Depression & Anxiety

Understanding Depression and Anxiety in Care Settings

Depression and anxiety are among the most common mental health conditions encountered in long-term care and hospital settings. For the Certified Nursing Assistant (CNA), understanding these disorders is critical because they affect a patient’s ability to participate in activities of daily living (ADLs), respond to treatment, and maintain social connections. Untreated depression and anxiety can worsen physical health outcomes and increase mortality risk.^[1] This guide focuses on what CNAs must know to recognize symptoms, provide supportive care, and maintain safety while respecting the patient’s dignity.

Core Mental Health Terms for Nursing Assistants

• Depression: A mood disorder characterized by persistent sadness, loss of interest or pleasure in activities, and a lack of energy lasting at least two weeks.^[2] In older adults, depression may present with physical complaints (e.g., pain, fatigue) rather than sadness.
• Anxiety: An excessive, uncontrollable worry or fear that is out of proportion to the actual threat. It can manifest as restlessness, muscle tension, racing heart, or avoidance of certain activities.^[3]
• Agitation: A state of restlessness, irritability, or emotional distress often seen in patients with anxiety or depression, especially in dementia-related conditions.
• Psychosocial care: Interventions that address emotional, social, and mental needs, such as active listening, validation, and providing meaningful activities.
• Suicidal ideation: Thoughts about self-harm or ending one’s life. CNAs must report any verbal or behavioral cues immediately to the nurse.

The CNA's Role and Common Anxiety Triggers

The CNA’s Role in Mental Health Care

1. Observe and report: Notice changes in mood, appetite, sleep, or social withdrawal.^[4]
2. Provide emotional support: Use a calm, reassuring voice; allow the patient to express feelings without judgment.
3. Encourage independence: Promote self-care to enhance self-esteem, but be patient if the patient moves slowly.
4. Maintain routine: Consistent schedules for meals, hygiene, and activities help reduce anxiety and support stability.
5. Redirect negative thoughts: Gently guide the patient toward positive topics or simple tasks.

Common Triggers for Anxiety in Healthcare Settings

• Pain or discomfort
• Fear of falls or medical procedures
• Loss of control over daily decisions
• Unfamiliar environment or staff
• Side effects of medications (e.g., steroids may increase anxiety)

Observable Signs of Depression and Anxiety

Depression (in older adults and general medical patients)

• Persistent sadness, tearfulness, or emptiness
• Loss of interest in hobbies or social activities (anhedonia)^[2]
• Changes in appetite (usually decreased) or weight loss/gain
• Sleep disturbances: insomnia (especially early morning awakening) or oversleeping
• Fatigue, low energy, slowed movements
• Feelings of worthlessness, hopelessness, or guilt
• Difficulty concentrating or making decisions
• Physical complaints such as headache, back pain, or digestive issues
• Social withdrawal and refusal to participate in activities

Anxiety Disorders (including Generalized Anxiety Disorder and Panic)

• Excessive worry about daily events (health, family, finances)
• Restlessness or feeling “on edge”
• Fatigue after minimal activity
• Muscle tension, trembling, headaches
• Racing heart (palpitations), shortness of breath, chest tightness^[3]
• Dizziness, sweating, hot flashes, or chills
• Avoidance of situations that cause fear (refusing to leave room, refusing care)
• Irritability or sudden anger outbursts

Screening Tools and Observation for CNAs

Note for CNAs: CNAs do not diagnose, but they are the frontline observers. The following tools and assessments are used by nurses and other licensed professionals. CNAs contribute by documenting accurate observations.

• PHQ-9: A 9-item depression screening tool often used in long-term care. The CNA may be asked to note patient responses to questions.
• GAD-7: A 7-item scale for generalized anxiety disorder.
• Behavioral monitoring: Track frequency of crying, pacing, repetitive questioning, or refusal of care.
• Pain assessment: Undiagnosed pain can mimic or worsen depression and anxiety. Use a standard pain scale.
• Medication review: Some drugs (beta-blockers, steroids, benzodiazepines) can cause or worsen depression or anxiety. Report any changes to the nurse.

Therapeutic Interventions and Medication Considerations

Non-Pharmacological Interventions (CNA Level)

• Active listening: Sit at eye level, maintain open body language, and allow the patient to talk without interruption.
• Validation therapy: Acknowledge the patient’s feelings (e.g., “It sounds like you’re feeling very sad today.”). Avoid false reassurance like “Don’t worry.”
• Activity engagement: Offer simple, meaningful tasks (folding towels, watering plants) to reduce helplessness.
• Physical activity: Assist with walking or chair exercises as ordered; exercise boosts endorphins and reduces anxiety.
• Relaxation techniques: Guided breathing, slow counting, or quiet music during care.
• Sleep hygiene: Offer warm milk, reduce noise, ensure comfort, keep room dim at night.^[1]

Pharmacological Considerations (Know for Exams)

• Antidepressants: SSRIs (e.g., sertraline, citalopram) are first-line. Side effects include nausea, sexual dysfunction, and insomnia. CNAs should note if patient refuses medication or experiences increased agitation.
• Anxiolytics: Benzodiazepines (e.g., lorazepam) may be used short-term; risk of dependence and falls. Monitor for drowsiness and confusion.
• Antipsychotics: Sometimes used for severe agitation, but associated with extrapyramidal symptoms and increased risk of falls.
• CNA action: Report any odd behavior, rash, or difficulty moving to the nurse immediately.

Safety Risks and Complications in Mental Health Care

• Suicide risk: Statements like “I’d be better off dead” or “I don’t want to wake up” are emergencies. Stay with the patient and notify the nurse immediately. Do not leave them alone.^[4]
• Fall prevention: Anxiety and depression can cause dizziness, muscle weakness, or restlessness. Ensure call light is within reach, keep pathways clear, and use gait belts if needed.
• Medication noncompliance: Patients may hide pills or spit them out. Observe and report to the nurse.
• Malnutrition or dehydration: Depression often reduces appetite. Offer favorite foods, small frequent meals, or supplement drinks.
• Wandering: Restlessness in anxiety may lead to exit-seeking behavior. Alert the team and use redirection.
• Self-neglect: Poor hygiene, refusal of baths, or not changing clothes. Encourage gently and provide choices (“Would you like a sponge bath now or after breakfast?”).

Exam-Focused Guidance for CNAs on Mental Health

• Remember the CNA scope of practice: You do not diagnose, prescribe, or provide counseling. You do observe, support, and report.
• Report changes quickly: Sudden withdrawal, crying, agitation, or comments about death are critical to communicate.
• Use therapeutic communication: Use open-ended questions (“Tell me how you’re feeling today”) rather than “Are you depressed?”
• Be mindful of stigma: Avoid labeling patients (“she’s crazy”). Use person-first language: “a patient with depression.”
• Know the “trifecta” of depression in older adults:
• Weight loss
• Sleep disturbance (early morning awakening)
• Pain complaints without clear cause
• Memory aid for signs of anxiety: “Anxious Patient Presents – Palpitations, Pacing, Panic, and Problems sleeping.”
• Safety first: For any patient with suicidal ideation, the CNA must stay with the patient and call for help. Never leave them alone.
• Comorbidity: Depression and anxiety often occur together; they also frequently accompany dementia, chronic pain, heart disease, and cancer.

References & Sources

1. Hegde S, Vidyarthi R. Better health through healthy partnerships: a CNA's guide to mental health. National Association of Health Care Assistants. 2019. Available at: https://www.cna-aiic.ca/en/policy-advocacy/advocacy-priorities/mental-health
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). 2013. doi: 10.1176/appi.books.9780890425596
3. National Institute of Mental Health. “Anxiety Disorders.” 2023. https://www.nimh.nih.gov/health/topics/anxiety-disorders
4. Sorrentino SA, Remmert LN. Mosby's Textbook for Nursing Assistants. 10th ed. Elsevier; 2020. Chapter 25: Mental Health and Social Services. ISBN: 978-0-323-65520-7. https://inspectioncopy.elsevier.com/book/details/9780323655606