Pathorpharmocologic Foundations

  1. Depression

Depression, as World Health Organization describes it refers to a mood disorder characterised by symptoms like loss of interest, lack of appetite, sadness, poor concentration, sleep disturbance, feeling guilty and having low esteem.  Individuals who suffer from depression show varying degrees of hopelessness and helplessness, insomnia, inability to concentrate, loss of interest and feeling sad. Depression is not caused by any specific element but various combined factors which depend on the genetic makeup and environmental conditions. However, there are multiple factors associated with depression. First, is the physical structure, family history, traumatic events, and hormonal changes. Depression is divided into nine different types including dysthymia, psychotic, bipolar disorder, atypical, seasonal affective, postpartum despair, premenstrual dysphoric disorder, situation, and significant depression. The paper aims to discuss the pathopharmocologic foundations of depression.

A1. Pathophysiology of Depression

The understanding of the pathophysiology of depression is challenging because a single hypothesis cannot explain the disorder symptomatology. Pathophysiologic mechanisms include immunologic, neurogenesis, monoamine hypothesis, environmental, genetic and endocrine factors. The first pathophysiologic mechanism, genetic factor has been of great interest leading to various studies and research exploring the likelihood of linking depression and genes. One of the research in linking depression and genes was conducted by a British research group where the scholars secluded a gene that seems to be prevailing in various family members having despair. The gene 3p25-26 was present in more than eight hundred relatives having recurring depression where scientist trust that forty per cent of individuals were having the disorder traces to a genetic link. The following pathophysiologic mechanism of depression is the immunologic factor. The immunological changes during psychiatric and side effects of depression caused by using cytokines in treating cancer and hepatitis provide evidence favouring the depression disorder. Additionally, hormones imbalance plays a significant role in despair and might lead to defaulting in the hypothalamic-pituitary-adrenal (HPA) axis which is the system managing the body’s stress response. After a person receives a scary situation, the hypothalamus produces substances like CRF which stimulates the pituitary gland to produce different hormones preparing someone for an answer. On the other hand, environmental factors which are linked to depression vulnerability are associated with changed cerebellar resting-state synchronisation. When independently considered both the cerebellar resting-state depression liability and connectivity are caused by the convergence of several environmental and genetic factors. Some environmental factors that may lead to depression are synthetic chemicals like preservatives/food additives, genetically modified foods, hormones/drugs, industrial byproducts as well as pesticides which bombard our bodies. Also, situations like childhood abuse, stress, coping with losing a loved one or traumatic acts are considered environmental stress factors.

The combination and linkage of the listed factors have been implicated in the depression pathogenesis rather than a unitary product. Factors like the environmental stressors, as well as heritable genetic features acting through endocrine and immunologic responses, initiates functional and structural changes in various brain regions leading to dysfunctional neurotransmission and neurogenesis which then manifest as a constellation of symptoms (Duman, 2014). The primary neurological link between the listed factors and development of depression is referred to as the Hypothalamo-Pituitary-Adrenal axis.

Depression is considered a possibly life-threatening ailment affecting millions of people around the globe. The disorder occurs at any stage from childhood to adulthood and is an incredible cost to society because it causes severe disruption or distress and if untreated it can be deadly. Additionally, the psychopathological situation comprises of symptoms with depressed or low attitude, anhedonia, and low fatigue or energy. The other symptoms like the psychomotor and sleep instabilities, low self-esteem, feeling guilty, suicidal propensities and autonomic as well as gastrointestinal disorders always exist. Depression is not just a homogenous sickness but rather a multifaceted phenomenon with several sub-types and likely more than one aetiology. The disease includes a disposition to intermittent and often liberal mood troubles, symptomatology variances range from minor to severe signs with or lacking psychotic features and relations with other somatic and psychiatric syndromes.

A2. Standard of Practice for Depression

The standards of practice for depression should be in line with the methods aimed at preventing and curing the disease. First, education and training are among the best ways in which society can best deal with depression. Physicians should maintain the best practices to ensure that patients adhere to proper measures and guidelines meaning that they should create and keep a healing alliance which collaborates with the patient in making decisions as well as attending to the preferences or concerns regarding treatment. Physicians should ensure that the psychiatric assessment is complete and evaluate patient safety. The other standard practices for physicians include evaluating the patient’s safety, the establishment of appropriate treatment setting, assessing functional damage or quality of life and organising for patients care with colleague clinicians. Monitoring of the patient’s psychiatric standing, integrating measurement into management as well as providing education to the family and patient are among the standards of practices which should be adhered to by every physician.

Physicians should ensure a high standard of care because patient’s benefit from increased access to antidepressants, active follow up, structured monitoring and reduced risk of chronic depression. Individuals suffering from depression must receive an assessment which identifies symptoms severity, the scope of associated functional impairment and the episode duration.

Depression patients require collaborative care which refers to an innovative way of treating anxiety and depression. Collaborative care involves various health professionals working with patients in helping them to overcome their challenges meaning that it always involves a medical doctor, psychiatrist, and case manager. The methods used in allocating patients to routine care are not free from bias, and many patients do not provide information or follow-up on their outcomes. Collaborative care appears better than usual care in anxiety improvement since it increases the number of patients using depression medication and improves mental health meaning that patients who are treated with collaborative care are more satisfied.

A2a. Depression Evidence-Based Pharmacological Treatments in Florida

Depression is among the most common mental ailments in the state of Florida. The disease is rampant among the youth. Depression among the Florida adolescents appears to nearly matching the national averages where 9.6% of the Floridians aged between 12-17 suffered from the disorder in 2013 (Hersen & Hasselt, 2013). A similar case is true in Panama City Beach although less than thirty-one per cent received specialised treatment for their ailment meaning that 69% of Florida adolescents lacked treatment. In Florida, a program referred to as JourneyPure is among those involved in the treatment of depression, especially in Panama City Beach. JourneyPure Emerald Coast is an organisation in Panama City Beach which supports various people who are addicted to drugs in overcoming prescribed medical habits as well as any co-occurring disorder. The program aims at treating and curing the disorder because even at most severe cases depression can be addressed by use of antidepressants which assist in improving how the brain engages with a specific chemical for controlling stress or mood. JourneyPure takes a complete and general approach in the Depression Treatment Program which includes cognitive behavioural therapy, medical intervention together with holistic services like experimental treatments. The plan has positively assisted in prescription medication thus, helping users to stay happy, prolific and with temperate lives.

To curb depression among the Florida residents’ various guidelines and regulations were enacted. The 2017-2018 Florida Best Practices Psychotherapeutic Medication Guidelines for Adults are founded on the current publications concerning effective care and clinical consent judgements. Depression remains to be a useful therapeutic target in bipolar disorder at Florida in most early and late phases of the disease. Depressive symptoms as part of bipolar disorder are always chronic and highly associated with functional impairment, suicidality, and comorbidity. The US Food and Drug Administration has authorised three psychotherapeutic bipolar depression agents. The expert panel for the Florida Guidelines jointly agreed to list lamotrigine as being a possible first-line treatment strategy in the treatment of depression. The specialist panel recognised that lamotrigine did not receive regulatory approval for marketing depression (Cuijpers et al., 2014). During the completion of 2017-2018 Florida Guidelines, outcomes from two pivotal registration trials in adults having depression show Cariprazine is useful in the acute treatment of depression. The 2017-2018 guidelines re-emphasise the hazards and ubiquity posed by bipolar disorder mixed features.

Managing of depression in Florida is mostly through the use of antidepressants. The method and utilisation of antidepressants are still an understudied and controversial matter in depression. No single antidepressant or group is authorised for bipolar disorder. The Florida Expert Panel recognises that antidepressants remain to be utilised at a very high rate in adults having bipolar disorder. The guidelines for using antidepressants is that they should not be prioritised more than the approved FDA treatment and should be used as adjunctive treatment strategies. In the treatment of depression electroconvulsive therapy (ECT) is the recommended therapeutic option with evidence supporting alternative neurostimulators approaches.

Accessing depression medications in Florida is a challenge to various individuals. First, there is a shortage of psychiatrists in the state. The other challenge is that parents might not see mental health problem symptoms or even be aware of the seriousness of depression. During diagnosis of depression doctors typically consider one’s history and reviews mental status and behaviour. The doctor then evaluates symptoms, rules out depression physical causes and decides whether the disorder is an appropriate diagnosis. The physician should also screen a brain disorder which might cause strange mood, energy and activity level shifting. The major classifications of antidepressants are SSRIs, SNRIs, TCAs, MAOIs, Remeron and Wellbutrin.

A2b. Clinical Guidelines for Assessment, Diagnosis and Patient Education for Depression

Clinical guidelines for assessing, diagnosing and educating depression patients are critical. First, physicians should consider establishing a detailed assessment and proper diagnosis of depression. The evaluation for the disorder should be based on detailed history, mental and physical state examinations. History should be obtained from all sources and especially the family. In assessing depression scales and interviews with a different scope of degrees are used as instruments for measurement of severity and response to treating depressive disorders. The apparatus used for assessment help in evaluating patient symptoms within a given timeframe through grading every item and providing a final score. The instruments used for assessment cannot be used in forming diagnosis which is established from psychopathological information. The guidelines for treatment of depression as released by the American Psychiatric Association (APA) have been updated to summarise recommendations on using antidepressants and therapies including cognitive behaviour therapy and electroconvulsive therapy (ECT). Depression should be treated according to the primary diagnosis guidelines including three phases like a continuation, maintenance and acute stages. In the acute phase, the treatment phase aims at decreasing depression or even eliminating the disorder. The second stage is the continuous phase which aims at preventing relapse. Systematic symptoms assessment and checking for opposing effects of medication together with therapy adherence and active status are relevant. The third stage is known as the maintenance phase and should be considered for patients having recurring risk factors. The other factors which should be regarded as include patient preference, treatment type received, comorbid conditions, the persistence of depressive symptoms and adverse effects.

Depression always presents with combined symptoms such as loss of interest, depressed mood, reduced attention and decreased energy and fatigue. Some of the symptoms are more marked and develop characteristic features depending on depression severity considered to have special clinical significance. Some depression patients might show fatigue, pain and may not show sad mood on their own (Duman, 2014). The important aspect of depression diagnosis is the ruling out of bipolar disorder. Several patients having a disorder avail themselves to the physician during depressive illness stage and instinctively do not account the previous manic or hypomanic occurrences. Vigilant history from a patient as well as other sources always provides necessary clues for depression.

Education regarding depression and treatments should be provided to all the patients together with the involved family members. Certain instructive elements might be supportive in various situations and active procedures being essential is critical for individuals who attribute their disorder to witchcraft or moral flaw. Education concerning the current treatments possibilities helps patients to make conversant decisions where they anticipate side consequences and adheres to behaviours. The other vital aspect of teaching depression patients is notifying the patient or family about the delay period of antidepressants action inception.

A2c. Comparing Standard of Practice for Depression Management

In the United States, around eleven per cent of the adult individuals are projected to have had a depressive illness for over 12 months. The lifetime frequency in the US is about 19% and gets to 24% among females. Depression symptoms also make a significant contribution to the morbidity in the population (Corona, Rastrelli & Maggi, 2013). The frequency at which depression signs and ailments occur in the community might be expensive procedures for healing or preventive measures to be monitored. To obtain detailed data for the broad community requires conducting a society survey with valid and reliable screening questions because there is a likely to access depression prevalence for subgroups through periodic screening.

The managing of depression among the Florida residents requires examining of socioeconomic or demographic characteristics for those not being cured. The examination/evaluation assists communities in assessing the necessary additional services and determining whether steps should be taken to improve access or accept the suitable amenities. In Florida managed care organisations (MCOs) together with other physicians can access the prevalence and number of untreated depression patients in the community. The organisations together with physicians offer great assistance to the individual suffering from depression in Florida.

A3. Characteristics of And Resources for Patients Who Manages Depression Well

Depression patients who can live according to the physician’s guidelines show improved access to care, treatment options, and better outcomes. Managing depression well is indicated by signs like less irritability, great interest in activities, normal appetite, feeling less overwhelmed, more energy and better concentration. Improving depression patients have more patience and engages well with other people. The other characteristic of a well-managed depression is showing more significant interest in activities and enjoying them more. Better concentration is another characteristic of a well-managed depression because the individual will be feeling sharper mentally. Depression patients have access to various resources which helps them in managing the disorder well. First, there are many organisations which educate and offer help to depressed patients. The organisations may also provide financial support which assists in managing the cost of medication and therapy. Depression patients can also read various patient blogs voicing the real experience of how to cope with the disorder.

A3a. Disparities Between Management of The Selected Disease on National and International Level

There are various disparities it comes to managing of depression brought up by ethnicity/race, age and insurance. First, the federal and state governments have complementary roles in regulation and funding of mental health and substance use treatment meaning that most of the disparities in managing of depression may be due to variations in handling the illness.  Disparities in managing depression are evidence because African Americans have a high probability of receiving adequate treatment compared to Caucasians when it comes to receiving counselling or psychotherapy.

Despite being one of the most common violent mental disorder in the globe access to depression care and treatment is still deficient particularly in low- and middle-income nations. According to the data from Global Burden of Disease Study in the year 2010, it indicated that depression is the leading contributor of Disability Adjusted Life Years (DALYs) accounting for 2.5% and the second leading cause of disability accounting for 8.2% of disorder period (Leontjevas et al., 2013). Depression was recognised as the leading source of sixteen million DALYs and around four million ischemic heart DALYs.

Primary care doctors in various states diagnose similar depression symptoms differently depending on the gender of the person. The differential diagnoses of depression are due to substantial variation among the states when it comes to managing and handling of individuals with depressive symptoms.  Disparities at international level occur due to alterations in depression frequency rates and changes of healthcare systems in various states. The international differences in diagnosing and managing depression are becoming a high interest in health service researchers or epidemiologists. The reported changes in depression frequency rates in various nations are assumed to be correct because the subsequent research and outcomes are focused on the family background together with genetics and culture differences.

Disparities at international level also occur due to differences in managing and diagnosing similar signs and symptoms of depression in various nation’s leading to variances in prevalence rates. The variations in management and diagnosing is highly used to explain the disparities in countries although the reason is rarely extended to understanding the international medical and healthcare differences.

A4. Factors Contributing to Ability of a Patient to Manage Depression

Some of the factors that contribute to the patient’s ability in managing depression include financial resources, Medicare/Medicaid, access to care as well as insured/uninsured individuals. The listed factors have great contribution when it comes to patient’s wellbeing. First, financial resources are vital because patients will be able to access medical care at any time and anywhere around the world. For the patients who are insured they cannot suffer due to lack of funds but can access care at any time since the resources and required capital is available. Insurance plays a more significant role for depression patients because there is guaranteed care for those who are enrolled in the program.

A4a. How Lack of Factors Leads to Unmanaged Depression

The first factor leading to unmanaged depression is financial resources. Depression patients are most likely to face financial problems or be in debt because the illness may interfere with money and employment management. Debt and unexpected unemployment exacerbate depression or triggers episodes for those prone to them. Regardless of whether it is mental illness or financial problem experienced first, the occurrence of any of the issues may fuel the other leading to shame and paralysis because every decision will appear to be wrong.

The other factor leading to unmanaged depression is lacking insurance cover. First, individuals who are covered by Medicare programs are likely to access quick and better care. Medicare/Medicaid or any other insurance programs ensure that depression patients are treated without limit due to lacking funds. For patients who are not under Medicaid/Medicare or any different program experience a lot of difficulties when it comes to management and treatment of depression (Corona et al., 2013). First, the individual might lack enough funds to access better and necessary care leading to improper management of depression. The patient will then live with unmanaged depression due to lacking insurance cover.

The last factor leading to unmanaged depression is access to quality care. Planning on how to implement advanced access to care requires individuals to do so in a way which enhances the management practices rather than conducting a harmful change. Changes applied to ensure managing of depression should aim at helping the patients to receive better treatment and care which enables them to heal quickly.

A4i. Characteristics of A Patient with Unmanaged Depression

Unmanaged depression is a severe problem because it increases the chances of risky behaviours like drug addiction. Individuals with unmanaged depression show various characteristics like experiencing loss and sadness when issues like job loss, divorce or death of loved ones occur. According to the University of California, Berkeley acute sadness lasting for more than two weeks should be brought to physicians’ attention. The most common signs of severe depression are acute sadness, changes in appetite, sleep troubles and losing interest in things which once brought pleasure.

The next characteristic of individuals with unmanaged depression is showing some side effects which are not universal. The characteristics might include stomach and headache problems, difficulties in concentration, falling frequently and increased muscle or body pain. The other characteristic of depression patients is experiencing suicidal thoughts, harming oneself or even murder are some characteristics associated with patients having unmanaged depression.




  1. How Depression Affects Patients, Families, and Populations

Depression has various effects on the patients, families and the population in general. First, depression might lead to various damages and destructions across several functioning areas. Depression patients with mild impairment experience high medical care needs, always use healthiness services and are most commonly hospitalised. Also, the patients are twice likely to be unemployed compared to ones lacking despair symptoms leading to substantial social or economic impacts. Depression is associated with increased use of health services like primary and specialized care which are shown by frequent and regular medical attention (Hersen et al., 2013). People who suffer from depression are downcast with less energy and capacity for enjoyment and activities meaning that things which appeared to be necessary for the individual no longer has special significance. Depression has significant effects on the patient’s close family members because they always feel powerless due to struggling with mixed emotions like fear and anxiety as well as anger or irritation.

B1. Financial Costs Associated with Depression

The financial costs of depression to the patients, families, and populations are significant. The economic ripples associated with depression are disproportionate and extensive. For any dollar used on depression treatment an extra $4.70 is utilised on direct and indirect charges of associated illnesses and $1.90 used on combined workplace efficiency as well as budgetary losses linked to direct associated depression suicide. In America, mental illnesses cost the society $210 billion annually where forty per cent of the total amount is used in managing and handling depression (Leontjevas et al., 2013). The cost of depression is related to mental illness like anxiety or post-traumatic stress disorder and physical illnesses including sleep and back disorders as well as migraines. Financial expenses for the individual having depression are a problem especially to patients who are financially challenged. According to Susan Hyatt, a depression patient at Denver the cost of managing and handling depression together with the associated seasonal affective disorder is extensive. Susan spends a lot of money on medication and around $70 monthly out-of-pocket for bupropion and trazodone. Also, Susan uses around $100 to $150 on complements and herbs each month as well as $300 for exercise and other lifestyle actions. The overall cost of managing depression in the society have slightly risen although the rate of treatment has substantially grown. Many of the depression patients are seeking medication, by all means, to ensure that they achieve the best care. Also, many organisations and programs have been implemented in the society to which has cost the concerned individuals a substantial amount of resources.

  1. How to Promote Depression Best Practices?

The best practices for managing depression can be promoted through the development and implementation of programs for preventing and treating depression. First, physicians should target interventions or actions aimed at supporting vulnerable, high-risk groups with proper plans or tools for building resilience. Governments and institutions can promote best practices through encouraging depression recognition across all care levels as well as among various types of health and medical professionals. Depression best practices can also be promoted through collaboration between education, health and labour sectors for awareness raising and enabling better access to support (Yamaguchi et al., 2013). There should be the implementation of evidence-based e-mental health tools which help with prevention of depression or mitigating the onset of the disease through self-help or even self-management approaches.


C1. Strategies for Implementing Best Practices for Depression Management

There are various strategies which can be applied for implementing the best depression management practices. The first strategy of implementation is at individual consumer level which is centred on health problems linked to increased depression rates and desire of improving enactment on individual consumer and healthcare system level for ensuring care satisfaction. For successful treatment practice, consumer health curing technologies have to address health practitioners concerns in the design phase, account for types of health practitioners, clinical practices and treatment methods. Depression patients should seamlessly strive towards integrating traditional or nontraditional despair indicators within several health practitioners’ clinical practices. Thus, an individual consumer level depression patients should develop a goal therapy, learn to improve any despair meta-awareness, determine the best treatment dose and not take depression as a personal flaw.

The next strategy for managing depression is at healthcare structure and plan levels. At the healthcare structure level, there are two possible implementation outcomes including low threshold and safe quality care (Duman, 2014). At the policy phase there emerges two likely outcome implementation areas which include the desire to reduce stigma through ensuring visibility of mental health complications.

The last approach is collaborative and stepped care. The results for effectiveness and cost-effectiveness depression collaborative care are promising although less conclusive. Collaborative and stepped care ensures new treatment methods which significantly improves depression management due to the explicit reference to the guidelines, establishing algorithms for treatment and diagnosis, integrating practices and clinics and implementing low-intensity treatment alternatives.


C2. Appropriate Method for Evaluation of Each of The Strategies

The most appropriate method for evaluating depression management is the linear growth curve models with sociodemographic and clinical covariates. The plan is suitable in determining the trajectory of symptom reduction throughout psychiatric hospitalisation together with identifying patient characteristics associated with recovery and quantifying the magnitude of the expected change through using recognised clinical benchmarks.

The evaluation of individual consumer level should be evaluated using the non-randomized method. The non-randomized method is classified into two, cohort and case-control studies. Cohort studies include arbitrary allocation of interventions which can be prospective and retrospective although adjustments can be found for confounders. The second classification, case-control studies include investigation of rare outcomes where individuals are defined as the basis of result instead of healthcare.

The best method in evaluating healthcare structure and plan levels is the health technology assessment. The process evaluates the best technology that can be used on a particular patient or population group to bring positive results. Health technology assessment method evaluates the cost-effectiveness of treatments against the next or current best healings.

The appropriate method in evaluating collaborative and stepped care method is through conducting a qualitative study among depressed patients. The process of qualitative research involves using a purposive sample strategy where semi-structured interviews are used to gather data. The patients provide answers which can be used to determine the effectiveness of collaborative and stepped care.





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