The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [154]
Depression
Definition
Currently, depression can be defined as:
… a range of mental health disorders characterised by the absence of a positive affect (a loss of interest and enjoyment in ordinary things and experiences), low mood and a range of associated emotional, cognitive, physical and behavioural symptoms. It is often accompanied by anxiety, and can be chronic even in milder presentations.
(NICE 2009a)
Depression describes a group of related disorders whose definition has changed over time.
Related theory
Depression is a common psychological response in patients with a chronic physical illness such as heart disease, diabetes and cancer. When this occurs, it is referred to as a ‘co-morbid’ depression. Co-morbid depression is difficult to detect as symptoms can be similar to the expected side-effects of the illness or treatment. For example, undetected depression rates in adult patients with cancer can be as high as 50% (Brown et al. 2009, Trask 2004). Depression can be found in 20% of patients with a chronic physical illness (NICE 2009a), which is 2–3 times higher than individuals in good health. It is therefore essential that patients with a long-term physical illness are regularly assessed for anxiety and depression.
Box 5.8 sets out some of the symptoms of depression (NICE 2009a).
Box 5.8 Symptoms that indicate a diagnosis of clinical depression
Behavioural
Tearfulness.
Irritability.
Socially withdrawn.
Changes to sleep patterns.
Lowered appetite.
Lack of libido.
Fatigue.
Diminished activity.
Attempts at self-harm or suicide.
Physical
Exacerbation of pre-existing pains.
Pains secondary to increased muscle tension.
Agitation and restlessness.
Changes in weight.
Cognitive
Poor concentration.
Reduced attention.
Pessimistic thoughts.
Recurring negative thoughts about oneself, past and future.
Mental slowing.
Rumination.
Emotional
Feelings of guilt.
Worthlessness.
Deserving of punishment.
Lowered self-esteem.
Loss of confidence.
Feelings of helplessness.
Suicidal ideation.
Depression can be accompanied by anxiety and can be diagnosed as either depression or mixed depression and anxiety. The incidence of depression in the UK has been quoted as 2.6% (2.3% male, 2.8% female). However, the figure for mixed anxiety and depression rises to 11.4% (9.1% male, 13.6% female) (NICE 2009a, p.18).
A normal low mood is differentiated from what is medically diagnosed as a depressive episode by the length of time the low mood is experienced. Low mood that persists for 2 weeks or more or rapid-onset/severe low mood are reasons for concern. The presence of other depressive symptoms contributes to a diagnosis as well as a consideration of how this low mood affects the individual’s ability to interact socially. Generally, depression is a time-limited disorder with the potential for full recovery within 6–8 months (NICE 2008a). However, if a chronic physical illness is present, this may be different. Severe depression may be accompanied by psychotic symptoms, that is, hallucinations or delusional thoughts.
Evidence-based approaches
Approaches to treatment of depression are influenced by the severity of the condition. Diagnosing depression has improved following the introduction of ICD-10 which lists 10 depressive symptoms, dividing them into:
sub-threshold <4 symptoms
mild 4 symptoms
moderately depressed 5–6 symptoms
severe 7 or more symptoms with or without psychosis.
Symptoms need to be present for greater than 2 weeks.
Core management skills include risk assessment plus the following.
Good communication skills are required to enable the nurse to elicit information from the patient (Brown et al. 2009, Strong et al. 2004) and show understanding of the problem.
A sufficient understanding of the signs and symptoms of anxiety and depression and ability to make a preliminary assessment.
A sufficient understanding of antidepressant medication to enable