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Assessing patients for depression

George Coxon
RMN
Director, Classic Care Homes
Devon
Independent Health Care Advisor/Nurse
Mental Health Specialist Advisor, Newcare Ltd, Devon
Mental Health Nursing Association (MHNA)
Regional Lead for Wales
National Professional Committee member

Increasing numbers of people are experiencing the debilitating symptoms of depression, so it is vital that patients are given the right information and support by primary care professionals

Estimates vary of the number of individuals suffering with depression at any one time, but the Office for National Statistics puts this figure at 10% of the population, or one in 10 adults. In terms of how many people will develop depression at some point during their lifetime, the figures range from one in four to one in six.1,2 The correlation of these data suggests that 55% of us either are, have been or will become, depressed at some point in our lives.

Each year, over 20 million prescriptions are written for antidepressants in primary care in the UK, with well in excess of six million sufferers currently living with the condition. The risk of experiencing depression makes up one of the highest proportions of mood and emotional distress, which can cause huge upset and disruption to a patient and their family.

Equally, many people with depression remain undiagnosed, including those who are suffering a decline in health due to chronic illness such as angina, arthritis, asthma and diabetes. Approximately 95% of depression is managed exclusively in primary care without the involvement of ongoing support from specialist mental health teams.

Frontline nurses across primary and community services deal with first presentations of cases of depression, and need to have good skills in recognition, assessment and responding to presenting symptoms to ensure the right help can be provided.
The Quality and Outcomes Framework (QOF) requirements offer GP practices incentives for new diagnosis of depression and a follow-up assessment at five to 12 weeks after the initial intervention.3 The principle of active follow-up and careful monitoring of treatment plans will almost always involve the primary care nurse in one way or another. Ensuring skills and knowledge about signs, symptoms and treatment models is, therefore, a key part of the nurse's core competencies.

There is a lot said about the causes of depression, but low mood or other common presenting symptoms may simply be a normal reaction to unpleasant or difficult life events; for example, losing a job or having a relationship crisis. These situations today do not cause depression tomorrow, although
support and help may well be very necessary and important.

There are many different types of support available, from cognitive behavioural therapy (CBT) and other efficacious psychological support and counselling, to lifestyle advice and help with general wellbeing and addressing physical ill health. Often, medicines including sleeping tablets or a short course of a non-habit forming sedative, can be effective in providing help when accompanied by an active management approach.

In the past, many people were prescribed antidepressants and/or tranquilisers, and quickly became habituated both physically and emotionally. This is far less common today, but many people seeking help will still expect a prescription to 'take away the upset' or help improve mood or sleep difficulties. It can be hard to resist suggesting medication in these situations.

Good diagnostic skills are essential when deciding which type of help is most suitable. However, the use of medication must be set against the lack of detection of depression, particularly in high-risk groups, such as the elderly, the young and with men, all of whom for different reasons are often reluctant to present or hard to engage to receive help. There is also a common pattern of under-prescribing in some instances where, although there are symptoms and a diagnosis is made, adequate levels of medication are not given or tolerated by some patients.

Assessment skills and identifying risk
Having some basic knowledge and skills, combined with the confidence and time to explore a patient's mood is important to help a sufferer with, or signpost them towards the right treatment and support. A few key questions or indicators can make this easier and confirm what, for many nurses, can be their intuition or 'gut feeling' that things aren't right with a patient (see Box 1).

[[Box 1 dep]]

It can be a dilemma for nurses when they are confronted with a patient who shares their feelings of low mood covertly or in a less open way. In this situation it can be difficult to find adequate time to offer help. Frequently, once someone begins to open up their negative thoughts, feelings and unhappiness, they feel significant vulnerability and distress and need a lot of sensitive care.

The nurse may have a list of other patients to see and will not have the time needed to contain these feelings. A 'toolkit of skills and responses' or a personal strategy for dealing with such situations is vital to both the patient and to assist with your own coping methods. Many nurses would argue that feeling responsible for the distress of others is an occupational hazard, particularly working as an independent practitioner in the community.

In the current climate of change and restructuring of health services there has never been a more important time to have a robust self-care strategy. This should include having the following in mind in feeling fit for purpose when dealing with depression in patients:

  • Good support systems within the service,
  • Adequate supervision.
  • Time for reflective practice reviews.
  • Excellent time management.
  • Personal organisation skills.
  • Knowledge of how to get back-up if particularly concerned about a patient you have seen.

Risk assessment is a key part of the toolkit of the nurse in dealing with mental health distress. There are best practice guidelines set out by the National Institute for Health and Clinical Excellence (NICE) and other professional bodies, as well as tools to use in measuring symptoms.4 These can be extremely helpful in providing a framework to use in supporting a person with depression and getting access to treatment and therapies for patients. Having a good understanding of an agreed management protocol for how to deal with a patient you are worried about is essential.

Patients with long-term conditions
There is a very clear relationship between a diagnosis of a long-term condition, such as heart disease, chronic obstructive pulmonary disease (COPD) or diabetes and its impact on someone's emotional health and wellbeing. Many people will immediately 'catastrophise' and plunge into a very negative state, fearing a life of restriction and deterioration.

A large part of the nurse's role is to offer a realistic and balanced professional opinion regarding a prognosis that helps a patient maintain strength and hope following a diagnosis of chronic illness. There is a correlation between physical and psychological health, and many people are susceptible to symptoms of anxiety and depression, with a direct link to their physical health.

Assessment, diagnosis and presentation of symptoms
Using well-constructed tools to properly diagnose depression in those with a long-term condition can be difficult, as many patients express low mood as a symptom of their physical condition. This increases the need to share your thoughts and concerns with colleagues, such as the GP, to decide on the best type of support and help to offer. Points to consider in your approach should include:

  • Trusting your instincts. If you are concerned about a patient's low mood, raise the issue with them and consider ways to get back up and help as required.
  • Consider using, or at least familiarising yourself with, a depression assessment or rating scale such as the Hamilton Depression Rating Scale.5
  • Seeking a second opinion from the patient's GP - letting the patient know you are doing this is important.
  • Sharing with colleagues in the supervision of clinical review meetings - gaining the consent of the patient to do this is necessary.
  • Reading up on signs and symptoms of depression.
  • Reflecting on past or personal experience relating to low mood.
  • Understanding the psychological impact of having a long-term condition.

Some key factors to enquire about during assessment can be seen in Box 2.

[[Box 2 dep]]
 
When to refer and how to get advice
There is no absolute rule of thumb for when to refer and get advice and support if concerned about a patient's low mood; although if you have concerns, especially where you have had a prior relationship with the patient and notice marked changes in their mood status, you should share your fears and take advice on options. This involves letting the patient know you are concerned and should include discussion with colleagues, including their GP, to work out the best ways to help.

Usually, this is welcomed by the patient. In the rare instances where a patient may not wish you to do this, you must reassure them, and gain their trust and consent to seeking support. You should also explain that this action is part of your duty of care to them and a requirement as part of your professional code of conduct. 

Treatment and management
Treatment and management can include a range of options, from medication to referral for counselling or specialist mental health involvement. There is a wide range of interventions that can work for people dealing with depression and anxiety as well as other common mental health difficulties. CBT is often seen as a preferred approach that offers a finite amount of structured sessional support from a trained practitioner oriented toward addressing common patterns of thinking and how to regain positive self-management skills. Other types of support may be offered, including the involvement of significant people in the patient's life, for example, through family or couple counselling. For many patients a combination of this type of help and medication should be used.

Challenging aspects of interventions with depression
Many will argue that the most common factor regarding common mental health problems, particularly depression and anxiety, is losing control and confidence in one's life. If this sense of powerless persists over time there is a risk of experiencing a depletion of personal resources, leading to loss of hope and positivity. This can be a source of depression. Enabling a patient to regain confidence and control can be a challenging undertaking and often will need a programme of support over time.

Discussion
Having a working knowledge of how to respond to mental health distress, particularly depression and anxiety, is a key skill when working as a primary or community care nurse. How to be confident in assessing and responding to indicators of symptoms requires a personal adapted set of management techniques. I would say that symptom recognition and listening skills should be taught and practised on a regular basis as well as some basic counselling techniques.

I have worked as a primary care mental health facilitator and advisor at strategic health authority level and many nurses admit to limited knowledge and skill. I know of a lot of nurses who want to become more confident through skills and knowledge training to enable better management of the high numbers of patients experiencing low mood. Perhaps a greater emphasis on this in accessible, affordable post basic training and education might be the answer?

Can mental healthcare be higher on the priority list for frontline physical healthcare nurses? Of course it can, but is there capacity for even more workload pressure in a context of QIPP and doing more for less?7 

Conclusions
This feature has only touched the surface when it comes to introducing the issue of depression and long-term condition management. Further reading and a simple internet search will provide a huge range of current and new thinking on the subject, together with a stream of evidence of approaches being developed.

This can provide a wide range of details from work with heart failure and mood disorder to models of care for those dealing with asthma and depression. The list is considerable and will offer information and support to knowledge and skills.

References

  1. Office for National Statistics. Psychiatric morbidity among adults living in private households in Great Britain. Available from: www.statistics.gov.uk/StatBase/Product.asp?vlnk=9324&Pos=3&ColRank=1&Ran...
  2. Hale AS. ABC of mental health. Depression. BMJ 1997;315(7099):43-6.
  3. Department of Health (DH). Quality and Outcome Framework, guidance statement. London: DH; 2010.
  4. National Institute for Health and Clinical Excellence (NICE). Depression: CG 90, management of depression in primary and secondary care. London: NICE; 2010.
  5. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.