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Guiding lights: The depression guidelines |
| Te Puawai April 2008 |
Joanna Davison
A desire for primary health care nurses to actively engage in addressing the mental health needs of people, and to be recognised for that role, were key factors in my decision to be the College of Nurses, Aotearoa, nominee on the New Zealand Guidelines Group (NZGG), guideline development team (GDT). NZGG is a not-for-profit organisation aimed at promoting effective health and disability services. Using the latest international and national research studies, the NZGG develop guidelines that are relevant to the New Zealand setting and that promote best practice. The guidelines that I participated in involved the recognition and assessment of common mental disorders and how to support people who experience depression within a primary care setting. As guidelines are intended for all health practitioners, it is essential that nurses participate in this process. Being asked to represent the College in this capacity, and having the opportunity to be involved in the development of national practice guidelines was a real privilege and I would strongly encourage any nurse to consider participating in such an activity. I have nearly 20 years nursing experience. I worked at Newtown Union Health Service as a primary mental health care nurse for over eight years, and four years ago I moved into education, and now teach at Whitireia Community Polytechnic, in the Bachelor of Nursing programme. Being involved in the development of guidelines at a national level was however my first time, and I found the entire process extremely interesting and fascinating. The first meeting to discuss the guidelines was held in October 2006. Membership on the guideline development team (GDT) was diverse, and included nominees from the Mental Health Consumers Union, the Mental Health Foundation, the New Zealand College of Mental Nurses, Clinical Psychologists, Physicians, Psychiatrists, and General Practitioners, and Te Rau Matatini as well as myself. Five one or two-day meetings were held in Wellington. In the first few meetings, in collaboration with the Ministry of Health who fund the NZGG, we developed the key issues and questions to be answered by the guidelines. These issues provided the framework for the NZGG staff to systematically review the research evidence that was available. Generally the studies reviewed were those that had been undertaken in primary health care settings, however, when these were not available, research from other settings was also considered. These findings were then presented at later meetings for our consideration. At these meetings the discussions were rich and full, and involved a review of the evidence in light of our own clinical experience. As we all know, the role of nurses at a primary health care level is varied and in some situations unique to our New Zealand setting. We have an enormous wealth of specialist knowledge and clinical expertise. Therefore a key focus of mine was to ensure that the guidelines were relevant to all members of the wider primary health care team, especially nurses. Having our nursing voice heard at this level, I believe is essential for the ongoing recognition and development of primary health care nursing. Whilst we were reviewing the research studies, the focus of the discussion would naturally gravitate towards chosen research methodologies and data analysis. Although I had not done any research papers in my nursing diploma, during these discussions I was very thankful for having completed, in the previous year, a Masters research paper. The NZGG team did attempt to prepare us for these discussions by giving us a crash course on research terminology in our first few meetings, but without this prior knowledge I think I may have struggled with certain aspects being considered. Being familiar with research methods allowed me to engage more easily with the evidence being presented, and better equipped to critique its relevance. As an aside, it is pleasing to know that all nursing graduates now have a good grounding in research. Having an understanding of research I feel is very important when we are promoting our nursing role and in this situation my research knowledge was invaluable. Mental health care, by its very nature, is often complex. As primary health care nurses, both the challenge and richness of working in primary health are the complexities we encounter when working alongside a person, their whanau and community. Psychosocial factors contribute significantly to this complexity, and the mental distress that often arises from these difficulties can, at times, render us to feel overwhelmed and at a loss as how to best support that person. Adding further to the complexity of mental health is the debate surrounding mental disorder diagnostic criteria, and concerns about medicalising normal human distress (Hickie, 2007). There are no simple blood tests or scans that confirm a person’s diagnosis of depression. However, even when diagnosed with depression, people are often poorly supported by health practitioners, poorly educated about depression and self-management strategies, and have high rates of relapse or recurrence (Ministry of Health British Colombia, 2004). Given the high prevalence and morbidity of common mental disorders such as depression, we are very likely to encounter a person who is experiencing a mental illness. The New Zealand Mental Health Survey (Ministry of Health, 2006) reported rates of depression and anxiety among adults as between 20-25% and similar results were also found in the MaGPie (2003) survey of common psychological problems that people presented with in primary care. The experience of depression and anxiety also seriously impacts on other aspects of health, especially a person’s ability to manage their physical co-morbidities such as diabetes and asthma. Managing the complexity of a person’s mental health needs within what could be considered a slightly reductionist guideline was a challenge for our guideline team. We wanted to produce guidelines that had enough depth and breadth to be meaningful and very usable, but at the same time, not become so broad that they became unwieldy and unmanageable. As a result we decided to concentrate on the common mental disorders that we may encounter within our practice and then to focus specially on the management of depression. Given that many mental health disorders may start in childhood and adolescence, and depression can occur at any time of life, the guidelines broadly outline assessments that can be used across the life-span. More detailed recommendations and interventions are then outlined for people who are experiencing depression. The development of these practice guidelines I believe helps untangle some of the complexities surrounding mental health. Everyday in our practice we effectively provide care for people with other complex needs, and we should consider every interaction as an opportunity to assess a person’s physical and mental wellbeing. These guidelines aim to enhance our assessment and decision-making skills and our abilities to support people in times of mental distress. Being involved in the development of these guidelines was an extremely positive and constructive process. As part of stating our authority and expertise within primary care, it is essential that nurses participate in development of guidelines. These guidelines are about our scopes of practice. As national guidelines can shape and influence how services are delivered, our nursing role must be incorporated into such recommendations. Being involved in these guidelines gave me an opportunity to use my nursing expertise to ensure the nursing role was recognised and integrated into these guidelines. This was a very satisfying process and I am thankful for the opportunity. My final recommendation from being a member on the NZGG guideline development team is: primary health care nurses have a specialist knowledge, let’s value it, voice it and get involved.
References Hickie, I. (2007). Is depression over diagnosed? British Medical Journal, 27(2), 329-335. |
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