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Depression has been much in the news recently. Marcus Trescothick talks openly about his own battle with the illness in his recently published book, and there have been several excellent documentaries on the effects of depression on people's lives. 
 
Depression - Sonia Hall of the Practice Nurse Association reviews some cases

There have been several excellent documentaries on the effects of depression on people's lives. I found one programme, which focused specifically on suicide, particularly moving.  For me as a practice nurse, there was one particular case which struck a chord: a well-off, good looking middle aged man seemed to have everything going for him when he was struck down by meningitis.  He had to have bilateral below knee amputations and bilateral lower arm amputations. He felt that his life had been lost.  People only truly became aware of how low he was feeling when he made a dramatic suicide attempt. During the interview he said that he felt guilty about not wanting to live because of all the kindness and hard work everyone had put in to keep him alive. He still finds life difficult at times, but now he can express his feelings more openly he has found it easier.

A young female presenting with depression
 
The case made me reflect on the case-finding we perform in General Practice as part of QOF.  Is it a number-crunching exercise, or do we really enquire into the lives of our chronically ill patients to see how they are mentally coping with their condition? The day after the suicide programme was shown I had a young patient present requesting a referral for counselling, as she reported she was increasingly having days when she felt very down and would cry for no apparent reason.

On further questioning it seemed that she had been experiencing periods of feeling low for some years, but she had dismissed them because she also had periods when she was full of energy. She experienced a nasty car accident approximately five years ago, which left her with epilepsy. When I asked her whether she felt that the mood swings were connected to the epilepsy diagnosis, she said she didn't think so.  She went on to say that she felt almost an obligation not to feel bad about the epilepsy as so many people had fought to keep her alive and, compared to death, epilepsy was only a small thing.  This was almost exactly the same response as the chap in the programme.

In-house resources really help 

I am fortunate to have an in-house counsellor within our practice who has a short waiting time for appointments.  Therefore, as I was happy that my patient wasn't in any danger of harming herself or others, I completed the referral form with a copy of my consultation notes and agreed with the patient she would ring or call in if she felt any change or just wanted to talk prior to the counsellor appointment.

Depression is much more powerful and unpleasant than the short episodes of unhappiness that we all experience from time to time.  It can last for months rather than days or weeks. Most people with depression will exhibit several of the symptoms listed below.
 

1. Feel unhappy most of the time
2. Lose interest in life and can't enjoy anything
3. Find it harder to make decisions
4. Can't cope with things you used to
5. Fell utterly tired
6. Feel restless and agitated
7. Lose appetite and weight (some people do the opposite and gain weight)
8. Take 1-2 hours to get off to sleep, and then wake up earlier than normal
9. Lose interest in sex
10. Lose your self-confidence
11. Feel useless, inadequate and hopeless
12. Avoid other people
13. Feel irritable
14. Feel worse at a particular time of the day, usually in the morning
15. Think of suicide 

Patients may not realise how depressed they are, because it can come on so gradually and they may be determined to struggle on, blaming themselves for being lazy or feeble. It is part of the nurse's role in general practice to persuade them it is not a sign of weakness and lead them to the right direction for help, such as a GP/counsellor appointment. 

NICE Guidance
 
The NICE Guidance for the management and diagnosis of depression in primary and secondary care highlights that the most important role of primary care is the screening of those patients most at risk.

• Treatment options in the Nice Guidance for mild depression include 
• Watchful waiting - if the patient does not want treatment or may recover with no intervention - further assessment should be arranged normally within 2 weeks
• Sleep and anxiety management
• Advise patients of all ages with mild depression of the benefits of following a structured and supervised exercise programme 
• Guided self-help - a programme that consists of the provision of appropriate written materials and limited support over 6-9 weeks. It includes professional follow-up of progress and outcome
• Computerised cognitive behaviour therapy - CBT helps you to look at and change the ideas that made you depressed.
• Psychological interventions - problem-solving therapy, brief CBT and counselling of 6 to 8 sessions over 10 to 12 weeks
• Review - consider contacting all patients with mild depression who do not attend for follow up

Guidance for moderate and severe depression can be found on the NICE Website.
 
Depression is an illness which, because of its stigma, can be often ignored and denied by patients.  Practice nurses are in a unique position to help screen these patients and signpost them to appropriate help.
 
Click here to read NICE Guidance 

 

This article is the sole work of the author and does not necessarily reflect the views of Johnson & Johnson Medical Limited or any of its affiliated business or companies, nor does the publication of this article on the CareMail website comprise an endorsement of its contents, for which Johnson & Johnson Medical Limited and its affiliated businesses and companies accept no responsibility. In particular no such Johnson & Johnson entity shall be liable for any damages or injury resulting from any reliance placed on any information provided in this article or for any possible inaccurate or misleading data or statements contained therein.

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