Tag: Anxiety and panic attacks

What you must know about depression

What do you know about depression?

Big red question mark with little which character of a man leaning against it

Before you go any further, count on your fingers the things you know about depression. Got it? Okay, keep that in mind. Let’s see if we can add to your knowledge here.

Trigger warning; the topics covered in this article may trigger emotional responses and you may wish to stop reading now.

So, what is depression?

Coloured image of man sitting on the floor, knees up and head leaning on his knees. Does he know what depression is?
Depression in men – Image by Holger Langmaier at Pixabay

Depression is a long lasting low mood disorder that affects your thoughts, feelings and behaviours. It can also affect your ability to feel pleasure, even in the things you used to enjoy. It can can render you unable to do everyday things and eliminate any interest in regular activities. And sometimes you may feel as if life isn’t worth living.

The NHS stipulates that depression is more than just a feeling of being unhappy or fed up for a few days. If you suffer from lasting feelings of unhappiness and hopelessness, and you are feeling tearful or you are loosing interest in everyday activities, make sure to take the depression self-assessment on their website.

Depression is a genuine health condition, it’s real and it has real soul-destroying symptoms. You can’t just ‘get over it’ or ‘snap out of it’, as some might suggest, and it’s most certainly not a sign of weakness.

Who does depression affect?

It can affect anybody, and it can also impact hugely on the depressed person’s family, carers or friends. Depression knows no boundaries and cuts across religion, faith, class, creed, race, gender, or age. Take a look at the following statistics, which have been borrowed from MHFA England:

  • Depression is one of the leading causes of disability worldwide and a major contributor to suicide and coronary heart disease
  • 24% of women and 13% of men in England are diagnosed with depression in their lifetime
  • Depression often co-occurs with other mental health issues and substance abuse
  • Depression occurs in 2.1% of young people aged 5-19

Do you know what causes depression?

Well, the jury’s out on this one. There is no one cause fits all with depression and there’s lots of different theories. However, as with lots of mental health disorders, a variety of factors could be involved, such as:

There are happy hormones such as dopamine, serotonin and endorphins, but also stress hormones that can trigger depression
Hormones might trigger depression
  • Life events such as loss (death, divorce, seperation), redundancy, loss of job status, loss of income, or loss of home appear to have a role to play in depression
  • Biological differences. People with depression seem to have physical changes in their brains.
  • Genetic/inherited traits. Depression is more common in people with blood relatives who also have it. But once again, it’s unclear and we can wonder — is it nature or nurture? Researchers are still trying to identify the genes involved in causing depression.
  • Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression.
  • Hormones. Changes in the body’s balance of hormones may be involved in triggering depression. These changes might occur during pregnancy or in the weeks or months after the birth (postpartum) and from pre-menstrual tension, the menopause or thyroid problems, or any one of a number of other conditions. See your GP; to rule out any other causes.
  • Low socio-economic status such as income, education, occupation, social class, or wealth and location/environment might also be the cause of depression.

How do people with depression think?

Educate yourself about depression, it will help to keep you motivated.
Changes in sleeping pattern may be a symptom of depression

Depression affects different people in different ways, and some describe it as feelings of sadness, loss, or anger. I’ve had all those feelings, and the thought of ending my life was/is never far away. But because I didn’t want to leave my sons with that legacy, I thought of how I could make it look like an accident. What if I run my car off the road? What if I fall in front of that lorry hurtling down the road on my way to work?

Obviously I can’t speak for others who’ve struggled with suicidal thoughts, but I’ve listened to many patients who’ve survived the experience. I now understand we had many things in common. One of which was that we didn’t want to die, it was that we couldn’t bear the pain, and if things were better we would choose to live. But there’s always impulsivity, or a perhaps window of opportunity arises and some people take it.

So, if you’re having thoughts of dying by suicide, please talk to someone urgently. Also, if you know someone who’s depressed and suicidal, please speak out. Ask them if they are having these thoughts — and soon.

If you’ve had a combination of the symptoms (below) for at least two weeks or more, and for most of the day, nearly every day, you might be depressed.

Symptoms of depression:

  • changes in eating patterns – either loss of, or increased appetite, weight gain or loss (when not dieting)
  • changes in your regular sleeping pattern like sleeping too much, too little, not at all, or waking regularly in the early hours of the morning
  • tiredness, fatigue or lack of energy where you can’t even do the little things
  • loss of interest in things like sex or activities you used to enjoy
  • unexplained physical problems, such as constant headaches, neck or back pain
  • feeling tearful, sad, empty, worthless or hopeless
  • feelings of self-loathing, self-blame, guilt, or fixating on past failures
  • having angry outbursts, being irritable or getting frustrated, even over little things
  • feeling anxious, agitated or restless and find yourself pacing or fidgeting
  • feeling lethargic, slowed down thinking, speaking or body movements
  • trouble concentrating, thinking, remembering, or making decisions
  • frequent negative and intrusive thoughts or recurrent thoughts of death, suicidal thoughts, suicide attempts, writing suicide letters – if this is you, please seek immediate support, from your GP in the first instance. You can also find a list of useful mental health contact numbers here.

Remember

This list above is not exhaustive and you may have other symptoms. If you are experiencing the above symptoms regularly, please speak to your GP or another mental health professional. If you’re reluctant to seek treatment, talk to someone you trust, like a loved one, a friend or faith leader. Recognizing that you’re depressed is essential to getting the right help. The earlier you receive support and attention, the better the outcome.

What helps with depression

Did you know full recovery from depression is a possibility?
You can make a full recovery from depression

I deliberately wrote ‘helps’ because currently, that’s all we have. There isn’t a cure as such. But the good news is, that with the right treatment and support, most people with depression can make a full recovery. Depression affects millions of people worldwide, and there are varying treatment options available. These might be anything from lifestyle changes, talking therapy to medication.

Prescription drugs and the treatment of depression

If you are suffering from depression, your doctor may choose to prescribe antidepressants. Antidepressants are medications used to treat depression. There are a variety of medications that can be used to treat depression. These antidepressants all work to take away or reduce the symptoms.

Antidepressants are classified into different types depending on their structure and the way that they work.

Seven types of antidepressant drugs:

  • Monoamine oxidase inhibitors (MAOIs)
  • Norepinephrine and dopamine reuptake inhibitors (NDRIs)
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs)
  • Serotonin antagonist and reuptake inhibitors (SARIs)
  • Tricyclic antidepressants (TCAs) and tetracyclic antidepressants (TeCAs)
  • Miscellaneous antidepressants.

Popular medicine for depression

The most popular medicine used in the treatment of depression are the serotonin reuptake inhibitors (SSRIs).

Popular SSRI’s include names such as Prozac (fluoxetine), Luvox (fluvoxamine), Paxil (paroxetine) and Lexapro (escitalopram).

Names of miscellaneous antidepressants are Wellbutrin (bupropion) – also used in the treatment of nicotine addiction – Trintellix (vortioxetine) and Spravato (esketamine).

Never take antidepressant prescription drugs without a prescription from a licensed psychiatrist or mental health care doctor.

Did you previously know :

  • that depression is one of the leading causes of disability worldwide?
  • and a major contributor to suicide and coronary heart disease?
  • the huge array of possible causes?
  • what causes depression?
  • that anyone can be affected by depression?
  • it can be treated successfully and people with depression can make a full recovery?

Over to you

What do you think?
Clipart.com

Okay my lovelies, for those of you who are not mental health professionals, did you learn anything new? For those of you ‘in the know’, have I missed something/anything? What are your experiences of depression? Maybe you have some tips to cope with depression? I’m looking forward to your comments, suggestions or questions.

In the meantime, you might find the following posts interesting:

Related: The best depression blogs of the year (1). Depression, anger and narcissistic vulnerability from the perspective of a depressed patient (2).

Mental Health rehab works—only if the staff do

Realkm.com

While I was a student on the rehab unit I had to complete my Practice Based Assessments (PBA’s) and I’d chosen four patients that I could work with to meet these over the twelve weeks placement. First there was Mandy who had Generalised Anxiety Disorder (GAD) and next was Sasha, Elsa and Edward who all had a diagnosis of chronic schizophrenia.

Mandy

I spent many pleasurable weeks working with Mandy, the lady who’d previously screamed for her medication several times a day. She repeatedly said that she could notice the reduction in each nought point five mg Diazepam, which was highly unlikely. However, I appreciate that for her, it was difficult, hence her continuous screeching at medication time.

From my parenting days, I knew that distraction worked well when children were upset so I hoped distraction might help Mandy too. I would offer her a cup of tea and ask what her plans were for the day or about her collection of teapots, rather than have the poor lady screaming and working herself into a panic attack.

It’s a shame that other nurses hadn’t picked this up as it would have been far easier for them in the long run and certainly better for Mandy. However following discussions with her Primary Nurse, the nurse who has overall responsibility for a patient, her care plan was updated and read “When Mandy is upset and screaming her allocated nurse must use distraction techniques.”

Example care plan
How a care plan might look

Care plans are prepared for each patient and wherever possible, are developed with the patient, rather than for the patient. The care plans are used to guide your practice with patients, to explain what care is required and how to carry it out.

As she got better, Mandy would eventually accompany me to the local Primark to get cheap knickers. Grinning cheekily, she would say the money she saved from buying these allowed her to buy her favourite yoghurts from Marks and Sparks next door. Once I’d left the unit it always cheered me up when I saw Mandy and I loved to stop for a chat.

Sasha

I had a lot of fun working with Sasha; she was witty, intelligent and was becoming much more cheerful as the weeks went on. Between us we managed to clear all the cereal boxes from her room along with the crumbs and mouldy, congealed leftovers we found in bowls under her bed.

This wasn’t my favourite task but I laughed all the way through it because Sasha was getting really cheeky. When I was busy scrubbing the floor she’d sit on her bed reading or stand at the window waving at random passersby and she’d crack up when I spotted it.

Many of Sasha’s care plans were updated or changed altogether now because she’d made great progress in several areas and some of her care plans were now outdated. One care plan read ‘Encourage Sasha to keep her bedroom tidy and work with her if necessary. If Sasha refuses, staff to advise her that they have a duty of care to ensure her environment is clean.’ It was like writing instructions for nine year olds rather than senior qualified nurses.

Another care plan read ‘Encourage Sasha to spend time off the unit and accompany her if needed.’ I loved spending time with her in the cafe, a local haunt for both patients and staff. I always took my badge off when accompanying patients outside as I wanted them to feel equal in the community. It really bugged me seeing staff wearing badges when outside with patients. It was like ‘them and us‘ and showing the staff member was in a position of authority, which I thought was unfair.

Elsa

At forty eight Elsa hadn’t aged well at all; she originally came from Greece and her face was craggy from the sun. She had short wiry grey hair which she hacked at herself, staring in the mirror taking great clumps out with almost blunt scissors. These were eventually taken from her as she’d often say to fellow-patients and staff “I will kill you.” She did this with a wicked grin so I didn’t think she was really serious but the scissors might have posed a risk to both her and others.

One of her care plan was updated and read ‘When Elsa wants to cut her hair, a staff member must be with her and remove the scissors back to the office once finished.’ I wanted to find out why Elsa chose to use her clothes as toilet paper but, despite using one of our translators, she just shrugged and grinned when asked. However, it was something we had to work on, we couldn’t just ignore it. I asked several staff nurses what has been tried in the past and what worked but was told “That’s just Elsa. She always does it and nothing works.” Elsa had been on the unit for months and nobody could tell me what had been tried.

When I was on duty as a nursing assistant (NA) or there on my student placement I tried to speak with Elsa every couple of hours to see if she needed the bathroom. I tried taking her to the toilet, getting her to sit for a while to see if she would poop, her favourite word. Sometimes it worked and I had to wait while I encouraged her to use toilet paper. “Too small.” she would grin “No enough.” and she’d try to use her skirt. Ah! Next time I accompanied her to the bathroom I took a roll of the large hand drying paper. Success!

NMC.org.uk

One of her care plans was updated to read ‘Encourage Elsa to use the toilet throughout the shift and have hand paper available.’ though I know this rarely happened as I never saw it documented. The Nursing & Midwifery Council (NMC) Code of Conduct states that ‘nurses should respect, support and document a person’s right to accept or refuse care and treatment.’ It did not say ‘if patient refuses support, just leave it at that.’

Once my placement ended I would later hear that Elsa had reverted back to using her clothing to wipe herself. I was truly mad that the nurses had allowed this to happen. It was like they’d given up caring and they were just passing time until retirement. However, I did learn how not to nurse and their disassociation made me even more determined to be a good nurse. Our patients deserved better.

Edward

Edward had long been on a medication called chlorpromazine, the first antipsychotic which was widely shown to be significantly more effective than later antipsychotics. However this drug had a range of distressing side effects, one of which Edward had was the shuffling gait known to nurses as the ‘chlorpromazine shuffle.’

He would also complain of constipation and impotence. He was prescribed a regular dose laxatives and he often requested Viagra but would talk about not being able to get rid of his erection for hours. You had to laugh with him, his tales were hilarious. He told me about one time when he was on the bus returning to the unit and the movement gave him an erection just as his stop was coming up. It was summer and he was wearing just shorts and a t-shirt so he had no way of covering the erection. He had to stay on the bus and went miles out his way.

My main task with Edward was to get him to take better care of his hygiene. He was physically fit and more than able but he really needed a ‘kick up the backside with my tiny size three’s’, I’d tell him. He also picked his nose and would later want to shake my hand. This was one habit that would have to go and I told him I would never shake his hand unless he hadn’t washed it. I also said I wouldn’t accompany him in the community if he was wearing his usual attire of stained tracksuit bottoms and a dirty old t-shirt. I often used my sons as examples, telling Edward that I wouldn’t go out with them if they weren’t clean.

One afternoon I arrived on the unit and there was Edward, spick and span. He was clean and reeking of cheap aftershave. His receding hair had been carefully dampened down and he wearing mismatched clothes but they were spotless. He’d been waiting for me since after lunch. How could I not take him out to the local snooker hall? This was his favourite outing as the voices he heard were much quieter and encouraging when he was concentrating. It became a weekly treat while I was there but I later saw him shuffling along the street, head down and miserable.

I don’t know why the nurses on the rehab unit ignored any improvement or the hard work that was done. They scoffed at his updated care plans, saying – it won’t last! Why did they think it was okay to let patients revert to their old habits.

Conclusion—Rehab does work — but only if the staff do!

*The Purpose of the Written Care Plan is to ensure continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient’s needs are attended to, the updated plan is passed on to the nursing staff at shift change and during ward rounds. http://www.rncentral.com/nursing-library/careplans

Spoiler – find out what happens on Mental Rehabilitation Wards

Early shift

memesmonkey.com

As I parked up my first morning, even above Slade’s Noddy Holder screaming “It’s Chriiiiiistmass”, I could hear a female screeching “Medication. I want my medication. Where’s my medication? I need my medication.” The poor neighbours either side of the building must have been well p’d off. It was six forty-five, pitch black outside and the streets were eerily quiet — other than the high pitched screeching coming from the Mental Health Rehab Unit piercing the air.

Someone in the office by the front door pressed a button to let me in and I was greeted by this tiny little lady who grabbed both my hands and panted “Help me. Help me please. I need my medication. You’re new. Are you an Agency Nurse?” Will you help me? Please?”

I spoke calmly but firmly, “Listen to me, I can’t help you right now…” I was trying to placate her enough so that she could hear me and take in what I was saying. At the same time I was trying to get her to take a breath as she was panicking and was as white as a sheet. I really felt for her.

“Please, please. I’m begging you,” she continued to screech, now in my face, as I tried to disentangle myself from the tight grip she had on my wrists. The office door opened and a nurse yelled “Cindy, stop it, leave her alone. Cindy!” I’d now managed to get myself free but Cindy had grabbed the nurse and was pulling on her cardigan, all the while screeching “You’re a bitch. You’re a fucking bitch! Get my medication you fucking black bitch.”

The nurse eventually pushed me into the office and she followed, turning to slam the door in Cindy’s face with a kiss of her teeth “Oh Lordy Lord. That Cindy. She will be the death of me. I am Ayo. Who are you?”

I breathed a sigh of relief and introduced myself as the Student Nurse. “I don’t know. See how it is here. I pray to God for her sins,” humphed Ayo. “Hmmm. Take a seat. Ah! Here come the staff.” and I turned to see two females and one male puffing away outside, the ciggie smoke belching through the office window. “Tsk, Tut. I don’t know. Smokers, heh!” moaned Ayo as she reached to slam the offending window shut.

Seven o’clock on the dot the three members of staff traipsed in, throwing their coats on top of a filing cabinet. Lisa was first to introduce herself as the RMN, the shift coordinator and my supervisor, and said “That’s Lorna, she’s a qualified (RMN) and that’s Graham the NA (Nursing Assistant).” Where’s the fourth member of staff? I thought to myself.

Morning handover

“Okay.” started Ayo, above Cindy’s screeching. “The lady herself. Cindy, she slept and now she has been shouting before six thirty. Lord help me! Everybody still in bed. Only Sasha, she awakes all night but she stay in her room. Somebody needs to clear her room. I saw the mouse there.” My feet moved on their own, up off the floor as I sat on a desk, and I shuddered involuntarily when I was looking around for the said mouse.

Ayo continued and ended with “Moses needs to see a Doctor and his toenails need to be cut. It’s in the diary for this morning. Now I’m going home. Goodbye!” She pulled off her slippers and put them in her bag then huffed and puffed as she bent down to put her shoes on. She grabbed a large woollen blanket and shuffled out of the door.

Lisa went through the diary, handed out tasks to the other two and said she was doing medication and that I should shadow her. Lorna went off to wake up the other nine patients that lived in the ten bedded unit and Graham wandered off to the kitchen to prepare for breakfast.

Medication

With our coffee, Lisa and I went to the medication room, we were met with Cindy who was still gulping in great lumps of air, wringing her hands and saying “Thank you Lisa.” and “Thank you nurse.” to me. Yes, I could get quite used to being called Nurse.

“Right Cindy. You know we start titrating down your Diazepam today.”

“No, please Lisa. Not today. I can’t cope. I can’t cope!” Cindy screamed.

“Nought point five milligrams Mandy. You won’t even notice it.” Lisa tutted and turned to me. “She’s been on thirty milligrams three times a day for years and you can see it doesn’t reduce her anxiety. So we’re going to try titrating down while she’s in Rehab.” Cindy lived in a one bedroom flat and had apparently relapsed over a period of six months prior to admission to an acute ward. Once stabilised she was transferred to rehab.

Cindy had generalised anxiety disorder (GAD) which is a long-term condition that causes you to feel anxious about a wide range of situations and issues, rather than one specific event. 

People with GAD feel anxious most days and often struggle to remember the last time they felt relaxed. As soon as one anxious thought is resolved, another may appear about a different issue. Titration looked like it would go on forever, reducing her Diazepam by nought point five mg three times a day. However, Cindy eventually accepted the reduced dose and greedily swallowed down all her medication, followed by gulps of water, then scurried off to the dining room.

Breakfast

We continued until each patient had had their medication then joined everyone for breakfast in the dining room because, on rehab, we were encouraged to eat with the patients each mealtime. Lisa waffled something about nurses having a responsibility to role model table manners and eating with the patients was supposed to encourage healthy eating. I wasn’t sure that this was an evidence-based intervention but I went along with it anyway.

Coffee and toast with jam was just what I needed but as I sat to eat I was immediately struck by an offensive odour. One older lady to my left had obviously not washed or brushed her teeth, yet there was another disgusting smell.

Graham screwed his nose up and said “She’s just sat there and shit herself and carried on eating!” to nobody in particular. “That’s Elsa.” he whispered with an Aberdonian accent. “She normally goes to the toilet but she uses her clothes to wipe herself and then hides them down the back of the toilets, eh Elsa?” he now boomed. “Elsa, say hello to Nancy, she’s our new student.” Elsa’s face was buried in the huge breakfast she was picking up with her teeth. She raised her head and gave me a toothless grin.

None of the staff got up to help Elsa so I offered, but Graham told me “No. Wait til after breakfast!” And this is rehab? I wondered — does it really work?

Around the table, there was belching, farting and one young chap was trying to snort back the snot that was threatening to hit his top lip. He eventually gave up and wiped a huge glob on the sleeve of his t-shirt leaving a silvery snail-like trail.

Coffee finished and my toast in the bin, I helped clear the table and took my time in the kitchen. I was hoping someone would deal with Elsa, as I was already feeling queasy. Fortunately, she’d gone by the time it took me to do the dishes but she’d left wet poop dribbling down the chair legs. Gloves and apron on and ten minutes later the chair was scrubbed and left outside in the back garden to dry.

Activities of daily living

To the bedrooms on the first floor now where I tried encouraging patients to wash and dress before attending any appointments or activities. Oh my word! I’d knocked and opened the door to Sasha’s room and was aghast at the cereal boxes piled as high as the ceiling. At a guess I’d say there must have been over two hundred boxes and the only other floor space was filled by her bed and two or three black sacks.

“Get out of my room.” stormed Sasha as she pushed me and slammed the door. I stood for a few seconds, stunned, then knocked and called out “I’m a student nurse Sasha. Is there anything I can do? Would you like me to help you clean your room.”

“Get lost.” Sasha muttered. I went to find Lisa and asked what I could do to help Sasha. “Not a lot,” Lisa laughed. “Her room’s been like that forever. She won’t let us in.” That can’t be right. Surely we have a duty of care? I went to the office to look through Sasha’s file and her painstakingly completed but outdated care plans to see if I could find ways to engage her.

I read that she was single, had no children and had been in care since the age of eleven when her mother couldn’t cope with her chaotic behaviour. She was thirty one and was diagnosed with Schizophrenia at eighteen. Sasha heard voices and was often heard talking back to them when alone in her bedroom. Apparently Sasha had no insight and didn’t believe she had a mental health problem. She’d been on the unit for six months and was awaiting housing but it was proving difficult to find a place that would meet her needs.

I decided then that I’d be really firm with Sasha right from the start, telling her that we have a duty of care to ensure that her environment is habitable. If she wouldn’t clean it herself, then we would have to do it! It annoyed me that staff had let her live like this for months. Even if Sasha had refused to let them clean it, surely the staff could have come up with a plan between them.

It was exhausting and often thankless, but I worked hard with Sasha for the next twelve weeks, updating her care plans and engaging her in meaningful activities; things that would both interest and help her rather drum banging or painting by numbers. I appreciate that one of her care plans previously stated ‘Engage Sasha in activities.’ But, while these particular activities may help with dexterity and fine finger/hand movement, I wasn’t sure they would support her development. It was clear that certain staff had intermittently tried to push Sasha into any activities and wrote in her notes ‘Declined to attend.’ I wondered why!

I’d eventually learned more about Sasha, along with the other patients on the unit, and had managed to form a professional bond with each of them. As I got to know them better, often by engaging them in friendly banter, I was better informed about their likes and dislikes. It was easy to see they weren’t interested in particular activities and that they had their own ideas about how to spend their time.

Mark liked football so I’d have a kickabout with him in the gardens – he was quite good – so encouraged him to attend the local leisure centre where he could access different types of exercise and look out for a local football team to join.

Jenny loved knitting so we bought her knitting needles, a few patterns for baby clothes (that she requested), and some wool. She wasn’t great, dropping more than a few stitches, but that wasn’t the point. She enjoyed it. Other staff who could knit helped her unpick and start again. Eventually, with the help of staff, she started her own small weekly knitting group on the unit.

We also got a group of patients to go swimming once a week, with a member of the team. We also went to the local pub once a week so that some of the young lads could have half a pint and a game of pool. They’d never felt comfortable going into a pub previously, because they were worried about what other people thought. We quite often did get some odd looks but as a rule, the regulars were great – helping the lads with their game and showing them trick shots.

At the end of my placement I loved seeing Sasha and the others laughing, smiling, engaging and growing in self-confidence and once again, I was sad to leave.

I would later bump into some these patients in various settings i.e. in the community or on the wards and I was either saddened by their relapse or delighted by their continued improvement.

Note to self: “Public service must be more than doing a job efficiently and honestly. It must be a complete dedication to the people and to the nation.” Margaret Chase Smith.

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