The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [155]
An ability to ‘refer on’ when it is recognized that the issues are beyond the scope of experience. This must be done with the patient’s consent.
Awareness of the stigma attached to a diagnosis of depression, and protection of the patient’s privacy and dignity.
Sensitivity to diverse cultural ethnic and religious backgrounds considering variations in presentations of low mood.
Awareness of any cognitive impairments or learning disabilities to ensure that specialist therapists are involved (where needed).
Use of hospital psychological care departments can assist with the care and treatment of patients as well as providing a supervisory and support framework for staff. Working with psychological care departments can help nurses develop their assessment skills of anxiety and depression helping them to identify the appropriate time for a referral to a specialist service if required (Towers 2007).
Preprocedural considerations
Pharmacological support
There are four main types of antidepressant (Royal College of Psychiatrists 2010). When prescribing antidepressants, the two main considerations are the presence of other physical health problems and the side-effects of the drugs which may affect the underlying physical disease.
There is minimal difference between the effectiveness of each type of antidepressant; however, there are clear differences in the side-effects of the different classes and types of antidepressants.
The therapeutic effect of antidepressants may take months to appear and treatment should continue for at least 6 months after a response to the treatment.
Selective serotonin reuptake inhibitors are safer in overdose than tricyclic antidepressants (TCAs), which can be dangerous. There is, however, an increased risk of gastrointestinal bleeding with SSRIs so they should be avoided in patients taking non-steroidal anti-inflammatory drugs.
Monoamine oxidase inhibitors can affect blood pressure, particularly when certain food types are eaten.
Serotonin-norepinephrine reuptake inhibitors are not appropriate for patients with heart conditions as they too increase blood pressure.
Table 5.2 lists the most commonly prescribed antidepressants (RCP, BSRM, NCPCS 2008).
Table 5.2 Most commonly prescribed antidepressants
Medication Trade name Group
Amitriptyline Tryptizol Tricyclic
Clomipramine Anafranil Tricyclic
Citalopram Cipramil SSRI
Dosulepin Prothiaden Tricyclic
Doxepin Sinequan Tricyclic
Fluoxetine Prozac SSRI
Imipramine Tofranil Tricyclic
Lofepramine Gamanil Tricyclic
Mirtazapine Zispin NaSSA
Moclobemide Manerix MAOI
Nortriptyline Allegron Tricyclic
Paroxetine Seroxat SSRI
Phenelzine Nardil MAOI
Reboxetine Edronax SNRI
Sertraline Lustral SSRI
Tranylcypromine Parnate MAOI
Trazodone Molipaxin Tricyclic related
Venlafaxine Efexor SNRI
SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin and noradrenaline reuptake inhibitor; MAOI, monoamine oxidase inhibitor; NaSSA, noradrenergic and specific serotonergic antidepressant.
Nurses have an important role in exploring with the patient any concerns they may have regarding taking an antidepressant. The patient should be equipped with all the necessary information regarding the optimum time to take the medication and the expected length of time before any therapeutic effect becomes apparent. Medication should be taken for at least 6 months following remission.
Discontinuation of treatment usually requires titration of doses. Therefore treatment must not be stopped abruptly and should be monitored by the prescribing doctor or nurse. Concerns regarding addiction require further information and reassurance confirming that this is unlikely to happen with the more modern antidepressant treatments. Further information on pharmacological intervention can be found in the NICE guidelines on depression (NICE 2009a).
Non-pharmacological support
Nurses can be involved in assessing depression in patients with physical illness. NICE guidance sets out a four-step model for managing a patient with depression.