Key learning points:
– Securing engagement and involvement
– Simple verbal questions for screening depression
– Evidence-based practice for community nurses
The Five-Year Forward View for Mental Health1 emphasised that early intervention and prevention services for children and young people would save £100 million for public services. There are opportunities to deliver preventive care in a range of community settings such as schools, which could be well placed to identify and support children and young people at risk. The second part of this paper is understanding the current picture, screening for depression and exploring evidence-based treatment options. Throughout this article when discussing young people the age range is 12 to 18 years and for children five to 11 years, in line with National Institute for Health and Care Excellence (NICE) guidelines.
The current picture
The most common mental health disorders among children and young people are anxiety and depression and the contributing factors are multiple and complex. Children and young people from backgrounds of lower socioeconomic status are three times more likely to develop mental health conditions.2 Childhood depression is linked with a range of negative outcomes including impaired social adjustment, academic difficulties and mood variation.3 Undiagnosed or untreated depression can increase the risk of suicide.
Symptoms of depression
Depression is characterised by feelings of sadness, being easily upset or tearful, feeling tired, irritable and lacking in interest. These feelings last for most of the day and persist over a period of time. Other features may include impaired appetite (eating little or too much), weight loss or gain, changes in sleep pattern, somatic complaints such as headaches or stomach upset, feelings of worthless or guilt, poor concentration, feeling hopeless or wanting to die, and deliberate self-harm.4
It is worth noting, though, that sleep and eating disturbances are common in childhood. Tearfulness and crying incidence have a different meaning and feelings of sadness are also common. It is also important to ‘normalise’ sadness as a passing phase unless it becomes persistent over time.5
Engaging with young people is the first step and is central to screening for depression in community settings. There is also an increasing need for community nurses to acknowledge the cultural dimension in the presentation of depression in order to increase rates of recognition and treatment. The majority of common mental health disorders are managed in primary care. Young people presenting with symptoms of low mood should be screened using two verbal screening questions (Whooley’s questions7):
– During the last month, have you often been bothered by feeling down, depressed or hopeless?
– During the last month, have you often been bothered by having little interest or pleasure in doing things?
If the response to both questions is ‘no’, the screen is negative. If the patient responds ‘yes’ to either question, use a recommended screening tool – for example, Patient Health Questionnaire 9 (PHQ 9), which has acceptable reliability, validity and sensitivity.8 NICE6 recommended its use across the lifespan in primary care as it is easy to administrate and interpret.
Community nurses are recommended to undertake routine enquiry at every contact and use the two Whooley questions even if time and training are limited. If depression is identified, a comprehensive assessment must be conducted with the involvement of GPs and mental health professionals. The model of depression guidance by NICE provides a five-step framework for services to support patients, carers and healthcare professionals in identifying and accessing the most effective interventions.
There are two main types of depression classification from a treatment point of view: major depression (mild, moderate and severe), and dysthymia (chronic depression, present over a long period).
In mild depression, some symptoms present as above for at least two weeks. The patient has some difficulty with ordinary work and social activities but probably does not cease to function completely. It can be resolved without treatment.6
In moderate depression the patient may have a number of symptoms to a marked degree for at least two weeks, and show considerable difficulty in continuing with social or domestic activities.
In severe depression, the patient usually shows considerable distress or agitation, loss of self-esteem, guilt feelings and uselessness. Suicide is a distinct danger in severe cases.6
Treatment of depression should be based on biological, sociological and psychological principles that respect individuality and engage patients to share decisions about treatment options. All plans should be orientated towards recovery goals.
In mild depression (including dysthymia), the person may refuse treatment or recover with no intervention. It is best practice to offer further assessment within two weeks. Treatments recommended by NICE are non-directive supportive therapy or group cognitive behavioural therapy (CBT) and guided self-help. Antidepressants are not recommended for mild depression because of poor benefit overall.
For moderate to severe depression, brief psychological therapy should be offered in combination with an antidepressant such as fluoxetine. The prescription of antidepressant should be guided for the user’s preference because of side-effects and the risk of overdose.
For depression that is unresponsive to treatment, recurrent or psychotic, intensive psychological therapy is recommended with an antidepressant augmented with an antipsychotic.
Exercise and nutrition
There is a substantial body of evidence showing physical exercise is an effective treatment for mild or moderate depression according to the Mental Health Foundation.9 Exercise had great benefits including enhanced mood, reduced anxiety and depression, improved cognitive functioning and self-worth. Exercise has few negative side-effects and can be used to treat patients who also have physical ill-health, for example, diabetes. It also promotes social inclusion and sustainable recovery.
Primary care nurses should instigate a structured and supervised programme with a referral and encouragement to attend local fitness club. Other forms of exercise to recommend include walking for at least half an hour daily, using stairs instead of a lift, jogging and riding a bicycle. These are also effective measures for weight management.
A growing body of evidence and a number of significant voices are championing the role of diet in the care and treatment of people with mental health problems, according to the Mental Health Foundation.10 A well balanced and healthy diet rich in essential fatty acids plays a major role in brain functioning and is crucial for healthy brain development in children. The polyunsaturated omega-3 fats DHA and EPA have particular roles in facilitating neurotransmission in cell membranes, which have shown the importance of the neurotransmitter serotonin and how lower levels are linked to depression.11 A daily balanced diet (protein foods, wholegrain cereals, pulses and five portions of fruits and vegetables) may help to protect mental health in mild to moderate depression.
The Improving Access to Psychological Therapies (IAPT) programme aims to restore balance and transform the habits that underpin people’s judgements and life decisions.12 Psychotherapy and counselling are useful for people who have a history of depression or severe traumatic experience for example, physical and sexual abuse or a history of self-harm.
For both mild and moderate depression, healthcare professionals should recommend a guided self-help programme based on computerised cognitive behavioural therapy (CCBT) as suggested by NICE guidance.6 CCBT can be accessed via a referral from a GP.
Over recent years, interest has grown in the delivery of effective treatment in primary care and public opinion favours psychological treatments. Several randomised controlled trials found that problem-solving therapy (PST) can be provided by non-medical practitioners in primary care and can increase patient satisfaction.13,14 A meta-analysis study15 supported that PST can be effective for depression, but more research is needed to ascertain the positive effects.
Evidence13,14 suggests that PST reduces functional disability for patients who have not responded to initial management by primary care physicians. PST is a brief method of intervention, a common-sense and structured approach that can be used in a wide range of primary care situations. Patient and therapist work together actively, to discover the principles of efficient problem solving and goal achievement and how they can be incorporated into daily life. PST helps patients to overcome problems and self-manage, which is a key goal.
A growing number of apps present opportunities for people to self-manage their mental health and digital platforms create new opportunities for self-referral and peer support.
Primary care has a significant role in promoting good mental health through direct provision and referrals to specialised services.16 The Government’s Mental Health Strategy for England17 emphasises that primary care nurses such as occupational health nurses, school nurses, health visitors, midwives and practice nurses will be expected to play a much greater role in identifying those at risk of mental health problems. They will also become increasingly important in the delivery of key aims such as giving children the best start in life, promoting their health and resilience as they grow up,18 and helping families and carers experience a better quality of life.19
Primary care nurses are in a unique position to improve public health as they are involved with people at all stages of life. There is an increasing need for all nurses to become agents of public health promotion and help people to stay independent, make good lifestyle choices and remain healthy.
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3. Burton M, Pavord E, Williams B. An introduction to Child and Adolescent Mental Health. Sage Publications, 2014
4. Royal College of Psychiatry. Depression in children and young people: information for young people. Mental Health & growing up factsheet, 2013.
5. Burton M, Pavord E, Williams B. An introduction to Child and Adolescent Mental Health. Sage Publications, 2014.
6. NICE. Depression (amended). Management of depression in primary and secondary care. NICE clinical guideline 23 Developed by the National Collaborating Centre for Mental Health 2007.
7. Whooley MA, Avins A, Miranda J, Browner WS. Case finding instruments for depression: two questions as good as many. Journal of General Internal Medicine 1997;12:439.
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9. Mental Health Foundation. Fundamental Facts. About Mental Health 2015 Publication.
10. Mental Health Foundation. Feeling Minds. The impact of food on mental health, 2007. mentalhealth.org.uk/sites/default/files/Feeding-Minds.pdf. (accessed 27 June 2016).
11. Phillips F. Diet and depression. Independent nurse for primary care and community nurses, April-May 2009.
12. Health and Social Care Information Centre. Psychological Therapies Annual /Report on the use of IAPT services – England 2013-2014. hscic.gov.uk/catalogue/PUB19098/psyc-ther-ann-rep-2014-15.pdf (accessed 5 February 2016).
13. Mynors-Wallis L, Gath D, Day A, Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication and combined treatment for major depression in primary care. British Medical Journal 2000;320:26-30.
14. Kendrick T, Simons L, Mynors-Wallis L et al. Cost effective of referral for generic care or problem-solving treatment from community mental health nurses compared with usual general practitioner care for common mental disorders. Randomised controlled trial. British Journal Psychiatry 2006;189:50-9.
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16. Barry MM. Promoting positive mental health and well-being. Practice and Policy. In C.L. Keyes (Ed.), Mental Wellbeing: International Contributions to the Study of Positive Mental Health. Springer, 2013.
17. Department of Health. No Health without Mental Health: a cross-government mental health outcomes strategy for people of all ages. Crown Copyright, 2011.
18. The Marmot Review. Fair Society, Healthy Lives. Strategic Review of Health Inequalities in England Post-2010.
19. Khan L, Parsonage M, Stubbs J. Investing in Children’s Mental Health. A review of evidence on the costs and benefits of increased service provision. Centre for Mental Health Report, 2015.