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CCM Nurses Depression Training2

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CCM Nurses Depression Training2 Powered By Docstoc
					CCM Nurses Depression CME 2
        May 2009



Screening and diagnosis
PHQ-9 (and K-10)
Nurse role in management
The Link Between Stress and
Mental Health/Illness
    From time to time, everyone faces things in life that cause
     stress – we will all move up and down this continuum

    Sometimes, people‟s normal coping skills are not enough to
     deal with these stress events, leading to developing
     symptoms

    In any one year, for 25% of the population, 33% of Primary
     Care attenders, life stressors will be causing a mental health
     or drug alcohol condition – or in our lifetimes this figure is
     66%

                                        Emotional Disorders
     Stress       Chronic Stress            (Depression, anxiety,
                                         alcohol and drug problems)



                  Increasing intensity of stressors
Awareness and Recognition:
Symptoms of Chronic Stress
                                               STRESS AND
          STRESS AND
                                              YOUR FEELINGS
          YOUR MIND

 Constant worry      Easily distracted      Irritability         Impatience
 Racing mind         Uncertainty            Anxiety              Depression
 Illogic             Forgetfulness          Anger                Loneliness
 Can’t concentrate   Poor memory            Low self-esteem



      STRESS AND                               STRESS AND
      YOUR BODY                               YOUR ACTIONS


 Churning stomach    Fatigue             Poor sleeping habits   Poor eating habits
 Backache            Headaches           Rapid speech           Drug use
 Palpitations        Diarrhoea           Reckless driving       Excessive smoking
 Chest tightness                         Excessive drinking
Anxiety, Depression and Substance
 Use disorders in General Practice
(12 months):

   Total
Depression            9.7%            Total Anxiety
  18.1%                                  22.2%
               8.0%          2.0%
                                             Total
                      2.5%                 Substance
                                            11.3%
             6.7%              5.8%
                      1.0%
Co-Morbidity of Medical Illness
and Depression
      Illness           % with Depression
      Cancer                   40 – 50%
      Heart Disease            18 – 26%
      Diabetes                 33%
      Multi-infarct Dementia   27 – 60%
      Multiple Sclerosis       30 – 60%
      Parkinson‟s Disease      40%
      Stroke                   30 – 50%
Diagnosis of Major Depression –
Screening

The “two question screen”:




 ?                                     ?
      1.   During the last month              2.   During the past month
           have you been                           have you been
           bothered by feeling                     bothered by little
           down, depressed or                      interest or pleasure in
           hopeless?                               doing things?

      This screening tool has 96% sensitivity for detection of depression,
               BUT only 57% specificity – i.e. lots of false positives,

        SO if positive need to go on to enquire re other symptoms of
                                  depression…
Major Depressive Disorder
    Diagnostic Criteria (DSM – IV)
         1. Key Symptoms:
                 Depressed MOOD
                 Diminished INTEREST

           2. Other Symptoms:
                  Appetite decrease (or increase) / weight loss (or gain)
                  Marked sleep disturbance (increase or decrease)
                  Psychomotor changes (agitation or retardation)
                  Fatigue or loss of energy
                  Feelings of worthlessness or guilt
                  Diminished concentration or indecisiveness
                  Recurrent thoughts of death or suicide

              Either Key, and 4+ Other, for 2+weeks – MAJOR
                   DEPRESSION
Use of the PHQ-9 and K-10

TIM Template
Suicide Risk Screening

 It looks from what you’ve told me that you’ve been feeling pretty bad
      lately -
     Do you see any future for yourself?
     Do you feel you would be better off dead?
     When you’re at your worst have you thought about ending your
      life?
     Have you thought about how to do it?
     Do you want to act on this plan?
     Have you got access to (planned means)?
     Do you feel others would be better off without you?
 * Escalating risk with each successive positive answer
Suicide Risk Factors
(Presence indicates increased risk)


 Severity of current depression and hopelessness
 Previous attempt(s)
 Alcohol/Drug abuse
 Social isolation
 Family History of suicide
 Medical co-morbidity
 Agitation
 Being an older male
 Recent significant loss(es)
    Role play in pairs



Engagement with patients with
       depression
Evidence-Based Treatments –
Overview
 Supportive counseling and education re the
  condition – what GPs and PNs do every day!
 Lifestyle factors – Exercise, Sleep, Diet
 Activity Scheduling
 Brief problem solving
 Medications – around 50% response rate (NB –
  placebo response rate 30%!)
 Phone follow-up/support – around 20% response
  rate (as good as medication!)
 Cognitive Behaviour Therapy (also same
  response rate as medication)
 Phone support/follow-up
Envisaged as a practice nurse role
2-3 x 5 min phone calls over the first weeks of
 treatment –
  enquire re progress, side effects of medication –
   early recall if required
  remind re delayed onset of response to medication
   – 2-3 weeks
  provide support
  HIGHLY valued by patients, DOUBLES medication
   adherence, improves outcome as much as meds
Exercise in Depression

Evidence that in elderly (over 60) exercise
 programme has same efficacy as
 antidepressants
Must be vigorous exercise (for age/fitness)
Some evidence that balance of aerobic
 and resistance exercise ideal
Integrate into Activity Scehduling
 Activity Scheduling

Use structured activity scheduling tool
 (provided as part of resource for programme
 – see handout)
Key aspect of “Behavioural Management”
Reverses cycle of low mood/despondency –
 reduced activity – more time to dwell on
 negative thoughts – lower mood
Important to include rating of sense of
 pleasure and mastery from activity
Brief Problem Solving

Proven effective in mild-mod depression
Focus is in mobilising the patient‟s coping
 and problem-solving capacity, to overcome
 the issues that are causing stress/inducing
 depression
Uses structured approach, increases sense
 of mastery and reverses “helplessness –
 hopelessness”
See handout
Self-Management

Key to improved outcomes in depression
 as in all chronic conditions
Use of information resources, care plans –
 negotiate agreed plan, follow-up re
 progress with this
Start small/achievable and build from
 there
Expect it will require fine tuning over time
Cognitive Behaviour Therapy
(CBT)

 Structured, time-limited, „here and now‟
 Specific skills for now and future
 Five components to problem (“Five-Part
  Model”)
 Cognitive model
 Evidence
 Balanced thinking
CBT - 5-Part Model
                Environment (Past & Present), Situation

                            Thoughts or
                            Cognitions




                                                      Behaviours,
  Physiology,
                                                       Actions
  Sensations



                               Feelings,
                               Emotions
  CBT - 5-Part Model (contd)

              COGNITIVE COMPONENT
                                               EMOTIONAL



                       AUTOMATIC
SITUATION               THTS AND    REACTION   BEHAVIOUR
                         IMAGES


       LENS OR FILTER THROUGH
       WHICH WE PRECEIVE OR                    PHYSIOLOGY
       INTERPRET SITUATIONS
Management of Distress -
Immediate Behavioural Management
   Agreeing and setting acheivable goals
   Safety contract (agreed steps to be taken if person feels at
    risk – if can‟t trust self to make this, consider risk high)
   Prescribing indicated lifestyle changes –
       Addressing stressors
       Reduced A+D use
       Activity Scheduling (N.B., use worksheets)
       Exercise (N.B., evidence for effectiveness in depression)
       “Sleep Hygiene” (N.B., use worksheets)
   Relaxation Training (N.B., use worksheets)
       Slow Breathing
       Progressive Muscle Relaxation
   Phone support/follow-up

				
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