EVALUATION OF DEPRESSION CLINICAL PRACTIE GUIDELINES3
Evaluation of Depression Clinical Practice Guidelines
United State University
Common Illness Across the Lifespan:
Depression is a mental disorder characterized by chronically depressed mood and by a lack of pleasure in initially pleasurable activities. It may result in a variety of psychological and physical complications and reduce the ability to operate at work and at home. It is highly prevalent in the US. Despite its increased prevalence, its management has been controversial in the US, with the recommendation that its treatment, both pharmacologic and non-pharmacologic, is effective for about 60 percent of the affected individuals. This underscores the possibility of concluding whether the available guideline is trustworthy. Therefore, it needs further revision to direct the delivery of care to depression patients effectively.
1. Description of Depression
Depression (major depressive disorder) is a common and significant clinical condition characterized by impaired mood, thinking, and behavior. Fortunately, it can be treated. Depression leads to feeling of sadness accompanied by a lack of pleasure in initially pleasurable activities. It may result in a variety of psychological and physical complications and reduce the ability to operate at work and at home (Goldman, 2019). Depression is a kind of mood illness characterized by chronic sorrow and lack of interest. It is distinct from the mood swings that individual encounter on a daily basis. Significant life experiences, such as grief or job loss, may trigger depression. However, psychiatrists consider grieving to be a component of depression only when it persists. Depression signs vary in severity from moderate to severe and the manifestations are as follows
· Depressed mood
· Loss pleasure in previously appreciated activities
· increase or reduced appetite
· increased or reduced sleep
· Energy loss or excessive weariness
· feeling of extreme guilt
· impaired though process, decision making and concentration
· Suicidal or self-harm ideations
Depression is a chronic condition, not a transitory one. It is composed of series lasting at least two weeks. Depression may endure weeks, months, or even years (Goldman, 2019).
2. Epidemiology of Depression
Between 2013 and 2016, 8.1percent of American adults aged 20 and older experienced depression over a two-week period. Women (10.4 percent) were nearly twice as likely to suffer depression as males (5.5 percent). Depression was much less prevalent among non-Hispanic Asian people than it was among Hispanic, non-Hispanic black, or non-Hispanic white individuals (CDC, 2019). Depression prevalence reduced as family wealth grew. Around 80% of persons with depression reported experiencing at least some difficulties at work, at home, or in social situations as a result of their depression. Between 2007–2008 and 2015–2016, the proportion of American adults diagnosed with depression remained stable. Additionally, depression has been to affect the Hispanic and African American communities more than the rest of the United States population. Women have been found to suffer from depression more than their male counterparts. according to the Center for Disease Control (2019), depression has high prevalence in individuals whose income is below the poverty line, and that the prevalence for depression decreases as the amount of income increase (NIMH, 2020).
3. Pathophysiology of depression
Psychological stress and traumatic life experiences early in life are both significant intermediate indicators of depression's development. While stress response suggests consistency or preservation of homeostasis, chronic stimulation of the stress response system may have detrimental or even deadly implications by increased risk of overweight, cardiovascular disorders, depression, as well as other illnesses (Ormel, et al., 2019). The hypothalamic–pituitary–adrenal axis (HPA) and its three major components —hypothalamic neurosecretory cells, pituitary gland, and adrenal cortex—function together to ensure successful adaptation to altered environmental circumstances and activation of the organism's reserves in response to various types of stress. To begin, traumatic situations in one's life are the most powerful triggers of depression. Second, depressive individuals usually have higher cortisol (the human endogenous glucocorticoid) and corticotropin (ACTH) levels in their plasma, urine, and cerebrospinal fluid (Ormel, et al., 2019). Additionally, depressed people have an enlarged hypophysis and suprarenal glands, as well as impaired corticosteroid receptors activity. Increased HPA axis stimulation is reported in 50percent of depressed individuals, and continued antidepressant treatment tends to reduce this stimulation.
Depression is a highly varied condition. Some genetic variability is intrinsic to polygenicity; afflicted people may have diverse configurations of susceptible alleles and healthy persons may also have some of these variations (Ormel, et al., 2019). Depression is a polygenic condition originating from the combined action of multiple genetic variations with separately tiny effect sizes. Defects at particular loci affect strictly defined systems such as conduction of dopamine in the prefrontal brain (Shadrina, et al., 2018). Owing to these mutations, succeeding offspring’s have significant likelihood of experiencing depression.
III. Neurotransmitter Imbalances
In individuals with Depression, Norepinephrine deficiency is related with a loss of positive emotional resources, including decreased enjoyment, motivation, pleasure, attention, vigor, and passion, as well as a loss of self-belief. Depression patients showed impaired Norepinephrine function in the lobar NE, which resulted in anhedonia, a lack of vigor and desire, and other associated depressive manifestations (Liu, et al., 2018).
5-HT deficit in the brain may exacerbate unpleasant feelings associated with Depressive disorders, such as depression, self-criticism, anger, worry, anxiety, aggressiveness, irritation, and isolation. Previous investigations discovered that blood 5-HT levels were considerably lower in individuals with MDD than in control subjects, implying a 5-HT deficit in people with MDD (Phillips, 2017). Similarly, postmortem investigations revealed decreased 5-HT and 5-HIAA levels in the central nervous system of depressive and suicidal individuals (Liu, et al., 2018). Reduced serotonin production over time may add to the increased vulnerability to MDD. Increasing scientific and clinical data establishes a relationship between antidepressant treatments and brain 5-HT systems, indicating that perturbation of central 5-HT systems plays a critical role in the pathogenesis of MDD. The serotonergic malfunction that contributes to the etiology of MDD is mostly due to decreased neuronal 5-HT production and aberrant 5-HT receptor activity.
Dopamine (DA) is a neurotransmitter found in the hypothalamus and pituitary gland that serves as a critical neurobiological substrate for pleasure, focus, desire, psychomotor speed, and the capacity to perceive pleasure, all of which may contribute to human emotion regulation. Depression is characterized by impairments in all of these processes (Liu, et al., 2018). Furthermore, instantaneous bidirectional modulation (suppression or stimulation) of specific midbrain DA neurons modifies several distinct depressed symptoms generated by chronic stress, indicating that mechanisms impacting symptoms of depression modify the limbic DA neuronal programming of action. Additionally, impaired DA neuron activity may result in depressed symptoms such as despair and lack of interest. In individuals with MDD, the amount of DA compounds in the CSF was significantly lower than in control subjects. Inadequate DA receptor activity may culminate to a breakdown of regulation from the prefrontal cortex to the amygdala, leading in amygdala hyperexcitability and the development of stress and abnormal anxiety.
4. Clinical Practice Guideline
Depression management requires a thorough examination and accurate diagnosis. The evaluation should be depended on a thorough history, physical exam, and investigation of the patient's mental status. History should be gathered from all possible sources, most notably family. The diagnosis should be made using the most up-to-date diagnostic criteria (Gautam, et al., 2017). The process of developing a therapeutic plan includes agreeing on the therapy environment, drugs, and psychological therapies that will be employed. Patients and carers may be contacted actively throughout the therapy plan's development. A reasonable, practical, and adaptable therapy plan may be developed to meet the demands of clients and caregivers. Additionally, the treatment plan may be analyzed and updated on a continual basis. A thorough evaluation of the client's suicide risk must be conducted. During the history taking process, suicidal thoughts and other adverse outcomes for suicide such as manic episodes, extreme anxiety, panic disorder, and alcohol or drug misuse must be assessed (Gautam, et al., 2017). In older individuals, it has been shown that the degree of depressive symptoms is a major predictor of suicide thoughts over time. Additionally, the evaluation covers a history of prior suicide tries, as well as the type of previous attempts. Additionally, patients' family histories of suicide should be elicited. Apart from inquiring about suicidal ideations, it is critical to inquire about the extent to which the patient wants to act on the suicidal thoughts as well as the extent to which the individual has formed plans or started to commit suicide during mental status tests.
Many patients who suffer from depression recur. As a result, patients and, if necessary, their relatives may be taught about the danger of recurrence. They may be taught to recognize the warning indications and manifestations of recurrent episodes. Additionally, individuals might be urged to seek appropriate therapy as soon as feasible during a new episode to reduce the probability of a complete recurrence or consequence. Electroconvulsive therapy (ECT), psychosocial therapies and antidepressants, and are the primary treatment choices for depression. Other therapies that are less often used or are utilized in individuals with depression that is resistant to treatment include light therapy, repeated transcranial magnetic stimulation (rTMS), ,transcranial direct stimulation, deep brain activation, vagal nerve activation, and sleep deprivation treatment (Gautam, et al., 2017). Benzodiazepines are often used in conjunction with other medications, particularly during the early period of therapy. Additionally, thyroid supplements and lithium may be utilized as adjunctive therapy in rare circumstances when a patient does not react to antidepressants.
The fact that this guideline begins with assessment of the patient and monitoring, I believe it adequately addresses depression, given the diverse methods of treatment and assessment of the client. Involvement of caregivers and family and education to all of them regarding the management of depression is key of key importance. Management of depressive patients based on this guideline has been effective in controlling the disease. However, this management is rarely found in primary care. This means that individuals are not able to access the care until it is too late and the symptoms too adverse. Using this guideline laid by the American Psychological Association, clinicians and other care providers can follow a stepwise methodology for caring and treatment of depression patients, from assessment, through diagnosis and education to treatment and follow ups. This enables complete recovery of the patient as well as preventing relapse.
Management of depression patients is based on trial methods. this means that different antidepressants are prescribed to manage the disease in trial for which works best for the patient. I feel that this is not effective to try patients on several drugs before they are finally given the drug they could tolerate. This is because the drugs could have adverse effects that can be prevented by secure and selective prescription. Additionally, the effectiveness of nonpharmacological intervention of managing depression is highly depended on the psychotherapist, owing much to their character and personality, as well as skills and expertise acquired during practice. Due to this, it can be difficult to ascertain its effectiveness in managing depression. However, it has been found that medications do not work for all depressive patients, and that only 60 percent of the depressive patients can be treated with drugs (Schimelpfening, 2021)
5. Analysis of the guideline
As mentioned previously that depression medication only account for about 60 percent recovery, it is important to revise the clinical guideline in quest to get a solution that can adequately cure depression. Additionally, non-pharmacologic interventions are not reliable since their effectiveness are dependent on the psychotherapist. There is a need to establish a dependable drug for treatment of depression. This will help to eliminate the try and error practice that is currently being used to manage depression patients. Also, there is need to in cooperate mental health screening in primary care as method of health promotion, in order to identify and treat depression early enough. This calls for a collaborative approach to manage the patient to ensure that the depression is done away with, and that relapses are eliminated. Furthermore, there are several antidepressants used despite the weak evidence for us. it would be important that these drugs are cleared so that only drugs with strong recommendations for use are utilized to manage depressive patients. The new guideline will ensure that there is a standard treatment of depression, and that following this treatment, clinicians are able to manage their patients well, to prevent recurrence of the condition and enhance patient satisfaction
It is critical to examine the efficacy of a new or amended clinical practice guideline to ascertain how it influences patient care, practitioner behavior and knowledge, and the variables that lead to non-compliance, if any. The evaluation findings indicate whether the updated clinical practice guideline achieved the anticipated care outcomes and is helpful in treating and managing depression. The following methodologies are used to assess the updated depression clinical practice guideline's efficiency:
· The first stage in determining the amended guideline's efficacy is to examine potential modifications in care service and practice as a result of the new guideline criteria. This is accomplished by analyzing the conversion of clinical practice and health outcomes in regions with very high levels of guideline promotion to the change in places with low levels of guideline implementation.
· The next stage is to compare the change of healthcare outcomes in regions with a high rate of guideline adoption to those with a low rate of guideline adoption. This may be accomplished by conducting a focus group to highlight the primary factors that affected the guideline's adoption.
7. Learning points
· Depression is a significant psychological disorder facing a large population in the United States, especially the Hispanic population, African American communities, and those whose income is low.
· The current guidelines are not sufficiently addressing the problem of depression since it has been discovered that the current therapeutic measures are only helpful to about 60% of the affected individuals.
· It is important to integrate mental health screening for susceptible individuals in to primary care to facilitate early detection and treatment of depression.
To conclude, depression (major depressive disorder) is a common and significant clinical condition characterized by impaired mood, thinking, behavior and feeling of sadness accompanied by a lack of pleasure in initially pleasurable activities. It may result in a variety of psychological and physical complications and reduce the ability to operate at work and at home. Its pathophysiology ca be explained in terms of neurotransmitter imbalances, genetics and stress. the current guidelines do not adequately address the issue since it is only effective in some people and therefore, they should be revised to ensure that the treatment is effective to all individuals.
CDC. (2019, June 7). Products – Data briefs – Number 303 – February 2018. Centers for Disease Control and Prevention.
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Goldman, L. (2019). Depression: What it is, symptoms, causes, treatment, and more. Medical and health information.
Liu, Y., Zhao, J., & Guo, W. (2018). Emotional roles of mono-aminergic neurotransmitters in major depressive disorder and anxiety disorders. Frontiers in psychology, 9, 2201.
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Ormel, J., Hartman, C. A., & Snieder, H. (2019). The genetics of depression: successful genome-wide association studies introduce new challenges. Translational psychiatry, 9(1), 1-10.
Phillips, C. (2017). Physical activity modulates common neuroplasticity substrates in major depressive and bipolar disorder. Neural Plast. 2017, 7014146. doi: 10.1155/2017/7014146
Schimelpfening, N. (2021). What is the chemistry behind depression? Verywell Mind.
Shadrina, M., Bondarenko, E. A., & Slominsky, P. A. (2018). Genetics Factors in Major Depression Disease. Frontiers in psychiatry, 9, 334.
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