The Ultimate Guide to a Care Plan for Depression

Depression is a serious mood disorder that can affect all areas of life, and it is tough to navigate through the sadness and feelings of worthlessness that seems to overtake a person’s daily activities. In many cases, a person can’t win the fight against depression alone. A person needs the help of mental health professionals to beat this illness. One of the most lethal weapons a mental health professional can use against depression is a care plan.

In many of the cases, medical health professionals create a customized care plan with the patient as a way to treat the health condition. The care plan identifies the patient’s needs and provides a holistic treatment plan of the best way to improve the patient’s condition.

The History of the Care Plan

Actually, the nurses, who are usually the ones to see the patient before the doctor, are the ones who create the nursing care plans. In fact, it was a nurse, Ida Jean Orlanda, who began the process that still instructs today’s mental health professionals.

The mental health professionals meet with the patient and talk to him or her to determine what is the best way to proceed with the treatment. The nurses, and the other medical experts on the patient’s team, use the care plan as a tool to help improve the patient’s physical, psychological, social, and spiritual care.

Steps to Creating a Care Plan

When creating the care plan, medical providers follow five steps to guarantee the care plan has covered all of the vital criteria to ensure accurate communication for all those who will be using the care plan. Those steps are the:

The Assessment: The first step in writing an efficient and flawless care plan is to conduct a detailed assessment (or evaluation) with the patient. It is during this stage that the nurse, or other medical health professionals talks to the patient to help determine what the patient needs. Some of the data the nurses gather could include information about the patient’s vital signs, physical complaints, visible body conditions, medical history, and neurobehavior.
Diagnosis: The health provider will use all of the information that has been collected to develop a diagnosis. NANDA International, the organization which develops, maintains, and promotes a standardized language for nursing diagnoses, defines a diagnosis as “a clinical judgment about the human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.” The diagnosis helps the mental health provider to determine what actions to take to achieve the patient’s desired outcome.
Outcomes and Planning: During this step, the health care provider prepares patient-specific, desired goals for the patient. These goals (which include long-term and short-term outcomes) are based on the patient’s overall condition, diagnosis, and any other relevant information. Each goal should be a realistic outcome that the patient knows he or she can achieve.
Implementation: With the goals in place, the health provider can determine what actions the patient needs to take in order to achieve the goals. These tasks are the actions the mental health professionals need to take, such as making sure the mental health provider is meeting with the patient on a consistent basis.
Evaluation: In this final step, a mental health professional will assess and determine if the desired outcome has been met. Based on the outcome, the mental health provider will adjust the care plan.

What Sections Are in a Care Plan?

The care plan also consists of six major sections, which includes:

Testing & Evaluation: All of the testing and evaluation results completed prior to the diagnosis the patient received.
Diagnosis: For this section, the mental health professionals will use the Diagnostic and Statistical Manual of Mental Illnesses (DSM) to help with diagnosing the mental health condition. The DSM is a reference manual of mental disorders and the American Psychiatric Association is responsible for the creation and publication of this book. The most recent version of this guide, known as the DSM-F-TR, was published in 2022.
Assessment Evidence The symptoms which led to the diagnosis, and the frequency and the duration of the symptoms.
Related Diagnoses: All other, related diagnoses which could result from the same symptoms as depression. Examples of such diagnoses could include impaired social interaction, body dysmorphic disorder, and internal or situational loneliness.
Outcomes: The patient’s desired outcome. For instance, a patient may say he or she wants to be able to feel happiness. Another patient may want the energy to complete daily tasks.
Plan of action: The steps the patient plans on taking (such as participating in routine therapy or taking the time to participate in social activities) to achieve the desired outcome.
Miscellaneous: There are other pieces of information that are included in the care plan too, such as the medication and the dosages the patient is receiving, the contact information of the health care providers, and the health insurance information.

To see an example of such a care plan, click here.

What Else Does a Care Plan Need?

The best care plan includes looking for information from a variety of resources. In many instances, the patient may not have all of the answers. A person, with depression, doesn’t always have a good memory of what’s happened, and may forget some important points, such as the symptoms he or she has had or the medications he or she has been taking. Therefore, the best medical professionals reach out to family members (with the patient’s permission) and past primary care and mental health providers to get a better understanding of the situation.

It’s also necessary to update the care plan at least once a year, because there might be treatment changes. For instance, the patient may need to take a different dosage of medication or the kind of medication may have changed too.

Care Plans for Depression

Now that we’ve gone over what a general care plan looks like. Let’s discuss a care plan that concentrates on a patient who has depression.

Diagnosis

The diagnosis made in the care plan is based on the patient’s history and the answers the health provider receives when talking to the patient and the patient’s family and/or friends (again, the health care provider must receive permission from the patient to talk to others.)

In addition, the health provider will also look at laboratory results to determine if the patient has depression, because the results could exclude other medical illnesses which may have similar symptoms as depression. The information collected from a laboratory study can include (but not limited to):

Complete blood cell count
Vitamin B-12
HIV test
Blood alcohol level
Blood and urine toxicology screen

After looking at the lab results and coming up with a diagnosis, mental health professionals have a few options to consider when deciding how to treat the patient. For instance, a psychiatrist may look at different medications the patient can take. A therapist can also provide psychotherapy. A combination of medications and psychotherapy may be the best way to treat a major depressive disorder.

Medical Management

Besides the behavior and social actions a patient may take, such as seeing a therapist, developing a daily routine or joining support groups, medication can also relieve depression. Some of the medications a psychiatrist may prescribe include:

Selective serotonin norepinephrine reuptake inhibitors (SNRIs)
Selective serotonin reuptake inhibitors (SSRIs)
Atypical antidepressants
Tricyclic antidepressants
Monamine oxidase inhibitors (MAOIs)

SNRIs are a popular class of medication used to help those with depression. They help relieve depression by influencing chemical messengers (called neurotransmitters) which affect a patient’s mood.SNRIs block the reabsorption of two neurotransmitters in the brain, serotonin and norepinephrine. By blocking the reabsorption, more serotonin and norepinephrine are available to ease symptoms of depression. However, before being prescribed these medications, it’s vital to inform the doctor of other medications, herbs, or supplements being taken to avoid any dangerous reactions.

Psychotherapy

Psychotherapy (also known as talk therapy) is a type of treatment, which uses multiple treatment techniques, which can help patients who are experiencing a wide range of mental health illnesses and emotional challenges. Some popular forms of psychotherapy include Cognitive-behavioral therapy (CBT) and Interpersonal Therapy (IPT).

CBT helps patients discover thinking patterns they’re using which is creating numerous challenges in their lives. The goal is to target these thinking patterns and learn different coping skills to replace the negative thoughts with newer, positive thinking patterns that can change the patient’s perspective on different issues, providing them with a sunnier outlook on their situation.

IPT focuses on having patients improve their relationships with others as a way to relieve depression. The therapist will work with patients, who have major depression, to better understand a patient’s emotions and how these emotions are impacting the patient’s relationships. Furthermore, the patient learns how to lean on loved ones for support.

Risk Factor: Suicide

A risk factor that plays an important role in what the care plan will look like is whether the patient has had previous suicide attempts, suicidal behavior, or had thought of a suicide plan. Patients, without a strong support system, which includes family members and friends, have stronger suicidal tendencies.

Doctors would consider a patient who has a history of attempting suicide, planning suicide, or experiencing suicidal ideation, a high-risk patient, and will likely recommend a hospital stay with higher-than-average supervision. Meanwhile, low-risk patients may have home care for depression, where they can have the support of their family and friends.

Benefits of a Care Plan

The care plan is beneficial, because it provides a guide for the patient about the treatment needed to improve his or her illness. But there are so many other benefits a care plan provides. A top benefit is the care plan also assists the home caregiver in knowing to provide the best services for the individual. That’s a great advantage, because 34.2 million of American adults are caring for someone who is 50 years old or older.

Other benefits include:

Reducing the number of emergency room visits and hospitalizations.
They can help with the patient’s overall medical management.
All of the important information can be found in one place, the care plan.
The care plan helps ensure the patient’s needs are being met.
The care plan also ensures the patient is receiving consistent and proper care during caregiving-transitioning-periods.

Most importantly, the care plan is a way to make sure the patient does not feel overwhelmed. The patient knows there’s a team of medical professionals, family, and friends who are working with him and her to get better and are supporting every action that is taken. In addition, the patient discovers that small steps can be taken, one day at a time, to get better. It’s a process. But it’s achievable.