Discuss about the Psychiatric Health and Nursing for Cochrane.
Depression is one of the highly prevalent psychiatric disorders. This mental illness is extensively researched. The essay aims to discuss the psychopathology of depression and the impact of the illness on the individual and family/carers. Further, the essay discusses the antidepressant medication, including key categories, examples of medications within those categories and a summary of their side effects. The role of the nurse in supporting a person with depression in their recovery through management and monitoring of antidepressant medications is also presented.
Depression is the mental illness that impairs the ability to feel emotions and is not just the state of sad. It involves body and thoughts and feeling of severe despondency. P atients with depression show lack of interest and pleasure in day-to-day activities (Gilbert, 2016). Across the world, more than 300 million people are suffering from depression and at all ages. As per World Health Organisation or WHO it is known to be the leading cause of disease and disability (World Health Organization, 2018). Therefore, this is one of most researched mental illnesses to understand the underlying pathophysiology and psychopathology.
The signs and symptoms of depression may be evident from a person’s behaviour, feelings, thoughts, and physical symptoms. The behavioural symptoms of the depression may include withdrawal from friends and close friends, not socialising any more, failure to do things at work, unable to enjoy previously interested activities, reliance on alcohol and sedatives and difficulty concentrating. The person with depression may feel guilty all the time, stay overwhelmed, demonstrate frustration, irritation, poor confidence, indecisiveness, disappointed, miserable, sad, and unhappy. The thought process of people with depression may indicate negative or pessimistic thinking such as “I am a failure, I am worthless, it is my fault” and other thoughts of worthlessness. The person may be physically weak, sick all the time, have severe headache, poor appetite, significant weight loss and disturbed sleep cycle (Karp, 2016). In case of the major depressive disorder the person shows symptoms of suicidal thoughts and lack of energy, in addition to decreased mood, and lack of motivation. Depression when accompanied with the manic episodes such as in Bipolar disorders, the episodes may vary in degrees and length. The symptoms may be more or less same. It can be summarised as fatigue, restlessness, impaired concentration, and feeling of worthlessness (Karp, 2016).
According to Gilbert (2016) the variation in symptoms of depression depends on severity and depth of the present situation. The factors underlying the variation in symptoms are social, physical and psychological factors. Based on the research conducted by the neurobiologists and cognitive psychopathologists, person with depression undergo altered functioning which is manifested as the above mentioned signs and symptoms. Joormann & Vanderlind (2014), highlighted that depression involves alteration in the functions in specific brain systems, due to cognitive biases, self-referential schemas, ruminations and processing mode. Prefrontal areas and cingulate cortex are associated with self-referential processes and ruminations. Lateral habenula and amygdale are associated with the cognitive bias. Hippocampus is also involved with the overall general processing and cognitive bias.
A self-referential process is attending to inward thoughts and feelings, which, involves the activation of Default Mode Network or DMN. It is active in resting phase and deactivates during any goal driven work. In case of depression an individual brains fails to deactivate the DMN that is interconnected with different brain areas such as prefrontal cortex, amygdale and others. It is difficult to deactivate DMN when one is reappraising the depressed events and processing the negative self images. This is known as negative schema or schemata (Belzung, Willner & Philippot, 2015). The signs and symptoms of the depression are also attributed to the “cognitive interlock and mood congruent processing”. A person maintains the depressive mood, by processing information that aligns with the content. Processing of such information is biased dues to schemata, which favours such mood congruent information processing. This phenomenon is further accelerated by the phenomena called cognitive interlock. Brain areas like anterior cingulate cortex, and orbit frontal cortex keeps processing the negatively valenced stimuli. Insula, and amygdala are dysfunctional in the depressed state and have associated associated emotion-congruent judgment. Therefore, it can be interpreted with this evidence that the depressive signs and symptoms are due to alteration in the brain function system involving the “mood-congruent processing” (Belzung, Willner & Philippot, 2015). This may be the cause of the feeling of worthlessness when a person keeps reappraising negative self image and loses problem solving skills. This is also called episodic buffer where an individual is trapped in the depressive loop, where the information primed by the schema is completed and reinforced (Joormann & Vanderlind, 2014).
This negative process of information and consequently depression impacts the quality of life. People with depression fail to concentrate on work or engage in the family life. Therefore, they have impaired social and physical life and decreased productivity. It is greater than the impact caused by the chronic physical illness. It is because of the several complications of depression and high lifetime prevalence of the illness. People with depression also present anxiety and show mixed symptoms (Belzung, Willner & Philippot, 2015). According to Gilbert (2016) one in five people with depression do not recover from first episode fully. The illness tends to recur in people at least once with 70–80% of those achieving remission. When compared to chronic illness like hypertension, back pain, diabetes and heart disease the average number of work lost per year is greater in depression.
The severity of depression determines the impact on the quality of the life of depressed person. The people with depression undergo economic burden for increasing health care costs due to expensive medications and mental health specialists. There are intangible burden of depression which includes the suffering, pain, and stress on family members. It also affects the relationship with loved ones as well as other carers which is evident from the disturbance in activities of daily living. It may also manifested as marital breakdown, homelessness and distant with family members. Family members neglect the symptoms or consider as weakness failing to interpret the signs. It negatively impacts the patient’s recovery who feels misunderstood and frustrated and delay seeking professional help (Ornstein & Gaugler, 2012). They do not recover quickly as they spent more time alone and devoid of partner’s attention. It is difficult to measure these intangible measures as they are complex. The carers and significant others may also feel depressed or anxious at times (Cohen, Greenberg & IsHak, 2013). It cannot be estimated in the costs of depression or considered when calculating the economic impact of depression.
According to WHO, the treatment of depression involves effective psychological and pharmacological interventions (World Health Organization, 2018). Pharmacological interventions include use of antidepressants drugs which are mainly categorised as selective serotonin reuptake inhibitors or SSRI and serotonin – norepinephrine reuptake inhibitors or SNRIs. These drugs help relieve symptoms of depression (Kishi & Iwata, 2014). The most commonly prescribed antidepressants are SSRIs as they block the absorption or reuptake of serotonin in brain. It improves the mood by making it easy for the brain cells to receive and send messages. These drugs are selective as they do not work on other neurotransmitters. Some of the commonly used SSRIs are citalopram (Celexa), sertraline (Zoloft), escitalopram (Lexapro) and paroxetine (Paxil). SNRIs like desvenlafaxine (Pristiq), venlafaxine (Effexor), and duloxetine (Cymbalta) are useful for treating the major depressive illness and mood disorders. These drugs act by raising the level of neurotransmitters such as norepinephrine, and serotonin that impact mood stabilisation. These drugs block the norepinephrine uptake (Hovda, Brutlag, Poppenga & Peterson, 2016; Gilbert, 2016).
The other category of antidepressant- drugs are Tricyclic antidepressants (TCAs). TCAs block the serotonin transporter and the norepinephrine transporter, therefore increasing the concentration of these neurotransmitter in synaptic reason (the granules of presynaptic nerves contain the neurotranmitters). It increases neurotransmission. These drugs are effective for both anxiety and depression and the chemical structures have three rings. They are CAs also known to block acetylcholine and histamine receptors. Examples include imipramine (Tofranil), amitriptyline (Elavil), and amoxapine- clomipramine (Anafranil), imipramine (Tofranil), and nortriptyline (Pamelor) (Von Wolff, Hölzel, Westphal, Härter & Kriston, 2013). Monoamine oxidase inhibitors such as tranylcypromine (Parnate), phenelzine (Nardil), selegiline (EMSAM, Eldepryl) are used for its actions on brain enzyme monoamine oxidase that breaks down the serotonin. Thereby, this drug increases the level of circulating serotonin causing less anxiety and greater mood stabilisation. These drugs interact with others and therefore are administered when SSRIs do not work (Shulman, Herrmann & Walker, 2013; Karp, 2016). The other category of drugs is Noradrenaline and specific serotoninergic antidepressants (NASSAs) that are effective in treating depression as well as personality disorders. It includes Mirtazapine (Remeron, Zispin) and Mianserin (Tolvon). These drugs act on the alpha-2 receptors in brain which enhances the action of noradrenaline and serotonin in the brain (Kishi & Iwata, 2014). Noradrenaline reuptake inhibitor (NARI) like Reboxetine prevents re-absorption of noradrenaline into nerve cells causing increase in noradrenaline in the brain (Sepede, Corbo, Fiori & Martinotti, 2012).
The side effects of the antidepressants can be summarised as weight gain, dry mouth, infertility, rash, nausea and vomiting and poor sex drive in both men and women (Bijlsma et al., 2014). However, SSRIs are known for lesser side effects than other antidepressants. Both SSRIs and SNRIs are known to have side effects such as rash, constipation, or diarrhea, low sodium years, nausea, dizziness, headache, anxiety and agitation and tremors. In people under the age of 18 years, taking SSRIs and SNRIs was found with side effects mainly suicide thoughts. For pregnant women SSRIs may lead to low birth weight or preterm birth and TCA may cause pregnancy induced hypertension. Seizures and arythmia are common in TCAs. Blurred vision and hypertension are common in Monoamine oxidase inhibitors. These drugs are also known to impact upon breastfeeding (Crawford et al., 2014; Hovda, Brutlag, Poppenga & Peterson, 2016). Owing to these side effects the patients taking antidepressants must be carefully monitored.
The role of the nurse is to monitor the antidepressant medications for efficacy and side effects. The nurse must educate the patient about the side effects of the medication and other instructions. The patient should be educated about depression and on time intake of prescribed drugs and affects of missing the given dosage on recovery. The nurse must assure the patient that taking the antidepressants may show no sign of improvement for the first week and that the full effect may be observed after 1-2 months. It will prevent the patient to withdraw from medications (Townsend, 2013). Since the adherence for the antidepressants are low among patients, there may be potential for treatment failure and eventually poor quality of life. The nurse must assess if the drug is suitable for the individual prior to admission and if the patient has suicidal tendencies. After medication (SSRIs and SNRIs), the nurse must assess the side effects and decrease in symptoms. Prior to medication, the nurse must also collect the patient’s health history to rule out any signs of allergy, family history of mood disorders, other disease that drug may interact with, and perform other baseline assessment. Further, the nurse must regularly monitor the vital signs, level of drugs and other laboratory work. The nurse must take patient feedback and individualise the dosages to prevent fatal interactions as in case of MAOIs (Townsend, 2013).
The nurse must provide patient centred care and support the patient empathetically. The nurse must assess the need of additional therapies such as cognitive behavioural therapy. The patient must be aware for the follow up appointments. It is also the role of the nurse to provide the patient with referrals to specialty providers. Such collaborative care is considered to be highly effective for patients with depression. The nurse may collaborate with the social worker to help with financial problems of patients. The nurse may encourage the patient for social instructions (Archer et al., 2012, Townsend, 2013).
Conclusion
Depression is caused by biases and attentional control impairments emerging form negative schemata of self. It results in failure to think analytically due to functional alterations. It is manifested as signs and symptoms like low energy, guilt, sleeplessness and suicidal thoughts. It severely impacts the life of person and loved ones who fail to interpret the signs of depression. It leads to poor quality of life. Antidepressant drugs used for treating depression are mainly SSRIs and SNRIs. There are many side effects of drugs such as seizure, hypertension, nausea and vomiting, rash, constipation and others. A nurse plays a vital role in patient recovery from depression. The nurse must conduct thorough assessment before and after medication administration to prevent complications. Further, the nurse must also educate the patient and the families about depression and its side effects as well as best practices to quick recovery.
References
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