Depression

The World Health Organization (2023) estimate that 5% of adults worldwide are living with depression, and that it is the leading cause of disability globally. Depression is twice as common in women than men, affecting one in six adults at some stage in their lifetime (Otte et al, 2016).

Depression is not the same as short-lived mood changes. People with short-lived mood changes will respond according to situations and the events happening around them. Depression may lead to suicide and is the fourth leading cause of death in people 15–29 years old worldwide (World Health Organization, 2023).

Depression takes many forms and in some cases, has a discernible cause, for example postpartum depression or seasonal affective disorder (National Institute for Health and Care Excellence (NICE), 2023). It should not be confused with normal psychological processes such as bereavement-related grief or other disorders, eg dementia (NICE, 2023). Depression can also be

Depression involves a continuum of signs and symptoms where the individual has a loss of positive affect, which refers to a loss of interest and enjoyment in life (anhedonia), a low mood and other emotional, physical and cognitive symptoms (NICE, 2022).

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) an individual displaying a major depressive episode would have symptoms such as:

• a depressed mood
• loss of interest in activities

Other common symptoms include:

• a changed appetite or body weight
• disturbed sleep
• fatigue
• feeling worthless and/or guilt
• diminished ability to concentrate
• suicidal thoughts (American Psychiatric Association (APA), 2013)

Nurses should be aware that there is some evidence that men and women report their symptoms of depression differently. For example, depressed men may report:

• harmful alcohol or drug use
• a high frequency of risk taking and poor impulse control

While women may report a higher frequency of:

• depressed mood

There is no single cause of depression; its aetiology is often multifactorial with about one-third of cases having an apparent hereditary element (Otte et al, 2016). Lifetime experiences are strongly associated with the development of depression. Strong associations exist between the development of depression and:

• bereavement
• disability and/or medical illness
• childhood abuse
• refugee status
• stressors in the workplace
• obesity
• lack of social support (Coulter et al, 2017)

There is also an association between socioeconomic status and depression. However, the evidence for this is equivocal (Coulter et al, 2017). More recently, COVID-19 and the pandemic have also had a prevalent negative affect on people's mental health.

The DSM-5 identifies several classifications of depression which are related to life events and physiological functions including bereavement, disruptive mood dysregulation disorder and premenstrual dysphoric disorder (APA, 2013).

People living with major depressive disorder may also display changes in the brain, including changes to the

Nurses should be more alert to the possibility of a diagnosis of depression in individuals who have had a previous diagnosis of depression (MacKinnon, 2024) or those living with a chronic condition which limits their functionality (NICE, 2009).

The severity of depression is categorised as:

• subthreshold
• mild
• moderate
• severe

Mild depression accounts for 70%, moderate 20% and severe 10% of all cases of depression (NICE, 2023).

Severity of depression can be composed of three elements:

• symptoms (frequency and intensity)
• duration
• impact (on personal and social functioning) (NICE, 2022)

According to the DSM–5, to be diagnosed with major depressive disorder, a patient must have at least five of the following symptoms for at least 2 weeks and be experiencing significant impairment in their ability to function; at least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.

• Depressed mood most of the day,

It is important for clinicians to develop and maintain a trusting and non-judgemental relationship with those affected by depression (NICE, 2022). Such relationships need to be built on positivity and optimism.

People living with depression need information and support so that they can understand and work through their symptoms. NICE (2011) identify how working with people experiencing any mental health issue requires a partnership approach to care. Such approaches help to:

• develop autonomy
• promote participation
• support self-management

It is important that nurses working with people living with depression make sure discussions take place in settings where confidentiality, privacy and dignity are respected. Nurses should also be clear about the limits of confidentiality, which social and health care professionals may have access to the patient’s information and in what circumstances this may be shared with others, for example, if there is a risk of harm to self or others (NICE, 2011).

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1: Procedures for assessing people’s needs for person-centred care

1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages

1.1 mental health and wellbeing status

Part 2: Procedures for the planning, provision and management of person-centred nursing care

11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th edn. American Psychiatric Publishing, Inc; 2013

Borglin G, Räthel K, Paulsson H, Sjögren Forss K. Registered nurses experiences of managing depressive symptoms at care centres for older people: a qualitative descriptive study. BMC Nurs. 2019;18(43). https://doi.org/10.1186/s12912-019-0368-5 

British National Formulary. Antidepressant drugs. 2024. https://bnf.nice.org.uk/treatment-summaries/antidepressant-drugs/ (accessed 6 February 2024)

Cavanagh A, Wilson C, Kavanagh D, Caputi P. Differences in the Expression of Symptoms in Men Versus Women with Depression: A Systematic Review and Meta-analysis. Harv Rev Psychiatry. 2017;25(1): 29-38. https://doi.org/10.1097/HRP.0000000000000128 

Cipriani A, Furukawa TA, Salanti G et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet. 2018;391(10128):1357-1366. https://doi.org/10.1016/S0140-6736(17)32802-7 

Loh HH, Lim LL, Yee A, Loh HS. Association between subclinical hypothyroidism and depression: an updated systematic review and meta-analysis. BMC Psychiatry. 2019;19(12). https://doi.org/10.1186/s12888-018-2006-2 

López-López JA, Davies SR, Caldwell DM et al. The process and delivery of CBT for depression in adults: a systematic review and network meta-analysis. Psychol Med. 2019;49(12):1937-1947.