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