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Nursing Interventions in Depression

Management

Michelle Laguinday

Carl Jayson Pabillo

Degree Thesis

Bachelor of Science in Nursing

DEGREE THESIS

Arcada Degree Programme: Bachelor Of Science In Nursing Identification number: Author: Michelle Laguinday, Carl Jayson Pabillo Title: Nursing Interventions in Depression Management Supervisor (Arcada): Pamela Gray Commissioned by: Abstract: Depression is not just a persistent feeling of sadness and low mood, it is more than that. The primary health care team shares different roles in managing depression. Nurses, in all care facilities take care of patients holistically (physically, mentally, emotionally, psychologically and spiritually). Nurses are on top of their profession tending the well and sick. Understanding nurses’ key roles in the management of illnesses is vital in the care process. The research is a literature review, which aims to identify the nursing interventions used widely in managing depression in the general population. Jean Watson’s Nursing Care Theory was used as a guide theoretical foundation for the research paper and search process uncovered 20 peer reviewed articles published from 2000- 2018. Keywords used were depression management AND nurse AND nurse’s role OR intervention. Databases included were Ebscohost, PubMed, CINAHL, Theseus and Sage. The research study aims to answer the following research questions: (1) What are the nursing interventions in managing depression? (2) How do the nursing interventions in managing depression help the patient/client? (3) Where does the nurse focus in management of depression?. Results from the study indicated that the nursing interventions in pharmacotherapy and cognitive behavioral interventions such as behavior therapy, cognitive therapy, communication enhancement, coping assistance, patient education and collaborative care, as a part of conclusion, are among the most evidenced-based interventions and are recommended for practice in depression management. Keywords: Mental health nursing, nursing, depression, nursing intervention, nurses roles Number of pages: 43 Language: English Date of acceptance:

• 1 INTRODUCTION
• 2 BACKGROUND
  • 2.1 DEPRESSION KEY CONCEPTS..............................................................................................................
    • 2.1.1 Treatment of Depression.....................................................................................................
  • 2.2 NURSING ROLES
• 3 THEORETICAL FRAMEWORK
  • 3.1 JEAN WATSON’S NURSING CARE THEORY..........................................................................................
• 4 AIMS AND RESEARCH QUESTIONS
• 5 METHODOLOGY
  • 5.1 LITERATURE SELECTION PROCESS
  • 5.2 DATA ANALYSIS
  • 5.3 ETHICAL CONSIDERATION
• 6 FINDINGS
  • 6.1 SUBTHEMES, THEMES AND CATEGORIES............................................................................................
  • 6.2 DISCUSSION OF FINDINGS
  • 6.3 RELATING THE FINDINGS TO THE THEORETICAL FRAMEWORK
• 7 CONCLUSIONS
  • 7.1 STRENGTHS, LIMITATIONS AND RECOMMENDATIONS
• REFERENCES
• APPENDICES
• TABLE 1. TYPES OF DEPRESSION
• TABLE 2. CAUSES AND TRIGGERS FOR DEPRESSION AND ANXIETY
• TABLE 3. SYMPTOMS OF DEPRESSION
• TABLE 4. INCLUSION AND EXCLUSION CRITERIA......................................................................................................
• TABLE 5. LIST OF ARTICLES COLLECTED.................................................................................................................
• TABLE 6. ILLUSTRATION OF THE CODES, THEMES AND CATEGORIES.............................................................................
• TABLE 7. NURSING INTERVENTIONS FOR DEPRESSION BY LEVEL OF EVIDENCE
• FIGURE 1. COMBINATION TREATMENTS FOR DEPRESSION........................................................................................
• FIGURE 2. CORES OF NURSING PRACTICE..............................................................................................................
• FIGURE 3. LITERATURE SEARCH FLOWCHART
• FIGURE 4. STEPS OF DATA ANALYSIS....................................................................................................................

Definition of Terms NIMH – National Institute of Mental Health ANA – American Nurses Association WHO – World Health Organization

Nurses in all health care settings frequently care for patients with mental illness, consequently, the nursing of patients with mental illness is not only provided in mental health care settings, but also in general health care settings such as general hospitals, rehabilitation center, and home care. These patients suffer from both physical and psychological complaints (van der Kluit, Goossens, 2015). Mental health nursing is the nursing specialty that is dedicated to promoting mental health through assessment, diagnoses and treatment of behavioral problems, mental disorders, and comorbid conditions across the lifespan (Boyd M., 2014). In treating patients with mental conditions, the roles of nurses are important. In the healthcare setting, nurses provide 24/7 patient care, they have their eyes and ears on patients and they are the ones who know more about the patients than anyone in the healthcare team. As described by Halter, nurses work with people throughout their lifespan: children, adolescents, adults and the elderly. Nurses assist people who are in crisis or who are experiencing life problems as well as those with long-term mental illness. Nurses work with individuals, couples, families and groups in every nursing setting. They work with patients in hospitals, in their homes, in halfway houses, in shelters, in clinics, in storefronts, on the street, virtually everywhere (Halter, 2018).

2 BACKGROUND

Knowing the basics of depression lead to a better understanding of the nature of the disease. Understanding the nature of the disease will aid the nurses into enhanced management of depression and accommodates patient-nurse relationship.

2.1 Depression Key Concepts

Depression—also called “clinical depression” or a “depressive disorder”—is a mood disorder that causes distressing symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working. To be diagnosed with depression, symptoms must be present most of the day, nearly every day for at least 2 weeks. (National Institute of Mental Health-NIMH 2016). According to NIMH (www), there are different types of depression and the most common are major depression and persistent depressive disorders. Table 1 below shows the different types of depression and how it differs from each other. Depressive symptoms include depressed moods, anhedonia, weight change, sleep disturbance, psychomotor problems, lack of energy, excessive guilt, poor concentration and suicidal ideation while dysthymic symptoms on the other hand include depressed mood, poor appetite or over- eating, sleep disturbance, lack of energy, low self-esteem, poor concentration and hopelessness.

Table 2. Causes and Triggers for Depression and Anxiety Source: (Buszewicz et. al.) Two of the common used means in defining depression are the American Medical Association's diagnostic and statistical manual (currently DSM-IV) and the WHO's international classification of disease (currently ICD-10). According to the World Health Organization (www), depression is a common mental health disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of self-guilt or low self-worth, disturbed sleep or appetite and poor concentration (WHO, 2012). As described by American Medical Association (www), depression is a type of mental disorder that disturbs person's mood, and it is often used to describe feelings of deep sadness. Depression distorts the way people view themselves, others and the world (AMA, 1998). For some people, sadness can be misunderstood as depression. To differentiate sadness from depression, the latter affects self-esteem (AMA, 1998). The table below shows the checklist for symptoms of depression based on DSM- 4 and ICD-10. Factors Definition Gender Twice as commonly diagnosed on women Socioeconomic factors More common among people at the lowest socio-economic level Ethnicity More common in South Asian women in England Medical Illness More common in people with coronary heart disease, diabetes, asthma or chronic obstructive pulmonary disease (COPD) Past history of depression and anxiety High risk of relapse Alcohol misuse Linked with anxiety disorders Antenatal and postnatal period Increased risk of depressive symptoms around pregnancy Psycho-social factors People experiencing difficult life such homelessness, poverty, debt or abuse

Table 3. Symptoms of depression Source: according to DSM-4 and ICD-10 (AMA, 1998) Symptoms of Depression DSM- 4 ICD- 10 Depressed mood + + Markedly diminished interest or pleasure in activities + + Loss of energy or fatigue + + Loss of confidence or self-esteem - + Unreasonable self-reproach or guilt + + Recurrent thoughts of death or suicide, or any suicidal behavior, unease or dissatisfaction (dysphoria)

Diminished ability to think or concentrate, or indecisiveness + + Psychomotor agitation or retardation + + Insomnia or hypersomnia + + Change in appetite + +

2.2 Nursing Roles

American Nursing Association (2010) defined nursing as “the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of individuals, families, communities and populations”. On the other hand, the International Council of Nurses (www) has their own similar definition of nursing as “including the promotion of health, the prevention of illness and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy, and health systems are also described as key nursing roles “. The World Health Organization (www) defined nursing as “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. It includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people”. Literatures give us various roles of nurses and as time passes by, the branch of the nurses’ responsibilities still grow and spread. Throughout the literatures, main concepts stood out as nurses’ most important roles and these are health promotion, disease prevention, caring for the sick and rehabilitation. Health promotion and disease prevention defines as a process of enabling people to increase control over and to improve their health. Nurses play a huge role in health promotion and disease prevention. Nurses are health educators providing people appropriate information which facilitates for optimal functioning. Nurses also initiates vaccinations, routine screenings and health seminars in the community. Caring of the sick and ill also determines the role of nurses. It includes other health care team and nurses play a key role in collaboration with the patient’s treatment and future plans on how the patient manage at home. Nurses are the ones who are always on the bedside and they are the bridge of the patient into other health care team member. Nurses roles comprises the whole entity from start until end (WHO, 1986).

Figure 2. Cores of Nursing Practice Source: WHO (1986) Promotion

• health teachings
  • encouraging healthy lifestyle Prevention
• vaccinations
• routine screenings
• health teachings NURSE Cure
• patient care
• collaboration
• medications
• diagnostics Rehabilitation
• follow up treatments
• maintaining maximum functions

as person versus object, individual perception of experience, authenticity, harmony among mind/body/spirit (Fitzpatrick, J., & Jones, J., 2012).

4 AIMS AND RESEARCH QUESTIONS

This study will provide a concise, evidence-based information on the nursing interventions in the process of managing depression. In order to reach the study aim, the researchers formulated three research questions; (1) What are the nursing interventions in managing depression, (2) How does the nursing interventions in managing depression help the patient/client, (3) Where does the nurses focus in management of depression.

5 METHODOLOGY

The research paper is a literature review and in the data methodology, the researchers have followed procedures to ensure a high quality review of literature on nursing interventions in managing depression.

5.1 Literature Selection Process

The search for potential articles began 15.4.2018. The literatures were chosen carefully as not to include the irrelevant journals and duplication. Furthermore, to capture as many relevant literatures as possible, the authors used widely academic data bases by using multiple resources (both computerized and printed). Researcher 1 (CP) looked for literatures from the databases Google scholar, Ebscohost, PubMed and CINAHL while Researcher 2 (ML) looked for literatures from databases Theseus and Sage. The researchers narrowed down the literatures by using key search engines and other filters like adjusting the publication dates and articles which are accessible for full free text. In Academic Search Elite (EBSCO), first attempt was made using the Boolean phrase nurses’ roles OR interventions AND depression, further filter was then used like full texts and publication year 200 0 - 2018. A total of 38 hits were shown and the authors considered 1 article from the database. Using the 2nd^ database CINAHL with the search words nurses’ roles AND depression. The authors ticked linked full texts, abstract available and the publication date was adjusted to the years 2000-2018. CINAHL showed 30 hits and since the literatures were almost the same as with the Academic Search Elite database, the authors didn’t get any from this database. PubMed showed generously 107 hits from the search words nurses´ roles AND depression and including publications year 2000-2018 with free full texts. 5 Articles corresponded to the qualifications and were further distributed into categories and themes. Google Scholar on the other hand is a compilation of different journals, the first attempt with the key search nurses’ roles AND depression came up with 21,300 hits. The articles

An in-depth collection and search of peer reviewed articles were completed basing on wide range of key terms including ”depression management” AND “nurse” AND “nursing roles OR intervention”. Data bases included are Ebscohost, PubMed, CINAHL, Theseus and Sage. The search process uncovered 21 peer reviewed articles published from 2000-2018. Citation chaining was utilized by the authors which is a way of searching both backward and forward in the literature to find more relevant papers using a single paper as a starting point. Such a search, starting with one paper, creates a “chain” of references linked backward and forward from the original paper (Penn State College of Medicine, 2018). Figure 3. Literature Search Flowchart EBSCO (Academic Search Elite) Keywords: nurses roles AND depression 38 hits EBSCO (Cinahl) Keywords: nurses roles AND depression 30 hits PubMed Keywords:nurses roles AND depression 107 hits Google Scholar Keywords: ”nurses roles” AND depression 1820 hits INCLUSION CRITERIA

• nursing peer reviewed articles
  • literatures years 2000- 2018
• linked full texts and abstract available
• English language
• depression without comorbid physical illness Selected Articles EBSCO (Academic Search Elite) EBSCO (CINAHL) PubMed Google Scholar Sage Theseus = 1 = 0 = 5 = 7 = 1 = 6 TOTAL ARTICLES: 20 Sage Keywords: nurses roles OR depression AND depression 47 hits Theseus Keywords: nurses roles OR intervention AND depression 1056 hits

Extensive review was made throughout the articles and the researchers came up with the following articles. Journals from around the world have been searched independently including Journal of Medical Association, World Health Organization publications, Journal of the American Psychiatric Association, Australian Nursing Journal, Canadian Journal of Nursing Research, Australian Journal of Nursing, African Journal of Nursing and Midwifery, Central European Journal of Nursing and Midwifery, Asian Journal of Nursing Education and Research. Table 5. List of Articles Collected

Author/s Source of Journal Title

1 Bennet, M. et.al. Plos One. September 2013. Structured Pro-active Care for Chronic Depression by Practice Nurses in Primary Care: A Qualitative Evaluation. 2 Aragones, E. et. al. Biomed Central Public Health. September 2007. Assessment of an enhanced program for depression management in primary care: a cluster randomized controlled trial. The INDI project (Interventions for Depression Improvement). 3 Jorm, A. et. al. BioMed Central (BMC) Psychiatry. June 2008. First aid strategies that are helpful to young people developing a mental disorder: beliefs of health professionals compared to young people and parents. 4 Van Beljouw, I. et.al. Implementation Science.

Implementing an outreaching, preference-led stepped care intervention program to reduce late life depressive symptoms: results of a mixed-methods study. 5 Berley, E. et. al. BioMed Central Family Practice. 2011. Managing depression in primary care: A meta- synthesis of qualitative and quantitative research from the UK to identify barriers and facilitators. 6 Aragones, E. et. al. Perspectives in Psychiatric Care. October 2008. Improving the Role of Nursing in the Treatment of Depression in Primary Care in Spain. 7 Richards D.A. et. al. Psychological Medicine.

Collaborative care for depression in UK primary care: a randomized controlled trial. 8 Whooley, M. et. al. The New England Journal of Medicine. December 2000. Managing Depression in Medical Outpatients