Page 16 Complete Your CE Test Online - Click Here that has persisted for at least two years in adults and one year in children and adolescents. Affected persons may also experience fatigue, lack of energy, difficulty concentrating, insomnia, lack of appetite or overeating, feelings of hopelessness, difficulty making decisions, and low self-esteem. Dysthymic disorder is diagnosed when the client exhibits at least two of the preceding symptoms lasting no more than two months during a two-year period. The disorder usually begins in children, adolescence, or early adulthood, is more common in women in adulthood, and equally common in both sexes in children and adolescents. Dysthymic disorder causes no more than mild social or occupational problems (National Institute of Mental Health, 2016). Risk factors Major depressive disorder is one of the most common mental disorders in the United States, affecting a significant portion of the general population. About 6.7% of adults in the United States experience a major depressive order every year (National Institute of Mental Health, 2016). Other factors that can influence the development of depression include (Durkin, 2013; National Institute of Mental Health, 2016; Videbeck,2017). ● ● Women are more than 70% more likely than men to experience depression during their lifetimes. ● ● Non-Hispanic black people are 40% less likely than non-Hispanic white people to experience depression during their lifetimes. ● ● Some research studies indicate that genetics and family history of depression increases its risk of development. ● ● Exposure to physical and/or emotional trauma can trigger depression. ● ● People with PTSD are especially likely to have coexisting depression. ● ● People dealing with serious and/or chronic physical disease are prone to depression. ● ● Research findings show that mood disorders such as depression and substance abuse often occur together. Nursing consideration: MRIs and other brain-imaging technologies have shown that the parts of the brain involved in mood, thinking, sleep, appetite, and behavior appear different in people who have depression than in those who do not have depression (National Institute of Mental Health, 2016). Nurses must facilitate the advancement of technology as a mechanism to identify causes and treatments for depression and other mental health disorders. Signs and symptoms Persons who are depressed may say that they find it hard to get out of bed in the morning, have trouble falling asleep or staying awake, and/or have no interest in activities that were once important to them (Durkin, 2013; National Institute of Mental Health, 2016). People with depression do not all experience the same symptoms. The number, frequency, and duration of symptoms varies depending on the person. The primary symptoms of major depression are a predominantly sad mood and a loss of interest in, or inability to experience pleasure in, daily activities (Durkin,2013; Videbeck, 2017). Other signs and symptoms include (Durkin, 2013; National Institute of Mental Health, 2016; Videbeck, 2017): ● ● Aches, pains, and headaches that do not improve even with treatment. ● ● Difficulty concentrating. ● ● Digestive problems that do not decrease with treatment. ● ● Fatigue and lack of energy. ● ● Feelings of guilt, helplessness, or worthlessness. ● ● Feelings of hopelessness or pessimism. ● ● Irritability. ● ● Loss of appetite or overeating. ● ● Loss of interest in once enjoyable activities. ● ● Loss of interest in sex. ● ● Persistent feelings of anxiety, sadness, or emptiness. ● ● Restlessness. ● ● Signs of agitation such as hand wringing. ● ● Suicidal ideation. Diagnosis To confirm a diagnosis of major depression, veterans and other clients must fulfill the criteria as published in the DSM-5. A summary of these criteria includes the following information (American Psychiatric Association, 2013). The client must experience five or more of the following symptoms during the same two-week period and be indicative of a change from previous functioning. At least one of the symptoms must be either depressed mood or loss of interest or pleasure. ● ● Depressed mood most of the day, almost every day, as evident by subjective reporting of feelings of sadness, emptiness, or hopeless, or observations made by others. ● ● Significant diminished interest or pleasure in all, or nearly all, activities most of the day, nearly every day. ● ● Significant weight loss when not dieting, or weight gain or decrease or increase in appetite nearly every day. ● ● Insomnia or hypersomnia nearly every day. ● ● Psychomotor agitation or retardation almost every day. ● ● Fatigue or loss of energy almost every day. ● ● Feelings of worthlessness or excessive or inappropriate guild nearly every day. ● ● Diminished ability to think or concentrate or indecisiveness, nearly every day. ● ● Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide. The symptoms that the client is experiencing cause significant distress or impairment in social, occupational, or other important areas of functioning. The episode (major depression episode) is not due to the physiological effects of a substance or to another medical condition. Additional restrictions related to a diagnosis of major depression include (American Psychiatric Association, 2013): ● ● The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. ● ● There has never been a manic episode or hypomanic episode. Treatment The most common treatments for depression are medication and psychotherapy (Durkin, 2013; National Institute of Mental Health, 2016; Videbeck, 2017). Medication. Nursing consideration: It can take weeks or even months for significant improvement in symptoms to occur after beginning antidepressant medications. Clients and their families should be taught that they should not expect immediate improvement of symptoms (Comerford, 2018; Videbeck, 2017). SSRIs: ● ● SSRIs are effective for most clients and are the newest classification of antidepressants. The action of SSRIs is believed to be linked to their inhibition of central nervous system (CNS) neuronal uptake of serotonin. This class of antidepressant is generally considered safe, but can interact with some commonly prescribed medications, especially those that also block serotonin reuptake, including, but not limited to: some pain medications, anti-Parkinson’s medications, other antidepressants, and some anti-nausea medications. The use of more than one medication that acts on or affects the amount of available Serotonin in the system can lead to Serotonin Syndrome (see below). One medication this phenomenon has been studied in is Tramadol (National Institute for Health and Care Excellence, 2016). Commonly prescribed SSRIs include Prozac (fluoxetine), Zoloft (sertraline), Lexapro (escitalopram), Paxil (paroxetine), and Celexa (citalopram). Common side effects of these drugs include headaches, nausea, restlessness, insomnia, and sexual problems (Comerford, 2018; Durkin, 2013; Videbeck, 2017). ● ● Tricyclics are older antidepressants, which are powerful but not often used in current practice because their side effects have the potential