| DEPRESSION AND SLEEP MANAGEMENT | |||||||||||||||||||||
There is a strong link between sleep and depression, and it is thought that disturbances in brain neurochemistry in depression affect the basic control of sleep, leading to insomnia or sometimes hypersomnia. Sleep disturbance is a key feature of all diagnostic systems for depression. Sleep symptoms may persist after effective treatment of the depressive episode, which not only leads to quality of life deficits in these patients, but is also a possible risk factor for relapse. Studies have found that patients who are diagnosed with depression and prescribed anti-depressants are more likely to be prescribed hypnotic medication than those depressed patients without an anti-depressant prescription. This would suggest that the use of anti-depressant medication may not offer effective treatment for insomnia. A survey of UK GPs has shown that while 90% recognise depression-associated sleep problems as a common and distressing symptom that should be managed in primary care, most (72%) fail to adopt more than a "watch and wait" strategy to managing patients with such symptoms. The results, from the second phase of the National Patient Sleep Assessment Questionnaire in depression (NAPSAQ-II), reveal that although GPs understand the significance of sleep disturbances and admit they cause patients to visit them more frequently, almost half (42%) said they find such symptoms difficult to treat. In a separate national survey, sleep disturbances were reported by 97% of people with depression, and are associated with an increased risk of depressive relapse and recurrence. In addition to adopting a "watch and wait" approach to patients with sleep disturbances, other management strategies GPs claimed to use included promoting good sleep hygiene, prescribing an add-on hypnotic treatment and switching antidepressant medication. Findings from a previous patient survey showed that of the 69% of patients taking an antidepressant, more than half said it had no effect or worsened their sleep. Results from NAPSAQ-II suggest that GPs may also question the benefit that current antidepressants have on sleep disturbances. The survey showed that just 21% switch their patient's medication in an attempt to alleviate symptoms. Commenting on the study, Professor David Nutt, NAPSAQ investigator from the University of Bristol, commented: "This survey highlights a real confusion about the most appropriate management strategies for this widely recognised issue." "If we are to improve the long-term outcome of patients with depression we not only need to support GPs with clearer recommendations on managing sleep disturbances but also ensure that these are reviewed as new therapeutic options become available.” A survey of the membership of the Depression Alliance was undertaken to investigate the impact of depression on their work and daily lives. The survey was designed to investigate a range of issues including work, quality of sleep, the distress caused by depression and the impact of depression on quality of life and daily activities. The results of this survey showed that over 60% of respondents considered that five aspects of depression have a severe or very severe effect on distress, quality of life and their ability to perform daily activities. These are:
Furthermore, when depressed, 62% of respondents consider disturbed sleep to cause severe or very severe distress and 65% of respondents think it has a severe or very severe impact on their quality of life. In addition, 60% of respondents said that poor sleep has a severe or very severe impact on their ability to carry out daily activities. Therefore, sleep disturbance can have a major impact in people with depression, and this therefore highlights the importance of healthcare professionals and patients working in partnership to manage their depression in a way that will not impact negatively on their sleep. With this in mind, it is imperative to address disturbed sleep as part of the overall management of depression. This CD-Rom has been produced to help increase awareness of the link between depression and poor sleep and review the management of the two jointly. Throughout this section there will a number of tasks to complete that will inform your clinical practice.
Using the Hospital Anxiety and Depression Scale (HADS) The HADS assessment tool fits well with the most prevalent common mental health problem Mixed Anxiety and Depression Disorder. You may wish to consider others and it may be that other clinicians are already using the Patient Held Questionnaire (PHQ9). The Medical Algorithms Project's website When selecting an assessment tool there are a number of issues that need consideration. The measure will need to be reliable, valid, and responsive. The HADS meets these criteria. The questions within the HADS are designed to reduce contamination with somatic symptoms, which are common in primary care. The HADS consists of an anxiety and depression sub-scale each containing seven items, making it quick and easy to use in clinical settings.
Don't take more than 4-5 minutes with this task:
The Scoring:
Remember your own clinical judgement is important - the HADS or any other clinical tools are not infallible. Having completed the holistic assessment process it is important that you now consider the patients pathway and ensure that the patient receives the appropriate care from the right professional in the most suitable setting. See the Measurement and Stepped Care Diagram
A review of the document 'Making it possible: Improving Mental Health and Well-being in England' (NIMHE 2005) clearly views well-being as more than the acquisition of happiness. Well-being is seen as being synonymous with the aims of mental health promotion, social inclusion and mental health service delivery models that exist across all age ranges. The tool is biopsychosocial in nature and can guide nurses and their patients through a range of well-being choices that can enhance the care process. The well-being care planning tool has become a very useful tool that is often utilised locally in Northampton by primary care practitioners in what is termed the 'watchful waiting' period. 'Watchful waiting' involves avoiding active treatment in those patients with mild or sub clinical presentations of common mental health problems. It is known that there is a high probability of recovery in the early weeks of a depressive episode (Patten, 2006).
Rather than just passively waiting, the well-being care plan encourages the individual to make lifestyle changes that can improve their chances of regaining well-being. Many of the lifestyle changes advocated are those that are within the individuals regular sphere of experience. For example if the patient enjoys dog walking the care plan will aim to increase that activity rather than medicalising the process by issuing a prescription for exercise. The tool also impacts on the individuals capacity to take some control over their symptoms and their lives by encouraging simple interventions such as dietary changes, breathing exercises and simple thinking strategies. It is known that a process of regaining control can be beneficial for people experiencing anxiety symptoms.
Sleep Problems Checklist (click on thumnail to see full size version of document):
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provides a range of clinical tools – including HADS and PHQ 9 – you will need to login into this site, but registration is free.
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