While the bulk of the care of a patient with depression is the same as any other person you will care for, there are some things I wish nurses/medical staff had known when dealing with me, a person living with chronic depression, anxiety and PTSD. My apologies for the length of the post. 1. What's wrong may not be obvious.
The patient may try to minimize or hide the symptoms of their illness or may even neglect to tell you about the illness at first, fearing stigma or a change in how you deliver care if you know. Once trust is built or when things become more (or less!) stressful, you may see more symptoms coming out, sometimes very suddenly.
When I had to have my wisdom teeth out, I was too embarrassed to tell the surgeon or anaesthesia that I had a fear of having things put in my mouth. Since they didn't know, they put me to sleep and did the surgery the way they normally would. I woke up in a sobbing panic, afraid that someone had sexually assaulted me while I was asleep-even though I had been put out and intubated, my body still sensed all the pressure against my mouth and the fears of being harmed overtook the logic that of course there will be pressure around the mouth when wisdom teeth are being removed.
When I woke up sobbing and shaking, the PARR nurses of course asked what was wrong and I told them what I had thought happened and they, though surprised by what I was saying (since they had no clue I had such fears), reassured me, told me I was fine, that nothing had happened, that it was okay. The nurse on the ward accused me of accusing the doctor of raping me (no, I just said I was afraid it had happened), which made me feel even more depressed and embarrassed than I already was.
My surgeon, though, was wonderful. When I saw him in follow up the next week, he asked why I hadn't told him. When I said I was too embarrassed, he told me that it would have been okay, that other patients had the same fear and that they could have done things a bit differently both before and during surgery to make things easier on me. Since then, I've been more open about what's wrong with me and what, if anything can be done to help me.
A patient with depression may be laughing and talking with family and friends but still be depressed. The family may be a good distraction or the patient may be trying to fake it for their visitors so as not to further worry or upset them. When the visitors are gone, the person's mood may change again. That may be a time that the person seems to crash, mood-wise, from having to keep their happy face on for so long.
Be cautious about making comments about how well a patient may be doing, mood wise. Some patients may feel good hearing that while others may feel like that means they have to be strong all the time and pretend to be up when they feel bad and want to ask for support. 2. Assess mood throughout the stay.
Stress that comes with being sick or having surgery can throw a well patient's mood off, nevermind one with a mood disorder. 3. Be aware of the patient's senses.
Especially when under stress, the person's senses may be hyperacute, or they may startle very easily. Their senses may also become narrowed (when I get stressed, I can lose my peripheral vision, as I'm trying to limit my sensory load).
Announce yourself when you come into the room (unless they're asleep, of course)-if the curtain is closed, talk to the person as you're coming into the room, so they know you're in the area and coming to see them. Whenever possible, come around so they can see you coming. I startle terribly (think a full grown adult with the Moro reflex, plus screaming) when I'm startled. I usually laugh about it and make a self-depreciating joke, but I feel embarrassed when it happens and I get angry if the same person startles me repeatedly.
Tolerance for sensory input can change from day to day or even situation to situation. The patient who may have constantly been trying to touch you or take your hand yesterday may pull back and shudder at touch today, or the patient who was happily watching and listening to the chaos at the nurses' desk yesterday may be completely overwhelmed by just having the meal trays delivered the next day.
When my senses are getting overwhelmed or I'm just feeling out of control or overly anxious, I sometimes have odd things I'll do-fingering fabrics, pacing, rocking. Somehow, those movements and that sensory soothing seems to help me settle-or at least gets some of the energy out. 4. The vast majority of patients with mental illness are not violent.
You probably hear in the news that person X committed murder or another heinous act and "has a history of mental illness"-yet you never hear that the person's mental illness actually had no more to do with that murder than the fact that they had an ingrown toenail at the time.
Are there sadists who have no problem hurting or killing others? Yes. Are there people who, in the height of a psychosis, honestly believe their lives are in danger and kill someone to 'protect' themselves? Yes, but both of these situations are extremely rare.
Think about how often you hear phrases like 'I could have strangled him', 'I could have killed her'-and you probably never think twice that the person meant anything by it. Yet, often when someone with a known mental illness makes such a comment, people start getting nervous that the person is about to become violent. In reality, depending which study you read, people with mental illness(especially those with chronic mental illness) are 3 to 11 times more likely to become a VICTIM of violence than a perpetrator.
At the same time, yes, be cautious for signs of increasing aggression-not just from patients with a mental health diagnosis, but every patient. Someone who has no symptoms of mental illness may become angry and lash out under times of stress just as easily as someone with depression or other mental illness.
If the patient does make comments about strangling/killing/choking someone, acknowledge the feelings and also assess risk: "You sound really angry. Are you really feeling like you might hurt that person?" Almost always, the answer will be no. Then you can let the issue go or if the comment about killing was directed at a staff member, gently tell the patient that expressing anger is okay, but making threats is not and perhaps ask if there is some way you can help them have a physical outlet for their anger (Extra pillow to punch, scrap paper to shred, etc). 5. Believe the patient if they say that a medication or treatment may negatively affect their mental health.
I become psychotic when given steroids-even taking an inhaled steroid BID can affect my mood. I've had doctors tell me that this is impossible-they're wrong. While being given IV steroids, I thought I was Anne Franke in Nazi Germany and that the hospital was actually a death camp; another time I thought Iodine was for drinking and was about to put a big bottle of it to my lips when the nurse walked in. Yet another time I lashed out physically at someone who really hadn't done anything wrong-yet after, had no memory of doing so. That was on 10mg of Prednisone.
If a treatment has to be given, work with the patient and doctor to find a way to lessen the impact on their mood. If I need to have steroids, my internist and I have agreed that he would admit me to hospital and give me a moderately high dose of antipsychotic as he's starting the steroid infusion.
Even if it seems silly, it may be best to go along with it-when I was in nursing school, one of the RNs had a patient who was in psychotic depression and was convinced that chicken would poison them and would become agitated and distructive (throwing trays, shoving the bedside table) when their dinner tray had poultry on it.
At that point, trying to reorient or talk down the belief, (the chicken here is cooked well; it won't poison you) is probably not going to achieve much, so why not put a poultry 'allergy' on the patient's chart and let them eat beef and pork until either they're discharged or the psychosis is properly treated? 6. It's okay to ask questions.
Ask the patient how the illness acts on them, what makes things better/worse and what you can do (within reason) to make their hospital stay easier on them.
Also think about what the patient may not ask for: Someone with severe depression may need a few extra minutes or a gentle touch as you come to give meds or do treatments. A request for psychology or a chaplain to come in and be a sympathetic ear for them during their stay may be helpful. Someone with sensory overload may do better in a private room or in a semi-private with a quiet roommate than in a double room with the patient who has a dozen visitors daily. 7. For an idea of what depression feels like: http://www.wingofmadness.com/Start-H...sion-feel-like