Pathopharmacological Foundations for Advanced Nursing Practice
Introduction
Depression is one of the medical conditions which affect many people around the world. According to a study carried out by McCance and Huether, (2014), about 14.8 million adults in the US suffer from depression. Statistics provided by World Health Organization, on the other hand, indicate that 350 million individuals in the world suffer from depression (Rayner, Price, Hotopf & Higginson, 2011). This has made depression to be the leading cause of disability. Depression has also a significant influence on the mortality and morbidity rates experienced in the world. The mortality rate due to depression mainly occurs because of suicide by depressed individuals. Depression is defined as a psychotic or psychoneurotic disorder that is marked by inactivity, sadness, feelings of hopelessness and dejection, difficulty in concentration and thinking, and, in some cases, suicidal tendencies. Depression has adverse outcomes upon victims. For example, it can result in substance abuse, disruption in interpersonal relationships, and poor performance in the workplace (Karg, Burmeister, Shedden & Sen, 2011). While depression is mostly connected to life events, it has medical implications for the victims. In this paper, the pathopharmacological issues that are related to depression will be analyzed.
Pathophysiology of Depression Process
No known disordered physiological processes are responsible for the development of depression. While a number of studies have been carried out on the pathophysiology of depression, there have been no conclusive findings that could point to a particular process. However, many of the studies carried out point to various biological mechanisms that could be responsible for the development of depression (Karg, Burmeister, Shedden & Sen, 2011). These are upregulation of inflammation, hyperactivity of the hypothalamic-pituitary (HPA) axis, low levels of vitamin D, and reduced neurotropic growth.
Upregulation of inflammation
Various studies on pathophysiology of depression indicate that upregulation of inflammation might play a role in the development of depression. This is because upregulation of inflammation reduces the production of monoamines such as serotonin and increases the creation of tryptophan catabolites which are toxic to the brain (McCance & Huether, 2014). Analyses carried out indicate that depressed individuals have significantly higher levels of pro-inflammatory cytokine interleukin and C-reactive protein as compared to individuals who are not suffering from depression.
Hyperactivity of hypothalamic-pituitary (HPA) axis
Hyperactivity of the HPA axis as one of the factors which cause depression has been studied extensively and results indicate that it is significantly connected to development of depression. The hyperactivity of the HPA axis is apparently caused by the malfunctioning of glucocorticoid receptors which, in turn, impairs the HPA negative feedback circuit (McCance & Huether, 2014). The malfunctioning of the glucocorticoid receptor might cause depression through reduced hippocampus and impaired neurogenesis. As such, hyperactivity of HPA axis is likely to result in the development and progress of depression.
Low Levels of Vitamin D
Recent studies on pathophysiology of depression associate low levels of vitamin D with depression. Researchers have suggested various pathophysiological mechanisms through which vitamin D influences the development of depression. For example, they suggest that vitamin D is neuroprotective through reducing levels of neurotic calcium in the brain. Neurotic calcium is believed to be one of the substances, which increase the development of depression among people (Karg, Burmeister, Shedden, & Sen, 2011). Low levels of vitamin D result in the increase of neurotic calcium in the brain thereby causing the development of depression.
Reduced Neurotropic Growth
Reduced neurotropic growth is believed to result in reduced level of brain-derived neurotropic factor (BDNF) which, in turn, causes depression. Recent studies on depressed individuals indicate that depressed patients tend to have lower BDNF levels as compared to those that are not depressed (McCance & Huether, 2014). In one of the studies, researchers discovered that drug-free depressed patients who had a long index episode of depression considerably have lower BDNF levels than the less depressed individuals with shorter index episodes.
Standard Practice for Depression
The standard practice for depression involves a number of activities that are observed by healthcare practitioners in the treatment of depressed patients. These practices include psychiatric management, psychiatric assessment, and enhancement of consistent treatment. In treating depressed patients, healthcare practitioners carry out psychiatric management, which involve establishing a broad range of activities and interventions that they provide to depressed patients through all the phases of treatment. Psychiatric assessment involves a thorough diagnostic assessment of patients in order to establish the causes of depression, identify other psychiatric conditions, and develop a treatment plan (Aschenbrenner & Venable, 2012). The assessment normally involves an evaluation of a patient’s psychiatric history, general medical history, and past responses to treatment. Enhancement of treatment involves assessment of barriers that hinder adherence to treatment by patients and collaborating with them and their families to reduce the effect of these barriers.
Pharmacological Treatments
Depression is a treatable problem. The main pharmacological treatment of depression is the use of antidepressant medications. There are various forms of antidepressant medications that are used to treat depression. They include tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and serotonin and norepinephrine reuptake inhibitors (SNRIs) (Fournier et al., 2010). The kind of medication used on a particular patient depends on his or her level of response to the medication as well as the side effects of the medication on the patient.
The use of pharmacological treatment has led to reduction in depression levels in many societies. This has helped in managing the prevalence of depression. However, while pharmacological treatments have helped to reduce depression, depressive symptoms still persist in many patients. For example, only a third of patients recover fully after three months of using antidepressants (Fournier et al., 2010). As such, pharmacological treatments have not helped to eradicate depression in the society. There is also the issue of side effects of antidepressants on patients, which limits their use.
Clinical Guidelines
Various clinical guidelines are used for assessment, diagnosis, and patient education for depression. The first guideline is complete psychiatric assessment. Clinicians are required to carry out a thorough assessment of patients so that they can diagnose their psychiatric status and the causes of the psychiatric conditions they are suffering from (Rayner, Price, Hotopf & Higginson, 2011). The second guideline is evaluation of functional impairment and quality of life of the patient. Clinicians are required to evaluate the functional impairment of patients due to depression to determine the level of the condition. This is to help them to develop the right treatment plan. Another guideline is providing education to patients and family. Healthcare professionals are required to provide education to patients and their families about the symptoms of depression and the treatment they can use to control it (Aschenbrenner & Venable, 2012). This is to enable patients to manage the condition on their own.
Standard Practice for Managing Depression
The standard practice of managing depression in the community involves mainly taking antidepressant medications for the patients. Most patients seek medical attention when they are depressed. This standard differs with the standard practice at the state and national level. At the state and national level, the standard practice does not only involve taking medication but comprises of other activities such as diagnosis of depression and its causes, medication, and counseling (Rayner, Price, Hotopf, & Higginson, 2011). The state and national practices comprise of many interventions unlike the local one which only involves medication.
Managed Disease Process
There are various characteristics as well as resources for a patient who manages depression well. The characteristics of this patient include the right mindset and adherence to treatment. A patient who is optimistic that his or her problems can be controlled is likely to manage depression well (McCance & Huether, 2014). A patient who also observes treatment as prescribed by the doctor can manage depression well. There are various resources that a depressed patient needs to have to manage the depression well. They include medication, treatment facilities, and support groups.
Disparities
There exists a disparity in the way depression is managed at the national and international level. At the national level, there are a number of interventions which have been put in place to manage depression. They include psychotherapy and counseling. This differs from the management of depression at the international level, especially among the developing nations (Karg, Burmeister, Shedden, & Sen, 2011). In most developing nations, depression is not considered to be a medical condition and most depressed individuals are left untreated. This has resulted in a high level of mental illnesses in most developing nations.
Managed Disease Factors
A number of factors contribute to the ability of a patient to manage depression. Such factors include financial resources, access to medical care, and family support. The availability of financial resources determines the ability of a patient to access to medical care. Patients with adequate financial resources are likely to access quality medical care since they can afford to pay for it (McCance & Huether, 2014). On the other hand, poor individuals are unlikely to access medical care due to inability to pay for it. Access to medical care also influences how one manages depression. Lack of access to medical care makes it hard for one to adequately manage depression. A patient who has supportive family members is likely to manage depression than the one who does not. This is because supportive family members are likely to provide the patient with moral and financial help to manage the disease. In addition, the members are likely to care for the patient thereby enabling him or her to recover quickly.
Effect of Depression
Depression has various effects on the patient, their family, and the community in general. For the patient, it makes one to be unable to think properly, execute duties at their place of work, sleep, and eat properly. Depression has therefore a negative effect on one’s health. On family members, depression in one of them can result in stress (Karg, Burmeister, Shedden, & Sen, 2011). This can be especially in a situation where family members do not know what the patient is suffering from. Other effects of depression on family members include strained relationship with the depressed individual and worry. Depression has also an effect on the community in general. For example, a depressed individual is unlikely to interact with other members in the community and this can raise concern among people (McCance & Huether, 2014). The inability of a depressed individual to carry out his or her duties effectively normally affects the community economically.
Financial Costs
Various financial costs are associated with depression. One of them is medical costs that are incurred including diagnosis and treatment of the patient. Another financial cost is the loss that is experienced due to inability of a depressed individual to carry out their duties in the place of work (Aschenbrenner & Venable, 2012). These financial costs result in financial strains for the patient, their family, and the community in general.
Best Practices
The best practices for managing depression are the non-drug treatments. They comprise of cognitive behavioral therapy, problem-solving therapy, and interpersonal care. There are a number of ways in which these practices can be promoted in healthcare organizations. They include training clinicians and creating awareness among healthcare professionals about the importance of these practices in managing depression (Aschenbrenner & Venable, 2012).
Strategies to Implement Best Practices
Various strategies can be used to implement the best practices for managing depression. For example, assigning roles and responsibilities to various individuals, putting in place structures that enhance implementation, and creating team responsibilities (Karg, Burmeister, Shedden, & Sen, 2011). Creating roles and responsibilities for people will ensure that each person takes part in the implementation while having structures in place would help people to easily implement the plan put in place. Team responsibilities, on the other hand, will enhance coordination among the implementers.
Evaluation Method
The evaluation method that should be used to analyze the implementation of the above mentioned strategies is observation. Observation will enable one to determine whether the strategies have been implemented or not. The evaluation should be carried out against an observation list (McCance & Huether, 2014). Use of observation is advantageous since it helps to determine the actual situation on the ground rather than relying on information provided by other people.
Conclusion
Generally, while depression is mostly connected to life events, it has medical implications for the victims. Various biological mechanisms could be responsible for the development of depression. They include upregulation of inflammation, hyperactivity of the hypothalamic-pituitary (HPA) axis, low levels of vitamin D, and reduced neurotropic growth. Depression does not only affect the patient but also family members and the community in general. As such, strategies should be put in place to control it. Some of the interventions that can be used include medication and psychotherapy.
References
Aschenbrenner, D.S., & Venable, S.J. (2012). Drug therapy in nursing (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. ISBN-13: 978-0-781-765879
Fournier, J. C., DeRubeis, R. J., Hollon, S. D., Dimidjian, S., Amsterdam, J. D., Shelton, R. C.,& Fawcett, J. (2010). Antidepressant drug effects and depression severity: A patient-level meta-analysis. Jama, 303(1), 47-53.
Karg, K., Burmeister, M., Shedden, K., & Sen, S. (2011). The serotonin transporter promoter variant (5-HTTLPR), stress, and depression meta-analysis revisited: Evidence of genetic moderation. Archives of general psychiatry, 68(5), 444-454.
McCance, K.L., & Huether, S.E. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, Missouri: Mosby Elsevier. ISBN: 978-0-323- 08854-1
Rayner, L., Price, A., Hotopf, M., & Higginson, I. J. (2011). The development of evidence-based European guidelines on the management of depression in palliative cancer care.European Journal of Cancer, 47(5), 702-712.
