02.07 Depression

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Depression Assessment (Mnemonic)
Depression Assessment (Picmonic)
SIG E CAPS for Major Depressive Disorder (MDD) (Picmonic)

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Okay, in this lesson we’re going to talk about Depression. Now, I’m going to be as objective as I can here - but also, I have struggled with Depression my whole life, so I also hope to give you guys my unique perspective and my unique experiences and I hope that makes it really real for you.

Depression can occur as a standalone condition or as a component of Bipolar disorder. If you remember, we talked about how some patients just find it very difficult to regulate their moods. In Bipolar they may have episodes of Mania and episodes of depression - or they may just have this super low mood that’s hard to manage or regulate. So, let’s start by just defining it. Depression is a state of low mood and aversion to activity that can affect a person’s thoughts, behaviors, feelings, and sense of wellbeing. Even just looking at that definition I’m thinking “yep! That’s about right!”

So, we’ll use a similar illustration from the Mood Disorders lesson - let’s say this is our normal baseline mood. Again, it’s normal to have some swings from this. So let’s say right here is sadness or mild depression. It usually lasts 2 weeks or less and it’s just kind of a normal level of sadness as if something had happened - usually you can still function and go about your daily life without much difficulty, but you’re just kind of down. Again, most people would enter this state because something happened, and then they would self-regulate back to baseline. In someone with depression, they’ll often enter these low states for no reason at all and they may struggle to just get back up to a normal mood again. This is something I experience in cycles. So I may have a week or 2 where I’m just sad. I don’t want to be around people, I don’t want to talk to anyone. I may even tear up or cry for no reason. I can still work and perform ADL’s and go about my daily routines, but I’m just not as excited about it as I had been in the past - that’s a big sign of depression - loss of interest in things you used to enjoy. So this would be a mild level.

When you get to a moderate level of depression, it’s much lower than just a normal sadness, it’s more persistent, lasts longer, and really starts to affect the thoughts and behaviors. People may sleep more, be very fatigued, and have no desire to do normal daily functions like showering, brushing their teeth, doing the dishes. They may overeat or drink alcohol to self-medicate or they may not eat at all. This is not a manageable level, they may cry all the time for no reason. And you may even start to see suicidal ideations - although oftentimes they don’t have enough energy to go through with it. We’ll talk about that more in the suicidal behavior lesson.

When you get to severe depression, I want you to see how significantly lower this is - it is intense and pervasive. Clients may even experience delusions or hallucinations. There are most often suicidal ideations and often they’re so desperate to end the sadness that they may follow through on those thoughts.

I’ll be honest guys, I lived here back and forth between moderate and severe, mostly hanging out at moderate for about 6 months a year ago. I was never suicidal but I had days where I refused to get out of bed or off the couch. I slept all day. I cried multiple times a day for no reason - it even starts to make you feel crazy like you’re broken. I went weeks without brushing my teeth, I went days or more without showering. I ate anything I could easily get because I wanted to numb the sadness. I couldn’t help around the house because I had no energy. I remember one day I actually got dizzy and weak emptying the dishwasher and had to go sit down. And all of that just compounded this feeling of guilt and like I was a bad wife - which made the depression worse. Let’s just say 2017 was an awful, awful year for me. But now, I can look back and say “wow, knowing what my patients are going through from such a personal perspective is going to affect my compassion and my empathy for them”. I have such a new respect for people who struggle with depression and still manage to get out of bed and brush their hair and go to work every day. I’m telling you - these people are some of the strongest people you’ll ever meet.

So, all that being said - let’s talk interventions. I’m going to share the most important things you need to know and I’ll share what worked for me. First things first, remember that safety is always first - we NEED to be doing a self-harm assessment for all clients who have or might have depression. Ask very directly - “Do you have any thoughts of hurting yourself or others?”. If they say yes, ask “Do you have a plan for how to do that?”. Either way, this client needs to be in suicide precautions - so follow your facility’s specific protocols. Most of them will include 1:1 supervision and direct observation by a sitter within arm’s length at ALL TIMES. This means they don’t even get to go to the bathroom by themselves. And we’ll remove anything from the room they could use to harm themselves like a phone cord - monitor cables IF ABLE - and they’ll get plastic utensils. Some places go so far as to remove all of their personal belongings, including their phone, and may even restrict visitors. So just make sure you know your facility’s policy.

In addition to suicide precautions if necessary - we also want to promote oral intake of good nutritious foods and normal sleep-wake cycles - they should not be sleeping all day if possible. We want to encourage them to perform their ADL’s and help them out wherever needed. I’ve had clients with depression who refused to bathe themselves and made us give them a bed bath even though they were perfectly capable - so we need to encourage them. Let them do their private parts, or their face, then let them do that AND their arms, and keep working up til they do all of it. We want to encourage expression of feelings and we MUST validate their feelings. I’m telling you - the ONE thing that helped pull me out of my severe depression more than anything else was somebody saying to me “It’s really okay to be sad, it’s okay to feel upset - but you still need to take care of yourself, so let’s just find a different coping strategy for what you’re feeling”. Or “That situation was really hard, I’m so sorry that happened to you - I can understand why you’d be sad about that”. This is not the same as agreeing with a hallucination or a delusion, we still don’t do that. But, feeling like you aren’t crazy, like what you’re going through is real and that there are options for you is so empowering. When you’re with them be really present, even if it just means sitting in the room with them or letting them cry - make time for that - it makes them feel more valuable. And when it comes to activities, start with simple activities that promote a sense of accomplishment. Coloring, card games, drawing. For me, I started making little baby hats to donate to the hospital’s NICU - they each took about 30 minutes to complete so I made 1 a day - it gave me a way to say “yes, I accomplished something today!”. You can even set small goals each day like “Today I want you to brush your teeth and wash your face by 9am”. I actually have a tracker that I STILL use to check a box when I do my morning routine and when I exercise and when I meditate - it makes me feel like I’m accomplishing things and it’s really helpful.

So, nursing priorities for a patient with Depression - safety, of course, coping, and mood/affect. Do that self-harm assessment. Provide alternative activities, encourage achieving those small goals, and validate their feelings.

So to recap - Depression is a state of low mood that persists for weeks, months, or years and may affect a client’s ability to perform daily functions or take any interest in life. We always want to do a self-harm assessment to put safety first and we want to set goals and encourage activities that promote a sense of accomplishment, validate their feelings, and help them manage their symptoms. I also want to make it clear that medication IS an option - personally, with therapy and counseling and a whole heck of a lot of personal reflection, I have been able to manage without medication, but medication is a perfectly reasonable and VERY helpful option for these clients so make sure you don’t stigmatize that or make them feel like a failure for choosing medication.

Okay guys, I hope it was helpful to hear a bit of what I go through. I was actually diagnosed with Persistent Depressive Disorder and it’s something I still deal with on a regular basis. So I hope this gives you a new perspective so you can make sure when you have these clients that you’re using compassion and empathy and validating what they’re feeling. I love you guys - y’all are my motivation every day! Go out and be THAT nurse today. Happy nursing!
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