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The focus of this academic work will be on one of the well-known mental health illnesses, Major Depressive Disorder (MDD). Its high prevalence in society today highlights the need to explore the available treatment for people with MDD. The pharmacological and non-pharmacological management of MDD will be discussed, together with possible community resources for MDD clients to rely on.
MDD also known as unipolar depression or clinical depression, is a type of mood disorder. People with MDD is characterised as being in a constant state of unhappiness (Videbeck, 2010, p281). Under the Diagnostic and Statistical Manual of Mental Disorders V, one is diagnosed with MDD when he is in a depressed state for a minimum of 2 weeks and show at least 4 or more symptoms (American Psychiatric Association, 2013). Some clinical manifestations of MDD are feeling sad, tired and unable to sleep well. MDD is the most common mental health illness worldwide such that it is referred to as the ‘common cold’ in mental health (Institute of Mental Health, n.d.). In Singapore, MDD is so widespread that it has a lifetime prevalence of 6.3% (Ministry of Health, 2012). Research has also shown that for every sixteen individuals in Singapore, one will have depression at some point in time (Choo, 2018). The etiology of MDD cannot be explained by just one theory.
Based on neurochemical theory, MDD occurs when there is a deficiency in neurotransmitters namely serotonin (5-HT), norepinephrine and dopamine (Nutt, 2008). These neurotransmitters control the emotional state of an individual by transmitting chemical messages in the brain. Dopamine is found to have correlation with happiness, while serotonin controls mood (Baixauli, 2017). The concentration of these neurotransmitters become low due to the reabsorption by receptors at presynaptic nerve terminals (Adams, Holland & Urban, 2013, p192), thus resulting in depressive signs.
According to the genetic theory, one with a first-degree relative that has MDD has a two to four times more risk for MDD as compared to the rest of the population (American Psychiatric Association, 2013). Gender also plays a role in the etiology of MDD as women have two times more risk for MDD than men (Videbeck, 2010, p284).
External factors also contribute to MDD. People with long term medical illnesses such as cancer, coronary heart disease may see themselves as a disability and simultaneously suffer from the pain inflicted by their illnesses (Turner & Kelly, 2000). It was found that chronically ill patients have two to three times more incidence of developing MDD than general patients (Katon, 2011). Other stressful life events such as death of loved ones, divorce and unemployment can also result in the same depressive symptoms (Jesulola, Micalos & Baguley, 2018).
It is significant for us to discuss MDD because a potential yet major consequence of MDD is suicide. A study has shown that out of individuals who have attempted suicide, 59% to 87% are diagnosed with MDD and approximately 15% of the MDD patients completed suicide (Gonda, Fountoulakis, Kaprinis & Rihmer, 2007). This high statistic is a worrying news as depression, as mentioned, is very common in the world. This means that more people may be prone to ending their lives if no effective medical intervention is provided. Hence, it is critical to discuss the medical treatment available for MDD clients.
Since MDD has been around for a long time, there are a variety of antidepressants invented to cope with the symptoms. The major classes of drugs for MDD are tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs) and selective serotonin reuptake inhibitors (SSRIs). SSRI is preferred among TCA and MAOI because it is safer to use on elderly and has fewer adverse effects for instance, cardiovascular risk (Ferguson, 2001). Therefore, SSRI is deemed as the first-line medication for MDD clients (Clevenger, Malhotra, Dang, Vanle & IsHak, 2018). Common SSRIs are namely Fluoxetine (Prozac), Citalopram (Celexa) and Paroxetine (Paxil).
SSRI acts by blocking the serotonin receptors, preventing the reabsorption of serotonin into presynaptic nerve terminals (Adams et al., 2013, p191). This increased level of serotonin then triggers a change to the presynaptic neuron such that it becomes desensitized to serotonin while the postsynaptic neuron undergoes changes which increases its sensitivity (Adams et al., 2013, p192). So, more serotonin can be transmitted across the neurons to pass signals in the brain to regulate mood. An advantage of SSRI as its name suggests, is that it only targets serotonin and does not affect other neurotransmitters (Videbeck, 2010, p285).
Research has shown that escitalopram has a prophylaxis efficacy of 36% which is the highest as compared to other SSRIs like fluoxetine and paroxetine (Clevenger et al., 2018). Thus, escitalopram is the better choice of drug for the prevention of MDD relapse.
Even though side effects of SSRI are more tolerable than TCA and MAOI, it includes gastrointestinal (GI) problems such as nausea and diarrhea (Ferguson, 2001). This is because of the overactivation of 5-HT3 receptors due to the high amount of serotonin available which fortunately, if given at a lower dosage, can reduce the side effects (Ferguson, 2001). Research found that citalopram shows the least adverse effect, thus Ferguson (2001) claims that it is the most tolerable SSRI.
One adverse consequence of SSRI is the serotonin syndrome, whereby there is extremely high level of serotonin available due to the excessive usage of SSRIs or insufficient washout period between taking SSRI and MAOI (Videbeck, 2010, p289). With the accumulation of serotonin inside the body, an individual experiences serotonin toxicity which may be life threatening (Buckley, Dawson & Isbister, 2014). Manifestations of serotonin toxicity include diarrhoea, nausea, and mental changes like agitation and confusion (Buckley et al., 2014). Hence, clients should be educated on the right dosage of SSRIs.
Like other antidepressants, SSRI has a black box warning under the United States Food and Drug Administration (Adams et al., 2013, p190) for suicide ideations, especially in the younger population (Nischal, Tripathi, Nischal & Trivedi, 2012). Due to the uplifting nature of SSRIs, clients may gain energy to carry out suicidal behaviors because they are still in a depressed state (Videbeck, 2010, p313). Thus, it is important to advise friends and relative to monitor the clients for any suicidal behaviors.
Psychoeducation is the process of teaching the client and his family about the diagnosed mental illness. A registered mental health nurse (RMN) is usually the one conducting the education in a hospital ward setting. A strong therapeutic nurse patient relationship (TNPR) is essential in psychoeducation so as to achieve desirable outcomes (Dziopa & Ahern, 2009). In order to achieve TNPR, the RMN will show understanding of the client by active listening and respecting the client’s thoughts rather than condemning their behaviors (Dziopa & Ahern, 2009).
From a client’s perspective, his illness may be a worry to him because he is foreign to the symptoms it presents. This is where the RMN will come in to share information with the client regarding the possible causes for MDD, symptoms, and available treatment for him (Bamual, Frobose, Kraemer, Rentrop & Pitschel-Walz, 2006). Psychoeducation allows the client to clarify doubts about his condition (Bamual et al., 2006), thus increasing his awareness and involving him in the treatment process. It is important for the RMN to emphasize to the client, about medication adherence in order for his condition to improve. For example, a client may assume that his SSRI is not working due to the long waiting time for the medication effect to peak, causing him to lose hope and give up on his medicine (Videbeck, 2010, p313). This scenario can be avoided when the RMN provided information about the timeline for SSRI to work.
From the family of the client’s perspective, they may also be anxious about the client’s condition. The pressure of taking care of the client may result in caregiver stress. When the stress is too overwhelming, family members may develop hostility and intolerance to the client which is termed as having high Expressed Emotion (EE) (McCann, Songprakun & Stephenson, 2015). This in turn drives the client into relapse (McCann et al., 2015). From an empathetic perspective, the RMN advocates for the family’s well-being such as advising on ways to cope with high EE.
In the Shimazu et al. (2011) study, families of clients with MDD were given four psychoeducation about depression and how to cope in high EE scenarios. The study found that the time taken for MDD clients to fall into relapse was longer for clients’ whose family received psychoeducation than the control group. After a nine months follow-up of the clients, the psychoeducation group had a 42% lower rate of relapse than the control group (Shimazu et al., 2011). Hence, family psychoeducation is beneficial to prevent the relapse of MDD clients.
During preparation for the client’s discharge, the RMN should also provide the family with instructions on what to look out for such as symptoms of MDD relapse and side effects of the medication (Videbeck, 2010, p298). For instance, it is crucial for the RMN to instruct the family to constantly observe the client’s behavior for any signs of suicide intention since consuming antidepressants may trigger suicidal thoughts (Adams et al., 2013, p190).
Therefore, with psychoeducation, clients can take charge of their own illness and their families can better understand and aid them in coping with their condition
Interpersonal Psychotherapy (IPT) is a psychotherapy developed in the 1970s for treating MDD. According to Wilfley (2001), IPT suggests that MDD develops due to the changes in interpersonal relationships surrounding the client. Death of a loved one is an example of the change in interpersonal relationship. Wilfley (2001) also claims that IPT aims to decrease the symptoms of depression by improving the client’s interpersonal relationships. This is done by targeting one of the four possible interpersonal issues which are grief, interpersonal role disputes, change of social role and lack of social interaction (Wilfley, 2001, p7863).
There are 3 main phases in IPT, the beginning (three weeks), middle (six weeks) and the end (three weeks). The overall duration of IPT takes twelve to sixteen weeks for acute MDD, because IPT revolves around a structured treatment plan (Markowitz & Weissman, 2004). A therapist can be the one to conduct IPT in an outpatient clinic. The client will thus visit the clinic every week for each IPT session. In the beginning, the therapist will gather information from the client regarding all of his present interpersonal relationships (Markowitz & Weissman, 2004). After detailed evaluation, the therapist will single out the most appropriate interpersonal issue that the client is affected by (Markowitz & Weissman, 2004). Hence, the interpersonal issue selected will be the main focus for upcoming sessions. It is important for the therapist to establish the idea to the client that the relation between his depression and life changes is “practical, not etiological” as stated by Markowitz and Weissman (2004). This means that the client should not blame himself for the cause of his depression. The client is given the role of a sick person by the therapist during this time, to take off any burden so as to allow him to feel more at ease (Lipsitz & Markowitz, 2013).
Markowitz & Weissman (2004) suggest that in the middle phase, the therapist advice the client on methods to resolve the interpersonal relationship. For instance, if the client is grieving about his dead wife, then the therapist can help him with the mourning (Markowitz & Weissman, 2004). If the interpersonal issue is the change of social role such as a divorce, then the therapist can also aid the client in mourning, but simultaneously encouraging the acceptance of the new social role (Markowitz & Weissman, 2004). Thus, the client learns new interpersonal skills from the therapist which is applicable for him to resolve his interpersonal issue.
In the final phase, the therapist informs the client of the ending of the therapy, and both can look back at the progress of the client’s interpersonal relationship (Lipsitz & Markowitz, 2013). If the result is not satisfactory, the therapist will then re-evaluate the problem that occurred and allow the client to try out new interpersonal skills again (Markowitz & Weissman, 2004). The therapist can praise the client’s efforts to resolve his interpersonal relationship when it shows improvement. Thus, the therapist is referred to as a “cheerleader” by Markowitz and Weissman (2004), because by doing so, the client is encouraged to resolve his interpersonal relationship. Finally, the therapist discusses with the client to schedule for future sessions at a less frequent basis so as to maintain the optimal state that he is in (Markowitz & Weissman, 2004).
Based on a meta-analysis, Cuijpers et al. (2011) states that IPT is “one of the most empirically validated” management for MDD. Various clinical studies also prove that the outcomes of IPT include remission and improvement in symptoms of MDD (Feijo, Mari, Bacaltchuk, Verdeli & Neugebauer, 2005). Hence, IPT is a good approach for MDD.
Nevertheless, one drawback is the time-limiting part of IPT. Clients who are more used to therapies that have no time limit may find IPT too short, thus may be unable to adjust to the structured plan (Addiction, n.d.).
In Singapore, one major governmental organisation called the ‘Agency for Integrated Care’ (AIC) is well-known for providing resources to re-integrate individuals into society. Under the AIC, there is an area meant for helping patients with mental illnesses. As the social stigma against mental illness is prevalent in Singapore, MDD clients may face discrimination when returning to the workforce (Baker, 2018). This is because of the perceived unproductivity of the clients due to their symptoms which portray them as unreliable candidates (Brouwers, 2016). Therefore, AIC aims to provide employment support for the clients through its psychiatric day care centres. The programs in these centres help clients to better manage their illness, simultaneously allowing clients to learn vocational skills (Agency for Integrated Care, n.d.). As such, clients can have more resources to prepare for employment.
‘Depression and Bipolar Support Alliance’ (DBSA) is an international organisation which aims to help client with mood disorders. In the Singapore branch, it is called ‘PSALT Care’. According to PSALT Care (n.d.), the organisation provides peer support groups to assist in the journey of recovery for MDD clients. It has a Christian-based support group, whereby MDD clients with identical religious beliefs come together. In each session, participants pray with the Bible and carry out worships, while keeping in mind the goal of changing themselves (PSALT care, n.d.). With the presence of peer support groups, participants know that they are not facing their condition alone, thus motivating them to work towards recovery (PSALT care, n.d.). The group sessions are conducted monthly, thus giving opportunities for clients to progressively manage their depression. PSALT Care (n.d.) also has a non-religious support group catering to the masses called ‘DSBA peer support group’. These group sessions are facilitated by peer support specialists who were once diagnosed with mood disorders but have since recovered. With the guidance of experienced facilitators, the sessions aim to empower participants to manage their own mental wellbeing (PSALT care, n.d.). A meta-analysis suggests that the addition of peer support group helps to reduce depressive signs as compared to normal treatment (Pfeiffer, Heisler, Piette, Rogers & Valenstein, 2011). Hence, peer support groups are advantageous for MDD clients.
In conclusion, MDD is a prevailing mental health condition around the world which can be influenced by genetics and environmental factors. It is vital to provide effective medical treatments for MDD clients because MDD may lead to suicide. One of the common classes of medication used to manage MDD is SSRI which reduce depressive traits by raising the blood serotonin level. Non-pharmacological interventions such as psychoeducation and IPT also help to cope with the symptoms of MDD. From a local context, there are community resources through peer support groups and employment assistance that clients can touch on. Therefore, MDD clients can receive help through various platforms to reintegrate into society.
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