{ "name": "Major Depressive Disorder", "slug": "depression", "url": "https://nursingplex.com/care-plans/depression", "category": "Mental Health & Psychiatric", "summary": "Persistent low mood and anhedonia; suicide screening, activity scheduling and adherence.", "nursing_diagnoses": [ "Risk for suicide", "Hopelessness", "Situational low self-esteem", "Imbalanced nutrition" ], "overview": [ "Major depressive disorder is a mood disorder characterized by at least two weeks of depressed mood or loss of interest and pleasure, accompanied by changes in sleep, appetite, energy, concentration, psychomotor activity and self-worth, and often by thoughts of death or suicide. It is not sadness or weakness; it involves dysregulation of serotonin, norepinephrine and dopamine, altered stress-hormone signaling, genetic vulnerability and psychosocial stressors acting together.", "Presentation varies. Some patients appear tearful and slowed; others are irritable and agitated. Older adults frequently present with somatic complaints, memory difficulty and withdrawal rather than stated sadness, which is why depression is mistaken for dementia. Adolescents often present with irritability, school decline and risk-taking. Anhedonia — the loss of pleasure in previously enjoyed activities — is one of the most consistent findings across ages.", "Safety comes before every other intervention. Suicide risk must be assessed directly and repeatedly; asking about suicide does not plant the idea. Risk can paradoxically rise in the first weeks of antidepressant treatment, when energy and initiative return before mood lifts, giving the patient the capacity to act on thoughts they already had. Most antidepressants take two to six weeks for full effect, which must be taught explicitly or patients stop early and conclude that nothing works." ], "key_facts": [ { "label": "Ask directly", "text": "Assess suicidal ideation, plan, means, intent and prior attempts in plain language. A specific plan with available means is high risk and requires immediate protective action." }, { "label": "Early-treatment risk window", "text": "Suicide risk may increase in the first one to two weeks of antidepressant therapy as psychomotor retardation lifts before mood improves — increase monitoring, don't relax it." }, { "label": "SSRI teaching", "text": "Full effect takes two to six weeks. Do not stop abruptly; discontinuation causes flu-like symptoms, dizziness and irritability." }, { "label": "Serotonin syndrome", "text": "Agitation, hyperthermia, tachycardia, tremor, hyperreflexia and diarrhea — usually from combining serotonergic agents. It is a medical emergency." }, { "label": "MAOI diet", "text": "Avoid tyramine-rich foods — aged cheese, cured and smoked meats, fermented soy, tap beer, red wine — to prevent hypertensive crisis." }, { "label": "ECT", "text": "Effective for severe, treatment-resistant or high-risk depression; expect transient confusion and short-term memory loss after treatments." } ], "nursing_priorities": [ "Establish and maintain physical safety from self-harm.", "Build a trusting therapeutic relationship the patient will actually use.", "Meet basic physical needs: nutrition, hydration, sleep, hygiene, elimination.", "Support medication adherence through the delayed-onset period.", "Gradually restore activity, structure and social connection.", "Challenge distorted thinking and rebuild self-worth at the patient's pace." ], "assessment": { "subjective": [ "Persistent sadness, emptiness, hopelessness or numbness", "Loss of interest or pleasure in previously enjoyed activities", "Guilt, worthlessness, self-blame or feeling like a burden", "Fatigue, difficulty concentrating and indecisiveness", "Thoughts of death, self-harm or suicide, with or without a plan", "Sleep disturbance — insomnia, early morning waking or hypersomnia", "Appetite change with weight loss or gain" ], "objective": [ "Flat or sad affect, poor eye contact, slowed or minimal speech", "Psychomotor retardation, or agitation with pacing and hand-wringing", "Neglected grooming, hygiene and clothing", "Weight change, poor oral intake or dehydration", "Social withdrawal, refusal of activities and isolation in the room", "Score on a validated screening tool such as PHQ-9 and on a suicide risk scale", "Sudden calm or unexplained improvement after severe depression — a possible sign a suicide decision has been made", "Giving away possessions, writing notes, or asking questions about medication lethality", "Constipation, dry mouth, sedation or other medication side effects" ], "related_factors": [ "Neurotransmitter dysregulation and altered stress-hormone signaling", "Genetic and family vulnerability to mood disorders", "Loss, grief, trauma, abuse or chronic stress", "Chronic medical illness, chronic pain, substance use or hypothyroidism", "Negative cognitive patterns and learned helplessness", "Social isolation, unemployment, financial strain and stigma" ] }, "goals": [ "The patient remains free of self-harm throughout the care episode.", "The patient verbally contracts to seek staff or a crisis line before acting on any self-harm thought.", "Sleep, appetite and self-care return toward the patient's baseline.", "The patient participates in at least one scheduled activity or group daily.", "The patient describes the purpose, timing and delayed onset of prescribed medications.", "The patient identifies two coping strategies and two support people to use after discharge.", "Depression screening scores decrease measurably by follow-up." ], "interventions": [ { "title": "Assess and maintain safety", "points": [ "Ask directly about suicidal thoughts, plan, means, intent and past attempts at admission and at regular intervals — indirect hinting produces false reassurance.", "Determine the ordered observation level and carry it out exactly, including during shift change, meals, night hours and bathroom use, when risk peaks.", "Remove means: belts, cords, sharps, glass, medications, lighters and personal items per unit policy, and search belongings per protocol.", "Increase, do not decrease, monitoring during the first weeks of antidepressant therapy and during any sudden lift in mood.", "Develop a written safety plan with warning signs, coping steps, support contacts and crisis line numbers, and have the patient keep a copy.", "Document risk assessments, observations and the patient's own words precisely." ] }, { "title": "Build the therapeutic relationship", "points": [ "Spend scheduled time with the patient without demanding conversation; presence itself communicates worth.", "Use simple, direct language and allow long pauses — processing is slowed in depression.", "Avoid false reassurance such as 'everything will be fine' and avoid cheerfulness that invalidates the patient's experience.", "Accept anger and silence without withdrawal, and follow through reliably on every stated commitment.", "Validate feelings while gently offering an alternative view rather than debating." ] }, { "title": "Meet physical needs", "points": [ "Offer small, frequent, high-calorie, nutrient-dense foods and preferred items, and sit with the patient during meals when appetite is poor.", "Track intake, output, weight and bowel function; constipation is both a depression symptom and a common drug side effect.", "Promote sleep hygiene: consistent schedule, reduced daytime napping, limited caffeine, quiet dark environment, and no screens before bed.", "Assist with hygiene and grooming with specific, achievable prompts rather than open-ended encouragement, and give genuine recognition for effort.", "Encourage daily physical activity, which has measurable antidepressant effect." ] }, { "title": "Manage medications and treatments", "points": [ "Teach that antidepressants take two to six weeks for full benefit and that early side effects usually fade — this single explanation prevents many treatment failures.", "Check that oral doses are actually swallowed when risk of hoarding exists.", "Monitor for and teach the signs of serotonin syndrome, and review all other serotonergic drugs and supplements including St. John's wort.", "Never stop antidepressants abruptly; taper as prescribed to avoid discontinuation syndrome.", "For MAOIs, teach the tyramine-restricted diet and the drug interactions thoroughly before discharge.", "For ECT, prepare the patient and family for the procedure, expected transient confusion and memory loss, and post-treatment orientation and safety needs." ] }, { "title": "Restore activity and social connection", "points": [ "Start with brief, simple, achievable tasks and structure the day; an unstructured day feeds rumination.", "Progress gradually from one-to-one interaction to small groups; large groups early are overwhelming and reinforce failure.", "Use behavioral activation: schedule pleasurable and mastery activities even before motivation returns, since action precedes mood improvement.", "Involve occupational and recreational therapy and encourage participation without shaming refusals.", "Involve family with consent, teach them that depression is an illness rather than a choice, and coach supportive rather than dismissive responses." ] }, { "title": "Address thinking and prepare for discharge", "points": [ "Help the patient identify all-or-nothing thinking, overgeneralization and catastrophizing, and test those thoughts against evidence.", "Encourage a daily record of small accomplishments and moments of relief to counter memory bias toward the negative.", "Screen for and address substance use, which worsens depression and raises suicide risk.", "Arrange follow-up therapy and medication management appointments before discharge and confirm transportation and cost coverage.", "Ensure the patient leaves with crisis line numbers, the safety plan and a limited medication supply when risk remains." ] } ], "patient_teaching": [ "Depression is a treatable illness, not a personal failure or lack of willpower.", "Antidepressants take two to six weeks to work fully — keep taking them even when nothing seems to change.", "Never stop your medication suddenly; call your provider to taper it safely.", "Report worsening mood, agitation or new thoughts of suicide right away, especially in the first weeks of treatment.", "Keep your safety plan and crisis line number where you can reach them instantly.", "Avoid alcohol and recreational drugs; they deepen depression and interact with your medication.", "Keep a routine: regular sleep, meals, daylight, movement and contact with at least one person daily.", "Attend every therapy and follow-up appointment — medication and therapy together work better than either alone." ] }