The second article in this two-part series focuses on supporting patients with depression
In this article…
- Prevalence of depression in people with long-term conditions
- The role of nurses in recognising depression
- How to support clients with long-term conditions and depression
Mike Nash is lecturer in psychiatric nursing, Trinity College, Dublin; Justin McDermott is lecturer in mental health, Middlesex University.
Nash M, McDermott J (2011) Mental health and long-term conditions 2: managing depression. Nursing Times; 107: early online publication.
This second article in a two-part series on mental health and long-term conditions discusses the complex area of comorbid physical health and mental health problems. It focuses on depression – one of the most common mental illnesses – examining its prevalence and symptoms in people with long-term conditions, and how it can affect the ability to self-manage them. It also examines how nurses can support clients who experience depression as part of their long-term condition.
Keypoints: Mental health service users, Long-term conditions, Depression
- This article has been double-blind peer reviewed
- Download a print-friendly PDF file of this article here
5 key points
- It is estimated that 15.4 million people in England have a long-term condition
- Depression is two to three times more common in people with a chronic physical health problem
- Pain and fear of the future are reasons why people with long-term conditions are at increased risk of depression
- Depression can go unnoticed because patients may not mention symptoms for fear of being labelled “mentally ill”
- Working in partnership is fundamental in managing comorbid physical and mental illness
In England, an estimated 15.4 million people have a long-term condition (Department of Health, 2008a). Conditions such as cardiovascular disease, diabetes and cancer are associated with mental illness; the more serious the condition, the higher the risk (Sederer et al, 2006). Long-term conditions can be complex and many people present with multiple conditions such as diabetes, obesity and hypertension. These conditions can impact on mental health, making clients more susceptible to anxiety or depression; comorbid mental ill health can present a risk to the successful management of long-term conditions.
Government policy is committed to reducing the number of people with physical ill health and long-term conditions who develop mental health problems (DH, 2011). This presents a significant challenge to nurses who have little or no training in mental health care.
Prevalence of depression in long-term conditions
Research has suggested a high prevalence of comorbid depression in a range of
physical illnesses – for example, prevalence is 33% in people with cancer and 44% in those with HIV/AIDS (World Health Organization, 2003). The National Institute for Health and Clinical Excellence (2009a) stated depression is approximately two to three times more common in patients with a chronic physical health problem.
Yohannes (2005) suggested depression affects as many as 40% of patients with chronic obstructive pulmonary disease and that this might be untreated.
Katon (2008) found depression frequently occurred comorbidly with diabetes, suggesting up to 80% of patients with diabetes and depression will experience a relapse
of depressive symptoms over a five-year period. Depression was also found to be associated with non-adherence to diabetes self-care.
Depression is a common problem in patients with acute and continuing cardiac conditions. In 2008, the British Heart Foundation found as many as three in every 10 people reported feeling anxious or depressed after a heart attack.
Why people with long-term conditions get depressed
There are several reasons why people with long-term conditions are at increased risk of depression. Pain is an obvious issue – in a systematic review Dickens et al (2002) found depression to be more common in patients with rheumatoid arthritis than in healthy individuals, partly because of the pain they experienced. Fear of the future is also a factor in degenerative conditions, for example people with multiple sclerosis are almost three times more likely to suffer from major depression than the general population (Reeves, 2003).
Another reason people become depressed is the nature of the interventions for their physical condition. For example, invasive daily treatments like insulin injections or having to modify lifestyle are constant reminders of illness. This can be disempowering for individuals, who can then feel their life is no longer their own.
Why depression might be missed
Depression can go unnoticed in patients with long-term conditions. Often individuals do not disclose their symptoms for fear of being labelled “mentally ill”; to compound this, nurses may not feel confident asking patients about depression because they lack the knowledge and skills to recognise symptoms.
Nurses may also overempathise with patients; for example, in thinking: “If I had to inject insulin three times a day, I’d be depressed too,” they may actually be re-labelling legitimate symptoms of depression as natural responses to ill health. This response can delay diagnosis and treatment.
Effects of depression on ability to self-care
Depression can impair people’s abilities to self-care and affect their ability to eat, drink or sleep. Poor diet and irregular sleep patterns can also magnify existing physical symptoms such as fatigue.
Depression can also negatively impact on mood, thinking, memory and concentration. This can impair the ability to “think straight” and may contribute to poor self-management of long-term conditions through unintentional non-concordance if a person’s ability to follow or understand complex treatment regimens may be compromised. Nurses should be mindful that variable treatment responses to established interventions could indicate depression in those clients who are vulnerable.
The role of nurses in recognising depression
Nurses need to recognise signs and symptoms of depression to intervene effectively. They also need to differentiate between depressive and physical symptoms as, at times, they can be similar. For example, poor memory and agitation may be mistaken for symptoms of dementia in older clients, rather than depression. Nurses need to be aware that having a long-term condition can increase the risk of experiencing a depressive episode.
Practitioners should note the various symptoms of depression; these are outlined in Table 1, which should be used as a general guide. If they have concerns about a patient, health professionals should contact the local mental health service.
Once depressive symptoms have been recognised, they can be assessed using validated tools such as the Hospital Anxiety and Depression Scale or the Beck Depression Inventory for Primary Care (Beck et al, 1997; Zigmond and Snaith, 1983). These tools help nurses to screen clients and identify those who may need more specialised mental health care (Box 1). However, nurses should know how to interpret such tools – for example, depression has some physical signs and symptoms which, if similar to symptoms of the physical illness, may increase the depression score.
Initially nurses will need training and support in using these tools, but will develop confidence and competence naturally with practice. Support and supervision from mental health colleagues can also be helpful. The focus should be to enable general nurses to recognise signs and symptoms of depression and communicate these effectively; the intention is not to turn general nurses into “mini mental health nurses” but to safely extend practice in order to offer holistic, high-quality care to clients.
Supporting clients with a long-term condition and depression
NICE (2009b) suggested health professionals manage depression depending on: the number, duration and severity of the presenting symptoms; past family history; and availability of social support. Making care for people with comorbid physical and mental health problems seamless is an important goal requiring a coherent policy response. The Darzi report (DH, 2008b) suggested working in partnership is vital for high-quality health services and in managing comorbid physical and mental illness.
The role of the general nurse in managing a comorbid mental health problem is to provide safe and competent care for both conditions. At a basic level this will not be too problematic but management can become more complex if a client develops a major depressive illness.
General nurses can provide holistic care to clients, even though they may not have specialist skills. If clients appear “out of sorts” this should prompt nurses to ask about depression. This is important as they may have an existing depression that has not yet been diagnosed.
Managing comorbidity interprofessionally
Most general health services, such as primary care centres, A&E departments and hospitals will have access to specialist mental health practitioners who can supervise and educate colleagues on issues such as depression. Avenues for sharing care, such as having temporary mental health input into long-term conditions, would enhance the philosophy of inter-professional working.
The Royal College of Psychiatrists (2010) suggested a quarter of all patients in general hospitals have mental health problems. Liaison psychiatry is the specialty that assesses and manages mental illness in patients with medical conditions. Harrison and Hart (2006) stated that it could be particularly beneficial in
settings such as A&E, cardiology, cancer and perinatal units.
Liaison psychiatry can benefit general nurses through support, supervision and joint working, and their clients through holistic and specialised assessment and joint management. Waghorn (2010) found that liaison psychiatry based in emergency departments strengthened staff relationships, and had the potential to reduce unnecessary admission, increase interprofessional working and provide more responsive services.
Primary care graduate mental health workers
In the community, district and practice nurses and health visitors can benefit from support from primary care graduate mental health workers, whose role is to provide increased capacity in the primary care setting to improve the management of common mental health problems. These practitioners help jointly to manage complex referrals. They can use brief therapy interventions and cognitive behavioural therapy techniques with clients and promote positive mental health by offering education to clients, carers, family and the primary care team.
Integrated care pathways
NHS Quality Improvement Scotland has developed integrated care pathways (ICPs) for several mental health problems, including depression. It defines these ICPs as a system of care that encompasses how it is organised, coordinated and governed (NHSQIS, 2008). Although not specifically for comorbid presentations, the ICP for depression can be used as a guide to managing depression care. Split into non-complex and complex needs, it is divided into five standards (Table 2).
Complexity in ICPs can be defined by severity of depressive symptoms, with non-complex cases being managed without specialist mental health input. Complex cases – for example clients with suicidal ideas – would need specialist mental health intervention.
Nurses considering developing ICPs for clients should do so in an interprofessional way, involving mental health services so specialist advice and input is given at the planning stage. Client and carer views should also be sought as they can offer a unique insight into the reality of service provision, which at times fails to live up to the rhetoric.
Depressive episodes can be, and are, effectively managed by general nurses. Offering support, listening to clients and allowing them to express their feelings will reassure them. Nurses should encourage clients to join self-help or support groups, which can also provide peer support.
Depression in physical illness is a modifiable risk factor – it can be changed. This will have implications for practice such as: providing individualised client care using evidenced-based guidelines and ICPs; educating clients about conditions and treatments so they can develop self-management strategies; and, ultimately, promoting independence, to give them back the sense of control they may feel has been taken away. However, this should be done cautiously and services should always be available to deal with any crises that occur with long-term conditions.
Nurses also need to have the confidence to enable clients to make positive choices; this will come from education and training. They should also engage in reflective practice and clinical supervision to identify their learning and skills needs.
Beck AT et al (1997) Screening for major depression disorders in medical inpatients with the Beck Depression Inventory for Primary Care. Behaviour Research and Therapy; 35: 8, 785-791.
British Heart Foundation (2008) Anxiety and Depression after a Heart Attack or Heart Surgery. IS40 Information Sheet. London: BHF.
Department of Health (2011) No Health Without Mental Health: a Cross-Government Mental Health Outcomes Strategy for People of All Ages. London: DH.
Department of Health (2008a) Raising the Profile of Long Term Conditions Care: A Compendium of Information. London: DH.
Department of Health (2008b) High Quality Care for All: NHS Next Stage Review Final Report. London: DH.
Dickens C et al (2002) Depression in rheumatoid arthritis: a systematic review of the literature with meta-analysis. Psychosomatic Medicine; 64: 52–60.
Harrison A, Hart C (2006) Mental Health Care for Nurses: Applying Mental Health Skills in the General Hospital. Hoboken, NS: Wiley-Blackwell.
Katon WJ (2008) The co-morbidity of diabetes mellitus and depression. American Journal of Medicine; 121: 11, Suppl 2, S8-15.
NHS Quality Improvement Scotland (2008) Toolkit for Integrated Care Pathways for Mental Health. Scotland: NHS QIS.
National Institute for Health and Clinical Excellence (2009a) Depression in Adults with a Chronic Physical Health Problem, Treatment and Management. London: NICE.
National Institute for Health and Clinical Excellence (2009b) Depression, the Treatment and Management of Depression in Adults. London: NICE.
Reeves D (2003) Multiple sclerosis and depression. MS Matters 50 INSIGHT Supplement;July/August. London: MS Society.
Royal College of Psychiatrists (2010) No Health without Mental Health. London: RCP.
Sederer LI et al (2006) Integrating care for medical and mental illnesses. Preventing Chronic Disease; 3: 2, A33.
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