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DOI: 10.1177/108482239600900107

1996 9: 8Home Health Care Management PracticeLeona G. McIntyre, Phyllis Oreck, Mary Ann Camarillo and Sharon McBride Valente

Depression and Suicide: Assessment and Intervention

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8

Depression and Suicide:Assessment andI ntervention

Leona G. McIntyre, Phyllis Oreck, MaryAnn Camarillo,and Sharon McBride Valente

Despite the ever increasing numbers ofolder persons in the home health care

system, often those who are suffering

from a depression are not treated

adequately. This article presents a case

study to illustrate assessment,

identification of risk factors, and

interventions aimed at preventing

suicide, a lethal outcome of untreated

depression. Once detected, depressioncan be effectively treated. Nurses are

vital in their role as educators and

counselors in treating depression andpromoting improved functioning forolder persons.

Key words: depression, elderly, geriatrics,home health care, suicide

PPROXIMATELY 25% of elderly people~~~ receiving home health care suffer fromF~~ untreated major depression.1-5 Untreated

Adepression

reduces the

patients compli-ance with treatment and quality of life and may leadto premature death by suicide.3 Major depressioncosts $2.1 billion annually, with an additional $4 bil-lion lost in work productivity. Careful assessmentby the nurse is key to the detection of depressionamong older adults receiving home care.l-3.s-8 Homecare nurses work directly with many elderly clients.

Thorough assessment over time often reveals subtleclues that alert the nurse to a major depressive epi-sode or potential suicide risk. The home care nurse

helps elderly clients adjust to physical and emo-tional losses and

provideseducation and

supportduring treatment and recovery. Timely, comprehen-sive nursing assessments are pivotal in the recogni-tion of depression and prevention of suicide in this

population. 1,4,5,1

Depression

Major depression is a major health problem in theUnited States among elderly people.About 10 mil-lionAmerican adults have a depressive disorder, but

only one third seek treatment.5.9Healthy People 2000

emphasized elimination ofthe unnecessary sufferingassociated with depression. Of those who seek treat-ment, most persons with major depression are seen

by primary care and other nonpsychiatric profes-sionals. Most caregivers fail to diagnose depres-sion.l Diagnoses that increase the risk of majordepression include acquired immune deficiencysyndrome (AIDS), cancer, diabetes, cardiovasculardisorders, and stroke.22

One serious and potential complication of depres-sion is suicide.Approximately 10,000 citizens over

age 60 kill themselves each year. This accounts for

about 25% of the total number of suicides in thiscountry.,,&dquo; Since late-life depression is usually

Home Health Care Manage Prac, 1996, 9(1), 8-177@ 1996Aspen Publishers, Inc.

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amenable to treatment, early diagnosis and appropri-ate referral are important in reducing the associated

morbidity and suicide. 1,5,12 To prevent these un-timely deaths, home health care nurses need to de-tect clues to suicide and act decisively with earlyand appropriate interventions.1.5.11-13 Researchers de-scribe the various components of a careful suicideassessment and characteristic symptoms of the sui-cidal elderly person (see box, &dquo;Criteria for Major De-pression&dquo;). Researchers suggest the most effective

prevention of suicide is to identify the intent beforethe act.1.5.12 Recognition is the first step in suicide

prevention.

Literature on

depressionAlthough scant research exists, Wang et a113 inves-

tigated home health care nurses knowledge of the

signs of potential suicide among elderly people.These nurses lacked knowledge of the suicidal intentof elderly people. 13 Home health care nurses need to

improve knowledge and skills in the recognition of

depression and the clinical management of the olderclient.14,15 Because elderly people are less likely thanthe younger adults to report suicidal thoughts, 1,5,11Valente et a115 and Valente16 outline the skills needed

for recognizing and treating major depression amongolder clients.

The following case illustrates a typical presenta-tion of depression.

Case study

Mrs LB, an 83-year-old widow with Type II diabe-

tes, arthritis, hypertension, and stable angina was re-ferred for home health care nursing after hospitaldischarge. Her medications included glyburide (Dia-beta) 5 mg daily, atenolol (Tenormin) 50 mg daily,nitroglycerine grains 1/150 as needed, and indo-methacin (Indocin) 75 mg three times daily asneeded. LB lived alone but had neighbors who vis-

ited daily. LB commented that she was glad her onlydaughter lived in another state. During the first threevisits, LB was not interested in learning about herdiabetes or about the glucometer. Instead, LB said,&dquo;Im sick of this life, my good years are past, and mybody is falling apart.&dquo; She complained her gardenfailed to give her pleasure anymore. She lamentedabout physical symptoms, insomnia, poor concentra-tion, sadness, and irritability. She said, &dquo;Occasion-

ally, I take one ofthose sleeping pills.&dquo; In response tothe nurses questions, LB admitted to feeling blueand tired most of the time. &dquo;Its just a part of being old

and having health problems,&dquo; she explained.As the home health care nurse, what would be

your plan for assessment and care? What is probablyprecipitating LBs noncompliance with treatment? If

your care plan focused primarily on diet, medica-tions, and education for her medical regimen, youwould miss a depression that, if left untreated, is po-tentially life threatening.The symptoms in LBs case (eg, daily sadness,

physical complaints, and noncompliance) suggestthat LB was suffering from a common, treatable dis-order. These symptoms are typical of major depres-

sion. The nurse who detects clues, evaluates symp-toms, encourages treatment, and begins supportivecare and education can reduce LBs suffering anddistress. The nurse who encourages early treatmentfor major depression can prevent suicide, the mostserious complication of depression. 1,2,5,7-9

Assessment ofDepression

The home health care nurse has the ideal opportu-nity to assess the home care client with a major de-

pressive episode. Knowing the current research lit-

erature enables the nurse to effectively assess for



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depression using interview and observationalskills. 16,17Assessment is the initial step of the nurs-

ing process.Acomprehensive assessment includes achart review, admission interview, medication and

symptom review, and appraisal of risk factors.,5,.15After review of routine diagnostic medical dataavailable for the client, the nurse conducts the ad-mission interview. Talking with significant othersabout their observations of and interactions with the

client can provide important data about a clients be-haviors, communication abilities, and mood. 4,18 Thenurse also makes objective observations of the gen-eral living environment and the clients behaviors.The observations of the nurse, friends, or family pro-

vide diagnostic data about the persons mood, behav-ior, and communication abilities.

Depression is accompanied by physical and psy-chologic symptoms. These include sleep and appe-tite changes, poor concentration, fatigue, multiplelosses, withdrawal, and either somatic complaints orthe inability to cope with these multiple com-

plaints. 1-5 The older depressed client demonstrates a

picture of apathetic withdrawal with great loss ofself-esteem. For instance, LBs loss of interest in a fa-

vorite activity, gardening, signals apathy. The personrarely acknowledges a depressed mood but often re-

ports numerous physical symptoms and few psycho-logic or emotional complaints.1,4,5,7 LBs complaintthat her body is falling apart is a good example.Atthe same time, marked impairment of cognitive abili-ties exists (eg, inability to concentrate, to remember,or to make a decision). Generally, the older clientwill have little expression of guilt in depression. 2,5Assessment includes asking about the clients or

familys prior history of depression. Informationabout past coping patterns, communication style,and existing support systems helps the nurse planinterventions. 4,5,7 Understanding the physical, emo-

tional, social, and cognitive aspects of the clients

status is necessary because the manifestations of de-

pression can be so variable.

In the case study, LB lives alone and has limitedsocial contacts. She exhibits passivity and loss of

pleasure in activities she formerly enjoyed. She hasnumerous physical complaints but minimizes herloss of weight. She also admits to some sadness, tear-fulness, insomnia, and fatigue. Her comments indi-cate she feels worthless.

Because clients often emphasize physical overemotional symptoms, any symptom that is not

readily explained should be a cue for increased at-tention by the nurse.4,7,18 The nurse should ask about

symptoms (see box, &dquo;Criteria for Major Depression&dquo;)

and risk factors if they are not mentioned by the cli-ent. The nurse must also ask about and evaluate any

changes in weight, appetite, interpersonal relation-

ships, sexual interest, sleep pattern, activities, levelof energy, or fatigue. For example, the nurse gentlyprobed LB about the start ofsymptoms of fatigue and

attempted to have LB describe feelings more explic-itly.Antihypertensives such as atenolol may contrib-ute to lethargy and depression.4.5.18The nurse should evaluate changes in the clients

motor activity.Agitation may be exhibited by pacingor hand wringing. Conversely, slowed motor activity

may affect movement, speech, and thought patterns.Cognitive changes such as difficulty in thinking,concentrating, level of distractibility, or decision

making need to be fully examined.Amental statusexamination is a critical part of assessment becauseit helps rule out various other mental health diag-noses, such as confusion or dementia.4.5.7.15.18

Knowledge of the clients previous and presentlevel of functional ability will help predict how wellthe client will participate in self-care. 5,7 Functional

ability will need to be assessed unless it is alreadydocumented.Asking the client to perform a simple

task such as walking across the room helps evaluateabilities. Questions about managing bathing and

dressing can clarify functional abilities. The clientsfunctional ability influences safety at home, mainte-nance of interpersonal relationships, and participa-tion in social activities. 1,5 The nurse will find the

OlderAdults Resource Survey (OARS) useful in as-

sessing general abilities. 5,7 Beyond that, the nurse

may need to seek assistance of physical or occupa-tional therapy for complete functional assessment.The clients medications require review because of

the danger of possible interactions and depressiveside effects. 1,5 The home care client may be taking



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11

over-the-counter medications and medications or-

dered by different physicians. 1,3,5 The altered physi-

ologic response of the older person contributes to theneed for medication monitoring. 4,1 Some medica-tions, such as antihypertensives, anxiolytics, analge-sics, hypoglycemic agents, and even antibiotics, areknown to cause depressive symptoms. 7,15,18,19

Several medical illnesses can cause symptoms of

depression. These illnesses include cardiovasculardisorders (eg, congestive heart failure), pulmonarydisorders (eg, chronic obstructive lung disease), neu-

rologic diseases (eg, Parkinsons or dementias),metabolic disturbances (eg, dehydration), or endo-crine disorders (eg, diabetes or Cushings disease).

Numerous infectious processes (eg, viral and bacte-rial pneumonia) as well as some genitourinary andmusculoskeletal disorders may result in depres-sion.18 Cancers, especially those of the head andneck or gastrointestinal (GI) tract, have a high inci-dence of depression and suicide. 6,15Among peoplewho haveAIDS, incidence ofdepression and suicideis high.3

3

Because of the similarity of symptoms of physicalillness and depression, Marzuk$suggests that cogni-tive and affective symptoms be given more value in

diagnosing a depression when there is concurrent

medical disease. The nurse must apply the nursingprocess to the ongoing education about illness and

symptom management. The nurse evaluates the af-fect or mood of the client and the ability ofthe clientto move through problem solving (eg, cognitive abili-ties). When the nurse helps clients to manage symp-toms and promotes the clients optimal functioning,clients can renew feelings of hope and restore self-esteem. 5,15,20

Multiple reasons exist for the failure to identify el-ders who are at risk for depression and suicide. Onereason depression and suicide risk is misdiagnosedcan be the failure of physicians and nurses to askabout depression.39 Differentiating between a majordepressive episode (see box, &dquo;Criteria for Major De-

pression&dquo;) and a more persistent, chronic mood dis-turbance can be difficult,18 Chronic depression mustbe present continually for at least 2 years with atleast two of the accompanying symptoms (eg, fa-

tigue, poor concentration, insomnia or hypersomnia,loss of appetite or excessive eating, low self-esteem,fatigue, hopelessness) present for that time.Ahistoryof difficulty adapting to life situations is common

among elderly persons with chronic depression.18

Finally, the similarity of symptoms of medical ill-

ness and depression further confound assessment ofthe depressed elderly. 2,4,18

Because the home health care nurse may face diffi-culty in assessing depression, Krachl has identifiedsome efficient assessment tools (see box, &dquo;Assess-

ment Tools&dquo;).Although she lists several, easy-to-administer screening tools, the Beck Depression In-

ventory (BDI) is often the most convenient for

identifying depression. The BDI is a self-report toolthat is readily available. The client can answer the 21

questions in 10 to 15 minutes. The BDI measures the

intensity and severity of depression.Ascore of lessthan 17 indicates minimal depression. Moderate de-

pression might yield a score between 17 and 25,

while anything over 30 is potentially a serious, pro-found depression. 20,22 The first BDI score of LB was28, indicating that she needed to be in treatment. Thehome health care nurse who uses one of these tools

can provide subjective and objective data to con-vince the physician that a major depression exists.

Suicide risk

Healthy People 2000 described suicide as &dquo;themost serious potential outcome of mental disor-ders&dquo;9(p2i0) and targeted reducing the age-adjustedsuicide rate from 11.7 to no more than 10.5 per

100,000 people by the year 2000.9About 70% ofpeople who died by suicide had been diagnosed withmedical problems. 23 Other risk factors that have been

scientifically related to suicide are male gender,white race, living alone, prior suicide attempt, psy-chosis, substance abuse, hopelessness, and depres-sion. 3,11,23

Marzuk stated that among terminally ill clients

thoughts of death should not be considered as an in-dicator of suicide but instead a possible indicator ofdepression. During assessment ofphysical problems,the nurse considers whether each symptom or prob-



6/11

12

lem is reversible.Anurse provides education aboutreversible symptoms (eg, insomnia, pain, constipa-

tion) and works with the client and family to managethe problem. Some irreversible problems such asloss of vision or hearing, amputations, or paralysisare not changeable. The nurse provides not only edu-cation, but also emotional and psychologic supportas the client and family move toward accepting the

irreversibility of the experience.The elderly home care population often confronts

an accumulation of losses that lead to depressionand hopelessness. These losses occur as part of ag-ing. The nurse needs to assess how the person has

adapted to any previous losses. Learning about the

adaptational abilities of the person to past develop-mental, emotional, or psychosocial losses could in-dicate current coping abilities.An accumulation oflosses can predispose the person to a serious depres-sive episode, particularly if social support, copingskills, and problem-solving abilities were weak. 4,5,21The nurses knowledge of depression risk factors

allows for sensitive, yet direct questioning of theseareas.Although physical, economic, emotional, andsocial losses or excessive use of alcohol might beoverlooked as acceptable in the older population,these place the client at greater risk. When a risk fac-tor exists, a thorough evaluation of depression is im-

portant.4,7,10,11,15,16Hints of suicide are revealed in obvious statements

such as, &dquo;Its so hard to go on,&dquo; or &dquo;Im never going to

get better.&dquo; For instance, LB said, &dquo;Im sick of this

life.&dquo; The client may also say, &dquo;I probably wont see

you.&dquo; Indirect expressions might include givingaway favorite items or a change of behavior (eg, de-cides to make or change a will, stops eating or takingmedications). The nurse asks for clarification of the

statements and behaviors. Elderly people often donot volunteer information about suicide.4z3 Unfortu-

nately, 80% of suicidal older adults had visited a

physician 1 week prior to their suicide. 16,22 The nursecan always seek assistance from others in determin-

ing suicide risk. The nurse assessing LB should beinterested in evaluating what LB meant when shesaid, &dquo;Im sick of this life; my good years are past.&dquo;The nurse should ask LB to clarify those commentsand should use them as an opportunity to exploreLBs life perspective.

Evaluating suicide risk

Clients with

depression, hopelessness,or

pastsui-

cidal behaviors require evaluation of suicidal in-

tent. 2-4,7,16,22,23 The nurse will emphasize an overrid-

ing concern for the clients safety.Asensitive nurse

will inform the client about the need to share withthe district supervisor and other health care teammembers information that affects safety. The nurseevaluates suicidal risk by asking open and direct

questions:Are you feeling so badly that you thinkabout killing yourself? The nurse asks specific ques-tions to determine whether thoughts of self-harm are

fleeting or include a definite plan. It is essential toask the person about intentions: How or when do

you plan to do this? What do you think might hap-pen ? Next the nurse determines whether the clienthas the means to carry out the plan. Does the personhave a gun or enough pills? The greater the specific-ity of plan, intent, and available method, the greaterthe risk of suicide. The degree of risk should be rou-

tinely assessed and documented, appropriate safetymeasures instituted, and other colleagues notified ofrisk potential. In the case example, the nurse learnedthat LB was feeling somewhat hopeless about ever

recovering fully, especially in the face of the newmedical diagnosis of diabetes. However, because of

strong religious convictions, denied suicide was an

option.When the nurse experiences a high level ofanxiety

about the suicidality of a client, the following ques-tions will help: (1) Have you ever thought about or

attempted to kill yourself? (2) How often have youthought about killing yourself in the past year? (3)Have you ever told someone that you were going tocommit suicide or that you might do it? (4) How

likely is it that you will attempt suicide one day? The

questions are brief and indicate severity and inten-

sity ofsuicide risk. The scoring ranges from 0 for a noanswer to 6 for an active, present thought or at-

tempt .25 Taking the few moments to ask key ques-tions can help to establish an appropriate level ofcare.

Interventions

Major depression and depressive disorders re-

spond well to treatment. 2-5,9,10,24 Management of

depression includes antidepressant medications,psychotherapy, electroconvulsive therapy, and edu-cation. Nurses play an active, vital role in educationand support of clients during treatment and recov-

ery. The nurse

helpsthe client

participatein

makingdecisions about depression.



7/11

13

Monitoring medications

Researchers suggest that biologic factors triggerdepression because clients of all ages respond to an-

tidepressant therapy. 26 There are numerous effective

antidepressant medications available for treatment.

Tricyclics (TCAs; eg,Amitriptyline hydrochloride),heterocyclics (eg, trazodone hydrochloride), mon-amine oxidase inhibitors (MA01s; eg, phenelzinesulfate), and selective serotonin reuptake inhibitors(SSRIs; eg, sertraline hydrochloride) are commonlyused.3,5Antidepressant therapy should providemaximal therapeutic effects with minimal adverseside effects. 5,16,18 The nurse educates clients and

families about prescribed medications and about the

importance of continual monitoring of the clients

response to medication.17

The nurse will educate the client and family aboutthe purpose of the medication, its dosage, and its ad-ministration schedule. Many antidepressants maytake several weeks to be fully effective. Providingsupport to the client during this time is essential.

Expected responses and management of uncomfort-able symptoms (eg, dry mouth or constipation) mustbe explained to the client and family. The side ef-fects, such as oversedation or urinary retention, thatdo not respond to nursing measures need to be re-

ported to the physician for possible medication ad-

justment or change.5,16.18 Because of fewer side effectsand decreased lethality, the newer heterocyclics are

preferred for the older depressed person.3-5As a lastresort, MAOIs are sometimes useful in older clients

with prior cardiac history.5Medication side effectssuch as tremors, restlessness, anorexia, nausea, and

headache might appear and without appropriatenursing interventions may contribute to poor ad-herence. 3,4 For example, when beginning new med-

ications, the dose is often altered due to slowed

physiologic responses,and blood tests for

therapeu-tic blood levels may need to be tested more fre-

quently.3.5.16 The home care nurse may need to en-

courage the physician to order the specific laboratory

tests. The nurse who provides consistent empathicsupport and education about depression, treatment,

and recovery promotes client adherence and pre-vents suicide3.7.19 (see box, &dquo;Antidepressants&dquo;).LB had been ordered the SSRI sertraline hydro-

chloride (eg, Zoloft) by her psychiatrist. This medi-cation is preferred for diabetics because of its lowerside effects and safety in combinations.9 The nursewas beginning to educate LB about the new medica-tion and discovered that LB was beginning to havesome hope for feeling better. LB stated that it was a

welcoming thought to even consider working in her

garden again once the medication began to take ef-fect.

Education and counseling

Psychotherapy is a time-limited treatment that ismost effective when coupled with antidepressantmedications.2.5.7,24 The clients who do not respond tomedication or who have marked functional impair-ment often respond favorably to a course of electro-convulsive therapy. 5,14 Nurses provide both educa-tion and emotional support to the client and familyduring these treatments.3,17Education and brief counseling at home can help

clients develop the knowledge and skills necessaryfor coping with depression. Occasionally clientsmay initially have difficulty telling their troubles to

strangers, a new nurse, for example; but more typi-cally patients feel very comfortable sharing concerns

regarding their current health. Depressed clients fearthat the health care community has given up on themand offers few alternatives.l4By encouraging the cli-ent to verbalize feelings, the nurse is being therapeu-tiC.5

Most home health care agencies have a full

complement of professional staff that allows thenurse to more readily access special services for a cli-ent. The nurse facilitates client requests. There maybe instances when the nurse recognizes a need for

specific skills training (eg, use of safety devices inthe home). Community resources for seniors provideassertion skills classes, travelogues, volunteer activi-

ties, and even job training for seniors. Nurses can beinstrumental in directing seniors to these activities.When the nurse provides new and different op-

tions, clients improve their coping strategies and be-come more willing to explore other self-managementstrategies. Realistic short-term goals that are made

collaboratively are more likely to be achieved, givingclients a sense of satisfaction. Strategies can include



8/11

14

increasing self-esteem through helping clients to rec-

ognize and appreciate their own strengths and at-tributes.1,3,15.21Asimple daily exercise program thatincreases mobility can produce physiologic and psy-chologic changes that diminish depression.1,5,s,16,21Examples might be a short daily walk or simple aero-bic exercises. Pet therapy can be helpful for those

living alone. Encouragement and facilitation of an

improved level of functioning are continuous proc-esses.

Educational approaches and community-basedservices help reduce depression and improve a cli-ents control over treatment.5,21 Group interventionscan prevent stressors, reduce isolation and loneli-

ness, and enhance social support and problem solv-

ing.Agroup intervention typically encourages cli-ents to share coping strategies. Groups can helpclients to identify and work out solutions to their

problems. Systematic problem-solving techniquesare used to resolve specific concerns while efforts aremade to reduce depression.1,6.9,21The nurses interventions move the client toward

an improved state of mental, physical, and social

health. The home care nurse uses professional skillsto establish a trusting relationship by acting in a

nonjudgmental, positive manner. When the nurse

practices empathetic, reflective listening and uses si-lence appropriately, those behaviors promote verbal-ization of feelings and thoughts .1,5,6 &dquo; The nurse alsocollaborates with clients to allow for realistic activityand goals .11,17,11 The nurse who allows just a few min-utes out of each visit for the client to reminisce can

help restore a positive self-image.l.5.l9 Zauszniew-

skill addresses the importance of a variety of strate-

gies for the depressed person. Creative nursing inter-ventions that promote resourcefulness and social

interactions, build self-esteem, and support inde-

pendent problem solving serve to reinforce the per-sons belief in personal effectiveness.21 The impact ofcultural differences and beliefs on health needs must

be considered in planning care.28Although a keymember of the home care team, the home health care

nurse is not alone in being responsible for the clientbut can be instrumental in inspiring renewed hopefor clients. The nurse is able to assume numerous

roles (eg, educator and counselor) to promote clients



9/11

15

participation, acceptance, and integration of theirlife situations.

When confronted with a suicidal client, the nursehas a clear professional obligation to maintain

safety.18,29 The nurse may ask someone to remainwith the high-risk client at all times; hospitalizationmay be indicated. The nurse may need to draw up a

no-self-harm contract with the client. The clientneeds to agree to notify the health care team of sui-cidal impulses and to not harm himself or herself.The contract must have specific objectives and mustbe reciprocal. This means the client must know whatthe nurse or health care team will do.2 The nurse

who has been interacting with elderly clients in a

nonjudgmental, accepting manner will be providingthe stimulus for open discussion of thoughts and

feelings in a trusting environment. Clear, concise,and consistent documentation of interactions and

specific interventions is essential.Although deci-sions about suicide risk require expert and decisive

action, the nurse need not make such decisions alone

but may consult regularly and often with the super-visor and other team members.

Once safety has been established, the nurse mustdetermine what factors provoked the suicidal behav-ior.Adetermination of helpful persons and support-ive resources needs to take place. Once the immedi-ate crisis has stabilized, the nurse will work closelywith client and family or friends to reestablish a real-istic plan for handling future incidents. Someone

may need to be responsible for keeping and adminis-

tering medications for a period of time. The personshould not be allowed to be alone until a renewed

sense of hope and commitment to life are apparent.Apastor or spiritual advisor can provide anothersource of support. If a client has returned home after

a suicide attempt, the nurse needs to be aware that

danger may still exist and must take appropriatemeasures to maintain safety of the client.24 The mul-tidisciplinary team approach is invaluable in long-term management of the elderly person at home.

Expected outcome

When a client receives treatment for depression,the nurse should see improvement in behavior andmood in about 6 weeks. Recovery takes time. Nursesenhance recovery by focusing on and praising small

improvements and accomplishments. Nurses can

help clients to recognize feelings by asking questionsthat help the client identify what may be causing the

distress. Expected outcomes include improved daily

hygiene with a resumed interest in the activities of

daily living (ADL). With improved appetite and

regular sleep patterns, clients are more able to con-centrate and remember pleasures forgotten. These

changes should begin when the antidepressantachieves therapeutic levels and should be visible in

approximately 4 to 6 weeks. Often the first indicatorsof improvement occur as clients begin to take an in-terest in their appearance, as moods lighten, and asclients make more positive statements about their

surroundings.As the nurse promotes a higher func-tional level, clients begin to value themselves again,often growing in new ways.

In the case example, LB was very receptive to the

calm, positive attitude of the nurse. LB had few so-cial contacts and was glad to have the nurse &dquo;taketime to listen to me.&dquo; LB was planning to join a groupfor newly diagnosed diabetics. The last BDI com-

pleted by LB was 25. LB was able to obtain therapeu-tic reliefwith the sertraline. Her Beck scores began to

slowly drop as she became more active in her ownhealth maintenance.

Ethical Issues

Nurses encounter conflicts regarding three bioeth-

ical issues (ie, the duty to care, confidentiality, andassisted suicide). The nurse must examine the issues

and prepare thoughtful responses before facing these

problems in practice.According to ethicists, thenurses primary duty is to provide for the clientscare, safety, and well-being. Secondly, the nurseshould possess the competence to detect depressionand to participate in a collaborative treatment plan.Conflicts occur when a duty to care and inform theteam clashes with the clients refusal of treatment.

Numerous books on ethics are available in any nurs-

ing library for use in examining ethical dilemmas

(eg, professional duties, values, ethical and profes-sional guidelines).Conflicts surround confidentiality issues. The

nurses duty to alert the team to suicide risk may



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clash with confidentiality requests, particularlywhen terminally ill clients have unrelieved sufferingor unacceptable quality of life. Confidentiality is notan absolute right and does not prevent informing thehealth care team. The Code of Ethics directs the

nurse to do no harm (eg, nonmaleficence) and to do

good (eg, beneficence).29 Conflict may occur in ap-plying these principles to practice; nurses may de-bate whether informing the physician or not is the

greater good. Nurses know they should sound thealarm when a client is suicidal but hesitate to do so

for confidentiality and other reasons. However, fail-ure to evaluate and disclose risk could lead to a pre-mature suicide. Suicide is the ultimate complicationof untreated depression.The nurses duty is to evaluate, document, and re-

port the clients suicide risk to the physician andteam. However, the nurse may also request a consul-

tation or team conference regarding the patient andseek consultation from the nursing supervisor and

hospital or state board ethics committees. Nurses candecrease suicide risk by ensuring the client receivesthe most effective management for symptoms, pain,and depression.Another response is to inform thehealth care team and also educate the patient aboutadvance directives, refusing treatments, or with-

drawing food and fluids. Educating the client andfamily about options and resources is one way to

provide advocacy within standards of practice.10When nurses believe that these standards prevent

death with dignity, they need to know that participa-tion in political efforts to revise professional and le-

gal standards is an appropriate mechanism for

change. Some nurses may advocate for such changeby joining the Hemlock Society, Death with Dignity,or other professional organizations, such as the

AmericanAssociation of Suicidology.

0 0 0

The complexity of assessing depression in theolder person in a home setting requires keen assess-ment skills. The major components of effective as-sessment of the depressed elderly poison must be agespecific and multidimensional. The nurse must have

knowledge to recognize depression in the older per-son and clinical competence for management of avulnerable population. The assessment challenge isthat the symptoms are difficult to detect. The older

person rarely reports psychologic symptoms but in-stead

expresses

numerous somatic

complaints.Con-

cise assessment data provide a framework to orga-nize a plan for a collaborative treatment approach.

Opportunities for supporting and reducing depres-sion in the elderly require home health care nurses tobroaden their own perspectives of the elderly.

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