B760 Mental Health Nursing

Introduction

Mental health problem is a major disease burden worldwide and mental health condition like depression is the primary cause of disability. Major depressive disorder (MDD) is the second leading cause of disability as it is contributing to burden of suicide and ischemic heart disease (Mental health statistics: UK and worldwide 2017). MDD is a major depression associated with continued period of sadness and low mood for at least two weeks. Patient with MDD are observed with poor hygiene and loss of weight. Other symptoms necessary in people according to the diagnostic criteria of MDD includes depressed mood, anhedonia (loss of pleasure in activities), psychomotor agitation, insomnia, loss of energy, indecisiveness, suicide ideation and feelings of worthlessness. These symptoms have an adverse impact on other illness and lead to disruptions in interpersonal relationship, suicide attempts, substance abuse and loss of productivity (Snyder, 2013). There is lack of clarity regarding the underlying pathophysiology of MDD. Some evidence explain the role of interaction between neurotransmitter availability and receptor regulation as the reason for symptoms, where as other suggest disruption in the central nervous system serotonin (5-HT) activity as the factor causing the disease (Schmaal et al. 2016). There are several treatment options for people with MDD and this report critically evaluates the role of mental health services, private providers and third sector organization in treating people with depression and supporting them in recovery.

Critical evaluation of the role of mental health services in treating people with MDD

Maintenance antidepressant treatment is a common treatment recommended by people with mental health services to people with high risk of recurrence of depressive symptoms. However, this medical treatment has many limitations due to moderate efficacy, high remission rate, slow onset of action and compliance problem. Many anti-depressants affect sleep of patients and leads to alteration of bodily rhythms (Berwian et al. 2017). Hence, mental health services were involved in the development of other therapeutic options for people with depression. Currently, mindfulness-based cognitive therapy is widely used an alternative treatment options for supporting people with MDD in mental health services. The efficacy of this intervention has been proved by a randomized controlled trial, which evaluated the effectiveness of this therapy compared with antidepressant in preventing recurrence in patients with depression. This study was done with adult patients from primary care setting in UK in who had at least three major depressive episodes and who were on antidepressants. Participants were randomly assigned to cognitive therapy or maintenance depressants intervention. The main outcome measure for the study was time to relapse of depression and study finding revealed that psychosocial treatment have no positive results compared to control group. However, this treatment is effective for those people who have the highest risk of depressive relapse (Kuyken et al. 2015. Hence, this intervention can protect those patients who are at immediate risk. The current approach for mental health service is to choose intervention on the basis of patient’s commitment and cost to that particular intervention.

Another new approach to treatment of major depression in mental health services includes the religiously integrated cognitive behavioral therapy (CBT). This intervention has been found to be beneficial for patients as it promotes spiritual well-being of patients. People with chronic illness have high incidence of depression and hence religiously integrated psychotherapy was developed for treating this group of people. CBT focuses on analyzing thought pattern, emotional state and behavior of an individual to change cognitive process and behavior of individual. This assessment is often not accurate due to the interpretation and perception of depressed patients. Hence, religious belief was integrated into CBT by explicitly analyzing the religious belief of patients to replace negative thoughts and behavior of patients. Religious beliefs act as a motivating factor for patients to build their resilience skill in combating depression (Pearce et al. 2015). This intervention is given by mental health services in 10 sessions, which starts from assessment of client to reinforcing the treatment rationale to patients and then identifying unhelpful thought of patient. Coping strategies are then taught to client to cope with emotional difficulties and motivation level in life. Clients were given idea about the benefits of gratitude, altruism and generosity to find meaning in life and gain positive outcome throughout the intervention procedure (Koenig et al. 2015). Therefore, the use of patient’s religious tradition as a means to reducing depressive symptoms facilitates positive emotions and useful in working with culturally diverse client in mental health setting.

Many online mental health services is also available in different countries to provide help to young people struggling with depression. As young people are more likely to use online services to seek help about mental health problems, it is necessary its impact on facilitating mental health of people. The review of the performance of these online mental health services revealed that they were of low quality and very few people the measures of help-seeking.  Although there is plethora of online services available, very few participants reported that they received the desired information about depression. Certain limitation in service was also seen due to barrier found in help-seeking behavior. Some of the barriers included lack of awareness about online services, lack of trust in online information, greater preference fir face-to-face services and presence of unfavorable content (Kauer et al. 2014). There is a need to improve the online mental health services by means of further research on identifying areas of improvement. A possible way to integrate face-to-face service in online service is to help people who want face-to-face service by appropriately directing them to those service in local areas through the online website.

Efficacy of private providers in treating people with MDD

Private providers in mental health services are growing due to the interest and trust in their ability to provide efficient and high quality health care service. The government based spending on mental health is low due to additional burden of mental disorder and lack of availability of cost-effective and affordable intervention. As poor countries spend lowest on mental health service, the transition to community care is difficult. Private health care providers have a wider role in this regard to overcome the limitation of scarcity, inequity and inefficiency in government based mental health service. Private providers have come a long way in equitable distribution of service and increasing accessibility of the service to socioeconomically deprived group. They have worked to address stigma around mental disorder and improving technical inefficiencies in the management of mental health services (Saxena et al. 2007).

Resource activation is a major role of private providers in meeting the clinical needs of patients with depression. Resource oriented therapies enhance the therapeutic relationship, resilience and coping capacity of patients. The efficacy of this intervention was tested and it showed that stabilizing resource and techniques helped in securing patient-therapist relationship. No barrier was seen between therapist and patient in such situation where compliance to treatment increased (Steinert et al. 2017).  

Depression is one of the contributors to worldwide disease burden and poor outcome in people is also attributed to high anticipated pattern of discrimination experienced by participants. This form of experience acts as a major barrier to social participation and vocation integration in mental health. In such condition, sustained approach to preventing stigmatization was needed (Lasalvia et al. 2013). Private providers have implemented many improvements in treatment approaches for this group and one of them was the telehealth problem solving therapy for depressed older adults. This intervention was provided to participants and they were found to have a high treatment evaluation inventory score (Choi et al. 2014). Hence, this can have great implication for those older adults who are home bounds and cannot access the treatment in mental health care setting.

Critical evaluation of the role of third sector organization in supporting people with depression and anxiety

Third sector organization are non-governmental not-profit organization which have an influential role in community development. Third sector organization like charities, self-help groups and other non-profit organization plays an important role in addressing mental health problems liked depression and anxiety in people. In the continuum of care, they are placed in the middle position providing self-help at one end and specialist care at the other end. Primary health care professionals unaware of the rich source and support that these organization can give to them. Therefore, there is a need to provide new perspective to mental health services regarding how third sector can identify and managed common health problems in people (Dowric  and Martin 2016). The critical evaluation of their role will help in gaining idea about how this sector can provide the much needed support in management of mental health problems apart from primary care professionals.  

Third sector organization helps to manage mild to moderate depression by means of mobile phone and web intervention. The impact of these resource provided by third sector was evaluated in a study with 49 people with depression. It relied on mental health self-efficacy scale (MHSE) to evaluate people’s confidence in managing mental health issues. The scale had high sensitivity to changes and the use of mobile phone and web-based intervention was found to increase the MHSE score of participants. This indicates that MHSE is associated with reduced depression and improved social functioning. Hence, this kind of intervention is beneficial in improving the self-efficacy of people with depression. It is an important attribute in improving the skill and motivation of patient in managing mental health symptoms (Clarke et al. 2014). If mental health service participates with third sector organization, they can support them in increasing the therapeutic potency and clinical efficiency of online interventions for people with mental illness.

Cognitive behavioral self-help intervention is also widely provided as self-help intervention by third party organization to enhance coping skill of patients with depression. This self-help program consisted of a workbook and a CD-ROM on management of depression. According to the self-help program, all the participant had to work on the intervention for 4 days per week till 4 weeks and very minimal coaching was provided to them. The coaching consisted of phone call to provide support to participants and motivate them to improve their self-coping skill. After the 4 months intervention, the outcome of the study showed that self-help intervention was effective in reducing of anxiety and depression in patient. Furthermore, it increased their coping self-efficacy compared to control group participants. Another significant advantage of this intervention is that mental health services can follow-up with patients (Garnefski et al. 2013). Third parties can easily deliver this kind of program through postal mail and internet. In this support can be provided to large number of patients and barrier to psychological treatment can be avoided. This study has significant practical implication considering the high prevalence of depression.

The concept of third parties involvement in mental health care has not yet been endorsed as many consider that non-specialist health workers cannot provide the right care. The acceptability and feasibility of non-specialist health workers in delivering mental health care was studied by Mendenhall et al. (2014) and different stakeholders like community members, public health care workers and policy makers gave their view on acceptability of task-sharing mental health services. Most participants regarded task-sharing as an innovative way to enhance access to mental health services. However, some of the systemic challenges in task sharing included lack of awareness, infrastructure, workload and community preferences. The study is important as it gave idea about the basic requirements for task sharing process in mental health services. Once task sharing role is clearly defined, it can significantly remove the burden of community and private health workers in treating patients.

Conclusion

The report critically evaluated the effectiveness of mental health service, private providers and third part organization in reducing depressive symptoms in patients with MDD. The role of these entire groups is different as they are placed in different positions in the continuum of care. Although mental health service and private providers are formal providers, the role of third party is also considered important to integrate the service more efficiently and provide better health outcomes to patient.

References

Berwian, I.M., Walter, H., Seifritz, E. and Huys, Q.J.M., 2017. Predicting relapse after antidepressant withdrawal–a systematic review. Psychological medicine, 47(3), pp.426-437.

Choi, N.G., Hegel, M.T., Marti, C.N., Marinucci, M.L., Sirrianni, L. and Bruce, M.L., 2014. Telehealth problem-solving therapy for depressed low-income homebound older adults. The American Journal of Geriatric Psychiatry, 22(3), pp.263-271.

Clarke, J., Proudfoot, J., Birch, M.R., Whitton, A.E., Parker, G., Manicavasagar, V., Harrison, V., Christensen, H. and Hadzi-Pavlovic, D., 2014. Effects of mental health self-efficacy on outcomes of a mobile phone and web intervention for mild-to-moderate depression, anxiety and stress: secondary analysis of a randomised controlled trial. BMC psychiatry, 14(1), p.272.

Dowrick, C. and Martin, S., 2016. Depression and Anxiety: The Role of the Third Sector. In Mental Health and Older People (pp. 121-131). Springer International Publishing.

Garnefski, N., Kraaij, V., Benoist, M., Bout, Z., Karels, E. and Smit, A., 2013. Effect of a Cognitive Behavioral Self?Help Intervention on Depression, Anxiety, and Coping Self?Efficacy in People With Rheumatic Disease. Arthritis care & research, 65(7), pp.1077-1084.

Kauer, S.D., Mangan, C. and Sanci, L., 2014. Do online mental health services improve help-seeking for young people? A systematic review. Journal of medical Internet research, 16(3), p.e66.

Koenig, H.G., Pearce, M.J., Nelson, B., Shaw, S.F., Robins, C.J., Daher, N.S., Cohen, H.J., Berk, L.S., Bellinger, D.L., Pargament, K.I. and Rosmarin, D.H., 2015. Religious vs. conventional cognitive behavioral therapy for major depression in persons with chronic medical illness: A pilot randomized trial. The Journal of nervous and mental disease, 203(4), pp.243-251.

Kuyken, W., Hayes, R., Barrett, B., Byng, R., Dalgleish, T., Kessler, D., Lewis, G., Watkins, E., Brejcha, C., Cardy, J. and Causley, A., 2015. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. The Lancet, 386(9988), pp.63-73.

Lasalvia, A., Zoppei, S., Van Bortel, T., Bonetto, C., Cristofalo, D., Wahlbeck, K., Bacle, S.V., Van Audenhove, C., Van Weeghel, J., Reneses, B. and Germanavicius, A., 2013. Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. The Lancet, 381(9860), pp.55-62.

Mendenhall, E., De Silva, M.J., Hanlon, C., Petersen, I., Shidhaye, R., Jordans, M., Luitel, N., Ssebunnya, J., Fekadu, A., Patel, V. and Tomlinson, M., 2014. Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda. Social science & medicine, 118, pp.33-42.

Mental health statistics: UK and worldwide. 2017. Mental Health Foundation. Retrieved 20 April 2017, from https://www.mentalhealth.org.uk/statistics/mental-health-statistics-uk-and-worldwide

Pearce, M.J., Koenig, H.G., Robins, C.J., Nelson, B., Shaw, S.F., Cohen, H.J. and King, M.B., 2015. Religiously integrated cognitive behavioral therapy: A new method of treatment for major depression in patients with chronic medical illness. Psychotherapy, 52(1), p.56.

Saxena, S., Thornicroft, G., Knapp, M. and Whiteford, H., 2007. Resources for mental health: scarcity, inequity, and inefficiency. The lancet, 370(9590), pp.878-889.

Schmaal, L., Veltman, D.J., van Erp, T.G., Sämann, P.G., Frodl, T., Jahanshad, N., Loehrer, E., Tiemeier, H., Hofman, A., Niessen, W.J. and Vernooij, M.W., 2016. Subcortical brain alterations in major depressive disorder: findings from the ENIGMA Major Depressive Disorder working group. Molecular psychiatry, 21(6), pp.806-812.

Snyder, H.R., 2013. Major depressive disorder is associated with broad impairments on neuropsychological measures of executive function: A meta-analysis and review.

Steinert, C., Bumke, P.J., Hollekamp, R.L., Larisch, A., Leichsenring, F., Mattheß, H., Sek, S., Sodemann, U., Stingl, M., Ret, T. and Vojtová, H., 2017. Resource activation for treating post-traumatic stress disorder, co-morbid symptoms and impaired functioning: a randomized controlled trial in Cambodia. Psychological Medicine, 47(3), pp.553-564.