Clinical and Management Guideline of Depression

A Pathophysiology and Pharmacology Investigation

Depression, or major depressive disorder (MDD), is regarded as a common and serious medical illness that negatively affects the manner in which an individual thinks and acts. Depression has been noted to cause feelings of sadness and/or a loss of interest. The disorder causes different emotional and physical problems that reduce an individual’s ability to function. Among the symptoms that may be experienced include sad feelings or depressed mood, loss of interest in activities once enjoyed, change in appetite, sleeping problems, increased level of fatigue, feelings of worthlessness or guilt, difficulty in making decisions, and suicidal thoughts. For a diagnosis of depression, the symptoms must be experienced for at least two weeks. 

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Patients with depression often experience symptoms of anxiety disorder. It may be difficult to differentiate between anxiety and depression disorder. The World Health Organization estimates that over 300 million individuals all over the world live with depression (Stringaris, 2017). The World Health Organization (WHO) ranks depression as the single largest causes of global disability. It is noted that the adolescents suffering from depression are 30 times likely to commit suicide. 

The WHO recognizes that depression is a major problem among many individuals. The population of the global population that was estimated to experience depression as of 2015 was 4.4%.  The prevalence rate in the global population was noted to be higher among females (5.1%) as compared to males (3.6%). The difference in prevalence of depression per region reveals a low of 2.6% for males located in the Western Pacific Region and a high of 5.9% for females in the African Region. A consideration of the prevalence of depression by age reveals higher rates in older age groups between 55 and 74 years at 7.5% for females and 5.5% for males (World Health Organization, 2017). Depression has also been noted to affect children and adolescents below 15 years old but at a lower level than higher age groups. 

The National Center for Health Statistics provides statistics that reveals that between 2013 and 2016, at least 8.1% of Americans at 20 years and above were noted to have depression for a given 2-week period. The figures for women were estimated to be 10.4%, which was almost twice that of men at 5.5%. The racial distribution of depression rates indicates lower rates among the non-Hispanic Asian adults as compared to the Hispanics, non-Hispanic blacks and non-Hispanic white adults. The prevalence for depression has been noted to largely reduce as the level of family becomes higher. Approximately 80% of the individuals with depression have been reported to have trouble at work, home, and in social relations because of depression (Brody, Pratt, & Hughes, 2018).

The prevalence of depression in the United States has seen it considered as an important public health issue. This has led many organizations in the country to consider the disorder among the main healthcare priorities in the country. Efforts to deal with this issue have been for a long time concentrated on developing an individualized treatment approach. However, in the recent past, efforts have been placed to come up with preventive intervention. It is worth to note that despite the fact that depression has been largely associated with causing disability amongst the population, and identified as an important public health concern, it has been ignored for long as an agenda for public health intervention (McLaughlin, 2011). There is need to enhance the collaboration between the mental health disciplines and public health to enable the development of a multilevel approach to the reduction of depression.

Depression has been noted to cause major impairments across numerous areas of function. National statistics have revealed that almost all people facing depression are likely to have disorder-related impairment. Approximately two-thirds of these people have severe impairment. It has been shown that even individuals who experience mild impairment resulting for depression, require to access medical care, utilize healthcare services regularly, are at a risk of being hospitalized, have higher risk of committing suicide, and are twice likely to be hospitalized even in the absence of depressive symptoms (McLaughlin, 2011). 

Depression has been largely connected to elevated morbidity and mortality. Depression is noted to lead to physical impairments that are of similar magnitude to those common with chronic diseases such as diabetes and cancer. Evidence has suggested that depression can be a predictor for prevailing myocardial infarction, worsening of cardiovascular disease, and spiking in the mortality rate after myocardial infarction and unstable angina. Depression has also been linked to increased risk of stroke and hypertension. A major result of depression on increased rates of depression occurs from elevated mortality connected to suicide (McLaughlin, 2011). This is because individuals with depression are eleven times likely to attempt suicide than those without, and one in every ten people with depression are likely to attempt suicide at one point of life. 

Pathophysiology

Evidence indicates that, major pathophysiology of major depressive disorder has not been clearly identified. However, current evidence points to a complex interaction between neurotransmitter availability and receptor regulation and sensitivity to other symptoms. Several trials have indicated that depression mainly affects the central nervous system serotonin (5-HT) (Halverson, 2018). Other transmitters affected include norepinephrine, dopamine, glutamate, and brain-derived neurotrophic factor. The role of CNS 5-H activity in pathophysiology of a patient suffering from depression is suggested by the therapeutic efficacy of selective serotonin reuptake inhibitors (Halverson, 2018). Seasonal affective disorders is a major depressive order that often rises during fall and winter and reduced in spring and summer. It has been indicated that the seasonal affective disorder is affected by alterations in the CNS levels of 5-HT and seems to be caused by alterations in circadian rhythm and sunlight exposure (Halverson, 2018). Vascular lesion related to depression has been known to disrupt neural networks that are responsible for emotion regulation especially the front striatal pathways that connect the dorsolateral prefrontal cortex, orbitofrontal cortex, anterior cingulate, and dorsal cingulate. 

Through functional neuroimaging, studies have revealed that depression has been connected to reduced metabolic activity in the neocortical structures, as well as, increased level metabolic activity in limbic structures. The serotonergic neurons that have been associated with affective disorder are noted to be located in the dorsal raphe nucleus, the limbic system and left prefrontal cortex (Halverson, 2018). Evidence shows that patients with depression have a smaller hippocampal volume. It has been established through positron emission tomographic that there is abnormally diminished activity level in the prefrontal cortex in patients suffering from unipolar depression and bipolar depression. These are the regions associated with emotional response and is largely connected to other parts of the brain that carry out the function of regulation of DA, noradrenaline (locus coeruleus, and 5-HT (Halverson, 2018). It has therefore been revealed that depression causes functional and structural abnormalities in the brain.

The application of magnetic resonance imaging (MRI) and positron emission tomography indicated a number of abnormalities in the brains of patients with a major depression. Studies involving patient’s major depression have revealed evidence of brain atrophy (Brigitta, 2002). It also revealed increased ventricle-brain volume and localized frontal lobes in patients suffering from late-life depression. Studies on functionality have revealed reduced blood flow in specific brain regions especially on the frontal lobe and basal ganglia. Among the highly studied regions of the brain in relation to depression is on hippocampus, the part of the brain engaged in learning and memory (Brigitta, 2002). Other imaging studies have revealed that the hippocampus undergoes selective volume reduction in stress-connected neuropsychiatric disorder such as recurrent depression.

Another major change in the body system that is associated with depression is aging. It has been indicated that depression causes age-related brain changes and disease-related changes (cerebrovascular disease) together with physiologic vulnerability such as genetic risk factors, and personal history of depression and psychosocial adversity causes disruption in the functional circuitry of emotion regulation (Halverson, 2018). This specifically affects the hypometabolism of cortical structures and hypermetabolism of limbic structures. It is noted that women with a history of depression have been associated with a higher risk of developing depression during menopause. Low testosterone levels have been linked to depression in older men.  

Another effect of depression is related to the stress hormones and cytokines. Corticotropin-releasing hormone (CRH) is produced by the hypothalamus to respond to the perception of psychological stress by cortical brain regions. The hormone is inducing the pituitary corticotropin. This leads to stimulation of the adrenal gland to produce cortisol into the plasma. It is estimated that the general stress responsiveness in women is higher than in men (Hasler, 2010). This matches the statistics that reveal a higher prevalence of major depression amongst women. Studies have revealed that men exhibit more cortisol responses to achievement challenges while women indicate more cortisol responses to social rejection challenges.

Monoamine-deficiency theory suggests the underlying pathophysiological basis of depression is on the depletion of the neurotransmitters serotonin, norepinephrine within the central nervous system (Hasler, 2010). Serotonin has been noted to be the most studied neurotransmitter in relation to depression. Evidence has revealed an abnormally minimized functionality of central serotonergic systems, especially from studies using tryptophan depletion, which minimizes the central serotonin production. The reduction in the production of serotonin is known to cause the development of depressive symptoms among patients and lead to an increased risk of depression (Hasler, 2010). It has also been shown to be possibly mediated by increased brain metabolism located in the ventromedial prefrontal cortex and subcortical brain regions. Experiments have indicated that the reduced level of central serotonin has been associated with mood-congruent memory bias, altered reward-related behaviors, and disruption of inhibitory effective processing. There is evidence on abnormalities of serotonin receptors in depression; especially on serotonin-1A, which regulates serotonin (Hasler, 2010). The reduced amount of serotonin has been indicated to influence multiple brain areas with major depressive disorder. Evidence has noted an increased availability of the brain monoamine oxidase that metabolizes serotonin, which leads to serotonin deficiency. 

Another major effect noted is the dysfunction of the central noradrenergic system from evidence based on reduced norepinephrine metabolism, the heightened activity level of tyrosine hydroxylase, and reduced density of norepinephrine transporter in the locus coeruleus among depressed patients. Postmortem analysis of suicide victims with depression indicated minimized neuronal counts in the locus coeruleus, increased alpha-2 adrenergic receptor density, and reduced alpha-1 adrenergic receptor (Hasler, 2010).

Standard of Practice

The management of depression entails a comprehensive assessment and proper establishment of the diagnosis. The assessment is based on the detailed history, physical examination, and mental state examination. The diagnosis needs to be recorded as per current diagnostic criteria. The process of basic assessment involves acquiring complete history information, physical examination, recording of vital signs such as blood pressure, weight, and BMI, mental state examination, diagnosis of using prevailing diagnostic criteria, differential diagnosis to rule out secondary depression, bipolar disorder, and premenstrual dysphoric disorder, ascertain the severity, specifier, and subtype depression (Gautam, Jain, Gautam, Vahia, & Grover, 2017). Among the areas to be evaluated include symptom severity, symptom dimensions including psychotic symptoms, catanionic symptoms, melancholic symptoms, reverse vegetative symptoms, and cognitive symptoms, comorbid physical, psychiatric & substance use conditions, risk of others, level of functionality, and the social-cultural status of the patient. The basic investigation seeks to evaluate levels of hemogram, blood sugars, and lipid levels, liver, renal, and thyroid functionality (Gautam et al., 2017). It is also important to carry out an assessment of the caregivers to ascertain their knowledge level of the illness, attitudes, and beliefs of the treatment, and the nature of the impact of the illness. The standard practice requires an ongoing assessment to establish the response to treatment, side effects, adherence to treatments, the effect of the patient’s immediate environment, assessment of disability impacts and other health care needs, and establish the ease of access and relationship with the treatment team (Gautam et al., 2017).

A comprehensive assessment enables accurate diagnosis of major depression and the collection of baseline measurements. This enables the identification of other underlying conditions such as physical, cognitive, psychiatric, functional, or psychosocial factors, which may lead to symptoms thereby, inform the treatment plan adopted. As assessment enables is also essential in facilitating early identification of suicide risk.  The U.S. Preventive Service Task Force (USPSTF) offers a recommendation for screening of adults for depression and provision of ample services for follow-up treatment to be provided through a variety of healthcare plans by clinicians (Oflson, Blanco, & Marcus, 2016).  

Pharmacological Treatments

Medication is normally offered for a dosage of 2-12 weeks with an assumption of total adherence. The choice of medication is noted to be guided by an anticipated safety and tolerability. These assist in the compliance as physician familiarity facilitates the development of patient education and enhances the anticipation of adverse effects and the history of past treatments (Halverson, 2018). In most cases, treatment failures are caused by medication noncompliance, limited duration of therapy, and/or inadequate dosing. The 2008 American College of Physician (ACP) guideline indicates that when using second-generation antidepressants as treatment plans to depressive disorder, the patient preference should be a serious consideration when selecting the most suitable pharmacotherapy for patients suffering from depression disorder (Halverson, 2018). This seeks to respect the decision of a patient to avoid using a certain antidepressant, which may be informed by a previous negative experience with the drug. The guidelines indicate that the treatment for major depressive disorder needs to be altered where the patient does not indicate enough response to pharmacotherapy within a period of 6 to 8 weeks (Halverson, 2018). Where satisfactory responses are noted, treatment should be maintained for over 4-9 months for patients who had suffered the first episode of major depression that has not be linked to a major significant suicidal or catastrophic outcome. For patients with two or more episodes of depression, it is essential to maintain a longer period of treatment. 

The American Psychiatric Association updated its Practice Guideline for the treatment of patients with a major depressive disorder in 2011. These guidelines highlighted the importance of establishing a customizable treatment plan for each patient following a careful assessment of symptoms based in rating scale measurements made by a clinician or the patient, and analysis of the therapeutic benefits and side effects (Halverson, 2018). 

Among the pharmacologic therapy for depression include selective serotonin reuptake inhibitors (SSRIs), serotonin/norepinephrine reuptake inhibitors (SNRIs), atypical antidepressants, serotonin-Dopamine activity modulators (SDAMs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs), and St. John Wort.

  1. Selective Serotonin Reuptake Inhibitors

Among the drugs, in this case, include citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, vilazodone, and vortioxetine (Halverson, 2018). These SSRIs have an advantage related with ease on the dosing and minimal toxicity in case of overdose. The SSRIs are mainly preferred over other classes of the drugs for the treatment of children and adolescents suffering from depression. The SSRIs are also the recommended first-line medications for the late-onset depression as per 2011 APA guideline (Halverson, 2018). An analysis of the adverse-effect profile of SSRIs is minimal than other agents, which is a huge factor in enhancing better compliance. The noticeable effects include gastrointestinal upset, sexual dysfunction, and variation in energy level casing restlessness and fatigue. 

The SSRIs are noted to be unproblematic in patients with cardiac disease. This is because these medications have no negative effect on blood pressure, heart rate, cardiac conduction, or cardiac rhythm. The US Food and Drug Administration (FDA) indicate that citalopram is not recommended for patients suffering from congenital long QT syndrome. The doe of citalopram has been indicated that it should not exceed 40mg/day to avoid the potentially fatal risk of cardiac arrhythmia. This has also been informed about the fact that higher doses have not proven to be more effective in treating depression. The recommended dosage for patients older than 60 years is 20 mg/day (Halverson, 2018).

In 2013, FDA approved vortioxetine (Brintellix) for the treatment of a major depressive disorder in adults. The drug’s mechanism of action entails the enhancement of serotonergic activity through 5-HT reuptake inhibition. It has also been indicated that it modulates serotonin receptor activity through 5-HT1A receptor agonism and 5-HT3 receptor antagonism (Halverson, 2018). The approval was made following five short-term studies. The studies revealed a statistically significant reduction in general symptoms of depression with vortioxetine. Among the noted adverse effects for this drug include nausea, diarrhea, dry mouth, constipation, vomiting, dizziness, and sexual dysfunction (Halverson, 2018). 

  1. Serotonin /norepinephrine reuptake inhibitors 

The drugs classified as SNRIs include venlafaxine, desvenlafaxine, duloxetine, and levomilnacipra. These drugs can be used as first-line agents, especially among patients with significant fatigue or pain syndromes linked with sessions of depression. The SNRIs have been found that to act as a second-line agent for patients where SSRIs has failed to work (Halverson, 2018). 

The trend on the concurrent use of SNRIs with other antidepressants has become problematic, associated with a greater risk of adverse events and cannot outdo monotherapy. In July 2013, the FDA approved a new SNRI levomilnacipram (Fetzima) that is offered as a once-daily sustained-release formulation (Halverson, 2018). This medication has been indicated to have a higher potential for norepinephrine reuptake inhibition than for serotonin reuptake inhibition without directly affecting the uptake of dopamine. 

  1. Atypical Antidepressants

This category of drugs includes bupropion, mirtazapine, nefazodone, and trazodone. Drugs under this category have been indicated to be effective in monotherapy in dealing with the major depressive disorder. It may be integrated with other forms of therapy to deal with the depression that has been hard to treat. This category of antidepressants has been noted to have low toxicity in overdose. Among the common side effects associated with this class of drugs include dysfunction and weight gain.

  1. Serotonin-Dopamine Activity Modulators

The drugs making up the SDAMs include brexpiprazole and aripiprazole. The SDAMs are used as a partial agonist at 5-HT1A and dopamine D2 receptors at similar potency and antagonist at 5-HT2A and noradrenaline alpha 1B/BC receptors. It is through this mechanism of action that makes it unique from other atypical antipsychotic drugs. Brexpiprazoel has been noted to use adjunctive therapy for the main depressive disorder. Aripiprazole is noted to be schizophrenia and episodes associated with bipolar that is an adjunct to MDD (Halverson, 2018).

Clinical Guidelines

In my current facility, there has been developed a care pathway for the assessment, diagnosis, and treatment for depression. Care pathway borrows from different guidelines provided by different organizations in the United States. The care pathway highlights the essential practices that are important in the management of depression, including screening, symptom remission, and specification (Lewandowski, Acri, Hoagwood, Olfson, Clarke, Gardner, & Frank, 2013). The care pathway has 11 steps that are to be followed:

  1. Screening positive for depression 
  2. Assessment to confirm the diagnosis
  3. Suicide risk assessment
  4. Brief supportive counseling
  5. Treatment initiation
  6. Communication and documentation 
  7. Treatment adherence 
  8. Symptom reassessment 
  9. If remission is present, maintain or complete treatment
  10. Where remission is absent, treatment is adjusted

The screening process is meant to identify the patient at risk. Screening is used as the initial step, followed by diagnosis, early treatment, and follow-up. The people considered to be at a risk include individuals who have been noted to have had prior depressive episode, recent stressful life event, family history of major depression, chronic medical conditions, cognitive impairment or dementia, anxiety and substance abuse, and multiple physical complaints, and unexplained physical symptoms (Ng, How, & Ng, 2016). Healthcare practitioners are required to be attentive to the life event stressors and the way they contribute to the onset of main depression. Some of the stressor to be considered under this includes recent loss bereavement, physical or emotional abuse, acts of humiliation, and rocky relationships. 

The Diagnostic and Statistical Manual of Mental Disorders provides a diagnosis process, which indicates, for the diagnosis of a major depression, a patient should have about five or more of the symptoms described below over a period of 2 weeks. The symptoms considered include depressed mood, loss of interest in the previously highly held activities, significant weight gain or loss, sleeping disorder, psychomotor agitation or retardation, excess fatigue, feeling on worthlessness, difficult in concentrations, and recurrent suicidal thoughts (Chapman, & Perry, 2008).

Screening in healthcare provision is noted to assist the individuals who are yet to be diagnosed with depression. Screening is essential to minimize the typical 4-year lag between depression onset and treatment initiation and thereby, avoid substantial suffering. It is important to carry out screening since most of the patients are not aware that they are experiencing depression. Depression screening offers an opportunity to recognize patients who are suicidal among those identified as having positive results during screening. The recommended screening instrument recommended at our facility is the patient health questionnaire (PHQ). The PHQ is a multipurpose instrument used in screening, diagnosis, monitoring, and measuring the severity of depression. The screening tool is noted to incorporate DSM-IV depression diagnostic criteria and other renowned depressive symptoms (O’connor, Rossom, Henninger, Groom, & Burda, 2016). The tool ranks the rate of occurrence of the symptoms into a scoring severity index. A key question in the screening instrument aims to assess the duration of suicidal thoughts. 

Part of the clinical guidelines for depression includes patient education. Patients’ education plays a critical role in the successful treatment of major depressive disorder. On the long-term basis, patients will be equipped to recognize the signs of relapse and thereby, allow them to seek treatment early in advance. Patient education should seek to make the patients aware of the rationale behind the choice of treatment, possible negative effects, and the expected effects. Patient education seeks to enhance the inclusion of patient input in the treatment plan with an aim of improving medication compliance and referral to counseling. The patient education needs to inform family members on the nature of depression since this offers supportive interactions. The inclusion of family is an essential part of the treatment plan, especially where it entails pediatric and late-onset depression. Family members are noted to be important informants to ensure that they enhance medication compliance. The family members are known to encourage patients to alter their behaviors that may cause the continuation of depression.  

Standard Practice of Depression Management 

The practice in our healthcare practice is in line with what is prescribed by the nation. The national guidelines provided by the US Preventive Services Task Force (USPSTF) highlight the need for screening for depression by professionals to look for conditions that the patient may not have identified. The guidelines highlight that the screening should only be offered where there are systems to refer the patient for further assessment, treatment, and follow-up. The national guidelines indicate that screening that is not followed by treatment is not effective. Screening is required to be carried out at an appropriate setting using a depression-screening instrument appropriate for an older population. In our facility, the screening instrument used is the patient health questionnaire (PHQ), which is among the instruments recommended by USPSTF. 

In the treatment of depression, the FDA has approved more than 25 medications. Research and evidence reveal the effectiveness of psychotherapies in primary care or specialty mental health care settings. Different guidelines have been proposed to offer guidance on effective management of depression in primary care and in specialty mental health care settings (Unützer, & Park, 2012). The guidance summarizes the evidence-base for pharmacological and non-pharmacological treatment therapy. The guidelines indicate that where non-pharmacological treatment is available, the physicians are required to ask the patient who is starting the depression treatment about their preferences on medications or psychotherapy. This has been encouraged due to the ability in addressing the patient’s treatment preference and improving the likelihood of an individual joining depression treatment and lead to improving treatment outcomes. The guidelines require the tracking of patients’ clinical outcomes using depression-rating scales, among them a 9-item Patient Health Questionnaire (Unützer, & Park, 2012). The guidelines require that the treatment is adjusted systematically for patients who did not improve on the initial treatments. The care pathway adopted in our facility abides by these guidelines with an aim of improving the patient’s outcome. 

Managed Disease Process

For an individual to facilitate the management of depression, it is essential that they fully understand the necessary information about the disease and the treatment option. The first important element in this is that an individual needs to understand the situation under which they could be regarded as being depressed. This requires that the individual understand the main symptoms that are considered for that diagnosis of the depression. It also requires an individual to develop and understand depression to facilitate the development of a better response. An individual with this kind of knowledge about the disease is able to recognize the warning signs of the various episodes of depression. The individual is then able to identify the relevant warning signs. 

In the management of the disease, an individual is required to play a critical role in the selection of allies. One is required to be aware of the role played by the members of the care team. This helps the individual understand the need for maintaining a relationship with the care team. They assist the individual to develop self-observing skills. An individual is supported to make a plan for the appointment with the doctor.  

The individuals are required to understand their personal responsibility on the management and treatment. One is required to become aware of self-criticism and resulting effects. A patient is required to make efforts to replace self-criticism gradually by building on self-worth and self-esteem. An individual is expected to make efforts towards better management of the emotion by developing systems for emotion regulation. 

The individual can facilitate their treatment journey by seeking support from family and friends. This requires one to understand how to differentiate between positive and negative energy. From this, it is crucial that the individual learns how to communicate their personal needs to friends and family. The network of friends and family can be essential sources of an anchor to assist the individual in recognizing and reactivating the activities that make them feel good and provides comfort.  

An individual is required to take charge of their lifestyle choices. This includes developing an understanding of the effects of the different effects of the good lifestyle choices on mood. It is important for one to take stock of the different lifestyle choices and point out to the possible areas of improvement. For instance, an individual needs to develop a different perspective, to be able to see things differently.

Another important thing that an individual can do to manage their disease is to understand more about the treatment of depression. After the diagnosis of depression, the healthcare providers offer information on the type of the depression. An individual is required to understand the different types of treatments such as psychotherapy, antidepressant medication, or an integration of the two. The patient needs to understand the effects of the severity of the depression on the treatment plan chosen. An individual is required to understand how long the effects of the treatment are expected. For pharmacological therapy, it is expected that improvements will be felt about 2-8 weeks after they start taking medicines. For patients on psychotherapy, it expected that it might take between 8-10 weeks to achieve the greatest benefits. An individual is expected to give feedback on the response to the treatment team to make any relevant adjustments to the care plan. 

Disparities

It has been established that there are disparities in depression treatment by factors such as age, race/ethnicity, and the insurance type (Harman, Edlund, & Fortney, 2004). A certain study revealed a difference in prevalence rate among different racial groups, which was at 5.4% for Asians as compared to 11.2% for non-Latino whites. It has been noted that among the patients noted to be suffering from a 12-month depressive disorder 63.7% of Latinos, 68.7% of Asians, and 58.8% of African Americans and 40.2 non-Latino whites, did not access any mental health treatment for the last one year. From the research findings, it can, therefore, be established that the minorities are significantly less likely than non-Latino to access quality care (Alegria et al., 2008).  Among the causal factor for these disparities is the under-detection of depression among the ethnic minorities. It was also observed that it is difficult for the health care practitioner to identify depression for the groups as the symptoms presentation for mental health disorders are different across racial and ethnic groups and can be different from what the clinicians are trained to look for or resulting clinical misdiagnoses. 

In another study involving the patients who had met WMH-CIDI criteria for a 12-month major depression, one in every 3 respondents were reported to have been under antidepressant agent for a period of one year (González, Vega, Williams, Tarraf, West, & Neighbors, 2010). It was noted that Puerto Rican and non-Latino white patients had the highest use while the Mexican American, Caribbean Black, and African American individuals were noted to have had the lowest use of pharmacotherapy (González, et al. 2010). A similar pattern was found to appear on the use of psychotherapy treatment plan. Further analysis indicates that proportions of Puerto Rican and non-Latino white who undertook the concordant therapies was almost twice as high as those of Mexican Americans, Caribbean blacks, and African American individuals (González, et al. 2010). The enabling factors for the higher rates of pharmacotherapy use included higher odds of pharmacotherapy. 

Another study indicated that Africans Americans and Latinos were less likely to fill an antidepressant prescription as compared to the Caucasians. It was however noted that for the patients who filled a minimum of one prescription for an antidepressant, no racial or ethnic disparities were observed. Africans Americans were more likely than the Latinos and Caucasians to acquire enough course of psychotherapy (Harman, Edmund, & Fortney, 2004). Another form of disparity indicated that people with no insurance coverage were less likely to access any form of depression treatment as compared to those with insurance coverage. 

There have been disparities in the management of depression across different countries. An analysis of the management of patients across the health care systems in Germany, the United Kingdom, and the United States reveals such internal differences. An analysis reveals that the German physicians are noted to be likely to diagnose depression in women while the UK and the U.S. clinicians were likely to diagnose depression in men. American healthcare providers were noted to be most certain of their depression diagnosis, while British general practitioners were noted to have the least certainty in their depression diagnosis. 

Research highlighted that British physicians were the least likely to prescribe an antidepressant or refer the patient to a mental health facility or practitioner. There were also disparities in the nature of referrals to a mental health professional and on the variation in the type of professional referral. In Germany, 51% of physicians made a referral to a mental health professional or a neurologist, 38% to a psychiatrist, and 11% to a therapist. In the United Kingdom, it observed that among the referrals, 57% were made to a therapist and 43% were to a psychiatric practice nurse. In the United States, among the referrals to a mental health professional, 57% were made to a therapist, 22% to a psychiatrist, and 22% of a psychologist. 

Another source of disparities in the management of depression as per the healthcare system in Germany, United Kingdom, and the United States is on antidepressant medication prescribed. In Germany, it was noticed that 33% of antidepressant prescriptions offered were for St John’s Wort, 24% were for a tricyclic antidepressant, 18% for SSRI and SNRI, 21% were unspecified, and 3% was made for benzodiazepine. Within the United Kingdom, 78% of the anti-depressant pharmacotherapy were made of SSRI/SNRI, 9% for tricyclic antidepressant and 13% were not specified. Within the United States, it was noted that 90% of prescriptions were on SSRI/SNRI and 10% of the prescription being on TCA (Link et al., 2011). 

Another essential disparity was on the interaction of country care and physician gender when making a decision to another practitioner. Female German physicians were more likely to refer a patient to another medical professional. Among the British physicians, the male physicians were more likely to refer patients to another professional as compared to their female counterpart. There was insignificant variation in practice by different genders among the American physicians (Link et al. 2011). The American physicians were noted to be more likely to offer lifestyle advice. 

Managed Disease Factors

Insurance coverage

Among the critical factors to ensure that a patient manages their depression, is the insurance coverage. It has been indicated that patients with depressive disorder and other mental disorder are more likely to be uninsured or on Medicaid, and less likely to be enrolled in a private insurance. Insurance coverage has been identified to be among the strongest determinant for receiving treatment. Insurance coverage has been identified as a reason for not receiving treatment (Walker, Cummings, Hockenberry, & Druss, 2015). The uninsured adults with depression order are more likely to report attitudinal barriers as compared with patients with insurance. 

Government assistance 

The federal government offers assistance for the treatment of people with depression. This is through the National Institute of Mental Health (NIMH), which is the part of National Institutes of Health (NIH) and is involved in carrying out and supporting medical research. The NIMH carries out an awareness campaign to sensitize people that depression is a real illness. This is influential in making people understand that depression is not a sign of an individual’s weakness or character flaw. This increases the willingness of people to seek treatment.

Cultural beliefs 

Another factor that influences patient to manage their depressive disorder is cultural beliefs. It has been identified that racial and ethnic differences, especially among the older adults with mental illness such as depression, affects the manner in which the patient perceives the roles of health care providers in decision -making, and the preferred characteristics of providers (Jimenez, Bartels, Cardenas, Dhaliwal, & Alegría, 2012). The African Americans were noted to consider the loss of family and friends, stress over money, and general stress as the main cause of stress of mental illnesses. The intergenerational family support and support acquired from the extended family was considered an essential element influencing healthcare among the African American community. African Americans considered a strong social network as a protective factor relevant in dealing with mental issues (Jimenez, et al., 2012). The African-American were noted to be open to talk to medical doctors but more reserved to speak to the mental health professionals. Asian-Americans were noted to hold the belief that mental illness is caused by medical illness, cultural differences, and family issues. The Asian American individuals have been noted to be less willing to speak to anyone about their mental illness (Jimenez, et al., 2012). This results from the high rate of stigmatization and the need to maintain a sense of dignity. The Latinos were found to hold the belief that mental illness is caused by the loss of family and friend, family issues and moving to a different place.  

Unmanaged Disease Factors

Lack of insurance cover implies that individuals will be unable to meet the need to cater to their mental health treatment. The ability to cater for the health needs is a major barrier to treatment that has been reported by people. This implies that the individuals suffering from this will be unable to seek treatment for the depression and may not be in a position to cater for medication. The lack of insurance coverage, in this case, is a clear barrier to treatment, especially where the government fails to support the patients suffering from depression. It implies that most patients and members of the society will have skewed perspectives about depression. 

Cost

It is estimated that depression in America costs the society approximately $210 billion per year. Out of this figure, 40% is directly associated with the depression itself.  It has been established that for every 1 dollar spent on treating depression, an extra $4.70 in used to cater for direct and indirect costs of other related diseases. It is also estimated that another $1.90 is utilized for reduced work productivity and economic costs connected with suicide directly linked with depression (Greenberg, 2015). For every dollar spent on depression, it is estimated that the $0.40 are used for prescriptions, $0.36 is used to cater for outpatient, and $0.18 caters for inpatient, while $0.06 is used for the emergency department. For the $6.60 additional costs that are incurred for every dollar spent on direct cost to depression, $2.57 is used for comorbidity direct cost, $2.12 for comorbidity workplace cost, and $1.55 for MDD workplace cost, and $0.35 for depression suicide-related cost. 

The cost of depression to the family is associated with increased caregiving costs. Depression affects the independent functioning of the patient thereby, contributing to increased rates of unpaid caregiving offered by family and friends. It has been estimated that the caregiving costs was almost totaling $9.1 billion for the year 2016. A more detailed breakdown revealed that about $5 billion was used in caregiver costs for individuals with about 1-3 depressive symptoms and $4.1 billion for patients with 4-8 symptoms for depression (Snow & Abrams, 2016). Other costs that may be considered under this include the downstream economic effects of caregiving that entails negative health consequences and productivity losses associated with caregiver burden. 

The cost of depression to the entire society may be considered under factors such as education, marital timing, and stability, childbearing, and occupation. Different studies have highlighted that early-onset of mental disorder leads to termination of education. This is associated with indirect costs to provide for the people who dropped out of schools. It has also been revealed that early onset of depression leads to the reduced likelihood of getting married and positively connected to early marriages before the age of 18 years, which has contributed to negative outcomes (Kessler, 2012). It has also been observed that a past history of mental disorders contributed to high rates of unemployment and work disability. 

Best Practices Promotion

In my role as an advanced nurse, the intervention I would seek to promote as a best practice for the treatment of depression would be the provision of psychosocial care to the depressed patients. In this, I would emphasize the recognition of distress among the patients and provision of available mental health resources. Psychosocial support to the patient entails culturally sensitive, provision of psychological, social, and spiritual care (Legg, 2011). The nurse has an essential role in the provision of support to patients. The function can be achieved by facilitating a dialogue between the patients and the nurses to bring a revelation of how the patients perceive themselves, understand what is important to the patients, and establish how their relationship with different individuals may influence their healing process (Legg, 2011). 

On this note, I would seek to promote good communication and assessment procedures as a means of developing a rapport with the patients. This approach would be helpful to the nurses in their quest to develop a clinical and therapeutic relationship with the patient and the family members. Where the patient is hospitalized, there is a higher chance of the building stronger relationships and gain the patient’s trust and offer optimal support to the patient. 

To offer psychosocial care, it would be important to have the nurses understand the importance of taking a case-by-case approach. This requires the nurse to treat each patient individually. This is because each patient is noted to be in need of unique physical, symptomatic, and psychosocial care (Renn, & Areán, 2017). The provision of this psychosocial care to the depression patients would be essential in assisting them to minimize the occurrence of the psychological distress and physical symptoms. The effects of this would be an increment in the quality of life and enhance coping mechanism. 

Among the psychosocial care that I would promote when dealing with depression patients would be the cognitive behavior therapy (CBT). Cognitive behavior therapy is a treatment approach that assumes that the maladaptive cognitions precipitate and thereby, maintain depression and other types of emotional distress. The CBT treatment approach seeks to engage the patients actively, to assist them in identifying and modifying their maladaptive cognitions. CBT treatment therapy is comprised of behavioral treatments such as behavioral activation, relaxation training, and skill rehearsal. The treatment, in this case, may include 12-16 treatment sessions. The implementation of the CBT approach for the older patients suffering from depression might need to be adjusted to cater for gerontological-relevant issues. The issues to be covered under this might include physical and cognitive changes, cohort beliefs, and losses and role transitions (Renn, & Areán, 2017).

Implementation Plan

Strategy 1: Use of Pharmacotherapy in Sequential Order

The initial plan for treating the patients with the major depressive disorder will be to use antidepressants medication. A major advantage of using this is the immediate effect to assist the patient to overcome the septostomy. For the patients suffering from mild to moderate depression, it is important to place them on the SSRIs. The SSRIs category of antidepressants has been noted to be very beneficial as compared to others, especially in terms of reduced risk level thereby, safer, as well as, having fewer side effects. The SSRIs is thereby prescribed as first-generation antidepressants. The implementation plan for this requires starting the patients on low doses. The patients will be required to attend sessions with the physicians thrice a week for the first two weeks. The sessions may later be reduced as the patient’s condition improves. The dosage offered may increase slowly where necessary. This will be effective in minimizing the possibility of the side effects. Under the plan, it is expected that within the first two weeks, the patient will have started experiencing some improvements. The antidepressant’s effect will be established to determine the full effect between 6-12 weeks. 

Strategy 2: Individual Psychosocial Therapy

Under this strategy, the patient will meet a mental health care professional for a one-on-one session. The therapist will seek to assist the patient to learn how to cope with feelings, problem-solving, and alteration of behavior patterns. The talk session on this case will not just be mere talking of problems, but rather will be a move towards seeking solutions. A very essential element in this strategy is that the patient will be required to engage in further activities after the session. These activities may include tracking the moods, noting down the thoughts experienced, and participating in some social activities that may have been a source of anxiety in the past. This therapy will be geared towards assisting the patient focus on their current thoughts, feelings, and life issues. This kind of focus will be geared towards assisting the patient cope with the present and get ready for the future. The first week into the therapy will have daily sessions, which will be reduced as the goals are progressively achieved. 

Strategy 3; Group Therapy for CBT

CBT is recommended as the first-line treatment for depression. I intend to offer this therapy to the depression patients in a group setting. Provision of the CBT in a group format is noted to be cost-effective as compared to individual treatment (Thimm & Antonsen, 2014). The group treatment is also coupled with a number of benefits. Under a group, patients will benefit from the power of group cohesion and normalization effects. The use of group for the CBT therapy will offer an arena for engaging in behavioral experiments, increase the chances of learning from others and provide an opportunity for the patients to act as co-therapists. This model will be applied to patients who have progressed towards their goals under the individual treatment plan. The group sessions will offer an opportunity for the patients to meet and interact with other people who are undergoing similar conditions in life. The group members are able to share their experiences and the strategies that each adopts to overcome the situation. The group therapy presents a give-and-take scenario that provides a platform for learning new methods and perspectives of the illness. 

Evaluation Method

Among the essential tools that will be used to carry out the evaluation of the effectiveness of the strategies mentioned above is the Beck Depression Inventory-II. This assessment tool is a 21-item self-report multiple-choice inventory, estimated to take approximately 10 minutes to complete. It is considered an effective tool for monitoring change over time as it offers an indicator of the severity of depression. For the 21 questions, every question is scored on a value ranging from 1 to 3. For this tool, the higher the total score, the more severe the depressive symptoms. The maximum score possible is 63. The scores are graded using different cut-offs that are interpreted differently. Scores ranging from 1-13 indicate a minimal depression, scores between 14 and19 reveal mild depression, 20-28 reveal moderate depression, and 29-63 indicate severe depression. 

Another means of evaluation that will be used to evaluate the progress of the implementation plan is the formal psychological assessment (FPA). The formal psychological treatment is a tool that seeks to exploit the advantages of a semi-structured interview and self-report questionnaires (Serra, Spoto, Ghisi, & Vidotto, 2015). This is achieved by overcoming the limitations that are common with these tools and to manage the problems that were previously experienced under the traditional assessment. The first step under the FPA is a deterministic model construction made up of the matrix, assigning to each item of the scale the subsets of attributes that it seeks to investigate. The second step in using this tool entails using the construction of the clinical structure from the attributes assignment (Serra, Spoto, Ghisi, & Vidotto, 2015). The results from the tool can be depicted as a lattice where each node represents a clinical state and the associated attributes. There is a use of a probabilistic approach with an aim of overcoming the problems presented by the deterministic approach. On this note, the basic local independence model (BLIM) is the model applied where a probability value is assigned to each clinical state (Serra, Spoto, Ghisi, & Vidotto, 2015). Using the BLIM, the responses from each item are locally independent given the clinical state of a subject. 

References

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Brody, D. J., Pratt, L. A., & Hughes, J. P. (2018). Prevalence of Depression Among Adults Aged 20 and Over: United States, 2013-2016. NCHS data brief, (303), 1-8.

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Chapman, D. P., & Perry, G. S. (2008). Peer reviewed: depression as a major component of public health for older adults. Preventing chronic disease5(1).

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Harman, J. S., Edlund, M. J., & Fortney, J. C. (2004). Disparities in the adequacy of depression treatment in the United States. Psychiatric services55(12), 1379-1385.

Halverson, J. (2018). Depression. Retrieved from https://emedicine.medscape.com/article/286759-overview#a3

Hasler, G. (2010). Pathophysiology of depression: do we have any solid evidence of interest to clinicians? World Psychiatry9(3), 155-161.

Jimenez, D. E., Bartels, S. J., Cardenas, V., Dhaliwal, S. S., & Alegría, M. (2012). Cultural beliefs and mental health treatment preferences of ethnically diverse older adult consumers in primary care. The American Journal of Geriatric Psychiatry20(6), 533-542.

Kessler, R. C. (2012). The costs of depression. Psychiatric Clinics35(1), 1-14.

Legg, M. J. (2011). What is psychosocial care and how can nurses better provide it to adult oncology patients. Australian Journal of Advanced Nursing, The28(3), 61.

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O’connor, E., Rossom, R. C., Henninger, M., Groom, H. C., & Burda, B. U. (2016). Primary care screening for and treatment of depression in pregnant and postpartum women: evidence report and systematic review for the US Preventive Services Task Force. Jama315(4), 388-406.

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Renn, B. N., & Areán, P. A. (2017). Psychosocial Treatment Options for Major Depressive Disorder in Older Adults. Current treatment options in psychiatry4(1), 1-12.

Serra, F., Spoto, A., Ghisi, M., & Vidotto, G. (2015). Formal psychological assessment in evaluating depression: a new methodology to build exhaustive and irredundant adaptive questionnaires. PloS one10(4), e0122131.

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