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Question:
Depression, as defined by the World Health Organization, is a common mental health disorder characterized by sadness, feeling of low self worth and a feeling of tiredness. (World Health Organization, 2016) Though it is manageable, it has a high risk of recurrence, could be fatal if left untreated for longer periods of time. Depression is attributed to be one of the major causes of mental illness, with nearly 10% of the population worldwide being affected by depression, at some point or the other. (Kessler & Bromet, 2013) In Australia, nearly 6% of the population is known to experience depression and related mental illnesses at least once in their lifespan. Depression is one of the major causes of suicides, with grim statistical figures of nearly 50% of the population experiencing depression contemplating suicide at any point of time. It is projected that in another five years, depression related suicides would be the second most common cause of death, only next to cardiovascular disorders. (Lopez & Murray, 1998)
In Australia, nearly 2% of the population committed suicide, which was reported to have increased in the past decade. It is estimated that females are more affected by depression than males, though suicides are more prevalent in males; even though depression leads to suicidal ideations in both genders. (Piccinelli & Wilkinson, 2000) Depression is the highest in the young age group of 18-25 years, and gradually decreases as one’s age increases. However, the levels of depression increase as one crosses 55 years of age, especially if the person has health issues due to ageing. There is a gradual reduction of suicidal attempts with increasing age, however strong the suicidal intentions and ideations might be. (Stordal, Mykletun, & Dahl, 2003) Depression and Suicidal intentions increase with prolonged hospitalization and delayed recovery, and this is more prominent in older ages. (Juurlink, 2004) Childhood abuse and trauma, intake of certain drugs, chronic illnesses, lack of a supportive environment, etc. are the risk factors for depression. (Hirschfeld & Weissman, 2002)
In this paper, the factors responsible for the mental health illness, ethical and legal issues, clinical concerns and the evidence based interventions are discussed in a presented clinical scenario.
Mr. Edward, the client, is a 62 year old man, with mental health issues on the lack of his family structure and bonding. Looking through his case, we can attribute his current state of mind to several reasons that might have driven him to depression, of which we shall discuss two of them.
Homesickness: The first reason for Mr. Edward’s depression can be attributed to his attachment to his native place Malta. Though he willingly moved to Australia, his soul was in Malta, and wanted to return back soon. However, he had married and settled in Australia, even as he felt homesick from missing his family. His inability to visit his parents when they were dying, and on their funerals due to his commitments in Australia, is an issue that makes him feel guilty, which eventually led to his depression. Research reveals that homesickness is one of the causes of depression (Verschuur, Eurelings-Bontekoe, & Spinhoven, 2004); though prevalent in the younger age group, it can manifest in older ages as well. In the case of Mr. Edward, the latent symptoms of homesickness had resurfaced in his older age.
Bereavement: Another reason for Mr. Edward’s depression can be attributed to the death of his family members, especially his son. According to the report, he had not been witness to the death of either of his parents, and he had to conduct the funeral of his son. This made him feel very low, and his subsequent depression made him incur heavy losses in his occupation. The fact that he has been losing his family members one after the other has made him feel guilty of not closely bonding with his family. Research reveals that the levels of adult depression are high when one incurs the loss of one’s child. (Wijngaards-de Meij, et al., 2005) Guilt of not performing one’s duty is also another main cause for depression. (Lavretsky & Kumar, 2002)
Other factors for his depression might be his increasing age, losses in business, and any co-existing clinical conditions related to old age.
Handling individuals with mental health issues has highly complex ethical and legal presentations and principles that needed to be adhered to (Haman & Hollon, 2010). In the case of Mr. Edward, shall discuss one ethical and one legal implication.
The Ethics of Privacy: Mr. Edward was reported to become severely distressed and poignant upon describing his issues to the concerned healthcare provider. Thus, it is not ethically and morally right to pester him to answer all questions directed at him. According to the ethical principle of “Right to Privacy”, Mr. Edward must be made to feel comfortable on his discussions. Any information needed must be obtained on a “need to know” basis. Usually, individuals tend to divulge more details once they feel that they can trust the provider. The choice of Mr. Edward must be respected, and his privacy must be maintained. (Wissow, Rutkow, Kass, Rabins, Vernick, & Hodge, 2012)
The Legal issue of Suicide: Mr. Edward was reported to have suicidal intentions, even though he is unsure about it. Though suicide is not a crime as per the Australian Law, is still a act that has to be discouraged. Suicidal intentions must be controlled and managed immediately upon detection, as failure to address the issue can lead to unwanted legal implications, such as negligence of duty (Wendy, Packman, O'Conoor, Pennoto, Bongar, & Orthwein, 2004). It is important to keep Mr. Edward under constant observation, to prevent any attempted suicide, even though its likelihood is quite low. Thus, suicide ideations and thoughts must be dealt with carefully, without having to face any legal issues.
Mr. Edward presents with depression, as a result of many factors, especially loss of his family members. As a result, he presents with many physical and mental issues which affect him as a person. From the perspective of a mental health nurse, two issues shall be identified, and two evidence based intervention plans for each concern shall be discussed.
Issue 1 – Suicidal intentions: Mr. Edward is reported to have developed suicidal thoughts and intentions. This is primarily a major issue of concern, as it is quite an undesirable intention. Even though he has not thought of ways to commit suicide, the risks are high, given his age and mental state. Over the next 1-5 days of nursing care, Mr. Edward must be monitored for any suicidal talks, references, and if he tries to gather more information on it.
Intervention 1 – Psychotherapeutic Management: A mental health nurse would first perform a complete risk assessment on the individual, and refer him for various psychological therapies, in order to get rid of suicidal intentions. (Carrigan & Lynch, 2003) Over the next 1-5 days of nursing care, Mr. Edward would be spoken to by a few of the healthcare staff including the nurse, in order to assess with whom he is more comfortable with. The rationale behind this move is that Mr. Edward might not cooperate with people he might not seem to trust, and that it is unethical to force him into any therapy. After the concerned specialists have established a good rapport with him, therapies in the form of problem oriented approach, group sessions, and behavioural therapies would be started. (Kenny & Williams, 2007) It is important to note that the management must not be hastened at any cost, but progress with the cooperation of Mr. Edward.
In order to positively contribute to Mr. Edward’s recovery journey, it is essential that he is given his personal space and time to introspect, and come up with his own ideas to address the issues he faces.
Intervention 2 – Pharmacological Management: After assessing the physical state of Mr. Edward, a mental health nurse would refer him to a psychiatrist or pharmacological management if necessary. Over the next 1-5 days of nursing care, Mr. Edward would be monitored and tested constantly for any drug reactions, so that an effective pharmacological treatment can be prescribed. The rationale behind the use of drugs in the management protocol is that Mr. Edward suffers from chronic depression since many years, and might be experiencing some co-morbid conditions specific to old age, reducing the effectiveness of psychotherapy as a standalone treatment. (Benedetti, Riccaboni, Locatelli, Poletti, Dallaspezia, & Colombo, 2013) The drugs administered would me mostly antidepressants, and any potential side effects must be taken into consideration. The starting dosage of antidepressants can be started early enough provided complete consent is obtained.
However, keeping in mind the contrasting studies of antidepressants on suicidal intentions (Gibbons, Brown, Hur, Davis, & & Mann, 2012) & (Leon, Fiedorowicz, Solomon, Li, & Coryell, 2014), modifications in management must be made accordingly.
Issue 2 – Changes in body patterns: Mr. Edward had a distinct change in his sleeping patterns since six months; he reported difficulty in falling asleep, and his tendency to wake up early, which has not been his routine so far. He also reported a loss of 6 kilograms of body weight, without any effort taken to reduce weight. The reasons for considering the change in body pattern and weight as potential concerns are that the physical and mental state of an individual are interrelated. Over the next 1-5 days of nursing care, Mr. Edward must be monitored for any eating disorders, or intake of any drugs that would have led to his condition.
Intervention 1 – Circadian Rhythm Manipulation: Mr. Edwards complained of a delayed observation in his sleep-wake pattern. Over the next 1-5 days of nursing care, he would be monitored for his body patterns, his sleep time, awakening time, and assessed for any factors which could hamper his sleep patterns. As sleep is closely linked to body weight, and there is a reported reduction in it, his weight is also kept under observation. The rationale is that the adverse health effects of a disturbed circadian rhythm can be reverted if it is made to function undisturbed (Hickie, Naismith, Robillard, Scott, & Hermens, 2013). A neuro-psychiatrist will be referred for the treatment, and the underlying reasons behind the disturbed rhythm will be analysed. Then, upon identifying the exact physiological process, specific interventions like cognitive-behavioural therapy, sleep therapy, etc will be planned.
However, it is important not to hasten with the proceedings, and give sufficient time before commencement of treatments.
Intervention 2 – Lifestyle Management Advice: Mr. Edward has reported extreme tiredness and sudden weight loss over a short span. Over the next 1-5 days of nursing care, he would be monitored for his day to day activities, eating disorders and unprescribed drug intake if any. Apart from the counseling and the pharmacotherapy which he is on, lifestyle management advice would be prescribed by his family physician. The rationale is that maintain proper lifestyle habits such as regular food, exercise, and cutting down on unwanted habits is found to be effective in reducing depression (Weinger & Ancoli-Israel, 2002). A healthy lifestyle is said to have a positive impact on his changing body patterns. However, it is important to note whether any lifestyle habits have occurred due to the intake of antidepressants, as they are reported to increase the levels of sleep in the individual (Berk, Sarris, Coulson, & Jacka, 2013). Lifestyle management advice must be provided once the patient is off hospitalization, and must be integrated as a part of his daily schedule.
In order to see a positive response to Mr. Edward’s recovery journey, it is essential that all the advice provided by the healthcare team is implemented by him, and that comes out of his depression and suicidal intentions as soon as possible.
Depression and Suicide are the most undesirable mental health concerns that are prevalent today. It is unnerving to see the amount of people with suicidal intentions. The issues can be managed easily, only if they are detected early in life. In the case of Mr. Edward, the earliest point at which depression could have occurred could be his guilt at being unable to live with his parents, or even see them die, all due to him being unable to afford a vacation to his hometown. It would have been helpful if he had approached any person and spoken his heat out; he would have been a less depressed individual. It is important to identify the early signs of depression, manage it as early as possible, so that suicidal intentions can be prevented and a healthier life can be enjoyed.
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