National Kidney Foundations Coffeehouse Chats

1
National Kidney FoundationsCoffeehouse Chats

• Understanding Depression
• Mary Beth Callahan, ACSW/LCSW
• Callahanm_at_dneph.com

2
Major Characteristics of Depression

• depressed mood most of day/almost everyday
• diminished interest or pleasure in activities
• weight loss/weight gain
• daily insomnia or hypersomnia
• psychomotor agitation/retardation
• feelings of worthlessness/excessive guilt
• decreased ability to think/concentrate/decide
• recurrent thoughts of death/suicidal ideation
• fatigue/loss of energy
• DSM IV-TR

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
3
Depression vs. Grief

• Depression
• does not accept support
• irritable
• may complain but does not directly express anger
• Does not relate experiences to a particular life
  event

• Grief
• responds to comfort and support
• often openly angry
• relates depressed feelings to loss experienced
• can still experience moments of enjoyment

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
4
Depression vs. Grief

• Depression continued
• pervasive sense of doom
• helplessness and chronic emptiness
• chronic physical complaints

• Grief continued
• sadness and emptiness
• transient physical complaints
• specific guilt
• temporary loss of self-esteem

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
5
Screening for Suicide

• hx of suicide attempt
• hopelessness
• physical illnesses
• family hx of substance abuse
• Caucasian
• depression
• male
• advanced age
• presence of psychotic symptoms
• social isolation/living alone

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
6
Assessment for Depression

• History of symptoms
• when started, how long, how severe
• what symptoms, have symptoms occurred before,
  treated?
• use of alcohol/drugs
• thoughts of death or suicide, suicide attempts
• social isolation
• family hx of depressive disorder or other mental
  health problems
• mental status exam
• current medications
• select a screening instrument

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
7
Depression Screening Program

• Select a user-friendly screener that you are
  comfortable with
• Report on a pilot with your screener in staff/CQI
  meetings to gain team support and reduce stigma
• Engage the patient
• psychoeducation
• help your patients become comfortable with a
  screener
• involve the patient and family
• Team effort

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
8
Which Type of Treatment is Best?

• Factors influencing choice of treatment
• type of depression
• patient preference
• clinician familiarity
• Commonly chosen options
• medication
• psychotherapy
• medication and psychotherapy

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
9
Phases of Treatment for Depression

• Acute Phase
• Time period First 1-12 weeks of treatment
• Goals To reduce symptoms and restore
  functioning
• Focus
• ensure adherence
• ensure relief of symptoms and treatment tolerance
• Consider change in regime if needed

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
10
Phases of Treatment for Depression

• Continuation Phase
• Time period 4-5 months following remission
• Goal Prevention of relapse
• Focus
• restore full psychosocial functioning
• monitor closely for relapse
• ensure adherence to treatment

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
11
Phases of Treatment for Depression

• Maintenance Phase
• Time period long-term treatment for persons at
  risk of recurrence (one years after remission)
• Goal To prevent a new episode of depression
• Focus
• to ensure medication adherence
• to monitor for new mood episode

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
12
Choosing a Medication for Depression

• Issues to consider
• any previous medication that was successful
• side-effect profile
• dosing hardships
• cost
• symptom management profile
• interaction with current medications
• physician familiarity with medications

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
13
Four-Component Depression Management Program

• Educate
• Prevent
• Identify
• Respond

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
14
Goals of Depression Education Programming

• patient/family awareness of degree of risk
• awareness of depression as a medical illness
• awareness of impact of depression on wellness and
  survival
• awareness of facility screening protocol
• awareness of symptoms to watch for
• awareness of treatment as safe and effective
• make it easy to seek help

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
15
Depression Education Programming

• Should be done at routine intervals to maintain
  awareness and promote self-screening for
  depression

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
16
Education Programming Options

• Brief audiotape
• Posters
• Handouts
• Depression Awareness month campaign
• Flipcharts
• MD referral to social worker
• wellness class to prevent depression and improve
  quality of life

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
17
Depression Means More Than Sad
Tools to Use for Education

• Sad Mood
• I feel down today
• I dont feel like anything matters today, but I
  like myself
• I hope things get better
• I feel tired

• Depression
• I feel down most days
• I fell worthless, like Im no good to anybody
• I cant imagine caring about anything else again
• I just want to stay in bed all day and pass the
  time.

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
18
Depression Does Not Mean Youre Crazy!

• Depression occurs in up to 60 of patients with
  kidney disease
• Depression is a medical condition
• Depression is easy to treat
• Talk to your doctor or social worker today if you
  notice the following symptoms
• Feeling down most of the day, almost every day
  for the past two weeks, etc.

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
19
Does Your Loved One Suffer from Depression?

• You may be the first to spot depression in your
  loved one
• If your loved one has these signs and symptoms of
  depression, dont blame it on dialysis, it could
  be depression. See the social worker right away!
• Feeling down all day, nearly everyday for at
  least two weeks.
• Feeling worthless, hopeless or guilty
• Loss of interest or pleasure in things
• Thoughts of giving up
• Encourage your loved one to speak with the social
  worker today if you feel he or she may be
  suffering from depression.

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
20
You Cant Snap out of Depression

• Depression is a medical illness that needs
  treatment, like any other medical illness.
• Dont try to get better by yourself. In most
  cases, it wont happen.
• Without treatment, it is likely you could get
  worse.
• If you have the following symptoms of depression,
  talk with your doctor or social worker, who can
  screen you for depression
• Feeling down or angry all day, nearly every day
  for the past two weeks, etc

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
21
Screening

• See list of Depression Screening Tools attached
• Do baseline and at least follow up not more than
  3 months later
• Be point person for asking about changing dose or
  medication
• Treat to remission, not response

22
Response vs. Remission

• Response
• Yes, I see a little difference, but Im still
  depressed.
• Remission
• Im able to participate in family/work
  activities like I did 2 years ago. Im able to
  think clearly through problems.

23
Stepping Back Into Life

• A wellness program to reduce stress, prevent
  depression and maximize quality of life for
  dialysis patients
• Three-part program (live/chairside or
  self-directed audio)
• Can be done all at once or one part at a time
• Can be used by family members for reinforcement
• Utilizes behavioral, cognitive and interpersonal
  training to create behaviors early that can
  prevent depression

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
24
Class 1Prevention Topic Scheduling Enjoyable
Activities

• Persons on dialysis might tend to decrease
  enjoyable activities
• Research shows that belongingness support helps
  prevent depression
• Application tools
• Behavioral prescription
• Stepping Back Into Life!
• Available soon through NKF

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
25
Class 2Communication and Problem Solving Skills

• Persons on dialysis might tend to ask others for
  less than before they became sick
• Withdrawal from relationships can lead to
  depression
• Interpersonal skills
• Application tools
• Behavioral prescription
• Stepping Back Into Life!
• Available soon through NKF

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
26
Class 3Prevention Concept Schema

• The way you begin to view yourself as you adjust
  to living with kidney failure can determine
  whether or not you might become depressed
• Balancing your thinking
• Application tools
• Behavioral prescription
• Stepping Back Into Life!
• Available soon through NKF

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
27

• FEELING BETTER AGAIN!
• A Depression Management Class for Persons with
  Chronic Kidney Disease

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
28
Class 1 Understanding Depression and How to
Feel Better Again

• Why are so many kidney patients depressed?
• Role of medication in treatment
• Effectiveness of CBT in reducing depression
• How this class will work/participation guidelines
• Screening and symptom tracking
• Getting started Scheduling enjoyable activities
• Homework Schedule an enjoyable activity
• Feeling Better Again!

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
29
Class 2 Cognitive-Behavioral Training and How
it Works

• Screening and review of symptom tracker
• Review of homework Enjoyable activity (EA)
• Situation Thoughts Feelings
• The role of thoughts in changing mood
• Redirecting thoughts
• Current situation (patients share)
• Homework practice redirecting thoughts/plan
  enjoyable activity
• Feeling Better Again!

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
30
Class 3 Balancing Your Thinking

• Screening and review of symptom tracker
• Review of homework (situation-thought-feeling/EA)
• The risk of distorting thoughts (schema)
• Common types of thinking that lead to distorted
  thoughts
• Balance your thinking
• Goal Positive illness self-schema
• Homework Practice redirecting thoughts/EA
• Feeling Better Again!

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
31
Class 4 Practicing New Skills

• Screening and review of symptom tracker
• Review of homework (redirecting thoughts
  worksheet/EA)
• Redirecting thoughts--class practice and feedback
• Daily meditations
• Homework Practice redirecting thoughts and plan
  enjoyable activities
• Feeling Better Again!

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
32
Class 5 Preparing for Success

• Screening and review of symptom tracker
• Role of homework redirecting thoughts/EA)
• What will it be like to get well? (hopes/fears)
• Combating worry with problem-solving
• Communicating with others about recovery (wheel)
• Thoughts about last class next week
• Homework Communicating our image of recovery
• Feeling Better Again!

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
33
Class 6 Maintaining and Moving Forward

• Screening and review of symptom tracker (discuss
  progress
• Review of homework (communicating about recovery
  with others/EA)
• Looking back summary of what we have learned
• Relapse How to prevent depression from
  returning
• Where do we go from here? (continue
  training/suspendmaintain)
• Saying goodbye Our hopes for ourselves and each
  other
• Meditations Patients read them
• Feeling Better Again!

NKF/CNSWs Outcomes Training Program
Interventions that Identify and Reduce
Depression, 2001
34
Depression Management

• Educate about managing stress and depression
• Preventteach coping and adapatation skills
• Identifycontinually assess as changes occur in
  chronic illness and life
• Respondintervene. Consider NKF programs to
  provide time efficient, effective interventions.