Depression with Suicidal Idea ( Body-Mind-Spirit Approach Nursing Care Plan )

1. Depression with Suicidal Idea(Body-Mind-Spirit Approach Nursing Care Plan) Introduction to Behavioral Health (MSBH 7001) Kwong Chung Man

2. Limitation of Pharmacotherapy • 50% response rate to antidepressant • At least 6 months antidepressant treatment • ~50% treatment adherence rate (World Health Organization, 2001)

3. Alternative Treatment • Electro-convulsive therapy • Counseling and Psychotherapy • Hospitalization

4. Indications for Hospitalizing a suicidal Patient • Possession of a means for suicide • Presence of a plan for suicide • Acute intoxication • Express feeling of out of control • Psychotic symptoms • Lack of social support • History of repeated suicide attempts • Patient is unreliable (Fadem, B., 2004)

5. Involuntary Admission in Hong Kong • Mental Health Ordinance Chap. 136, Section 31 (1999) • Forms 1, 2, & 3 • 7 days detention in psychiatric unit • 21 days extension

6. Hospitalization • Many patients can be saved only with hospitalization • Hospitalization means different things to different people • Recognize patient’s fear of being locked up • The quality of care – from doctors, nurses and attendants is crucial (Leenaars A, 2004)

7. Frustrated Psychological Needs Unbearable Psychological Pain Suicidal Ideation Suicide Attempt Understanding of Suicide (Shneidman E., 1993)

8. Characteristics of Suicide • In great psychological pain (psychache) • Cannot stand the pain (lowered threshold for suffering) • Sees ending life as escape (death as solution) • Sees no possibilities other than death (constriction) • May or may not have symptoms of depression (suicide as mental state) (Shneidman E., 1993)

9. Psychache (psychological pain) • Hurt, anguish, soreness, aching in mind • Excessive shame, guilt, humiliation, loneliness, fear, angst, dread of growing old, dying badly…. • Psychache is created and fueled by frustrated psychological needs • The remediation of the suicidal state lies in addressing and mollifying the vital frustrated psychological needs. (Shneidman E., 1993)

10. Abasement 謙卑 Achievement 成就 Affiliation 結盟 Aggression 征服 Autonomy 自主 Counteraction 抗爭 Defendance 自衛 Deference 順從 Dominance 支配 Exhibition 表現 Harmavoidance 避害 Infavoidance　避辱 Inviolacy 不被侵犯 Nurturance 養育 Order 秩序 Play 遊戲 Rejection　排斥 Sentience　感覺 Succorance　被保護 Understanding　理解 (Murray H. 1938) Psychological Needs

11. Nursing Care Plan (Safety) • Assess suicidal risk • Provide supervision to prevent self-harm • Control environmental hazards • Make a no-suicide contract

12. NCP (Mind): Reduce Suicide Risk • Communicate empathy for unbearable psychological pain • Address vital frustrated psychological needs • Mollifying the vital frustrated psychological needs • Increase threshold for suffering • Discuss possibilities other than death • Establish a balanced perspective of psychological needs

13. NCP (Mind): Reduce Depression • Administrate the 抑鬱症問卷, and 身心靈健康問卷. Evaluate results and give feedback to patient • Encourage patient to share feelings of depression • Assist patient in developing awareness of cognitive messages that reinforce helplessness and hopelessness

14. NCP (Mind): Reduce Depression • Assign patient to keep a record of daily events and associated dysfunctional cognition and emotions. Challenge dysfunctional thoughts for accuracy, and identify alternative cognitive interpretations that are more positive and realistic • Reinforce positive, reality-based cognitive messages that enhance patient’s self confidence and increase adaptive action

15. NCP (Mind): Reduce Depression • Educate patient about depression and accepting some sadness as a normal variation in feeling • Assign patient to write at least one positive affirmation statement daily regarding self and the future • Verbally reinforce patient’s positive self-statements

16. NCP (Mind): Reduce Depression • Challenge patient to focus on capabilities rather on disabilities • Recommend self-help books on coping with depression • Provide social-recreational activity (Karaoke, Mahjong etc.) • Assist patient in developing a plan for increasing participation in recreational activities

17. Nursing Care Plan (Body) • Monitor patient’s medication compliance and the effectiveness of medications on level of functioning • Provide balanced diet and monitor intake & body weight • Teach physical exercise (手部運動，八段錦） • Teach breathing exercise (“哈”呼吸法） • Teach methods to promote sleep (指壓，腳底按摩) • Monitor and redirect patient in maintaining daily grooming and hygiene • Assist patient in developing a plan for increasing participation in physical exercise

18. Nursing Care Plan (Spirit) • Arrange religious services • Discuss meaning of life • Discuss meaning of death • Discuss pain and suffering (人生八苦) • Promote transcendence (reframing pain in ways that normalize and confirm the humanity of our clients while also suggesting that pain itself has a healing function) (Levington C., & Gruba-Mccallister F., 1996)

19. To the extent that suicide relates to happiness, it relates in people of any age – not to lack of mundane happiness but to the loss of childhood’s magical joys. (Shneidman E., 1993)