Introduction and Case Description
Recent developments in healthcare and medical research have placed increased emphasis on depression in young people. Studies have revealed alarming prevalence of depression among teenagers in certain communities. One study showed a prevalence of 4.7% among youth aged between 14 and 16 years of major depressive disorders. This was in addition to a 3.3% prevalence of dysthymic disorders (chronic minor depression) (Kashani et al, 1987 p.931-4.).
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It is not uncommon for young people to feel depressed or unhappy for brief periods; the transition from childhood to adulthood placed significant physical, mental and spiritual stress on the individual. However, this should not be a permanent situation; and if so, appropriate steps should be taken to mitigate the situation through active medical psychological therapy. Key to helping these teenagers is to effectively separate normal moody and gloomy introspections and those that constitute a grave risk to the teens’ mental and physical well being.
There also has been a demonstrated connection between alcoholism and depression in all ages; as such, people engage in alcoholism as a method of self medication to dull the feelings of depression, hopelessness and lack of self worth. Alternatively, alcoholism may be the cause of depression by causing these feelings on a permanent basis. Many parents and other stakeholders’ often associate drug and alcohol abuse with the drive to experiment with new things by the changing teenagers; and often see it as a phase which when handled firmly will eventually subside (McMiller & Plant, 1996 p.394-397). Additionally, the low moods which are commonly seen in teenagers are also often seen as passing phases. For these reason, teenage depression and alcoholism are often not as well handled as it would ideally be.
Nurses are often the first line of contact for all patients visiting healthcare setups; this is indeed also true for teenagers visiting hospitals for any reason. As such, nurses are often placed in a unique position to identify and evaluate symptoms of major depression and substance abuse in the pubescent teen. This is therefore a very good reason to put in place measures and systems which will enable the nurse to provide quality solutions for these youth.
A well trained, experienced and equipped nurse would surely be of great help to our case study. Lorina Hall, a 19year old collage freshman was presented to a hospital by some of her friends with acute alcohol intoxication and a blood alcohol concentration of.26. Miss Hall, according to her friends had been experiencing some major upsets in her life during the period; these including flunking three examinations and breaking up with her boyfriend; additionally, Lorina weighed in at 120 pounds. After being treated for her emergency condition in the ER then in the Intensive Care Unit; later she was transferred to the psych unit.
Teenage Adolescence and Alcoholism
Depression is a condition that is more likely to be missed in teenagers than in other groups; this also put them at a bigger risk of developing alcoholism and drug abuse since the condition may easily go undiagnosed and untreated. This diagnosis is also made more difficult by the discomfort teenagers usually feel in discussing their intimate issues even with doctors. This secrecy can be attributed to various issues including a fear of being revealed to their parents and/or teachers; or being ostracized from the social groups.
Indeed, many teenagers will prefer to consult a primary care practitioner whom they trust rather than mental health specialists. On the other hand, these practitioners and nurses have been shown to have difficulty in seeking to unravel the intimate issues which the teenager fear to be forthright about such as sex, alcohol or drug abuse (Gregg et al, 1998 p.909-910). This whole situation puts the teenagers at a precarious position in regards to the diagnosis of depression and alcoholism.
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Depression usually shows a similar pattern in patients of all age groups; however, with changes in age, different aspects show different prominence in different groups. In teenagers, it is quite often difficult to separate occurrences taking place due to the psychological and physiological changes taking place in their bodies and those caused by depression; this is of more importance in teenagers who have shown overtly impaired behavior from a different etiology before or in conjunction with the occurrence of depression (McCauley et al, 1993 p.714-22).
There are, however, some signs which may lead a parent or guardian to suspect that the teen may be experiencing some form of imbalance. Some important markers include poor performance in school; chronic, repeated and unexplained absence from school; fatigue; and general withdrawal from the society. These markers can progress into more serious issues such as engaging in high-risk sexual behavior, alcoholism and drug abuse.
Signs and symptoms
As mentioned before, as much as teenage depression has a unique flavor, it is usually based on a core set of attributes similar to the condition in all other age groups. Depression, can therefore be only diagnosed when there has been a report of one or more major depressive episodes; but excluding the occurrence of hypomania, manic or manic-depressed(mixed) disorders. A teenager must have a history of at least two weeks of these symptoms including change in mood seen as loss of interest or pleasure. This should also be accompanied by other signs characteristic of depression such as changes in diet and appetite and subsequent effects on the weight and metabolism of the patient; changes in sleep patterns; loss of concentration; low energy and fatigue; poor self esteem and lack of motivation and/or drive.
To further make an accurate diagnosis, to be made, such changes in the demeanor must be demonstrated to have affected previous relationship and social interactions; and to have impaired any relationship that the teenager may have had, to a point which other parties can perceive and comment on it. Indeed, for such a diagnosis to be accurate, it is important to establish the true source of such emotions; and eliminate issues such as drug and alcohol abuse, loss of a loved one through death, mental illness or any other form of physical of metabolic disease.
As mentioned before, it is important to separate the periods of low spirit which teenagers commonly show with true depression; as such it is important to enforce the measures mentioned above to filter out psychologically normal teens who may just be slightly agitated. On the other hand, looking for signs of depression as commonly seen in adults may be grossly misleading. Depressed adults classically report fatigue, defects in sleeping patterns and sadness. On the other hand, a teen will most likely express irritability and loss of interest in activities previously enjoyed (McCauley et al, 1993 p.714-22).
Depression in teenagers also carries a higher risk of deteriorating into a self-destructive spiral with activities such as high-risk sexual behaviors, drug and alcohol abuse; thus designating them as high risk groups for incidence of sexually transmitted disease and HIV/AIDS. Teenagers often tend to deteriorate into some of these vices in an attempt to medicate themselves; to dull the feelings of hopelessness and anguish.
A primary care practitioner should always know his/her own limits when dealing with a depressed teenager. Indeed, the teen may be drawn towards violence due to unstable moods; such patients exhibiting psychotic symptoms or harboring suicidal thought should be immediately referred to a mental health specialist.
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Major depression in teenagers can easily also be accompanied by other conditions; it is important to identify these conditions so as to treat them simultaneously and achieve faster rates of recovery in a patient. Otherwise, all the progress will be reversed by half-backed interventions. Among the most common of the accompanying disorders seen in teens is anxiety disorder; some schools of thought state that anxiety separation is either an early form of depression or an indicator of it thereof.
It is important to note however that anxiety is a common thing among teens; this is caused by worries regarding issues such as academic performance, physical conformation et cetera. However, excess or prolonged periods of anxiety can very well result in major depressive disorder. Anxiety disorder may also persist in the patient even after full recovery from the concurrent depression.
Bipolar disorder may also have an insidious onset in the teen; and may complicate the depressive disorder. However, the condition only becomes evident when the patient takes anti-depressant medication. In such a case, the surfacing of the bipolar tendencies may cause mania in more susceptible patients. Therefore, it is common practice to warn parents to be on the watch out for the development of a bipolar disorder when the teens are put under an anti-depressant medical regime.
It is prudent to mention the difficulty of recognizing a bipolar disorder in a teenager; and evaluation for its occurrence should be done in case the teen has shown extreme mood swings, and attention-deficit/hyperactivity symptoms (ADHS). Unfortunately, about 20-40 of teenagers who experience major depression have been shown to develop a bipolar disorder within five years of the first depression diagnosis (Harper et al, 2002 p.10).
Another condition related to depression in teenagers is dysthymia; while this condition has relatively milder conditions as compared to major depression, is may still cause some level of social dysfunction. This form takes a longer time; and involves changes in mood extended over a relatively longer time. In a year, the teen has to exhibit irritable mood, mild depression and at least two of the following; disturbed sleeping patterns (insomnia or hyposomnia); positive, negative or composition changes in appetite and subsequent metabolic responses; feeling of being fatigued; hopelessness; poor self esteem; and lack of concentration, focus or inability to make decisions efficiently.
These must occur in more days in the year than those which they do not. After the initial one year, major depression may result; and may occur superimposed on the dysthymic disorder. In this case, about 70% of teens who develop the disorder also develop major depression within three years of diagnosis (Harper et al, 2002 p.10 ).
Depression and alcoholism have been shown to have an inseparable link; indeed, depression is the disorder most frequently diagnosed in alcoholic patients; whereby 27-69% shows high depression scores; and approximately 15-28% suffers from an episode of major depression (Uekermann et al, 1998 p.1521–1529). The link between depression and alcoholism has not been fully described; however, strong relationships have been shown between the neuropsychological pathways of development of the two conditions; with the occurrence of one precipitating the development of the other.
Researchers have also tried to link alcoholism and depression to genetic factors; studies have identified a genetic variant of alcoholism to depression thus linking these two conditions. Already, studies had shown that 30 to 70% of the alcoholics suffered from depression and anxiety. The relationship is linked to a gene known as the CREB gene (because it codes for the production of a protein known as CREB-cyclic AMP). The activity of this gene in a section of the brain known as the Central amygdala has been shown to affect how consumption of alcohol and depression are related [Li et al 2004 p.11-18].
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The lack of the CREB gene determines how one responds to stressful situations and is implicated for driving this response towards alcohol consumption. In studies carried out on rats, the candidates that did not have an active CREB gene were shown to drink 50% more alcohol than those with the gene. This in comparison to the intake of water; the rats were also tested for the intake of sugar water of which they had equal preference thus eliminating the issue of taste preference from play. When exposed to stressful situations, the ‘alcoholic’ rats tended to drink more alcohol than the other rats which resulted in reduced anxiety; however, the alcohols effects of reducing depression and anxiety were not as great as on the normal rats [Li et al 2004 p.11-18].
Another plausible explanation is the need on the part of the patient to dull the symptoms through self-medication with alcohol; this is more likely to take place in a environment where alcohol is widely accepted as a means of coping with stressful situations; such as in alcoholic families (McMiller & Plant, 1996 p.394-397).
Role of the Nurse in Teenage Depression and Alcoholism
As mentioned before, the nurse forms a crucial first line which the teenager meets first when they come to the health service delivery point. In the case, for example, when Lorina was presented in the emergency room, the most likely medical profession she interacted with would be a nurse. Indeed, if this contact is not fruitful, the teen may not be transferred to the next tire of care which would deal with the specific condition rather than general symptoms such as poisoning.
The teenager’s family often provides very fruitful insight to any changes which may have taken place in the teen’s behavior, habits, mood or demeanor. For example, the friends of Miss Hall were able to highlight some key events in her life; such as the breakup with her boyfriend and failed examinations. By getting this basic information, the nurse will be able to provide to the mental department a patient with a comprehensive history. It is important to be objective during gathering of information from the next of kin due to the sensitivity of the issue particularly the teen.
The patient should also be interviewed preferable in privacy; this would earn the trust so long as their confidentiality is guaranteed; commonly, teenagers would like to reveal some of the issues which may be disturbing them, but not in front of their parents (Gregg et al, 1998 p.909-910). Additionally, while the teen may be diagnosed with depression, it is also a difficult task to convince them that they are “not crazy”. Apart from diagnosis, it is important to evaluate the teen for issues such as suicidal ideation; physical, sexual or emotional abuse; sexual orientation and activities; and drug & alcohol abuse. These are very sensitive issues; and the nurse should be prepared to deal with patients who are resistance. Indeed, some of the issues unearthed during the interview could the original factors causing the mental imbalance (Garland, 1994 p.1583-1587).
Great advances have been made in the creating interventions best suited for teenagers in the last decade. This can be attributed to both the increased incidence of teenage depression and alcoholism and increased interest in the subject. Short term psychotherapy forms a very useful initial tool to handle mild to moderate cases of depression among teenager. This service is usually available in health care service delivery points.
On the other hand, medical therapy has had its limitations for teenagers. For example, some of the psychoactive drugs have not been approved for use in people under the age of 18 years. Additionally, some schools of thought have urged against the use of such drugs in minors as they may have an unknown effect on the maturing process of the central nervous system (CNS). Medical treatment can however be recommended in cases where it is clear that psychotherapy cannot be used; in case of concurrent psychosis; depression occurring over a long period; and in patients who are unwilling to undergo psychotherapeutic processes (Harper et al, 2002 p.10).
Depression commonly has a high rate of recurrence; and the selected approach of therapy or a combination of them thereof should continue for 6months to one year. In all these interventions, the nurse plays a key role by managing the whole process; ensuring that the patient for instance has the correct medication; or has her appointments with the attending psychiatrist at well planned intervals.
Implications to Nursing of Teenage Depression and Alcoholism
The prevalence of teenage depression and alcoholism is on the increase; this may be attributed either to a changing society with diminished family support; or to increased rate of reporting. In either of these scenarios, there is one constant; that the symptoms seen in the teenager differ form those of an adult; and this may lead to a failure to make the correct diagnosis. Being the first line of contact for any health organization, it is of utmost importance for a nurse to be able to identify the subtle signs of depression and alcoholism in teenagers; and retain them for more specialized treatment.
Additionally, more and more registered nurses are pursuing higher education and becoming nurse practitioners; indeed, such NPs will only bring in much needed fresh blood into the practice with novel methods of handling the situation.
From the case scenario, it is evident that Miss Lorina Hall may be very well experiencing teen depression and alcoholism. Signs such as falling grades, breakups, loss of weight and alcohol poisoning are good indicators; and the move to admit her to the psychiatric department was the right move.
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Gregg R., Della Freeth and Carmel Blackie (1998). Teenage Health and the Practice Nurse: Choice and Opportunity for Both? British Journal of General Practice, 48, 909-910.
Harper G; Marks A; Nelson WM III (2002). Adolescent medicine. Teen depression: overlooked and undertreated. Patient Care for the Nurse Practitioner.
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