||Appetite changes (low/increased appetite or weight loss/gain)|
|P||Psychomotor changes (retardation, agitation)|
Offer PHQ9 test to collect self-reported depression symptoms and functional status; a score of 5-9 indicates mild depression, 10-14- moderate depression, 14-19 moderately severe depression, and 20-27 severe depression. https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/depression_patient_health_questionnaire.pdf (B.C Guidelines, 2013).
When to initiate antidepressants?
According to theCANMAT guidelines, second generation antidepressants are recommended as the first line medications formanaging moderate or greater severity of major depressive disorder (MDD). Patient with mild depression can be treated with psychotherapy except in situations such as: no response to non-pharmacological measures, patient preference of antidepressant, previous positive response to antidepressants (2016). Available data doesn’t indicate any significant difference inthe efficacy of pharmacotherapy vs psychotherapy in the management of mild to moderate depression; however, pharmacotherapy had offered better outcome in managing severe depression, and dysthymia.Evidence also shown an additive effect with the combined use of pharmacotherapy and psychotherapy in depression management, regardless of the baseline severity (Cuijpers et al.,2014). Antidepressants with superior efficacy, based on a meta analyses are the following: Escitalopram, Mirtazapine, Sertraline, Venlafaxine, Agomelatine, and Citalopram (Kennedy et al., 2016). A list of first line medications, s/e, dosage can be viewed in the following link: https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/depress_appc.pdf
Cognitive Behavioral Therapy is a well-supported, first-step alternative to pharmacological treatment of MDD. Similarly, St.John’s wort, and use of omega 3 fatty acids had shown some benefit in management of mild to moderate depression. There is some evidence to support the benefit of regular physical exercise when used an adjunct to pharmacotherapy and/ or psychotherapy in mild to moderate depression, but not as monotherapy. A systematic review that looked at the role of non-pharmacological interventions in MDD management, identified a significant knowledge gap in this area(Gartlehner et al, 2017).
Selective Serotonin Reuptake Inhibitors (First Line):
Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline. Common side effects include: GI, CNS disturbances, and sexual dysfunction. It should be prescribed cautiously for patients at risk of GI bleeding. Long term use of SSRI has shown some associated with falls, and fracture. It may also cause hyponatremia in seniors (Kennedy et al, 2016).The present findings support the efficacy of fluoxetine being superior than any other antidepressants in children and adolescents (Cipriani et al, 2018).
Serotonin-Norepinephrine Reuptake Inhibitors (First Line) - Venlafaxine, duloxetine, and Desvenlafaxine. Venlafaxine should be prescribed with caution in hypertensive patients. Duloxetine is also used in treating neuropathic pain and fibromyalgia. Trazadone is a post synaptic serotonin receptor antagonist with some serotonin reuptake inhibitor. It is usually prescribed as an adjutant with other antidepressants at 50-100mg po dose. Mirtazapine acts on both adrenergic and serotonergic systems. It is associated with sedation and weight gain, with lesser GI and sexual side effects.
Tricyclic antidepressants - second line antidepressants. Amitriptyline, Nortriptyline, and clomipramine. Overdose of TCA can cause cardiac toxicity. Amitriptyline is used for night time sedation, and analgesia. Clomipramine is widely used for OCD management.
Dual action antidepressants
Bupropion: It is a first line agent in MDD, antidepressant effect is through norepinephrine and dopamine reuptake inhibition. Also prescribed as an adjutant to SSRI/ SNRI, and as a smoking cessation drug. It should not be prescribed for patients with seizure, eating disorders. Thiscan be prescribed as an alternative for patients with sexual side effects from SSRI.
Antipsychotics: Quetiapine and aripiprazole are the atypical antipsychotics—quetiapine is approved as second line agent for depression management. Aripiprazole is an adjunct to antidepressants in adults with MDD.
Monoamine Oxidase Inhibitors: Phenelzine and tranylcypromine (third line) can cause serious side effects with food / drug interaction; therefore, reserve for specialist’s discretion. Moclobemide is areversible and selective MAOI that is included in the list of first line antidepressants.
Pharmacological Management Guideline
You are entering to the 3rd stage of Kolb’s learning cycle- concrete experience. By this time, you are confident enough to create your own SOAP notes!You are ready to make a concrete concept on depression management through your previous active experimentation which probably must have taken several attempts or clinical encounters.
SOAP NOTE (example)S
c/o low mood, crying episodes x 1 month
no SI/HI, no past h/o hospitalization, criminal charge, violence
no past h/o mood disorder, mania/ hypomania, or substance abuse
no major life events reported recently, no comorbidities, not taking any medications
less appetite, poor concentration, guilt feeling-+
less interest in things that she used to enjoy, insomnia +, less libido
NAD, grooming-wnl, eye contact- wnl
speech volume, communication- wnl
judgement-wnl, crying-+, no tics
facial expression- wnl, no flat affect
Discussed psycho therapy, encouraged counselling
Initiated celexa 10 mg po OD, discussed s/e- including – SI/HI
Informed that it may take 2-4 weeks to notice symptomatic changes
In case of worsening of symptoms, SI/HI, should rtc immediately
Discussed community support services, aware of crisis number, f/u in 1 month
- Always verify if any suicidal or homicidal ideation
- Arrange regular follow- up, Verify drug interactions
- Inform patients that it may take 2-4 weeks to notice any mood improvement
- Encourage psychotherapy, physical activity
- Read the following article to get an in-depth understanding of current guidelines on MDD diagnosing/ management: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994790/
Now, since you are capable to assess, diagnose, and manage depression independently, its time for you to reflect on your learning experience and to create new ideas…
Write a summary on your experience with management of MDD; explain your learning experience by using Kolb’s Experiential Learning Technique? What are the new ideas that you developed based on your learning experience? When applicable, use a case scenario.
Your reflections from the above learning cycle gives you new abstract concepts; are you ready to actively experiment them?? Thus, the learning cycle continues…
Government of Canada (2019). What is depression. Retrieved from https://www.canada.ca/en/public-health/services/chronic-diseases/mental-illness/what-depression.html
B.C Guidelines (2013).Major Depressive Disorder in Adults - Diagnosis and Management. Retrieved from https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/depression-in-adults
Kennedy et al (2017).Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments. The Canadian Journal of Psychiatry 62(5): 540-560.Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994790/
Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., & Reynolds, C. F. (2014). Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. World psychiatry: official journal of the World Psychiatric Association (WPA), 13(1), 56-67.
Gartlehner G, Wagner G, Matyas N, et al. Pharmacological and non-pharmacological treatments for major depressive disorder: review of systematic reviews BMJ Open 2017 (7) DOI: 10.1136/bmjopen-2016-014912
Cipriani, A., Furkawa. T., Salanti, G., Chaimani, A., Atkinson, L., ogawa, Y., et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis 391 (10128). Retrieved from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32802-7/fulltext