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Major Depressive Disorder: Etiology, Symptoms, and Treatment Options, Exams of Nursing

University of Colorado - Colorado Springs (UCCS)Nursing

A detailed overview of major depressive disorder (mdd), covering its etiology, risk factors, neurovegetative symptoms, and various theories including object loss, cognitive, and learned helplessness. It also discusses endocrine dysfunction, the hypothalamic-pituitary-adrenal axis, and chronobiological aspects of mdd. Furthermore, the document outlines incidence rates, risk factors, and treatment options such as ssris, tcas, maois, and snris, along with their side effects and considerations for medication management. This resource is valuable for students and professionals in psychiatry and mental health, offering a comprehensive understanding of mdd from multiple perspectives, including genetic predispositions and the impact of neurotransmitter imbalances. It also covers the importance of medication and counseling in treatment.

Typology: Exams

2024/2025

Available from 07/03/2025

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ANCC Certification PMHNP
Mood Disorders
- Most common psych illnesses
Primary characteristic is persistent disturbance in mood
- Major Depressive Disorder
Often occurs without precipitating event
- MDD
Object loss theory
- Fairbairn, Winnicott & guntrip
Aggression turned inward theory of MDD
- Freud
Cognitive Theory
- Beck
Learned Helplessness-Hopelessness Theory
- Seligman
Genetic predisposition
- Strong genetic load for depression for child of depressed parent -having 3 fold
increase in lifetime risk of MDD & 40% chance of depressive episode before age 18.
Endocrine dysfunction Theory
- Probably related to etiology of MDD
Sleep disturbances, appetite disturbances, libido disturbances, lethargy, anhedonia are
neurovegitative symptoms that are related to functions of the
- Hypothalamus and pituitary gland secretions
Endocrine dysfunction and pregnancy
- A high incidence of postpartum mood disturbances is suggested with this
Hypothalamic-pituitary-adrenal axis (HPA)
- A theory of MDD, may be a result of an abnormal stress response related to
dysregulation of this system
HPA axis
- Controls the physiological response to stress and is composed of interconnective
feedback pathways between the hypothalamus, pituitary gland, and adrenal gland.
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ANCC Certification PMHNP

Mood Disorders

  • Most common psych illnesses Primary characteristic is persistent disturbance in mood
  • Major Depressive Disorder Often occurs without precipitating event
  • MDD Object loss theory
  • Fairbairn, Winnicott & guntrip Aggression turned inward theory of MDD
  • Freud Cognitive Theory
  • Beck Learned Helplessness-Hopelessness Theory
  • Seligman Genetic predisposition
  • Strong genetic load for depression for child of depressed parent - having 3 fold increase in lifetime risk of MDD & 40% chance of depressive episode before age 18. Endocrine dysfunction Theory
  • Probably related to etiology of MDD Sleep disturbances, appetite disturbances, libido disturbances, lethargy, anhedonia are neurovegitative symptoms that are related to functions of the
  • Hypothalamus and pituitary gland secretions Endocrine dysfunction and pregnancy
  • A high incidence of postpartum mood disturbances is suggested with this Hypothalamic-pituitary-adrenal axis (HPA)
  • A theory of MDD, may be a result of an abnormal stress response related to dysregulation of this system HPA axis
  • Controls the physiological response to stress and is composed of interconnective feedback pathways between the hypothalamus, pituitary gland, and adrenal gland.

Hypothalamus releases

  • corticotropin-releasing hormone (CRH) Adrenocorticotropin hormone (ACTH)
  • Released by pituitary in response to CRH by hypothalamus Cortisol
  • Released by adrenal glands in response to ACTH by pituitary gland Hyperactivity of the HPA axis
  • Demonstrated to be present in individuals with MDD. May also have elevated cortisol levels Elevated cortisol levels
  • Over time damages the CNS by altering neurotransmission and electrical signal conduction. Cortisol over time can cause changes in size and function of brain tissue Dexamethasone suppression test (DST)
  • Not commonly used in clinical practice for screening of depression as it is too non specific. Hypovolemic hippocampus and hypovolemic prefrontal cortex-limbic striatal regions
  • Abnormalities demonstrated by neuroimaging in individuals with chronic and severe depression Brain damage, including that from stroke and trauma
  • Depression is a acommon comorbidity in individuals who have experienced these events What is the Chronobiological theory of MDD
  • Desynchronization of the circadian rhythms produces the symptom constellation collectively called MDD Circadian rhythms control these biological processes that are frequent problems with depressed individuals
  • Sleep-rest cycle disturbances * Increased cortisol secretions * REM abnormalities Increased emotional reactivity Frequent waking More intensified dreaming Diurnal variations to circadian-related behaviors Decreased arousal and energy levels Decreased activity patterns * Incidence of MDD
  • 5% of U.S. population ages 18 and older each year. About 9.9 million Americans

Appearance, speech, affect, mood, thought process, thought content (including suicidal thoughts/behaviors); cognition, orientation, memory, concentration, abstraction, judgment

  • Mental Status Exam Endocrine Disorders implicated in MDD
  • Hypothyroidism, DM, hyperaldosteronism, and Cushing's/Addison's Disease Infectious and inflammatory states implicated in MDD
  • Mono, AIDS, viral and bacterial pneumonia; systemic lupus erythematosus, temporal arteritis, tuberculosis Nutritional disorders implicated in MDD
  • Pernicious anemia and pellagra Psychiatric disorders commonly associated with MDD
  • Anxiety disorders, eating disorders, Bipolar disorder, substance abuse/dependence disorders One should continue use of antidepressants for a minimum of
  • 8 - 12 months If patient has prior episodes of depression, than consider using antidepressants
  • For longer than 8-12 months Medication and counseling
  • Research demonstrates that the most effective intervention is a combination of these two treatment modalities Action primarily to increase serotonin levels in CNS by inhibiting their reuptake:
  • Selective Serotonin Reuptake Inhibitors (SSRIs) Elevate serotonin and norepinephrine levels primarily by inhibiting their reuptake
  • Tricyclic Antidepressants (TCAs) Elevate serotonin and norepinephrine levels primarily by inhibiting MAO, the enzyme that destroys neurotransmitters
  • Monoamine Oxidase Inhibitors (MAOIs) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
  • Inhibit dual reuptake; action very selective on neurotransmitters; elevate serotonin and norepinephrine levels by inhibiting their reuptake. Norepinephrine Dopamine Reuptake Inhibitors (NDRIs)
  • Inhibit dual reuptake; action very selective on neurotransmitters; elevate dopamine and norepinephrine levels by inhibiting their reuptake.

Serotonin Agonist and Reuptake Inhibitors (SARIs)

  • Dual action; agonist of serotonin 5HT-2 receptors; action very selective on neurotransmitters; elevates serotonin levels by inhibiting serotonin reuptake SSRIs side effects
  • Most common side effects of this class: gi upset, sexual dysfunction, nervousness, headache and dry mouth Name the six SSRIs
  • Celexa, Lexapro, Prozac, Luvox, Paxil (Pexeva), Zoloft. Which is safer in overdose, Paxil or Nortriptyline?
  • Paxil. SSRIs are safer in overdose than TCAs. SSRI's are also effective for treatment of panic disorder, OCD, bulimia, GAD social phobia and
  • PTSD and premenstrual dysphoric disorder Which SSRI has long half-life?
  • Prozac Two SSRIs have potential for teratogenic effects, name them.
  • Paxil and Zoloft This SSRI has a black box warning for liver toxicity.
  • Luvox GI upset, sexual dysfunction, nervousness, headache and dry mouth are common side effects associated with...
  • SSRIs Second line drugs for treatment of MDD:
  • Tricyclic Antidepressants (TCAs) The side effect profile for TCAs
  • Dirty side-effect profile Dirty side effect profile contributes to
  • Poor patient compliance Anticholinergic dirty side effects associated with TCA's:
  • Dry mouth, blurred vision, constipation, memory problems. Caused due to muscarinic receptor blockade. Antiadrenergic dirty side effects associated with TCAs:

A TCA with multiple uses that include chronic pain, insomnia, sciatica, fibromyalgia, trigeminal neuralgia and diabetic neuropathy.

  • Elavil. Never first-or second-line agents for MDD
  • MAOIs Occurs with MAOIs are taken with foods containing tyramine
  • Hypertensive crisis Tyramine
  • A dietary precursor to norepinephrine When monoamine oxidase is inhibited
  • Tyramine exerts a strong vasopressor effect What is released when tyramine exerts vasopressor effects?
  • Catecholamines, epinephrine, and norepinephrine which will increase blood pressure and heart rate Certain medications can cause hypertensive crisis and possible death when administered with an MAOIs. Name them:
  • Meperidine, SSRIs, decongestants, TCAs, atypical antipsychotics; St. John's wort, L- trytophan, Ritalin, asthma medications. Symptoms of hypertensive crisis:
  • Sudden, explosive-like headache, usually in occipital region; increased BP, facial flushing, palpitations; pupillary dilation; diaphoresis and fever. What medication is given to treat hypertensive crisis?
  • Phentolamine Phentolamine
  • Binds with norepinephrine receptor sites, blocks norepinephrine. MAOI's are ______ in overdose.
  • Not safe. Dirty side-effect profile and stringent dietary restrictions promote __________________.
  • Poor patient compliance In addition to hypertensive crisis, clinically significant side effects of MAOIs include:
  • Insomnia, weight gain, anticholinergic side effects, light-headedness and dizziness, and sexual dysfunction.

MAOI, generic selegiline

  • Ensam MAOI, generic isocarboxazid
  • Marplan MAOI, generic phenelzine
  • Nardil MAOI, generic tranylcypromine
  • Parnate No dietary restrictions with 6 mg dosage
  • Ensam transdermal patch (Restrictions needed for 12 mg patch) MAOI also used for panic disorder, phobic disorders, and selective mutism
  • Marplan, Nardil and Parnate. Oral MAOIs should be given in _______doses.
  • Divided doses, bid and qid. Two SNRIs:
  • Effexor and Cymbalta NDRI:
  • Wellbutrin Wellbutrin and Wellbutrin XL dosing:
  • 150 - 450 mg daily. Headache, nervousness, tremors, tachycardia, insomnia, decreased appetite are side effects from:
  • Wellbutrin, an NDRI antidepressant Wellbutrin, bupropion, is also used for ADHD and ___________.
  • Smoking cessation. Wellbutrin SR requires _______ __________.
  • BID dosing. Wellbutrin can increase:
  • Energy level Wellbutrin in contraindicated in patients with eating disorders and ___________.
  • Seizures.

Therapies used with the depressed individual

  • CBT and Brief (Solution focused) Therapy, Group therapy, Family therapy Identify 12 risk factors for suicide

  • 45 & male; >55 & female; divorced, single, separated; white; living alone, psychiatric disorder; physical illness; substance abuse; previous attempt; FH of suicide; recent loss, male gender. Symptoms of depression that may be more pronounced in children:

  • Irritability, somatic complaints and social withdrawal. Core symptoms of depression that are less common in children before onset of puberty:
  • Psychosis, motor retardation, hypersomnia and increased appetite. In children, MDD has a
  • strong separation anxiety component Population that responds better to SSR's than to TCA's:
  • Children Children taking antidepressants should be monitored closely for
  • Suicide Individuals admitted to long term care facilities are ____% more likely to die within the first year than the normal control population
  • 65 It is important to complete a _______ __________ for elderly individuals with depression.
  • Functional Assessment One reasons to complete a functional assessment on an elderly patient is to
  • Identify whether problems are related to dementia or depression. Drug combinations that may cause serotonin syndrome:
  • SSRIs & MAOIs; Durg and herbal interactions; SSRIs & St. John's wort Autonomic instability, restlessness, agitation, myoclonis, hyperreflexia, hyperthermia, diaphoresis; altered sensorium, tremor, cills, diarrhea and cramps, ataxia, headache and insomnia:
  • Symptoms of serotonin syndrome Flu-like symptoms, fatigue and lethargy, myalgia, decreased concentration, nausea/vomiting, impaired memory, shock-like sensations; irritability, anxiety, insomnia, crying without provocation, dizziness and vertigo:
  • Symptoms of discontinuation syndrome Why should TCAs be discontinued slowly?
  • Clients can get cholinergic rebound syndrome: nausea, gi upset, diaphoresis, myalgias, especially of neck muscles. Patients who have had two or more episodes of MDD usually require
  • Lifelong medication. Time criteria for MDD
  • Symptoms present over a two week period Symptom criteria for MDD
  • Either depressed mood OR loss of interest or pleasure AND four other symptoms: Weight loss/gain, insomnia/hypersomnia, psychomotor agitation/retardation, fatigue/loss of energy, feelings of worthlessness/guilt, poor concentration/thinking, recurrent thoughts of death.