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When Nicole Allison, MSN, PCNS-BC, prescribing clinical nurse specialist at The Providence Center, Providence, RI, went online to see what people thought about a recent study showing the response to antidepressant medications may be minimal or nonexistent in patients with mild or moderate symptoms, she was dismayed (Fournier, 2010).
"I was really surprised to find many seemed to support the idea that antidepressants may not be helpful for many patients who are already taking them," she said. "This was alarming, as virtually all of my professional colleagues who discussed the study shared their concerns regarding generalizations patients may infer regarding antidepressants and psychotropic medication without really understanding the serious nature of depression and possible co-existing disorders."
One Size Doesn't Fit All
While the study substantiated the effectiveness of anti-depressants in people with severe depression, Allison is convinced drug therapy is not a "one-size-fits-all" approach.
"We see so much improvement, with lives changing dramatically for the better, when we carefully evaluate a patient for mental illness, keep focus to the importance of therapy, exercise, diet, support systems, and, if clinically indicated, prescribe appropriate medication," she said.
Mary Collins, MS, NPP-BC, assistant professor of clinical nursing and specialty director of the University of Rochester School of Nursing's Adult/Family Psychiatric Nurse Practitioner program, explained the need to customize drug therapy.
"If a patient in a med/surg setting asks a nurse about stopping his antidepressant medication based on these study findings, I'd recommend the nurse talk with the patient to get a better understanding of the situation," she said. "The nurse can ask what prompted the patient to go on the psychotropic medication in the first place. Did the patient go on an antidepressant because he presented with a laundry list of depression symptoms years ago, or was it a major depressive episode? Is the patient receiving ongoing care and counseling? Any decision to change a medication ought to go under careful review by the person prescribing that medication."
Talking Points
Deborah Mindnich, MS, RN, CS, psychiatric clinical nurse specialist at McLean Hospital, Belmont, MA, shared some talking points for nurses to follow when a patient asks about stopping antidepressant medication.
"If a patient came to me with that question, I'd take a really close look at the symptoms of depression," she said. "I ask whether these symptoms interfere with the patient's ability to live his activities of daily life. If someone is socially withdrawn, not sleeping well, able to get to work most days but lacking energy, and doesn't have many friends, the depression is interfering with his life. If the antidepressant medication has made a difference in his life, I would say stay on that drug."
Allison described how she partners with patients at McLean to make sound decisions.
"I recommend the nurse talk with the individual about why she wants to go off the medication, explain the limits of the study, review history and previous attempts at tapering and discontinuing medication," she said. "If Sally Jones is doing well after 6 months on fluoxetine 20 mg, perhaps part of the reason she's doing well is because she is responding to treatment. It's important to provide ongoing psycho-education and medication teaching within the context of the patient's treatment plan. Tapering medication and providing follow-up visits after the patient has gone off the medication are keys for transitional periods in treatment."
Patient-Centered Approach
Elizabeth Maree, MSN, RN, PMHCNS-BC, director of nursing and psychiatric programs at Shands Vista Behavioral Health, Gainesville, FL, agreed, adding, "The study makes a good contribution to our evidence, but it's only one piece of the information. Learning antidepressants have a bigger impact on patients with more severe depression isn't really different from what we already know.
"Both in physical medicine and in psychiatric medicine, the more severe the symptoms are, the more robust the effect you'll see from a treatment," she explained. "Both professionals and patients get a lot of snippets of information from various studies, and nurses are in a good position to partner with patients to understand the information in the context of the individual's own health."
Maree emphasized the importance of a patient-centered approach.
"When a patient asks whether he should continue taking his antidepressant medication, it's important to consider where his question comes from and be very accepting of the question," she remarked. "The worst thing you can do is be judgmental or defensive. The patient who is deciding whether to continue antidepressant therapy needs to have a conversation with the provider who prescribed the medication and can give a rationale for its use. A knowledgeable healthcare professional takes the scientific evidence and, in partnership with the patient, integrates it into the treatment plan. As part of that process, the provider reviews the patient's history, goals, side effect profile, and progress."
Hard to Tell
Deborah Sweat, MBA, BSN, RN, who manages the behavioral health nursing services at Texas Health Springwood Hospital in Bedford, shared a pragmatic view of the findings.
"The first thing I would tell nurses is there are a number of tests to rank depression, but it's difficult to tell whether an individual who is already on antidepressants is being treated for mild, moderate or severe depression," she said. "Depression needs to be assessed intensively and taken seriously. We know a combination of medication and therapy can be very beneficial, and I wouldn't want anyone to miss out on the opportunity for a professional evaluation and sound plan of care."
Sweat emphasized the need for a consultation with the prescribing provider. "If an antidepressant is stopped suddenly and the patient isn't monitored, he or she could spiral down into a deep depression and experience a negative outcome," she said.
Working It Out
Donna Vermes, PMHNP-BC, research administrator for the Anxiety Disorders Clinic at the New York State Psychiatric Institute and nursing instructor at Columbia University School of Nursing, New York City, collaborates with her patients to make sure medication decisions work within the context of their lives.
"I've seen a lot of people with dysthymia, which is a chronic form of low-level depression, respond very positively to antidepressant medications," she said. "If the dysthymia is impairing their lifestyle or daily functioning, I believe medications such as escitalopram or citalopram may be indicated. Some of my patients with dysthymia have had improvement from the antidepressants and said they've never felt this good in their lives."
While she is conservative about prescribing medications, Vermes noted, "There are other options, such as cognitive therapy, but someone who is too depressed may not have the interest and energy to do his homework and benefit from that treatment. If I'm treating someone's first episode of depression, evidence-based practice says the individual may need to be on an antidepressant medication for about a year before we start tapering it off."
It's important to listen to what the patient has to say.
"If someone tells me he's doing well, is stable in his life and wants to come off the drug, then I'll start tapering his dose," Vermes explained. "I'll usually see him again in 1 to 2 weeks, but tell him to call me if he's not feeling good before then. If he's not sleeping well, is unable to concentrate, is feeling down, or is experiencing unusual fatigue, we'll talk about the need to continue the medication."
Resource
Fournier, J.C. et al. (2010). Antidepressant drug effects and depression severity. JAMA, 303(1), 47-53.
Sandy Keefe is a frequent contributor to ADVANCE.
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