Introduction
Depression is a common and widespread mental illness that seriously affects the behaviour, mood, and capability to assess certain life situations and react accordingly (Karp 2017). The mechanisms of depression are not fully understood, but common symptoms of the disease are sadness, loneliness, and a loss of interest in life and daily activities. Typically, depression is caused by emotional and psychological stress due to extreme situations or long-standing problems or issues. In some scenarios, depression may lead to significant health issues due to a lack of personal care, or even to death by suicide.
Issues in Treating Depression
Clinical Recognition
Depression is a complex phenomenon from both medical and sociological perspectives, which make it more difficult to treat. According to Sato and Yeh (2013), one of the major reasons why depression often goes untreated is because it is unrecognized and underdiagnosed by clinicians. The symptoms of depression are common side effects of being sick, as many patients exhibit sadness, fatigue, and moodiness as a result of suffering from an ailment. It is hard to evaluate the depth and permanency of the symptoms without conducting specialized tests.
Medications
As it stands, medical science struggles with understanding the causes of depression and the processes behind it. Most antidepressants are aimed at treating the symptoms rather than addressing the cause. Pharmacological treatment, while effective for certain symptoms, comes with a variety of dangerous side effects. The most common ones present in practically all antidepressants are nausea, dry mouth, loss of appetite, and dizziness, which makes them particularly dangerous in elderly patients. Some of the more severe side effects include hallucinations, insomnia, and the exacerbation of symptoms that the medicine was supposed to treat. As a result, many patients are hesitant to use antidepressants. In other cases, the patient may be ineligible for pharmacological treatment due to acute adverse reactions to the drugs. According to McCann and Lubman (2012), certain symptoms of depression may become resistant to particular drug treatments.
Biological Factors
Depression is accompanied by numerous physical symptoms as well as comorbidities and associated diseases. According to Sato and Yeh (2013), physical symptoms include fatigue, insomnia, nausea, and various pains, while comorbidities affect the senses and affiliated organs, muscular-skeletal apparatus, the respiratory tract, and gastrointestinal tract. Many other symptoms are also likely to be present. As a result, depression can easily be confused with one of many other diseases.
Socio-Economic Factors
Psychological ailments are often looked down upon in Western and Asian societies, which makes patients hesitant to acknowledge that they need help and to seek out assistance. When they do, however, they face a multitude of obstacles, such as delays in finding appropriate practitioners, long waiting lists from mental health services, and high costs for treatments, consultations, and drugs. Many poor people, who are more likely to suffer from depression, cannot get treatment without proper coverage. In many cases, MDD impairs the ability to work and form meaningful relationships, further exacerbating the issue (Bland, Renouf & Tullgren 2015).
Patient Challenges when Encountering Depression
Patients face several obstacles when developing depression. The first and most obvious obstacle is the inability to recognize an MDD in order to seek help. Depression is typically diagnosed when symptoms persist for longer than one or two weeks (Karp 2017). The disease impairs the patient’s ability to think rationally and make appropriate decisions about their health, which further delays treatment (Halter 2017). In addition, depression severely undermines the ability to identify one’s own emotions, so the patient does not even notice changes in their own behaviour, thinking that they are acting naturally while expressing all the symptoms of emotional stagnancy and myopia (Bland, Renouf & Tullgren 2015). Lastly, a lack of empathy and care from the primary healthcare practitioner or social worker often affects the desire to seek treatment, which is detrimental to an already declining emotional state (Griffith & Crisp 2013).
Patient Needs
Patients diagnosed with MDD have a plethora of medical, psychological and social needs that have to be addressed in order to support them on their road to recovery (Griffith & Crisp 2013). While medical facilities often provide adequate medical treatment and psychological consultation, the social needs of the patient often remain neglected. According to Griffiths and Crisp (2013), depression undermines the patient’s will to function as well as the desire to follow any prescribed treatments. In order for them to continue steadily on their road to recovery, it is paramount to provide a supportive network and build up a social circle that would further motivate them. Social isolation is one of the main causes of depression, especially in the elderly. Without eliminating it as a factor, long-term recovery is impossible. Other aspects include economic and financial needs, as patients suffering from MDD often lose their jobs and are unable to support themselves (Griffith & Crisp 2013).
Challenges in Supporting the Needs of the Patient
One of the major challenges that arise in supporting the needs of a patient who has MDD is the fact that it frequently goes underdiagnosed by clinicians (Sato & Yeh 2013). If a patient is not acknowledged as such, the mechanisms of assistance cannot be applied to them. In cases where depression is indeed recognized by medical professionals, the challenge rises from coordinating medical and social services in order to assist the patient. In many remote areas, social services are either in poor shape or nonexistent, making it impossible for the patient to receive appropriate support. In addition, clients diagnosed with depression may also have several comorbidities, such as alcoholism, drug abuse, and unfamiliarity with any kind of work, which exacerbates financial issues for the patient. Lastly, although socialization is generally viewed as beneficial to the patients, in some particular incidents, they may pose a threat to others. At the same time, isolating them is likely to make things worse. Case managers are tasked with balancing numerous variables. As a result, every individual treatment is adapted to fit the available pool of resources rather than the actual needs of the patient.
National Standards for Mental Health Services in Australia
The National Standards for Mental Health Services is the primary document that regulates mental health assistance standards for Australia. It was first introduced in 1996 in order to ensure a unitary standard for all states that make up the commonwealth (National standards for mental health 2010). Its purpose is to assist in the development and implementation of appropriate treatment practices and ensure that healthcare centres follow the highest standards of quality of care. This document addresses practices employed by state hospitals and private clinicians alike. Before the introduction of the NSMHS, standards of care differed from one mental health institution to another, which created a discrepancy and a lack of continuity between healthcare specialists, meaning that a patient treated in one psychiatric ward would face considerable difficulties when moving to another (Bland, Renouf & Tullgren 2015).
The document established not only the procedures of care but also the procedures of government funding on all levels. Both the public and the private sector of mental health care welcomed it, as it established an even playing field and had the interests of the patient in mind. The document was revised in 2006 in order to address the most pressing matters that were arising between consumers and healthcare professionals.
In its current form, the NSMHS focuses on several critical areas of mental health care, such as (National standards for mental health 2010):
- The ways in which various services are delivered. This area establishes guidelines and standards that are to be followed when providing care to mental health patients.
- Policy compliance. This area establishes the authority of various bodies to conduct investigations in order to ensure compliance.
- Expected standards of communication and consent. This area establishes the proper protocol for engaging the patient and obtaining their consent in situations where consent is required.
- Standards of competency and credibility. This area deals with government monitoring of practices associated with the risk to the consumer as well as invasive and coercive interventions.
NSMHS standards are enforced mainly through accreditation, as well as key performance indicators and licensing agreements. This system is in place in order to ensure quality, safety, and good performance across the private and public sectors. The standards also address the issues of legislation and chart alteration, which involve a process of extensive consultation with stakeholders (National standards for mental health 2010).
History of Mental Health Policies in Australia
The concept of caring for the mentally ill existed in Australia since the beginning of the 19th century. For most of Australia’s history, the views on mentally ill patients were conflicting. According to a popular paradigm, hard and honest work was supposed to bring prosperity and peace of mind. Those who did not possess peace of mind were blamed for their own misfortunes. Healthcare efforts were largely aimed at isolating the mentally insane from the rest of society. This paradigm persisted well into the first half of the 20th century. While the conditions under which patients were held improved over time, they still largely remained isolated and stigmatized (Bland, Renouf & Tullgren 2015).
The first efforts towards a mental health strategy appeared in the 1980s, beginning with the Richmond Report NSW, published in 1983 (Bland, Renouf & Tullgren 2015). Prior to this event, however, there was a significant push for the rights of patients with mental illnesses. This coincided with the adoption of the declaration of human rights and its growing popularity in the western world. Various non-profit groups and activist organizations such as ANAMH and RANZCP were using the declaration of human rights as a basis for their campaigns aimed at popularizing and increasing government support for centralized financing programs, or 5-year plans. They advocated for changing social perceptions of mental diseases in accordance with the newest recovery paradigm that started dominating the field of mental health care in the 1980s-1990s (Bland, Renouf & Tullgren 2015). In addition, clinicians pointed out the inadequacy of many mental care wards, which were often underfunded or overcrowded. Private care centres often lacked the accreditation and expertise necessary for handling some of the more difficult patients.
The Eisen-Wolfenden report showed significant deficiencies in funding, government spending, allocation of resources, and other failings of the mental health care system (Bland, Renouf & Tullgren 2015). The first National Mental Health Policy was adopted in 1992, which revolved around modernization of the existing healthcare infrastructure. It was supported by all sides of the social and political spectrum, reflecting the major changes in public perception of mental illnesses that had taken place over the past 40 years. Ever since mental health care acts have been adopted on a regular basis in order to reflect changes in the industry and to provide care according to the latest evidence-based practices. The next mental health policy was adopted in 1996 and was revised in 2006.
Practice Approaches to Mental health care Challenges and Needs
The two most common methods utilized in addressing MDD in patients are interpersonal therapy and cognitive-behavioural therapy. Each of these methods is used to address the specific needs of individuals, and all three of them are frequently used as parts of more complex therapy.
Interpersonal therapy is a type of therapy that focuses on relationships with other people. It is frequently used when the suspected cause of depression is found in other people. This therapy is focused on the present and helps people identify wrongful and detrimental behaviour and develop a plan of action. Interpersonal therapy addresses the following needs of the patient (Huibers 2015):
- Complicated bereavement situations – usually associated with major losses in life.
- Role transitions – beginning or ending a marriage, or coping with a diagnosis.
- Role disputes – conflicts in relationships.
- Interpersonal deficit – lack of interpersonal skills and major character-defining moments in life.
Although this kind of therapy is efficient at dealing with social issues, it cannot be used to treat a case of depression that is caused by hormonal dysfunctions, and it has little effect in treating phobias. Typically, it is utilized in cases where medical treatment is not necessary. It is a useful tool in the arsenal of social workers but requires a deep understanding of psychological processes as well as personal qualities and qualifications in order to be effective. Without building rapport with the customer, this style of treatment cannot be effective.
Mindfulness-based cognitive therapy is a meditation-based practice that is used to gain control over negative emotions and achieve inner peace. It addresses the patient’s need to be able to continue with their daily tasks and keep negative thoughts at bay. MBCT relies on affecting the activity of the prefrontal cortex and interrupting the automatic processes that trigger depressive syndromes through practising mindfulness (Sipe & Eisendrath 2012). MBCT is currently being researched as an alternative to drug-based and interpersonal therapies. It is a useful tool for social workers, as they could teach the patients to perform it on their own, without the need for direct supervision. One of the challenges of this method is that MBCT does not affect patients whose depression is associated with critical events that have occurred in their lives, such as trauma, assault, or loss of a loved one.
Competencies Required to Provide Mental Care
The general competencies of a mental health therapist are not significantly different from those of physicians in other fields of medicine. The primary demand for healthcare professionals is to possess the required skills, knowledge, training, and experience in the chosen type of therapy (Rush et al. 2013). Responsibility, knowledge of professional boundaries, and confidentiality are important in mental health care, even more so than in any other field of medicine due to the presence of stigma and the highly personal nature of the treatment. A therapist should be able to maintain high levels of personal efficiency as well as high ethical and moral standards. The last area of competency revolves around the legality of the treatment provided. Obtaining informed consent from a patient could only be undertaken after explaining the nature of the situation, the mental illness, potential treatments, costs, and side effects. A patient’s visit and a plea for help should not be considered as implied consent (Avasthi & Grover 2009). In emergencies, when the patient is considered a threat to themselves or society, a therapist might be required to take extraordinary measures that bypass the need for consent (Rush et al. 2013).
The Available Evidence Base for Depression Treatment
Numerous articles and researches indicate that interpersonal therapy and mindfulness-based cognitive therapy are effective in treating symptoms and causes of depression.
The results of a randomized controlled trial by Lemmens et al. (2015), which was performed involving 182 adults diagnosed with major depressive disorder, indicate that both interpersonal therapy and MBCT show significant improvements for patients at 2, 3, and 7 months, as well as 3 months after the conclusion of the treatment phase. Both treatment methods performed similarly one to another at every stage and maintained significant results in the baseline of up to a year. The severity of depression did not seem to affect the overall effectiveness of either method.
Hetrick et al. (2016) have accumulated evidence from 83 randomized control trials in order to determine the usefulness of interpersonal therapy and MBCT as preventive interventions against depression in children and adolescents. The results indicate that both show better results when compared to other preventive programs. However, the overall effectiveness of either method remained relatively low. These findings, in conjunction with previous researches, indicate that MBCT and interpersonal therapy are effective at treating depression, but show only marginal effectiveness at preventing it.
Major Challenges to be Faced in the Next Five Years
One of the major roadblocks before mental health medicine is the lack of understanding of the mechanisms behind the development and treatment of the disease. As was already mentioned in this paper, most drugs and techniques currently implemented are aimed towards reducing symptoms rather than addressing the underlying causes of depression. Incorrect diagnoses and wrongly-prescribed medicines can cause more harm than good. The majority of physicians trained to treat mental illnesses are currently unable to fully address the implications of dual diagnosis, as identifying even a single diagnosis is already difficult.
A major issue involves the understaffing and undertraining of social workers. The majority of social workers in Australia do not have the appropriate education and experience to help patients with depression. In many cases, they are not able to recognize the symptoms and refer the patient to healthcare professionals. The number of social workers is currently insufficient to cover everyone in need of help, and this issue is likely to become worse in the future. Lastly, there is a need for culturally-competent social workers due to the increased diversity of patients requiring help (Bland, Renouf & Tullgren 2015).
Potential Venues for Mental health care
Further advancements in mental health care are impossible without new technological developments. Electronic devices such as smartphones offer many potential venues by passively tracking the presence of different symptoms, supplying important reminders and information, and establishing contact with various supportive networks (Technology and the future n.d.).
The ability to gather data about patients while guaranteeing anonymity is very important for further scientific research. As it stands, many RTCs are difficult to conduct due to the time and expense associated with these studies. Technological advancements in communication would increase the amount of data available to clinicians (Technology and the future n.d.). Lastly, new advancements in brain research and brainwave scanning have the potential to help explain the processes behind depression.
Advancements in technology would also improve the lives of families and communities as a whole (Halter 2017). Families would receive an efficient way of seeing the progress of treatment as well as an ability to supervise and control the process in cases where it is needed. Communities would appreciate better outcomes, whereas social workers would be able to use an optimized and advanced database on patients and prepare interventions suited to every individual case (Halter 2017).
Reference List
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