English
中文Introduction
Anxiety and depression are both mental illnesses widely prevalent in the UK today, with depression affecting 1 in 4 women and 1 in 10 men; and women twice more likely to suffer from an anxiety disorder than men (The Office for National Statistics Psychiatric Morbidity Report, 2001). Anxiety is described by the Diagnostic Statistical Manual (DSM-IV) for Mental Health Disorders as a heightened feeling of apprehension and worry; symptoms include panic attacks, irritability, loss of sleep and concentration due to worrying. Anxiety disorders include both panic disorder and generalised anxiety disorder. Depression is the manifestation of a depressed mood (i.e. sadness and feeling of emptiness) and a loss of interest in activities; accompanied by symptoms such as weight gain/loss, feelings of worthlessness, low energy and suicidal thoughts. Depression can be mild, moderate, severe or chronic. Overall both disorders cause severe impairments in functioning and are extremely distressing for the patient and for those around them. To take a particular example, a nurses’ assistant working with elderly patients suffering from anxiety and depression would have a variety of treatments options available in order to endeavour to effectively treat such patients’ e.g. cognitive behavioural therapy (CBT), medicines, electroconvulsive therapy and self-help.
One of the earliest forms of treatment available for dealing with mental disorders was Electroconvulsive therapy (ECT), which was first used in 1938 (Fitzsimons, 1995), and was most often used for the treatment of depression. One study found that ECT produced a positive outcome for 70% of depressed individuals (Fitzsimons, 1995). This was the most common treatment before the introduction of drugs in the late 1950’s (Irvin, 1997), resulting in a dramatic decrease in the use of ECT. Its decreased use was mainly due to the negative side-effects which included memory loss, cognitive impairment, myocardial infraction and ventricular tachycardia; especially in the elderly patients, and strong criticism from practitioners (Sackeim, 1994b).
The fall of the ECT treatment led to the rise of drugs being used as the preferred choice of treatment for anxiety and depression. The three main types of drugs used to treat depression are Tricyclic medications, Monoamine Oxidase Inhibitors (MAOIs) and more recently Selective Serotonin Reuptake Inhibitors (SSRI’s). These affect neurotransmitters such as dopamine and have the affect of stabilising mood that is thought to result from a chemical imbalance. Drugs specific to anxiety disorders include benzodiazepines and clonazepam which have the effect of calming the person’s physiological reactions. However, among the elderly this type of drug treatment may not be the best option due to the physiology of ageing, for example, as an individual age their body water decreases and the amount of adipose tissue increases and this could potentially affect drug distribution (Heffern, 2000). Although drugs were at one point the preferred choice of treatment for depression in the elderly, it is no longer considered suitable because of the co morbidity of other physical illness which would contraindicate antidepressants and anxiety drugs (Jenike, 1989).
More recently Cognitive-behavioural Therapy (CBT) has risen in prominence as the choice of treatment for anxiety and depression. This treatment, also known as the ‘talking therapy’ has its roots in Aaron Beck’s cognitive conceptual framework (Beck, 1975). Beck (1975) argued that deviant cognitive processes are intrinsic to mental illnesses. He argued that disorders, namely depression were the result of the negative triad – negative views of oneself, world and the future. Based on this CBT is used to help people modify their thinking patterns and reactions to events and replacing them with more productive and positive thinking patterns. This illustrates a huge shift in thinking on depression and anxiety; instead of viewing it as a simple chemical imbalance that needs restoring, anxiety and depression is now viewed as largely emanating from distorted thinking patterns, and thus a more fundamental approach to treatment is taken which considers underlying thought processes. The National Association of Cognitive-Behavioral Therapists (2007) identifies the key features of CBT. CBT treatment emphasises the importance of changing negative thoughts; treatment is briefer than other forms of psychotherapy such as psychoanalysis; positive patient-therapist relationship; it is supported by evidence that most emotional and behavioural reactions are learned and so the aim is to learn other ways of reacting and thinking about certain situations, thus relieving the patient of distressing symptoms; and the importance of practicing these learned techniques in patients own time and not just during therapy sessions. CBT implies that the patient has more control over their disorder and should play a more active role in the treatment process rather than passively accepting treatments such as drugs. CBT is said to be evidence-based which means that there is underpinning evidence to suggest that it is effective in achieving its desired aim i.e. cure for depression and anxiety.
There have been numerous studies on the effectiveness of CBT in comparison to the other treatments i.e. namely drugs. Research shows that medication (e.g. SSRI’s, Benzodiazepines) used to treat anxiety can treat it effectively by up to 70%, however, once off the medication relapse rates are as high as 50%; one the other hand CBT has a 75% success rate in effectively treating anxiety (Toni et al. 2000). For the treatment of depression CBT has again been found to be extremely effective. Hensley, Nadiga and Uhlenhuth (2004) found CBT to be just as effective as antidepressants. Keller and Boland (1998) report that 85% of people who suffer from depression will relapse at some point, however if the depression is treated with CBT this rate drops dramatically to just 25% (Fava, Rafanelli, Grandi, Conti, & Belluardo, 1998).
Another treatment (based on the principles of CBT) that is usually available for mild forms of anxiety and depression is self-help. It uses similar techniques to CBT but without the help and guidance from a professional therapist. Studies comparing a computer-aided CBT to treatment by a real therapist found that self-help is nearly as effective as the latter treatment that is delivered face-to-face (Proudfoot et al. 2003). A meta-analysis of self-help treatments found that it is more effective than having no care at all (Marrs, 1995), and self-help is sometimes more effective than GP care, who are often thought to be reluctant to deal with mental health issues.
Governmental organisations such as NICE (2004), based on such research continually publish and update guidelines for treating disorders such as anxiety and depression within the NHS. NICE (2004) provide separate guidelines (based on rigorous empirical research) for anxiety and depression on the types of treatments that should be used. A nurse assistant working with elderly patients would be expected to consult these guidelines so that for each particular patient and their set of circumstances the treatments being offered are of a high standard and the most effective. Strict adherence to these guidelines is not necessary since every patience circumstances differ, for example a nurse assistant would probably have to select a different treatment for a young patient and a different one for an elderly patient. These recommended guidelines are based on Eccles and Mason’s (2001) internationally agreed conventions on what constitutes reliable evidence. Thus these guidelines are evidence-based in the sense that rigorous empirical research underpins these guidelines. Hence, guiding clinicians in selecting the most appropriate and effective treatment that has been proven to have a high success rate (Mann, 1996).
All guidelines are graded (A-D) depending on the strength of their underlying evidence. A- a meta-analysis of randomised controlled trials (RCT’s); B – at least one of the controlled studies is without randomisation or is a quasi-experimental study; C – non-experimental source, usually descriptive comparative study or correlation study; D – expert opinion derived from experience. A nurse assistant dealing with an elderly patient suffering from anxiety would by following the guidelines be highly recommended to choose CBT as the main treatment. Self-help (based on CBT principles) is also highly recommended for treating mild anxiety. Drugs such as benzodiazepines are highly discouraged as a choice of treatment since research points to a less favourable outcome in the long-term, however it is recommended as an initial immediate treatment if anxiety is severe and then to use CBT and self-help as the main choices of treatment.
In terms of depression, namely mild to moderate depression, the NICE (2004) guidelines recommend that antidepressants should not be used since RCT’s have found that for these types of patients there is little or no difference between the affect of administering an actual antidepressant or placebo. Instead self-help and CBT is highly recommended as the choice of treatment. A form of self-help called Cognitive-Behavioural therapy via Computer Interface (CCBT) is also emerging as a treatment for anxiety and depression, however, to date it has not been subjected to rigorous research and the recommendation is only based upon expert opinion. For moderate to severe depression it is suggested that antidepressant medication is given before CBT. In fact, antidepressants should be continued for 6 months after remission; the particular drug recommended is SSRI because it has been found to be just as effective as tricyclic antidepressants with the added benefit of reduced side-effects. CBT should be also considered if antidepressants have not had the desired effect. For severe depression then it appears that the guidelines are actually recommending antidepressants as the first choice treatment over CBT. In the case of chronic depression (2 years or more) the treatment prescribed by the guidelines is CBT and antidepressant medication.
Since the publication of these NICE guidelines governing the treatment of anxiety and depression more research on the effectiveness of self-help has emerged, which subsequent NICE guidelines will have to consider evidence when drawing up recommendations. Anderson et al (2005) carried out a systematic review and meta-analysis of self-help books on depression. It was found that self-help books are effective in reducing depressive symptoms and they recommend that self-help be used as a complementary treatment for mild-to-moderate depression. Similarly, Van Boeijen (2005) undertook a review of self-help books for anxiety disorders and found that they too were effective in reducing anxiety symptoms. There now appears to be a growing body of research evidence for self-help which will be reflected in the type of treatment choices preferred in the near future.
Since the publication of these NICE guidelines governing the treatment of anxiety and depression more research on the effectiveness of self-help has emerged, which subsequent NICE guidelines will have to consider evidence when drawing up recommendations. Anderson et al (2005) carried out a systematic review and meta-analysis of self-help books on depression. It was found that self-help books are effective in reducing depressive symptoms and they recommend that self-help be used as a complementary treatment for mild-to-moderate depression. Similarly, Van Boeijen (2005) undertook a review of self-help books for anxiety disorders and found that they too were effective in reducing anxiety symptoms. There now appears to be a growing body of research evidence for self-help which will be reflected in the type of treatment choices preferred in the near future.
However it is important to note that the research underpinning these evidence-based guidelines is not without its limitations. In many cases it is just not ethical to carry out randomised controlled experiments e.g. to test the effectiveness of particular drugs. So despite the guidelines recommendations there may be particular treatments with lower evidence grades that are more effective in treating anxiety and depression than the treatments with higher grades. The choice of treatment the will most likely reflect the nurses past experience with dealing with such illnesses rather than relying solely on empirical research.
Conclusion
A nurse assistant dealing with elderly patients who suffer from anxiety or depression would have a number of treatments available in order to endeavour to effectively treat such patients. In particular CBT which has in recent years risen in prominence as the choice of treatment by many practitioners. According to the NICE (2004) who regulate treatment of mental health disorders within the NHS, the recommendations they make should usually be adhered to since they are evidence-based and as such will make sure the most effective treatments are selected. In the case of anxiety it appears that CBT would be the treatment of choice as it is much more effective in actually curing individuals of their disorder than medications (Toni et al, 2000). However, in the case of depression it is a little more complicated, although CBT has been proved to be an effective treatment, antidepressants still appear to be the choice of treatment especially for severe and chronic depression (NICE, 2004). In the case of elderly patients however, it may be the case that CBT and self-help is favoured over antidepressants due to possible co-morbidity which would compromise the suitability of drugs being used to treat anxiety and depression.
