According to World Federation for Mental Health (2012), depression is a serious and common mental disorder characterized by the feelings of worthlessness, persistent sadness, accompanied by loss of interest and energy to carry out daily activities for at least two weeks. Depression is a global health issue that affects millions of people in all communities around the world. 322 million people are affected by depression, the number of people reported they diagnosed with depression had increased more than 18.4% between 2005 and 2015 (World Health Organization, 2017). Although depression is the leading cause of disability in both males and females, females (5.1%) are more likely to be affected by depression when compared to males (3.6%) (World Health Organization, 2017). If major depression left untreated, it can lead to fatal results.
This paper first highlights the symptoms of depression based on the case study and the impact of depression on the individual. Furthermore, mental health assessment such as Mental Status Examination and Risk Assessment will be discussed. Role of the Mental Health Nurse will be clearly defined in this paper as well. In addition, Mental Health nursing management in term of pharmacological and psychological treatments, nursing interventions and discharge planning strategies will be further discussed in this paper.
Depression Symptoms and Impact
Major depression symptoms can range from mild to severe based on the individual condition. Symptoms such as depressed mood, loss of interest in activities, loss of energy, changes in appetite, significant weight change, sleep disturbances, feeling worthless or useless, lack of concentration, psychomotor retardation and suicidal thoughts can be seen in an individual with major depression (Athanasos, 2017). Individuals may present some of the symptoms stated above, but not necessarily all.
Based on the case study, the patient, Amanda Wilson had shown to experience most of the depression symptoms stated above. She stated she was struggling to get out of bed most of the times in the morning and preferred to stay at home rather than enjoying her usual activities such as basketball game. Amanda had shown that she lost interest in her social activities and work. Besides that, Amanda had experienced insomnia over the last four weeks. Lack of sleep caused her to become fatigued and unable to concentrate on her work and daily activities. Amanda weight had been losing significantly due to her poor appetite. In addition, Amanda stated that she was feeling useless or worthless and she didn’t feel that there is any meaning for her to be in this world. She had thought of ending her life.
For an individual to be diagnosed with major depression, five or more of the symptoms above must be present for at least two weeks accompanied with at least one of the symptoms must be either 1) depressed mood or 2) loss of interest (Athanasos, 2017). Amanda had experienced most of the symptoms over the last four weeks accompanied by depressed mood and loss of interest. Hence, she fulfilled the criteria for a major depressive episode and had been diagnosed with major depression by the psychiatrist.
Major depression can impact an individual in several domains such as family life, social life, work life, health status and personal financial by severely compromising the functionality of an individual (Fried ; Nesse, 2014). According to McKnight and Kashdan (2009), emotion does help us to maintain an interpersonal relationship with others by facilitating it and emotion of an individual with major depression will be greatly influenced. For example, the emotion of Amanda can no longer function normally due to her illness. She withdrew herself from her family and social activities, showing no interest and preferred to stay at home. This will interfere Amanda interpersonal relationship with others and thus affect her social and family life.
Health status of an individual with major depression can be impaired. A research had been conducted and showed that major depression could have a negative impact on an individual brain, heart, and other parts of the body (Walker et al., 2017) associated with a higher risk of cardiovascular disease, stroke and hypertension (Voss, Boettger, Schulz, Gross ; Bar, 2011). For example, Amanda had a poor appetite which resulted in weight loss recently. This may affect Amanda nutritional status which in turn contributed to tiredness or some illnesses such as muscle weakening.
Furthermore, major depression poses a great impact on an individual working life and their finances. For example, Amanda has taken several days off work because of her illness. She was not interested in work, unavailable to focus on her work and feeling fatigue. These will affect Amanda work performance, showing low productivity or even absence from work. As its worst, she may lose her job and income. In 2011, McLaughlin had conducted a study which showed that depressed workers lose 5.6 hours of effective working a week compared to 1.6 hour a week in non-depressed workers which results in a great reduction of income.
Role of Mental Health Nurse
Mental Health nurse works closely with patients who are diagnosed with mental health issues and plays a vital role in the healthcare system. One of the roles of mental health nurse is the formation of a therapeutic relationship between the patient and the nurse. The therapeutic relationship is important in providing care and promoting health outcome for the patient and can form through an effective communication, listening to the patient, showing compassionate care (Mendes, 2015; Pazargadi, Moghadam, Khoshknab, Renani ; Molazem, 2015). This makes patients feel safe and comfortable to disclose their emotional struggles or problems to the nurse. Moreover, Mental health nurse has the responsibility to provide fundamental nursing care based on the patient needs and focus on the recovery model of the patient.
Besides providing care for the patient, mental health nurse requires developing skills in assessing the patient. Assessment is important to recognize symptoms and aids in the treatment planning or nursing care delivery for the patient (O’Brien & Allman, 2017). Furthermore, mental health nurse has a key role in medication administration and patient education. The nurse should educate patient regarding their illness symptoms, the side effect of the medication and the illness management. The nurse also has the responsibility in providing support and encourage patient involvement in the decision-making process (Gray, Pfeil & Jones, 2009). However, a study showed that most of the patients stated they do not receive appropriate education regarding their condition and they have no involvement in treatment decision making (Hemingway & Snowden, 2013).
Mental Health nurse should carry out an ongoing assessment for their patient to review symptoms and evaluate the effectiveness of the treatment. Mental Status Examination is the important component used in Mental Health Assessment by using the BATOMI mnemonic. BATOMI refers to Behaviour and Appearance, Affect and Mood, Thought and Speech, Orientation, Cognition and Sensorium, Memory and Insight and Judgement (O’Brien ; Allman, 2017). This assessment is carried out through observation and conversation.
According to the case study, Amanda was assessed and information was documented as below:
Appearance ; Behaviour: Sudden change in appetite resulting in weight loss, withdrawn herself from social activities.
Mood ; Affect: Depressed mood, sleep disturbance, feeling worthless in her life and fatigue.
Thought: Suicidal thought.
Judgement: Amanda judgement was not impaired as she was agreeable to her admission.
Information provided by the case study was not applicable to other aspects of the Mental Status Examination. As a result, ongoing Mental State Examination is required to obtain a more complete and thorough information from Amanda in order to monitor her condition. Besides that, physical health assessment should also be considered in Amanda nursing care plan because many physical conditions would influence depression and vice versa (David ; Brenda, 2011).
Since Amanda had a suicidal thought, risk assessment should be conduct to identify the possible risk from the illness and prevent or minimize the risk that will compromise Amanda recovery process (Gilbert, Adams ; Buckingham, 2011) through conversation and observation. Amanda had mentioned before to her mother that she wanted to end her life and she did have a suicide plan. Apparently, Amanda has the risk of suicide. In addition, Amanda has the possibility of developing the risk of self-harm and risk of neglect. Factors that contributing to self-harm and neglect include low mood, depressed mood and sense of useless or abandonment (Wand, 2012) which in turn relates to Amanda condition as her mood was depressed and feeling worthlessness for the past 4 weeks.
Therapeutic relationship between Mental Health nurse and the patient need to be developed prior to any nursing interventions. The therapeutic relationship should develop based on trust and empathy towards the patient. A study had shown that developing of therapeutic relationship before any application of nursing interventions will improve the effectiveness of nursing management (Cronin, Lawrence, Taylor, Norton ; Kazantzis, 2015). Therefore, therapeutic relationship plays an important role in all healthcare setting.
After a good rapport had been developed between the Mental Health nurse and the patient, the nurse should provide physical needs for the patient. Patient with major depression will usually have a poor self-hygiene, weight loss and poor sleep due to their depressed mood (O’Brien & Allman, 2017). Based on the case study, Amanda had experienced fatigue, poor sleep and poor appetite which resulting in weight loss. All these factors can interfere with Amanda appearance and self-hygiene. As a result, the Mental health nurse should assist with the patient self-care and educate the importance of personal hygiene to the patient (Wilkinson, 2009).
In addition, the nurse should encourage the patient to eat and drink enough for their body needs and monitor their body weight (Prokofieva, Koukia & Dikeos, 2016). If food and fluid intake remain inadequate in the patient, the nurse should make a referral to the dietitian. Furthermore, nurses should monitor the sleep pattern of the patient, encourage the patient to sleep by giving them some warm milk to improve their sleep and assist patient to maintain a normal sleep cycle (Prokofieva, Koukia & Dikeos, 2016). If patient still not compliance with those interventions, sleep medication will need to be considered. Risk of neglect in Amanda can prevent through assisting in her self-care.
Risk of suicide and self-harm will increase as Amanda depressed mood lifting. The Mental Health nurse requires assessing Amanda regularly for her suicidal ideation or plan (Chauliac, Brochard & Payet, 2016). Nurses have the responsibility to create a safe environment for the patient and keep all of the danger or sharp objects away from the patient. Besides that, a verbal contract should be formulated by the nurse that the patient will not self-harm (Brunero & Lamont, 2017).
Furthermore, Mental Health nurse needs to encourage Amanda to participate and make a decision on her care plan and scheduled group activities. Participation in decision making and group activities can increase the patient self-esteem (Queensland Health, 2013). Nurses also have to spend 1 to 1 time with Amanda to educate her about depression and introduce some effective methods for Amanda to cope with or relieve her depressive symptoms. Hopelessness in Amanda is another area that requires nursing management. Nurses should identify the stressors in Amanda’s life that trigger the crisis and encourage Amanda to express her feelings and perceptions (Vyas ; Agius, 2011). Nurses also need to help Amanda to set goals and identify her skills and knowledge in order to help Amanda improve her sense of self-worth and move towards recovery (Anthanasos, 2017).
Mental Health nurse plays a role in educating medication to the patient as the patient has the rights to know what they are taking and the side effects of the medication (Hochberger ; Lingham, 2017). Amanda had been prescribed with Escitalopram 5mg and Mirtazapine 7.5mg by her psychiatrist. Escitalopram is an anti-depressant medication that used for major depressive order through inhibits the reuptake of serotonin at the presynaptic membrane (Usher, 2017). The side effects of Escitalopram include nausea, diarrhoea, insomnia, restlessness, loss of appetite, weight loss, headache and sexual dysfunction (McKenna ; Anecita, 2014). This medication should not be increased dosage or use in combination with other serotonergic drugs without doctor’s permission due to serotonin toxicity (Kennedy & Rizvi, 2009).
In the other hand, Mirtazapine also is an anti-depressant medication that used to treat depression in adults through inhibiting the reuptake of noradrenaline and serotonin (Usher, 2017). However, Mirtazapine was used as a sedation in Amanda case. The common side effects of Mirtazapine are nausea, dry mouth, excessive sweating, dizziness, agitation and constipation (McKenna & Anecita, 2014). Caution that needs to be considered with anti-depressant medications is the risk of suicidality as the mood of the patient will lift once they start with anti-depressant medication (Kirino, 2012). Besides that, nurses have to monitor closely for the side effects or any allergy reaction to the drugs for a period of time to ensure patient does not have any reaction towards the drugs. In addition, nurses also have to encourage patient complaint with their medications although they have not experienced any improvement in their condition initially and avoid intake of alcohol (Usher, 2017).
There are several treatments exist for the major depression and the selection of treatments was based on the severity of the patient condition. Individual psychotherapy is a treatment which aims to change the personal character and linked difficulties of living to the patient childhood development (Palmer, 2017). The study had shown that individual psychotherapy can improve mood and sleep issues in the patient (Blair, 2012). Besides that, cognitive behaviour therapy (CBT) is another treatment for the patient with depression that aims to change the patient unhealthy thinking, feeling and behaving (Palmer, 2017). This therapy usually carried out over 16-20 sessions. The therapist will use task-based approach for the patient to solve problems and providing them a more positive and full-filling solution. CBT had found to be very effective for many years and had been used widely in the mental health setting (Handley, Egan, Kane & Rees, 2015).
In addition, music therapy and exercise can be one of the treatments for major depression as well. Kvam, Kleppe, Nordhus & Hovland (2016) note that exercise is an effective treatment for depression by reducing the depressive symptoms in adults with depression. Furthermore, several studies believe that music therapy was effective in reducing the depressive symptoms and improving the sleep quality in the patient with depression (M. F. Chan, E. A. Chan & Mok, 2010). Both music therapy and exercise studies showed a reduction in patient’s depression scores (Verrusio et al., 2014). Lastly, electroconvulsive therapy (ECT) is a treatment using electric current to relieve depressive symptoms in the patient who diagnosed with severe depression (Palmer, 2017).
Recovery refers to “a process where the individual develops a new approach to life by taking responsibility for one’s illness, renewing a sense of hope, managing symptoms, overcoming stigma and being supported by others” (Meehan, 2017, p. 507). Strategies that enhance recovery need to be identified prior to patient discharge. Mental Health nurse has to involve Amanda’s family members in the meeting session to ensure her family members understand Amanda condition and able to ask clarifying questions. Besides that, nurses should educate Amanda and her family members regarding depression and coping skills because this enables patient family members to recognise early symptoms and able to seek help.
Education regarding medications and the importance of medication compliance should also be given to the patient and her family members to make sure patient compliant with medications. Pre-discharge assessment such as the risk of suicide, self-harm and self-neglect, diet intake, quality of life, sleep quality, early recognition of depression symptoms and social supports should be conducted to assess the independence of the patient (Department of Health & Human Services, 2018). Referral to the patient’s GP and community supports need to be made before discharge for follow up the patient condition in the community.
Depression is a common mental health issue in the Australia population and can affect an individual physical health and well-being. If depression left untreated, depression can affect one’s entire body. Therefore, an early recognition of symptoms and thorough mental health examination is important in reviewing the patient. Mental Health nurse plays an important role in assessing the patient mental status, suicide or self-harm risk, deliver nursing care, promote health outcome and enhance recovery process in the patient. Besides nursing care management need to be delivered effectively, treatments such as psychotherapy, music therapy, exercise and electroconvulsive therapy had proved to be effective in treating depression as well.