9.3 Depression, Substance Use Disorders & Alcohol Withdrawal
Key Takeaways
Major depression requires low mood or anhedonia for at least 2 weeks, and any positive self-harm response needs a same-day suicide risk assessment.
SSRIs take 2–4 weeks to start working, and suicide risk may rise early in treatment as energy returns before mood improves.
Alcohol withdrawal seizures typically occur at 12–48 hours and delirium tremens at 48–96 hours after the last drink.
Thiamine is given before glucose to people with alcohol dependence to prevent Wernicke's encephalopathy.
Naloxone reverses opioid overdose but may wear off before the opioid does, so monitoring must continue after it is given.
Depression, Substance Use Disorders and Alcohol Withdrawal
Psychosocial and psychiatric disorders, including substance abuse, stress, suicide and psychoses, appear in every adult age band of the CARICOM Blueprint. Section 9.2 covers the mental status examination, mania, psychosis, antipsychotics and restraint. This section covers depression and substance use, two conditions every RN meets on general wards as well as in mental health units.
Depression
Major depression means low mood and/or loss of interest or pleasure (anhedonia) for at least 2 weeks, with other symptoms such as:
- sleep and appetite change;
- fatigue;
- poor concentration;
- psychomotor slowing or agitation;
- worthlessness or guilt; and
- thoughts of death or suicide.
Depression is common in people with chronic illnesses such as diabetes, stroke, HIV and cancer, and it worsens their outcomes.
- Screening: the PHQ-2 (two core questions) and PHQ-9. PHQ-9 scores of about 5, 10, 15 and 20 mark mild, moderate, moderately severe and severe depression. Any positive answer on the self-harm item needs a same-day suicide risk assessment (Section 9.2).
- Grief versus depression: grief comes in waves linked to the loss, with self-esteem preserved. Depression brings pervasive emptiness and worthlessness.
- Older adults may present with memory complaints ("pseudodementia") rather than sadness (Section 9.4).
Nursing Care
- Build a therapeutic relationship and spend short, frequent periods with the client.
- Encourage small achievable activities.
- Monitor nutrition, hydration, sleep and hygiene.
- Ask directly about suicidal thoughts, and keep the environment safe.
Antidepressants
- SSRIs (fluoxetine, sertraline) are first-line. Benefit starts after 2–4 weeks, with full effect after 6–8 weeks. Common early effects are nausea, headache and insomnia; sexual dysfunction may persist.
- Suicide risk may rise in the early weeks as energy improves before mood does, especially in young people. Watch closely and limit the quantity of medicine supplied.
- Do not stop suddenly, because of discontinuation symptoms. Taper with the prescriber.
- Tricyclic antidepressants (for example amitriptyline) are dangerous in overdose because of arrhythmias and seizures.
- Serotonin syndrome (agitation, clonus, fever) can occur with combinations (Section 9.2).
- Electroconvulsive therapy may be used for severe or psychotic depression. Care includes consent, fasting, and post-procedure monitoring of airway, orientation and temporary memory loss.
Perinatal Mood
| Condition | Timing | Features | Action |
|---|---|---|---|
| "Baby blues" | Days 3–5, resolves within about 2 weeks | Tearfulness, mood swings | Reassure, support, monitor |
| Postpartum depression | Persists beyond 2 weeks, within the first year | Depressive symptoms, difficulty bonding | Screen (for example the Edinburgh Postnatal Depression Scale), refer, treat |
| Postpartum psychosis | Usually within the first weeks | Confusion, hallucinations, delusions | Emergency: risk to mother and baby; urgent psychiatric care |
Substance Use Disorders
Approach
Use non-judgemental, person-first language ("a person who uses alcohol"). Screen with validated tools: AUDIT or CAGE for alcohol (CAGE asks about Cutting down, Annoyance, Guilt and Eye-openers). Use SBIRT: screening, a brief intervention using motivational interviewing (Section 3.4), and referral to treatment. In Jamaica, the National Council on Drug Abuse leads prevention and treatment referral. Common defence mechanisms include denial and rationalisation. Gently confront these with facts, but do not argue.
Alcohol Withdrawal: Timeline and Care
| Time since last drink | Features |
|---|---|
| 6–24 hours | Tremor, anxiety, sweating, nausea, tachycardia, insomnia |
| 12–48 hours | Withdrawal seizures (generalised) |
| 48–96 hours | Delirium tremens: confusion, hallucinations (often visual or tactile), fever, autonomic instability. It can be fatal |
Care:
- Assess regularly with the CIWA-Ar scale. Symptom-triggered benzodiazepines (for example chlordiazepoxide, diazepam or lorazepam) are given according to the protocol score.
- Give thiamine before glucose. Glucose given first to a thiamine-deficient person can precipitate Wernicke's encephalopathy (confusion, ataxia and eye-movement abnormalities). Untreated, it can progress to Korsakoff syndrome (memory loss and confabulation).
- Provide a quiet, well-lit room, orientation, hydration, nutrition, seizure precautions and fall prevention.
- Disulfiram causes flushing, vomiting and palpitations if alcohol is taken, including alcohol in mouthwash or cough syrups.
Cannabis (Ganja)
Jamaica amended its Dangerous Drugs Act in 2015. Possession of 2 ounces or less became a ticketable minor offence rather than a criminal one, and a licensing framework for medical cannabis was created. Decriminalisation does not mean the drug is harmless. Health risks include:
- cannabis-induced psychosis and worsening of schizophrenia;
- effects on adolescent memory and learning;
- impaired driving; and
- cannabinoid hyperemesis syndrome: recurrent severe vomiting that clients often relieve with hot showers, and which resolves only when they stop using.
Stimulants (Cocaine, Crack)
Stimulants cause agitation, hypertension, tachycardia, hyperthermia, chest pain (myocardial ischaemia) and seizures. Management is supportive with benzodiazepines for agitation, plus cooling and cardiac monitoring.
Opioid Overdose
The signs are pinpoint pupils, respiratory depression and reduced consciousness:
- support ventilation with a bag-valve-mask;
- give naloxone (IV, IM or intranasal) and repeat as needed; and
- keep monitoring, because naloxone wears off sooner than many opioids and sedation can return.
Dual Diagnosis and Recovery
Mental illness and substance use often occur together, so treat both. Recovery involves relapse-prevention planning, peer support (for example Alcoholics Anonymous), family involvement and harm reduction.
A client admitted for a fractured femur had his last drink of rum 36 hours ago. He becomes tremulous and sweaty, then has a generalised seizure. What does this most likely represent?
Wernicke's encephalopathy from thiamine deficiency
An alcohol withdrawal seizure, typical at 12–48 hours
Delirium tremens, which typically begins in the first 6 hours
Korsakoff syndrome
A confused, malnourished client with long-term alcohol dependence is admitted. Capillary glucose is 3.2 mmol/L. The medical officer prescribes IV thiamine and IV dextrose. What is the correct order?
Dextrose only; thiamine is not needed if the client can eat
Thiamine only; dextrose is contraindicated in alcohol dependence
Dextrose first, then thiamine 24 hours later
Thiamine first, then dextrose without delay
Ten days after starting sertraline for severe depression, a client seems more energetic and is suddenly calm and giving away belongings. What should the nurse do?
Document that the medication is working and reduce the level of observation
Encourage the client to plan a weekend pass home with the family
Ask directly about suicide and increase observation
Tell the client the medicine will now work fully
A client was given naloxone for an opioid overdose 20 minutes ago and is now awake and asking to leave. Why should the nurse continue close monitoring?
Naloxone causes rebound hypoglycaemia that appears about an hour after the dose
Naloxone can wear off before the opioid does, so sedation may return
Naloxone commonly causes delayed allergic reactions after the first hour
The client must stay until a urine drug screen is negative
Sections you finish are checked off in the contents.