Train nurses to improve outcomes for depression

Observation and conversation are key

Depression is often the rule rather than the exception for most home health patients, but home health nurses are often not taught how to recognize symptoms of depression and assess the need for intervention, according to researchers at Cornell University's Weill Medical College in Ithaca, NY.

"Older home health patients often have coexisting medical conditions as well as emotional issues which they are facing, such as loss of social connections and role changes within their families," points out Martha L. Bruce, PhD, MPH, professor of sociology in psychiatry at Weill Medical College. Although depression may be common in home health patients, it is important not to overlook the condition in nursing assessments and development of patient care plans, she adds.

The challenge for home health nurses is the lack of training related to depression or other psychological conditions, but it is possible to educate home health nurses so that they can recognize symptoms of depression, says Thomas Sheeran, PhD, ME, assistant professor of psychology in psychiatry at Weill Medical College.

The Cornell Homecare Research Partnership is working with home health agencies to teach nurses how to assess depression and to help agencies develop the infrastructure necessary to help depressed patients, says Sheeran. The key is to correctly identify depression and to bring in the right resources to help the patient, he says.

One of the first steps to correct assessment of depression is to realize that older people won't talk about depression, says Sheeran. "You have to learn to speak their language," he says. Don't ask if the patient feels depressed instead ask if they smile or laugh as much as usual, he suggests.

Look also for visible symptoms such as a disheveled appearance in a normally neat patient, a patient who is wearing nightclothes when the nurse makes an afternoon visit, or no lipstick on a female patient who always wears makeup, recommends Bruce.

A lack of interest in activities in which they usually participate is also another indicator of depression, says Bruce. If a patient is no longer interested in their favorite activities such as knitting, reading, or watching television, it is important to talk with them to determine the level of depression.

Observe patient before making a referral

Not every depressed patient needs a referral to a mental health clinician, points out Bruce. "If the depression doesn't present a safety issue and the nurse sees some improvement over the course of a few visits, then it makes sense to wait before a referral is made," she says. "A nurse should look for persistence of the depression or for increased depression before making a referral," she adds.

While a patient's depression might be triggered by a specific event such as the loss of a family member or friend, or the diagnosis of illness, it is important to remember that older patients may develop depression over time due to the change in their own role, says Bruce. "We often find that older patients develop a sense of worthlessness in their daily lives as they rely upon other people to care for them," she explains.

This ongoing sense of worthlessness does increase the risk of suicide for older patients who can't overcome the depression, points out Bruce. "It's important that the nurse be comfortable asking a patient if he or she has thought about hurting themselves, or listening for cues from the patient's conversation," she says. "You won't put the idea of suicide in a patient's mind by asking about it," she says.

If the patient admits to suicidal thoughts or if the nurse believes that there is a risk, it is important to talk to the family, says Bruce. "Ask the patient if it is OK to talk with his or her family members," she says. Many times family members won't know that the patient is depressed and at risk for suicide, she adds.

Every agency should have a list of appropriate resources for depressed patients, even if it means "beating the bushes" to find the best help, says Sheeran. "Mental health counselors, outpatient clinics, and primary care physicians who will treat depression should be on the agency's resource list," he says.

Another important part of a nurse's training should address how to talk to the physician or mental health professional, points out Bruce. "Depression care is very evidence-based and it is important to talk to the clinician in the same language," she says. "Nurses should be taught how to present a case so that it is clear to the clinician," she adds.

Antidepressants can be very effective for many patients but Sheeran points out that many home health nurses are wary about management of the medication. "Antidepressants are very easy to manage and monitor and there are fewer drug interactions with antidepressants than with other medications older patients are often taking," he says.

One of the tools that participants in the research partnership use is a clinical guideline that gives the nurse a roadmap to use for ongoing, routine monitoring of patients for depression. "Nurses are initially reluctant to care for a patient with depression because they are not sure how to monitor the patient," says Bruce. "A guideline that helps nurses to know when to call a mental health professional is valuable to them," she adds.

Agencies that approach identification and treatment of depression as a disease management process with thorough training of staff and development of protocols and resources that help nurses manage their patients will see an overall improvement in outcomes, points out Sheeran. Depression has been linked to falls, incontinence, and medication noncompliance, he says. He points out that by treating depression appropriately, the patient's quality of life and outcomes are improved.


For more information about home health patients and depression, contact:

  • Martha L. Bruce, PhD, MPH, Professor of Sociology in Psychiatry, Weill Medical College of Cornell University, 21 Bloomingdale Road, White Plains NY 10605. Phone: (914) 997-5977 or (914) 682-5488. Fax: (914) 682-6967. E-mail: