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Depression and Suicide: Assessment and Intervention

Leona G. McIntyre, Phyllis Oreck, Mary Ann Camarillo and Sharon McBride Valente Home Health Care Management Practice 1996 9: 8 DOI: 10.1177/108482239600900107 The online version of this article can be found at: http://hhc.sagepub.com/content/9/1/8

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Depression and Suicide: Assessment and

I ntervention
Leona G.

McIntyre, Phyllis Oreck, Mary Ann Camarillo,

and Sharon McBride Valente

Despite the ever increasing numbers of

older persons in the home health
care

suffering from a depression are not treated adequately. This article presents a case study to illustrate assessment, identification of risk factors, and interventions aimed at preventing suicide, a lethal outcome of untreated depression. Once detected, depression can be effectively treated. Nurses are
are

system, often those who

vital in their role

as

educators and

depression and promoting improved functioning for

older persons.

counselors in treating

PPROXIMATELY 25% of elderly people receiving home health care suffer from F~~ untreated major depression.1-5 Untreated depression reduces the patients compliance with treatment and quality of life and may lead to premature death by suicide.3 Major depression costs $2.1 billion annually, with an additional $4 billion lost in work productivity. Careful assessment by the nurse is key to the detection of depression among older adults receiving home care.l-3.s-8 Home care nurses work directly with many elderly clients. Thorough assessment over time often reveals subtle clues that alert the nurse to a major depressive episode or potential suicide risk. The home care nurse helps elderly clients adjust to physical and emotional losses and provides education and support during treatment and recovery. Timely, comprehensive nursing assessments are pivotal in the recognition of depression and prevention of suicide in this

~~~

population. 1,4,5,1
Key words: depression, elderly, geriatrics,
home health care, suicide

Depression
Major depression is a major health problem in the United States among elderly people. About 10 million American adults have a depressive disorder, but only one third seek treatment.5.9Healthy People 2000 emphasized elimination of the unnecessary suffering associated with depression. Of those who seek treatment, most persons with major depression are seen by primary care and other nonpsychiatric professionals. Most caregivers fail to diagnose depression.l Diagnoses that increase the risk of major depression include acquired immune deficiency syndrome (AIDS), cancer, diabetes, cardiovascular 2 disorders, and stroke.2 One serious and potential complication of depression is suicide. Approximately 10,000 citizens over age 60 kill themselves each year. This accounts for about 25% of the total number of suicides in this country.,,&dquo; Since late-life depression is usually

Home Health Care Manage Prac, 1996, @ 1996 Aspen Publishers, Inc.

9(1),

8-17 7

8
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amenable to treatment, early diagnosis and appropriate referral are important in reducing the associated morbidity and suicide. 1,5,12 To prevent these untimely deaths, home health care nurses need to detect clues to suicide and act decisively with early and appropriate interventions.1.5.11-13 Researchers describe the various components of a careful suicide assessment and characteristic symptoms of the suicidal elderly person (see box, &dquo;Criteria for Major Depression&dquo;). Researchers suggest the most effective prevention of suicide is to identify the intent before the act.1.5.12 Recognition is the first step in suicide

for recognizing and treating major depression among older clients. The following case illustrates a typical presentation of depression.
Case

study
an

prevention.
Literature
on

depression

research exists, Wang et a113 invesAlthough home health care nurses knowledge of the tigated signs of potential suicide among elderly people. These nurses lacked knowledge of the suicidal intent of elderly people. 13 Home health care nurses need to improve knowledge and skills in the recognition of depression and the clinical management of the older client.14,15 Because elderly people are less likely than the younger adults to report suicidal thoughts, 1,5,11
scant

Valente et a115 and Valente16 outline the skills needed

83-year-old widow with Type II diabetes, arthritis, hypertension, and stable angina was referred for home health care nursing after hospital discharge. Her medications included glyburide (Diabeta) 5 mg daily, atenolol (Tenormin) 50 mg daily, nitroglycerine grains 1/150 as needed, and indomethacin (Indocin) 75 mg three times daily as needed. LB lived alone but had neighbors who visited daily. LB commented that she was glad her only daughter lived in another state. During the first three visits, LB was not interested in learning about her diabetes or about the glucometer. Instead, LB said, &dquo;Im sick of this life, my good years are past, and my body is falling apart.&dquo; She complained her garden failed to give her pleasure anymore. She lamented about physical symptoms, insomnia, poor concentration, sadness, and irritability. She said, &dquo;Occasionally, I take one of those sleeping pills.&dquo; In response to the nurses questions, LB admitted to feeling blue and tired most of the time. &dquo;Its just a part of being old and having health problems,&dquo; she explained.
Mrs LB,
care nurse, what would be for assessment and care? What is probably your plan precipitating LBs noncompliance with treatment? If your care plan focused primarily on diet, medications, and education for her medical regimen, you would miss a depression that, if left untreated, is potentially life threatening. The symptoms in LBs case (eg, daily sadness, physical complaints, and noncompliance) suggest that LB was suffering from a common, treatable disorder. These symptoms are typical of major depression. The nurse who detects clues, evaluates symptoms, encourages treatment, and begins supportive care and education can reduce LBs suffering and distress. The nurse who encourages early treatment for major depression can prevent suicide, the most serious complication of depression. 1,2,5,7-9

As the home health

Assessment of Depression
The home health care nity to assess the home

has the ideal opportuclient with a major depressive episode. Knowing the current research literature enables the nurse to effectively assess for
nurse care

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10

depression using interview and observational skills. 16,17 Assessment is the initial step of the nursing process. A comprehensive assessment includes a chart review, admission interview, medication and symptom review, and appraisal of risk factors.,5,.15 After review of routine diagnostic medical data available for the client, the nurse conducts the admission interview. Talking with significant others about their observations of and interactions with the client can provide important data about a clients behaviors, communication abilities, and mood. 4,18 The nurse also makes objective observations of the general living environment and the clients behaviors. The observations of the nurse, friends, or family provide diagnostic data about the persons mood, behavior, and communication abilities. Depression is accompanied by physical and psychologic symptoms. These include sleep and appetite changes, poor concentration, fatigue, multiple losses, withdrawal, and either somatic complaints or the inability to cope with these multiple complaints. 1-5 The older depressed client demonstrates a picture of apathetic withdrawal with great loss of self-esteem. For instance, LBs loss of interest in a favorite activity, gardening, signals apathy. The person rarely acknowledges a depressed mood but often reports numerous physical symptoms and few psychologic or emotional complaints.1,4,5,7 LBs complaint that her body is falling apart is a good example. At the same time, marked impairment of cognitive abilities exists (eg, inability to concentrate, to remember, or to make a decision). Generally, the older client will have little expression of guilt in depression. 2,5 Assessment includes asking about the clients or familys prior history of depression. Information about past coping patterns, communication style, and existing support systems helps the nurse plan interventions. 4,5,7 Understanding the physical, emotional, social, and cognitive aspects of the clients

status is necessary

because the manifestations of de-

pression can be so variable. In the case study, LB lives alone and has limited social contacts. She exhibits passivity and loss of pleasure in activities she formerly enjoyed. She has numerous physical complaints but minimizes her
loss of weight. She also admits to some sadness, tearfulness, insomnia, and fatigue. Her comments indicate she feels worthless. Because clients often emphasize physical over emotional symptoms, any symptom that is not readily explained should be a cue for increased attention by the nurse.4,7,18 The nurse should ask about symptoms (see box, &dquo;Criteria for Major Depression&dquo;) and risk factors if they are not mentioned by the client. The nurse must also ask about and evaluate any changes in weight, appetite, interpersonal relationships, sexual interest, sleep pattern, activities, level of energy, or fatigue. For example, the nurse gently probed LB about the start of symptoms of fatigue and attempted to have LB describe feelings more explicitly. Antihypertensives such as atenolol may contribute to lethargy and depression.4.5.18 The nurse should evaluate changes in the clients motor activity. Agitation may be exhibited by pacing or hand wringing. Conversely, slowed motor activity may affect movement, speech, and thought patterns. Cognitive changes such as difficulty in thinking, concentrating, level of distractibility, or decision making need to be fully examined. A mental status examination is a critical part of assessment because it helps rule out various other mental health diagnoses, such as confusion or dementia.4.5.7.15.18 Knowledge of the clients previous and present level of functional ability will help predict how well the client will participate in self-care. 5,7 Functional ability will need to be assessed unless it is already documented. Asking the client to perform a simple task such as walking across the room helps evaluate abilities. Questions about managing bathing and dressing can clarify functional abilities. The clients functional ability influences safety at home, maintenance of interpersonal relationships, and participation in social activities. 1,5 The nurse will find the Older Adults Resource Survey (OARS) useful in assessing general abilities. 5,7 Beyond that, the nurse may need to seek assistance of physical or occupational therapy for complete functional assessment. The clients medications require review because of the danger of possible interactions and depressive side effects. 1,5 The home care client may be taking

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11

over-the-counter medications and medications ordered by different physicians. 1,3,5 The altered physiologic response of the older person contributes to the need for medication monitoring. 4,1 Some medications, such as antihypertensives, anxiolytics, analgesics, hypoglycemic agents, and even antibiotics, are known to cause depressive symptoms. 7,15,18,19 Several medical illnesses can cause symptoms of depression. These illnesses include cardiovascular disorders (eg, congestive heart failure), pulmonary disorders (eg, chronic obstructive lung disease), neurologic diseases (eg, Parkinsons or dementias), metabolic disturbances (eg, dehydration), or endocrine disorders (eg, diabetes or Cushings disease). Numerous infectious processes (eg, viral and bacterial pneumonia) as well as some genitourinary and musculoskeletal disorders may result in depression.18 Cancers, especially those of the head and neck or gastrointestinal (GI) tract, have a high incidence of depression and suicide. 6,15 Among people who have AIDS, incidence of depression and suicide
is
3 high.3

ness

the

and depression further confound assessment of depressed elderly. 2,4,18

Because the home health care nurse may face difficulty in assessing depression, Krachl has identified some efficient assessment tools (see box, &dquo;Assessment

Tools&dquo;). Although she lists several, easy-toscreening tools, the Beck Depression In(BDI) is often the most convenient for ventory
administer

identifying depression. The BDI is a self-report tool that is readily available. The client can answer the 21 questions in 10 to 15 minutes. The BDI measures the intensity and severity of depression. A score of less than 17 indicates minimal depression. Moderate depression might yield a score between 17 and 25, while anything over 30 is potentially a serious, profound depression. 20,22 The first BDI score of LB was that she needed to be in treatment. The 28, home health care nurse who uses one of these tools can provide subjective and objective data to convince the physician that a major depression exists.

indicating

Suicide risk
most serious

Because of the similarity of symptoms of physical illness and depression, Marzuk$suggests that cognitive and affective symptoms be given more value in diagnosing a depression when there is concurrent medical disease. The nurse must apply the nursing process to the ongoing education about illness and symptom management. The nurse evaluates the affect or mood of the client and the ability of the client to move through problem solving (eg, cognitive abilities). When the nurse helps clients to manage symptoms and promotes the clients optimal functioning, clients can renew feelings of hope and restore selfesteem. 5,15,20 Multiple reasons exist for the failure to identify elders who are at risk for depression and suicide. One reason depression and suicide risk is misdiagnosed can be the failure of physicians and nurses to ask about depression.39 Differentiating between a major depressive episode (see box, &dquo;Criteria for Major Depression&dquo;) and a more persistent, chronic mood disturbance can be difficult,18 Chronic depression must be present continually for at least 2 years with at least two of the accompanying symptoms (eg, fa-

Healthy People 2000 described suicide as &dquo;the potential outcome of mental disorders&dquo;9(p2i0) and targeted reducing the age-adjusted

suicide rate from 11.7 to no more than 10.5 per 100,000 people by the year 2000.9 About 70% of people who died by suicide had been diagnosed with medical problems. 23 Other risk factors that have been scientifically related to suicide are male gender, white race, living alone, prior suicide attempt, psychosis, substance abuse, hopelessness, and depression. 3,11,23 Marzuk stated that among terminally ill clients thoughts of death should not be considered as an indicator of suicide but instead a possible indicator of depression. During assessment of physical problems, the nurse considers whether each symptom or prob-

tigue, poor concentration, insomnia or hypersomnia, loss of appetite or excessive eating, low self-esteem, fatigue, hopelessness) present for that time. A history of difficulty adapting to life situations is common among elderly persons with chronic depression.18 Finally, the similarity of symptoms of medical ill-

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12

lem is reversible. A nurse provides education about reversible symptoms (eg, insomnia, pain, constipation) and works with the client and family to manage the problem. Some irreversible problems such as loss of vision or hearing, amputations, or paralysis are not changeable. The nurse provides not only education, but also emotional and psychologic support as the client and family move toward accepting the irreversibility of the experience. The elderly home care population often confronts an accumulation of losses that lead to depression and hopelessness. These losses occur as part of aging. The nurse needs to assess how the person has adapted to any previous losses. Learning about the adaptational abilities of the person to past developmental, emotional, or psychosocial losses could indicate current coping abilities. An accumulation of losses can predispose the person to a serious depressive episode, particularly if social support, coping skills, and problem-solving abilities were weak. 4,5,21 The nurses knowledge of depression risk factors allows for sensitive, yet direct questioning of these areas. Although physical, economic, emotional, and social losses or excessive use of alcohol might be overlooked as acceptable in the older population, these place the client at greater risk. When a risk factor exists, a thorough evaluation of depression is im-

tent. 2-4,7,16,22,23 The nurse will emphasize an overriding concern for the clients safety. A sensitive nurse will inform the client about the need to share with the district supervisor and other health care team members information that affects safety. The nurse evaluates suicidal risk by asking open and direct questions: Are you feeling so badly that you think about killing yourself? The nurse asks specific questions to determine whether thoughts of self-harm are fleeting or include a definite plan. It is essential to ask the person about intentions: How or when do you plan to do this? What do you think might happen ? Next the nurse determines whether the client has the means to carry out the plan. Does the person have a gun or enough pills? The greater the specificity of plan, intent, and available method, the greater the risk of suicide. The degree of risk should be routinely assessed and documented, appropriate safety measures instituted, and other colleagues notified of risk potential. In the case example, the nurse learned that LB was feeling somewhat hopeless about ever recovering fully, especially in the face of the new medical diagnosis of diabetes. However, because of strong religious convictions, denied suicide was an

option.
When the nurse experiences a high level of anxiety about the suicidality of a client, the following questions will help: (1) Have you ever thought about or attempted to kill yourself? (2) How often have you thought about killing yourself in the past year? (3) Have you ever told someone that you were going to commit suicide or that you might do it? (4) How likely is it that you will attempt suicide one day? The questions are brief and indicate severity and intensity of suicide risk. The scoring ranges from 0 for a no answer to 6 for an active, present thought or attempt .25 Taking the few moments to ask key questions can help to establish an appropriate level of
care.

portant.4,7,10,11,15,16
Hints of suicide are revealed in obvious statements such as, &dquo;Its so hard to go on,&dquo; or &dquo;Im never going to get better.&dquo; For instance, LB said, &dquo;Im sick of this life.&dquo; The client may also say, &dquo;I probably wont see you.&dquo; Indirect expressions might include giving away favorite items or a change of behavior (eg, decides to make or change a will, stops eating or taking medications). The nurse asks for clarification of the statements and behaviors. Elderly people often do not volunteer information about suicide.4z3 Unfortunately, 80% of suicidal older adults had visited a physician 1 week prior to their suicide. 16,22 The nurse can always seek assistance from others in determining suicide risk. The nurse assessing LB should be interested in evaluating what LB meant when she said, &dquo;Im sick of this life; my good years are past.&dquo; The nurse should ask LB to clarify those comments and should use them as an opportunity to explore LBs life perspective.

Interventions

Evaluating suicide risk Clients with depression, hopelessness, or past suicidal behaviors require evaluation of suicidal in-

Major depression and depressive disorders respond well to treatment. 2-5,9,10,24 Management of depression includes antidepressant medications, psychotherapy, electroconvulsive therapy, and education. Nurses play an active, vital role in education and support of clients during treatment and recovery. The nurse helps the client participate in making decisions about depression.

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13

Monitoring medications
Researchers suggest that biologic factors trigger depression because clients of all ages respond to antidepressant therapy. 26 There are numerous effective antidepressant medications available for treatment. Tricyclics (TCAs; eg, Amitriptyline hydrochloride), heterocyclics (eg, trazodone hydrochloride), monamine oxidase inhibitors (MA01s; eg, phenelzine sulfate), and selective serotonin reuptake inhibitors (SSRIs; eg, sertraline hydrochloride) are commonly used.3,5 Antidepressant therapy should provide maximal therapeutic effects with minimal adverse side effects. 5,16,18 The nurse educates clients and families about prescribed medications and about the importance of continual monitoring of the clients response to medication.17 The nurse will educate the client and family about the purpose of the medication, its dosage, and its administration schedule. Many antidepressants may take several weeks to be fully effective. Providing support to the client during this time is essential. Expected responses and management of uncomfortable symptoms (eg, dry mouth or constipation) must be explained to the client and family. The side effects, such as oversedation or urinary retention, that do not respond to nursing measures need to be reported to the physician for possible medication adjustment or change.5,16.18 Because of fewer side effects and decreased lethality, the newer heterocyclics are preferred for the older depressed person.3-5 As a last resort, MAOIs are sometimes useful in older clients with prior cardiac history.5Medication side effects such as tremors, restlessness, anorexia, nausea, and headache might appear and without appropriate nursing interventions may contribute to poor adherence. 3,4 For example, when beginning new medications, the dose is often altered due to slowed physiologic responses, and blood tests for therapeutic blood levels may need to be tested more frequently.3.5.16 The home care nurse may need to encourage the physician to order the specific laboratory

tests. The

nurse

who

provides

consistent

empathic

support and education about depression, treatment,

and recovery promotes client adherence and prevents suicide3.7.19

(see box, &dquo;Antidepressants&dquo;).

LB had been ordered the SSRI sertraline

hydro-

chloride (eg, Zoloft) by her psychiatrist. This medication is preferred for diabetics because of its lower side effects and safety in combinations.9 The nurse was beginning to educate LB about the new medication and discovered that LB was beginning to have some hope for feeling better. LB stated that it was a welcoming thought to even consider working in her garden again once the medication began to take effect. Education and

counseling Psychotherapy is a time-limited treatment that is most effective when coupled with antidepressant medications.2.5.7,24 The clients who do not respond to
medication or who have marked functional impairment often respond favorably to a course of electroconvulsive therapy. 5,14 Nurses provide both education and emotional support to the client and family during these treatments.3,17 Education and brief counseling at home can help clients develop the knowledge and skills necessary for coping with depression. Occasionally clients may initially have difficulty telling their troubles to strangers, a new nurse, for example; but more typically patients feel very comfortable sharing concerns regarding their current health. Depressed clients fear that the health care community has given up on them and offers few alternatives.l4 By encouraging the client to verbalize feelings, the nurse is being therapeutiC.5 Most home health care agencies have a full complement of professional staff that allows the nurse to more readily access special services for a client. The nurse facilitates client requests. There may be instances when the nurse recognizes a need for specific skills training (eg, use of safety devices in the home). Community resources for seniors provide assertion skills classes, travelogues, volunteer activities, and even job training for seniors. Nurses can be instrumental in directing seniors to these activities. When the nurse provides new and different options, clients improve their coping strategies and become more

strategies. Realistic
clients
a sense

willing to explore other self-management short-term goals that are made collaboratively are more likely to be achieved, giving
of satisfaction.

Strategies

can

include

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14

increasing self-esteem through helping clients to recognize and appreciate their own strengths and attributes.1,3,15.21 A simple daily exercise program that increases mobility can produce physiologic and psychologic changes that diminish depression.1,5,s,16,21 Examples might be a short daily walk or simple aerobic exercises. Pet therapy can be helpful for those living alone. Encouragement and facilitation of an improved level of functioning are continuous processes.

health. The home care nurse uses professional skills to establish a trusting relationship by acting in a nonjudgmental, positive manner. When the nurse practices empathetic, reflective listening and uses silence appropriately, those behaviors promote verbalization of feelings and thoughts .1,5,6 &dquo; The nurse also collaborates with clients to allow for realistic activity and goals .11,17,11 The nurse who allows just a few minutes out of each visit for the client to reminisce can

help

restore

positive self-image.l.5.l9

Zauszniew-

Educational approaches and community-based services help reduce depression and improve a clients control over treatment.5,21 Group interventions can prevent stressors, reduce isolation and loneliness, and enhance social support and problem solving. A group intervention typically encourages clients to share coping strategies. Groups can help clients to identify and work out solutions to their

problems. Systematic problem-solving techniques are used to resolve specific concerns while efforts are made to reduce depression.1,6.9,21
an

The nurses interventions move the client toward improved state of mental, physical, and social

skill addresses the importance of a variety of strategies for the depressed person. Creative nursing interventions that promote resourcefulness and social interactions, build self-esteem, and support independent problem solving serve to reinforce the persons belief in personal effectiveness.21 The impact of cultural differences and beliefs on health needs must be considered in planning care.28 Although a key member of the home care team, the home health care nurse is not alone in being responsible for the client but can be instrumental in inspiring renewed hope for clients. The nurse is able to assume numerous roles (eg, educator and counselor) to promote clients

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15

and integration of their life situations. When confronted with a suicidal client, the nurse has a clear professional obligation to maintain safety.18,29 The nurse may ask someone to remain with the high-risk client at all times; hospitalization may be indicated. The nurse may need to draw up a no-self-harm contract with the client. The client needs to agree to notify the health care team of suicidal impulses and to not harm himself or herself. The contract must have specific objectives and must be reciprocal. This means the client must know what the nurse or health care team will do.2 The nurse who has been interacting with elderly clients in a nonjudgmental, accepting manner will be providing the stimulus for open discussion of thoughts and feelings in a trusting environment. Clear, concise, and consistent documentation of interactions and specific interventions is essential. Although decisions about suicide risk require expert and decisive action, the nurse need not make such decisions alone but may consult regularly and often with the supervisor and other team members. Once safety has been established, the nurse must determine what factors provoked the suicidal behavior. A determination of helpful persons and supportive resources needs to take place. Once the immediate crisis has stabilized, the nurse will work closely with client and family or friends to reestablish a realistic plan for handling future incidents. Someone may need to be responsible for keeping and administering medications for a period of time. The person should not be allowed to be alone until a renewed sense of hope and commitment to life are apparent. A pastor or spiritual advisor can provide another source of support. If a client has returned home after a suicide attempt, the nurse needs to be aware that danger may still exist and must take appropriate measures to maintain safety of the client.24 The multidisciplinary team approach is invaluable in longterm management of the elderly person at home.

participation, acceptance,

hygiene with a resumed interest in the activities of daily living (ADL). With improved appetite and regular sleep patterns, clients are more able to concentrate and remember pleasures forgotten. These changes should begin when the antidepressant achieves therapeutic levels and should be visible in approximately 4 to 6 weeks. Often the first indicators of improvement occur as clients begin to take an interest in their appearance, as moods lighten, and as clients make more positive statements about their surroundings. As the nurse promotes a higher functional level, clients begin to value themselves again, often growing in new ways. In the case example, LB was very receptive to the calm, positive attitude of the nurse. LB had few social contacts and was glad to have the nurse &dquo;take time to listen to me.&dquo; LB was planning to join a group for newly diagnosed diabetics. The last BDI completed by LB was 25. LB was able to obtain therapeutic relief with the sertraline. Her Beck scores began to slowly drop as she became more active in her own
health maintenance.

Ethical Issues
Nurses encounter conflicts regarding three bioethical issues (ie, the duty to care, confidentiality, and assisted suicide). The nurse must examine the issues and prepare thoughtful responses before facing these problems in practice. According to ethicists, the nurses primary duty is to provide for the clients care, safety, and well-being. Secondly, the nurse should possess the competence to detect depression and to participate in a collaborative treatment plan. Conflicts occur when a duty to care and inform the team clashes with the clients refusal of treatment. Numerous books on ethics are available in any nursing library for use in examining ethical dilemmas (eg, professional duties, values, ethical and professional guidelines). Conflicts surround confidentiality issues. The nurses duty to alert the team to suicide risk may

Expected outcome
When a client receives treatment for depression, the nurse should see improvement in behavior and mood in about 6 weeks. Recovery takes time. Nurses enhance recovery by focusing on and praising small improvements and accomplishments. Nurses can help clients to recognize feelings by asking questions that help the client identify what may be causing the distress. Expected outcomes include improved daily

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16

clash with confidentiality requests, particularly when terminally ill clients have unrelieved suffering or unacceptable quality of life. Confidentiality is not an absolute right and does not prevent informing the health care team. The Code of Ethics directs the nurse to do no harm (eg, nonmaleficence) and to do good (eg, beneficence).29 Conflict may occur in applying these principles to practice; nurses may debate whether informing the physician or not is the greater good. Nurses know they should sound the alarm when a client is suicidal but hesitate to do so for confidentiality and other reasons. However, failure to evaluate and disclose risk could lead to a premature suicide. Suicide is the ultimate complication of untreated depression. The nurses duty is to evaluate, document, and report the clients suicide risk to the physician and team. However, the nurse may also request a consultation or team conference regarding the patient and seek consultation from the nursing supervisor and hospital or state board ethics committees. Nurses can decrease suicide risk by ensuring the client receives the most effective management for symptoms, pain, and depression. Another response is to inform the health care team and also educate the patient about advance directives, refusing treatments, or withdrawing food and fluids. Educating the client and family about options and resources is one way to provide advocacy within standards of practice.10 When nurses believe that these standards prevent death with dignity, they need to know that participation in political efforts to revise professional and legal standards is an appropriate mechanism for change. Some nurses may advocate for such change by joining the Hemlock Society, Death with Dignity, or other professional organizations, such as the American Association of Suicidology.
0 0 0

cise assessment data provide a framework to organize a plan for a collaborative treatment approach. Opportunities for supporting and reducing depression in the elderly require home health care nurses to broaden their own perspectives of the elderly.

REFERENCES
1. Krach P. Assessment of depressed older persons living in a home setting. Home Healthcare Nurse. 1995;13(3):61-64. 2. US Department of Health and Human Services. Depression in Primary Care: Vol 1, Detection and Diagnosis Clinical Practice Guideline No. 5 AHCPR No. 93-0550. Washington, DC: Government Printing Office; 1993. 3. US Department of Health and Human Services. Depression in Primary Care: Vol. 2, Treatment of Major Depression Clinical Practice Guideline No. 5 AHCPR Publication No. 93-0551. , Washington, DC: Government Printing Office; 1993. 4. Valente S. Suicide and elderly people: Assessment and intervention. Omega. 1993a;28:317-331. 5. Buschmann MBT, Dixon MA, Tichy AM. Geriatric depression. Home Healthcare Nurse. 1995;13:47-56. 6. Buchanan D, Farran C, Clark D. Suicidal thought and selftranscendence in older adults. J Psychosoc Nurs Ment Health Serv. 1995;33:31-34. 7. Browning MA. Depression, suicide, and bereavement. In: Mo:

Hogstel MO, ed. Geropsychiatric Nursing. 2nd ed. Mosby; 1995.

1994;18:497-512.

St. Louis,

8. Marzuk PM. Suicide and terminal illness. Death Studies.

9. US

Department of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: US Government Print-

ing Office; 1990. DHHS Publication No. (PHS) 91-50212. 10. Goodnick PJ, Henry JH, Buki VMV. Treatment of depression in patients with diabetes mellitus. J Clin Psychol 1995;56: . 128-136. 11. Jorm AF, et al. Factors associated with the wish to die in el12. American

13.

The complexity of assessing depression in the older person in a home setting requires keen assessment skills. The major components of effective assessment of the depressed elderly poison must be age specific and multidimensional. The nurse must have knowledge to recognize depression in the older person and clinical competence for management of a vulnerable population. The assessment challenge is that the symptoms are difficult to detect. The older person rarely reports psychologic symptoms but instead expresses numerous somatic complaints. Con-

derly people. Age Ageing. 1995;24:389-392. Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. Wang W-L, Anderson F, Mentes J. Home healthcare nurses knowledge and attitudes toward suicide. Home Healthcare

14.

15.
16.

17.
18.

Nurse. 1995;13:64-69. Lavizzo-Mourney R. Special skills for the clinical management of the older patient. Geriatrics. 1988;43(Supplement): 3-9. Valente S, Saunders J, Cohen M. Evaluating depression among patients with cancer. Cancer Pract. 1994;2:65-71. Valente S. Recognizing depression in elderly patients. AmJ Nurs. 1994;12:19-24. American Nurses Association. Standards of Psychiatric and Mental Health Nurs Practice. 1982. Kurlowicz LH. Depression in hospitalized medically ill elders : Evolution of the concept. Arch Psychiatr Nurs. 1994,8: 124-136.

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17

19. Messner RL, Lewis S. Doubletrouble: Managing chronic illness and depression. Nurs 95. 1995;25:46-49. 20. Doka KJ. Living with Life-Threatening Illness: A Guide for Patients, Their Families, and Caregivers New York, NY: Lexington Books; 1993. 21. Zauszniewski JA.

25. Cotton

CR, Peters DK, Range LM. Psychometric properties of the suicidal behaviors questionnaire. Death Studies. 1995;19:

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