Skill List > Communication with Depressed Patients
Clinical Alert
First acknowledge and take care of the depressed patient’s physical and emotional discomfort, but avoid dwelling on physical complaints. Focus on understanding the patient, giving feedback, assisting in problem solving, and providing an atmosphere of warmth and acceptance.

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation
Authors:
Based on Mosby Nursing Skills
Adapted by: Chris Brooker BSc MSc SRN SCM RNT
Updated by: Chris Brooker BSc MSc SRN SCM RNT
Last updated: July 2017
Learning Objective
After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of communicating with depressed patients.

Introduction

Depression is a feeling state that is more than just sadness. It is a common mental health condition that affects a person’s ability to function in day-to-day activities. There are many symptoms of depression. The most common are low mood, apathy, feelings of sadness, fatigue, guilt, poor concentration, sleep disturbance, and suicidal thoughts. ‘It is important to recognise that clinical depression, which is a serious mental health illness, can be life threatening, as suicide and self-harm are frequent outcomes in severe depression' (Simon & Fawcett 2011). Depression results in both subjective and objective behaviour (Box 1). Subjective behaviour includes the patient reporting feelings of sadness and tearfulness, lack of energy, and an increase in physical complaints. Some patients report feeling anxious when depressed. Objective signs include decrease in performance of activities of daily living and decreased time spent in social activities (altered social interaction).


Box 1 Symptoms of depression. (From Keltner N, Steele D 2015 Psychiatric Nursing, 7th edn. Mosby Elsevier, St Louis.)


Most common symptoms
  • Apathy
  • Sadness
  • Sleep disturbances
  • Hopelessness
  • Helplessness
  • Worthlessness
  • Guilt
  • Anger
 
Other symptoms

  • Fatigue
  • Thoughts of death
  • Decreased libido
  • Ruminations of inadequacy
  • Psychomotor agitation
  • Verbal beratings of self
  • Spontaneous crying
  • Dependency, passiveness

Many patients in acute care settings suffering from either acute or chronic health conditions have symptoms of depression. Some patients will have been formally diagnosed and treated with medications or psychotherapy, and others may not have been diagnosed or treated. Use the nursing process to develop nursing interventions, expected outcomes, and evaluation of those outcomes for patients with depression. The intervention strategies emphasise use of therapeutic communication techniques.

Teaching the patient to identify possible sources of depression, such as acute or chronic illness, personal vulnerability, ineffective coping, or other known stressors, gives the patient  an understanding of depression and increases their sense of control over feelings of depression.

Make teaching modifications, taking into account that the depressed patient may suffer from impaired concentration and memory (e.g., present a small amount of material at a time).

Cultural considerations

Nurses face challenges when communicating with culturally and linguistically diverse patients. Effective communication between culturally diverse patients and nurses is essential to improving health outcomes (Al Abed et al. 2014). Research shows that providing both general and disease-specific information to patients in a culturally sensitive manner improves chronic illness self-management. Conversely, a language barrier prevents the delivery of timely health care, thereby worsening existing health problems and causing new health issues.
The following factors are essential to effectively care for culturally and linguistically diverse patients:

  1. use of appropriate linguistic services, for example, an interpreter or bilingual healthcare workers, and other communication strategies
  2. a display of empathy and respect
  3. use of accurate health history taking for diagnostic and treatment purposes and health promotion and teaching
  4. use of patient-centred communication behaviour, including the patient's part in all decision making about their care. It is also helpful to speak plainly. Understand that members of certain cultures use cultural phrases or slang common to their culture and this is not an indication that they do not understand English.

When nurses communicate with patients of diverse cultures, an interpreter is sometimes necessary. When using an interpreter, address the patient and family directly and do not direct questions or comments to the interpreter. Take care to make sure that the patient understands. Speak slowly in normal tones and avoid overly technical jargon or terms unique to a culture (Box 2).

Box 2 Special approaches to patients who speak different languages. (From Giger J 2016 Transcultural Nursing: Assessment and Interventions, 7th edn. Mosby Elsevier, St Louis.)

  • Use a caring tone of voice and facial expression to help alleviate the patient's fears.
  • Speak slowly and distinctly, but not loudly.
  • Use gestures, pictures, and play acting to help the patient understand.
  • Repeat the message in different ways if necessary.
  • Be alert to words the patient seems to understand and use them frequently.
  • Keep messages simple and repeat them frequently.
  • Avoid using medical terms and abbreviations that the patient may not understand.
  • Use an appropriate language dictionary.

Adopting a flexible, respectful attitude that also communicates interest in the patient bridges any communication barriers that exist because of cultural differences between patient and caregiver. Some patients may wish to be cared for by same-gender healthcare staff and interpreters.

Not all cultures express anxiety, anger, and depression in the same way as in Western culture. Sometimes people present with somatic complaints, such as loss of appetite or poor sleep.

Children and depression

Children often demonstrate symptoms of depression that differ from those of adults. They manifest depression through physical (increased somatic complaints) and behavioural signs (poor school performance, social isolation) and are often unable to express depression verbally. Some children express depression through restless behaviour or behavioural regression. It is important to note any changes in a child’s behaviour that occur during illness or hospitalisation (Hockenberry & Wilson 2015).

Older people and depression


Depression among older adults is a major health concern. It is important to differentiate between depression and any underlying medical illness in this population because the symptoms sometimes overlap, for example, depression in hypothyroidism. In addition, suicide risk is increased in older adults (Keltner & Steele 2015).

Care in the person's home

Depression is often present in home care settings. Manage depression based on the patient’s presenting behaviour taking into consideration any cognitive or physical impairment.

Care in a mental health unit/a care home/nursing home or general hospital

Preparation and safety

  • Are you competent to provide this care? Should you ask an experienced colleague to help?
  • Assess for physical, behavioural, and verbal cues that indicate the patient is depressed, such as feelings of sadness, tearfulness, difficulty concentrating, increase in reports of physical complaints, and statements such as ‘I am sad’.
  • Assess for possible factors causing the patient’s depression (e.g., acute or chronic illness, personal vulnerability, history).
  • Assess factors influencing communication with the patient (e.g., environment, timing, presence of others, values, experiences, poor concentration).
  • If needed, discuss possible causes of the patient’s depression with family members, including history of the illness.
  • Prepare for communication by considering patient goals, time allocation, and resources.
  • Be aware of your own non-verbal cues that affect communication with the depressed patient (e.g., body language, posture, cadence of speech). Remain non-judgemental.
  • Prepare the physical environment by providing a quiet, calm area and allow ample personal space.

Procedure

  1. Perform hand hygiene.
  2. Check the patient’s identity – either verbally or using the patient's name-band, according to local policy.
  3. Introduce yourself and provide a brief explanation of the purpose of the interaction to obtain the patient’s consent and cooperation.
  4. Accept the patient as they are and focus on the positive aspects of the patient. Provide positive feedback.
    Rationale Depressed patients often have low self-esteem and this approach helps them to focus on their strengths.
  5. Be honest and empathic.
    Rationale Facilitates the development of trust.
  6. Use appropriate non-verbal behaviour and active listening skills, such as staying with the patient at their bedside or in their room.
    Rationale – Non-verbal messages to the patient show the nurse’s interest and help to alleviate depressive symptoms.
  7. Use appropriate verbal techniques that are clear and concise to respond to the depressed patient. Use observational statements that both acknowledge their current feelings and provide direction to the patient.
    Rationale Appropriate techniques and statements provide reassurance to the depressed patient and show empathy.
  8. Use open-ended statements, such as ‘Tell me how you are feeling’ or ‘You seem sad; tell me about your sadness’.
    Rationale Encourages the patient to continue talking, facilitating an in-depth discussion of symptoms.
  9. Reward small decisions and independent actions. When necessary, make decisions that the patient is not ready to make. Present situations that require no decision making.
  10. Provide necessary comfort measures.
    RationaleDepressed patients often have multiple physical complaints; address and adequately treat the physical complaints (e.g., pain, nausea).
  11. Spend time with the patient who is withdrawn.
  12. Ask the patient about suicidal ideation and the presence of a plan for suicide.
    Rationale Depressed patients are at increased risk of suicide. Other risk factors include general medical conditions, hopelessness, male gender, and advanced age. The more developed the plan, the greater the risk of suicide (Keltner & Steele 2015).
  13. Perform hand hygiene.
  14. Document the procedure in the patient’s record.

Ongoing care, monitoring and support

  • Observe for continuing presence of physical signs and symptoms or behaviour indicating depression.
    Rationale Observation determines the extent to which the planned interaction relieved the patient’s depressive symptoms.
  • Encourage the patient to discuss ways to cope with depression in the future and make decisions about their own care.
    RationaleMeasures the patient’s ability to assume more health promoting behaviour.
  • Evaluate the patient’s ability to discuss the factors causing depression.
    Rationale Measures the patient’s ability to attend to or focus on an area of concern. 

Documentation and reporting

  • Document in the nursing notes the objective and subjective behaviour (associated with depression) you observed while with the patient. Include:
    • methods used to improve behaviour associated with depression and the patient’s response
    • patient and family education.
  • Speak to a colleague if you have any concerns.
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