Nursing Interventions for Depression In Female
Depression in Women
Women seeking help in the general health care sector often are depressed. Studies indicated that between 20% to 45% of women using primary care have major depressive disorder (MDD) ( Bixo , Sundström-Poromaa , Björn, & Åström , 2001; Hauenstein , 2003; Kirmayer & Robbins, 1996; Miranda, Azocar, Komaromy & Golding, 1998).
In these settings, patients are more likely to report their depressive symptoms as physical problems (Barsky, Peekna , & Borus , 2001; Katon , Sullivan, & Walker, 2001) and physicians less likely to identify and treat the disorder ( Freiman & Zuvekas , 2000; Katz et al., 1997; Sundstrom , Bixo , Björn, & Astrom , 2001).
Nurses are positioned to
detect and manage this major public health problem because of their prominence
in the general health sector and their often-greater proximity to patients.
Significant Source of Morbidity and Disability in Women
MDD remains a significant source of morbidity and disability in women under 65. The physical symptoms of lethargy and sleep and appetite disturbance combine with the cognitive symptoms of disinterest, helplessness, hopelessness, and worthlessness to exact both significant mood disturbances and functional impairments.
Unfortunately, MDD is common among women. The population prevalence of MDD in women is 6% to 17% (Kessler et al., 2003). Combined with dysthymia, a milder but more chronic and equally disabling mood disorder, the population prevalence ranges from 12 to 25%, a rate twice that of men (Kessler, 2003).
Women's key risk factors for MDD include a family history of the disorder, single parenting, a history of child abuse, implementation, and poorer educational achievement (Brown & Moran, 1997; Hanson et al., 2001; Kessler et al., 1994; Kessler et al., 2003; Weiss, Longhurst, & Mazure , 1999).
Social discrimination and sexual harassment also contribute. to the preponderance of MDD in women. Marginalized women have the highest rates of MDD (Brown, Schulberg , Madonia , Shear, & Houck, 1996; Hauenstein & Peddada, in revision; Miranda et al., 1998).
While MDD is present in elderly women, the highest incidence of the disorder occurs in women 25 to 34, a time when women are developing both their work and family careers.
Depressed women have higher rates of unemployment or partial employment, absenteeism, poor work productivity, and fail-to progress in their work careers. This translates to an estimated annual cost per employer of almost $10,000 for every depressed woman working in the firm (Birnbaum, Leong, & Greenberg, 2003).
Mood disorder also impairs women's family careers ( Gotlib , Lewinsohn , & Steely, 1998; Wade & Cairney, 2000). Depressed women are more likely to divorce than are unaffected women, and divorced women tend to be economically disadvantaged. Divorced women often are responsible for young children, and raising these children alone is difficult.
These work and family patterns associated with MDD contribute to a cycle of hopelessness, worthlessness, and poverty that promotes a chronic and recurrent course of MDD that is refractory to treatment.
This is a global phenomenon non; the World Health
Organization Global Burden of Disease study showed that MDD was the leading
cause of disease related disability in women (NIMH Research on Women 's Mental
Health-Highlights FY2001-2002).
Depression And Effect
Maternal depression also has significant effects on children, Research has shown cognitive and social deficits in children of depressed mothers that appear early in infancy (Essex, Klein, Cho, & Kalin, 2002; Field, 1998; Kaplan, Bachorowski , & Zarlengo Strouse, 1999).
These deficits persist into
childhood and adolescence and have chronic effects on personal, school, and
social functioning (Essex, Klein, Miech , & Smider , 2001; Gotlib et al.,
1998; Murray, Sinclair, Cooper, Ducournau , & Turner, 1999 ; Oyserman ,
Bybee, & Mowbray, 2002).
Biological And Psychological Factors
A complex interaction of biological, psychological, and social factors contributes to MDD in women. Gender disparities in the occurrence of MDD and its coincidence with women's hormonal changes point to estrogen as a physiological mechanism in women's depression ( Shors & Leuner , 2003; Steiner, Dunn, & Born, 2003).
Gonadal hormones are thought to alter
neurotransmitter functioning and learning resulting in more affective symptoms
and non-responsiveness in stressful circumstances. There is mounting evidence
that childhood trauma such as sexual abuse can alter
hypothalamic-pituitary-adrenal axis (HPA) functioning and increase
vulnerability to future depression (Putnam, 2003).
Hormonal Effect Causing Depression
Hormonal factors alone do not precipitate MDD in women (Kessler, 2003). The unstable HPA system is affected by women's psychological and social environment, which may serve to precipitous physiological events.
For example, animal models show that female rats when exposed to uncontrollable stress will fail to respond in subsequent controllable stress situations, a response style not shared by males ( Shors & Leuner , 2003).
Interpersonal distress is one example of uncontrollable stress. Research has shown that women locked in dysfunctional relationships for economic or other reasons are more likely to have recurrent depressive episodes (Hammen, 2003).
Pessimistic thinking arising from low self-esteem also has been associated with depressive symptoms in women ( Peden , Hall, Rayens , & Beebe, 2000). Not surprisingly, MDD is more common among women who exhibit dependent personality traits ( Widiger & Anderson, 2003).
Despite progress in reducing gender discrimination, many women's social environment contributes to MDD by stripping them of personal power. Early victimization contributes to victimization as adults. Low self-esteem increases the likelihood of an early and often unstable marriage that leads to divorce.
Divorce is associated with economic hardship and single parenting. Victimization, marital instability, single parenting, and economic hardship have all been associated with often intractable depression (Bauer, Rodriguez, & Pérez-Stable, 2000; Brown & Moran, 1997; Earle, Smith, Harris, & Longino , 1998; Gotlib et al., 1998; Kessler, Walters, & Forthofer , 1998; McCauley, Kern, Kolodner , Derogatis , & Bass, 1998; Petterson & Albers, 2002; Scholle, Rost , & Golding, 1998; Wade & Cairney, 2000).
While the evidence for these associations is convincing, the reciprocal
relationship between MDD and the social condition of women is far less
understood and is an area of needed research.
Evidence Based Treatment of Depression
Evidence-based treatments for MDD include pharmacotherapy and psychotherapy. Minimum treatment includes 2 months of an antidepressant at a dose known to be efficacious in treating MDD or at least eight visits to a specialty mental health provider that last a minimum of 30 minutes each (Kessler et al., 2003; Young, Klap , Sherbourne , & Wells, 2001).
The data show that minimum treatment can affect remission in the short-term but the extent to which there are long-term benefits is yet to be determined. There is significant evidence, however, that few receive even this minimum level of care (Kessler et al.; Wang, Berglund, & Kessler, 2000).
While there are few large trials focusing specifically on women, three studies using evidence-based treatments have demonstrated modest treatment effects with both urban and rural women attending primary care ( Hauenstein , 2003; Miranda, Nakamura, & Bernal, 2003; Pyne et al. , 2003).
The multifactorial nature of depression in women, however, may require different or more complex psychological and social interventions than those that meet the minimum standards for depression treatment. Many of the psychotherapies are considered gender neutral but few studies address gender differences in outcome.
One example where gender differences in outcome were examined is that by Pyne and his group who used a simple, nurse-managed intervention, which included tailoring known efficacious treatment to the preferences of the patients and regular telephone follow-up. The treatment was cost-effective in women, but not in men, when quality of life was evaluated as the outcome.
Gender-specific treatments might target psychological and social factors known to exacerhate depression in women. For example, because of the reciprocal effect of marital instability and MDD, interventions that focus on reducing interpersonal distress and spousal conflict may be especially promising for women ( Hammen , 2003; Wade & Kendler, 2000; Worell , 2001).
Interventions
that stimulate positive life change also may work preferentially in women
(Albertine, Oldehinkel , Ormel , & Neeleman , 2000). Treatment for MDD
driven by gender-specific theories based on women's own voices and experiences,
and the diversities and complexities of women's experience may promote recovery
instead of simply remission ( Eun -Ok & Afaf Ibrahim, 2001; Worell , 2001).
Recommendations For Research On Depression
Recommendations for needed research on MDD in women have been enumerated by the American Psychological Association and the Office of Women's Health at the National Institutes of Health ( Mazure , Keita, & Blchar , 2002; US Department of Health and Human Services, 19995).
Recommendations for research range from bench research to public education. Research focused on treatment approaches is especially relevant to nursing. First, gender-specific treatments for MDD need to be developed and tested.
Treatments must be based on the unique biological, psychological, and social conditions of women generally, and tailored to the needs of ethnically diverse women and those indirect social circumstances. The design of treatment programs should target recovery, not simply symptom remission.
Second, research on treatment outcome requires evaluation of multiple areas of functioning including marital stability, parenting, and work productivity.
From a policy perspective, MDD in women will not become a priority until the impact of MDD at the family and community level is realized and the effects of adequate treatment are determined. Third, attention must be paid to the provision of treatment that is accessible.
Health services research in this area should consider novel venues and providers. For example, treatment services for women could be moved to the community in places where women commonly gather, such as churches, schools, and community centers.
Because mental health care is a dwindling commodity it is important to consider non specialty professional and lay providers.
Nurses can be pivotal here, both in
providing direct service and in organizing and supervising lay providers. Research
paradigms that develop and test alternative health delivery methods will go far
in closing the gap between need and treatment.
Give your opinion if have any.