MAJOR DEPRESSIVE DISORDER AND

GENERALIZED ANXIETY DISORDER

Dana Bartlett, RN, BSN, MSN, MA

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material and textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and pharmacy students.

ABSTRACT

Major depressivedisorder and generalized anxiety disorder are psychiatric conditions with primary symptoms that often overlap. The treatment of each condition is often similar. Medication, psychotherapy and lifestyle changes are typically recommended as part of the patient treatment plan. Although often diagnosed as separate conditions, major depressivedisorder and generalized anxietydisorder often co-occur, and thoughtful considerationby psychiatric and primary care providers and nurses of selective treatment strategies to target primary symptoms will support patient compliance, progress and remission.

Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses.It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Pharmacology content is 0.5 hour (30 minutes).

Statement of Learning Need

Nurses need to understand the diagnostic criteria, and treatment for a major depressive disorder and generalized anxiety disorderin order to best support and to educate patients and their families.

Course Purpose

To provide nurses with knowledge of the common psychiatric conditions of major depressive and generalized anxiety disorder.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Dana Bartlett, RN, BSN, MSN, MA, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC -all have no disclosures.

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC.

Release Date: 1/1/16 Termination Date:4/18/18

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

  1. Risk factors for major depressive disorder include:
  1. Chronic disease and substance abuse.
  2. Smoking and obesity.
  3. Male gender and high socioeconomic status.
  4. High level of education and age > 65.
  1. People who have major depressive disorder are:
  1. Depressed only during stressful life events.
  2. Depressed once or twice a week.
  3. Depressed almost every day.
  4. Depressed only during episodes of substance abuse.
  1. Screening for depression should be done:
  1. If the patient has noticeable signs and symptoms.
  2. For every patient ≥ age 18 if there is appropriate clinical support.
  3. Only during stressful life events.
  4. Only for patients who request screening.
  1. First-line medications used to treat major depressive disorder would be:
  1. Diazepam and imipramine.
  2. Bupropion and phenelzine.
  3. Amoxapine and trazodone.
  4. Citalopram and fluoxetine.
  1. True or false: ECT is effective for treating major depressive disorder.
  1. True.
  2. False.

Introduction

Major depressive disorder and generalized anxiety disorder are two of the most common psychiatric disorders. These diseases are not as prevalent as medical illnesses, such as cardiovascular disease and diabetes, but they result in a significant cost to the individual and society. This problemis compounded because major depressive disorder and generalized anxiety disorder are chronic in nature and often resistant to treatment. Psychotherapy and pharmacotherapy can be effective, but availability, cost, patient compliance issues, and a relative lack of clinical evidence supporting who should be treated, how, and for how long have restricted the successful treatment of major depressive disorder and generalized anxiety disorder.

Epidemiology Of Major Depressive Disorder

Major depressive disorder has been identified by the World Health Organization (WHO) as the leading cause of disability worldwide.1 Approximately 20% of all adults willhave an episode of major depression at some point2 and the lifetime prevalence of major depression has been estimated to be 7%-12% in men and 20%-25% in women.3 These statistics vary depending on the clinical setting, and there is strong and consistent evidence that major depression is often undetected or underdiagnosed.

Major depressive disorder is more common in women, it is substantially more common in people who have co-existing medical problems such as coronary atherosclerosis, diabetes, Parkinson’s disease, stroke, or traumatic brain injury,3 and the rate of major depressive disorder increases with the seriousness of medical morbidity.4 Major depressive disorder is associated with a very high risk for suicide5and many people who suffer from major depressive disorder never receive treatment.6

The pathogenesis of major depressive disorder is unknown, but it is probably a complex interaction between genetic, biological, social or environmental, and psychological factors.2,7,8 Risk factors for major depressive disorder are listed in Table 1.

Table 1: Risk Factors for Major Depressive Disorder

Age (18-29)
Childhood adversity and/or trauma
Chronic diseases
Cognitive impairment, i.e., dementia
Gender (Female)
Low socioeconomic status
Poor social support
Race (White)
Serious medical illness
Stressful life events
Substance abuse
Unemployed
  • Genetics:

Depressionis to some degree an inherited disease.8People who have major depressive disorder are three times more likely to have a first-degree relative (parent or sibling) who hasor haddepression than people who do not,9 and twin studies have estimated that the risk of developing depression is approximately 30%-50% associated with genetic variations.10-12However, despite a consistent body of evidence that indicates people inherit a susceptibility to depression, genome-wide association studies and gene-environment interaction studies have not yet clearly defined the role and contribution of genetics in the development of depression.8

  • Biological:

Biological causes of major depressive disorder include abnormal changes in brain structures, impaired and/or abnormal neurotransmitter function, and immune system dysfunction that can cause inflammation and oxidative stress.2,13-22 Whether these changes in structure and function are cause or effect has been difficult to determine, given the heterogeneity of major depressive disorder and the treatments for the disease.

  • Environmental:

Major life stressors are considered to be a strong predictor for the development of major depressive disorder.2,6,23-27Chronic diseases such as cancer, chronic obstructive pulmonary disease, diabetes, heart disease also increase the risk for developing depression, as do acute illnesses such as stroke.

Diagnostic Criteria For Major Depessive Disorder

The American Psychiatric Association’s diagnostic criteria for major depressive disorder, located in the Diagnostic and Statistical Manual of Mental Disorders, are listed in Table 1.28

Table 2: Diagnostic Criteria for Major Depressive Disorder

1.Five or more of the following symptoms have been present during a two week period; they are a signficant change from the patient’s previous mood and funcioning; at least least one of the symptoms is depressed mood or loss of pleasure or interest, and; the symptoms are not caused by a medical condition.
  • Depressed mood most of the day, nearly every day. The depressed mood can be subjective (i.e., the patient reports feeling sad, hopeless) or can be observed by others. In children or adolescents irritation is often present.
  • Markedly diminished interest or pleasure in daily activities. This happens nearly every day and is reported by the patient or by others.
  • Significant weight loss (> 5% of body weight) when not dieting or a decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain).
  • Insomnia or hypersomnia nearly every day.
  • Psychomotor agitation or retardation nearly every day: this should be observable by others and not just the patient’s feelings of restlessness or feeling lethargic.
  • Fatigue or loss of energy nearly every day.
  • Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day, reported by the patient or observed by others.
  • Recurrent thoughts of death; recurrent suicidal ideation without a specific plan; a suicide attempt or a specific plan for committing suicide.
2.The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3.The episode is not attributable to a substance or another medical condition.
4.The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
5.There has never been a manic episode or a hypomanic episode.

Screening For Depression

Screening for depression is recommended by the U.S. Preventive Service Task Force (The Guide to Clinical Preventive Services) in non-pregnant adults 18 years and older when staff-assisted depression care supports are in place to provide accurate diagnosis, effective treatment, and follow-up.29Screening for depression should also be considered in certain high-risk populations, i.e., people who have cancer or cardiovascular disease, people who have recently had a stroke or a myocardial infarction, or people whohave chronic pain.

There are a variety of screening tools available and comparative studies indicate that they are reasonably equal in effectiveness and ease of use.30,31The Patient Health Questionnaire - 9 (PHQ-9) is a screening test that is often used, it is availble without charge, and it has been shown to be accurate, specific, and sensitive.32-36

Table 3: The Patient Health Questionnaire-9

Over the Last 2 weeks, How Often
Have You Been Bothered by Any of the Following Problems? / Not At all / Several Days / More Than Half the Days / Nearly Every Day
1. Little interest or pleasure in doing things / 0 / 1 / 2 / 3
2. Feeling down, depressed, or hopeless / 0 / 1 / 2 / 3
3. Trouble falling or staying asleep, or sleeping
too much / 0 / 1 / 2 / 3
4. Feeling tired or having little energy / 0 / 1 / 2 / 3
5. Poor appetite or overeating / 0 / 1 / 2 / 3
6. Feeling bad about yourself — or that you are
a failure or have let yourself or your family
down / 0 / 1 / 2 / 3
7. Trouble concentrating on things, such as
reading the newspaper or watching television / 0 / 1 / 2 / 3
8. Moving or speaking so slowly that other
people could have noticed? Or the opposite —
being so fidgety or restless that you have
been moving around a lot more than usual / 0 / 1 / 2 / 3
9. Thoughts that you would be better off dead or
of hurting yourself in some way / 0 / 1 / 2 / 3
0+ / ______
+ / ______+ / ______
=Total Score: ______
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or getalong with other people?
Not difficult at all / Somewhat difficult / Very difficult / Extremely difficult

A score of 10 or higher indicates the posssibility of a depressive disorder, and scores of 5, 10, 15, and 20 indicate the presence of mild, moderate, moderately severe and severe depression, respectively.37 The diagnosis of depression requires that there is a score of 2 or higher on one of the first two questions.37A shortened version, the PHQ-2, uses the first two questions of the PHQ-9 and it appears to offer good sensitivity and specificity as well.37

The SIGECAPS mnemonic is another useful screening tool for detection of major depressive disorder.38

Table 4: SIGECAPS Mnemonic

S / Sleep disturbance – either insomnia or hypersomnia.
I / Loss of interest in everyday activities –anhedonia.
G / Guilt – helplessness, hopelessness, worthlessness
E / Lack of energy
C / Difficulty concentrating
A / Appetite disturbance – either increased or decreased
P / Psychomotor blunting or agitation
S / Suicidal thoughts, thoughts of death
Also ask the patient if they feel depressed.

Patients who have a major depressive disorder often complain of lack of energy, decreased appetite, dizziness, inability to concentrate or think, fatigue, insomnia, pain, restlessness, and they frequently have many non-specific somatic complaints.3,28, 39,40 These complaints should be evaluated, but it should be remembered that many patients who are depressed may have somatic complaints but will not admit to or cannot express feelings of depression.3,39-41 These somatic complaints and patients not reporting feelings of depression may contribute to a missed diagnosis,42 and Deneke et al.,(2014) noted that there is evidence that many cases of depression are not detected by primary health care providers or in a medical setting.3.43

Learning Break:
Is screening for depression effective? Williams et al., (2014) statesthat depression is frequently undetected if targeted screening is not done and that screening is not harmful.39 There is also evidence that for screening to be helpful beyond increasing detection and diagnosis rates it must be used in conjunction with appropriate follow-up and effective care; i.e., screening alone is not enough.39,43

Clinical Course Of Major Depressive Disorder And

Consequences Of The Disease

The clinical course of major depresive disorder is quite variable.3 The disease typically has its onset when the patient is in his or her mid-20s or 30s28,43 but a later onset is not uncomon.44Most patients who have major depessive disorder will eventually remit, but some patients will never have a remission (two months or more with no symptoms, or one or two symptoms to a mild degree) and others may have many years in which they have no signs and symptoms of depression.28

Early recognition and treatment and a short duration of depressive symptoms are associated with spontaneous recovery, a better response to treatment, and a higher chance of remission.28,45,46

Patients who have had severe depression or who havehad an onset at a relatively young age are more likely to have recurrent depression,28 and depression accompanied with anxiety, personality disorders, or psychotic features has a poor prognosis for remission.28Gender and age do not seem to affect the progression of major depressive disorder.28

Major depressive disorder is associated with a high mortality risk and most of this risk is from suicide. Major depressive disorder is considered to be a signficant risk factor for suicidal behavior,47and suicide attempts or threats of suicide are considered to be consistent risk factors for suicide in patients who have major depressive disorder.48 Major depressive disorder is a risk factor for the development of chronic diseases (and it negatively influences the progression of these diseases) such as cardiovascular diseases, diabetes, and neurological disorders.43,49-51People who have major depressive disorder are more likley to smoke, abuse alcohol and drugs,49 they report a lower quality of life, and this disorder has a profound effect on the patient’s family life, personal relationships, and professionaland social life.

Treatment For Major Depressive Disorder

Antidepressant medication and psychotherapy are the two primary treatments for major depressive disorder. They will be discussed separately, but they can be and often are used together.

Antidepressant Medication

The antidepressant medicationused to treat major depressive disorder are often classified as first-generation or second-generation. First generation refers to the monoamine oxidase inhibitors (MAOIs) such as phenelzine and selegiline and the tricyclic anti-depressants (TCAs) such as amitriptyline and nortriptyline; second-generation refers to all other drugs used to treat major depressive disorder.

These terms are still commonly used, but the antidepressants cannot be easily or usefully divided into these two categories. These medications work by affecting the activity or level of neurotransmitters, but the mechanism of action is specfic to each drug.

Learning Break:
The MAOIs and the TCAs are called first-generation simply because these drugs were developed and used many years before the advent of the so-called second-generation antidepressants.

The generic name is provided first and the trade name is in parentheses. Some of the older medications are rarely if ever prescibed with trade names.

Table 5: Currently Available Antidepressants/Atypical Anti-Depressants

Monoamine Oxidase Inhibitors
Isocarboxazid
Phenelzine
Selegiline, transdermal
Tranylcypromine
Selective Serotonin Re-Uptake Inhibitors/Receptor Partial Agonists
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
Vilazodone (Viibryd)
Serotonin-Norepinephrine Re-Uptake Inhibitors
Desvenlafaxine (Pristiq)
Duloxetine (Cymbalta)
Milnacipran (Ixel)
Venlafaxine (Effexor)
Tricyclic and Tetracyclic Anti-Depressants
Amitriptyline
Amoxapine
Clomipramine
Desipramine
Doxepin
Imipramine
Maprotiline
Nortriptyline
Protriptyline
Trimipramine
Aytical Antidepressants (unrelated to serotonin, tricyclic, tetracyclic, and MAO inhibitors)
Bupropion (Wellbutrin)
Mirtazapine (Remeron)
Nefazadone (Serzone)
Trazodone (Desyrel)
Vilazodone (Viibryd)

A drug that is representative of each of these categories is briefly discussed below. However, it is important to remember that the mechanism of action described (and thus the category each medication is placed in) is the primary way the drug works; and, to lesser or greater degree, all of the antidepressants can affect other neurotransmitters and bind to other receptor sites.52 For example, the antidepressant effect of the TCAs is mediated through re-uptake of norepinephrine and serotonin but the TCAs also bind to peripheralα-adrenergic receptors and histamine receptors, and postural hypotension and anticholinergic effects such as dry mouth and dizziness are common side effects of the TCAs.