Chapter 5: Communication, psychological wellbeing and safeguarding
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Source: Adapted from WHO ([285]).
Source: Adapted from NICE ([203]).
Depression
Definition
Depression is a broad and heterogeneous diagnosis. Central to it is a depressed mood and/or loss of pleasure in most activities (NICE [203]). Depression is often accompanied by symptoms of anxiety and can be short lived (sometimes dependent upon physical symptoms) or chronic.
Related theory
Depression is a common psychological response in patients with a chronic physical illness such as heart disease, diabetes or cancer. When this occurs, it is referred to as ‘co‐morbid’ depression. Co‐morbid depression is difficult to detect as symptoms can be similar to the expected side‐effects of the illness or treatment, such as fatigue. Psychological screening and outcome measures for depression in physical healthcare settings need to be carefully selected to account for this overlap; the Hospital Anxiety and Depression Scale (Zigmond and Snaith [294]) is an appropriate measure.
Depression can be found in 20% of patients with a chronic physical illness (NICE [203]), which is two to three times higher than the rate in individuals in good physical health. Pitman et al.’s ([223]) review of depression in people with cancer reported that it affects up to 20% of adult patients and that ‘geographical variations in the diagnosis and treatment … impl[y] under‐recognition’ (p.1). It is essential, therefore, that patients with a long‐term physical illness are regularly assessed for anxiety and depression.
Box 5.11 sets out some of the symptoms of depression (NICE [203]). A normal experience of sadness or low mood is differentiated from what is diagnosed as a depressive episode by the length of time the low mood is experienced and its pervasive and debilitating nature. Low mood that persists for 2 weeks or more, rapid‐onset low mood and severe low mood are reasons for concern. The presence of other depressive symptoms contributes to a diagnosis as well as a consideration of how this low mood affects the individual's ability to function. Depression frequently follows a pattern of relapse and remission, and the key aim of intervention is to relieve symptoms (NICE [203]). However, this may or may not include the alleviation of the low mood itself; third‐wave cognitive–behavioural therapies aim to support a person with depressed mood to develop psychological flexibility, whereby they can live alongside difficult thoughts and emotions, including depression, and commit themselves to engaging with a meaningful life.
Box 5.11
Symptoms that indicate a diagnosis of clinical depression
Behavioural
- Irritability
- Socially withdrawn
- Diminished activity
- Changes to sleep pattern
- Changes to eating patterns that are not related to attempts to diet
- Self‐harm or suicide attempts
Physical
- Tearfulness
- Exacerbation of pre‐existing pains
- Pains secondary to increased muscle tension
- Agitation and restlessness
- Changes in appetite and weight
- Fatigue or loss of energy
- Lack of libido
Cognitive
- Poor concentration
- Reduced attention
- Mental slowing
- Pessimistic thoughts
- Recurring negative thoughts about oneself, past and future
- Rumination
- Suicidal ideation
Emotional
- Guilt
- Worthlessness
- Feeling of being deserving of punishment
- Lowered self‐esteem
- Loss of confidence
- Feelings of helplessness and hopelessness
- Reduced enjoyment or interest in most activities
Evidence‐based approaches
Approaches to treating depression are influenced by the severity of the condition. Diagnosing depression has improved following the introduction of the 10th edition of the WHO's International Classification of Diseases (ICD‐10), which lists 10 depressive symptoms (Box 5.12). The level of severity of depression is categorized according to the number and severity of the symptoms a person experiences:
- mild: two or three symptoms – the person is distressed but able to continue with most activities
- moderately depressed: four or more symptoms – the person is usually having considerable difficulty carrying on with ordinary activities
- severe (without psychotic symptoms): an episode of depression in which many symptoms are present; they are obvious and distressing, and loss of self‐esteem, feelings of worthlessness and guilt are typically present. Suicidal thoughts may also be present.
Symptoms need to be present for greater than 2 weeks. Core management skills include risk assessment plus the following:
- good communication skills, which will enable the nurse to elicit information from the patient (Brown et al. [37]) and show understanding of the problem
- a sufficient understanding of the signs and symptoms of anxiety and depression and an ability to make a preliminary assessment
- a sufficient understanding of antidepressant medication to enable the nurse to give an explanation of its actions to the patient
- an ability to refer the patient on for further assessment when it is recognized that the issues are beyond the scope of the nurse's experience (this must be done with the patient's consent)
- awareness of the stigma attached to a diagnosis of depression
- sensitivity to diverse cultural, ethnic and religious backgrounds, considering variations in presentations of low mood and its understanding
- awareness of any cognitive impairments or learning disabilities to ensure that specialist therapists are involved (where needed)
- protection of the patient's privacy and dignity.
Use of available psychological support services can assist with the care and treatment of patients as well as providing a supervisory and support framework for staff. Working with psychological support services can enable nurses to develop their assessment skills around anxiety and depression, helping them to identify the appropriate time for referral to a specialist service if required (Towers [272]).
Box 5.12
The ICD‐10’s list of 10 depressive symptoms
- Lowering of mood
- Reduction of energy
- Decrease in activity
- Reduction in capacity for enjoyment and interest in life
- Reduction in concentration
- Marked tiredness even after minimum effort
- Sleep disturbance
- Reduced appetite
- Ideas of guilt or worthlessness
- Reduced self‐esteem and confidence
Pre‐procedural considerations
Psychological support
Nurses can be involved in assessing depression in patients with physical illness. NICE ([203]) guidance sets out a four‐step model for managing a patient with depression. The first step (Box 5.13) could be implemented by a nurse in an acute environment.
Box 5.13
Managing a patient with depression: NICE ([203]) guidance, step 1
Key questions
-
During the last month, have you often been bothered by:
- feeling down, depressed or hopeless?
- having little interest or pleasure in doing things?
- How long have you felt like this for?
If the patient answers ‘yes’ to question 1 and the timescale is longer than 2 weeks, it is important that a referral is made for further assessment by a healthcare professional with clinical competence in managing depression, such as a psychologist or a registered mental health nurse, so they can determine whether the patient has been bothered by ‘feelings of worthlessness, poor concentration or thoughts of death’ (NICE [203], p.9).
Other questions
Further questions should assess for the following:
- other physical health problems that may be significantly affecting the patient's mood, such as uncontrolled pain, sleep disruption, excessive nausea and vomiting, physical limitations on their independence or body image disturbance
- a history of psychological difficulties such as depression
- a consideration of the medication the patient is taking, specifically medication for mental health problems (have they been able to take it and absorb it or have they had any digestive issues?)
- social support for the patient (who else is around to support the person, and are they isolated?).
It is important to assess how the patient's low mood has affected their usual daily activities, such as eating, dressing and sleeping. The nurse can also encourage the patient to engage with activities that would be normal for them as this can provide them with opportunities for connecting, achievement or enjoyment. Some people who are low in mood have thoughts about death and dying – these can be very natural thoughts in the context of a serious physical health problem and do not necessarily imply any risk of harm to self. However, some people do have thoughts about wanting to die or to harm themselves, and it is important that nurses are able to explore these thoughts and feelings with patients (Problem‐solving table 5.17). It is important that any conversation about self‐harm or suicidality is collaborative and person centred (rather than protocol driven) and aims to understand the social context of these thoughts and feelings with the intention to reduce the causes of the depression where possible (HEE [128]).
Pharmacological support
Antidepressant medication can be both effective and acceptable to patients for the treatment of their depression. There are several classes of antidepressant medication:
- tricyclic antidepressants (TCAs), e.g. amytryptiline
- selective serotonin reuptake inhibitors (SSRIs), e.g. fluoxetine, citalopram and sertraline
- serotonin–norepinephrine reuptake inhibitors (SNRIs), e.g. venlafaxine and duloxetine
- noradrenaline reuptake inhibitors (NARIs), e.g. atomoxetine, reboxetine and bupropion
- monoamine oxidase inhibitors (MAOIs), e.g. phenelzine and moclobomide.
Table 5.15 lists the most commonly prescribed antidepressants.
Table 5.15 The most commonly prescribed antidepressants
| Medication | Trade name | Group |
|---|---|---|
| Amitriptyline | Tryptizol | Tricyclic |
| Clomipramine | Anafranil | Tricyclic |
| Citalopram | Cipramil | SSRI |
| Dosulepin | Prothiaden | Tricyclic |
| Doxepin | Sinequan | Tricyclic |
| Fluoxetine | Prozac | SSRI |
| Imipramine | Tofranil | Tricyclic |
| Lofepramine | Gamanil | Tricyclic |
| Mirtazapine | Zispin | NaSSA |
| Moclobemide | Manerix | MAOI |
| Nortriptyline | Allegron | Tricyclic |
| Paroxetine | Seroxat | SSRI |
| Phenelzine | Nardil | MAOI |
| Reboxetine | Edronax | SNRI |
| Sertraline | Lustral | SSRI |
| Tranylcypromine | Parnate | MAOI |
| Trazodone | Molipaxin | Tricyclic related |
| Venlafaxine | Efexor | SNRI |
| MAOI, monoamine oxidase inhibitor; NaSSA, noradrenergic and specific serotonergic antidepressant; SNRI, serotonin‐norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor. |
When a patient is prescribed antidepressants, it is important to consider the presence of other physical health problems, medications the patient is already taking and their side‐effect profile, and any history of a good or poor response to antidepressant medication. There is little difference in terms of effectiveness between the types of antidepressant; however, there are clear differences in the side‐effects of the different classes and types of antidepressant. SSRIs are safer in overdoses than TCAs, which can be dangerous. There is an increased risk of gastrointestinal bleeding in the elderly with SSRIs so they should be avoided for patients who are taking non‐steroidal anti‐inflammatory drugs. Monoamine oxidase inhibitors can affect blood pressure, particularly when certain food types (e.g. cheeses) are eaten. SNRIs are not appropriate for patients with heart conditions as they too increase blood pressure. Citalopram and sertraline (both SSRIs) are associated with fewer interactions and so are more likely to be prescribed if the patient has a long‐term chronic condition (NICE [203]).
Due to increased sensitivity to side‐effects in the medically ill, treatment may need to be introduced at a lower dose before cautiously increasing it. Dividing the dose may improve tolerance, as may liquid preparations, which can be helpful in low‐dose prescribing and for patients who have difficulty swallowing.
Nurses have an important role in exploring with patients any concerns they may have about taking an antidepressant. Patients should be given all the necessary information regarding the optimum time to take the medication, and the expected length of time before any therapeutic effect becomes apparent; this is usually 4 to 6 weeks. Medication should be taken for at least 6 months following remission.
In general, treatment should not be stopped abruptly, and discontinuation of treatment usually requires a gradual reduction of the dose over 4 weeks (NICE [203]). Addiction is unlikely to happen with modern antidepressant treatments, but patients may need to be provided with further information and reassurance that this is the case. Further information on pharmacological interventions can be found in the NICE guidelines on depression (NICE [203]).
Table 5.16 Communicating with a person who is depressed
| Principle | Rationale |
|---|---|
| Initiate the conversation and develop rapport. Develop a person‐centred communication style. | Good communication is essential to assess and individualize support (NICE [203], C ). |
| Show understanding, caring and acceptance of behaviours, including tears or anger. | Accepting patients as they are, without attempting to block or contain their emotions, helps them to express their feelings. E |
| Encourage the patient to identify their own abilities or strategies for coping with the situation. | To promote self‐efficacy. E |
Table 5.17 Prevention and resolution (Principles table 5.16)
| Problem | Cause | Prevention | Action |
|---|---|---|---|
| Patient expresses ideas of self‐harm or taking their own life; for example, patient says that they sometimes wish they would not wake up in the morning so that they do not have to face their difficulties | Low mood, depression |
Assess for risk: this can be as simple as remarking upon the person's low mood and asking them if they have ever thought of hurting themselves. For example:
If the patient says that they are actively thinking about harming themselves, you need to explore any plans they have and any intention to act on these plans. For example:
| If you have any concerns that the patient is at risk, follow the procedure of your organization. This may include contacting psychiatric liaison services or other psychological support services. |
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Crucially, you will also need to explore what stops the patient from acting (known as ‘protective factors’) and what changes might cause them to act. For example:
If you consider the patient to be at risk, explain to them that you need to refer them for further support. The patient may be reluctant for you to share this information; however, it is your duty to act in their best interests and reduce the risk of harm. For example:
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