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Guided learning

Depression in adults with long term conditions 1: how to identify and assess symptoms  

  • 7 Comments

People with long term physical health conditions are at greater risk of suffering from depression. NICE provides guidance on carrying out assessments

Authors

Mark Haddad, PhD, MSc, BSc, RMN, RGN, is clinical research fellow, Institute of Psychiatry, King’s College London; Clare Taylor, DPhil, MPhil, BA, is editor, National Collaborating Centre for Mental Health; Stephen Pilling, PhD, MSc, BSc, is joint director, National Collaborating Centre for Mental Health, and professor of clinical psychology and clinical effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London.

Abstract

Haddad M et al (2009) Depression in adults with long term conditions 1: how to identify and assess symptoms. Nursing Times; 105: 48, early online publication.

The first in this two-part unit on depression in adults with long term conditions examines new NICE guidance on identifying and managing this mental health problem. It discusses the prevalence and causes of depression in this group, how to identify and assess the condition, and initial management options for those with subthreshold/mild to moderate symptoms.

Keywords: Mental health, Depression, Long term condition

  • This article has been double-blind peer reviewed

 

 

 

Learning objectives

1. Understand the impact of depression in adults with long term conditions and the challenges of recognising depression in this group.

2. Understand the range of interventions appropriate for milder levels of depression, and develop confidence in assisting in their delivery.

 

 

The National Collaborating Centre for Mental Health recently developed a national guideline on treating and managing depression in adults with long term conditions (NICE, 2009a).

Long term physical health problems, such as diabetes, heart disease, stroke, cancer and chronic obstructive pulmonary disease (COPD), are the leading cause of death throughout the world (including in developing countries) and contribute to nearly half of global disability. Over the next decade these conditions are projected to cause 73% of deaths and 60% of disability worldwide (World Health Organization, 2005). In England, over 15 million people (one third of the population) are living with long term conditions; in some PCTs the proportion of people with one or more such condition may be nearly 50% (Department of Health, 2008).

People with long term conditions are frequent and intensive users of health services – accounting for 72% of inpatient days in England and 65% of outpatient appointments (Office for National Statistics, 2006). As a result nurses and other healthcare professionals spend much of their time helping to care for this group. Nurses’ role with these people is varied and involves approaches such as systematic monitoring and proactive care linked to personalised care plans, encouraging and developing self care, and targeted case management (Department of Health, 2009a).

People with long term conditions are at increased risk of mental health problems, especially depression (Tylee and Haddad, 2007), and a key part of healthcare professionals’ role is to be alert to the possibility of depression. The assessment and appropriate care and referral of this group requires particular skills and knowledge.

The new NICE guideline (2009a) on treating and managing depression in adults with long term conditions provides important guidance on the health needs of people with these combined problems. The overall framework for the provision of services is based on stepped care, which was advocated in the first NICE guideline on depression published in 2004, and features in the updated guidance (NICE, 2009b). This approach has also been used to guide the management of asthma, heart disease and weight problems. The stepped care model (see NICE, 2009a) supports patients, carers and practitioners in identifying and accessing the most effective interventions. In stepped care the least intrusive, most effective intervention is provided first; if a person does not benefit from the intervention initially offered, or declines an intervention, they should be offered an appropriate one from the next step.

Depression in people with long term conditions

Depression occurs in about 20% of people with long term physical illness - a rate two to three times higher than in those who are in good health (Egede, 2007). This increased prevalence has been identified for a wide range of conditions such as cancer, heart disease, diabetes and musculoskeletal, respiratory and neurological disorders. Although there is a markedly higher prevalence of depression in those with long term conditions, the direction and reasons for this link are more complex and varied.

Research studies (for example, Benton et al, 2007; Harris et al, 2006; Lenze et al, 2001) show that having a physical long term condition can contribute to depression and increase the severity of pre-existing depressive symptoms. This comorbid relationship involves the symptoms and effects of a physical health problem: factors such as persistent pain, together with disability and difficulty maintaining certain roles in the face of long term illness, are unsurprisingly linked to the onset and exacerbation of depression (Prince et al, 2007). Moreover, some physical health problems appear to increase the risk of depression by physiological pathways. For instance, in stroke, neurological conditions such as Parkinson’s disease and heart disease, vascular and neurotransmitter changes contribute to the incidence of depression.

Conversely, depression can be a risk factor in the development of a number of physical illnesses such as cardiovascular disease (Nicholson et al, 2006), hypertension (Meyer et al, 2004) and diabetes (Mezuk et al, 2008). This is most obviously related to the effects of depression on health behaviours: people who are depressed are less motivated to engage in exercise or have healthy diets, and rates of smoking are increased (Murphy et al, 2003). Depression also exerts direct physiological effects that heighten the risk of physical illness. Depression related changes in the hypothalamic-pituitary-adrenal axis function influence cortisol secretion and affect inflammatory and immune system responses. This may cause atherosclerosis, as well as influencing changes in platelet aggregation and heart rate variability, and also decreases insulin sensitivity.

When people with long term conditions are also depressed, their level of functional impairment is likely to be greater than if they had depression or the physical health problem alone (Lenze et al, 2001). Treating depression in people with long term conditions has the potential to increase their quality of life and life expectancy.

The NICE guideline uses the DSM-IV (American Psychiatric Association, 1994) definitions of severity, outlined in Box 1. It also covers depressive symptoms below the DSM-IV (and ICD-10 [WHO, 1992]) threshold because it is increasingly recognised that these can be distressing and impairing if they are persistent.

 

 

Box 1. Severity of depression (according to DSM-IV)

Note that a comprehensive assessment of depression should not rely simply on a symptom count, but should take into account the degree of functional impairment and/or disability.

Subthreshold depressive symptoms: fewer than five symptoms of depression.

Mild depression: few, if any, symptoms in excess of the five required to make the diagnosis and symptoms result in only minor functional impairment.

Moderate depression:symptoms or functional impairment are between mild and severe.

Severe depression:patients have most symptoms and these markedly interfere with functioning. This level can occur with or without psychotic symptoms.

Source: American Psychiatric Association (1994)

 

 

Identification and assessment

Depression is a relatively common and disabling disorder. It is characterised by a particular pattern of symptoms; it is the cluster of symptoms together with their persistence and effect on function that distinguishes clinical (or major) depression from unhappiness or another mental health problem. Sustained low mood and loss of interest in normally pleasurable activities are central features, and experiencing one (or both) for most of the day for most days over a period of at least two weeks is necessary for diagnosis.

In addition to these core symptoms, other features of depression involve physical and psychological aspects of function, such as sleep or appetite disturbance, lack of energy, feelings of worthlessness or guilt, and poor concentration. At least five depressive symptoms with associated impairment of function are required for a diagnosis (see Box 1).

Around 30-50% of depressed patients are not recognised as such in consultations (Cepoiu et al, 2008). This may be because people are reluctant to disclose depressive symptoms or seek treatment, or it may be related to limitations in practitioners’ knowledge and skills, and obstacles related to consultations such as time pressures and lack of systematic procedures or guidance.

It appears that the problems in recognising depression in the general population are amplified when people have comorbid physical health problems (Koenig, 2007). This may be due to healthcare professionals interpreting depression symptoms as symptoms of the physical health problem. Often it may be the physical features of depression, such as poor appetite, weight loss, sleep disturbance and fatigue, which are misinterpreted.

One of the NICE guideline’s key priorities for implementation is identifying depression in people with long term conditions by using a two question screening tool (Whooley et al, 1997) (Box 2). This approach has been used in England since 2006, as part of thequality and outcomes framework (QOF) with those on the primary care registers for coronary heart disease and diabetes, rather than for all those with long term conditions. The NICE guideline promotes extending current practice to other settings and a wider patient group.

A positive response to either (or both) of these initial questions indicates the likelihood of depression – which should be followed up by a more detailed assessment, involving checking for all depressive symptoms together with associated impairments. NICE recommends using three questions about non physical symptoms following the two-question screen (see Box 2), as these are likely to improve the accuracy of assessment, and will usually form part of a mental health assessment. Healthcare professionals not trained to conduct assessments should refer patients to an appropriate professional.

 

 

Box 2. Depression identification questions

Consider asking patients who may have depression two questions:

  • 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 a patient answers yes to either of the above questions, ask:

  • During the last month, have you often been bothered by feelings of worthlessness?
  • During the last month, have you often been bothered by poor concentration?
  • During the last month, have you often been bothered by thoughts of death?

 

Assessment

In addition to physical illness, a wide range of psychological and social factors are likely to affect the course of depression and its response to treatment. Therefore, when assessing people with possible depression it is important to ask about any personal and family history of the condition. The impact of physical health problems on the development or continuation of depression should also be considered, as should any currently prescribed medication, which may be responsible for some symptoms or affect the choice of treatment for depression. If people have significant language or communication difficulties, consider using the Distress Thermometer (Roth et al, 1998), a visual scale on which patients mark their response to a single question: “How distressed have you been during the past week on a scale of 0-10?” Scores of four or more indicate a level of distress that should be investigated further.

All patients with depression should be assessed for their risk of suicide; this should be part of their mental health assessment and involves questions about suicidal ideas, intentions or plans, and any history of self harm. If people present significant immediate risk to themselves or others, they should be referred to a specialist mental health service.

Assessment of depression, as for many other health problems, is not limited to symptoms and their effects, but should also encompass patients’ social situation, range of supports and their own views about ways of managing their problems. Involving partners, family and carers in decisions about treatment and problem management is always an important aspect of care. In the case of chronic physical illness the likely impact on relationships and daily activity make it particularly important to include thier views and needs in management plans where appropriate.

Working effectively with people with long term conditions

The NICE guideline sets out principles for working effectively with people with depression and long term conditions, which include building a trusting relationship, being aware of possible stigma associated with having depression, providing good information about depression and its treatments and communicating clearly. Respecting diverse cultural, ethnic and religious backgrounds is also important and nurses who conduct mental health assessments and initiate treatment should be competent in culturally sensitive assessment and addressing cultural and ethnic differences when developing treatment plans. All healthcare professionals should also be familiar with latest guidance on consent (DH, 2009b), particularly if people have severe depression or are being treated under the Mental Health Act.

When people are treated in both primary and secondary care, there should be an agreement outlining the responsibility for monitoring and treatment, and the GP should be informed.

Initial treatment

Subthreshold symptoms and mild to moderate depression

Very often nurses - in primary care, the community, outpatients or in hospital - will be the healthcare professionals able to identify those with features of depression and, following assessment, help in determining initial approaches to management. The condition occurs at varying levels of severity, and the extent and intensity of symptoms are an important element in reaching decisions about the most appropriate management approach. Additionally, and of crucial importance, are the individual’s choices and available support resources, together with any past history of depression (and the types of treatment and help that worked or did not work).

People with few symptoms, or whose symptoms are relatively mild, require the same comprehensive assessment as more severe cases. This is because lower level symptoms may be a precursor to greater severity, and mild, subthreshold features can be associated with significant distress and impairment, which impacts on occupational and social function and physical health problems.

For people with mild depression and those who are likely to recover without formal treatment, those who do not want any interventions, or people with subthreshold symptoms who request an intervention, NICE (2009a) recommends:

  • Discussing the presenting problem(s) and any concerns;
  • Providing information about depression;
  • Arranging a further assessment, normally within two weeks;
  • Making contact if patients do not attend appointments.

Advice on improving quality of sleep may also be helpful, as sleep disturbance is a common symptom of depression. Education on sleep hygiene and associated printed information should be readily available. for patients. If subthreshold symptoms persist (or complicate the care of long term conditions) or patients have mild to moderate depression, NICE advises that a range of “low intensity” psychosocial interventions should be considered (Box 3). Relevant details and access arrangements should be readily available to nurses and other healthcare professionals.

 

Box 3. Low intensity psychosocial interventions

  • Physical activity programme (modified for the particular physical health problem)
  • Peer support programmes in groups of people with a shared long term condition
  • Individual guided self help based on principles of cognitive behavioural therapy (CBT)
  • Computerised CBT (CCBT)

 

 

NICE cautions that antidepressants should not be used routinely to treat subthreshold depressive symptoms or mild depression, but can be considered for:

  • People with a past history of moderate or severe depression;
  • Mild depression that complicates the care of physical health problems;
  • Initial presentation of subthreshold depressive symptoms that have been present for at least two years;
  • Subthreshold depressive symptoms or mild depression that persist(s) after other interventions.

 

Conclusion

Depression is far more common among people with long term conditions than in the general population. It seriously limits the quality of life of those affected, adding to their disability and negatively affecting the illness course, resulting in significantly increased mortality. All nurses are in a prime position to play an active role in recognising depression and managing this vulnerable patient group. The recent NICE guideline provides important evidence based support in planning and delivering the assessment, education and treatment for people with this combination of health problems.

  • Part 2 of this unit, to be published in next week’s issue, examines core treatments for moderate to severe depression in people with long term conditions
  • The work on which this Guided learning unit is based was undertaken by the National Collaborating Centre for Mental Health, which received funding from NICE. The views expressed here are those of the authors and not necessarily those of the Institute.

 

 

  • 7 Comments

Readers' comments (7)

  • When I read this sort of stuff, my heart sinks, why on earth are we tolerating such nonsense. It is obvious that people who are disabled for any length of time are going to be more likely to feel depressed.
    Anyone who has worked with Human beings will be painfully aware of this. To think that people are wasting money doing academic studies on these obvious conditions beats me.
    The question that follows is of much more importance than this irrelavant nonsense.
    The question is. Now that you have found out something that was obvious, what now? What causes this depression?
    I will guess the answer. When we were a herd animal relying on instinct, we probabally travelled over the plains of Europe, America, Asia, and Africa moving between the seasons, keeping fit and utilizing the warmth of the sun to sustain us.
    I imagine that the herd instinct kept us safe from the wild animals which knew how tasty we could be.
    We often quote the flight and fight hormone which helped our forefathers to survive attacks from preditors, and how, although fairly redundant in the modern world with its overprotected society, it still exists, and plays havoc with our mental health. Anxiety attacks have been attributed to adrenaline overproduction.
    So we generally accept this notion.
    So what happens to to some of the other defence mechanisms, now redundant in the modern world.
    Imagine this great herd travelling steadily across the plains of plenty. The standard reqirement for survival would be fitness to keep moving, the sheer numbers of the herd would provide protection from the predators in the way that flocks or shoals do for birds and fish.
    If a person became injured, or infirm, they would have to heal quickly or perish.
    In becoming injured they would hold the herd back, and drop to the rear of the community here they would gradually sink physically and mentally.
    By way of explanation I shall digress. On my way to work I nearly drove over a pigeon. I got out of the car to check on it. On inspection the bird looked depressed, it was lacklustre, slow and apparently unaware of its surroundings and the dangers therein.
    An oldish man said to me that it was "fed up" because it was a homing pigeon and it had lost its way, and got lost from the flock, he said it had given up.
    So back to the tribe of humans. If the injured fell back to the rear of the herd instinct would set in and the danger of being eaten by a Sabre tooth would become apparent. The flight and fight hormone would become exausted and something else replace it, after all the reality of being eaten alive would be hard to bear. So like the pigeon, the person would, by natures intervention, become depressed and "not care if they live or die" the feeling of "being no use",resembling the suicidal ideation symptomatic of modern day severe depression.
    The Herd of course, keeps moving, relaxing in the knowledge that so long as the injured fall back and dissapear, the survival of the rest remains assured.
    This is mirrored in modern mans apparent disinterest in the fate of the weak in society.
    I suppose that if this notion of mine is correct, then drawing depressed people back into a "herd" that cares for its citizens is the answer; and in order to acheive this, we should return to the asylums of the past where a person could recover the need to belong.

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  • please let me know if you read this

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  • Hello Glyn,
    I disagree with you on the count that it is 'nonesense'. I agree with you on the count that it is self-evident. On the first count: some nurses may find Nursing Times articles easier to read and more accessible than traditional text books. This is especially the case with 'younger' nurses trained in the internet age. Also, repetition re-inforces memory, and as a mental health nurse, revisiting the symptoms of mental illnesses keeps them at my finger tips.

    On the second count: the authors have not answered your nagging question; ''What causes this depression?''. The causes are linked to the risk factors which are numerous; bereavement, loss of professional identity (or identity of any kind), long term physical illness, sensory deprivation, perceived uselessness(for one reason or the other), dementia, other mental illnessess and a host of other risk factors. Depression is an illness which can only exist with the minimum of cognition. In other words, the individual must be able to think to become depressed. Persistent and prolonged negative rumination underpinned by any of the risk factors deepens low mood, and is very likely to lead to clinical depression. This is the cognitive cause. And this is why cognitive therapy is effective in treating depression because it aids the individual in understanding, and modifying his/her thinking pattern. However, there is a medical model backed up by studies which suggest an unexplained nuerochemical imbalance as a cause of depression. Hence, the use of antidepressants. In either case, the treatments are the same. But then again Glyn, these may also be self evident.

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  • So the poor little darlings cant think for themselves and can only get information from the internet. How arrogant is that? The internet carries a fantastic amount of information, and most learner Nurses know how to get that information as well as by using text books.
    And the stuff about CBT..another fraud. What really helps people is the warmth and care given skilfully by others., not this huge hoax called CBT.
    My heart sinks at the realization that you can be so sure of what you are most ignorant.
    However I respect the fact that you have replied to my comments and wish you good luck with your attempts to explain the obvious. Unfortunately I am slowly falling out with the faulty concept that depression is an illness that can be cured by the therapist explaining to the patient that they could recover if only they thought and felt differently about things.
    I dont think comparisons between treatments are of any help either. I dont think that one can be explained as being better or more suitable than the other.
    Again in my humble opinion,and I would love to be proved wrong, but the only thing that really helps is the warmth, regard, empathy, and listening skills of the helper. Im not even sure how these skills can be taught but if they can draw out the humanity and strength of the patient the patient can truly help themselves.
    Best wishes and Seasons greetings Glyn.

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  • Think you make a very important point about the significance of the restorative power of genuine compassion and respect (and associated qualities), sadly all too easily stifled and neglected within our systems of care.

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  • But of great worth where genuinely found and not given without cost, may those who give of themselves in the cause of helping to lift others up to a place of recovery be trully appreciated for the precious work they generally quietly but faithfully do. What an honour to to know it's not beyond anyone's power to make what may seen a small difference, yet lifechanging one.

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  • Are people who are depressed this way all the time every moment of every day? probably not and indeed they may be able to telll you when they don't feel so bad and on some days or parts of some day they don't feel as bad. Lets explore when things are not so bad how do they get through the day ?

    Can they imagine what its like if this feeling of depression are gone what it would be like? what would they notice?
    Too often we as Mental Health nurses follow the medical model of assessment and only want to know about the problem...we should ask what its like when the issue is less intense or not there.

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