Psychiatry and Psychological Disorders

Abstract

Abstract

Introduction:

Depression is one of the syndromes that is common among mental illnesses and creates a global burden of disease. Studies have reported that the cognitive behavioral approach has positive results in the treatment of depression. For this reason, the case was made to emphasize the effect of the cognitive and behavioral approach on the structured interview process in a patient diagnosed with chronic depression, which is one of the most common diseases that psychiatric nurses encounter in hospitals.

Material and Methods:

In this study, the Perceived Stress Scale, Zung Depression Scale, Warwick-Edinburgh Mental Well-Being Scale and Brief Psychiatric Rating Scale were applied before the interviews with Ms. B. Scales were repeated monthly. A total of 16 sessions of individually structured interviews, including 10 sessions during the hospitalization period and 6 sessions after discharge, were conducted once a week for 4 months, and the case formulation technique of cognitive behavioral therapy was applied.

Results:

As a result of the interviews, A decrease was observed in the scores of the patient from the scales. In these interviews, techniques such as verbal feedback, stress management chart, activity and future plans, homework, relaxation exercises, pain management, behavior charts were included. Healthy coping methods were taught, and they were supported in their participation in group activities and socialization, and their developmental stages were followed one by one.

Conclusion:

The formulation of the cognitive behavioral approach has shown a guiding map feature in identifying the problem in structured interviews.

Entrance

Emotional and cognitive processes are inseparable in the spiritual life of man. While the concepts of recognition, perception, evaluation, establishing cause-effect connections and placing in the memory express mental abilities, concepts such as joy, fear, grief, anger, grudge, anxiety, and anxiety express affect (Öztürk & Uluşahin, 2008, s. 337). Depression is a mental illness that results from the complex interaction of social, psychological and biological factors, affects individuals of all ages, contributes to the global burden of disease and creates disability (WHO, 2019). According to World Health Organization data (2019), it is a common disease worldwide, affecting more than 264 million people (WHO, 2019). For this reason, in this disease, which affects many people in terms of both cost and incidence, it is seen that the situations that give pleasure no longer give pleasure to the person, loss of interest, depression and pessimism are predominantly dominant (WHO, 2019). The presence of symptoms for more than 2 years is called chronic depression (Öztürk & Uluşahin, 2008). When we look at the studies on the treatment of chronic depression, it is emphasized in the study of Ridgway and Williams (2011) that 60-80% of the people exposed to this disease can be effectively treated with medication or psychotherapy in primary care (Ridgway & Williams, 2011).

Cognitive therapy is a treatment process that allows patients to correct their false beliefs that can lead to negative moods and behaviors. The basic assumption is that thought precedes a mood; Therefore, learning to replace negative thoughts with healthy thoughts can result in improving one's mood, self-concept, behavior, and physical condition (Rupke, Blecke, & Renfrow, 2006). In this context, the cognitive behavioral approach is a type of psychotherapy that is widely used in the treatment of depression and has positive results (Oud, ve diğerleri, 2019; Ridgway & Williams, 2011; Franklin, Carson, & Welch, 2016). The difficulties faced by the individual in his life are often accompanied by a medical disorder or a psychiatric disorder. This situation may cause the individual's coping skills to be negatively affected. This approach aims to help the individual to cope with these difficulties by applying the learning theory to the problems faced by the individual in life (Demiralp & Oflaz, 2007). Studies have shown that cognitive therapy is an effective treatment for depression and is comparable to its effectiveness in antidepressants or psychodynamic therapies (Oud, ve diğerleri, 2019; Keles & Idsoe, 2018). Cognitive therapy has also proven useful in treating patients with only partial response to adequate antidepressant therapy (Mohr, ve diğerleri, 2019).

Diagnosed with chronic depression to the disease depends on their cognitive schemas and coping skills. The goal of the cognitive-behavioral approach is to help change the unrealistic beliefs, thoughts and negativity situations, as well as to help them adapt to the experiences related to the disease (Hawley , ve diğerleri, 2017).

In the cognitive behavioral approach, many techniques can be used to change the emotions, behaviors, perceptions and physiology of patients diagnosed with depression. The techniques used are aimed at correcting negative beliefs such as failure, hopelessness, and uselessness (Franklin, Carson, & Welch, 2016). Some of the techniques used can be used at work, at home, at school or as a leisure time activity. For this reason, the cognitive behavioral approach can be used by psychiatric nurses in all areas of health care in order to change the individual's maladaptive and inappropriate behaviors and to develop effective coping skills (Demiralp & Oflaz, 2007). In this case report, the successful treatment obtained by using the formulation technique of the cognitive and behavioral approach during the interview process with the patient who has been treated with the diagnosis of chronic depression for 14 years is shared.

Method

Considering that the successful results obtained from the interviews with a patient who was treated in a hospital with the diagnosis of Chronic Depression, would contribute to the literature, it was decided to convert them into a case report, and written permission was obtained by making necessary explanations to the person concerned.

Case

The female patient, referred to as Ms. B, is single, university graduate, an employee of an institution, and lives alone. It was noticed that the patient, who was born in 1997 with normal delivery and without complications, had visual disturbances in the left leg (shortening of the left leg) and contractions. With the diagnosis of congenital left fibular ageniza and left tibia hypoplasia, leg lengthening operations were performed approximately 35 times at periodic intervals. Finally, the patient's leg was extended by 18 cm, and the difference remained 5 cm. His first complaints started about 15 years ago in the form of unhappiness, malaise, not enjoying life, crying attacks, anxious worry, guilt, worthlessness, suicidal and pessimistic thoughts. Hospitalization was repeated almost every 2 years with the same complaints periodically. These admissions usually coincided with the death anniversary of her first boyfriend. She had previously taken psychotherapy as an adjunct to medical treatment, but did not see much benefit from it. He suffered nerve damage as a result of his last leg lengthening operation 4 years ago, so opioid treatment was started for his chronic pain. The patient constantly repeats his hospitalizations, “I have a resistant depression and I am responsible for this situation. My pain is too much, when I can't stand the pain and when I'm alone at home, I find myself here.”

Evaluation of the current situation

The patient stated the reason for his current hospitalization, “I was constantly coming for control. I started not enjoying life. I started crying attacks. Then my sleep started to deteriorate. I couldn't stand my pain. The thing that has bothered me the most lately is work. Because I am disabled at work, they constantly mobbing, they do not allow me to have close relationships with anyone, I am very unhappy at my workplace. When necessary, when I was very stressed, when my muscles contracted, I was taking nervium. Over time, this situation became inextricable as it deepened even though I took medication. I lost five kilos in 2 months. I had no appetite. I could spend the day with a toast. There was a sense of meaninglessness in me. For this reason, I applied to the polyclinic and they made my admission.”

When the clinical mental state is evaluated, reluctance, loss of appetite, sleep problems, fluctuations in mood, and malaise are in the foreground. Undernutrition, problems in sleep pattern, deterioration in hygiene due to daily disposable catheter used due to neurogenic bladder and risk of infection, social isolation, sedentary lifestyle were determined as nursing problems at the first stage.

APPLICATION

In this study, the Perceived Stress Scale adapted to Turkish by Bilge, Öğce, Genç, and Oran (2007) before starting the interviews with Ms. B, and the Warwick-Edinburg Mental Well-Being Scale adapted to Turkish by Keldal (2015) and Gençdoğan (2001).) Zung Depression Scale and Brief Psychiatric Rating Scale adapted into Turkish were applied. The scales were repeated monthly to evaluate the effectiveness of the training, homework and practices given during the interview process. A total of 16 sessions of individually structured interviews, including 10 sessions during hospitalization and 6 sessions after discharge, were conducted once a week for 4 months, and the case formulation technique of cognitive behavioral therapy was applied. The application of the study was carried out by the first author, who had basic level CBT training and also the title of Specialist Psychiatric Nursing, under the supervision of the second author.

Distribution of psychoeducational topics applied in the research

Results

Findings of the scales used during the interviews

The results of the patient's Zung Depression Scale, Perceived Stress Scale, Warwick-Edinburg Mental Well-Being Scale and Brief Psychiatric Rating Scale, which were used before the interviews and at 1-month intervals, are given in Table 1.

Table 1. Findings of the scales used during the interviews

A total of 16 sessions, 10 sessions before the patient's discharge and 6 sessions after discharge, were conducted. As a result of the negotiations, A decrease was observed in the scores of the patient from the scales. In these interviews, techniques such as verbal feedback, stress management chart, activity and future plans, homework, relaxation exercises, pain management, behavior charts were included. Healthy coping methods were taught, skills were taught, participation in group activities and socialization were supported, and developmental stages in this regard were followed one by one.

Findings of the cognitive behavioral case formulation

The verbal expressions of the patient in the interviews were analyzed with qualitative methods, the main themes were determined, and these main themes were taken into account and transferred to the cognitive behavioral case formulation chart. However, the case formulation is shown in 2 ways in itself. These are given in Figure 1 and Figure 2 as behavioral and cognitive conceptualization formulations. source)

Figure 2. Cognitive Conceptualization Formulation

Argument

The prevalence and burden of depression requires the use of effective and accessible treatment methods. In chronic depression, it is very important to plan the interview processes in this direction by analyzing the problems and needs of the patient with a holistic perspective and to achieve success in therapy. It was observed that Ms. B used the symptoms of depression to get family support and hospitalization and turned this into secondary gain over time. However, her unwillingness to be hospitalized anymore, with the active participation of the patient in the individually planned structured interviews, taking into account her readiness for treatment and her priorities in the next stages, helped her to support her independence, ensure social adaptation, and acquire healthy coping skills. After the 6th session, she started to participate in the interviews more actively and to research what she really wanted to change in her life and what she should do about it, and her belief that she would never recover was broken at this point. Similarly, in case reports reporting cooperation in treatment in our country, positive progress has been reported in treatment (Coşkun, 2019; Ateş & Arcan, 2018). In studies conducted abroad, it has been stated that the use of cognitive behavioral approach is effective in reducing the problems related to the disease and increasing their coping skills (Conklin, ve diğerleri, 2019; Wesner, ve diğerleri, 2019). Ms. B was given a chart on stress management, and she was asked to record the stressful situations, her reactions to these situations, her current thinking and alternative reactions, so that the person could gain her own acquisition in the face of stress. The case developed new coping methods by noticing in which situations she experienced stress by following all the given instructions.

When the other studies in which the cognitive behavioral approach was used in the treatment of depression were examined, it was seen that there was information about positive results in the treatment. In a study conducted in Japan by Tanoue et al. (2018), it was emphasized that the cognitive and behavioral approach led by trained nurses achieved a positive treatment outcome for individuals with major depression in the clinical setting (Tanoue, ve diğerleri, 2018). In the study of Shulman et al. (2018), it was stated that cognitive behavioral therapy is an adjunctive treatment method for postpartum depression and anxiety. After the discussions on Ms. B's ineffective coping methods, healthy gains were achieved in this regard. Similarly, in the study conducted by Yüksekdurmaz and Öz (2016), it was stated that the cognitive behavioral group counseling program had positive results on interpersonal sensitivity, coping and automatic thoughts (Hiçdurmaz & Öz, 2016).

The presence of Ms. B's chronic pain was one of the triggering factors for depression. As a result of the interviews, pain management was achieved with a cognitive behavioral approach, relaxation techniques were taught and negative emotions caused by the feeling of pain were tried to be eliminated . Similarly, in a study conducted by Rutledge et al. (2018), it was emphasized that the supportive cognitive-behavioral approach they apply to chronic pain, provided by nurses, has a healing effect on pain management (Rutledge, ve diğerleri, 2018).

Conclusion and Recommendations

In chronic depressive illness, an effective medical and rehabilitation process is required to prevent exacerbations and to ensure quality of life. As a result of 16 sessions, it was learned that the doses of drugs he had used for depression for the last 8 months decreased, he had a social environment and did not have any problems in his work life, and his pain was not as painful as before. The formulation of the cognitive behavioral approach has shown a guiding map feature in identifying the problem in structured interviews. Formulating in this way and creating a concept map not only ensures that the problems are taken into account, but also reveals the causes of the problems and where to work with the patient. With the inclusion of this practice in psychiatric nursing care plans, it is thought that the cognitive processes underlying the behaviors will be noticed and it will be an effective guide focused on problem solving.

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