The rampantness of neuropsychiatric condition increases everyday with people. It is increasing with pressures of work and stress, and this puts exposed people more at risk of neuropsychiatric diseases. The combination of several variables causes the disorder of central nervous system (CNS) level. Causes of abnormal mood changes are idiopathic but health, stress and hormonal changes are risk factors along with genetic factors and lifestyle practices like alcohol can make one susceptible to the disroder. Some other conditions that might happen are:
i) major depressive disorders;
ii) disruptive mood dysregulation disorder;
iii) persistent depressive disorders;
iv) depressive disorders caused by other medical illnesses;
v) premenstrual dystrophic disorder;
vi) depressive disorders due to medication or substances;
vii) other unspecified causes.
From the above list, the main and most prevalent are the mood depressive disorders (MDD) which have a worldwide prevalence, in the general population, of 20% (Brigitta, 2002). The condition In the United States alone, the disorder has an annual prevalence of 7% with the cases being 1.5 to 3-fold higher in females than males (American Psychiatric Association, 2013). A clear factor that predisposes women to greater chances of being depressed is the fluctuation in hormonal levels and genetic factors. In additions, women tend to live longer til old age where the disease has a higher occurrence rate than in former years. Mood depressive disorders tend to occur in all age groups including children and the aged. However, individuals between 18 years and 29 years are three times more likely to be depressed than individuals who are 60 years and above (American Psychiatric Association, 2013). Youths are more active than grown-ups due to their young ages and their vibrancy. Some of the risk factors for mood depressive disorders include temperamental factors, environmental, genetic and psychological factors, and nonmood disorders. Neurotic or negatively affective individuals are at a higher risk of being depressed as a response to stressful and adverse life events from one's environment (American Psychiatric Association, 2013). Also, people related in a first-degree manner to individuals who have the disorder tend to be two to four times more predisposed than the general population (American Psychiatric Association, 2013). American Psychiatric Association (2013) continue to add that heritability of mood depressive disorders stands at 40% with other nonmood disorders such as substance abuse, personality disorders and anxiety being modifiers of the disease. Additionally, chronic conditions such as diabetes, cardiovascular diseases, and obesity increase the risk of the disorder as suggested by American Psychiatric Association (2013).
Pathophysiology
Two hypothesis have explained the development and progression of major depressive disorders. The two hypothesis include the monoamine hypothesis and the neurotrophic hypothesis which have revealed the great complexities surrounding MDD pathophysiology. The two hypothesis will be studied below:
Neurotrophic Hypothesis
Brain-derived neurotrophic factor (BDNF) is involved in offering neuronal survival and neuronal growth by activating a type of receptors in neurons and glia known as tyrosine kinase receptor B (Katzung, Masters, & Trevor, 2012, p. 522). Studies have shown that pain and stress are linked to a drop in BDNF brain levels which causes a loss in neurotrophic support leading to atrophic changes in brain regions such as the hippocampus, anterior cingulate and the medial frontal cortex (Katzung, Masters, & Trevor, 2012, p. 522). The hippocampus is known to be involved in control contextual memory and the hypothalamic-pituitary-adrenal axis while the medial frontal cortex controls emotions, learning, and memory. Attention functions and emotional stimuli are integrated by the anterior cingulate. Depression has been associated with a loss in volume of these three regions leading to an increase in the persistence of the disease (Katzung, Masters, & Trevor, 2012, p. 523). Animal studies have revealed antidepressant-like effects following the direct infusion of BDNF into the midbrain and the hippocampus (Katzung, Masters, & Trevor, 2012, p. 523). In humans, depression has been associated with a decrease in the activity of tyrosine receptors while BDNF levels fall significantly (Katzung, Masters, & Trevor, 2012).
Monoamine Hypothesis and other Neurotransmitters
The hypothesis links depression to the deficiency of norepinephrine, serotonin, and dopamine in the limbic and cortical regions of the brain (Katzung, Masters, & Trevor, 2012, p. 523). Reserpine, which is a monoamine-depleting drug, has been shown to cause depression thus offering evidence to the hypothesis. Relapse of depression occurs in previously depressed patients who are undergoing treatment with antidepressants like fluoxetine when given diets deficient in serotonin precursors such as tryptophan (Katzung, Masters, & Trevor, 2012, p. 523). Also, to support this hypothesis, all antidepressants function by increasing the availability of serotonin and catecholamine in the synapses (Katzung, Masters, & Trevor, 2012, p. 523). Apart from the two hypothesis, hormonal abnormalities also play a role in mood depressive disorders. Abnormalities in the HPA axis have been linked to the disorder. As a result, there have been high levels of cortisol, adrenocorticotropic hormone, and corticotropin-releasing hormone during the depression (Katzung, Masters, & Trevor, 2012, p. 524). Thyroid dysregulation has also occurred in 25% of patients presenting with depression which included reduction of the activity of thyrotropin-releasing hormone on thyrotropin and an increase in thyroxine levels during the depression (Katzung, Masters, & Trevor, 2012, p. 525). Estrogen and testosterone deficiency in women and men respectively have also been linked to depressive symptoms.
Pharmacological Treatment
Treatment of major depressive disorders can be carried out in phases depending on the severity of the symptoms, presence of psychological stressors co-occurring disorders. In the acute phase, the aim of medication is to instill remission of the MDD episodes so that the patient can return to baseline level of functioning (American Psychiatric Association, 2010). The phase lasts at least 6-12 weeks. Before initiating treatment, factors to be considered include patient experiences such as side effects and other preferences of the patient, half-life of the drug, drug interactions, cost, and safety (American Psychiatric Association, 2010, p. 31).The optimal medications for most patients include serotonin-norepinephrine reuptake inhibitor (SNRI), selective serotonin reuptake inhibitor (SSRI), bupropion and mirtazapine (American Psychiatric Association, 2010, p. 17). Examples of SSRIs include drugs like fluoxetine, fluvoxamine, and citalopram while SNRIs include venlafaxine, duloxetine, and desvenlafaxine. Monoamine oxidase inhibitors (MAOIs) such as phenelzine should only be used in patients failing to respond to other medications due to the dietary restrictions following their use (American Psychiatric Association, 2010, p. 17). Upon the patient's request, optional therapies include St. John's wort and S-adenosyl methionine (SAMe) (American Psychiatric Association, 2010, p. 17). After a successful acute phase treatment, a continuation phase that lasts for about 4-9 months should be instituted (American Psychiatric Association, 2010, p. 56). The phase ensures that relapse does not occur. In this phase, the successful 12- week acute phase medication should be continued at the same dosage with limited randomized controlled trials (American Psychiatric Association, 2010, p. 56). A maintenance phase follows the successful continuation phase. The phase is essential in patients with chronic or recurring depressive states and has successfully gone through the continuation phase. The medication used in the previous phases should be continued. The above remedies contribute effective remission of mood depressive disorders in the community. Assessment, Diagnosis and Patient Education To establish a definitive and accurate diagnosis, patients should receive thorough assessments from the psychiatrist or attending physician. Such a comprehensive assessment includes the following: a history of the current symptoms and presenting illness; a psychiatric history; 3) social history; 4) a family history; 5) occupational history; 6) a medication history; 7) review of body systems; and 8) relevant diagnostic tests (American Psychiatric Association, 2010, p. 15). For diagnosis, at least 5 of the following symptoms need to have been present over the past two weeks to qualify it as a mood depressive disorder: 1) depressed mood during the day marked with sadness, hopelessness or tearful states; 2) a reduction in interests in activities; 3) significant weight gain or weight loss; 4) lack of sleep or excessive sleep; 5) psychomotor retardation; 6) loss of energy or fatigue; 7) poor concentration or reduced ability to think or indecisiveness; 8) a feeling of worthlessness or inappropriate guilt; and 9) suicidal ideation with recurring thought about death (American Psychiatric Association, 2013) The symptoms need to have occurred during most of the day. Proper education to patients and adherence to guidelines by clinicians should be followed. Apart from the normal face-to-face instructions offered to patients and caregivers, printed forms such as pamphlets, books and websites can also be employed by the clinicians. Patients should receive guidance on how to effectively use medication and change from one drug to another. Misconceptions and side effects of antidepressants should be elaborated before and during pharmacotherapy. Healthy lifestyle behaviors and feeding habits such as exercised and balanced diets should be imparted on patients to ensure full remission. The standards of practice at the state and national level are harmonized to ensure effective therapies thus ensuring that disparities in national health are reduced to almost nil. Patients who are experiencing MDD tend to have characteristic lifestyles which allow them to effectively manage their mental condition. First, such patient has access to insurance plans or Medicaid schemes which allow them to pay for the frequent hospital visits (Rhodes, 2008). The patient-doctor relationship that is fostered also accords proper management and assessment during the visits which should be frequent (Katon, 2011). Hospital emergency departments serve as the primary location where most depression illness patients first report (Rhodes, 2008). Proper referrals should be made by the ED doctors to relevant primary health care which must include qualified primary caregivers. Apart from pharmacological therapies, patients can choose between different treatment modalities which include electroconvulsive therapy; psychotherapies such as group and family therapy; transcranial magnetic stimulation; and vagus nerve stimulation (American Psychiatric Association, 2010, p. 17). Mood depressive disorders tend to reduce life expectancy by about 11 years while 30%-40% of patients develop resistance to treatment (Qureshi & Al-Bedah, 2013). Disparities exist in the treatment of depression in various countries and at a national level. Nationally, the stratification of individuals into different status has led widening the gap between the poor and the rich. Those that have the economic ability can access insurance facilities and special attention in private facilities while the less privileged are left struggling with high hospital bills. The difference in provider behavior nationally also accounts for the national disparities (Link, et al., 2011). Internationally, the difference in prevalence of the disease leads to variations in the management methods. The variation emanates from the diagnosis process, medication prescription and the referral habits of various countries. For instance, German doctors are more likely to diagnose the disease in women than American doctors who diagnose the disorder more in men (Link, et al., 2011). The referral of patients to professional mental health doctors is a common practice in Germany than in the United States (Link, et al., 2011). Factors Encouraging Remission Among the most critical factors is the access to finances which translates to better health care. Individuals who cannot afford private medical care get the attention from public hospitals. The level of medical intervention does not vary since similar assessment and diagnosis guidelines are implemented in all hospitals. Despite this, patients with limited financial resources are limited to the number of medication which can be accessed thus impacting negatively on remission. Secondly, insurance policies help cover patients during emergency medical states (Rhodes, 2008). Lack of insurance policies leads to unaffordable medical expenses which impede medical intervention. Additionally, medical schemes such as Medicaid are being implemented to help cover patients from medical emergencies (Rhodes, 2008). The aid strives at equalizing health care by eliminating disparities in the access of quality medical interventions. Admission to the most relevant health facilities remains to be a critical step in diagnosis and disease management. It is imperative for patients to get admissions to the right medical centers so as to access professional health services that are focal on managing depressive mental disorders. Patients with unmanaged mood depressive disorders enter a state of chronic and recurring episodes. Symptoms become magnified as the frequency presentation increases. Suicidal ideation and thoughts about death punctuate the lives of such patients. Other characteristics include lack of motivation and loss of interest in activities in most of the day, alteration in sleep patterns with insomnia and excessive sleep during abnormal hours of the day (American Psychiatric Association, 2013). Guilt increases in the lives of the unmanaged patients leading to feelings of worthlessness together with altered concentration and decision-making skills (American Psychiatric Association, 2013). The Burden of Mood Depressive Disorders As noted, depression has a higher prevalence in young individuals than in old-aged elders. The economy and financial state of the patient, the family, community, and the nation stand to lose from this illness. The cost of buying medication and paying for clinical assessments impacts greatly on the patient. After the patient loses the financial ability, they turn to family members who end up in the same state. Economic activities that once acted as a source of income become neglected due to loss of physical strength for execution. It is estimated that the rate of depressed people with impaired daily functioning stands at 8% while more than 5 hours of productivity are lost by depressed individuals every week (Leahy, 2011). On average, by the age of 50 years, a depressed individual tends to lose $10,400 every year with a 35% reduction in lifetime income (Leahy, 2011). On a national level, the country loses up to $83 billion annually to the menace of depression. The cost of depression is far-reaching to all sectors of the economy, not only on an individual level. Due to this, some families have entered bankruptcy while others break as a means for survival. Development of the community has lagged due to the lack of manpower for city and state projects. Health Promotion Practices To alleviate the suffering brought about by depression, some strategies can be adopted to empower and equip the community. Education is pivotal in ensuring and creating awareness at a national and state level. Written sources can be used to supplement verbal pieces of advice from medical practitioners (American Psychiatric Association, 2010). Magazines and websites can be created to ensure interactive exchange of information. In healthcare facilities, education points can be set up where people can access professional advice for free. Initiation of campaigns to create awareness can also be employed. Collaboration with various recreation activity bodies, for instance, sporting agencies and the entertainment industry will help publicize the information related to depressive mood disorders. To evaluate the implementation of these strategies, constant diagnosis and screening for depressive disorders will be carried out in the states where the strategies have been implemented. The results will be analyzed constantly to note the trend which will offer insight into the effectiveness of the strategies. Necessary amendments will be implemented depending on findings.
References
American Psychiatric Association. (2010). Practice guideline for the treatment of patients with major depressive disorder. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association. Brigitta, B. (2002). Pathophysiology of depression and mechanisms of treatment. Dialogues in Clinical Neuroscience, 4(1), 7-20. Katon, W. J. (2011). Epidemiology and treatment of depression in patients with chronic medical illness. Dialogues Clin Neurosci, 13(1), 7-13. Katzung, B. G., Masters, S. B., & Trevor, A. J. (2012). Basic & clinical pharmacology. New York [u.a.:: McGray-Hill Medical. Leahy, R. (2011, May 25). The Cost of Depression. The Huffington Post. Link, C., Stern, T. A., Piccolo, R. S., Marceau, L. D., Arber, S., Adams, A., . . . McKinlay, J. B. (2011). Diagnosis and management of depression in 3 countries: results from a clinical vignette factorial experiment. Primary Care Companion CNS Disorders, 13(5). Qureshi, N. A., & Al-Bedah, A. M. (2013). Mood disorders and complementary and alternative medicine: a literature review. Neuropsychiatric Disease Treatment, 9, 639-658. Rhodes, K. V. (2008). Mood disorders in the emergency department: the challenge of linking patients to appropriate services. General hospital psychiatry, 30(1), 1-3.
