Spotting the signs of depression to ensure early treatment and reduce suicide deaths
Depression is one of the most common psychiatric disorders, with a lifetime prevalence of about 6%, yet it is estimated that only about half the number of adults who meet the criteria for ‘major depression’ receive treatment. Many die as a result of their own actions before contact with health- care services, and many die in a similar manner despite contact with the services.
Peter Melia, MA, BA (Hons), PGDE, RMN, FETCert.
Nurse Consultant (Forensic Mental Health), Tees and North East Yorkshire NHS Trust
The White Paper Saving Lives: Our healthier nation (DH, 1999a) set a target to reduce the death rate from suicide and undetermined injury by at least one-fifth (20%) by 2010 (see Policy box, below). This target is reinforced in the National Service Framework for Mental Health (DH, 1999b).Suicide rates are highest in young people aged 25-35 years, an age at which individuals are at their peak potential in terms of work and family commitment. The consequence for those left behind is considerable (DH, 2002). In England, one person dies every two hours as a result of suicide. It is the most common cause of death in men under age 35.
The National Confidential Inquiry into Homicides and Suicides (Appleby et al, 1999) noted that, nationally, of those people who died through suicide (as recorded by coroners’ offices), 24% (more than 1000) had been in contact with health services in the year before their death. Half of them had had contact with health services in the week before they died.The most common method of suicide among men was by hanging; among women it was poisoning by overdose, usually using the psychotropic medications (especially tricyclic antidepressants) prescribed for their mental health problems. More than half of both men and women (63%) had a history of self-harm and almost one-fifth (19%) had a history of violence towards others. There was a high prevalence of drug and alcohol abuse, and again almost a fifth (17%) had a history of abusing both alcohol and drugs (Appleby et al, 1999). The most commonly recorded diagnosis was depression.
Depression is a disorder of mood (the internal experience of emotion) rather than affect (the external presentation of emotional experience). We all display changes in mood as part of our ordinary interpersonal styles and social interactions, and most of us have a broad range of moods and associated expressions of affect.Mood disorders, however, are a group of clinical conditions characterised by the inability of individuals to exert control over their mood. In the case of depression, this can lead to a disabling degree of subjective distress and functional impairment (American Psychiatric Association, 1994).The major clinical characteristics of depression are low/sad mood and a loss of interest in activities from which the person previously gained pleasure (anhedonia). It is also common for the person to experience a range of associated symptoms, which are listed below.The person will also commonly have thoughts of suicide or death, sometimes unwanted (intrusive negative thoughts) and may become increasingly irritable and aggressive. Depression nearly always results in impaired interpersonal, social and occupational functioning.
To make a diagnosis of depression, the person must have exhibited specific characteristics continually for a period of at least two weeks. The essential criteria for making a diagnosis are:- Low mood/sadness- Loss of interest in pleasurable activities.The person will also need to exhibit at least four of the following:- Disturbed sleep- Loss of appetite- Agitation, irritability, aggression- Guilt or low self-worth- Pessimism or hopelessness- Fatigue or loss of energy- Slowing of movement or speech- Diurnal variation in mood- Poor concentration- Suicidal thoughts or acts- Loss of confidence- Reduced libido.The intensity of symptomatology can and often does vary throughout the day (diurnal variation) and it is important for the clinician to establish a clear picture of the individual’s experience of depression and its impact on his or her ability to function independently.
Similarly, it is necessary to establish whether the patient has been continually depressed for a period of two weeks or more so as to rule out a recent (normal) grief/loss reaction or adjustment disorder due to personal circumstances. In establishing this, the nurse can elicit the change in mood state across the day (better in the morning, worse in the evening or vice versa).Frequently, depressed individuals will have a sense of complete hopelessness and will feel that their perspective on the futility of life is true and accurate, and this can cause difficulty in establishing any sense of hope and interfere with efforts to build a therapeutic alliance.
Estimates of the prevalence of depression in the UK is 21 per 1000 of the population, with a gender ratio of 17 men to 25 women (Meltzer et al, 1995a; 1995b). The same studies show that the figure rises markedly to 98 per 1000 population when the broader category of mixed depression and anxiety is considered, with an even greater bias towards women (71 men to 124 women).
Age, ethnicity and marital status also affected the figures, with a higher prevalence of depression among widowed and divorced/separated individuals. Women with Asian or Oriental backgrounds had a markedly higher suicide rate (51 per 1000 population) than those from white European (24 per 1000) or West Indian and African (6 per 1000) cultures. (These figures are per total population.) The prevalence of depression in both men and women was low among those in employment, but rose significantly among the unemployed, with the number of women more than double the number of men (56 women to 27 men per 1000 population). Similarly, those living in rented accommodation were significantly more likely to take their life than those who lived in their own homes. Among the homeless and those living in hostels, the prevalence of depression is estimated to be as high as 60% (Gill et al, 1996).
The voice of the patient
There was considerable patient input in the compilation of the National Institute for Clinical Excellence (NICE) guideline on depression (NICE, 2004), which highlights important points, including the use of the term ‘patient’ to refer to people with depression.The document includes various accounts of living with depression. One person recounts: ‘The really effective treatment only began when I consulted a GP who … took time to explain what was happening, described the possible side-effects, the interaction with alcohol and other medications but, most importantly, assured me that depression did not necessarily have to be a ‘life sentence’ … .’It is important actively to involve patients in their treatment and to provide them with good information regarding both their clinical condition and the treatments available. The patient consensus is that health-care professionals have traditionally relied too heavily on prescribing antidepressant medication without offering concomitant psychological support (Smith, 1995; Singh, 1995).
Pharmacological treatmentA number of medicines that have been proven to have so-called mood-lifting effects are used in treating depression. Broadly speaking, they work by blocking the synaptic reuptake of monoamines such as noradrenaline, 5-hydroxytryptymine and dopamine.Traditionally, these medicines fall into the class of tricyclic antidepressants (TCAs) and have significantly benefited patients when taken regularly over a period (normally four to six months) (Geddes et al, 2003a). However, the beneficial effects do not become evident to the patient for some time (normally three to six weeks) and the side-effects can be unpleasant. As a result, patient concordance can be sporadic and difficult to ensure. Even then, there is a high mortality rate associated with the overdose of tricyclic antidepressants, and patients who present as suicidal need very close monitoring until they are well recovered.This is especially important for those who have been severely depressed, as they are often at greater risk of suicide when they begin to recover and their volition increases (and, thus their ability to act on the wish to be dead). This is particularly relevant for nurses looking after such patients, who will need to monitor closely progress and concomitant changes in risk .
A relatively new class of drugs - selective serotonin reuptake inhibitors (SSRIs) - has been shown to have good mood-lifting effects but with significantly fewer unpleasant side-effects and less risk of toxicity if taken in large doses, thus reducing the risk of overdose (Montgomery, et al, 1994). These medications inhibit the reuptake of serotonin into the presynaptic neurone, thereby increasing neurotransmission. They have a reduced effect on noradrenaline and dopamine, and they are less cardiotoxic and much safer in overdose than TCAs or monoamine oxidase inhibitors (MAOIs). These factors have contributed to SSRIs becoming the first choice of prescription antidepressant.Monoamine oxidase inhibitors are a group of drugs that have been available for more than 50 years, and are effective in the treatment of depression. However, they have the potential to induce hypertensive crisis if taken alongside foods containing tyramine; consequently, this class of drug is rarely prescribed, even in in-patient settings.
So-called third generation antidepressants were developed after the introduction of SSRIs to offer the benefits of both the long-term mood-stabilising effects of the TCAs and the low risk of toxicity and fewer side-effects of the SSRIs. Their action is on monoamines other than serotonin but they avoid the toxic side-effects of TCAs. In particular, venlafaxine is notable as the first of the new generation of dual-action antidepressants, which inhibit reuptake of serotonin and noradrenaline in the same way as TCAs while also inhibiting the reuptake of dopamine at higher doses. Recently, a third generation antidepressant, duloxetine (Cymbalta), has become available for treating depression. It is a serotonin (5-HT) and noradrenaline (NA) reuptake inhibitor.
A number of psychological approaches have proven to be effective in helping individuals reduce the distress associated with depression and increase their ability to lead an independent life. The range and complexity of these is great, and the focus differs according to the approach.
Cognitive behavioural therapy - This therapy explores the link between behaviour, thought and mood, and examines the thinking processes that maintain the individual’s negative view of life. By modifying or adapting these thinking styles, it is possible to reduce the associated level of distress and increase activity. For example, consider someone who says: ‘I’m so fat and ugly no one could ever love me.’ In this case, it is neither the individual’s weight nor their physical features that cause the distress but the thoughts and beliefs associated with how they compare themselves to a culturally constructed ideal. The distress emanates from the person’s own thoughts and the impact of these thoughts on mood.Therapy aims at understanding and deconstructing the ‘faulty’ beliefs behind this reaction, which is probably something like ‘People will only love me if I’m physically attractive’, although establishing an accurate understanding of the patient’s thinking, rather than the therapist’s assumptions of what the patient is probably thinking, is probably crucial.This model depends on the clinician having a sound therapeutic alliance with the patient to facilitate exploration of the individual’s ‘schemas’ (sometimes referred to as core beliefs or character traits), so as to identify thinking styles or patterns that contribute to negative thoughts, establish how these are activated and understand the impact on mood. By so doing, we are able to work with patients to modify or make sense of their thinking style and how it maintains their depression.
Behaviour therapy - This focuses more on the symptomatology of depression and on learning to tolerate and cope with certain feelings and circumstances by employing relaxation or problem-solving techniques (Nezu et al, 1989). This links with problem-solving therapy in that the focus is not on the individual’s previous experiences or the circumstances leading to the current depressive episode but on the aggregate of problems faced by the patient at this time (Lewis, et al, 2003). For example, the clinician may ask patients: ‘If your problems vanished, what would be different about your life?’ This will generally encourage patients to focus on specific aspects of their life that contribute to their distress; in answer they will often highlight material aspects, such as: ‘I wouldn’t be in this much debt’ or ‘I’d have a better job.’ The focus is then on helping these patients to regain some sense of being in control of their life by making decisions about how to deal with these issues. These styles differ markedly from counselling and psychodynamic psychotherapy, which focus more on exploring the drives and early life experiences of an individual as being contributory to the way the person makes sense of the world.
Electroconvulsive therapy - ECT is possibly the most contentious treatment. Many clinicians believe it is an effective option in cases of severe depression and that it has been used to good effect for more than 70 years. Others, and some patient groups, consider it to be antiquated. Despite these concerns, the NICE Technology Appraisal Guide (2003) concluded that it is an effective treatment for depression, especially severe and life-threatening depression.The procedure involves placing electrodes across one or both temples to the side of the forehead and briefly passing an electric current through the brain. This is designed to induce a seizure similar in nature to that of an epileptic fit (Geddes, et al, 2003b). A muscle relaxant is also administered beforehand, to minimise muscular spasm during seizure.
The role of the nurse in detecting and diagnosing depression is crucial. It is even more vital in engaging patients to explore their experience and in establishing a therapeutic alliance that will allow supportive and therapeutic psychological intervention as the treatment of choice in mild depression and as an adjunct to medication in moderate to severe depression.Well informed and supportive intervention from the nurse can dramatically aid recovery and help others to understand the experience of the patient and the effects of the illness.Early and accurate detection, timely and appropriate intervention and support for the family and carers of such individuals will contribute significantly to reducing the number of deaths resulting from suicide, self-harm or neglect.
The White Paper Saving Lives: Our healthier nation (DH,1999a) set a target to reduce the suicide rate by at least one-fifth by 2010. This would be achieved by developing better understanding among those able to provide early detection, diagnosis and treatment, and by targeting high-risk groups, such as seriously mentally ill young men aged 15 to 24 and people who self-harm, for screening.The National Service Framework for Mental Health (DH,1999b) states that its aim is to ensure that health and social services play their full part in achieving the target in Saving Lives (1999a). Some primary mechanisms for doing this are:- Promoting good mental health- Providing high-quality primary mental health care- 24-hour access to care/help for people with mental health needs- Better training in risk assessment, audit and analysis to identify high-risk performance.
Author’s contact details
Peter Melia, Nurse Consultant (Forensic Mental Health), Tees and North East Yorkshire NHS Trust, The Hutton Centre, St Luke’s Hospital, Marton Rd, Middlesborough TS4 3AF. Email: email@example.com
American Psychiatric Association. (1994)Diagnostic and Statistical Manual of Mental Disorders (DSM-!V). APA: Washington DC.
Appleby, L., Shaw, J., Amos, T. et al. (1999)Safer Services. Report of the national confidential inquiry into suicide and homicide by people with mental illness. London: The Stationery Office.
Department of Health (1999a)Saving Lives: Our healthier nation. London: DH.
Department of Health (1999b)National Service Framework for Mental Health. London: DH.
Department of Health (2002)National Suicide Prevention Strategy for England. London: DH.
Geddes, J. R., Carney, S.M., Davies, C. et al. (2003a)Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet 361: 9358, 653-661.
Geddes, J., Carney, S.M., Cowan, P. et al. (2003b)Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 361: 9360, 799-808.
Gill, B., Meltzer, H., Hinds, K. et al. (1996)Psychiatric Morbidity Among Homeless People. OPCS Survey of Psychiatric Morbidity in Great Britain. Report 7. London: DH.
Lewis, G., Anderson, L., Araya, R. et al. (2003)Self-help Interventions for Mental Health Problems. Report to the DH R&D Programme. London: DH.
Meltzer, H., Gill, B., Petticrew, M. et al. (1995a)The Prevalence of Psychiatric Morbidity Among Adults Living in Private Households. OPCS Surveys of Psychiatric Morbidity, Report 1. London: DH.
Meltzer, H., Gill, B., Petticrew, M. et al. (1995b)Economic Activity and Social Functioning of Adults with Psychiatric Disorders. OPCS Surveys of Psychiatric Morbidity, Report 3. London: HMSO.
Montgomery, S.A., Henry, J.A., McDonald, G. et al. (1994)Selective serotonin reuptake inhibitors - meta-analysis of discontinuation rates. International Clinical Psychopharmacology 9: 47-53.
National Institute for Clinical Excellence. (2003)Technology Appraisal Guide. London: NICE.
National Institute for Clinical Excellence. (2004)Depression: Management of depression in primary and secondary care. London: NICE. Available at: www.nice.org.uk/CG023fullguideline (accessed February 7, 2005).
Nezu, A.M., Nezu, C.M., Perri, M.G.Problem-solving Therapy for Depression: Theory, research and clinical guidelines. New York, NY: Wiley.
Singh, S. (1995)Treatment-resistant depression: causes and consequences. Psychiatric Bulletin 19: 11, 676-680.
Smith, A. (1995)Treatment-resistant depression: causes and consequences. Psychiatric Bulletin 19: 11, 680-685.