Implementing an integrative model into mental health nursing practice.

This article is written for nurses who are interested in an Integrative approach to mental health nursing

This article was published in the Kai Tiaki: New Zealand Journal for Nurses.

The depressed or anxious patient who comes to see their general practitioner may be given the option of prescription medication, but often very little else. Talking therapy may be offered, however, there is often a waiting list and at times there are challenges in finding the right fit for the person - and the small issue of whether it will be funded - either through GP provider services, employee service providers or ACC.

A mildly depressed or anxious individual who isn’t at risk of self-harm or suicide doesn’t need crisis input, and may not need long-term psychotherapy or the type of intensive care that a Community Mental Health Centre (CMHC) would provide. They often don’t need to talk about their childhood and sometimes have no major trauma going on in their lives (past or present), but could benefit from some practical strategies and support to improve their mood and well-being.

There is a vast disparity in the services that General Practitioners (GPs) and CMHCs are able to offer. This gap is generally due to limited time and resources, but also due to a knowledge gap that is across conventional psychiatry and conventional medicine.

Conventional medicine within psychiatry has had little to offer the individual when it comes to preventative mental health. While we are regularly exposed to ‘eat 5+ a day’ and ‘quit smoking’ strategies to improve our physical health - there has been little attention paid to mental health and well-being.

Part of a model of prevention is having people get the right care at the right time. We know that there is so much that contributes to a person’s well-being. And we know that mild depression or anxiety - given support, time and the right practical tools - will often resolve without medication use when early intervention is applied.

Nurses within primary care positions and secondary care facilities are in a perfect position to provide short-term intervention to people who suffer from mild mental health disorders, either while waiting for an appointment with a psychologist or counsellor, or as part of the treatment process itself.

So what can you do, as a nurse, to support someone with mild depression and anxiety? There are many things we can offer without going outside our scope of practice.

The Basics

A listening ear

Never under estimate the power of a friendly face and a listening ear. Even if all you do is listen patiently, there are times when this has incredible power. Sometimes, a person just wants to feel heard. And sometimes, even in their own story telling, they come to answers themselves as to what to do next. A good cry (the patient), reassurance from the nurse that you are there for them if they need it, may be enough to support the person through a difficult time.

An explanation

Although we don’t actually have an clear understanding as to what causes depression or anxiety, we can explain that a) it’s not their fault b) depression is usually self resolving c) there are things that they can do to help themselves get better. It’s important they understand they are not alone and there are many organisations (and people) there to help them.

Additional supports

Offer a phone call every few days to see how they are getting on. Ask if they would like more support from a social worker, budgeting advisor, religious leader (if they are that way inclined). Pull in people around them, sometimes this might be calling in a friend or family member too (with permission).

Attending to self-care

The basics to self-care include eating, sleeping, movement and strangely; breathing. Along with this is social relationships, time outside (exposure to sunlight) and attending to basic hygiene needs. Explaining that improvements in these areas can lead to improvements in their mental health can be very empowering, and will make them more likely to engage and take steps to help themselves. They gain motivation, become interested in their own well-being journey and understand that simple things they can do every day may have a positive outcome.

Below I’ll cover some of the areas to focus on and to inquire and make suggestions about.

Nutrition

Probably one of the least asked questions in mental health is: ‘What are you eating?’ . You’ll be surprised how many people who feel flat and miserable are eating minimally or drinking (water). Ask about fasting or dieting which may be contributing to anxiety / depressive symptoms, or if it’s simply an issue of having no appetite. Find out what types of foods they are turning to (sugar, caffeine, high-processed carbohydrate, poor quality, pro-inflammatory diets) which can significantly effect how a person is feeling.

Studies suggest that changing from a SAD (Standard American/Australasian Diet) to a Mediterranean style diet can reduce depression in over 30% of depressed people. You don’t need a degree in dietetics/nutrition to offer basic nutritional advice. (I’m not talking about specific dietary regimes or diets for physically compromised people). The New Zealand Ministry of Health (MOHNZ) guidelines have recently been updated (December 2020), and can become part of your usual repertoire. Encourage a simple but whole food diet, (fruit, vegetables, meat, whole grains) as this alone has been shown to help improve mood.

Check in with the patient, ask specifics (don’t let them tell you their diet is ‘good’ without asking what that means!) What exactly do they eat for breakfast? When? What do they eat for lunch? What do they eat for dinner? Do they consume energy drinks, soft drinks? How much coffee do they consume? How much alcohol are they consuming? Do they eat carbohydrates, fats and proteins? Does their diet have variety? These may be basic questions, but you will be surprised how far someone can get through the mental health system before anyone actually questions a persons diet.

sleep

Are they sleeping? (see my blog on supporting sleep here). Sometimes people who experience poor sleep or nightmares put off going to bed until very late or early hours of the morning - significantly decreasing their length and quality of sleep.

It’s important to understand the significance of the impact of poor sleep (including sleep apnoea) on anxiety, appetite, depression and mood. Research has found that poor sleep often precedes a mental health deterioration and poor sleep often accompanies depression, anxiety or other mood disorders.

Ideally a person should be getting a minimum of 7 - 8 hours a night. Less than six hours or more than 9 or 10 hours increases the chances of stroke and developing metabolic syndrome among other things.

Find out when they sleep - are they staying up until 3 and sleeping til 1pm? How do they feel when they wake? Are they waking regularly and not able to return to sleep? Initial insomnia? Early morning waking? Is their circadian rhythm completely disrupted? Is pain stopping them from sleeping?

They may be able to use sleep strategies (sleep apps, mindfulness, relaxation, breathing exercises). Encouraging exposing eyes to natural light first thing in the morning stimulates melatonin production to support night time sleepiness. Exercising during the day supports sleep at night. Other tips such as reducing screen time in the evening, writing down everything that’s on their mind before they go to sleep and sometimes removing themselves from a snoring partner.

movement

Are they moving? Exercise has a big impact on mood and is shown to decrease depression in up to 30% of those who do the minimal amount. Encourage them to do exercise outside (whatever they enjoy) to encourage vitamin D levels (shown to be low in the majority of psychiatric patients admitted to mental health hospitals). It really doesn’t matter what they do, as long as they enjoy it.

And for those that are exercising - check-in that they aren’t overdoing it. Some people are driven by the exercise they do - as it helps them feel better - but aren’t eating enough or resting enough to sustain their energy levels, leading to exhaustion, poor sleep, anxiety and low mood.

breathing

Observe their breathing pattern. Are they mouth or nose breathing? Is it shallow, tense? Encourage deep, relaxed, slow and long belly breaths - this can be calming, help support sleep and relaxation and has a number of other positive health benefits including reducing anxiety.

Physical assessment

In some cases we can encourage testing which can take a look into some of the contributing issues associated with depression. Low vitamin D levels are associated with mental illness, low ferritin/iron levels are associated with fatigue and depression. Low B12 & folate and other B vitamins can effect energy levels, memory function and cognition and thyroid disorders can present as anxiety or depression. Compare the current blood test to previous blood test results - are there significant changes? Is their cholesterol not only not too high - but not too low (associated with low mood)? Vitamin levels should be in the upper range of normal (except for ferritin - high levels may indicate other disease states and illnesses).

Assess hair, nails, skin pallor and ask about slow-healing wounds which may suggest a zinc or other vitamin deficiency. Is the person overweight or obese? This can increase inflammation (associated with depression) and is associated with lower vitamin D levels. People with diabetes have a higher risk of becoming depressed.

In some cases the medication the person may be taking may be contributing to their symptoms - ask if there is an association between starting a medication on onset of symptoms. Are they on medications which may impact on their nutrient status (eg methotrexate - folate, diuretic - magnesium, calcium or potassium deficiency, Omeprazole - vitamin B deficiency). Accutane has been associated with psychiatric disturbances, but also consider; beta-blockers, statins and hormone therapies, including the oral contraceptive pill.

Supplements and Nutrients

Although we can’t prescribe or advise specific treatments - we can look at some of the research available and explain some of these results to the patient. Use evidence based research, but also be pragmatic. Waiting for a meta-analysis to tell us that a simple intervention is shown to be statistically significant can be a long wait. There is some good clear evidence around omega three fatty acids for depression and research around the impact a multi-vitamin might have for premenstrual syndrome. Treating a vitamin D, B12 or folate deficiency can have an impact. Amazing improvements can be made with people improving their diet and having basic vitamin supplementation.

Specific herbs and supplements have been shown to support mood. Ashwaganda and Rhodiola are fantastic to support people under a lot of stress. St Johns Wort has good evidence as an antidepressant. N‐acetylcysteine has been shown to help with mental health issues. Always check for interactions with any medication they may currently be on - and ask them to check with the pharmacist or prescribing doctor.

Furthering our knowledge

Psychological & Behavioural Therapies

There are many nurses who train in modalities such as Cognitive Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT), Solution Focused Therapy (SFT), Acceptance and Commitment Therapy (ACT). Each one of these modalities can be a very good tool in a nurses toolbox and I highly recommend getting some extra training in these areas.

There are also plenty of online courses such as The Science of Happiness, which can offer direct knowledge on how to build resilience, what supports well-being, motivational strategies and tools to use such as mindfulness, gratitude practices, re-framing techniques etc.

Nutritional

Without going into too much detail - reading up on the Ministry of Health Guidelines for eating or taking part in a online course from a verified university can be a simple way to improve knowledge around diet and nutrition. Nutrition does not need to be complicated if you stick with the basics.

The Australasian College of Nutritional and Environmental Medicine (ACNEM) has online courses for health professionals wanting to extend their knowledge in this area and AIMA (Australasian Integrative Medicine Association) can also be a helpful resource.

Summary

Nursing is a complex task - and knowing what to do for someone who is anxious or depressed can be challenging. We often want to ‘refer-on’ to psychological therapists or to mental health services. However, there is a lot we can do to support the person during this time. We can (and should be) knowledgeable and comfortable providing some basic advice and support, which may mean the difference between a relatively quick recovery and a downward slide into a worsening or chronic depression or anxiety.

Many patients miss out on techniques, lifestyle advice, dietary changes and tools that might help them take those extra few steps towards wellness. These tools and knowledge may last them a life time and help to prevent future relapses.