This case study concerns a teenage service user whom we shall refer to using a pseudo name, Katie, to maintain confidentiality in line with the Nursing & Midwifery Council Code of Conduct (NMC, 2015). Katie suffers from a comorbidity of Type 1 Diabetes (T1D) and depression, and the focus of case study is on thedepression component. Managing and treating depression has proved to be sometimes difficult for both practitioners and patients due to its multi-dimensional aetiology which is attributed to a combination of biological, environmental and personal factors. Its impact is equally challenging as it usually associated with poor disease control, adverse health outcomes and quality of life impairment (Andreoulakis, Hyphantis, Kandylis, & Iacovides, 2012).The case study will explore pathophysiological and psychological perspectives in the aetiology of depression. The objective of the survey is to undertake a systematic enquiry (Holloway, & Wheeler, 2010). Using a real world situation to gain a deeper understanding of the situation to try and solve a problem and improve the current situation (Aitken & Marshall, 2007).The utility of Cognitive Behaviour Therapy (CBT) is discussed as the intervention that was prescribed for Katie. The rationale is that CBT is relevant to the assessment outcomes and the symptoms presented by Katie.
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The GP referral to the Community Mental Health Team states that Katie is a 16-year-old enthusiastic teenager, who is in full-time education and enjoys extramural activities in school and also enjoys socialising. Recently Katie was diagnosed with type 1 diabetes (T1D) and prescribed insulin pump therapy. Following this diagnosis, Katie became remarkably withdrawn from friends and family, with expressions of hopelessness and low self-esteem. She has lost interest in the activities that she has been enjoying in her life. Her GP diagnosed depression. The condition has been getting worse and persistent for three weeks, putting a significant strain on her parents, including two siblings who live with her. The GP concluded the case warranted specialist attention and referred Kate to the Community Mental Health Team.
Katie’s referral notes suggested that her depression should be assessed further due to deterioration in her mental health. The assessment highlighted significant depression symptoms such as poor sleeping patterns, weight loss, burdensomeness, constant feeling of sadness (National Institute for Health and Care Excellence, 2016). Also, self- loathing, insomnia, lack of energy, irritable mood, physical pains and a gloomy outlook on life including diminished pleasure in enjoyable activities were the contemporary (National Institute for Health and Care Excellence, 2016). The symptoms are likely to impact on the ability to cope, personal relationships and the general quality of life (Pryjmachuk, 2011). To determine the severity of Katie’s mental health, the Registered Nursing Practitioner took the lead in completing a Patient Health Questionnaires (PHQ-9) with Katie. Katie scored as having major depression. This self-reporting tool is critical in aiding practitioners to conceptualise depression as it can be used to monitor, diagnose, and measure the severity of depression (Wu, 2014). The risk of harm is critical to the assessment of depression (NICE, 2016). Studies show that mental disorders are present in 90% of suicide cases in the UK, with depression found in 60% of the cases (Centre for Suicide Research, 2012). Hence, Katie was assessed on the risk of self-harm. However, she did not state any thoughts or actions of self-harm or suicide attempts. Due to the severity and the diverse nature of her symptoms an appointment was arranged for Katie to see the team Psychiatrist. Katie agreed to the decision. This led to the intervention discussed later in the essay.
Katie’s symptoms include loss of appetite, and there is substantial evidence that links eating disorders with depression, especially among young females (Allen, Crosby, Oddy, & Byrne, 2013). As pointed out by Allen et al. (2013) Eating disorders can lead to over eating, which contributes to other problems such as obesity and type 2 diabetes, Loss of appetite can lead to malnutrition, Loss of weight and fatigue. Eating problems also lead to stomach aches, cramps and constipation (Allen et al. 2013). Literature also shows that depression is linked to nearly every other physical and mental illness, as according to the joint report (Royal College of Psychiatrists and Royal College of General Practitioners, 2009). Also, there is sufficient of evidence that physical illness disturbs our feelings and thinking, just as social, and personal stress can cause ill health (Royal College of Psychiatrists and Royal College of General Practitioners, 2009). Also, other diseases can trigger stress and onset depression, as is the case with Katie who got depressed after a diagnosis of diabetes. Oladeji & Gureje (2013) suggest that patients can be caught in a vicious circle in which depression contributes to other present conditions and vice versa.
Conceptualising the pathophysiology of depression is made complicated by the fact that while the majority of patients respond to pharmacological treatments such as antidepressants, some patients remain partially or wholly unresponsive to drugs (Cryan, & Leonard, 2010).In these illustrations, there are individual differences in the manifestation of depression that cannot be addressed in current drug regimes. It follows that treatment for depression needs to be observed according to how each patient’s response to treatment(Andersson, & Cuijpers, 2008).And this should provide guidance in formulating Katie’s care plan in this study. However, there is research evidence that links depression for the maintenance of the homoeostasis and stress levels (Leonard, 2005; Cryan, & Leonard, 2010). Stress is often well-defined as a state of real or perceived threat to homoeostasis (Leonard, 2005). The homoeostasis process function is to provide the essential balance and stability in the body systems to enable cells to sustain life (Clancy, & McVicar, 2011).Stress to the homoeostasis will activate stress response to provide the required body function balance (Leonard, 2005). Critically to the depression paradigm, the stress response mechanism is mediated by multiple responses that involve the endocrine, nervous, and immune systems, which are collectively known as the hypothalamic-pituitary-adrenal axis (HPA) (Cryan, & Leonard, 2010). Changes that happen to the HPA and the immune system as a result of chronic stress can trigger anxiety and depression (Leonard, 2005). Depression is also ascribed to imbalances that arise in the brain about serotonin, norepinephrine and dopamine (Charney, Feder & Nestler, 2009).
Evidence suggests that the physiological functions that are mediated by neurotransmitter serotonin include sleep, aggression, eating, sexual behaviour and mood (Nutt, Demyttenaere, Janka, Aarre, Bourin, Canonico, Stahl, 2007). All these symptoms are much dominant in most depression cases, and indeed symptoms such as insomnia, loss of appetite experienced by Katie. Research also suggests that reduced production of serotonergic neurones that make serotonin has an impact on mood states and contributes to depression (Nutt et al. 2007). However, several lines of evidence suggest that neurotransmitter dopamine is involved in motivation that drives to seek reward and pleasure, and it is believed low levels on this transmitter play a role when depressed people cease to enjoy activities that they enjoyed in the past (Charney et al. 2009). Katie had been a vibrant juvenile and lost all the passion for passion when she was diagnosed with depression. Research suggests antidepressants play a role in improving neurotransmitter imbalances (Anderson, 2013). However, in the case of Katie, National Institute for Health and Care Excellence, NICE (2017), recommends that antidepressants should be used in young people and children only after alternative therapies have been considered.
The psychological impact of depression on the patient is concerned with the patient’s concepts of self, how they conceptualise their illness and the world around them (Barlow, 2014). It is quite critical as this impact on behaviour and treatment outcomes (Sanders & Hill, 2014). Above all, an analysis of Katie’s symptoms and assessment suggest there are significant psychological issues. The symptoms that relate to behaviour include lack of motivation as shown by poor school work and lack of interest in social events that she enjoyed before. She is no longer taking responsibility for daily actions and routines. Katie’s care plan and treatment should aim to address this. There are also symptoms that relate to self. She felt continuously sad about her present condition, resulting in emergency visits to her GP. In other words, Katie may have felt a loss of status and purpose, having become remarkably withdrawn from friends and family, she was not able to retain a sense of confidence in her the future. Some of Katie’s psychological concerns can be addressed within the Community Mental Health Team working with other professionals and Katie’s Care-Coordinator, and also with Katie’s family. The support of family and friends could be mobilised to give emotional, spiritual and financial assistance, with her family assuming an influential changing role and responsibilities when one person is ill (Washington & Leaver, 2009). The motivation for Katies to participate in daily activities could be initiated by working with the Occupational Therapy to engage in activities at the community centre.
Sanders and Hill (2014) examined the psychological impact of depression, in so far as it is conceptualised by the patient, as grounded in the concept of self. They assert that the idea of self is concerned with perceptions and awareness of being, the pattern of perceptions, which is also concerned with consequences for personality and change (Sanders & Hill, 2014). Also, a well-functioning self-characterised by assimilation and ability to respond to new experiences. However, a good self-process can become impeded by other impaired person -processes such as intrusive thoughts and any other perceptions that pose a threat and target the self (Sanders & Hill, 2014). Threats to the self, which can be internal or external, can culminate in patterned restrictions on perceptions and response which is configured as depression expressed in symptoms such as pervasive feelings of negativity (Sanders and Hill, 2014). This conceptualisation encapsulates Katie’s perception of herself as Katie could still enjoy her life only if she could change her perception of herself. Katie’s intervention needs to focus on changing her perception of herself.
Specifically, the Nursing process involves identification of priorities as well as the determination of appropriate patient-specific outcomes and arbitration, thus determine the urgency of the identified problem and prioritising the patient’s needs (Ackley, & Ladwig, 2013). In other words, mutual goal setting, along with symptom, pattern, recognition and triggers, will help prioritise interventions and determine which intervention is going to provide the greatest impact (Ackley, & Ladwig, 2013). Heeramun-Aubeeluck, & Luo, (2012) assert that collaborative care, behavioural interventions, and psycho-education are helpful in encouraging patients to maintain treatment and enhance psychological well-being and quality of life. The intervention chosen for Katie in this case study is Cognitive Behaviour Therapy (CBT). CBT can be accessed through referral to Improving Access to Psychological Therapies (IAPT). CBT is supported by NICE (2017), and also various government publications over the years have recommended the use of CBT such as No Health without Mental Health (Department of Health, 2011) and Talking Therapies. CBT is concerned with how people think (cognition), how they feel (emotion) and how they act (behaviour) (Daniels, 2015). CBT is psychoeducational and focused on changing the way people conceptualise illness to influence their behaviour and attitude (Daniels, 2015). The objective of cognitive processing is to examine patients’ thoughts and help them to learn the skills of acknowledging negative thoughts, often referred to as negative automatic thoughts (NATs). They will then be able to re-evaluate these ideas using an objective framework, and this can involve using approach to gathering evidence for the validity of ideas, such as proof against and for, surveys, or asking a trusted other (Grist, 2011). The rationale for CBT in this study is that its characteristics as a therapy would be helpful to address Katie’s symptoms and profile, as mostly the symptoms that impact on her quality of life are of cognitive and behavioural nature.
Equally important, a problem-solving approach will be adopted to structure and organise Katie’s nursing care and treatment. Katie will be involved in the whole process to empower her in her care plan through a person-centred approach and intervention that is evidence-based. Evidence-based interventions are practices or programs that have peer-reviewed, documented empirical evidence of effectiveness. Evidence-based interventions use a continuum of activities, strategies, integrated policies, and services whose effectiveness has been verified or informed by research and evaluation (National Resources Centre for Mental Health Promotion & Youth Violence Prevention, 2017).Gulanick & Myers (2016) contend that intervention is a basis for excellence in nursing practice, which includes correctly identifying existing needs, as well as recognising potential needs or risk, planning, delivering care in own fashion to address actual and prospective needs as well as evaluating the effectiveness care. More importantly, nurses must be able to work autonomously with confidence with significant others, such as families, friends, and carer’s to ensure Katie’s needs are met, including self-care arrangement (Nursing and Midwifery Council, 2015). Besides, as the name suggests, CBT comprises distinct therapy approaches that the address either the cognitive or the behavioural aspects associated with mood disorders, including depression. In CBT cognitive and behavioural approaches can be used in combination or unilaterally (Dobson & Dozois, 2009).
The behavioural perspective in CBT looks at the environment and behaviour of the patient. Depressive symptoms are attributed to a decrease in environmental reward, reinforcement
of depressive reactions and avoiding alternative actions that facilitate good health (Hopko, Lejuez, Lepage, Hopko, & McNeil, 2003). The behavioural perspective to depression underpinned by the works of Lewisohn (1974), who concluded that the pleasure obtained through interaction with one’s environment increases the likelihood of a rewarding behaviour. Further, change in the environment could result in deficient response-contingent positive reinforcement (RCPR) which directly contributes to depression (Dobson & Dozois, 2009). Dobson & Dozois, (2009) highlights Response-Contingent Positive Reinforcement as positive or pleasurable effects deriving from the behaviour of a person within their environment and the likelihood of increasing such conduct. Behavioural Activation therapy has proved to be useful in addressing deficient RCPR and improving mood and thoughts. This treatment focuses on availing activities that support environmental reinforcement (Hopko et al. 2003). Both the cognitive and the behavioural components of treatment would benefit Katie. Sheldon (2011) contends that CBT is a therapeutic approach that involves talks and conferences. In this therapy, the patients are involved in discussions, and they express their feelings, behaviours and thoughts to a CBT professional during the initial assessment (Sheldon, 2011). Kassel (2016)asserts the value of CBT as a therapy that teaches individuals how to think and react to certain stressful situations appropriately and can be used for some across a range of disorders including phobias, schizophrenia, depression, eating disorders, anxiety disorders, and relationship difficulties. When embarking on CBT interventions, the therapist uses information collected from an interview the patient; in this case, it would be with Katie and guides her through a description of the CBT model of depression as it applies to her profile and symptoms (Kassel, 2016). Also, general models of how thoughts, moods, behaviours, and physical sensations interact are discussed, enabling identification of a model as it relates to the patient’s life.
Several lines of evidence suggest that CBT is one of the most effective treatments when anxiety and depression present as the primary symptoms (Royal College of Psychiatrists, 2009). Further, CBT helps to make sense of a profound problem by breaking it down into smaller bits (Kassel, 2016). The National Centre for Biotechnology Information (2012) highlights that a combination therapy consisting of medical drugs and CBT has been establishing to be more efficient when that when medication is used alone in patients with more severe, recurrent or chronic forms of depression in the acute treatment phase. However, as highlighted by RCP (2009) CBT does not a quick fix, and if the patient is feeling depressed, it will be difficult to concentrate on getting them motivated. Further, CBT courses can last for six weeks to sixths months depending on the type of problem, and how motivated the patient is on engaging. CBT offers some significant advantages as an alternative therapy. Given all that has been mentioned so far, it is evident that CBT has considerable influence on the disease burden of depression as the treatment is safe and cheap (RCP, 2009). Also, it can administer as a self-help programme. CBT is now also delivered online, however, the quality of these trails is not always right (Andersson, & Cuijpers, 2008). RCP (2009) notes that some research suggests that CBT may be better than antidepressant at preventing depression relapses. However, it is necessary for the patient to keep practising their CBT skills, even after they are feeling better
CONCLUSION
The two dominant approaches to conceptualising and treating depression that is the physiological perspective and psychological perspective, offer plausible concepts in understanding the aetiology of depression, yet the patient may attach different conceptualization of the illness, which results from the idea of the self. The idea of the self is quite critical in treatment outcomes in so far as it mediates changes in cognition and behaviour. However, it has not yet been clearly established how the perspectives interact to cause depression symptoms. This case study highlights that when treating depression, it is essential to carefully monitor the response to treatment as some people will not respond to available therapies. Further, as some people don’t respond to treatment, there is a lot of research that needs to be done to understand how antidepressants work in different people entirely. Finally, cognitive behavioural therapy has numerous benefits for patients, including, decreased psychological distress, improved pain management, increasing self-efficacy, execute the sources of action required to manage prospective situations, better quality of life and function.
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