Depression is a common response to health problems and is anoften underdiagnosed problem in the patient population. People may become depressed as a result of injury or illness; may be suf-fering from an earlier loss that is compounded by a new health problem; or they may seek health care for somatic complaints that are bodily manifestations of depression.
Clinical depression is distinguished from everyday feelings of sadness by its duration and severity. Most people occasionally feel down or depressed, but these feelings are short-lived and do not re-sult in impaired functioning. Clinically depressed people usually have had signs of a depressed mood or a decreased interest in plea-surable activities for at least a 2-week period. An obvious impair-ment in social, occupational, and overall daily functioning occurs in some people. Others function appropriately in their interactions with the outside world by exerting great effort and forcing them-selves to mask their distress. Sometimes they are successful at cam-ouflaging their depression for months or years and astonish family members and others when they finally succumb to the problem.
Many people experience depression but seek treatment for so-matic complaints. The leading somatic complaints of patients struggling with depression are headache, backache, abdominal pain, fatigue, malaise, anxiety, and decreased desire or problems with sexual functioning (Stuart & Laraia, 2000). These sensa-tions are frequently manifestations of depression. The depression is undiagnosed about half of the time and masquerades as physi-cal health problems (Carson, 1999). People with depression also exhibit poor functioning and high rates of absenteeism from work and school.
Specific symptoms of clinical depression include feelings of sadness, worthlessness, fatigue, and guilt and difficulty concen-trating or making decisions. Changes in appetite, weight gain or loss, sleep disturbances, and psychomotor retardation or agita-tion are also common. Often, patients have recurrent thoughts about death or suicide or have made suicide attempts (American Psychiatric Association, 2000). A diagnosis of clinical depression is made when a person presents with at least five of nine diag-nostic criteria for depression. Chart 7-10 lists these criteria (American Psychiatric Association, 2000). Unfortunately, only one of three depressed people is properly diagnosed and appro-priately treated.
In the United States, about 15% of severely depressed people commit suicide, and two-thirds of patients who have committed suicide had been seen by health care practitioners during the month before their death (National Institute of Mental Health, 1999). When patients make statements that are self-deprecating, express feelings of failure, or are convinced that things are hope-less and will not improve, they may be at risk for suicide. Risk fac-tors for suicide include the following:
· Age younger than 20 or older than 45 years, especially older than 65 years
· Gender—women make more attempts, men are more successful
· Dysfunctional family—members have experienced cumu-lative multiple losses and possess limited coping skills
· Family history of suicide
· Severe depression
· Severe, intractable pain
· Chronic, debilitating medical problems
· Substance abuse
· Severe anxiety
· Overwhelming problems
· Severe alteration in self-esteem or body image
· Lethal suicide plan
Because any loss in function, change in role, or alteration in body image is a possible antecedent to depression, nurses in all settings encounter patients who are depressed or who have thought about suicide. Depression is suspected if changes in the patient’s thoughts or feelings and a loss of self-esteem are noted. See Chart 7-11 for a list of risk factors for depression. Depression can occur at any age, and it is diagnosed more frequently in women than in men. For el-derly patients, the nurse should be aware that decreased mental alertness and withdrawal-type responses may be indicative of de pression. Consultation with the psychiatric liaison nurse to assess and differentiate between dementia-like symptoms and depression is often helpful.
For all patients, talking about their fears, frustration, anger, and despair can help alleviate a sense of helplessness and facilitate the process of obtaining the necessary treatment. Helping pa-tients learn to cope effectively with conflict, interpersonal prob-lems, and grief, and encouraging patients to discuss actual and potential losses may hasten their recovery from depression. Pa-tients can also be helped to identify and decrease negative self-talk and unrealistic expectations and shown how negative thinking contributes to depression. Because physical health and self-care activities are adversely affected by depression, nurses should mon-itor patients for the onset of new problems. All patients with de-pression should be evaluated to determine whether they would benefit from antidepressant therapy.
In addition to the measures cited previously for helping pa-tients manage depression, research studies indicate a reduction in distress when anxiety and depression are treated with psycho-educational programs, the establishment of support systems, and counseling (Devine & Westlake, 1995). Referrals to psychoedu-cational programs can be instrumental in helping patients and their families understand depression, treatment options, and cop-ing strategies. (In crisis situations, it is better to refer the patient to a psychiatrist, psychiatric nurse specialist, or crisis center.) Ex-plaining to patients that depression is a medical illness and not a sign of personal weakness, and that effective treatment will allow them to feel better and stay emotionally healthy, is an important aspect of care (Stuart & Laraia, 2000).
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