Thinking about depression.

Not too long ago, a 25-year-old patient I was working with committed suicide. Already suffering from neurologic deficits, he had recently been diagnosed with a malignant brain tumor and decided to throw himself in front of a train. My initial reaction was shock, not only because of the manner

His death acutely reminded me of the prevalence of depression among the patients with whom we work. Depression is common among persons who have suffered a stroke, who live with epilepsy, who have degenerative diseases, and so on. Although logic would tell us that depression is a consequence of neurologic disease--after all, who wouldn't be depressed after a spinal cord injury--recent research has further explored the relationship of depression to neurologic illness. In fact, depression has been suggested as a causative factor in many diseases, for example, Parkinson's disease, as well as a component of the disease, adversely affecting outcomes. Yet, how often do we nurses evaluate our patients for depression?

This editorial was written in recognition of those patients who have taken their lives in the face of serious neurologic illness. It is a call to action to prevent any other lives from being lost in this way. Prevention begins with recognition of the problem. Depression is not a problem just for psychiatrists; it affects all healthcare professionals, patients, and their families.

The importance of recognizing that depression is common in neurologic patients cannot be underestimated. Nurses must include depression assessments in their overall patient assessments, paying particular attention to suicidal ideation. Signs and symptoms that may suggest depression may be difficult to distinguish from the neurologic problem, but they include

* feelings of sadness

* loss of enjoyment of previously pleasurable things

* loss of energy

* feelings of hopelessness or worthlessness

* difficulty concentrating or making decisions

* insomnia or excessive sleeping

* stomach or digestive problems, appetite change

* unexplained aches and pains, particularly headache

* decreased libido.

It is important to involve the family in the assessments, because patients may put on a happy face for a nurse or physician. Tools are available for depression screening that can be incorporated easily into nursing assessments. Depression screenings may be offered as part of health screenings as well. When depression is an issue, it is important to look for causes that can be alleviated. For example, substitutions for drugs that can contribute to depression may be able to be made to improve mood.

Creating a positive environment should not be overlooked as a preventive measure. Hospital rooms, inactivity, and strange routines are only a few of the factors that can contribute to depression. Making the environment more cheerful, promoting exercise, and involving family members in care can contribute positively to a patient's well-being. When depression is an issue, never underestimate the seriousness of the problem, particularly if the patient is having suicidal thoughts. Refer the patient to a psychologist, psychiatrist, or psychiatric nurse practitioner for more detailed evaluation and treatment. If medication is used, monitor the effects, and be aware that results are not immediate.

Nurses also can support, promote, and conduct research that facilitates understanding of the relationship between stress and depression. Major research initiatives are already under way. Nurses also must incorporate related research findings into practice.

It is unrealistic to expect that our patients will not be sad or that we will pick up every instance of depression in our patients. But perhaps we will be able to save a life. Depression is a treatable problem, but it must be recognized for treatment to begin. Nurses are on the front lines in confronting this problem and can make a major difference preventing tragic outcomes.

Chris Stewart-Amidei

Editor