Mosby's Pocketbook of Mental Health [2 ed.] 9780729582247, 9780729541909

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Mosby

is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067

This edition © 2014 Elsevier Australia. First edition published 2010 eISBN: 9780729582247 This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation. This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication. National Library of Australia Cataloguing-in-Publication Data Muir-Cochrane, Eimear Mosby’s pocketbook of mental health / Eimear Muir-Cochrane, Patricia Barkway, Debra Nizette. 2nd edition 9780729541909 (paperback) Includes index. Mental health–Handbooks, manuals, etc. 616.89 Content Strategist: Libby Houston Content Development Specialist: Vicky Spichopoulos Project manager: Anitha Rajarathnam Edited by Matt Davies Proofread by Tim Learner Cover and internal design by Lisa Petroff Index by Robert Swanson Typeset by Toppan Best-set Premedia Limited Printed in China by 1010 Printing Int’l Ltd.

Foreword I am delighted to provide the foreword to the 2nd edition of Mosby’s Pocketbook of Mental Health. In the day-to-day work of health, public health and other human services, mental health care is an increasingly important component of care. As identified by the World Health Organization over a decade ago, mental health is everyone’s business and people with mental health problems now access and receive assistance from specialist services as well as welfare services and non-governmental organisations. Mosby’s Pocketbook of Mental Health continues to be a versatile, one-stop reference text specifically targeted at Australian and New Zealand health and nursing students, paramedics, teachers and social and human services workers. This quick reference guide to clinical practice captures the core elements of mental health care including: the context of mental health care; clinical signs and interventions; medications; co-occurring disorders; and legal and ethical issues. Recovery is a foundational approach to the text, fulfilling the need to provide consumer-focused care. The second edition has been thoroughly updated. It also features a new opening chapter, Mental health: every health professional’s business, which focuses on the incidence of mental illness in the community and provides strategies for addressing what is clearly a significant societal need. Importantly, Chapter 3 includes the recently updated national practice standards for the mental health workforce and there is a new Appendix 2 covering who does what in mental health. I had the pleasure of launching the first edition of this text at the NETNEP International Nurse Education Conference in Sydney in 2010. I can confirm that this text is what is says it is: a highly informative pocketbook written by experts in the field. As such the format of the pocketbook facilitates a wide range of health and other professionals and students to access current research evidence and best practice wherever they are working or studying. Professor Patrick Crookes PhD, BSc(Nurs), RN, CertEd, MACN

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Contents Foreword



v

Preface



ix

Authors and reviewers

xi

Chapter 1

Mental health: every health professional’s business

1

Chapter 2

Working in a recovery framework

9

Chapter 3

Essentials for mental health practice

21

Chapter 4

Mental health assessment

32

Chapter 5

Culture and mental health

47

Chapter 6

An overview of mental illness

59

Chapter 7

Psychiatric and associated emergencies

83

Chapter 8

Managing medications

98

Chapter 9

Contemporary talking therapies

116

Chapter 10

Co-occurring medical problems

121

Chapter 11

Loss and grief

128

Chapter 12

Law and ethics

140

Chapter 13

Settings for mental health care

148

Appendix 1 Surviving clinical placement!

158

Appendix 2 Who does what in mental health?

160

Appendix 3 Working with people with challenging behaviours

162

Appendix 4 Prescription abbreviations

164

Appendix 5 Top tips for people taking psychiatric medication

166

Appendix 6 Mental health terminology

168

Further reading and resources

190

Index

193





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Preface

Approximately 450 million people worldwide have a mental health problem, with one in four people experiencing some kind of mental health issue in the course of a year. Following the reform of mental health services, including mainstreaming and the delivery of care within a recovery framework, all health workers now need a range of mental health skills and knowledge in order to practise effectively in their work with mental health consumers and their carers/families. This handy, readable text is intended to provide easy access to immediate advice for a range of health professionals and workers, including general nurses, general practitioners, paramedics, police, mental health workers, drug and alcohol workers and allied health professionals who encounter people with mental health problems in their daily work. This text will also be useful for mental health support workers and those in consumer care roles. We have endeavoured to distil the core elements of engaging and working with people with mental health problems into practical skills and approaches that can be applied to a range of settings for care. This second edition has been thoroughly updated to provide the latest evidence about mental health care and also includes a new chapter on the extent of mental health as a problem worldwide. At the core of mental health practice is a focus on social inclusion and recovery, culture and respect for and promotion of consumer rights in mental health care. Accordingly, we have included chapters that reflect these foci and associated ‘hands on’ strategies. We have used text boxes to provide practical tips about what to do in commonly encountered situations. Do and don’t sections give handy, practical quick guides for practice. Revised and extended appendices serve as an aide mémoire or checklist for quick reference in relation to, among other things, working with consumers with challenging behaviours, tips regarding undertaking a successful work placement and guidance about taking psychiatric medications. We have included extensive web-based resources to provide the latest bibliography of reliable electronic resources for ease of access. In writing this book we set out to ‘cut to the core’ in terms of what practical, doable and helpful strategies would be of use to health ix

PREFACE

professionals who don’t have formal mental health qualifications. We think this is what we have achieved and trust readers will find this book to be a practical and useful adjunct to their professional practice. Eimear Muir-Cochrane Patricia Barkway Debra Nizette

x

Authors and reviewers Authors Eimear Muir-Cochrane BSc(Hons), RN, CMHN, GradDip—Adult Ed, MNS, PhD, FACMHN, MACN Professor and Chair of Nursing (Mental Health), School of Nursing and Midwifery, Flinders University, South Australia Patricia Barkway RN, CMHN, FACMHN, BA (Psychology/Education), MSc(PHC) Senior Lecturer, School of Nursing and Midwifery, Flinders University, South Australia Debra Nizette RN, CMHN, FACN, FACMHN, DipAppSc—Nurse Ed, BAppSc—Nursing, MNSt Assistant Director of Nursing, Nursing and Midwifery Office, Queensland Health, Queensland

Reviewers Gayelene Boardman PhD, MHSc, GDip AppSc, RN Discipline Leader, Mental Health, Victoria University, Victoria Sherphard Chidarikire RN, BHlth(Nurs), MN(Nurse Pract) Lecturer and PhD candidate, School of Health Sciences, University of Tasmania, Tasmania Sally Drummond RN, CMHN, BN, MNP Lecturer in Nursing/Mental Health, School of Nursing Midwifery and Indigenous Health, Charles Sturt University, New South Wales Paula Duffy Cert IV WPAT, Cert IV D&A, RPN, BN GDipAdvClinNrsg, MH, MPET Mental Health Lecturer, Australian Catholic University, Victoria Kate Emond RN, BN, PGDip MentalHlth, MN Postgraduate Mental Health Course Coordinator, Faculty of Health Sciences, La Trobe Rural Health School, Department of Rural Nursing and Midwifery, Victoria Cindy Hoswell RN, BN, GCMH Lecturer in Nursing, School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, New South Wales; Nurse Unit Manager, Community Mental Health Drug and Alcohol, Western NSW Local Health District xi

AUTHORS AND REVIEWERS

Mairwen Jones BA(Psych), PhD Clinic Head, The University of Sydney Anxiety Disorders Clinic, Senior Lecturer in Psychology, The University of Sydney, New South Wales Elijah Marangu RN, MPH Lecturer, School of Nursing and Midwifery, Deakin University, Victoria Phil Maude RN, PhD, FACMHN A/Professor Mental Health and Addictions Programs, RMIT University School of Health Sciences, Victoria Anthony J O’Brien RN, BA, MPhil(Hons), FNZCMHN Senior Lecturer School of Nursing and Centre for Mental Health Research, Faculty of Medical and Health Sciences, The University of Auckland; Nurse Specialist (Liaison Psychiatry), Auckland District Health Board Eddie Robinson RN, MHN, MNursing, GrdCertHlth, ProfEd (GCHPE) Mental Health Nursing Lecturer, Monash University, Victoria Alasdair Williamson RN (RMN UK), MSc (Public Health), PGCert (HlthSci) Senior Lecturer, Faculty of Health Science, Eastern Institute of Technology, Hawke’s Bay, New Zealand Sue Willis RN, BN, GradDip—Adult Ed, ACMHN Associate Lecturer, University of Western Sydney, New South Wales

xii

CHAPTER

1

 

Mental health: every health professional’s business

Introduction

A decade ago the World Health Organization (WHO) made two statements that have been embraced by policymakers as core principles of worldwide mental health plans (NHS Mental Health Strategy Branch 2012, New Zealand Mental Health Commission 2012, WHO 2013). They are that there is no health without mental health and that mental health is everybody’s business (WHO 2004). WHO (2011) defines mental health as: … a state of well-being in which in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.

Mental illness, however, is defined as the presence of cognitive, affective and/or behavioural symptoms that are persistent, pervasive and impair the individual’s functioning. The Fourth Australian National Mental Health Plan (Australian Health Ministers 2009 p 84) states that mental illness is: A clinically diagnosable disorder that significantly interferes with an individual’s cognitive, emotional or social abilities. The diagnosis of mental illness is generally made according to the classification systems of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD).

Mental health is integral to health and wellbeing, yet throughout the world mental illness remains a significant health, social and human rights concern, and the burden is growing (WHO 2013). Furthermore, living with a mental illness is also associated with poorer physical health and shortened life expectancy, while living with a chronic physical condition increases the risk for mental health problems (National Mental Health Commission 2012a, b). In other words the disadvantage works both ways. 1

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

This chapter presents statistics on the incidence of mental illness in the community and recommends strategies to address the needs of people experiencing mental health problems.

The extent of mental illness in the community

At any one time it is estimated that 20% of the adult Australian population and 15% of young people have a mental illness (Australian Bureau of Statistics (ABS) 2013, Slade et al 2009). If you add to these figures the unknown, but presumably significant, proportion of the population who are experiencing mental health problems, it is clear that mental health and illness are issues of major concern for the community in general and, in particular, for governments, health care services, non-government organisations, families, carers, friends and those people who are living with a mental illness. Every 10 years the Australian Government surveys the mental health of the nation (ABS 1998, 2013, Slade et al 2009). Table 1.1 summarises the key findings of the most recent survey. Based on these prevalence rates, it is estimated that over a 12-month period more than three million Australians will be diagnosed with a mental disorder, nearly one million will be diagnosed with affective disorders, more than 2.3 million will have anxiety disorders and more than 800,000 will have substance use disorders. These findings are similar to other international statistics for developed nations (Mental Health Foundation of New Zealand 2011). The survey also found that social TABLE 1.1  Key findings of the 2007 Australian mental health and wellbeing survey Incidence

Mental disorders in the Australian population

45.5%

Mental disorder at some point in one’s lifetime

20.0%

Any mental disorders in the preceding 12 months for the population aged 16–85 years—more prevalent in females (22.3%) than males (17.6%)

6.2%

Affective (mood) disorders—more prevalent in females (7.1%) than males (5.3%)

14.4%

Anxiety disorders—more prevalent in females (17.9% compared with 10.8%)

5.1%

Substance use disorders—more prevalent in males (7.0%) than females (3.3%)

Sources: ABS 2013, Slade et al 2009

2

Chapter 1  Mental health: every health professional’s business

determinants (poverty, education level, marital status, etc.) were strongly associated with experiencing a mental illness or problem in the preceding 12 months (Slade et al 2009). Furthermore, these figures relate to individuals who seek and receive treatment. Not all people experiencing symptoms of mental illness have access to appropriate care or seek assistance (National Mental Health Commission 2012a, b). Therefore, the actual number of people living with mental illness in the community is greater than the statistics suggest.

Vulnerable populations

People who have been identified as having increased risk of experiencing mental health problems include: indigenous peoples; those from culturally and linguistically diverse backgrounds; lesbian, gay, bisexual and intersex people; homeless people; young men; people with an intellectual disability; people with comorbid drug and alcohol problems; people in the justice system; and people living with chronic physical illness (National Mental Health Commission 2012a, b, World Federation for Mental Health 2010). Despite having increased risk these populations often have less than optimal engagement with health care services.

Risk for co-occurring mental illness

People living with a chronic physical illness are at increased risk of developing depression, anxiety and substance abuse. People with diabetes experience anxiety and depression at three to four times the population incidence; 20% of people living with asthma or chronic obstructive pulmonary disease (COPD) also experience depression and anxiety; and up to 30–40% of cardiac patients exhibit clinically significant symptoms of depression (Thombs et al 2008, World Federation for Mental Health 2010). Katon (2010) found that up to two-thirds of people who had co-occurring diabetes and depression did not receive treatment for the depression. This is of concern because depression and anxiety are disabling conditions that can diminish a person’s quality of life, can lead to poor control of the co-occurring medical condition and add to the cost of health care due to reduced engagement in managing the chronic health condition. They are also associated with poor self-care and an increased incidence of complications among people with diabetes (Katon 2010, World Federation of Mental Health 2010).

Risk for co-occurring physical illness

People with a mental illness die younger—10–32 years earlier than the general population. They also have higher rates of physical illness, poorer 3

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

dental health, are less likely to engage in exercise and smoke tobacco at twice the rate of the general population (National Mental Health Commission 2012a, b, Thoms 2013). Despite these discrepancies, people with mental illness are less likely to receive hospital treatment than the general population. For example, people who are diagnosed with schizophrenia or major depression have a 40–60% greater chance of premature death than the rest of the population as a consequence of physical health problems that are not addressed. Such conditions include cancers, cardiovascular diseases, diabetes and HIV infection (Gibson et al 2011, WHO 2013). This is further compounded by a low level of engagement with health care services for this population (Gibson et al 2011). Co-occurring physical illness can be attributed to the side effects of psychotropic medications and lifestyle factors like smoking, inactivity and diet (Thoms 2013). Metabolic syndrome (the presence of three or more of the following symptoms: central abdominal obesity, hyperglycaemia, hypertension, elevated triglycerides or low levels of high-density lipoprotein cholesterol) is prevalent among people taking atypical antipsycotic medications and accounts for the increased risk for cardiovascular disease (Mitchell et al 2013, Vancampfort et al 2013). See also Chapter 10 on co-occurring medical problems.

Providing general health care for people with mental illness in the primary care setting Most people living with a mental illness live in the community and their first point of contact with the health care system is usually through primary care services. Hence, general practitioners and general practice nurses, in particular, are well positioned to screen and respond to the physical health problems of people living with mental illness. Box 1.1 summarises the recommendations made by Gibson et al (2011) and Mitchell et al (2013) to promote wellbeing and to monitor for early signs of metabolic syndrome in people living with mental illness.

Providing mental health care for people with a chronic physical illness in the acute care and primary care settings Health professionals both in acute general hospital settings and in primary care can play a role in supporting the mental health of people living with chronic physical conditions. These health professionals are ideally placed to screen for symptoms of mental illness or mental health problems and to refer for specialist assessment if indicated (see Box 1.2). 4

Chapter 1  Mental health: every health professional’s business

Box 1.1

Providing general health care for people with a mental illness in the primary care setting

Promote healthy lifestyle choices:

■

– physical activity and fitness – healthy eating – avoiding or reducing tobacco smoking – drinking alcohol in moderation – avoiding or minimising illicit drug use. Undertake psychosocial assessment and review regularly.

■

Regularly review psychiatric medications and their metabolic risk.

■

Establish and monitor the person’s BMI, weight, waist circumference, cholesterol levels, blood pressure and blood glucose, and respond early to any changes.

■

Refer for specialist assessment if indicated.

■

Adapted from Gibson et al 2011 and Mitchell et al 2013

Box 1.2

Providing mental health care for people with a chronic physical illness in the acute care and primary care settings

Promote healthy lifestyle choices

■

– physical activity and fitness – healthy eating – avoiding or reducing tobacco smoking – drinking alcohol in moderation – avoiding or minimising illicit drug use. Undertake and monitor psychosocial as well as physical assessment.

■

– Use tools to screen for mental distress such as Kessler-10 (Australian Mental Health Outcomes and Classification Network 2005). – Refer for specialist assessment if indicated. Adapted from World Federation for Mental Health 2010

5

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

Conclusion

To re-phrase and expand on the WHO slogans—not only is there no health without mental health there is also no mental health without physical health. Furthermore, this makes mental health every health professional’s business. Individuals living with mental illness and chronic physical conditions need regular monitoring of both physical and mental health indicators to ensure they achieve optimal care to maintain their health and wellbeing. Both the acute hospital and the primary care sectors are particularly well placed to undertake this role and thereby promote mental wellbeing; prevent mental illness; and to screen and intervene early when mental illness symptoms are evident—and also to respond early to physical health problems experienced by people living with mental illness. REFERENCES Australian Bureau of Statistics. (1998). Mental health and wellbeing: profile of adults Australia 1997, Cat no 4326.0. Online. Available: 13 Aug 2013. Australian Bureau of Statistics. (2013). Gender indicators, Australia: Mental health, Cat no 4125.0. Online. Available: 13 Aug 2013. Australian Health Ministers. (2009). Fourth national mental health plan: an agenda for government collaborative action 2009–2014. Canberra: Commonwealth of Australia. Australian Mental Health Outcomes and Classification Network. (2005). Kessler-10 training manual. Sydney: NSW Institute of Psychiatry. Gibson, M., Carek, P. J., & Sullivan, B. (2011). Treatment of co-morbid mental illness in primary care: how to minimise weight gain, diabetes and metabolic syndrome. International Journal of Psychiatry In Medicine, 41(2), 127–142. Katon, W. (2010). Depression and diabetes: unhealthy bedfellows. Depression and Anxiety, 27(4), 323–326. Mental Health Foundation of New Zealand. (2011). Mental health quick statistics. Online. Available: 21 Aug 2013. Mitchell, A., Vancampfort, D., Sweers, K., et al. (2013). Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders—a systematic review and meta-analysis. Schizophrenia Bulletin, 39(2), 306–318. National Mental Health Commission. (2012a). A contributing life: the 2012 national report card on mental health and suicide prevention. Sydney: NMHC. National Mental Health Commission. (2012b). National Mental Health Commission’s strategies and actions 2012–2015. Canberra: Australian Government. Online. Available: 21 Aug 2013. New Zealand Mental Health Commission. (2012). Blueprint II: improving mental health and well-being for all New Zealanders. Online. Available: 21 Aug 2013. NHS Mental Health Strategy Branch. (2012). No health without mental health. London: NHS. Slade, T., Johnston, A., Teesson, M., et al. (2009). The mental health of Australians 2. Report on the 2007 National Survey of Mental Health and Wellbeing. Canberra: Department of Health and Ageing. Thombs, B., de Jonge, P., Coyne, J., et al. (2008). Depression screening and patient outcomes in cardiovascular care: a systematic review. Journal of the American Medical Association, 300(18), 2161–2171. Thoms, D. (2013). The physical burdens of mental illness. Nursing Review. Online. Available: 14 Aug 2013. Vancampfort, D., Probst, M., Scheewe, T., et al. (2013). Relationships between physical fitness, physical activity, smoking and metabolic and mental health parameters in people with schizophrenia. Psychiatry Research, 207, 25–32. World Federation for Mental Health. (2010). Mental health and chronic physical illness: the need for continued and integrated care. Online. Available: 21 Aug 2013. World Health Organization. (2004). Mental health promotion. Geneva: WHO. Online. Available: 21 Aug 2013. World Health Organization. (2011). Mental health: a state of well-being. Geneva: WHO. Online. Available: 21 Aug 2013. World Health Organization. (2013). Draft comprehensive mental health action plan 2013–2020. Geneva: WHO. Online. Available: 21 Aug 2013.

WEB RESOURCES Australian College of Mental Health Nurses Chronic disease and mental health. This is a free interactive e-learning program for nurses working with people who live with chronic disease. It uses video vignettes and a range of activities to highlight the key issues related to mental health. Australian Government, Department of Health and Ageing. This is the site for the Fourth National Mental Health Plan: An agenda for collaborative government action in mental health 2009–2014. Mental Illness Foundation New Zealand. The foundation works to enhance and ensure the mental health of all New Zealanders. The site provides resources and information about mental health and illness for the general public and health professionals, including links to mental health care services. National Mental Health Commission. This is the site for accessing A Contributing Life: the 2012 national report card on mental health and suicide 7

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

prevention—the first report of the National Mental Health Commission on the mental health of Australians and identifying the factors that facilitate recovery and enable people living with mental illness to live a ‘contributing life’. New Zealand Mental Health Commission. Blueprint II: Improving mental health and well-being for all New Zealanders is a 10-year plan that presents the vision of the Mental Health Commission to improve the health and wellbeing of all New Zealanders. It encompasses all of government and provides guidance on future needs and required changes. World Health Organization. The Draft comprehensive mental health action plan 2013– 2020 has at its core the globally accepted principle that there is ‘no health without mental health’. It proposes for member states clear actions, key indicators and targets, with an emphasis on prevention, promotion, treatment, rehabilitation, care and recovery. The plan is global in scope and aims to provide guidance for national action plans.

8

CHAPTER

2

 

Working in a recovery framework

Introduction

A recovery-oriented approach to mental health care aims to facilitate mental health, minimise the impact of mental illness and manage the symptoms of mental illness. The recovery model emerged in the latter part of the 20th century amid worldwide reform of mental health services. It is a person-centred approach, underpinned by principles of social justice and equity, which challenges an exclusive biomedical model of focusing mainly on symptom identification and treatment. This chapter examines recovery as a philosophy and as a framework within which to deliver mental health services, from the perspective of consumers and carers, health professionals and the health care system.

Recovery

Recovery is a philosophical and practical approach to mental health care in which the emphasis is on the person’s wellbeing, autonomy and empowerment. Recovery is not just about reducing or eliminating symptoms; it is about an individual’s journey while living with a mental illness. Recovery in this context has many meanings. It is an individual and a dynamic experience, not a static process. Anthony, an early advocate of the recovery approach, described the journey as: … a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness. (Anthony 1993)

For consumers and carers, therefore, recovery means living well with an ongoing mental illness, having hope and setting goals for the future— not just symptom management. It encompasses learning about the illness and factors that trigger episodes, and making necessary lifestyle changes. 9

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

TABLE 2.1  Comparison of biomedical and recovery-focused understandings Biomedical approach to mental illness

Person-centred recovery approach

A linear process of illness and wellness

A cyclical process of trying and trying again

Focus on treatment and medication management

Focus on meaningful relationships and leading an ‘ordinary life’

Spirituality and meaning are not viewed as important

Spirituality is important in developing meaning and understanding

Relapse is viewed as a failure

Relapse is viewed as an opportunity for growth and learning

The experience of mental illness is a negative one

The experience of recovery from a mental illness has positive aspects

The nature of mental illness is predetermined

Having a mental illness is an individual and unique process

Relinquishing roles and responsibilities is accepted

Maintaining roles and responsibilities is promoted

For health professionals, recovery means not only working with the person to manage the symptoms of mental illness but also working with the person to enable them to lead a full and meaningful life, despite the illness. In the past, the phenomenon (i.e. the lived experience of the person with a mental illness) was at the core of mental health care. However, throughout the 20th century, the focus shifted from a person-centred approach to a biomedically dominated one. The biomedical model concentrates on symptom identification and reduction, primarily through medication, with the subjective experience having less emphasis. Recent decades, however, have seen a shift towards a recovery approach in which ‘person-centred’ care is now central. Table 2.1 provides a comparison of biomedical and recovery-focused understandings.

Protective and risk factors

A recovery approach acknowledges that some factors increase the risk of relapse, while others are protective of mental health. Hence, a recovery approach encompasses more than merely treating or managing the symptoms of the illness. It includes recognition of and attention to the social and economic aspects of people’s lives, as well as their mental illness or 10

Chapter 2  Working in a recovery framework

disability. Health professionals who use a recovery framework work in partnership with the individual (and carer) to maximise the quality of life for the person living with mental illness (O’Kane 2013). Rickwood (2006) distinguishes protective and risk factors for the development of and recovery from mental illness. She states that protective factors reduce the likelihood that a disorder will develop by reducing the exposure to risk, and by reducing the effect of risk factors for those exposed to risk. Protective factors also foster resilience in the face of adversity and moderate against the effects of stress, whereas risk factors increase the likelihood that a disorder will develop, exacerbate the burden of an existing disorder and can indicate a person’s vulnerability. Both protective and risk factors include genetic, biological, behavioural, sociocultural and demographic conditions and characteristics (Rickwood 2006), with some factors being internal to the person, while others are external. Internal factors include genetics, disposition and intelligence, while external drivers comprise the social determinants of health related to social, economic, political and environmental factors, including the availability of opportunities in life and access to health services (World Health Organization 2008). Risk factors increase vulnerability to mental illness and mitigate against recovery from mental illness. Risk factors for mental illness in children, for example, have been identified as: the child having special needs; poor family functioning; living in a rural area or unsafe neighbourhood; financial stress; and poor parental (particularly maternal) mental health (Goldfeld & Hayes 2012). Protective factors assist the person to maintain emotional and social wellbeing, and to cope with life experiences—including adversity. They can provide a buffer against stress, as well as be a set of resources to draw upon to deal with stress. Factors that have been identified as protective against mental illness in children, for example, include having individual, family, school and social resources (Ottova et al 2012). A recovery-based model is underpinned by an emphasis on a number of protective factors that can be harnessed to reduce the severity and impact of the experience of mental illness. Protective factors serve a number of purposes. They can buffer risk factors and provide a cushion against negative effects. Also, they may interrupt the processes through which risk factors operate. For example, a literacy program for illiterate young people may interrupt a potential path to unemployment. Protective factors are social determinants of health outcomes and can be grouped into three areas: individual; family and peers; and community (see Box 2.1). 11

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

Box 2.1

Protective factors

Individual Resilient characteristics, such as effective coping skills and being able to manage stress

■

A sense of one’s own spirituality

■

Effective interpersonal skills

■

Problem-solving skills

■

A perception of social support from family and peers

■

A healthy sense of self and a sense of belonging

■

Positive expectations/optimism for the future

■

Meaningful activities in which to engage

■

Family and peers Good relationships and regular contact with family members

■

A stable family involvement with positive peer-group activities and norms

■

Friends to socialise with

■

Community An economically sustainable community

■

A safe and health-promoting environment

■

Active community centres

■

Neighbourhood cohesion

■

Recovery-oriented mental health services

A framework for recovery-oriented mental health services in Australia was proposed by the National Mental Health Promotion and Prevention Working Party in 2006, following an extensive consultation process with consumers, carers and service providers (Rickwood 2006). In 2013 the Australian Government published a national framework that identifies the responsibilities of recovery-oriented mental health service delivery. These are to: ■ provide evidence-informed treatment, therapy, rehabilitation and psychosocial support that helps people to achieve the best outcomes for their mental health, physical health and wellbeing 12

Chapter 2  Working in a recovery framework

work in partnership with consumer organisations and a broad cross-section of services and community groups ■ embrace and support the development of new models of peer-run programs and services (Australian Health Ministers Advisory Council 2013 p 3). ■

In 2011 the Victorian Department of Health developed the Framework for recovery-oriented practice, which outlines domains and core principles for delivering recovery-oriented mental health care. They are summarised in Table 2.2.

Providing recovery-oriented mental health care

Hildegard Peplau first drew attention to the pivotal role of the therapeutic relationship in mental health care in her book Interpersonal relationships in nursing (Peplau 1952). In her model Peplau identifies the foundation for developing a therapeutic relationship with consumers as requiring: unconditional positive regard; authenticity; genuineness; and respect. Her model led to a shift in psychiatric nursing practice from doing to a client (consumer) to being with a client (consumer)—an approach to mental health care that is evident in the contemporary recovery models of today. Peplau’s model also empowers health professionals ‘to move away from a disease orientation to one whereby the psychological meaning of events, feelings and behaviours could be incorporated in [health care] interventions’ (Peplau 1996). In clinical practice establishing rapport and a therapeutic relationship between the health care worker and the person and their family is the cornerstone of effective mental health care. It requires empathy, trust and effective communication. The purpose of the relationship is to: ■ engage with the person in order to complete a full assessment and care plan ■ encourage the person to define their problems and perceptions of their distress ■ facilitate the development of learning and coping skills by the person ■ resolve or minimise existing problems or symptoms. ■

The role of health professionals in mental health promotion is to: facilitate a healthy lifestyle through education about diet and nutrition, rest, sleep and exercise 13

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

TABLE 2.2  Framework for recovery Domain

Core principles to facilitate recovery

Promoting a culture of hope

Promote values of hope, self-determination, personal agency, social inclusion and choice Enable a culture of hope and optimism, and encourage the person’s recovery efforts

Promoting autonomy and self-determination

Involve the person as a partner in their mental health care, ensuring their lived experience and expertise is recognised Encourage informed risk taking within a safe and supportive environment and organise the service environment to ensure safety and optimal wellbeing

Collaborative partnerships and meaningful engagement

Provide personalised mental health care through collaborative partnerships with the person and their support networks Promote mental health, wellbeing and recovery by establishing and sustaining a collaborative partnership with the person

Focus on strengths

Focus on the person’s strengths, resources, skills and assets Support the person to build their confidence, strengths, resourcefulness and resilience

Holistic and personalised care

Provide personalised mental health care informed by the person’s circumstances, preferences, goals and needs Understand the range of factors that can impact on the person’s wellbeing

Family, carers, support people and significant others

Recognise the role of family and significant others in supporting the person’s recovery Support the person to utilise and enhance their existing support networks

Community participation and citizenship

Foster positive relationships, meaningful opportunities and community participation Recognise the impact of stigma on recovery

Responsiveness to diversity

Provide mental health care, which is personalised, respectful, relevant and responsive to diversity including the person’s culture and community background, gender and sexual identity

Reflection and learning

Engage in ongoing critical reflection and continuous learning Recognise that the person’s lived experience of mental illness and recovery are valuable resources

Adapted from Department of Health 2011

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Chapter 2  Working in a recovery framework

support people to access employment services, housing, education and health services ■ provide mental health care early and provide continuing intervention programs. ■

The Tidal Model

Developed by Dr Phil Barker in the United Kingdom in the late 1990s, the Tidal Model is an example of a recovery-oriented model of mental health care. It is a philosophical approach underpinned by the following core values: ■ People need to reclaim their personal story of mental distress and mental illness in order to reclaim their lives. ■ The role of health professionals is to help people realise what they want in relation to their lives. The following 10 commitments guide the Tidal Model approach to mental health care clinical practice (Barker 2013): 1 Value the voice of the person. Their voice of experience is central, not the professional medicalised account. 2 Respect the language. Use the person’s words to describe their experience. 3 Develop genuine curiosity. Listen to the person, be interested in what they have to say, not just ‘what is wrong with them’. 4 Become an apprentice. The person with a mental illness is the expert—learn from them. 5 Use the available toolkit. What resources does the person have? What worked before? 6 Craft the step beyond. What needs to be done now? Plan. 7 Give the gift of time. Take time to listen and communicate. 8 Reveal personal wisdom. The person knows themselves best. 9 Know that change is constant. While change is inevitable, growth is optional and requires choices and decisions. 10 Be transparent. Be honest and upfront and use the person’s language in their care and assessment plans.

Working with individuals

When working with individuals to facilitate recovery, ‘Rethink’ (the leading United Kingdom mental health charity) challenges an exclusive 15

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

biomedical model approach of focusing on illness and symptom management, and advocates a model in which mental wellness is the goal. Rethink recommends an approach that: ■ focuses on goals, not problems ■ values the strengths the person brings to their personal recovery ■ respects the person’s self-direction ■ creates an environment that supports personal recovery and values small steps (Rethink 2013). In summary, the Rethink model is person-centred and directed, and proposes working with the person’s strengths and addressing issues of everyday living—as well as managing the symptoms of mental illness.

Working with families

An example of a recovery-oriented approach to working with families is the Canadian Mental Health Alliance (2013). This organisation supports and educates families and friends during the recovery process in order to build on the strength and resilience of families to enhance their lives. They provide recovery-related educational courses and support groups to: develop a stronger voice for families in the mental health and addiction system; strengthen the supports provided to families; and raise awareness of issues from a family perspective. The alliance has identified four needs of families and caregivers of people with mental illness and/or addictions as: Services for families: educating, supporting and caring for the caregivers. Provide psychoeducational programs for families, carers and friends of people with a mental illness, aimed at increasing the capacity for carers to care for themselves, other family members and their relative living with a mental illness. ■ Peer support: families helping families. Provide support and funding for peer-support initiatives and facilitate access for consumers. ■ Recognition as partners in care, rehabilitation and recovery. Develop organisational policies and provide training that assists clinicians to work with families. Include family members in policy development and the delivery of education for clinicians. ■ Families as system partners. Recognise and involve family members as key stakeholders of mental health services (e.g. as members of advisory committees and boards of mental health services) (Family Mental Health Alliance 2006). ■

16

Chapter 2  Working in a recovery framework

Addressing the needs of families and caregivers recognises the significant role they play in caregiving and, importantly, that they, too, have needs as a consequence of their caregiving role.

Recovery competencies for mental health workers

The former New Zealand Mental Health Commissioner, Mary O’Hagan, describes a competent mental health worker as one who: Understands recovery principles and experiences, supports service users’ personal resourcefulness, accommodates diverse views on mental health issues, has self-awareness and respectful communication skills, protects service users’ rights, understands discrimination and how to reduce it, can work with diverse cultures, understands and supports the user/ survivor movement, and understands and supports family perspectives (O’Hagan 2004 p 2).

This is exemplified in the Recovery competencies for New Zealand mental health workers, which were developed by the Mental Health Commission of New Zealand (2001). The competencies outline the knowledge, skills and disposition required by mental health workers to enable them to work within a recovery framework. According to the competencies, a competent mental health worker: 1 understands recovery principles and experiences in the Aotearoa/ New Zealand and international contexts 2 recognises and supports the personal resourcefulness of people with mental illness 3 understands and accommodates the diverse views on mental illness, treatments, services and recovery 4 has the self-awareness and skills to communicate respectfully and develop good relationships with service users 5 understands and actively protects service users’ rights 6 understands discrimination and social exclusion, its impact on service users and how to reduce it 7 acknowledges the different cultures of Aotearoa/New Zealand and knows how to provide a service in partnership with them 8 has comprehensive knowledge of community services and resources, and actively supports service users to use them 9 has knowledge of the service user movement and is able to support their participation in services 17

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

10 has knowledge of family/whānau perspectives and is able to support their participation in services (Mental Health Commission of New Zealand 2001 p 7).

Recovery and risk

When working within a recovery framework (which encourages individual choice, empowerment and self-management) tensions can arise regarding risk management. The Victorian Department of Health (2011) acknowledges this and states that a level of risk tolerance is required, and that this needs to occur in an environment that is safe, and that staff need to be aware of their duty of care. In delivering recovery-focused services the Victorian Department of Health recommends ‘positive risk taking’, which requires: ■ assisting the person to decide what is an appropriate level of risk taking for their recovery journey (within a safe environment and within the limits of duty of care) ■ balancing the risk by articulating the threshold of risk that is appropriate for the setting, and within the parameters of duty of care ■ providing guidance, training and support to staff regarding flexible responses to an individual’s circumstances and preferences while maintaining appropriate risk management (Department of Health 2011 p 3).

Conclusion

Recovery is the journey undertaken by the person living with mental illness (often in collaboration with a health professional) as the individual rethinks their identity, goals and hopes (Slade 2009). For health professionals, practising within a recovery framework involves working with the individual and their family to: understand the person’s story or narrative; identify strengths; set goals; and address issues of everyday living—as well as managing the symptoms of mental illness. Finally, as a guiding framework for clinical practice, recovery is an approach to achieving mental health, which involves more than the absence of symptoms of mental illness. It includes notions of hope and empowerment of consumers and their carers, the delivery of person-centred care and the establishment of a partnership between consumers, carers and health professionals in attaining the goal of mental health. Importantly, there is a focus on the individual’s strengths, rather than the deficits that may be a consequence of the mental illness. 18

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REFERENCES Anthony, W. (1993). Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11–23. Australian Health Ministers Advisory Council. (2013). A national framework for recovery-oriented mental health services: guide for practitioners and providers. Canberra: Commonwealth of Australia. Barker, P. (2013). The Tidal Model: reclaiming stories, recovering lives. Online. Available: 31 Aug 2013. Canadian Mental Health Alliance. (2013). Support for families and caregivers. Online. Available: 31 Aug 2013. Department of Health. (2011). Framework for recovery-oriented practice. Melbourne: Mental Health, Drug and Alcohol Division, State Government of Victoria. Family Mental Health Alliance. (2006). Caring together: families as partners in the mental health and addiction system. Ontario: Family Mental Health Alliance. Goldfeld, S., & Hayes, L. (2012). Factors influencing child mental: a state-wide survey of Victorian children. Journal of Paediatrics and Child Health, 48, 1065–1070. Mental Health Commission of New Zealand (MHC). (2001). Recovery competencies for New Zealand mental health workers. Wellington: MHC. O’Hagan, M. (2004). Recovery in New Zealand: lessons for Australia? Guest editorial. Australian e-Journal for the Advancement of Mental Health, 3(1), 1–3. O’Kane, D. (2013). Partnerships in health. In P. Barkway (Ed.), Psychology for health professionals. Sydney: Elsevier. Ottova, V., Hjern, A., Rasche, C., et al. (2012). Child mental health measurement: reflections and future directions. In J. Maddock (Ed.), Public health—methodology, environmental and systems issues. Online. Available: 31 Aug 2013. Peplau, H. (1952). Interpersonal relations in nursing. New York: GP Putnam. Peplau, H. (1996). Fundamental and special—the dilemma of psychiatric and mental health nursing. Commentary Archives of Psychiatric Nursing, 10(1), 14–15. Rethink. (2013). Recovery. Online. Available: 31 Aug 2013. Rickwood, D. (2006). Pathways of recovery: preventing further episodes of mental illness (monograph). Canberra: Commonwealth of Australia. Slade, M. (2009). 100 ways to support recovery: a guide for mental health professionals (Vol. 1). London: Rethink Recovery Series. World Health Organization (WHO). (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: WHO.

WEB RESOURCES Australian Health Ministers’ Advisory Council. A national framework for recoveryoriented mental health services: guide for practitioners and providers is a guide for 19

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

mental health professionals and services to Australia’s national framework for recovery-oriented mental health services. Canadian Mental Health Association. The monograph ‘Caring together: families as partners in the mental health and addiction system’ was produced by the Family Mental Health Alliance in partnership with the Centre for Addiction and Mental Health, Canadian Mental Health Association and the Ontario Federation of Community Mental Health and Addiction Programs. Recovery Competencies for New Zealand Mental Health Workers. This document describes the competencies that mental health professionals require to be able to work within a recovery framework in their clinical practice. Recovery Hub. The Recovery Hub contains many activities, articles and practical resources to provide choice, encourage hope and inspire consumers to improve their health, wellness and live a positive lifestyle. Rethink (UK). Rethink is the largest severe mental illness charity in the UK. It is dedicated to improving the lives of everyone affected by severe mental illness, whether they have a condition themselves, care for others who do or are professionals or volunteers working in the mental health field. Richmond Fellowship. The Richmond Fellowship is established in most Australian states and territories. It was founded in Richmond, England in 1957 and has since grown into a worldwide network of support services for people with mental illness. It promotes mental health and recovery for people living with a mental illness by providing community-based rehabilitation within an accommodation support framework. Tidal Model. The Tidal Model is the first mental health recovery model developed conjointly by mental health nurses and people who have used mental health services.

20

CHAPTER

3

 

Essentials for mental health practice

Introduction

People seeking assistance for mental health concerns require care that meets their needs for support, treatment, information, advocacy or refuge. All care delivered by health professionals needs to be generated from values such as respect and concern for each person and their experience. Valuesbased care guides the provision of appropriate health care and promotes the connection between the health care provider and the person seeking support. Health professionals from all disciplines are guided in their practice by their level of education and unique discipline knowledge, personal values and established standards and principles of practice. This chapter outlines some key components of practice when working with people needing mental health care. The chapter introduces the term ‘working alliance’ to establish that health professionals work with consumers in a committed professional partnership, acknowledging their experience and supporting the person’s recovery (see Chapter 2). Mental health promotion and prevention of mental illness underpin mental health care. Promotion and prevention aim to strengthen a person’s resilience. They aim to increase protective factors and lessen a person’s vulnerability to mental health problems. For those who are unwell, promotion and prevention strategies aim to increase relapse-prevention skills. A focus on individual strengths and building resilience are a necessary component of recovery-oriented practice.

Practice essentials

National practice standards

There are 13 national practice standards that relate to all health professionals working with mental health consumers and their families in Australia. The standards aim to provide a benchmark for practice, education and skill development. Table 3.1 lists the 13 practice standards. 21

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TABLE 3.1  National practice standards for the mental health workforce 2013 National standard

Explanation (adapted from the practice standards overview)

1. Rights, responsibilities, safety and privacy

Mental health professionals uphold the rights of people affected by mental health problems and mental disorders, and those of their family members or carers, maintaining their privacy, dignity and confidentiality, and actively promoting their safety

2. Working with people, families and carers in recoveryfocused ways

Mental health professionals support people to become decision-makers in their own care

3. Meeting diverse needs

Mental health professionals respectfully respond to the social, cultural, linguistic, spiritual and gender diversity of consumers and carers, incorporating those differences in their practice

4. Working with Aboriginal and Torres Strait Islander people, families and communities

Mental health professionals provide culturally safe systems of care, reduce barriers to access and improve social and emotional wellbeing

5. Access

Mental health professionals facilitate timely access to quality evidence-based assessment

6. Individual planning

Mental health professionals facilitate and support care planning from a quality evidence base

7. Treatment and support

Mental health professionals provide quality evidenceinformed interventions

8. Transitions in care

Mental health professionals support the exit or transition of a person’s care in a structured and timely way

9. Integration and partnership

Mental health professionals recognise and support the provision of coordinated care across the broad network of carers, community, programs and services

10. Quality improvement

Mental health professionals collaborate with people with a lived experience, families and team members to actively improve mental health practices

11. Communication and information management

Mental health professionals establish therapeutic relationships and maintain quality documentation, information systems and evaluation to monitor and evaluate needs

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Chapter 3  Essentials for mental health practice

TABLE 3.1—cont’d National standard

Explanation (adapted from the practice standards overview)

12. Health promotion and prevention

Mental health clinicians seek to build resilience in individuals and communities through mental health promotion and primary prevention principles

13. Ethical practice and professional development responsibilities

Mental health professionals are aware of their individual scope of practice and the codes and regulations supporting their practice; they take responsibility for their own professional development and continuing education and contribute to the development of others

Source: Department of Health 2013

Guiding principles

The following principles form the basis for a holistic, preventative, health-promoting and recovery-oriented system of specialised care (Department of Health 2013). Guiding principles embedded in these standards are: ■ Promote optimal quality of life for and with people with a mental illness. ■ Deliver services with the aim of facilitating sustained recovery. ■ Involve service users in all decisions regarding their treatment, care, support and, as far as possible, the opportunity to choose their treatment and setting. ■ Recognise the right of the person to have their nominated carer involved in all aspects of their care. ■ Learn about and value the lived experience of people using services, and their family and carers. ■ Recognise the role played by carers, as well as their capacity, needs and requirements, separate from those of the person receiving services. ■ Recognise and support the rights of children and young people affected by a family member with a mental illness to appropriate information, care and protection. ■ Support participation by people and their families and carers as an integral part of mental health service development, planning, delivery and evaluation. ■ Tailor mental health treatment, care and support to meet the specific needs of the individual. 23

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

In delivering mental health treatment and support impose the least personal restriction on the rights and choices of people, taking into account their living situation, level of support within the community and the needs of their family or carer. ■ Be aware of and implement evidence-informed practices and quality improvement processes. ■ Mental health professionals should participate in professional development activities and reflect what they have learnt in practice. ■

The National practice standards for the mental health workforce 2013 provide further information and examples. The practice standards complement the National standards for mental health services 2010, both ensuring a supportive framework for quality mental health practice. In New Zealand the Mental Health Commission released the document Recovery competencies for New Zealand mental health workers in 2001. This document (available at ) comprehensively addresses recovery and suggests that practitioner competencies can inform standards. The document also includes examples of using competencies in practice. The 10 competencies are listed in Chapter 1 of the document (see pp 8–9).

Settings and models for care

The environment across mental health care settings is sometimes referred to as the therapeutic milieu. The environment is seen as having the potential to contribute to a person’s recovery. Mental health professionals can influence and assist in increasing the therapeutic potential of the environment. The elements in the environment that contribute to this potential and can be promoted (Elder 2012) are: ■ a place of safety ■ a predictable, organised structure ■ personal and social support ■ involvement and collaboration in the care environment ■ validation of each person’s individual experience through interpersonal communication ■ symptom management ■ maintaining links with the person’s family and support structure ■ developing links and resources in the community. More and more care is being delivered to people in their local community or their home and through a range of non-government, primary 24

Chapter 3  Essentials for mental health practice

health and community organisations and partnerships (see Chapter 13). Care delivered in different settings has seen the development of a range of models of care—for example, integrated teams that provide triage, crisis and case management optimising and streamlining care delivery and recovery. Another example is the mental health nurse incentive program (MHNIP) where credentialled mental health nurses work to their full scope of practice providing primary and supportive ongoing care to people with the full range of mental health issues.

Teamwork

The multidisciplinary team is a team approach for care delivery. Because the multidisciplinary team comprises nursing, medical and allied health professionals, this model optimises options for the person, as each health professional has unique and complementary skills that provide holistic coordinated care to assist the person’s recovery. There can be overlap in skill sets among mental health professionals so frequent meetings are required to ensure coordinated care. Case management is a model of care in which treatment options and care delivery is provided and coordinated by one health professional in a consistent manner. Case management can be used in all mental health settings; its strengths are that the case manager can refer the person to other members of the team with expertise to meet the person’s specific needs.

Scope of practice

Each health practitioner works within a scope of practice, which describes the full spectrum of roles, functions, responsibilities, activities and decision-making capacity that individuals within professions are educated, competent and authorised to perform. The scope defines boundaries of responsibility and accountability for each mental health professional, and therefore influences decision making in care and service delivery. Scope of practice within the multidisciplinary team requires that individual members negotiate care delivery and establish who is responsible for particular care or services, even if a particular discipline is accountable for care or service delivery.

Mental health literacy and psychoeducation

Mental health literacy refers to an individual’s or group’s awareness, understanding and knowledge about mental health and illness. It can influence their response to recognising signs or behaviours of mental illness and 25

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

identifying pathways for treatment and recovery. Mental health practitioners and consumers play an important role in increasing public awareness and understanding of mental illness to facilitate early recognition and intervention. Awareness raising and increasing mental health literacy can be achieved by identifying or providing resources such as: ■ information brochures about mental health services, types of treatments and types of mental health problems ■ medication information sheets (in a style and format appropriate for the general public) ■ website addresses ■ referrals to and engagement with community support groups, parenting programs, employment programs, abuse-related programs, addiction programs, health advisory groups and health and mental health education programs ■ peer support services. Psychoeducation is the provision of information required by the person, their family or a group to improve mental health literacy, self-determination and quality of life. Mental health literacy and psychoeducation are vital to enabling the person and family to determine their own needs and make their own decisions about treatment and recovery.

Assessment and history

Assessment is an ongoing process because a person’s functioning can change depending on what is happening in their environment (internal and external). The person’s internal environment consists of their thoughts, feelings and physical health; their external environment can be their family, their physical world and the social relationships within it. A range of assessments can be performed by different mental health professionals depending on a person’s presentation and needs. Holistic mental health assessment measures the person’s functioning in the following domains: ■ physical ■ cultural ■ spiritual ■ mental and emotional (mental state assessment; see Chapter 4) ■ developmental and functional ■ family ■ social/environmental. 26

Chapter 3  Essentials for mental health practice

Practitioner essentials

Personal and professional values

Humanistic and holistic values have underpinned the development of mental health practice for many health professionals. Humanism can be defined as a perspective on life that is centred on a concern for human interests, values and upholding the person’s dignity. It is particularly relevant in health care when people may be vulnerable and seeking assistance. Holism in health relates to the idea that the person is more than the sum of their parts and that if we recognise the importance of the interrelationships between biological, psychological, social and spiritual aspects of the person, healing and wellbeing are enhanced. Important values include: ■ A person-centred approach. A person-centred approach is essential for mental health care. You are there for the person and to liaise with carers/family/friends as appropriate. ■ A working alliance. Developing a working alliance enables you to understand the person’s (and family’s) recovery plan. Work with the person to achieve recovery defined by them using their strengths. You remain positive and hopeful for consumers and support their recovery plan. ■ Compassionate care. Compassionate care supports recovery and emotional wellbeing. It matters how you care because it impacts on the person and their family’s feelings (e.g. maintain compassion and best practice in situations of distress, anxiety and ‘busyness’). ■ Respect. Respect underpins person-centred care and includes respect for both the person and their experience. ■ A ‘safe’ environment. Mental health care is best delivered in environments that support cultural, physical and emotional safety. Encourage feedback about the environment and appropriateness of care delivery. ■ A multidisciplinary team. A multidisciplinary team approach provides the person with a wide range of therapies and treatment options. You present consumers with suitable options to promote recovery.

Self-awareness Self-awareness involves consciousness of our own values, our beliefs and who we are (identity); it also includes the ability to reflect on and accommodate the values and beliefs of others. It requires being grounded in the here and now, and knowing our thoughts, feelings and reactions. Having this awareness will help you to focus on consumers, families and their 27

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

needs. Self-awareness is developed over time through experience and focused activities. Strategies that can develop self-awareness include: ■ clinical supervision ■ mentorship ■ requesting feedback on your practice ■ asking questions of mentors ■ keeping a journal of your practice for reflection or discussion with a mentor. Appendix 1 provides some guidance on surviving clinical placement and developing self-awareness.

The working alliance

The aim of the working alliance is to develop a relationship where the therapeutic goals for the person and/or family can be realised. Empathy, understanding the consumer’s experience and working with them to achieve their goals is the process essential to the alliance. The following is a framework for the working alliance: ■ Professional boundaries are in place and are the responsibility of the practitioner. ■ The consumer and their recovery pathway are the focus of the alliance. ■ The consumer determines or defines their desired outcomes of the working alliance. ■ Respect for the experience of the consumer and a non-judgmental attitude are essential for care provision. ■ Communication skills are the foundation of the working alliance. The practitioner often needs to role model health communication techniques. Box 3.1 provides some tips for initiating the alliance, Box 3.2 provides tips for developing and maintaining the alliance and Box 3.3 provides tips for building strengths in the alliance.

Professional boundaries

Boundaries refer to verbal and non-verbal actions and interactions between individuals or groups of people. Safe and appropriate boundaries are in place when interactions are mutually respectful of the person or group, their culture and experience. Health practitioners are responsible for setting and/or negotiating boundaries in the working alliance to focus and facilitate the achievement of the person’s goals. Most professions have 28

Chapter 3  Essentials for mental health practice

Box 3.1

Tips for initiating the alliance: developing rapport

Put aside everything else that is happening to you and around you and focus on the consumer.

■

Choose a time and place to invite the consumer to tell you their story or discuss their issue when it is convenient for them.

■

Be gentle and confident in your approach. You may lead the interaction initially by inviting the consumer to set timelines. However, the consumer will take the lead and define their therapeutic needs.

■

Collaborate with the consumer in setting expectations and timelines for the working alliance.

■

Box 3.2

Tips for developing and maintaining the alliance: responding

How can you respond usefully? Everything you need to know about the consumer is in what they tell you and what you observe in their appearance and behaviour. Listed below are steps to a useful response. Listen Listen to the consumer’s story for content (the ‘what’ of their story), their feelings (the tone of their story) and themes (the priorities of their story).

■

Identify a key word, feeling or theme, and reflect it back to the consumer—for example, ‘You mentioned that you had a car accident (content). Can you tell me more about it?’ ‘You sounded angry (feeling) when you told me about your car accident.’ ‘You mentioned your car accident several times (theme). It sounds like it was a significant event in your life.’ Any of these responses and single-word prompts or non-verbal nods also work to indicate to the consumer that you are listening and interested to hear more.

■

Pay attention Show in your body language that you are making an effort to attend to the consumer’s story.

■

Summarise and clarify content, feelings and themes in the consumer’s story—for example, ‘You continue to be angry and blame yourself for the car accident and it sounds like you find it difficult to cope with your anger in general since the accident. Is this how it is for you?’

■

Explore previous coping and available or needed skills and options for the future. This exploration might need to occur at a later time when the consumer is less distressed or you may need to refer them to a more experienced practitioner. Negotiate a time for further alliance work.

■

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Box 3.3

Tips for building strengths in the alliance: developing resilience

Resilience can be developed by: encouraging mutual and shared learning (psychoeducation)

■

providing and exploring options

■

being clear and assertive

■

challenging and responding openly to challenge

■

identifying and providing resources

■

maintaining a positive attitude

■

role modelling a wellness attitude

■

persevering and maintaining hope.

■

Box 3.4

Tips for setting boundaries

Introduce yourself and state what you prefer to be called and the purpose of your role. Consistently refer to the consumer using their preferred title.

■

Keep a focus on the consumer’s story during communication with the person. Keeping the storyline in focus helps them tell a rich and detailed story, free of distractions.

■

Provide summaries and updates on therapeutic goals. Summaries will help the consumer self-monitor and keep a focus on their recovery.

■

Remain open and non-judgmental. Criticism or disapproval is a warning of boundary vulnerability. Attempt to clarify instead.

■

Discuss any uncomfortable or unexpected feelings, or feelings of confusion, with your line or clinical supervisor. Feelings of guilt, anger and attraction can disrupt the alliance. Talk to your supervisor or mentor.

■

Remember that the alliance is not the same as a social relationship/ friendship. Stop and reflect if it starts to feel like friendship. This includes things friends do, such as give each other small gifts, make contact out of work time or chat socially. All of these behaviours impair the alliance.

■

Respond respectfully and thoughtfully to the consumer at all times. Keeping your communication at a professional level will keep the alliance on track.

■

Engage in clinical supervision. Clinical supervision develops your practice expertise and professional awareness.

■

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Chapter 3  Essentials for mental health practice

codes of conduct and/or codes of ethics that identify boundary setting as part of the professional responsibility. Box 3.4 provides tips for setting boundaries. Pathways to developing expertise and the capacity to provide holistic assessment and care in mental health work exist in the professional health disciplines and human services. Acquiring additional communication, engagement and therapeutic alliance skills, as well as self-awareness, promotes the potential for consumers’ wellbeing and recovery.

Conclusion

Working from a humanistic and holistic values base is the foundation for mental health work; it also requires an awareness and adherence to national standards and principles, and any jurisdictional standards as a baseline for practice. Skill in developing the working alliance increases with experience, feedback from consumers and peers, clinical supervision and greater self-awareness from critical reflection on practice. REFERENCES Department of Health (2013). National practice standards for the mental health workforce 2013. Melbourne: State Government of Victoria. Elder, R. (2012). Settings for mental health care. In R. Elder, K. Evans & D. Nizette (Eds.), Psychiatric and mental health nursing (3rd edn). Sydney: Elsevier.

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CHAPTER

4

 

Mental health assessment

Introduction

This chapter focuses on the essentials of mental health assessment. The purpose, aims and reasons for assessment are described in detail. The mental state examination (MSE), a semi-structured interview that assesses mental functioning, is a crucial component of mental health assessment and is a really useful tool for all those working with people with a mental health problem.

What is a mental health assessment?

Assessment is a method of gathering information in a structured and comprehensive manner. Mental health assessment is a comprehensive, holistic assessment based on the person’s developmental, family, social, medical, recreational and employment history. It includes an MSE and history of current functioning and presenting problems (see Figure 4.1). The person and family members or carers may contribute perspectives to this assessment. Other standardised assessments (such as specific cognitive or family assessments) may form a part of a comprehensive mental health assessment. An MSE (also referred to as a mental state assessment (MSA)) is a semistructured interview to assess another person’s current neurological and psychological functioning across several dimensions, such as perception, affect, thought content, form of thought and speech. An MSE forms only part of an overall mental health assessment. For specialised health professionals, including mental health nurses and psychiatrists, the gathering of data for a complete mental health assessment is part of their daily practice. For other health workers, such a comprehensive assessment may not be within their scope of practice, and a careful MSE can aid them in providing information to the mental health treating team in order to follow up concerns about a person’s mental state. An MSE can occur at a first meeting as part of a first presentation assessment, during an admission interview, or at any time while 32

Chapter 4  Mental health assessment

Mental health assessment

Mental state examination (MSE)

Background

- Appearance, activity and behaviour

- Recent and relevant past life events

- Conversation, affect and mood

- Personal

Strengths/ resources

- Social connectedness - Access to resources

- Family

- Thought form, content and process

Challenges/ threats

- Risk - to self - to others - Social isolation - Few resources

- Perceptions - Conscious awareness - Insight - Judgment - Memory Figure 4.1  Mental health assessment 

communicating with a person. It gathers information about the person’s experience and history, with the aim of making informed judgments about their need for care and options for care delivery. An MSE is a ‘point in time’ assessment and needs to be conducted at regular intervals, as a person’s mental state may alter or deteriorate rapidly. An initial MSE forms the benchmark for future assessments.

Why assess?

Reasons for assessment include to: engage with the person in a helpful way collect information about the person

■ ■

33

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allow the person to ‘tell their story’ (i.e. their understanding of what is happening for them) ■ decrease anxiety in the person ■ validate that the information they have provided is accurate ■ gain a full health picture and make a formulation ■ develop an action or treatment plan with the person. ■

Settings for a mental state examination

The context for assessment will vary according to the setting (e.g. emergency department, community health centre, acute inpatient unit, ambulance call to home, police attendance). Try to find a quiet and safe place to provide privacy and encourage the person to engage with you. Establishing a relationship with the person is essential to gain trust and rapport. This may not be possible if you are in a public place. Remember to assess and maintain your own safety before approaching people in distress. Approach slowly but confidently, and be careful not to invade their personal space.

Cultural issues

It is important to ensure enquiries are made regarding the person’s main language spoken and if an interpreter may be required. Religious beliefs may also need to be considered. Factors such as the person’s gender and culture and the context in which the assessment is being undertaken need special consideration in order to provide culturally appropriate care. (See Chapter 5 for further detail about cultural issues.)

How to talk to family and friends

While your focus is on the individual in care, be aware of the needs of family and friends to be informed about what is going on. When talking to family and friends: ■ offer reassurance and understanding ■ listen to their perspective and acknowledge their concerns.

Essential mental state examination skills Essential skills include:

Always introduce yourself. For example, ‘My name is … and I am a nurse/police officer/ambulance officer/youth worker …’

■

34

Chapter 4  Mental health assessment

Allow a greater than normal personal space. Listen carefully. ■ Be polite and gentle in your demeanour, but also be clear and direct. ■ Observe non-verbal behaviour. ■ Be honest in your responses. ■ Keep communication open and allow the person to explain what they think is the current problem. ■ Focus your attention on the person (be ‘in the moment’ with the person). ■ Bear in mind that the person may be anxious or fearful. ■ Focus on the content of the person’s conversation, as well as the associated feelings (e.g. sadness, anger) and thoughts (unusual ideas). ■ Ask open questions first. Focus on specific, closed questions later on. ■ Use paraphrasing to convey to the person that you understand how they are feeling—for example, ‘So you say this is the worst you have ever felt? Have I got this right?’ ■ Don’t make promises you cannot keep. For example, don’t agree you won’t tell anyone else what the person has told you. ■ ■

Box 4.1 provides tips about taking a good history.

The basics and purpose of the mental state examination

The basics of an MSE are to: ■ closely observe and evaluate the person’s appearance and behaviour ■ listen attentively to the content of speech, which usually reflects thoughts and thinking ability ■ ask specific questions about the person’s thoughts, feelings and perceptual experiences ■ document your assessment and determine a plan of action. Remember that undertaking an MSE is not an end in itself. Conducting an MSE provides the framework for your plan of care. Its purpose is to: ■ clarify the nature of a person’s mental health problems ■ evaluate a person’s present mental state 35

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

Box 4.1

History taking tips 

Begin with questions such as ‘What seems to be the problem today?’ or ‘What can I help you with today?’

■

Look like you are listening!

■

Be empathetic and acknowledge how the person is feeling.

■

Repeat the person’s statements.

■

Use open and closed questions to gain information.

■

Clarify if needed.

■

Take notes and tell the person why you are writing things down.

■

Show that you care by displaying your concern.

■

Make sure that you understand the core complaint.

■

If there are multiple concerns ask the person to rank them in order of importance.

■

identify areas for immediate intervention (e.g. relapse) provide a baseline so that a future MSE can evaluate changes in the person’s condition and responses to treatment.

■ ■

The components of a mental state examination

Figure 4.2 illustrates the eight components of an MSE, beginning with appearance, physical activity and behaviour, then moving to observations that can be made before and during conversing with the person and continuing through to insight and judgment assessments.

1.  Appearance, physical activity and behaviour Appearance

The purpose of this section of the MSE is to describe the general appearance of the person to get a sense of their ability to conduct their personal activities of daily living and the appropriateness of their attire. Noting physical characteristics can be useful (e.g. for future identification). The following can be noted: gender and ethnicity general appearance, chronological age and apparent age ■ physical characteristics, such as body build, posture and any distinguishing marks ■ ■

36

Chapter 4  Mental health assessment

Components of the mental state examination (MSE) Appearance, physical activity and behaviour Conversation, affect and mood

Memory

MENTAL STATE EXAMINATION

Judgment

Thought: form, content and process

Perceptions

Insight Conscious awareness

Figure 4.2  Components of a mental state examination 

clothing, including condition of clothes, cleanliness and appropriateness to weather conditions ■ grooming, including peculiarities of dress, use of cosmetics, jewellery and hairstyle ■ gait (how a person walks). ■

Physical activity and behaviour

The aim of this section is to describe what the person does in terms of observable behaviour, manner and attitude. Record your observations of: ■ posture, gait, gestures, tics, grimaces, tremors and mannerisms ■ activity (e.g. overactive or underactive, purposeful or disorganised, pacing, restless, sedentary) 37

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

any signs of physical slowing down facial expression (e.g. alert, tense, worried, happy, sad, frightened, angry, laughing, smiling, suspicious) ■ rapport with the interviewer (friendly, aloof ) ■ attitude during the interview (e.g. indifferent, friendly, dramatic, evasive, sullen, irritable, afraid, impulsive, embarrassed, sexually provocative). ■ ■

2.  Conversation, affect and mood Conversation

This section includes how the person talks (e.g. quantity, rate, volume). Use the following prompts as a guide: ■ Is the person’s conversation soft, loud, stuttering or hesitant? ■ Is the flow of speech even or uneven, slow or rapid? ■ Does the person’s conversation contain references to disordered, negative, unrealistic or unusual thoughts? Affect

Affect refers to the feeling or emotional state inferred by the assessor on the basis of the person’s statements, appearance and behaviour. Table 4.1 lists a range of descriptors for affect. Other descriptors include aloof, apathetic, complacent, composed, dull, elated, grandiose, tense, worried and euthymic (normal mood).

TABLE 4.1  Descriptors for affect Affect

Descriptor

Full range

What would normally be expected in variations of facial expression and gestures

Blunted

Reduction in the emotions expressed or low intensity

Flat

Absence or near absence of expressed emotion

Inappropriate or incongruent

Outward expression of the emotional state is not congruent with what the person is expressing

Labile

Expressed emotion fluctuates or is variable beyond normal expression

Restricted

Limited variability of expressed emotion

38

Chapter 4  Mental health assessment

Mood

Mood refers to the person’s subjective statement about their emotional state—their own description of their internal feeling or emotion. Mood might be either: ■ depressed, happy or sad ■ neutral or apathetic ■ irritable, anxious or angry, or ■ fearful or euphoric.

3.  Thought: form, content and process Thought form

Form refers to the amount of thought and its rate of production, such as: ■ lack of ideas (cannot identify any thoughts) ■ flight of ideas (cannot remain on one topic) ■ loose associations (thinking jumps around without apparent connection) ■ slow or hesitant. Thought content

Content refers to the topics or areas that one thinks about. Assessment involves making a judgment about what the person is saying. Does it make sense? Are the ideas related and do they flow logically from one to the next? For example, is the person experiencing any delusional thinking? Is the person ruminating about particular ideas. It is vital to ask the person if they have suicidal, self-harm or homicidal thoughts. Delusions

Delusions are known as fixed false beliefs, or uncompromising beliefs held in the face of incontrovertible evidence to the contrary, and are not consistent with one’s cultural or religious beliefs. Examples of delusions are: Persecutory delusions. The person has thoughts that life events are in the form of punishment for past wrongdoings. ■ Grandiose delusions. The person believes they possess unusual talents, virtue, insight or identity. ■ Delusions of reference. The person believes ordinary events have special meaning or significance only intended for themselves. ■ Delusions of influence. The person believes others are controlling or manipulating them. ■

39

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

Religious delusions. The person believes they have a special link with a deity. Delusions can also involve the following: ■ Thought insertion. The person believes others are putting thoughts into their head. ■ Thought broadcasting. The person believes others can hear or know what they are thinking. ■ Thought withdrawal. The person believes someone is taking away his or her thoughts. ■

Obsessions

Obsessions are involuntary and unwelcome ideas that intrude on the person’s other thoughts that then demand their attention even though the person may recognise them as irrational (e.g. a fear of being contaminated when touching door handles or other surfaces). Compulsions

Compulsions are insistent, repetitive and unwanted urges to perform a certain act (e.g. wash their hands 10 or more times after going to the toilet). Thought process

Thought process refers to the movement and dynamics of how one thought connects to the next. They may be: ■ Logical thought. Analyses are well founded and make sense. ■ Loose associations. Thinking is disorganised and jumps from one idea to another with little apparent connection. ■ Word salad. Real words and sometimes neologisms are used, but there is no connection between the words that convey any sense of meaning to the listener. ■ Echolalia. The person repeats what is said to them. ■ Clang association. One word follows the next based on similarity of sound or rhyming. ■ Perseveration. The person continues to repeat an idea, phrase or word, and has trouble shifting to a new thought or idea.

4.  Perceptions

Perceptions refer to the person’s experience of their world through their senses (their interpretation). The following experiences are false or misperceptions usually associated with mental illness. 40

Chapter 4  Mental health assessment

Hallucinations

A hallucination is a false sensory perception that occurs without an actual external stimulus. Hallucinations can involve all five senses: ■ Auditory. These are the most common type of hallucination and often involve voices but can also be humming, tapping, music or laughing. ■ Visual. These are common in mental disorders with a physical cause (e.g. substance abuse) and involve seeing objects, people or images that others are not able to see. ■ Olfactory. These are common in mental disorders with a physical cause and involve smelling things that do not exist (e.g. gas from the gas fire or oven, but it is important to check that the gas has not in fact been left on). ■ Gustatory. These are most common in organic mental disorders and involve a sense of an unexplained taste in the mouth. ■ Tactile. These are commonly experienced during a delirium, and involve a false perception of touch or sensation (e.g. insects crawling on or under the skin). Illusions

An illusion is a misinterpretation of an actual external stimulus (e.g. seeing a coat hanging on the wall and thinking that it is a person standing in the room). Depersonalisation

Depersonalisation refers to a feeling of unreality where the perception of self seems different or unfamiliar (e.g. a person may describe a sense of not being a part of their body or having an out-of-body experience). This sensation is often associated with stress, fatigue and extreme anxiety. Derealisation

Derealisation refers to the sense that the external world feels unreal, different or altered. People report feeling distanced or cut off from the world. This experience is also associated with stress, fatigue and extreme anxiety.

5.  Conscious awareness Level of consciousness

Level of consciousness refers to the overall state of alertness, and may be: ■ Alert. The person is awake, fully aware and responsive. ■ Lethargic. The person is drowsy but responds when spoken to. They may fall asleep. 41

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

Stuperous. The person is difficult to rouse, may groan or may become restless when attempts are made to rouse them. ■ Coma. The person is unresponsive to voice or painful stimuli. ■

Orientation

This includes orientation to: ■ Time. This includes orientation to hour, day and month, or whether they can identify the prime minister or state or territory leader. ■ Place. This relates to whether the person can identify which hospital, city and country they are in. ■ Person. This relates to orientation to self or others. Concentration

Concentration is usually assessed by asking the person to count back from 100 in serial sevens (ask the person to take seven from 100, seven from 93 etc.), spell ‘world’ backwards or repeat a three-part task. Abstract thinking

Abstract thinking refers to the ability to deal with concepts and to extract meaning or to juggle more than one idea at a time. Asking the person to explain the meaning of a common proverb is a good way to assess abstract thinking ability. Examples are: ■ All that glitters is not gold. ■ When the cat’s away the mice will play. ■ Don’t count your chickens before they hatch. ■ A stitch in time saves nine. ■ Don’t put all your eggs in one basket. ■ Strike while the iron is hot. ■ Rome wasn’t built in a day.

6.  Insight

Insight is the degree to which the person realises the significance of their symptoms or illness and their current situation, or the degree of selfunderstanding. Consider the following: Is there an appreciation of how their illness may affect their life? Do they think they have an illness? ■ Do they have full or partial understanding of their situation? ■ Are they able to explain why an ambulance has been called? ■ ■

42

Chapter 4  Mental health assessment

7.  Judgment

Judgment is the ability to make sensible decisions based on expected consequences in everyday activities and social situations. Consider the following: ■ Are judgments socially appropriate? ■ Are judgments about personal relationships appropriate? ■ Is the person able to manage his or her own finances?

8.  Memory

Memory includes: ■ Remote past recall. This is the ability of the person to present a coherent life story with dates and places (e.g. birth, employment, relationships). ■ Recent past recall. This is the ability of the person to recall the history and events leading to their hospitalisation. ■ Immediate past recall. This is the ability of the person to recall a person’s name and three unrelated facts five minutes after being given them.

Summary

An MSE should include a summarising statement containing a formulation of what the central issues are and the reasons for admission, and a brief problem list. For further detail, see Elder et al (2012).

Additional information required for a mental health assessment Presenting information

For the overall mental health assessment, a statement is required of the actual reason for the presentation, the nature of the presenting problem and the history of the presenting problem, including precipitating factors and recent stressors. In particular: Note the history of compliance with the current treatment regimen if any. ■ Identify if there are any urgent social issues that may need to be addressed. ■ Provide a brief outline of the support structures available to the person. ■

43

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

CASE STUDY:

a mental state examination Phillipa is a single 31-year-old female with previous admissions to psychiatric hospitals for relapse of schizophrenia. Phillipa has called an ambulance at 7.30 pm because she is convinced there is a man outside her house who is spying on her. She asks the ambulance staff to find the man and call the police to take him away. Appearance, physical activity and behaviour Phillipa answers the door in her pyjamas and a dressing gown. Her hair is not brushed, but she appears clean and appropriately dressed for a cool autumn evening. Her height is about 162 cm, and she has a slim build. She exhibits a closed posture, sitting hunched up on her lounge, rocking slightly and chewing skin around her fingernails. There is occasional appropriate but brief eye contact. She appears tense and anxious. The living room is clean but untidy. There are few furnishings and the curtains are drawn (but it is dark outside). She admits to keeping the curtains drawn during the day. Conversation, affect and mood Phillipa is softly spoken and her conversation exhibits normal rate and flow. Her main concern is that a man is waiting outside and she thinks he is going to break in and hurt her. Because of this, she is sleeping poorly and refuses to leave the house. She exhibits labile affect and pervasive anxiety. She is suspicious of ambulance staff and tearful at times. She is responding minimally to verbal reassurance. Thought: form, content and process Thought form appears normal. For thought content, there is a preoccupation with the man who she thinks is outside her house. She has been outside to check but thinks he hides when she ventures out. Perceptions Phillipa describes feeling outside her body (depersonalisation) and being cut off from the world (derealisation). Conscious awareness Phillipa is alert and oriented to time, place and person. Her memory is fully intact. Her concentration is poor and she is easily distracted (e.g. by street noise). Insight Phillipa does not relate her belief of being watched by a stranger to her mental illness. Judgment Phillipa’s judgment is impaired due to her mental state. She is unwilling to leave her house and is unable to plan her day because she is persistently worried about being harmed.

Chapter 4  Mental health assessment

Identify the person’s strengths and any predisposing, precipitating and perpetuating factors.

■

Medical history

Medical history includes: ■ previous operations, illnesses and admissions to hospital ■ family history of illness, medications and allergies ■ drug and alcohol use ■ nutritional state (weight gain/loss), energy levels, sleep/rest patterns and exercise levels.

Psychiatric history

This section includes a brief summary of: ■ any episodes of illness, including admissions to inpatient units and types of treatments/interventions that were helpful or unhelpful ■ attitude to mental health services and treatment ■ premorbid personality and level of functioning ■ family history ■ current mental health services involved in care.

Risk assessment

The mental health assessment should include a risk assessment, including risk of harm to self or others, risk of falls and risk of poor nutrition.

Social history

Social history includes: ■ developmental history (childhood illnesses, life events, education) ■ current family structure (marital status, dependants, significant relationships) ■ housing situation ■ social supports, employment and occupational history ■ financial situation ■ forensic history/legal issues ■ spiritual and cultural considerations. It is important to identify a person’s personal strengths and resources as well as challenges in order to gain a holistic person-centred assessment. 45

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

Conclusion

This chapter has provided the essential elements of a mental health assessment. Careful gathering of information and engagement with the person will allow useful care to be planned in partnership. It is important to practise assessment skills to become proficient in this activity. REFERENCES Elder, R., Evans, K., & Nizette, D. (2012). Psychiatric and mental health nursing (3rd ed.). Sydney: Elsevier.

WEB RESOURCES Palmerston Association Inc. . Understanding the Mental State Examination (MSE): a basic training guide is funded by the Australian Government under the Improved Services for People with Drug and Alcohol Problems and Mental Illness through the Department of Health and Ageing. The Kessler Psychological Distress Scale. . The Kessler (K10) measure is a 10-item self-report questionnaire intended to yield a global measure of ‘psychological distress’ based on questions about the level of anxiety and depressive symptoms in the most recent four-week period. Mini mental state examination. . The MMSE is a commonly used instrument for measuring cognitive function.

46

CHAPTER

5

 

Culture and mental health

Introduction

In this chapter the social construct of culture is defined and ways of engaging with consumers who have mental illness or mental health problems, which take into account the person’s cultural background, are examined. The New Zealand model of ‘cultural safety’ is presented as an exemplar of how mental health professionals can practise in ways that demonstrate cultural competence, and how mental health services can provide a culturally inclusive environment in which mental health care and treatment can be delivered. Practical examples of culturally competent practice and culturally inclusive environments are also included.

What is culture?

Culture is a socially defined, dynamic and ever-changing phenomenon that refers to the history, beliefs, language, practices, dress and customs that are shared by a group of people, and that influences the behaviour and values of the members. There is a caveat on this definition, though, because it cannot be assumed that all members of one culture necessarily share identical worldviews on any or all issues. This is particularly so for second-generation immigrants who move between their culture of origin at home and the adopted culture in which they live. Consider, for example, a young person who was born in Australia to Vietnamese parents who immigrated in the 1980s. The young person moves between the Vietnamese culture at home and the wider Australian culture outside the home. Consequently, their cultural practices will be influenced by the context and environment in which they occur. Commonly, culture is equated with ethnicity, but this is a limited interpretation. Other cultural groupings also exist based on social demographics. Box 5.1 lists examples of social groups that are united by shared understandings that influence worldview, norms and social interactions. 47

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

Box 5.1

Examples of social groups united by shared understandings

Cultural groups can be defined by: ethnicity (a common shared view about ancestry)

■

race (biologically determined by genetic inheritance)

■

sex (biologically determined—male/female)

■

gender (cultural understandings of masculinity and femininity)

■

sexual orientation (gay, lesbian, bisexual, heterosexual)

■

life-span phase (infancy, old age)

■

religion and spirituality (organised/informal)

■

geographic location (metropolitan, regional, remote)

■

socioeconomic status.

■

Cultural diversity in Australia and New Zealand

For more than 200 years immigration has expanded the populations of Australia and New Zealand and thereby contributed to the diverse ethnic cultural make-up of these two nations. In 2011 the population of Australia was approximately 20 million, with 2.5% identifying themselves as Indigenous Australians, 30.2% as being born overseas and 46.3% with at least one parent born overseas. Collectively, Australians speak more than 200 languages (50 of which are indigenous) and 23.2% of Australians speak a language other than English at home (Australian Bureau of Statistics 2011). Similarly, in the New Zealand population of 4.3 million people, 14.6% are Māori and 67.7% are of European descent, with the remaining 17.8% comprising Asian, Pacific and African peoples. Additionally, 23% of New Zealanders were born overseas and 17.5% of people speak two or more languages (Statistics New Zealand 2006). And when the diversity of other cultural groups (as outlined in Box 5.1) is added to the ethnic diversity of these two nations, it is clearly evident that cultural diversity is a defining feature of both Australia and New Zealand.

Culture and risk of mental illness

Some people, as a consequence of their cultural heritage and history, are at increased risk of being diagnosed with a mental illness. Colonisation, 48

Chapter 5  Culture and mental health

Box 5.2

Risk factors for diagnosis of mental illness

Risk factors include: previous experience of trauma or flight

■

experience of racism or discrimination

■

cultural bereavement or dislocation from community

■

lack of cultural capital within the community (established networks)

■

experience of institutional racism and lack of cultural competence within the health system

■

change of traditional roles within the family, and lack of social and family support networks

■

loss of status (e.g. employment)

■

loss of self-esteem, feelings of powerlessness and communication difficulties.

■

for example, has had a devastating effect on the health of the indigenous peoples of Australia and New Zealand. At particular risk are people from backgrounds that are culturally and linguistically diverse (CALD) from the mainstream dominant culture, including immigrants, refugees and indigenous peoples. In Australia the National Health and Medical Research Council (2006 p 19) identified the risk factors in Box 5.2 as increasing a person’s risk for mental illness.

Explanatory models of mental illness

It is important to recognise that, in the main, theories of mental illness were developed in the Western world, which for the most part is composed of individualistic cultures—that is, a society in which the smallest socioeconomic unit is the individual and the autonomy of the individual is paramount (Rothwell 2010 p 22). Different interpretations of health and explanations for mental illness exist between cultures that are individualistic and cultures that are collectivist—that is, a society in which the smallest socioeconomic unit is the family and commitment to the group is paramount (Rothwell 2010 p 22). Western medicine, with its individualistic view of health, ascribes responsibility for health to the individual, whereas collectivist cultures emphasise the role of family and community. For example, traditional Māori beliefs regard health as being influenced by the four domains of mind, spirit, family (extended) and the physical world (Ministry of Health 49

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

2013). Consequently, caution must be exercised when applying theories from Western medicine, which are derived from research conducted in individualist societies, to people from collectivist societies such as Australian Aboriginal or Torres Strait Islander peoples, New Zealand Māori, immigrants and refugees. Also, in practice, this may mean that decisions about mental health care and treatment for a person whose culture is collective will be made by the extended family and not by the individual, as is the practice in Western individualised cultures. Furthermore, in traditional Australian Aboriginal culture illness, including mental illness, is usually attributed to external forces or reasons. This, therefore, makes the Western model of attributing mental illness to an internal disease process inappropriate or irrelevant to the beliefs of most Aboriginal people (Westerman 2010). Additionally, some phenomenon, such as seeing the spirit or hearing the voice of a deceased loved one, is a common experience for Aboriginal people (Aboriginal Mental Health First Aid Training and Research Program 2008), yet this could be diagnosed as a hallucination by Western medicine.

Cultural safety

The Aboriginal Health Council of Western Australia (2013) in its Cultural Safety Training Program uses the definition proposed by Williams, who said cultural safety is: … an environment, which is safe for people; where there is no assault, challenge or denial of their identity, of who they are and what they need. It is about shared respect, shared meaning, shared knowledge and experience, of learning together with dignity and truly listening. (Williams 1999 p 2)

Cultural safety is a concept derived from the discipline of nursing in New Zealand in the late 1980s in response to recruitment and retention issues regarding Māori nurses, and the poor health status of New Zealand’s indigenous people. The model integrates cultural safety with the Treaty of Waitangi and Māori health. Previously, professional codes of ethics directed health professionals to care for people regardless of their sex, race, culture, educational or religious backgrounds, whereas the New Zealand cultural safety model directs nurses to take regard of these by acknowledging and responding to difference, and to ‘take into account all that makes [human beings] unique’ (Nursing Council of New Zealand / Te Kaunihera Tapuhi o Aotearoa 2011 p 7). The New Zealand model comprises three phases of preparation for culturally safe practice (see Table 5.1). First, cultural awareness sensitises 50

Chapter 5  Culture and mental health

TABLE 5.1  Phases of preparation for culturally safe health care practice Phase

Description

Cultural awareness

Awareness of difference and own cultural heritage

Cultural sensitivity

Acceptance of the legitimacy of difference

Cultural safety

Occurs when the consumer perceives health care to be delivered in a manner that preserves and respects cultural heritage

Source: Nursing Council of New Zealand / Te Kaunihera Tapuhi o Aotearoa 2011

students and health professionals to their own cultural heritage and to difference. This is followed by cultural sensitivity, which alerts students and health professionals to the legitimacy of difference, and, finally, cultural safety is achieved when the consumer perceives that the health care was delivered in a manner that respected and preserved their cultural integrity. This is an important feature of the New Zealand model (i.e. that cultural safety is identified by the consumer, not the health professional providing care). It is the consumer who determines whether or not they have been cared for in a culturally appropriate (safe) way. Finally, the model requires not only that the health professional be culturally competent but also that the health service provides a culturally inclusive environment.

Cultural competence

Culturally competent health professionals possess a set of qualities that enable them to deliver care in a culturally safe manner. They possess the attributes outlined in Box 5.3.

A culturally inclusive environment

A culturally inclusive environment is one in which the organisation has structures in place to ensure difference is respected, discrimination is not tolerated and the special needs of people from culturally diverse backgrounds are accommodated. It possesses the attributes outlined in Box 5.4.

Working with people from an indigenous or CALD background

When working with people from an indigenous or CALD background, it is important to be prepared. Use the information in Boxes 5.3 and 5.4 to reflect on your own cultural competence, and to assess how culturally inclusive your workplace is. Additionally, you can prepare yourself by undertaking training courses (e.g. a ‘cross-cultural competency’ or a 51

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

Box 5.3

Cultural competence: required values of health professionals

A culturally competent health professional is: aware of, respects and accepts difference, including

■

• an awareness of their own ancestral history • an awareness of their own values and what shapes them • a non-judgmental attitude (difference is neither right nor wrong) • an ability to treat others with respect flexible and responsive to the unexpected

■

willing to learn and undertake continuing professional development

■

willing to work with ambiguity

■

able to manage the dynamics of difference

■

confident in working with people from CALD backgrounds and other cultures

■

able to be an advocate with or on behalf of consumers.

■

Sources: Goode 2008, National Health and Medical Research Council 2006

Box 5.4

Features of a culturally inclusive environment

A culturally inclusive environment is one in which: difference is acknowledged, valued and respected

■

difference is accommodated (i.e. the organisation is structured to respond to individual needs, such as access to interpreters and gender-appropriate health professionals)

■

policies are in place to protect individuals (e.g. equal opportunity) and these policies are followed, including consequences if they are not

■

cultural knowledge is institutionalised in policy and practice

■

cultural self-assessments are conducted

■

consumers and staff feel free to

■

• express their cultural identity • express their opinions and values • engage in cultural practices (e.g. prayer) • feel safe from unfair criticism, abuse or harassment. Sources: Flinders University 2012, Goode 2008

52

Chapter 5  Culture and mental health

‘working with an interpreter’ course) and by becoming familiar with the indigenous and multicultural services in your organisation and within the community. These services and agencies can assist communication and understanding. Importantly, avoid using stereotypes, be flexible in your approach, demonstrate a willingness to learn and be open to the fact that the person’s view of health may differ from your own and/or the mainstream view. Nevertheless, while a cultural safety model directs health professionals to seek understanding of difference, and to accept and work with difference, such acceptance must not be undertaken in the absence of critique. Some practices, which are purported to be cultural, can transgress the values and laws of the wider society. For example, customs like denying education to girls, or sexual relationships between adults and children, must be challenged, rather than accepted without being questioned.

Working with interpreters

When English is not the consumer’s first language or a cultural consultant is required, an interpreter can facilitate communication and understanding (including verbal, non-verbal and written). This applies to indigenous peoples as well as consumers from a CALD background. When available, always use a professionally trained interpreter, either in person, via a telephone interpreter service or via a teleconference. Avoid using family CASE STUDY:

New Zealand Māori Traditional Māori views of health acknowledge the link between the mind, the spirit, the connection with family (whānau) and the physical world in a way that is seamless and natural. Until the introduction of Western medicine, there was no division between these four domains. Consequently, Māori philosophy towards health is based on a wellness (holistic health) model in which whānau (family health), tinana (physical health), hinengaro (mental health) and wairua (spiritual health) comprise the four cornerstones (or sides) of Māori health. Many Māori believe the major deficiency in modern health services is in taha wairua (the spiritual dimension). Māori view mental health as the capacity to think, and to feel that mind and body are interconnected and one, and therefore inseparable. Thoughts, feelings and emotions are integral components of the body and soul. This is how Māori see themselves in the universe, how they interact with that which is uniquely Māori, and the perceptions that others have of Māori (Ministry of Health 2013).

53

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

Box 5.5

When to engage an interpreter

When the person requests one

■

When health care staff cannot understand the client

■

At intake or admission to the health service

■

During assessment, including initial assessment and mental status examination

■

During ongoing treatment

■

For family assessment

■

During specialist and multidisciplinary assessments

■

For explanation of assessment outcomes, diagnosis, treatment, medication and/or side effects

■

To explain legal rights and changes of legal status

■

When obtaining informed consent for procedures deemed necessary

■

For risk assessment

■

In a crisis situation

■

When debriefing clients following critical incidents

■

In ongoing reviews whether at the service agency or during a home visit

■

For the development of an individual service plan or individual program plan and including allied health programs and interventions

■

For discharge planning

■

In monitoring clients who are in inpatient units or receiving intensive treatment

■

During rehabilitation and disability support process sessions

■

In related settings such as in child and adolescent mental health services (CAMHS)

■

Case conferences at schools and other agencies that involve the client and family

■

Source: Victorian Transcultural Psychiatry Unit 2006

members or ancillary or other staff members, except in an emergency. They may have a conflict of interest or may not be able to accurately translate medical or psychiatric terminology, and the consumer may withhold information because of their relationship with the person. See Boxes 5.5 and 5.6 for guidelines regarding working with an interpreter and when to engage one. 54

Chapter 5  Culture and mental health

Box 5.6

Guidelines for conducting an interview with an interpreter

Pre-interview Always use a professionally trained interpreter, except in an emergency.

■

Be prepared. Have the interpreter service and telephone interpreter service contact details on the health unit’s list of frequently used numbers.

■

If possible, book the interpreter well in advance to ensure the availability of the most suitable interpreter.

■

Match the consumer and interpreter as closely as possible. Seek more than a language match. Consider also ethnicity, religion, migration history and political context.

■

Avoid using family members or ancillary or other staff members, except in an emergency.

■

Consider whether the interpreter needs to be a specific gender. Ask the consumer about gender preference.

■

Check whether the interpreter and the consumer know each other socially or have a relationship.

■

Optimise seating and other spatial arrangements.

■

Set a time for a pre-brief and post-interview discussion with the interpreter.

■

Consider safety. Identify a code word to use if the meeting needs to be stopped.

■

During the interview Introduce everyone and their role.

■

Explain the purpose of the interview.

■

Explain that confidentiality will be observed.

■

Explain that the interpreter and the health professional may take notes during the interview.

■

Explain that everything will be translated.

■

Ensure that only one person speaks at a time.

■

Address questions to the consumer, not the interpreter. Speak to the consumer in the first person.

■

Look at the consumer when the interpreter is reporting the consumer’s response.

■

Avoid using technical language, jargon or slang.

■

Use short sentences and pause frequently to enable the interpreter to translate.

■

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Box 5.6

Guidelines for conducting an interview with an interpreter—cont’d

Post-interview Have a debrief discussion with the interpreter.

■

Give and seek feedback on how the interview went.

■

Ask the interpreter for their comments and concerns.

■

Identify safety issues.

■

Source: Victorian Transcultural Psychiatry Unit 2006

CASE STUDY:

Indigenous Australians Generally, Australian indigenous culture is holistic; therefore, concepts of mental illness must ‘take into account the entirety of one’s experiences, including physical, mental, emotional, spiritual and obviously cultural states of being’ (Westerman 2010 p 215). Indigenous Australians attribute illness to external events, which are likely to be culturally based, with mental illness viewed as a sickness of spirit, heart and mind. Common attributions for illness, including mental illness, are ‘doing something wrong culturally’ or ‘being paid back’ for wrongdoing. This reflects the intertwining of spirituality and particularly relationships with family, land and culture (Westerman 2010).

Conclusion Like health care in general, culturally safe mental health care is based on social justice and equity principles that advocate the importance of knowledge acquisition, mutual respect and negotiation (Multicultural Mental Health Australia 2002). This chapter has outlined strategies that facilitate culturally safe mental health care and has presented the New Zealand model of cultural safety as a framework for providing culturally appropriate care and treatment in mental health settings. The model proposes that for health services to be culturally safe, they need to be provided in an environment that is culturally inclusive and delivered by health professionals who are culturally competent. The model is equally applicable in mental health contexts as it is in general health settings. 56

Chapter 5  Culture and mental health

REFERENCES Aboriginal Health Council of Western Australia. (2013). Cultural Safety: working better in Aboriginal and Torres Strait Islander health. Online. Available: 22 Aug 2103. Aboriginal Mental Health First Aid Training and Research Program. (2008). Cultural considerations and communication techniques: guidelines for providing mental health first aid to an Aboriginal or Torres Strait Islander person. Melbourne: Aboriginal Mental Health First Aid Training and Research Program. Australian Bureau of Statistics (ABS). (2011). Census data 2011. Online. Available: 22 Aug 2013. Flinders University. (2012). Cultural diversity and inclusive practice toolkit. Adelaide: Flinders University. Online. Available: 22 Aug 2013. Goode, T. (2008). Diversity across the physician education continuum: the role of cultural competence in faculty development. Washington DC: National Center for Cultural Competence. Ministry of Health. (2013). Māori Health. Online. Available: 22 Aug 2013. Multicultural Mental Health Australia (MMHA). (2002). Cultural awareness tool: understanding cultural diversity in mental health. Sydney: MMHA. National Health and Medical Research Council. (2006). Cultural competence in health: a guide for policy, partnership and participation. Canberra: NHMRC. Nursing Council of New Zealand (NCNZ) / Te Kaunihera Tapuhi o Aotearoa. (2011). Guidelines for cultural safety, the Treaty of Waitangi and Māori health in nursing education and practice (2nd edn). Wellington: NCNZ. Online. Available: 22 Aug 2013. Rothwell, J. D. (2010). In the company of others. New York: Oxford University Press. Statistics New Zealand. (2006). Census 2009. Online. Available: 22 Aug 2013. Victorian Transcultural Psychiatry Unit (VTPU). (2006). Guidelines for working effectively with interpreters in mental health settings. Melbourne: VTPU. Online. Available: 1 Jun 2013. Westerman, T. (2010). Engaging Australian Aboriginal youth in mental health services. Australian Psychologist, 45(3), 212–222. Williams, R. (1999). Cultural safety: what does it mean for our work practice? Darwin: Northern Territory University.

WEB RESOURCES Australian Indigenous Healthinfonet. . This site provides comprehensive and up-to-date information for everyone interested in the health of indigenous Australians. It aims to contribute to ‘closing the gap’ in health between indigenous and non-indigenous Australians by informing practice and 57

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

policy in indigenous health by making research and other knowledge readily accessible. Māori Health. . This site provides information about Māori health and highlights the policies, programs and people who are addressing Māori health. Multicultural Mental Health Australia. . Multicultural Mental Health Australia provides national leadership in building greater awareness of mental health and suicide prevention among Australians from CALD backgrounds. Nursing Council of New Zealand / Te Kaunihera Tapuhi o Aotearoa. . This site provides guidelines for cultural safety, the Treaty of Waitangi and Māori health in nursing education and practice. Victorian Transcultural Psychiatry Unit (VTPU). . The VTPU is a statewide unit that supports area mental health and psychiatric disability support services in working with CALD consumers and carers throughout Victoria.

58

CHAPTER

6

 

An overview of mental illness

Introduction

This chapter provides a quick reference to the common mental illnesses that health professionals may come across in their daily practice. Incidence, aetiology (causation) and description of the major mental illnesses are covered, with reference to useful websites. The major mental illnesses include disorders of anxiety, mood, thinking and perception and personality disorders. Disorders specific to particular populations—the young, the elderly, those with intellectual disabilities and substance abuse disorders— are also described here, acknowledging that intellectual disabilities, delirium and substance abuse disorders are not mental illnesses per se, but are generally discussed in association with the diagnostic groups of mental illness. The National Survey of Mental Health and Wellbeing (Australian Bureau of Statistics 2008) found that almost half of the 16 million Australian population aged 16–85 years (45% or 7.3 million) had a lifetime mental disorder (i.e. a mental disorder at some point in their life). One in five (20% or 3.2 million) Australians had had a mental disorder within the 12 months preceding the survey.

Primary health care

Primary health care is the first point of contact for people and health professionals in community health centres; mental health issues are the second most common presenting comorbidity. General practitioners, practice nurses and mental health nurses as well as other allied health professionals are increasingly collocated, creating opportunities to provide care and information about mental health wellbeing to the general public. Primary health care principles include a person-centred approach that is holistic and aimed at promoting mental health and preventing the development of mental health issues. Practice nurses, as well as mental health nurses in general practice settings, have a vital role in undertaking comprehensive health assessments including mental state examinations. While people with serious mental illness are treated by specialist mental health 59

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professionals, the majority of people with mental health problems are cared for in the community.

Diagnostic classifications

There are two main classifications for diagnosising mental illness used around the world. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (known as DSM-5), which is published by the American Psychiatric Association (2013), is commonly used in most states and territories in Australia. This classification system assesses the consumer across five domains, which helps with treatment planning and outcomes. The International Statistical Classification of Diseases and Related Health Problems, 10th revision (known as ICD-10), which is published by the World Health Organization (2010), provides a listing of clinical diagnoses that are coded and is commonly used in Europe and the northern hemisphere, as well as in some states of Australia (e.g. Queensland). The 11th edition of the ICD is due out in 2015. While there is discussion about future classification systems referring more to the experience of mental illness and specific symptoms rather than definite categories of illness such as depression and schizophrenia, these categories remain the basis of diagnosis around the world at present. With that in mind, it is important to note that there is significant overlap between symptoms in mood disorders and other diagnoses such as personality disorders. Further, symptoms of anxiety can occur in a range of anxiety and depressive disorders. Finally, psychotic symptoms can occur in schizophrenic, depressive and bipolar conditions. In this chapter, the DSM-5 is referred to in relation to descriptions of the major mental illnesses and associated cognitive/neurological disabilities. However, this chapter is not meant to be a guide to the DSM-5 per se, but rather an overview of the common mental illnesses recognised today.

Anxiety disorders  Incidence

Approximately 10% of the population experience anxiety at a level that affects their daily life, with 2–4% having an anxiety disorder (Royal College of Psychiatrists 2013). Anxiety disorders are more common in females than males. Aetiology

There are several theories, including genetic, familial history, neurochemical (imbalance of the neurotransmitter serotonin), social/cultural factors and upbringing. 60

Chapter 6  An overview of mental illness

Generalised anxiety disorder

Generalised anxiety disorder is characterised by persistent and troublesome worrying for a period of more than six months independent of other mental health conditions (Bermak 2008). There is controversy concerning the validity of this diagnosis and that such people are in fact ‘the worried well’. However, the prevalence rate in general practice is estimated at 8% and these people present frequently for assistance to health services (Barton et al 2012). Symptoms

Symptoms are: ■ a feeling of being consistently on edge ■ irritability ■ poor concentration ■ physical tension. Prognosis

Early-age onset has poorer outcomes, high relapse rates and a substantial social and economic impact on the person. It tends to have a chronic fluctuating course. Approximately 50% of people will be free of symptoms within six months. The remainder, however, are left with a chronic and often disabling lifelong condition (Barton et al 2012).

Panic disorder

Panic disorder is different from the normal fear and anxiety reactions to stress in our lives. Symptoms of panic disorder include sudden attacks of fear and nervousness, as well as physical symptoms such as sweating and a racing heart. Symptoms need to be of more than a month’s duration, accompanied by significant behavioural changes due to the attacks and a preoccupation of concern or worry about having another attack. For a definition of panic attacks, see Chapter 7. Prevalence

Approximately 1% of the population have panic disorder (Barton et al 2012), which can have a serious deleterious effect on interpersonal relationships and work life. Panic attacks are sudden and highly distressing, and can last from a few seconds to up to 20 minutes or when help arrives. People with this condition may become socially isolated as they avoid stressful situations. Comorbid conditions such as depression are common. 61

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Phobias

A phobia is defined as a marked and persistent fear that typically lasts more than six months. Fear is cued by the presence or anticipation of a specific object or situation (e.g. flying, heights, animals, receiving an injection, seeing blood). Exposure to the phobic stimulus results in extreme anxiety. A useful mnemonic to remember the key elements necessary for a diagnosis of phobia is ‘PHOBIA’: P persistent H handicapping (restricted lifestyle) O  object/situation B behaviour (avoidance) I irrational fears (recognised as such by consumer) A anxiety response. For a diagnosis of a specific phobia, the person’s fear must result in significant interference with their functioning, not just distress. There are five subtypes of specific phobia, depending on the type of trigger: ■ animal: animals or insects ■ natural environment: for example, storms, heights and water (generally childhood onset) ■ blood/injections/injury: seeing blood or injury, or receiving an injection or other procedure (vasovagal fainting response) ■ situational: for example, bridges, elevators and flying ■ other: for example, choking, vomiting and contracting an illness. Often more than one type will be present. Features associated with specific phobias include a restricted lifestyle. Comorbid conditions include other anxiety disorders, mood disorders and substance-related disorders (Evans 2012 pp 321–325).

Agoraphobia

Agoraphobia is a specific fear of being in places or situations from which escape may be difficult. The term comes from the Greek agora, meaning marketplace, but typical agoraphobic situations include being home alone, queuing, being in a crowd or travelling on public transport.

Obsessive-compulsive and related disorders

Obsessive-compulsive disorder (OCD) is characterised by obsessions (persistent and recurrent intrusive thoughts or feelings perceived to be 62

Chapter 6  An overview of mental illness

inappropriate by the person) and compulsions (thoughts, actions and behaviours that the person feels compelled to undertake in order to reduce the anxiety experienced).This disorder is no longer listed in the chapter about anxiety in the DSM-5. Any reduction in anxiety is short-lived, and the obsessive thought and associated ritual compulsive behaviours recur, causing havoc in a person’s daily life. How common is it?

Between 2% and 3% of the population, with a complete remission rate of 10–15% (Albucher 2008). Prognosis

Cognitive behaviour therapy (CBT) with medication (antidepressants) is the best treatment for this disabling illness. Either CBT or medication alone is less successful, with relapse in more than 50% of cases. Comorbid substance abuse—in particular, alcohol—is common. Table 6.1 lists examples of common themes of OCD. Newly listed disorders in the DSM-5 include hoarding disorder and excoriation (skin picking) disorder. TABLE 6.1  Common themes of obsessive-compulsive behaviour Obsession

Compulsion

Contamination

Excessive handwashing

Pathological doubt

Checking the gas is off or the door is locked

Physical illness

Excessive visits to a general practitioner

Need for symmetry

Lining things up, straightening things, counting or checking excessively

Religious

Excessive recitation of the rosary

Post-traumatic stress disorder

It is now acknowledged that post-traumatic stress disorder (PTSD) can follow any traumatic event, particularly if the event was life-threatening. PTSD used to be called shell shock after soldiers from World War I returned emotionally scarred from their experiences. PTSD is no longer categorised in the DSM-5 with anxiety disorders as it is described under trauma and stressor-related disorders. 63

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Incidence

Incidence depends on the nature of the trauma. Incidence can be as high as 90% (e.g. in torture victims). Aetiology

Aetiology is a specific traumatic event. Major traumas can include natural disasters (e.g. bushfire, flood, earthquake), robbery, accidents such as train and plane crashes, sexual and physical assault, armed combat and torture. Diagnosis is made if symptoms persist for more than one month and are associated with significant impairment or distress to the person (Posner 2008). Symptoms

Symptoms are in four groupings focusing on the behavioural effects of symptoms, which are: intrusion; avoidance; negative alterations in cognitions and mood; and alterations in arousal and reactivity. Two new symptoms were also added: persistent and distorted blame of self or others; and reckless or destructive behaviour (American Psychiatric Association 2013). Prognosis

Untreated chronic PTSD may become less troublesome but not completely go away. Some people will remain severely disabled without treatment. Complete recovery occurs within six months in about half of all cases, with many others having symptoms for a year or longer after the trauma. Prognosis is worse if the person has experienced PTSD in the past (Barton et al 2012). Assessment scales

The Impact of Events Scale (http://academic.regis.edu/clinicaleducation/ pdf ’s/IES_scoring.pdf ) is a scale of current subjective distress related to a specific event, and is based on a list of items composed of commonly reported experiences of intrusion and avoidance.

Schizophrenia 

Schizophrenia is a severe mental disorder affecting approximately 1% of the population worldwide, beginning in the 16–35 age group. It occurs equally in males and females. Schizophrenia means different things for people with the condition. The diagnostic label refers only to the presence of a specific set of symptoms. 64

Chapter 6  An overview of mental illness

Aetiology

Aetiology is unclear, but there is some evidence of the following causes: ■ biological: abnormalities of dopamine and serotonin (neurotransmitters) ■ genetic: while no single genetic factor has been identified, identical and non-identical twins are more likely to develop the disease if their twin has it (i.e. more than the general population). Prognosis

Prognosis can be improved with early intervention and shorter periods of psychosis. However, a significant percentage of people have poor quality of life due to the chronic and debilitating symptoms of this condition (Bardwell & Taylor 2012). Diagnostic criteria

Diagnostic criteria (DSM-5) are two or more of the following for a significant proportion of time in the preceding month: ■ delusions, hallucinations, disorganised speech (at least one of these symptoms) ■ grossly disorganised behaviour ■ negative symptoms (flat affect, lack of volition) ■ social and occupational dysfunction ■ evidence of dysfunction in the previous six months. Symptoms of schizophrenia are often divided into two groups: positive and negative symptoms. Positive symptoms

Positive symptoms involve a loss of contact with reality and include hallucinations, delusions, thought disorder and disorders of movement. Negative symptoms

Negative symptoms refer to reductions in normal emotional and behavioural states including: ■ flat affect (immobile facial expression, monotone voice) ■ lack of pleasure in everyday life ■ diminished ability to initiate and sustain planned activity ■ speaking infrequently, even when forced to interact. People with schizophrenia may neglect basic hygiene and need help with everyday activities when acutely unwell. People with schizophrenia 65

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are sometimes perceived as lazy, as others do not recognise these behaviours as symptoms of schizophrenia. Assessment scales

Information about the Positive and Negative Symptoms Scale (PANSS) can be found online at .

Schizoaffective disorder

Schizoaffective disorder is characterised by the presence of symptoms of schizophrenia with an abnormal (elevated or lowered) mood.

Schizophreniform

Schizophreniform disorder differs only from the diagnosis of schizophrenia in that the duration of the symptoms is less than six months and functioning has not been negatively affected in the person.

Brief psychotic disorder

Brief psychotic disorder refers to a person experiencing a psychotic episode that endures for more than one day but less than one month.

Drug-induced psychosis

Drug-induced psychosis refers to a person presenting with symptoms of schizophrenia as a direct result of the ingestion of prescribed or nonprescribed medication.

Disorders of mood 

Between 3% and 5% of the population experience depression (Sadock & Sadock 2007). Among young people aged 12–25 years depression is the most common mental health problem. Depression is a leading cause of disability in the Western world. Aetiology remains unclear, but it is thought to be a combination of biological, environmental and psychosocial factors. It is more common in women than men and has a genetic component. Around 15% of people with a major depressive disorder take their own life. It can have a chronic pathway and is often associated with other chronic physical illnesses, such as cancer, stroke and Parkinson’s disease.

Major depressive disorder

Criteria for diagnosis of major depressive disorder (DSM-5) are at least five of the following present in the preceding two weeks, with a significant reduction in functioning:

66

Chapter 6  An overview of mental illness

depressed mood (has to be present for diagnosis) loss of pleasure in activities that were previously pleasurable (has to be present for diagnosis) ■ significant change in weight (up or down) ■ sleep disturbances ■ psychomotor agitation or retardation ■ loss of energy/fatigue ■ feelings of worthlessness ■ impaired concentration ■ suicidal ideation. ■ ■

Bipolar disorder Previously known as manic depression, bipolar disorder is characterised by episodes of depression and mania. These episodes must last at least one week. Manic episodes are characterised by insomnia, boundless energy, inability to concentrate, persistently elevated mood, irritability and labile mood. Depressive episodes have the same criteria as for major depressive disorder. The incidence is between 1% and 2% (Australian Bureau of Statistics 2008). Types of bipolar disorder

Bipolar illness is usually grouped into two types: bipolar I and bipolar II. Although bipolar I is the most studied of the two types, guidance on managing bipolar II is based on data from those studies. People with bipolar I experience at least one lifetime episode of mania, and usually episodes of depression. People with bipolar II experience episodes of depression plus episodes of a mild form of mania called hypomania (persistent elevation of mood, energy and activity). It can take up to 10 years for a diagnosis of this disorder to be made (DSM-5). Web resource

For a website on bipolar disorder, see .

Childbirth and mood disorders

Although childbirth is usually seen as a happy event, some women (up to 50%) and a few men experience postpartum (after birth) blues. Symptoms include anxiety and tearfulness and may be episodic, with the person feeling happy one minute and very upset the next. The cause is unclear,

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but exhaustion, hormonal changes and stress appear to play a part. If symptoms persist beyond two weeks, medical assessment for postnatal depression is required.

Pre- and postnatal depression

About 13% of women may develop depression during their pregnancy and it can be life-threatening (Sadock & Sadock 2007). The signs of preand postnatal depression are similar to general depression. Postnatal depression can develop several months after giving birth. The main symptoms that are common to postnatal depression are low mood, poor appetite, altered sleep pattern and low self-esteem. Treatment may involve medications that are not thought to cause damage to the baby. Postpartum psychosis is rare, affecting one in 1000 mothers. This condition is characterised by depressed mood and delusions, often with thoughts of self-harm and/or harming the baby. In Australia the National Perinatal Depression Initiative (Department of Health and Ageing 2013) aims to improve prevention and early detection of antenatal and postnatal depression and provide better support and treatment for expectant and new mothers experiencing depression. This initiative benefits women who are at risk of or experiencing depression during pregnancy or in the first year following childbirth. The National Perinatal Depression Initiative involves routine and universal screening for depression for women during the perinatal period (once during pregnancy and again about four to six weeks after the birth) by a range of health professionals including midwives, child and maternal health nurses, general practitioners and Aboriginal health workers using the Edinburgh Postnatal Depression Scale. Follow-up treatment and care is also provided (Department of Health and Ageing 2013). Web resource

For more information on pre- and postnatal depression, see .

Disorders in young people

Attention deficit with hyperactivity disorder

Attention deficit with hyperactivity disorder (ADHD) is a controversial disorder that is thought to be a syndrome of behaviours where children have more difficulty with concentrating on what they are doing (problems with attention) than other children of their age. These difficulties occur due to the way that the child’s brain works. They are not caused by brain damage, but specialised brain imaging tests can show differences in brain 68

Chapter 6  An overview of mental illness

function compared with children without ADHD. There is uncertainty about the incidence (perhaps 5–10%) and prevalence of this disease, and as to whether this disorder exists in adults also. Boys are more likely to be diagnosed with this disorder than girls. Criteria for diagnosis (adapted from DSM-5) includes several of the behaviours listed below (always including both hyperactivity/impulsivity and inattention behaviours) developing before the age of 12, with a duration of longer than six months. The behaviours must not be associated with other developmental or medical conditions, must occur at home and school and must be negatively disrupting the child’s life. The behaviours are: ■ lack of attention to detail with schoolwork or other activities ■ has trouble organising tasks and activities ■ loses things needed for tasks or activities (e.g. toys, school assignments, pencils, books) ■ has trouble sticking to tasks or play activities ■ does not seem to listen when spoken to directly ■ does not follow through on instructions (that they are able to understand) and does not finish tasks (e.g. at school or chores at home) ■ tries to get out of doing things that require a lot of thinking and concentrating (because the activities are considered hard work and tiring) ■ is easily distracted and forgetful generally ■ hyperactivity/impulsivity, which includes • fidgeting of the hands or feet, or squirming in their seat • being unable to remain seated in the classroom when asked to • running about or climbing excessively (more than most other children) • trouble playing quietly • talking ‘all the time’ • difficulty waiting their turn • interrupting conversations. Aetiology

There is no clear explanation for why ADHD happens in some children. The slight differences in the way that a child’s brain works (shown by specialised brain imaging) cause the child’s brain to deal with some activities, information and feelings in a different way from other children. There may be a familial component. Sleep apnoea (blocking of the airway during 69

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sleep) is linked to problem behaviours in many children. Some research has shown that about 30% of children who have ADHD have some sleep apnoea. Signs of sleep apnoea include snoring (often loud snoring) and stopping breathing for a brief time during sleep. Not all children who snore have sleep apnoea, but if a child with ADHD also snores, this might be part of the problem. Web resource

For more information on ADHD, see .

Eating disorders  Anorexia nervosa

Anorexia nervosa is an eating disorder that affects 0.3–0.5% of the population. It affects more females than males (ratio 10 : 1). There are two main types: ■ the restricting type, where the person inhibits food overall, is less impulsive and there are fewer self-harming behaviours and suicide attempts ■ the bingeing/purging type, which is characterised by family history of obesity or being overweight prior to the condition developing, use of vomiting and medications to decrease weight, self-harm and suicidal behaviours (Makhdoom 2008). Criteria

Diagnostic criteria for anorexia nervosa are: ■ persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory and physical health) ■ either an intense fear of gaining weight or of becoming fat or persistent behaviour that interferes with weight gain (even though significantly low weight) ■ disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight (Eating Disorders Victoria 2013). Prognosis

If untreated, there is a high mortality rate due to starvation or suicide. With treatment, approximately a third will fully recover, a third will have a partial recovery and a third will have chronic ongoing problems (Makhdoom 2008). 70

Chapter 6  An overview of mental illness

Aetiology

Aetiology includes: ■ Familial factors. This includes a family history of depressive disorders, eating disorders and obesity and alcoholism. ■ Sociocultural factors. This is more common in Western countries, and there is some association to professions (e.g. fashion, ballet, gymnastics) where thinness is highly desirable. ■ Individual factors. Problems in family relationships, low self-worth, a feeling of loss of personal control and physical and sexual abuse are all risk factors. Physical symptoms

Physical symptoms include: ■ loss of muscle mass ■ fine downy body hair ■ hypotension (low blood pressure) ■ bradycardia (low pulse rate) ■ anaemia (low iron blood count) ■ eroded teeth enamel. Mental health symptoms

Mental health symptoms include: ■ low self-esteem ■ poor concentration ■ depression ■ insomnia ■ loss of appetite ■ poor memory ■ lack of energy ■ social withdrawal ■ obsessive behaviour around food.

Bulimia nervosa

Bulimia nervosa is an eating disorder where the person has patterns of bingeing and purging, causing emotional distress, preoccupation with body shape and weight, and often normal body weight. It affects 1–3% of young adult females, and is less common in males. Onset usually occurs in late adolescence, and it is more common in Westernised countries. 71

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Criteria

Diagnostic criteria for bulimia nervosa (DSM-5) are: ■ craving for food ■ preoccupation with eating ■ a pattern of overeating followed by compensatory behaviour to reverse food intake (exercise or purging or self-induced vomiting). Physical and psychological symptoms

Symptoms are similar to that for anorexia nervosa, but body weight may be within the normal range. Purging-related symptoms include: ■ stomach ulcers ■ tooth decay ■ irregular heart beat ■ oesophageal/gastric perforation ■ constipation ■ electrolyte (salt) imbalance.

Intellectual disability

About 1% of the population have an intellectual disability. Intellectual disability is not a mental illness per se; rather it is a neurodevelopment disorder, and is listed in the DSM-5. Aetiology

Aetiology may be various, including infections, trauma, toxins, problems during childbirth and genetic problems (e.g. Down syndrome, Angelman’s syndrome). Criteria for diagnosis

In the new DSM-5 less emphasis is placed on an IQ (measure of intelligence) of less than 70 for diagnosis. Instead, it focuses on problems with functioning in the following areas: communication with others; activities of daily living; and lack of independence are key. Treatment

Recovery-based models of care focus on personal strengths and maximum level of functioning in the community. Assessment tools

Assessment tools include the Mini Psychiatric Assessment Schedule for Adults with Developmental Disabilities (Mini PAS-ADD) (www.pasadd 72

Chapter 6  An overview of mental illness

.co.uk). It is an accessible assessment tool based on a life-events checklist and the person’s symptoms. Web resources

See for more information on intellectual disabilities. This is a UK-based information website about the nature of intellectual disability and resources. See also , which is a website for people with a disability, their family and carers.

Autism spectrum disorder

In the DSM-5, autism spectrum disorder in a new name that conflates four previously separate disorders into one condition. Asperger’s disorder is not included in the 2013 manual and neither is autism disorder. Autism spectrum disorder is characterised by deficits in social communication and social interaction, as well as restricted repetitive behaviours, interests and activities.

Personality disorders 

Personality can be defined as a person’s lifelong, persistent and enduring characteristics and attitudes, including their ways of thinking, feeling and behaving. These characteristics affect all aspects of a person’s life, including their work, social and personal relationships. Personality disorder can be defined as abnormal, extreme, inflexible and pervasive variations from the normal range of one or more personality attributes, causing suffering to the person as well as those around them. Personality has generally formed by about 16 years of age, and so after this age a disorder can be diagnosed. Personality traits are continuous and need to be distinguished from episodic symptoms and behaviours that occur with mental illness. Diagnosing and treating personality disorders remains controversial and problematic, as critics of these diagnoses believe that personality, by definition, cannot be changed and therefore is untreatable by the mental health system. What we do know is that people with serious mental illnesses also often have personality problems and that health professionals have a legitimate role in reducing the distress and suffering they endure on a daily basis (MacLean 2008). Appendix 3 provides guidance on working with people with challenging behaviours. In the DSM-5, personality disorders are classified based on the principal personality features. In clinical practice, there is often overlap between diagnostic categories. 73

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Aetiology

There are a number of theories of personality disorder, which can be summarised as being based on: ■ Genetic factors. There appears to be some evidence that affective disorders and personality disorders (borderline personality disorder) are linked. ■ Sociocultural factors. Poor family relationships with physical and/or sexual abuse in childhood, and behavioural difficulties in childhood, may increase the risk of developing a personality disorder in adulthood. Incidence

It is thought that about 3% of the general population has a borderline personality disorder, the most common disorder of personality. Rates for other personality disorders are much smaller and hard to establish. Within inpatient mental health settings, as many as 30% of patients may have a diagnosis of a personality disorder, many of which have another mental illness (Sadock & Sadock 2007). Prognosis

Prognosis is variable, and it can be poor. In borderline personality disorder, risk of suicide is high. Personality disorder groups

There are three groups of personality disorders (see Table 6.2): ■ Cluster A—the odd or eccentric. As a group, these people tend to be perceived as odd, eccentric and withdrawn. This group of personality disorders includes paranoid personality disorder, schizoid personality disorder and schizotypical personality disorder. ■ Cluster B—the dramatic and emotional. People with these disorders appear dramatic, emotional and erratic. This group of personality disorders includes histrionic personality disorder, antisocial personality disorder, narcissistic personality disorder and borderline personality disorder. ■ Cluster C—the anxious or fearful. People with these disorders appear highly anxious and fearful of events and people. This group of personality disorders includes avoidant personality disorder, obsessive-compulsive personality disorder and dependent personality disorder. 74

Chapter 6  An overview of mental illness

TABLE 6.2  Personality disorder groups Personality disorders by type

Characteristics

Cluster A Paranoid

Distrusting and suspicious Highly sensitive

Schizoid

Cold and unemotional Lack of interest in other people Very introspective

Schizotypal

Socially isolative Has unusual ideas Often has odd behaviours and appearance

Cluster B Borderline

Unstable relationships with other people Poor self-image Unpredictable and erratic moods Impulsive substance use and abuse Impulsive self-harming behaviours

Narcissistic

Strong sense of entitlement Grandiose Seeks admiration Lack of empathy for others

Antisocial

Tendency to violate the boundaries of others Superficial charm Poor behaviour control: expressions of irritability, threats, aggression and verbal abuse

Histrionic

Excessive attention-seeking behaviours Egocentric Highly emotional

Cluster C Avoidant

Insecure Social isolation due to fears of rejection or humiliation by others

Obsessivecompulsive

Preoccupation with orderliness and control over situations Rigid behaviour Perfectionism

Dependent

Excessive need to be taken care of Clinging, submissive Feels helpless when not in a relationship

Source: Sadock & Sadock 2007

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Assessment tools

The Minnesota Multiphasic Personality Inventory is a commonly used personality test in mental health and copies can be found online at . It is used by professionals to examine personality structure and psychopathology. Web resource

For more information on personality disorders, see the Australian Government Department of Health and Ageing website, which outlines the main types, possible causes, treatment options and where to go for help at .

Disorders in older people  Delirium

Delirium is not a mental illness or disorder. Rather, it is a reversible clinical syndrome, which is often commonly confused with other disorders such as depression. It is a relatively common health problem in old age, particularly with those in residential care or in hospital. It is marked by an acute disturbance in attention and thinking. Any changes in old age associated with a decline in function and/or thinking are not normal, and need to be investigated and treated. It is very easily confused with dementia or depression. Delirium is an acute medical condition, which can lead to death. It should be treated as a medical emergency. Delirium can be precipitated by: ■ pain ■ drug or alcohol withdrawal ■ infections ■ dehydration and/or constipation ■ other disorders (e.g. cancer, neurological disorders) ■ immobility ■ kidney or liver problems ■ lack of sleep. Diagnostic criteria

The three main criteria for a diagnosis of delirium are: ■ rapid onset of symptoms (hours) and/or fluctuating mental state ■ attention span impairment ■ change in cognitive function / altered perception (e.g. hallucinations, thought disorder). 76

Chapter 6  An overview of mental illness

TABLE 6.3  Differences between delirium, dementia and depression Mental state assessment

Delirium

Dementia

Depression

Onset

Hours to days

Over months

One or more weeks

Behaviour

Restless and uneasy

Wandering and searching

Slowed, changes to activities of daily living, eating and sleeping

Cognition

Impaired

Impaired

Slowed, may seem impaired

Attention

Poor/fluctuates

Impaired

May appear impaired

Affect

Changeable; may be irritable or flat, withdrawn

Normal/flat/confused

Sad/irritable/ worried/ depressed/guilty

Thought

May be incoherent

Shallow; content may be paranoid due to memory problems

Slowed up, guilty thoughts, hypochondria

Judgment

Often impaired

Declining

May seem impaired

Insight

Poor

Reduced

Changeable

It is extremely important to differentiate between delirium and other disorders, such as dementia and depression, in order to provide the most appropriate care. Essential differences are listed in Table 6.3. Aide mémoire: Depression develops over days and weeks, dementia develops over months and delirium develops over hours.

Dementia

Dementia affects about 10% of people aged older than 60 and about 40% of people aged older than 85. There are two main types: Alzheimer’s dementia (more common) and vascular dementia (Australian Institute of Health and Welfare (AIHW) 2007). Dementia is characterised by one or more of the following cognitive disturbances: ■ difficulties with speech ■ disturbance of memory ■ loss of motor control 77

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

decline from previous level of functioning impaired social or occupational abilities and performance.

■ ■

Aetiology

Aetiologies include: ■ Alzheimer’s disease ■ stroke ■ Parkinson’s disease ■ vascular diseases ■ Huntington’s disease ■ infections, trauma, tumours and vitamin deficiencies (Moyle 2012). Prognosis

Dementia is gradual, leading to a decline in previous functioning. Treatment is symptomatic. There is a large human cost to the family and carers, with most people with dementia being cared for in supported residential care towards the end of their lives. Recent developments in medications have seen the use of memory-enhancing drugs that can support better thinking and memory but do not reduce the progression of the disease. Assessment scales

The Mini-Mental State Examination (MMSE), an abbreviated form of the mental state examination (MSE), is based on observable behaviour in a consumer assessment interview (www.minimental.com). The Rowland Universal Dementia Assessment Scale (RUDAS) is a multicultural cognitive assessment scale (www.alzheimers.org.au).

Other mental disorders in older people

Older people are particularly prone to depression because of a range of life events, including physical illness, isolation, chronic pain and bereavement. The presence of depression is not a sign that the person will necessarily develop dementia or Alzheimer’s disease. Schizophrenia and bipolar disorder are less likely to occur in the older population, but given the chronic nature of these illnesses, older adults may be living with this condition. Web resource

Alzheimer’s Australia is the peak body providing support and advocacy for the 500,000 Australians living with dementia: see . 78

Chapter 6  An overview of mental illness

Substance abuse disorders 

Substance abuse disorders are the second most prevalent of the mental health disorders and affect approximately 5% of Australian adults (Australian Bureau of Statistics 2008). Substance abuse can involve alcohol, cannabis, stimulants (amphetamines, cocaine), sedatives (temazepam, oxazepam, diazepam) and opioids (morphine and codeine). It is considered that 25% of men and 50% of women with substance abuse disorders have an underlying anxiety disorder or depression (Rothbard et al 2009). This disorder commonly occurs with people with a mental illness. Diagnostic criteria

The DSM-5 defines substance abuse in the following way: A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: 1 recurrent substance use resulting in a failure to fulfil major role obligations at work, school or home (e.g. repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household) 2 recurrent substance use in situations in which it is physically hazardous (e.g. driving a car or operating a machine when impaired by substance use) 3 recurrent substance-related legal problems (e.g. arrests for substance-related disorderly conduct) 4 continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g. arguments with spouse about consequences of intoxication, physical fights). ■ The symptoms have never met the criteria for substance dependence. Substance dependence refers to the following symptoms and behaviours. There is a maladaptive pattern of use leading to clinically significant impairment involving three or more of the following occurring in a 12-month period: 1 tolerance 2 withdrawal 3 desire to reduce and unsuccessful attempts to reduce use 4 increase in amounts taken over time 5 increasing time spent on activities associated with gaining substances ■

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6 reduction of activities because of use 7 use continues despite knowledge of having a physical or psychological problem caused or exacerbated by the substance (Curtis 2009). Assessment scales

Assessment scales include: ■ the AUDIT alcohol assessment scale at ■ the CAGE alcohol screening test, which is one of the oldest and most popular screening tools for alcohol abuse. It is a short, four-question test that diagnoses alcohol problems over a lifetime. See . Web resource

See the AIHW website at . The impact of the use of drugs and alcohol within the Australian population has become increasingly evident. The AIHW has estimated that in 2003 around 16,700 deaths were drug or alcohol related. The AIHW collects data and reports on two broad categories of drug-related and alcohol-related information. These categories are general population information, which includes the prevalence and impact of drug and alcohol use within Australia, and service-related information, which details the characteristics of alcohol and other drug treatment services and their clients.

Conclusion

The most common mental illnesses have been included in this chapter as an introduction to the types of symptoms, thoughts, feelings, behaviours and beliefs that people with a mental illness may have and suffer from. Diagnostic groups are helpful only in as much as they group symptoms together to gain a clear understanding of what is happening for the person. Some symptoms, such as altered mood, altered perceptions and suicidal feelings, can occur across a range of mental illnesses. Finally, each person with a mental illness has a unique experience and, for that reason, carefully designed individualised care is required by trained health professionals. REFERENCES Albucher, R. C. (Ed.). (2008). Psychiatry: just the facts. New York: McGraw-Hill. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). Washington DC: American Psychiatric Publishing. Australian Bureau of Statistics. (2008). National survey of mental health and wellbeing. Online. Available: 1 Nov 2013. 80

Chapter 6  An overview of mental illness

Australian Institute of Health and Welfare (AIHW). (2007). Dementia in Australia: national data analysis and development. Online. Available: 1 Nov 2013. Bardwell, M. & Taylor, R. (2012). Schizophrenic disorders. In R. Elder, K. Evans & D. Nizette (Eds.), Psychiatric and mental health nursing (3rd edn). Sydney: Elsevier. Barton, D., Joubert, L. & Alvarenga, M., et al. (2012). Anxiety disorders. In G. Meadows, M. Grigg & J. Farhall, et al. (Eds.), Mental health in Australia: collaborative community practice (3rd edn). Melbourne: Oxford University Press. Bermak, J. C. (2008). Generalized anxiety disorder. In R. C. Albucher (Ed.), Psychiatry: just the facts. New York: McGraw-Hill. Curtis, J. (2009). Substance-related disorders and dual diagnosis. In R. Elder, K. Evans & D. Nizette (Eds.), Psychiatric and mental health nursing (2nd edn). Sydney: Elsevier. Department of Health and Ageing. (2013). National Perinatal Depression Initiative. Online. Available: 1 Nov 2013. Eating Disorders Victoria. (2013). Diagnostic and Statistical Manual of Mental Disorders. Anorexia nervosa. Online. Available: 1 Nov 2013. Evans, K. (2012). Anxiety disorders. In R. Elder, K. Evans & D. Nizette (Eds.), Psychiatric and mental health nursing (3rd edn). Sydney: Elsevier. MacLean, L. M. (2008). Personality disorders. In R. C. Albucher (Ed.), Psychiatry: just the facts. New York: McGraw-Hill. Makhdoom, S. (2008). Eating disorders. In R. C. Albucher (Ed.), Psychiatry: just the facts. New York: McGraw-Hill. Moyle, W. (2012). Mental disorders of old age. In R. Elder, K. Evans & D. Nizette (Eds.), Psychiatric and mental health nursing (3rd edn). Sydney: Elsevier. Posner, D. S. (2008). Anxiety disorders. In R. C. Albucher (Ed.), Psychiatry: just the facts. New York: McGraw-Hill. Rothbard, A. B., Blank, M. B. & Staab, J. P., et al. (2009). Previously undetected metabolic syndromes and infectious diseases among psychiatric inpatients. Psychiatr Serv, 60, 534–537. Royal College of Psychiatrists. (2013). Anxiety panic and phobias (leaflet). Online. Available: 1 Nov 2013. Sadock, B. J. & Sadock, V. A. (2007). Synopsis of psychiatry: behavioral sciences/ clinical psychiatry (10th ed.). Philadelphia: Lippincott Williams. World Health Organization. (2010). International statistical classification of diseases and related health problems, 10th revision (ICD-10). Online. Available: 1 Nov 2013.

WEB RESOURCES Beyond Blue. . Beyond Blue is an Australian organisation provides information about depression to consumers, carers and health professionals. 81

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National Drug Strategy. . This website provides information about the National Drug Strategy and the advisory structures that support the strategy, links to the current drug campaign sites, key research and data components and links to relevant governments, professional organisations and drug-related portal sites. National Institute of Mental Health. . This website provides data and statistics about mental illnesses in the United States. Royal College of Psychiatrists UK. . This website provides information about major mental illnesses for health professionals and the general public. World Health Organization (WHO). . WHO is the health arm of the United Nations and provides up-to-date information on a wide range of health-related data. WHO’s classification of diseases (ICD-10) is available at .

82

CHAPTER

7

 

Psychiatric and associated emergencies

Introduction

This chapter explores emergencies in mental health settings. An emergency can be defined as a situation in which a person is in extreme distress (e.g. having a panic attack, being violent, intoxicated or suicidal or having experienced a trauma). In such situations, the role of health professionals is to assess the situation with a primary focus on risk assessment of the person in terms of harm to themselves or others (i.e. the bottom line is to maintain safety for everyone). A situation where someone is angry or aggressive does not in itself constitute an emergency if the person can be aided to calm down.

What is risk assessment?

Risk assessment refers to the role of the health professional assessing possible risk to the overall health and safety of the person and those around them. Risk assessment is important so that health professionals can decide on an appropriate plan of action with, and for, the person to reduce the likelihood of an adverse event occurring. The health professional needs to establish a therapeutic working relationship with the person and assess the needs of the person, with a focus where possible on their strengths. Risk management then is the process wherein a plan of care is designed to address identified needs and to continue to assess and evaluate the efficacy of the planned interventions.

Why assess risk?

Risk assessment does not replace care planning. It is a useful aspect of the overall process of care planning. Risk assessment ought to be done with the person; it is not something that is done to the person. The core issue with risk assessment is to establish the level of risk (low, medium or high) so that plans can be made to protect the person (i.e. keep them safe) and others. Further, establishing what strengths and resilience the person has can reduce risks and give the person confidence that they have some control in their lives. Questions to ask are highlighted in Box 7.1. 83

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Box 7.1

Risk assessment questions

Risk can be assessed by asking the following questions: What is the risk?

■

Who is at risk?

■

What is the chance of the risk occurring?

■

How immediate is the risk?

■

Over what time frame is the risk being assessed?

■

What factors can increase or decrease the risk (e.g. stressors, people, situations)?

■

Are alcohol or other drugs involved?

■

What do we need to do to reduce or manage the risk?

■

Risk in mental health settings generally refers to acute immediate risk issues, such as the risk of harm to self or others, but it can take many forms. It includes the risk of: ■ homelessness ■ not taking psychiatric medication ■ financial, physical or sexual exploitation ■ verbal or physical abuse ■ unemployment ■ social isolation ■ adverse effects of medication (e.g. side effects, toxicity) ■ obesity and other illness ■ substance abuse ■ poverty or self-neglect ■ absconding (leaving hospital without permission) ■ falls ■ danger to self and others ■ physical health deterioration ■ sexual promiscuity ■ gambling ■ notoriety due to bizarre behaviour. It is important for health professionals to be aware of the less obvious but significant risks that people with a mental illness face, and the effect that these risks can have on their day-to-day functioning. Being homeless 84

Chapter 7  Psychiatric and associated emergencies

Box 7.2

Risk factors for suicide 

Risk factors include: being single, divorced or widowed

■

being male younger than 25 or older than 85 years of age

■

being unemployed

■

being of indigenous heritage

■

history of prison incarceration

■

recent life stresses

■

having a mental illness

■

having a previous episode of self-harm

■

having a substance abuse problem (alcohol or drugs)

■

expressing hopelessness and helplessness

■

expressing excessive guilt

■

poor physical health

■

social isolation.

■

and socially isolated, or being dependent on drugs and/or alcohol, increases day-to-day stresses on the person and can contribute to an increase in self-harming behaviour or an increase in the symptoms of mental illness.

What to do if the person is suicidal/ self-harming

Suicide is defined as the voluntary and intentional act of ending one’s life. Self-harming behaviour is defined as any non-fatal act in which the person causes self-injury. Box 7.2 lists the risk factors for suicide.

Risk assessment

A useful risk assessment tool is the Nurses’ Global Assessment of Suicide Risk (Cutcliffe & Barker 2004).

Suicide myths

Common myths about suicide include: Suicide happens without warning. All people who suicide are mentally ill. ■ Self-harming is just attention-seeking behaviour. ■ ■

85

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Most people who suicide do it in winter. Suicide is more common at night. ■ People who talk about suicide never do it. ■ Most people who commit suicide leave notes. ■ Once a person has made up their mind to commit suicide, nothing can change their mind. ■ Talking about suicide increases the risk of someone doing it. ■ ■

Box 7.3 lists the aims of assessment for people who have attempted or who are contemplating suicide, while Box 7.4 lists the dos and don’ts of assessment. Box 7.3

Aims of assessment 

The essential aims of assessment are to: attempt to measure how serious the self-harm or suicidal intentions are through gentle questioning

■

establish if there are medications, guns, knives or ropes around that the person is planning to use

■

attempt to identify the underlying issues that are causing emotional distress and thoughts about self-harm or suicide

■

determine the future risk of self-harm

■

identify strengths in the person

■

identify personal supports as well as supports from care services.

■

What to do if the person has experienced an acute trauma (physical or sexual assault)

A traumatic event is one in which the person may have either, for example: ■ been involved in a traffic or physical accident ■ witnessed a traffic accident ■ been physically and/or sexually assaulted ■ been mugged or robbed or is a victim of domestic violence ■ witnessed a terrible event (e.g. fire, shooting, bank hold-up, hit and run), or ■ been involved in severe weather events (e.g. bushfire, flood, cyclone). People respond to such unexpected events in different ways, but in the initial phase they experience physical shock and may appear dazed and 86

Chapter 7  Psychiatric and associated emergencies

Box 7.4

Dos and don’ts of assessment 

Do: stay with the person

■

ask if the person is suicidal

■

ask if the person has a plan

■

ask if the person has any weapons (guns, knives) and their location

■

ask if the person is on any medication and where those medications are

■

ask if the person has taken any medications and/or other drugs and alcohol, and what amounts

■

ask about the frequency and nature of their suicidal thoughts

■

engage in conversation with a view to helping the person realise suicide is not the only or best option

■

acknowledge their distress

■

call for help / call an ambulance if the person is bleeding or loses consciousness. Don’t: ■

dismiss the person’s reasons for wishing to die

■

express frustration with the person

■

make judgments about the person’s behaviour (e.g. that they are selfish)

■

tell the person they are just attention seeking, or

■

dismiss self-harming behaviour as not requiring help and support (selfharming behaviour acts as a stress-reduction mechanism for people and is a hard pattern to break).

■

feel numb. They may physically tremble, be very distressed or agitated, cry or wail, wander around in a confused state, or sit without appearing to realise what is happening around them. This is entirely normal in relation to what has happened to them. Box 7.5 lists the dos and don’ts if the person has experienced an acute trauma.

After the crisis has passed

After the initial shock of the trauma, people commonly experience symptoms of anxiety, fear and dizziness, breathlessness, pounding heart and insomnia. It is useful to encourage them to attend to normal daily activities as much as they can, to be as physically active as possible and to eat and drink well to promote a beneficial daily routine. Further support may 87

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Box 7.5

Dos and don’ts if the person has experienced an acute trauma

Do: establish if the person has been physically hurt and needs medical attention

■

talk to the person, but don’t pressure them to talk

■

stay with the person and reassure them that help is being arranged / on its way

■

keep the person warm

■

reassure the person that what they are feeling is normal given what has happened to them. Don’t: ■

minimise what has happened or what the person has witnessed

■

offer the person alcohol

■

tell the person to pull themselves together or that they will ‘get over it’, or

■

ask them questions repeatedly.

■

be required and the person should be encouraged to see their health professional for monitoring.

What to do if the person is aggressive or violent

Aggression often results due to an unmet need, usually in relation to fear, intimidation or frustration. A person may behave in an aggressive or violent manner because of situational factors (environmental factors) or because of medical conditions, such as conditions of the brain (brain tumours, brain trauma, brain infections), endocrine disorders (hypo/ hyperthyroidism), metabolic disorders (hypoglycaemia) and infections (AIDS, tuberculosis, urinary tract infections). Further, a number of mental illnesses are associated with aggression or violence, but this does not mean that all people with these diagnoses are dangerous to themselves or the general public. Box 7.6 lists some conditions associated with aggression and violence.

Aggression scales

Aggression scales can be useful in assessing risk of aggression or violence but need to be used as an adjunct to care, rather than as the sole tool, due 88

Chapter 7  Psychiatric and associated emergencies

Box 7.6

Conditions associated with violence

Conditions include: acute confusional states such as delirium

■

head trauma

■

schizophrenia, especially paranoid schizophrenia

■

mania

■

paranoid psychosis

■

psychosis due to methamphetamine use

■

personality disorder, especially the antisocial type

■

alcohol intoxication or withdrawal

■

substance intoxication or withdrawal (e.g. alcohol, cocaine, amphetamines, benzodiazepines, anabolic steroids)

■

post-traumatic stress disorder

■

dementia

■

learning disorders.

■

to their limited accuracy. Scales include the Nurses’ Observation Scale for Inpatient Evaluation (NOSIE) (Lyall et al 2004) and the Modified Overt Aggression Scale (MOAS) (Knoedler 1989). Remember, though, that an aggressive situation does not have to lead to an emergency situation; a person may be angry and letting off steam and the role of health professionals is to manage the situation and restore calm.

How to tell if someone is potentially violent

If a person is angry and potentially violent, they are likely to exhibit some of the following: ■ be pacing and restless ■ be grinding their teeth ■ be swearing ■ be shouting or talking very quietly ■ be staring or exhibiting prolonged eye contact ■ be verbally threatening or sarcastic ■ have poor concentration ■ have dilated pupils 89

MOSBY’S POCKETBOOK OF MENTAL HEALTH 2E

have furrowed brows, or be voicing delusions or hallucinations with violent content. Note that more than one attribute often applies.

■ ■

Risk factors

Individual risk factors for violence include: ■ a previous history of violence or disturbed behaviour ■ a previous history of alcohol or substance abuse ■ a previous expression of intent to hurt ■ a low level of remorse or insight into the effects of violent behaviour ■ a previous use of weapons ■ the severity of previous acts.

De-escalation: act don’t react!

De-escalation is a process intended to reduce tension in a situation and prevent the situation from deteriorating, therefore avoiding violence and people being hurt and traumatised. Never approach an angry person without backup and do not attempt to restrain someone on your own, unless life is in immediate danger. Call for assistance if you need to. Remember to speak slowly and calmly, in a quiet voice but loud enough to be heard. Introduce yourself to the person by saying your name and explain your actions. One person should assume control of a potentially disturbed situation. The lead person needs to manage the environment (e.g. remove bystanders, create space, direct security guards, call the police). Box 7.7 lists the dos and don’ts in an aggressive or violent situation.

Debriefing

After any incident, debriefing is a useful way to allow the emotions of the event to be discussed and dealt with. It is also an important process to gain insights into the sequence of events, mistakes that were made and associated learning. The purpose of debriefing is to: ■ establish what happened and how people perceived the event and their level of comfort/discomfort ■ make changes to prevent or reduce similar events in the future ■ increase the preparedness of those being debriefed for further such incidents. Workplaces ought to have processes to support staff and people in their care when unwanted events occur. It is important to check what these are where you work. 90

Chapter 7  Psychiatric and associated emergencies

Box 7.7

Dos and don’ts in an aggressive or violent situation

Under stress, people often behave in ways that are thought to be helpful to all concerned at the time, but in fact have the opposite effect and make the situation worse. The following dos and don’ts are intended to guide your interaction in situations of violence. Body posture and eye contact Do: allow the person more personal space than you might normally

■

lower your voice; often the upset person will lower their voice too

■

try to relax your posture and stand at a slight angle with your arms by your sides, but make sure your stance is such that you can retreat if necessary

■

make intermittent eye contact

■

appear calm and genuinely interested in the person. Don’t: ■

cross your arms

■

stand with your legs well apart and front-on to the person

■

keep your hands in your pockets

■

stare at the person, or

■

try to touch the person.

■

Engagement and communication Do: introduce yourself by name

■

speak clearly and slowly

■

explain your actions

■

attempt to establish rapport

■

encourage the person to talk and tell you how they view the problem

■

give clear brief instructions

■

take your time (do not try to rush things along)

■

emphasise your concern and desire to work together

■

offer options that are realistic

■

focus on the person, nod when their talk, accept their concerns as valid and demonstrate empathy

■

use open questions and say ‘Go on … tell me more about that …’

■

match the person’s arousal but not their anger (e.g. ‘It sounds like we need to sort this out straightaway’).

■

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Box 7.7

Dos and don’ts in an aggressive or violent situation—cont’d

Don’t: ask ‘why’ questions (they are more likely to provoke the person)

■

tell the person you know how they feel (you don’t)

■

disagree with the person

■

tell the person to calm down

■

shout or talk to the person loudly (unless it is to be heard)

■

make promises you cannot keep

■

make threats (e.g. ‘If you don’t comply, you will be taken to hospital against your will/detained/secluded’), or

■

use sarcasm, humour or minimise what they are saying (e.g. put downs such as ‘Don’t be silly’ or ‘That’s ridiculous’), which can make things worse.

■

What to do if the person is acutely psychotic

If a person is acutely psychotic, be very clear about what the purpose of your interaction is (e.g. to establish rapport, to help them remain calm, to encourage the taking of medication, to request that they come with you to hospital, to conduct a mental state assessment, or to gain information about family so they can be informed of the person’s whereabouts). It is likely that the person may be too thought-disordered to maintain concentration or stay on track in a conversation. Box 7.8 lists the dos and don’ts if a person is psychotic.

What to do if the person is having a panic attack

A panic attack is an episode of intense fear. It is generally triggered by negative thoughts and accompanied by one or more symptoms, such as: fear of dying chest pain ■ shortness of breath ■ choking ■ trembling or shaking ■ ■

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Chapter 7  Psychiatric and associated emergencies

Box 7.8

Dos and don’ts if the person is acutely psychotic 

Do: establish if the person is oriented

■

listen to the person

■

acknowledge that the person may be feeling frightened/scared/upset/angry/ confused

■

speak slowly, calmly and clearly

■

acknowledge that what is happening is real to the person (i.e. don’t try to talk them out of it or deny it is real, which is likely to make things worse)

■

try to find some common ground through chatting

■

say ‘I know the voices are real to you’

■

try to establish how much insight the person has (i.e. awareness of their illness)

■

say you are trying to understand what is happening for them

■

acknowledge how they are feeling (e.g. ‘Those thoughts must be frightening to you’). Don’t: ■

argue with the person or disagree with their reality

■

tell them that they are sick/mad/loony

■

make glib remarks (e.g. ‘You’ll be right’)

■

tell them to pull themselves together, or

■

express frustration.

■

sweating nausea ■ dizziness ■ fear of losing control ■ heart palpitations ■ urge to escape ■ intense feelings of dread. Panic attacks are frightening, but fortunately they are physically harmless episodes. They can occur at random or after a person is exposed to various events that may bring on a panic attack. They peak in intensity very rapidly and go away with or without medical help. People experiencing panic attacks may fear that they are dying, that they are suffocating or that they are having a heart attack. They may voice fears that they are ■ ■

93

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‘going crazy’ and seek to remove themselves from whatever situation they may be in. Some people may begin breathing very rapidly and complain that their ‘heart is jumping around in their chest’. Then, within about an hour, the symptoms fade away. About 5% of the population will experience panic attacks during their lifetime. People who have repeated attacks require further evaluation from a mental health professional. Panic attacks can indicate the presence of depression, panic disorder or other forms of anxiety-based illnesses. Box 7.9 lists the dos and don’ts if the person is having a panic attack. Box 7.9

Dos and don’ts if the person is having a panic attack 

Do: take some deep breaths yourself and remain calm and in an open posture

■

encourage the person to take slow deep breaths

■

remind the person that the attack will pass and cannot harm them

■

acknowledge their acute distress

■

try to remove the person to a quiet place with some privacy

■

stay with the person until they calm down. Don’t: ■

rush the person in any way

■

express frustration

■

tell the person they are being ridiculous

■

give orders

■

tell the person to snap out of it or calm down (they can’t), or

■

encourage the person to face their fears (this is not the right time).

■

What to do if the person is intoxicated with drugs or alcohol

Almost half of people with a severe mental illness have a substance abuse problem. Reasons for substance abuse include: dealing with uncomfortable symptoms coping with anxiety-provoking social situations ■ peer group acceptance ■ coping with boredom and isolation. ■ ■

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Chapter 7  Psychiatric and associated emergencies

Possible consequences of psychoactive (mind-altering) substance abuse include: ■ prolonged treatment response times ■ increased psychotic symptoms ■ increased chance of relapse and hospitalisation ■ early death ■ increased risk of suicidal behaviour ■ increased risk of homelessness. If you are not sure whether the person is having a panic attack or a heart attack, call an ambulance and apply first aid—airway, breathing, circulation—until help arrives. Alcohol and other drugs have complex effects on the central nervous system. Intoxicated people can be aggressive, upset or frightened. General signs of intoxication include: ■ poor coordination, impaired reflexes ■ sudden changes in mood and/or behaviour ■ glassy/red eyes (the pupils may be constricted or dilated) ■ sweaty or clammy appearance ■ slurred, rapid and incoherent speech ■ loss of bodily control (e.g. vomiting, soiling self ). Box 7.10 lists the dos and don’ts if a person is intoxicated.

Useful tools

The CAGE questionnaire and the AUDIT (Alcohol Use Disorders Identification Test) are useful tools for assessing substance abuse. The Glasgow Coma Scale is used for measuring the level of consciousness in people affected by drugs.

General management principles

General management principles for people with a substance abuse and a mental health problem include the following: Attempt to engage the person and provide education. Educate the person about safe and unsafe levels of substance use and about the safe use of drugs (e.g. safe sex, using clean needles and not sharing needles). ■ Refer the person to relevant community services (e.g. Alcoholics Anonymous) for ongoing support and assistance. ■ Identify triggers for relapse. ■

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Box 7.10

Dos and don’ts if the person is intoxicated

Do: talk in a slow, clear and simple manner

■

summon help immediately

■

observe the person closely

■

maintain the person’s airway and breathing

■

maintain the physical safety of the person and those around them

■

conduct a full physical examination, including a urine screen

■

assess the level of use in the last month, including the type of drug, volume, frequency and route of administration (oral, intramuscular, intravenous)

■

observe closely and document for signs of withdrawal, such as tremor, sweating of hands and face, insomnia, fatigue, anxiety, irritability and physical cramps. Don’t: ■

attempt to engage in lengthy discussions while the person is intoxicated, or

■

invade their personal space. Note: Acute withdrawal requires hospital care due to the risk of seizures and severity of withdrawal symptoms. ■

Encourage motivation to change. Emphasise the person’s strengths and future potential. For more detailed information, see Elder et al (2012 pp 380–382). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is a useful tool to detect and manage substance use and related problems in primary and general medical care settings. ■ ■

About alcohol withdrawal

Withdrawal usually occurs within 24 hours of the last drink. Symptoms include some of the following: tremor (‘the shakes’), increased blood pressure, sleeplessness, anxiety and loss of appetite. About 15% of chronic alcohol users will experience seizures within a couple of days of abstinence. A small percentage of people experience delirium tremens three to 10 days after their last drink. This is characterised by agitation, disorientation, visual hallucinations (often spiders or insects), fever and paranoia and requires hospitalisation. 96

Chapter 7  Psychiatric and associated emergencies

Assessment for withdrawal using the CAGE or AUDIT tools is necessary to manage the condition and needs to be undertaken by a qualified health professional.

Conclusion

Emergencies can involve any situation where a person is highly distressed. It will take time how to learn how to manage such situations effectively. Appearing calm, interested and confident is the best first impression to give to a person in distress. REFERENCES Cutcliffe, J. R. & Barker, P. (2004). The Nurses’ Global Assessment of Suicide Risk (NGASR): developing a tool for clinical practice. Journal of Psychiatric and Mental Health Nursing, 11, 393–400. Elder, R., Evans, K. & Nizette, D. (Eds.). (2012). Psychiatric and mental health nursing (3rd edn). Sydney: Elsevier. Knoedler, D. W. (1989). The Modified Overt Aggression Scale. American Journal of Psychiatry, 146(8), 1081–1082. Lyall, D., Hawley, C. & Scott, K. (2004). Nurses’ Observation Scale for Inpatient Evaluation: reliability update. Journal of Advanced Nursing, 46(4), 390–394.

WEB RESOURCES AUDIT alcohol assessment scale. . The World Health Organization’s Alcohol Use Disorders Identification Test (AUDIT) is a reliable and simple screening tool which is useful for identifying those at risk of alcohol misuse. CAGE alcohol screening test. . The CAGE questionnaire is one of the oldest and most popular screening tools for alcohol abuse. It is a short, four-question test that diagnoses alcohol problems over a lifetime. Glasgow Coma Scale. . The Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). . ASSIST was developed for the World Health Organization (WHO) by an international group of substance abuse researchers to detect and manage substance use and related problems in primary and general medical care settings.

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CHAPTER

8

 

Managing medications

Introduction

Psychiatric medications are prescribed by health professionals including psychiatrists, general practitioners and nurse practitioners authorised to dispense medications to treat symptoms of mental illness. This chapter describes general management issues for health professionals, issues concerned with concordance (compliance/adherence) with medication regimens, commonly used medications to treat these symptoms and associated side effects; it also outlines the difficulties facing people required to take these medicines for long periods of time. The information contained in this chapter will also be useful in advising carers about the responsibilities they may have regarding medications for a person in their care. See Appendix 4 for a list of commonly used prescription abbreviations.

Categories of medication

There are four essential pharmacological categories of medication used to treat mental illness. These are: ■ anxiolytics (antianxiety drugs) ■ antidepressants ■ antipsychotics ■ mood stabilisers. Medications can have two names—the generic name (i.e. the active compound of the drug) and the trade name (i.e. the registered brand name given by a particular drug company). For example, diazepam is the name of the actual drug, but Valium is a brand name for this drug. In Australia, generic-named medications are often cheaper than their brand-name counterparts. In this chapter, the generic name is listed first, with the brand name in parenthesis.

Anxiolytics

Anxiolytics are used primarily in mental health settings for relieving acute panic and anxiety, insomnia, obsessive-compulsive disorder, post-traumatic 98

Chapter 8  Managing medications

stress disorder and alcohol withdrawal. Diazepam is the most well known anxiolytic and belongs to the benzodiazepine family. They are often referred to as ‘benzos’ colloquially. These drugs act by enhancing the effects of GABA (gamma-aminobutyric acid), a neurotransmitter in the central nervous system. Diazepam is a very useful drug as it has muscle-relaxant effects, stops seizures, reduces anxiety and promotes calm. Other commonly used anxiolytics include: ■ alprazolam (Xanax) ■ bromazepam (Lexotan) ■ clonazepam (Rivotril) ■ flunitrazepam (Rohypnol) ■ lorazepam (Ativan) ■ nitrazepam (Mogadon) ■ oxazepam (Serepax) ■ temazepam (Normison). In small doses, these drugs have a calming and slowing-down effect; in high doses, they are a sedative. Side effects are common and include headache, nausea, hypotension (low blood pressure) and unsteadiness. People taking anxiolytics are encouraged to exercise care when driving or operating machinery. Anxiolytics may also be used to treat acute psychosis in psychiatric wards as an adjunct to antipsychotics. Anxiolytics are sometimes used in the acute phase of delirium as well. In the short term, these drugs relieve anxiety and insomnia but should only be prescribed for two to three weeks because of the risk of dependency. Further, higher doses are required over time to achieve an equivalent initial therapeutic effect. Abrupt discontinuation can result in increased anxiety, sleep disorders, aching limbs and nausea, which can be very unpleasant. Withdrawal from long-term use requires medical supervision and should be gradual to avoid unpleasant withdrawal symptoms. The serious side effects listed in Box 8.1 are often seen in people taking benzodiazepines for long periods of time. Often people have started these drugs without having been prescribed them by a health professional. Drug interactions

Benzodiazepines can be dangerous when combined with other drugs such as alcohol or methadone. These can potentiate the respiratory depressant effect of benzodiazepines, which sometimes results in vomiting, respiratory obstruction and death. 99

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Box 8.1

Side effects of anxiolytics

Side effects include: drug dependency (i.e. being unable to stop taking the drug)

■

impaired memory and concentration

■

sedation

■

feelings of being ‘cut off’ from one’s own feelings

■

low mood

■

poor motor coordination

■

mood swings, irritability and anger.

■

Antidepressants

Antidepressants are used to relieve depressive symptoms, including suicidal thoughts and feelings. There is an array of antidepressants available today in four main groups: ■ tricyclics (an older group and less commonly prescribed today) ■ monoamine oxidase inhibitors or MAOIs (an older group and less commonly prescribed to new patients) ■ selective serotonin reuptake inhibitors or SSRIs ■ serotonin and noradrenaline reuptake inhibitors or SNRIs. These drugs are prescribed for the following conditions: moderate to severe depression ■ severe anxiety and panic attacks ■ the depressed phase of a bipolar episode ■ obsessive-compulsive disorders ■ chronic pain ■ eating disorders ■ post-traumatic stress disorder. Antidepressants are not necessary for people experiencing a mild depression or a normal grief reaction after the death of a loved one. Such experiences are understood to be within the normal range of behaviour given a major loss. However, if depression persists beyond a four- to sixmonth period, assessment and treatment is advised (see Chapter 11). Commonly used antidepressant medications are listed in Table 8.1. ■

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Chapter 8  Managing medications

TABLE 8.1  Commonly used antidepressant medications Generic name

Brand name

Group

Sertraline

Zoloft

SSRI

Paroxetine

Seroxat

SSRI

Venlafaxine

Efexor

SNRI

Reboxetine

Edronax

SNRI

Phenelzine

Nardil

MAOI

Tranylcypromine

Parnate

MAOI

Imipramine

Tofranil

Tricyclic

Amitriptyline

Endep

Tricyclic

Selective serotonin reuptake inhibitors

SSRIs are believed to work by preventing the reuptake of serotonin (5-hydroxytryptamine or 5-HT) in the central nervous system. Side effects of SSRIs include nausea, diarrhoea, agitation and headaches. Serotonin syndrome is a potentially life-threatening emergency resulting from excessive serotonin activity (see Box 8.2).

Serotonin noradrenaline reuptake inhibitors

SNRIs are a relatively new form of antidepressant that work on both noradrenaline and 5-HT neurotransmitters. They typically have similar side effects to SSRIs and may require a slow reduction in dosage before the drug is ceased to prevent a withdrawal syndrome. Sexual side effects are also common, such as loss of libido, failure to reach orgasm and erectile dysfunction. Serotonin discontinuation syndrome

If people stop taking antidepressants abruptly a range of distressing and bothersome, but non-life threatening, symptoms may be experienced. The following medications appear to be associated with this syndrome (SSRIs): citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil) and sertraline (Zoloft). Symptoms may include a flu-like reaction, as well as a variety of physical symptoms—headache, gastrointestinal distress, faintness and strange sensations of vision or touch. Sometimes people also experience anxiety 101

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Box 8.2

Serotonin syndrome

Serotonin syndrome, a potentially life-threatening emergency resulting from excessive serotonin activity, can result from other antidepressants being combined with SSRIs (e.g. MAOIs) or being administered while the person is taking St John’s wort. Serotonin syndrome can lead to hyperthermia (overheating), kidney failure and death if left untreated. Emergency interventions include ceasing administration of SSRIs and administering anticonvulsants and clonazepam to reduce agitation and induce calm. Symptoms of serotonin syndrome are: confusion

■

mania

■

agitation, restlessness

■

sweating

■

an urgent need to urinate and frequently

■

tremor

■

nausea

■

diarrhoea

■

headache.

■

and depression, which makes it hard to differentiate if a person is becoming ill again or has discontinuation symptoms. It is very important to explain to people considering reducing or coming off their medication that they need the support of their medical and nursing staff in tailoring a reduction slowly, over time.

Tricyclics

Tricyclic antidepressants are the oldest group of medications and their mode of action is thought to be due to their blockade of the reuptake of the neurotransmitters noradrenaline and serotonin in the central nervous system. More recent drugs are more selective in blocking specific neurotransmitters and also have fewer side effects, and so are more likely to be used as a first choice of antidepressant. However, tricyclics remain the drug of choice for some people, especially those who have responded well to them, who have a serious depressive illness and who experience few bothersome side effects. Side effects include increased heart rate, drowsiness, dry mouth, constipation, urinary retention, blurred vision, dizziness, seizures and confusion. Tricyclics are toxic, and so can be lethal in 102

Chapter 8  Managing medications

Box 8.3

Signs of tricyclic overdose

Signs include: agitation

■

confusion

■

drowsiness

■

bowel and bladder paralysis

■

dysregulation of body temperature and blood pressure

■

dilated pupils.

■

Source: Usher et al 2009b

overdose. Tricyclic toxicity is a medical emergency and requires immediate medical intervention. Box 8.3 lists the major signs of tricyclic overdose.

Monoamine oxidase inhibitors

MAOIs are rarely prescribed today because they induce life-threatening high blood pressure if foods containing tyramine (e.g. aged cheeses, certain types of fish, red wines, broad beans) are eaten when taking an MAOI. Other antidepressant medications and other ‘amine’ medications (e.g. nasal decongestants, cough medicines and medication to treat hayfever) also need to be avoided when taking this group of antidepressants. MAOIs may be used as a last resort if no other medications have been useful. Their mode of action is by blocking the enzyme monoamine oxidase, which breaks down the neurotransmitters dopamine, serotonin and noradrenaline. There are also more recent MAOIs available, known as reversible MAOIs, which do not require a special diet (e.g. moclobemide (Aurorix)). Health professionals are more likely to encounter older people who are taking tricyclics and MAOIs because they have been effective for them in the past or they have been taking them for long periods of time. Side effects include dry mouth, sedation, constipation, hypotension, seizures and urinary retention.

Antipsychotics

Antipsychotics are prescribed for treating schizophrenia in the acute and maintenance stage. Over the past 15 years new antipsychotics (the atypicals or second-generation antipsychotics) have been introduced and have equal efficacy to the traditional antipsychotics (typical or first-generation antipsychotics), yet they have fewer but different side effects. Table 8.2 lists antipsychotics. 103

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TABLE 8.2  First-generation and second-generation antipsychotics Typical or first-generation antipsychotics (infrequently used now)

Atypical or secondgeneration antipsychotics (first choice drugs)

Generic name

Brand name

Chlorpromazine

Largactil

Flupenthixol

Fluanxol (depot)

Fluphenazine

Modecate (depot)

Haloperidol

Serenace Haldol Decanoate

Pericyazine

Neulactil

Trifluoperazine

Stelazine

Aripiprazole

Abilify

Amisulpride

Solian Amisulpride Winthrop

Clozapine

Clozaril Clopine

Olanzapine

Zyprexa Zyprexa IM

Quetiapine

Seroquel

Risperidone

Risperdal Risperdal Consta

How antipsychotics work

Antipsychotics reduce or eliminate delusions, hallucinations, abnormal mood and thought disorders. They also reduce the likelihood of further episodes of psychosis. Their mode of action is blockage of dopamine and 5-HT2A receptors within the central nervous system. However, because these drugs work on other dopaminergic pathways in the brain, a range of unpleasant motor (movement) side effects can be experienced, known as extrapyramidal side effects (EPSEs) (see Table 8.3).

Anticholinergic drugs

These drugs are specifically used to reduce the distressing and unwanted motor side effects of antipsychotic medication. They block the neurotransmitter acetylcholine at the muscarinic receptor site. However, they also 104

Signs and symptoms

Muscular spasm in any part of the body, such as eyes rolling upwards (oculogyric crisis) Head and neck twisted (torticollis) In extreme cases, the back may arch or the jaw may dislocate Acute dystonia can be both painful and frightening Person may need assistance breathing

Tremor and/or rigidity Bradykinesia (decreased facial expression, flat monotone voice, slow body movements, inability to initiate movement) Bradyphrenia (slowed thinking) Salivation Parkinsonism can be mistaken for depression or the negative symptoms of schizophrenia

Extrapyramidal side effect

Dystonia

Parkinsonism

TABLE 8.3  Extrapyramidal side effects of antipsychotics

Days to weeks after antipsychotic drugs are started or the dose is increased

Acute dystonia can occur within hours of starting antipsychotics (minutes for intramuscular or intravenous use) Tardive dystonia occurs after months to years of antipsychotic treatment

Approximately 10% but more common in young males, in the neurolepticnaïve and with high-potency drugs (e.g. haloperidol) Dystonic reactions are rare in the elderly

Approximately 20%, but more common in elderly females and those with pre-existing neurological damage (e.g. head injury, stroke)

Time it takes to develop

Prevalence (with older drugs)

Several options are available depending on the clinical circumstances: reduce the antipsychotic dose; change to an atypical drug; or prescribe an anticholinergic medication

Anticholinergic drugs given orally, intramuscularly or intravenously depending on the severity of symptoms (remember the individual may be unable to swallow) Response to intravenous administration will be seen in five minutes Response to intramuscular administration takes around 20 minutes

Treatment

Chapter 8  Managing medications

105

106

A subjectively unpleasant state of inner restlessness where there is a strong desire or compulsion to move Foot tapping when seated Constantly crossing/uncrossing legs Rocking from foot to foot Constantly pacing up and down Akathisia can be mistaken for psychotic agitation and has been linked with suicide and aggression towards others Sometimes mistaken for anxiety

A wide range of movements can occur such as lip smacking or chewing, tongue protrusion, choreiform movements (pill rolling or piano playing) and pelvic thrusting Severe orofacial movements can lead to difficulty speaking, eating or breathing Movements are worse under stress

Akathisia

Tardive dyskinesia

Source: Usher et al 2009

Signs and symptoms

Extrapyramidal side effect

TABLE 8.3—cont’d

Five per cent of individuals per year of antipsychotic exposure More common in elderly women, those with affective illness and those who have had acute EPSEs early on in treatment

Approximately 25%

Prevalence (with older drugs)

Months to years Approximately 50% of cases are reversible

Acute akathisia occurs within hours to weeks of starting antipsychotics or increasing the dose Tardive akathisia takes longer to develop and can persist after antipsychotics are withdrawn

Time it takes to develop

Stop anticholinergic if prescribed Reduce dose of antipsychotic Change to atypical drug Clozapine is the most likely drug to be associated with resolution of symptoms Other drugs such as valproate and clonazepam may be prescribed, but evidence is poor

Reduce antipsychotic dose Change to an atypical antipsychotic Low-dose benzodiazepine

Treatment

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Chapter 8  Managing medications

TABLE 8.4  Management of other side effects of antipsychotics Side effect

Management strategy

Increased appetite, weight gain

Get regular exercise, avoid sweet or fatty foods, eat a high-fibre diet, drink low-calorie drinks

Nausea

Take medication with food or before going to bed

Constipation

Increase fluid intake, eat a high-fibre diet (more fruit and vegetables), take fibre supplements

Postural hypotension

Get up slowly from lying or sitting, avoid very hot showers or baths, drink adequate fluids, avoid caffeinated drinks, avoid alcohol and marijuana

Drowsiness

Take a divided dose or a single dose before going to bed

Dry mouth

Ensure regular fluid intake, suck on ice cubes, avoid sweet drinks, use sugarless gum or lollies, use antiseptic gargles or brush teeth regularly (to limit tooth decay), limit alcohol or caffeine (both cause dehydration), use artificial saliva (available from a chemist)

Sensitivity to sunburn

Avoid direct sunlight, wear a hat and long sleeves, use sunscreen

Source: Usher et al 2009

have side effects that include dry mouth, constipation and dizziness. Anticholinergic drugs include: ■ benzhexol (Artane) ■ benztropine (Cogentin). Table 8.4 lists other side effects of antipsychotics, with associated management strategies. Atypical antipsychotics also have serious side effects, including weight gain, diabetes and metabolic syndrome (clozapine, olanzapine, risperidone). Weight gain is caused by side effects that cause craving and never feeling full after eating. A serious side effect of clozapine is agranulocytosis (affects 1–2% of people). Regular blood screening is required—weekly for 18 weeks and monthly thereafter. Neuroleptic malignant syndrome

This is a condition where individuals develop stiffness and fever, usually after commencing on antispychotics. It requires immediate medical attention, hospital observation and maintenance of adequate hydration. 107

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Depot antipsychotic medication

Depot medication is a long-term (two to four weeks) medication that is given to those who are unwilling or unable to maintain a daily regimen of taking medication orally. Depot medication is administered by deep intramuscular injection into the dorsogluteal or ventrogluteal area using a Z track technique according to manufacturer recommendations. The injection site needs to be rotated to avoid long-term damage to the area. Those coming off depot medication need to be monitored closely as the effects of discontinuation will be delayed.

PRN antipsychotic medication

PRN (as needed) medication is used as an adjunct to medication treatment in managing acutely unwell people when they are agitated or distressed due to the severity of their symptoms. Common reasons for administering PRN medication include irritability, self-harming behaviour, distressed mood, agitation, threatening behaviour, insomnia and at the person’s request. Commonly administered medications in this form are antipsychotics and benzodiazepines to calm the individual emotionally and settle behaviour. PRN medication can be given orally or by intramuscular injection. Users need to be monitored for mental and physical status when PRN medication is administered.

Mood stabilisers

Mood stabilisers are the medications prescribed to maintain a balanced mood for people with intense or shifting moods. Lithium, a naturally occurring salt, is the drug of choice for treating acute mania and for the ongoing maintenance of those with a history of mania. Just how lithium works is not clear, but it is known to mimic the effect of sodium, thereby compromising the ability of neurons to release, activate or respond to neurotransmitters. Lithium may also be used to treat bipolar disorder but is often used in conjunction with other medications, depending on whether mania or depression is being treated. Some of the anticonvulsants, such as sodium valproate (Epilim), carbamazepine (Tegretol) and lamotrigine (Lamictal), are also used as mood stabilisers, particularly in bipolar disorder. Box 8.4 lists common side effects of mood stabilisers. The therapeutic range for lithium is 0.6–1.2 mmol/L for acute mania and 0.6–0.8 mmol/L for maintenance, but more conservative levels are increasingly being used. Symptoms of lithium toxicity rarely appear at levels below 1.2 mmol/L but are common above 2.0 mmol/L. Therefore, as the therapeutic and toxic levels are so close, extreme care must be taken in monitoring the person’s blood level regularly, especially during early 108

Chapter 8  Managing medications

Box 8.4

Side effects of mood stabilisers

Common side effects include: sleepiness

■

dizziness

■

a metallic taste in the mouth

■

increased appetite and weight gain

■

a feeling of sickness, nausea

■

skin rashes

■

changes in blood count

■

irregular menstrual periods in females. Very rare side effects include: ■

pancreatitis (less than one in 10,000 cases)

■

abdominal pain, nausea and vomiting

■

liver failure (less than one in 50,000 cases)

■

weakness, loss of appetite, lethargy and drowsiness.

■

phases of the treatment. If the level exceeds 1.5 mmol/L, the next dose should be withheld and a doctor notified. Levels are usually monitored weekly until stable, and then monthly. The blood samples for testing should be taken 12 hours after the last dose when lithium has been taken for at least five days. Box 8.5 lists signs of lithium toxicity. Lithium toxicity is a medical emergency and requires immediate medical intervention (i.e. call an ambulance). It is important to educate about the side effects and signs of toxicity. Users must be informed of the need for regular blood-level testing. Also encourage users to drink about 10 glasses of water every day, and ensure they know to take their medication regularly, even when they are feeling well, and that machinery should not be operated until the initial drowsiness subsides. If relevant, also discuss the risks of taking lithium during pregnancy.

Anticonvulsants

A number of anticonvulsant drugs have also been used to treat mania, especially when lithium is ineffective. These drugs are now rapidly becoming the drug of choice for many people. Carbamazepine, valproate and topiramate are examples of commonly used anticonvulsants. These drugs 109

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Box 8.5

Signs of lithium toxicity

Signs of lithium toxicity in the early stages include: anorexia

■

nausea

■

vomiting

■

diarrhoea

■

coarse hand tremor

■

twitching

■

lethargy

■

slurred speech

■

hyperactive deep tendon reflexes

■

ataxia

■

tinnitus

■

vertigo

■

weakness

■

drowsiness. Signs of lithium toxicity in the later stages include: ■

fever

■

decreased urinary output

■

decreased blood pressure

■

irregular pulse

■

electrocardiograph changes

■

impaired consciousness, seizures and coma.

■

Lithium toxicity can be a life-threatening event.

have been found to have acute antimanic and mood-stabilising effects. They are not, however, antidepressants. Box 8.6 lists side effects of anticonvulsants.

Drugs used to manage dementia

The aim of drugs used in dementia is not to cure the dementia but to improve cognitive function. Cholinesterase inhibitors include: ■ donepezil (Aricept) ■ rivastigmine (Exelon) ■ galantamine (Reminyl). 110

Chapter 8  Managing medications

Box 8.6

Side effects of anticonvulsants

Side effects include: carbamazepine: blood dyscrasias, drowsiness, nausea, vomiting, constipation or diarrhoea, hives or skin rashes and hepatitis

■

valproate: prolonged bleeding time, gastrointestinal tract upset, tremor, ataxia, somnolence, dizziness and hepatic failure

■

topiramate: cognitive impairment, sedation, nausea, weight loss, dizziness, vomiting, rash, agitation and paraesthesias.

■

Cardiac conditions can be worsened by these drugs, and so regular heart monitoring is required.

Tools for assessing side effects of medications

Assessment tools include: ■ the LUNSERS (Liverpool University Neuroleptic Side Effect Rating Scale) (Morrison et al 2001) ■ the AIMS (Abnormal Involuntary Movements Scale), which is a widely used tool for use with people on long-term antipsychotic medications and is designed to assess for signs of tardive dyskinesia (http://www.cqaimh.org/pdf/tool_aims.pdf ).

General management issues

Taking medicines every day for more than a few days is difficult for most people to do. People with a mental illness, however, are no more likely not to take their medications than the general public. People with chronic illnesses such as diabetes and hypertension (high blood pressure) also have difficulty in taking medications regularly but face dire health consequences when they stop taking, or forget to take, their regular doses. Tips to assist those taking psychiatric medications are listed in Appendix 5. Medication concordance, or medication compliance, refers to a person adhering to a specified regimen of taking medication. Maintaining adequate levels of medication through regular tablet taking is essential for people with a serious mental illness such as schizophrenia. Medication noncompliance is one of the most common reasons for recurrence of psychotic symptoms and readmission to hospital. 111

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There are many reasons why people discontinue psychiatric medications or refuse to take them. For example, a person may: ■ not think they are ill ■ forget to take their medication ■ believe they are better and do not need their medication any more ■ mistrust health professionals ■ experience or have experienced uncomfortable, disabling or frightening side effects ■ think the medication has not worked quickly enough ■ not have the money to buy medication, run out of or lose their medication or have their medication stolen ■ have friends and family telling them they do not need medication ■ be ashamed of having an illness and don’t want to be seen as weak ■ be homeless and have difficulty storing or establishing a routine to remember to take their medication, or ■ sell their medication on the street to make money. Each of the above reasons is real and logical to the person involved, and such feelings need to be taken seriously and talked through. Making negative judgments about people taking or not taking psychiatric medications raises barriers between health professionals and those with whom they work. Box 8.7 lists questions that the person can be asked when assessing medication management and Box 8.8 lists strategies for medication concordance.

Special populations

Pregnancy and breastfeeding

The major period for teratogenic (drug-induced and abnormal) effects in an unborn child is in the first eight weeks. Difficult ethical issues involve weighing the health of the mother in relation to the risk for the unborn child. Specialised medical advice needs to be provided to women who are pregnant and/or breastfeeding and experiencing symptoms of mental illness. Breastfeeding may not need to be discontinued (e.g. if there is insufficient evidence that it will harm the baby), but such a decision needs to be made by specialist medical staff.

Younger people

Prescribing psychiatric medications to children and adolescents is controversial. The central concerns include efficacy, long-term use and the effect on normal growth and development. 112

Chapter 8  Managing medications

Box 8.7

Assessment of medication management

Questions to ask the individual directly include: What type of medication are you on?

■

What is the dose?

■

How often is the medication supposed to be taken?

■

When do you take it?

■

What does it do?

■

What side effects are there?

■

Do you alter the doses or do you follow the prescription exactly?

■

Are you on any over-the-counter (OTC) medications? (Note that some OTC medications such as St John’s wort and cough and cold medicines cannot be taken when a person is on psychiatric medication.) Observe the person for their ability to: ■

read the directions on the medicine container

■

see the pills

■

discriminate between pills of a different colour

■

handle the pills

■

count out the pills or measure liquids

■

remember the regimen.

■

Older people

Both the physiological changes of ageing and existing medical conditions complicate the administration of medications to this population. Reduced cardiac output and reduced liver and kidney function can affect the transport and absorption of medications, in turn affecting efficacy. Older people tend to be more sensitive than younger adults to a number of psychiatric medications, and so prescription needs to be tailored to the least dose with the maximum effect and least side-effect profile. Risks associated with polypharmacy (where an individual is on a number of medications for different conditions) can include increased risk of falls, adverse medication reactions and a reduction in the accurate diagnosis of mental illness. 113

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Box 8.8

Strategies to encourage medication concordance

Strategies include: Spend time establishing how the person feels about medications and their illness.

■

Tailor the medication regimen to the person’s schedule.

■

Educate the person about self-monitoring of symptoms and side effects of the medication.

■

Give the person a medication container and show them how to use it (dosette).

■

Establish regular contact with the person.

■

Establish what factors would motivate concordance (e.g. being able to work, engage in community activities, socialise).

■

Examine what factors inhibit medication taking (e.g. uncomfortable side effects such as nausea, visible side effects such as tremor of the hands).

■

Encourage the person to have regular contact with their general practitioner for health checkups and the mental health treating team for monitoring.

■

Provide information about individual-oriented and recovery-oriented groups and associations for the person to access.

■

Provide education in verbal and written form to the person in small amounts and frequently.

■

Encourage the person to ask questions and request more information.

■

Provide information to the person’s family, carers and friends about medications and side effects, and the importance of medications in maintaining wellness.

■

Conclusion

This chapter has provided an overview of common medications used to treat mental illness. It is important to work with the person regarding them taking the right drug at the right time to maintain wellness. An acute awareness of the side effects and risks of taking psychiatric medications is a vital aspect of the knowledge and skills of all health workers caring for people with mental health problems. REFERENCES Morrison, P., Gaskill, T. & Meehan, T., et al. (2001). The use of the Liverpool University Neuroleptic Side-Effect Rating Scale (LUNSERS) in clinical practice. Australian and New Zealand Journal of Mental Health Nursing, 9(4), 166–176. 114

Chapter 8  Managing medications

Usher, K., Foster, K. & Bullock, S. (2009). Psychopharmacology for health professionals. Sydney: Elsevier. Usher, K., Foster, K. & Luck, L. (2009b). Psychopharmacology. In R. Elder, K. Evans & D. Nizette (Eds.), Psychiatric and mental health nursing (2nd ed.). Sydney: Elsevier.

WEB RESOURCES Mental Health Foundation of Australia. . This site explains various medications. Australian Indigenous HealthInfoNet. . This site contains Psychiatric medication information: a guide for patients and carers 2009.

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CHAPTER

9

 

Contemporary talking therapies

Introduction

Talking therapies are used to reduce distress in people, increase a person’s sense of wellbeing and enable more effective coping skills to be developed. Techniques include open communication, problem identification, goal setting and problem solving. Talking therapies are provided by health professionals with appropriate training and educational preparation, including counsellors, mental health nurses, psychologists, doctors, psychiatrists, social workers and marriage and relationship counsellors.

What is therapy?

There are many different ways of practising therapy. Therapy can be undertaken with individuals or in groups. All therapies generally involve: ■ sessions of about one hour, which involve sitting and talking ■ techniques to help people to overcome stress, emotional problems, relationship problems or troublesome habits (e.g. excessive worrying or excessive anxiety) and gain insight ■ talking, which is the vehicle to help a person to understand themselves better and/or to change unwanted or unhelpful thoughts or behaviours.

Psychodynamic psychotherapy Psychodynamic psychotherapy:

focuses on the feelings we have about people with whom we are close (i.e. family and friends) ■ involves discussing past experiences and how these may have led to our present situation ■ involves new understandings, which allow the person to gain insights about how they feel and to make choices about the future. ■

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Psychodynamic psychotherapy can be brief (one or two sessions) and focus on specific issues, or it can take place over longer periods of time (months to years in some cases).

Behavioural psychotherapy

Behavioural psychotherapy focuses on changing patterns of behaviour that are bothersome to the person (e.g. avoiding certain situations such as heights, shopping centres or flying). It is often used to change behaviour in children through the use of star charts etc. to encourage desirable behaviours. People learn to overcome their fears by spending increasing amounts of time in the situation they fear and by learning ways of reducing their anxiety (e.g. relaxation and breathing training). Homework exercises enable new skills to be practised (e.g. breathing and keeping a diary to record feelings, thoughts and anxiety levels). Behavioural psychotherapy is particularly effective for anxiety, panic attacks, phobias, obsessive-compulsive disorders and various kinds of social or sexual difficulties. Relief from symptoms often occurs quickly.

Cognitive therapy

Cognitive therapy focuses on changing thinking patterns, but it involves close attention to the way we think about certain things, particularly focusing on thinking that affects us in a negative way and causes us to experience distressing emotions. Cognitive therapy: ■ aims to replace unhelpful thoughts and feelings with more realistic and positive ones ■ uses principles from behavioural learning theory and cognitive psychology ■ is present- and future-oriented, and is not concerned as much with childhood or past experiences ■ is thought to be very helpful with people who are depressed, are anxious or have personality disorders, and in some cases it is effective with people with schizophrenia ■ is often used in combination with psychoactive medications ■ is goal-oriented and time-limited, usually over a couple of months (French 2009). Cognitive therapy is often used in conjunction with behavioural therapy so that thoughts and behaviour are mirrored. 117

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Family therapy

Family therapy: ■ focuses on relationships within families and in relationships ■ sees the family or the couple together ■ involves talking about issues in an open and honest way to develop new ways of viewing and solving problems ■ usually takes place over a few months, with two therapists attending all the sessions.

Narrative therapy

Narrative therapy: ■ focuses on a person’s ‘own story’ and how this shapes their lives ■ identifies a person’s specific problems and how the problem has affected them (hence externalising the problem and separating it as coming from inside the person) ■ encourages reflection of a person’s values, hopes and potential ■ through dialogue aims to reauthor a person’s experience. The role of the therapist is to facilitate the person examining, reflecting and changing how they perceive a problem, therefore encouraging new meanings for that person (Corey 2008).

Dialectical behaviour therapy

Originally developed to treat people with borderline personality disorders, dialectical behaviour therapy has also been found to be very effective in people who self-harm and in treating mood disorders. Dialectical behaviour therapy: combines aspects of cognitive behaviour therapy with mindfulness (self-awareness) and distress tolerance ■ help people recognise various viewpoints of a situation and to reduce ‘black and white’ (things are either perfect or awful) thinking ■ focuses on becoming aware of experiences in a more realistic way and separating experiences from worries about the past or future ■ uses individual sessions and group meetings (up to two hours in length) to gain self-awareness, improve communication skills and learn how to reduce emotional distress (Palmer 2012). ■

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Solution-focused therapy

Solution-focused therapy was originally designed for brief therapy (i.e. a few sessions). It is now also used over longer periods of time to assist people to solve their own problems. Solution-focused therapy: ■ focuses on the solution, with little emphasis on the problem ■ differs from other approaches such as cognitive therapy, as it does not assume that a person has faulty thinking ■ assumes the person is the expert, that change is inevitable and that only small changes are required. What works for the person is a key element, as is building on a person’s strengths and abilities. Talking focuses on present-oriented and futureoriented situations and experiences, using questions to develop a full understanding of the person’s perspective. It has wide applications in health care settings, from alcohol and substance abuse, and depression to chronic pain.

Acceptance and commitment therapy

Acceptance and commitment therapy (ACT) is based on the concept of ‘mindfulness’, which is a mental state of full awareness that requires a focus on ‘being in the moment’. This focus allows the person to calm and ground themselves. In this state the person is more able to accept their current situation and commit to an action; this assists the person to have more control and fulfilment in their life. This therapy is helpful to people with a wide range of concerns including anxiety, phobias, post-traumatic stress disorder and abuse histories.

Motivational interviewing

This therapy aims to overcome ambivalence that a person may have about making change in their life. It helps the person explore from their perspective the good and not so good reasons involved in making a change. It relies on identifying the person’s readiness to change and then using supportive and persuasive strategies to help the person clarify their options and actions in making changes. This therapy is helpful to people with a wide range of concerns including drug and alcohol misuse, excessive smoking and people ambivalent about other lifestyle changes.

Creative therapies

Other forms of therapy include creative therapies, which involve art, crafts, music or dance. The group engages creatively and members express themselves. 119

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Conclusion

The impact and effectiveness of talking therapies cannot be underestimated; a novice practitioner can be a great support just by listening and validating the person and their story. Experience and education in any of these therapies will enable the practitioner to have increased therapeutic capacity to support people with their recovery. REFERENCES Corey, G. (2008). Theory and practice of counseling and psychotherapy. Belmont, California: Thompson/Brooks Cole. French, P. (2009). Cognitive-behavioural therapy. In P. Barker (Ed.), Psychiatric and mental health nursing (2nd edn). London: Hodder. Palmer, C. (2012). Therapeutic interventions. In R. Elder, K. Evans & D. Nizette (Eds.), Psychiatric and mental health nursing (3rd edn). Sydney: Elsevier.

WEB RESOURCES Beck Institute for Cognitive Therapy and Research. . Beck Institute for Cognitive Behavior Therapy is a leading international source for training, therapy and resources in CBT. The website offers links to its newsletter, blog, videos and podcasts. Beyond Blue. . This website provides information about a range of anxiety-related and depression-related help, as well as treatment-focused and consumer-focused resources. New Zealand Guidelines Group. . This website includes a brief review of recent literature on the evidence about using cognitive behaviour therapy, dialectical behaviour therapy and motivational interviewing, as well as cultural issues in therapies and on the therapeutic alliance.

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10

 

Co-occurring medical problems

Introduction

This chapter explores common medical problems that coexist in people with a mental illness. All health professionals and many workers in allied health, social services and residential support settings will encounter people with physical conditions who also have a mental health problem. Nurses in general settings and acute care, as well as practice nurses and nurses working in primary health care, are well placed to provide holistic care for both physical and mental health care needs.

The extent of the problem

About 12% of people living with a mental illness will also have a chronic condition such as asthma, diabetes and sinusitis (National Mental Health Commission 2012). People with schizophrenia are almost three times more likely to die of natural causes, particularly of heart conditions, than people in the general population (National Mental Health Commission 2012). Metabolic syndrome and diabetes mellitus are strongly associated with schizophrenia due to the serious permanent side effects of both the typical and the atypical antipsychotic medications prescribed. People with a mental illness are also more likely than the general population to have significant dental problems (Kisley et al 2011). Obesity, cigarette smoking and alcohol and substance abuse are all significant health risks for people with chronic mental health problems, including depression and bipolar affective disorder. Depression can lead to increased heart disease deaths (Shah et al 2011). These issues place people with a mental illness as a significantly vulnerable group with associated social, economic and health burdens on society as a whole (World Health Organization 2012). Although the rate of deaths due to heart disease has decreased in the general population over the past 20 years, this trend has not been mirrored in people with a mental illness. The President of the World Psychiatric Association declared that poor physical health of people with a mental illness is emerging as a great public health and ethical concern worldwide (Maj 2009). In support of this, the Australian Bureau of Statistics (2008) 121

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found that 58.5% of all people who had experienced a mental illness for 12 months also experienced at least one physical illness. All those working with people with a mental health problem can facilitate optimal health by enquiring about physical health complaints as well as use of alcohol, tobacco and illicit substances. Encouraging and assisting people to access health services and having health checkups can reduce long-term damaging effects of such behaviours. Practice and primary health care nurses are ideally positioned to screen for high blood pressure, respiratory problems, diabetes and metabolic syndrome. Table 10.1 lists common physical conditions found in people with a mental illness, as well as the role of medication and lifestyle factors in each physical condition.

Diabetes mellitus

Prevalence of diabetes mellitus in those with a mental illness is double that of those in the general population. A link between type 2 diabetes and antipsychotic medication is suggested with olanzapine and clozapine. Screening of people on antipsychotics should include regular monitoring of blood, including glucose.

Metabolic syndrome

Metabolic syndrome can be defined as a cluster of risk factors for obesity, insulin resistance and cardiovascular disease. The presence of metabolic syndrome can be detected through medical history taking, anthropometry (body mass index (see Box 10.1) and hip/waist circumference), blood pressure measurement and measurement of lipid values and blood or plasma glucose. Box 10.2 lists the diagnostic criteria for metabolic syndrome.

Prevention and management: ongoing monitoring

Ongoing monitoring of the person is important, as regular monitoring of basic observations can greatly assist the early recognition, prevention and management of chronic health issues. Basic observations that can be carried out by health professionals include: weight, including BMI (see Box 10.1) BP, temperature, respirations ■ oral care (teeth, lips, gums) ■ skin care, rashes, infections ■ foot care, including nails. ■ ■

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People with schizophrenia are at increased risk of developing glucose regulation abnormalities, insulin resistance and type 2 diabetes All antipsychotics (atypical and typical) increase the possibility of developing diabetes

Antipsychotic medications have been associated with the development of hyperlipidaemia (both related to and independent of weight gain) Some typical antipsychotics (e.g. haloperidol) have no effects on lipids; phenothiazines (e.g. chlorpromazine) tend to raise triglyceride levels and reduce levels of high-density lipoproteins Other atypical antipsychotics (e.g. clozapine and olanzapine) are associated with increased levels of fasting glucose and lipids compared with risperidone

People with a mental illness have higher rates of cardiovascular and respiratory disorders than the general population Antipsychotic agents contribute to metabolic syndrome (hypertension, hyperlipidaemia, hyperglycaemia, insulin resistance and obesity) Mortality due to ischaemic heart disease, cardiac arrhythmias and myocardial infarction is high in people with a mental illness

Between 40% and 62% of people with schizophrenia are obese or overweight Both typical and atypical antipsychotics can induce weight gain Dibenzodiazepine-derived atypicals (e.g. clozapine, olanzapine) cause rapid weight increase in the short term

Type 2 diabetes

Hyperlipidaemia (high levels of lipids (fats) in the bloodstream)

Cardiovascular disease (hypertension, cardiac arrhythmias)

Obesity

Sources: Hennekens et al 2005, adapted from Lambert et al 2003, Rowley et al 2008 and Rothbard et al 2009

Psychiatric condition and medication effects

Physical condition

TABLE 10.1  Common physical conditions found in people with a mental illness

A high-fat, high-carbohydrate diet with a lack of physical activity and a poor ability to modify behaviour also influence obesity

Smoking, alcoholism, poor diet and lack of exercise contribute to an increased risk of cardiac problems

A high-fat diet and lack of physical exercise increase the risk of hyperlipidaemia

A poor diet and sedentary behaviour exacerbate and contribute to an increased risk of diabetes

Lifestyle factors

Chapter 10  Co-occurring medical problems

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Box 10.1

Body mass index

Body mass index (BMI) is determined by a person’s weight in kilograms divided by their height in metres squared. The formula is: BMI =

Weight (kg) Height (m)2

The BMI is designed for men and women over the age of 18. A healthy BMI is between 20 and 25. A result below 20 indicates that the person may be underweight, while a result above 25 indicates that the person may be overweight. A BMI over 30 indicates a risk of developing metabolic syndrome.

Box 10.2

Diagnostic criteria for metabolic syndrome

Diagnostic criteria include: a waist circumference of > 94 cm for men and > 80 cm for women

■

BMI over 30

■

raised blood triglyceride and raised cholesterol levels (measured through blood tests)

■

raised blood pressure (BP): systolic BP >130 mmHg or diastolic BP > 85 mmHg (or treatment for hypertension in the past)

■

raised fasting plasma glucose > 5.6 mmol/L (or previously diagnosed type 2 diabetes).

■

Factors affecting poor physical health

There are many factors that contribute to a person having poor overall health. Having a mental illness often requires taking medication that decreases physical health. People with a mental illness may suffer symptoms such as suspicious thoughts, paranoia, depression or poor motivation, making them less likely to leave their homes or plan shopping trips that involve a number of different shops. They are more likely to make short local trips and buy food that requires little preparation because of their reduced cognitive ability and associated lack of motivation. Physical symptoms from co-occurring illnesses such as pain, reduced mobility and respiratory problems can further reduce physical activity and increase social isolation. Healthy foods are often expensive in comparison with ready-made frozen foods or fast foods, and people with enduring mental illness are 124

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Box 10.3

Why people with mental health problems tend not to engage with general practitioners and other health professionals

Possible reasons include: a tendency by mental health professionals to focus on mental health issues, while other health complaints are ignored

■

reluctance of general practitioners to take comprehensive care of people with schizophrenia

■

screening for physical problems is not carried out routinely

■

time and resources for general health checkups are not available in mental health service settings

■

a lack of support regarding medication issues

■

fragmentation of the health care system, with physical and mental health services not well integrated

■

inaccurate self-assessment of symptoms

■

inability and reluctance to describe medical problems

■

lack of awareness of physical symptoms due to high pain tolerance associated with the use of antipsychotic medication

■

a lack of contact with general practitioners

■

a lack of continuity of care and follow-up due to itinerancy

■

difficulties in making changes to lifestyle (e.g. to stop smoking, change diet or reduce drug or alcohol intake).

■

Sources: Connelly & Kelly 2005, Lambert et al 2003

likely to be on low incomes, compounding their health risks. A diet low in fibre, vegetables and fruit, and little physical exercise, increases the likelihood of cardiovascular disease, high blood pressure and stroke. Hence, an interplay between behaviours such as smoking, alcohol and substance abuse, combined with symptoms of mental and physical illness, create health problems and poor quality of life for those people living with a mental and physical illness. People with a mental illness often do not make regular visits to health professionals, in particular general practitioners (see Box 10.3).

Strategies for improving physical health Exercise is recognised as an effective strategy for improving general physical and emotional health. Walking is the easiest activity to encourage

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people with a mental illness to engage in. Engaging people in community walking groups can increase exercise, and also provides opportunities for socialisation. Reducing cigarette smoking (by connecting people with national ‘Quit’ programs) is also an important lifestyle change, together with attention to a healthy diet. Reminding people about the availability of free health checks and providing information about centres such as GP Plus can also be of use. Other strategies include encouraging annual medical and dental checkups, including full blood tests and electrocardiograms (ECGs), and providing brochures about prostate checks, mammograms and bone density tests for people older than 50. Encouraging people to attend their closest general practice clinic and to visit them on a regular basis can facilitate an effective working relationship and allow for early recognition of symptoms.

A primary care focus

We know that people with mental health problems often have physical health needs that are not as yet being adequately screened for and treated. We also know that while almost 90% of people living with psychosis saw a general practitioner in the last year, more than 60% said they did not have a health check of any kind (Morgan et al 2011). Comorbidity between mental and substance use disorders is also very common globally. People with a substance use disorder have high comorbid rates of mental disorders. Substances include alcohol, tobacco, marijuana and other illicit substances such as methamphetamine and cocaine. There is a strong relationship between the severity of comorbidity and the severity of substance use disorders. For these reasons we need better primary health care approaches to address the poor physical health of people with a mental illness. Using alcohol and other screening tools, undertaking physical health checks and enquiring about a person’s wellbeing can have significant benefits for people with comorbid health problems. Assessment scales include: ■ the AUDIT alcohol assessment scale (www.therightmix.gov.au) ■ the CAGE alcohol screening test, a short, four-question test that diagnoses alcohol problems over a lifetime (www.healthyplace.com) ■ Quit smoking assistance, assessment tools and information (http:// smokefree.nhs.uk/?&gclid=CLXOno_NnKkCFQNP4QodhErpuA). The UK’s National Health Service website has multiple tools for people to self-assess against common physical and mental health problems at . 126

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Conclusion

This chapter has explored the physical, social and behavioural problems that people with a mental health problem face. Awareness of these additional challenges by all those who work with people with mental health problems provides opportunities to provide support, encourage attendance at health centres and plan strategies to reduce the harm caused by poor diet and using tobacco, drugs and alcohol. REFERENCES Australian Bureau of Statistics. (2008). National Survey of Mental Health and Wellbeing: summary of results, 2007. Cat No 4326.0. Canberra. Connelly, M. & Kelly, C. (2005). Lifestyle and physical health in schizophrenia. Advances in Psychiatric Treatment, 11, 125–132. Hennekens, C. H., Hennekens, A. R., Hollar, D., et al. (2005). Schizophrenia and increased risks of cardiovascular disease. American Heart Journal, 150, 1115–1121. Kisley, S., Lake-Hui, Q., Pais, J., et al. (2011). Advanced dental disease in people with severe mental illness: systematic review and meta-analysis. The British Journal of Psychiatry, 199, 187–193. Lambert, T. J. R., Velakoulis, D. & Christos Pantelis, C. (2003). Medical comorbidity in schizophrenia. Medical Journal of Australia, 178, S67–S70. Maj, M. (2009). Physical health care in persons with severe mental illness: a public health and ethical priority. World Psychiatry, 8(1), 1–2. Morgan, V. A., Waterreus, A., Jablensky, A., et al. (2011). People living with psychotic illness: report on the second Australian national survey. Canberra: Commonwealth of Australia. National Mental Health Commission. (2012). A contributing life: the 2012 national report card on mental health and suicide prevention. Sydney: NMHRC. Rothbard, A. B., Blank, M. B., Staab, J. P., et al. (2009). Previously undetected metabolic syndromes and infectious diseases among psychiatric inpatients. Psychiatric Services, 60(4), 534–537. Rowley, K. G., O’Dea, K., Anderson, I., et al. (2008). Lower than expected morbidity and mortality for an Australian Aboriginal population: 10-year follow-up in a decentralised community. The Medical Journal of Australia, 188(5), 283–287. Shah, A. J., Veledar, E., Hong, Y., et al. (2011). Depression and history of attempted suicide as risk factors for heart disease mortality in young individuals. Archives of General Psychiatry, 68(11), 1135–1142. World Health Organization. (2012). Risks to mental health: an overview of vulnerabilities and risk factors. World Health Organization, 28(4), 805–817.

WEB RESOURCES National Mental Health Commission. . Site for A contributing life: the 2012 national report card on mental health and suicide prevention. National Institute of Drug Abuse. . Site with information on comorbid drug abuse and mental illness. 127

CHAPTER

11

 

Loss and grief

Introduction

Change, transition and loss are constant features of everyday life. Loss can have a major impact on the person involved (e.g. the death of a parent) or it may be less significant (e.g. moving house). The experience of grief and mourning following a significant loss can be intense, including distressing affective, cognitive and behavioural responses; nevertheless, as upsetting as they are, such reactions are normal and are not necessarily evidence of a mental health problem. Health professionals constantly work with people who are experiencing loss and, thereby, may find themselves in the unique position of being a key support in a significant experience for a grieving person. This chapter examines the concept of loss and identifies ways that health professionals can understand and best assist a person experiencing a loss and bereavement.

Understanding loss, grief and mourning

Loss involves the separation from a person or an object that has meaning to the person and to which the person feels strongly connected (Bull 2013). The loss may be tangible (e.g. the death of a loved one) or intangible (e.g. loss of self-esteem following redundancy). The period in which the person experiences grief (affective reactions) and engages in mourning behaviours is referred to as bereavement. Table 11.1 distinguishes between the terms loss, grief, mourning and bereavement. While loss and grief experiences are distressing they are a normal human response and not usually indicative of mental illness. Grief responses are individual and vary with each person—that is, the magnitude of the loss and the meaning the loss has for the bereaved person. Responses can include feelings of deep sadness, anger, guilt and despair; cognitive reactions can include disbelief, confusion and ruminations about the loss. Mourning behaviours include physical reactions such as fatigue and a hyper-startle response, and behavioural responses like social withdrawal and sleep disturbances. Some behavioural responses are life enhancing (e.g. crying and talking about the loss) and facilitate grieving, but 128

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TABLE 11.1  Loss, grief, mourning and bereavement Term

Definition

Loss

Being parted from someone or something that the person values

Grief

The affective (emotional) component of mourning, including the painful affects (feelings) associated with the loss (e.g. sadness, anger, guilt, shame, anxiety)

Mourning

The behavioural component of bereavement, which includes biological reactions, behavioural responses and cognitive and defensive reactions related to the loss

Bereavement

The experience of grief and mourning

others are life depleting (e.g. excessive drinking or making suicidal gestures) and potentially harmful for the person (Bull 2013). Mourning behaviours are also culturally determined and traditional indigenous cultures often have more prescribed mourning practices than those found in Anglo-European Australian or New Zealand cultures. For example, tangihanga, the Māori approach to the process of grieving, includes protocols and practices to not only mourn the person who has died but also the ancestors who have passed before them (Kōrero Māori nd).

Models and theories of loss and bereavement

Models and theories of loss and bereavement have been proposed since the middle of the 20th century in order to understand and thereby assist the bereaved. Kübler-Ross’s influential model identified the phases a dying person experiences as they approach their death. These phases included denial, anger, bargaining, depression and acceptance (Kübler-Ross 1969). Kübler-Ross never intended her model to apply to all losses, nor did she describe the phases as sequential, though some health professionals have applied the model in this way. Another contemporary model of grieving has been proposed by William Worden (2010). He identifies the tasks of mourning as: Accept the reality of the loss. Experience the pain of grief. ■ Adjust to the environment where the ‘loss’ is missing. ■ Emotionally relocate the ‘loss’ and move on with life. ■ ■

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According to Worden, accomplishing these tasks marks the completion of grieving, though he does not prescribe a period within which this should occur, nor does he propose that everyone complete this grief cycle. Rather, Worden stresses that mourning is a long-term, sometimes lifelong, process. Additionally, Worden states that the completion of grieving does not return the person to their pre-bereavement state—rather, the bereaved person is now able to think about the loss without intense pain and has integrated the experience into their new post-bereavement life. Finally, while theories and models of loss and mourning provide useful insights into the experience of the bereaved, they must be used cautiously because everyone’s loss experience is different. Grieving is not a linear experience, grief has no end point, culture influences grief responses and loss is not always a negative experience (e.g. when death follows a long period of suffering and disability).

Uncomplicated grief

The grief of most people following loss will be uncomplicated. However, the person’s bereavement experience may be distressing and disrupt their lives in the short term, such as after a natural disaster like an earthquake. The person’s grief may also be upsetting for bystanders (including health professionals) who feel helpless in being able to relieve the person’s pain. During this period, the bereaved require support as they accept the reality of the loss and adjust to living their life without the person or lost object. Strategies that support people experiencing uncomplicated grief are listed in Box 11.1. Some strategies, however, are not supportive of grieving and may actually hinder uncomplicated grief. Unhelpful strategies, identified by GriefLink (2013b), are listed in Box 11.2.

Complicated grief

Complicated grief may affect between 10% and 20% of people who are grieving. It is difficult to distinguish complicated from uncomplicated grief, especially in the first six months, because intense emotional, cognitive and behavioural responses to loss are normal. Nevertheless, indicators for complicated grief include suicidal thoughts and gestures, depressive disorders, post-traumatic stress reactions and persistent grief reactions. People whose grief is complicated may engage in life-depleting behaviours such as compulsive or excessive behaviours like overeating, shopping or gambling, or agitated, aggressive and demanding behaviours (Bull 2013). In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) the diagnosis of ‘persistent complex 130

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Box 11.1

Strategies for supporting the grieving person

Supportive strategies include the following. Contact the person as soon as you hear of the death and express your sorrow for their loss—give a hug if appropriate.

■

Maintain contact by

■

– visiting (visits don’t have to be lengthy) – telephoning, writing or sending a card if you are unable to visit. Listen if the person wants to talk about the deceased or tell their story again and again—listening is possibly the most important thing you can do.

■

Talk about the person who has died.

■

Accept extreme behaviours (e.g. crying, screaming, being quiet, laughing).

■

Accept expressions of anger, guilt and blame.

■

Indicate that grief takes time.

■

Include children in the grieving process.

■

Be sensitive about dates that might be upsetting or significant for the bereaved person, such as anniversaries, birthdays and Mother’s Day.

■

Offer practical help, such as cooking a meal, child minding or walking the dog.

■

Try to understand and accept the person—everyone’s grief response is different.

■

Source: GriefLink 2013b

bereavement-related disorder’ has been added as an appendix. The inclusion of this new diagnosis arose from concerns by researchers and clinicians about the inappropriate association of complicated grief with anxiety, depression and post-traumatic stress disorder. Nevertheless, despite the inclusion of this disorder the American Psychiatric Association recognises that further research of this construct is required to establish the validity of bereavement-related disorders (Bull 2013).

Loss in special circumstances

For some people, grief and mourning may be affected or exacerbated by additional contributing factors. For example, losses experienced by people with a mental illness may be disenfranchised or not acknowledged because of societal attitudes to mental illness; loss for indigenous peoples may be compounded by cultural expectations and the prevalence of multiple losses in some communities. 131

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Box 11.2

Strategies that may be unhelpful to the grieving person

Unhelpful strategies include: not talking about the deceased person

■

using platitudes and clichés

■

offering false reassurance

■

telling the person: ‘I know how you feel’

■

inhibiting the person’s grief experience by offering advice about what they should think, feel or do

■

ceasing contact with the person if the going gets ‘too heavy’

■

advising the person on how to grieve, or trying to explain or rationalise their feelings

■

having expectations of how the person should grieve and judging the person by these expectations

■

taking over and doing things the person can do for themselves

■

making comparisons between the person’s and others’ losses

■

using theories of grief to predict experience

■

changing the subject (it dismisses the importance of what the person is saying)

■

comparing your losses to the bereaved person’s loss

■

talking about your own grief experiences (unless the bereaved person finds this relevant to their situation and invites you to tell your story).

■

Source: GriefLink 2013b

Loss for people living with a mental illness

As with any illness, there are losses associated with experiencing a mental illness (e.g. loss of independence, income and wellbeing). However, with mental illness, additional losses may occur due to the stigma associated with the illness, including loss of one’s sense of confidence, social standing, self-esteem and self-image. Furthermore, people with a severe and enduring mental illness may experience additional losses, particularly in relation to changes in employment, independent living, social relationships and life goals. This type of loss is what Doka (1993, 2002) refers to as disenfranchised loss—one that is not considered to be legitimate by society. Doka suggests that disenfranchisement occurs when a person experiences a loss but ‘does not have a socially recognised right, role or capacity to grieve’, resulting 132

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in the person having ‘little or no opportunity to mourn publicly’ (Doka 1993 p 128). In disenfranchised loss, other people do not acknowledge the nature of, or the meaning of, the loss for the bereaved person, which inhibits the person’s ability to openly grieve for their loss, or to seek and receive support from others in their mourning. Examples of losses that can be disenfranchised include miscarriage, the death of an ex-partner and adoption.

Loss across the life span

While children experience similar feelings of loss and grief as adults they may express them in behaviours (e.g. bed wetting or sleep disturbances) rather than words. They need assistance in expressing their feelings and thoughts, as well as reassurance that their distress is reasonable and acceptable. Similarly, teenagers may display their distress behaviourally (e.g. mood changes, withdrawal). At the other end of the spectrum the losses experienced by elderly people can be multiple and cumulative (death of friends, loss of health/independence), which can complicate their grieving.

Loss following suicide

Grief following loss of a loved one to suicide can be complicated and intense due to the circumstances of the death and feelings of guilt, shame, blame and anger that can be experienced by the person’s surviving family and friends. Health professionals can assist a person bereaved through suicide by offering compassion, non-judgmental support, an opportunity to tell their story (repeatedly if necessary) and recognition and validation of the person’s experience of loss. Providing information about support services for survivors of suicide may also be helpful (Support after suicide 2013).

Loss for indigenous peoples

Losses experienced by indigenous peoples are complex, multifaceted and frequently have intergenerational consequences. In addition to the losses that are experienced by all people, Māori and Australian Aboriginals and Torres Strait Islanders experience additional losses as a consequence of a history of colonisation, past trauma and separation from family, land and culture. This has led to ‘unresolved or ongoing grief [being] common in Aboriginal communities because of the unfinished business of colonisation and the Stolen Generations’ (Mental Health First Aid 2009). For social and historical reasons, indigenous peoples may experience multiple losses and more frequent death of relatives than the wider population, hence they are engaged in more frequent ‘sorry business’. Furthermore, not only have indigenous peoples suffered major losses, they have 133

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also suffered the loss of the practices and rituals that enable them to deal with these losses (GriefLink 2013a). Suggested strategies for responding to losses among indigenous peoples are summarised in Table 11.2. TABLE 11.2  Strategies for responding to losses among indigenous peoples Strategies for indigenous peoples

How non-indigenous people can help

Create awareness about the impact of losses and the unresolved grief on people

Continue to change non-indigenous history books Develop loss and grief counselling courses for indigenous and non-indigenous peoples Ensure healing centres deal with indigenous health issues from a holistic perspective Develop loss and grief programs and workshops as a part of the curriculum within primary and secondary schools Assist towards a true reconciliation, with the full understanding that both groups, non-indigenous and indigenous peoples, have deep grief Throughout all levels of the medical profession, teach students about the complexities of indigenous and nonindigenous grief

Create and develop grieving ceremonies suited to today Re-create women’s business/ ceremonies Re-create men’s business/ ceremonies Re-create rites of passage (young people)

Source: GriefLink 2013a

Assisting a bereaved person

Health professionals are in the unique position of being a caregiver in the loss and bereavement experience of a person who may well be a stranger to them, and being able to facilitate the person’s grieving. Two areas in which the contribution of health professionals can make a difference are breaking bad news and providing support for bereaved people.

Breaking bad news

At times, health professionals will need to break bad news to people and their families. How this news is delivered can significantly influence the bereaved person’s experience. Box 11.3 provides tips for health professionals when delivering bad news.

Professional support for bereaved people

When providing support to a bereaved person, it is important not to interpret intense grief and mourning reactions as symptoms of mental 134

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Box 11.3

Dos and don’ts for breaking bad news

Do: start from where the person is, asking: ‘What do you already know?’

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prepare the person for what they are about to hear, by saying: ‘I am afraid the news is not good’

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give the key facts briefly, and then pause and check for understanding

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elicit concerns and feelings (this validates the loss)

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give permission for feelings to be expressed (e.g. offer a box of tissues)

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allow time for questions by asking: ‘Is there anything else you would like to know?’

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give the person time and space, and ensure news is delivered in a private setting

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offer further contact (if the person wants it). Don’t: ■

use the telephone, unless there is no other option

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use euphemisms and platitudes, as they minimise the loss

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use jargon (instead, use words the person will understand)

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rush, as the person needs time to absorb the information

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give bad news in a public place, or

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say you understand how the person feels, as each loss is unique.

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illness. Health professionals can provide support for people experiencing uncomplicated grief by: being there for the person; allowing the person to express emotional pain; being sensitive to cultural considerations in death and dying and acknowledging the meaning of death and dying in different cultures; acknowledging difficulties; and exploring opportunities for advanced professional training (Morrison 2012 pp 166–169). Bull (2013) identifies guidelines (based on Worden’s model) that health professionals can utilise in supporting a person who is grieving (see Box 11.4).

Looking after yourself

Finally, while loss and bereavement are a normal part of life for all people, health professionals are exposed to other people’s losses on a regular basis, which can lead to intense personal emotional reactions to the distress observed (Morrison 2012 p 178). Furthermore, health professionals may 135

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Box 11.4

How health professionals can support someone who is grieving

Help the griever actualise the loss ■ Help the griever express their loss. Health professionals can provide a ‘fresh’ listening ear for the story of loss. Help the griever identify and experience feelings ■ Be willing to empathise with the griever’s painful feelings. Responses such as ‘It seems like you are really missing …’ or ‘I imagine that you must be very lonely since … died’ help name and express feelings associated with loss.

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Help find meaning in the loss ■ Meaning-making in grief is highly individual, but health professionals can facilitate the process. Ask the griever what their loss has meant to them and share stories of how others have found meaning.

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Share your own perceptions of meaning (e.g. ‘It sounds like your life would never have been as happy without your relationship with …’).

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Introduce the griever to meaning-making exercises (e.g. Neimeyer 2007, 2010).

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Facilitate emotional relocation of the deceased/lost object ■ Support the griever in remembering and reminiscing about who/what has been lost. Support the griever regarding concrete efforts to remain connected to the lost person or thing.

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Be cautious about a griever’s efforts to quickly find a ‘replacement’.

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Provide time to grieve ■ Recognise that active grieving can take time (one to two years, or longer). Avoid giving messages that people should ‘be over’ their grief.

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Remember and support continuing grief at special times (e.g. on the anniversary of a death, birthdays or holidays).

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Educate the griever’s support system (family, friends) that grieving takes time.

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Interpret normal behaviour ■ Help the griever to understand and ‘make sense’ of their often intense grief responses. Assure the griever that their reactions are not uncommon, while still acknowledging how they might be upset or worried about their reactions.

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Box 11.4

How health professionals can support someone who is grieving—cont’d

Connect the griever with those who have had similar experiences (e.g. support groups).

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Allow for individual differences ■ Recognise the great diversity of grieving responses. Avoid imposing a ‘prescription’ about how grievers should react.

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Educate those around the griever that differences in grieving styles and methods are to be expected.

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Consider defences and coping styles ■ Watch for potentially unhelpful grief responses, such as excessive use of alcohol or drugs, withdrawal, refusal to be reminded of the loss, ‘burying’ oneself in work or some other activity. Within a trusting relationship, help the griever explore more useful ways of coping.

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Identify grief complications and refer ■ Monitor for grief complications (see ‘Complicated grief’ in this chapter). In keeping with professional ethics, recognise one’s own practice limitations.

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Refer grievers with complications for more advanced assistance.

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Source: Bull 2013, adapted from Worden 2010

have experienced a loss similar to that of the person they are caring for, which can reactivate the health professional’s own previous grief reaction. Consequently, working with people experiencing loss can be stressful, and health professionals need to be mindful of managing their own mental health. This can be achieved through self-awareness, acquiring knowledge about loss and grief (e.g. regarding cultural expectations and practices) and developing helping skills (e.g. listening and acceptance) to assist the grieving person and their families (Morrison 2012). Furthermore, clinical supervision can be utilised to examine one’s professional and personal reactions when working with a grieving person and to critically reflect on how this impacts on the health professional’s clinical practice. 137

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Conclusion

Loss is a distressing, relatively common human experience. Though upsetting, most people’s bereavement experience is uncomplicated, with only a small number of people experiencing a complicated grief reaction requiring professional intervention. The nature of the work undertaken by health professionals means they may play a role in the loss experiences of the people to whom they provide care. In such situations, health professionals can assist the bereaved by validating the loss, acknowledging feelings, facilitating mourning behaviours and making referrals to self-help support groups or counselling as appropriate. REFERENCES Bull, M. (2013). Loss. In P. Barkway (Ed.), Psychology for health professionals (2nd edn). Sydney: Elsevier. Doka, K. (1993). Disenfranchised grief: a mark of our time. Paper presented at the 8th Biennial Conference of the National Association for Loss and Grief (NALAG). Yeppoon, Queensland, pp 128–132. Doka, K. (2002). Disenfranchised grief: new directions, challenges and strategies for practice. Champaign, Illinois: Research Press. GriefLink. (2013a). Grief reactions associated with indigenous grief. Online. Available: 14 May 2013. GriefLink. (2013b). Helping the bereaved. Online. Available: 14 May 2013. Kōrero Māori (nd). Tangihanga. Online. Available: 14 May 2013. Kübler-Ross, E. (1969). On death and dying. London: Macmillan. Mental Health First Aid (MHFA). (2009). MHFA guidelines for Australian Aboriginal and Torres Strait Islander peoples: trauma and loss. Online. Available: 14 May 2013. Morrison, P. (2012). Crisis and loss. In R. Elder, K. Evans & D. Nizette (Eds.), Psychiatric and mental health nursing (3rd edn). Sydney: Elsevier. Neimeyer, R. A. (2010). Lessons of loss: a guide to coping. New York: Routledge. Neimeyer, R. A. (2007). Meaning reconstruction and the experience of loss. Washington DC: American Psychological Association. Support after suicide. (2013). Understanding suicide and grief. Online. Available: 22 Aug 2013. Worden, W. (2010). Grief counseling and grief therapy: a handbook for the mental health practitioner (4th edn). New York: Springer.

WEB RESOURCES Australian Centre for Grief and Bereavement. This website provides education, publications and resources about loss for health professionals and the wider community. National Association of Grief and Loss (NALAG). NALAG (NSW)—www.nalag.org.au; NALAG (New Zealand)—www.nalag.org.nz. NALAG is an international 138

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voluntary, non-profit organisation that focuses on issues related to loss and grief. It provides an information resource on death-related grief for the community and professionals. Skylight Bereavement Support NZ. This website provides information and resources for children, families and health professionals dealing with change, loss and grief. Survivors of Suicide. This organisation aims to help those who have lost a loved one to suicide resolve their grief and pain in their own personal way.

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Law and ethics

Introduction

This chapter explores core legal and ethical issues concerned with the care and treatment of people with a mental illness. The intent is to provide a ‘taster’ of some of the issues rather than a comprehensive unpacking of the interplay between legal and ethical issues.

Mental health law

Mental health legislation refers to laws regarding the treatment, care and rehabilitation of consumers with a mental illness. The legislation is designed to protect consumers from inappropriate treatment and to direct the provision of mental health care and the services in which it is provided. Most mental health legislative documents cover both the treatment and the care of voluntary and involuntary consumers (Muir-Cochrane et al 2012). In Australia, each state and territory currently has a separate mental health Act with different requirements regarding treatment and detention. Involuntary detention continues to be controversial, as it involves the removal of a person’s freedom and autonomy under the auspices of mental health legislation. Therefore, the State can compel people with a mental illness to undergo treatment against their will, raising complex legal and ethical issues. The World Medical Association’s Statement on ethical issues concerning patients with mental illness (2006) states that compulsory hospitalisation should only be used when it is medically necessary and for the shortest possible duration. Laws regarding involuntary hospitalisation and treatment vary worldwide; however, it is generally acknowledged that such a decision requires the following criteria to be satisfied: 1 The person is suffering from a severe mental illness. 2 The person is a danger to self or others. 3 Immediate treatment is required. 4 Appropriate treatment in approved mental health settings is available. In Australia, New Zealand and overseas, the terms ‘detained, sectioned, ordered and scheduled’ all refer to involuntary commitment to 140

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a psychiatric hospital for treatment, or to involuntary treatment in the community under a community treatment order. In general terms, consumers can usually be held for 24 hours in the first instance after examination by a medical practitioner (in some mental health Acts a mental health nurse can undertake this role) but must then be examined as soon as is possible by a psychiatrist who can then allow the detention to lapse or apply a three-day detention. Further detention of 21 days may be involved and, under certain circumstances, forced treatment may be instituted if it is felt that the person requires ongoing care and treatment in hospital or the community. A person in care may apply for a review of their detention to a panel of mental health professionals and consumer advocates and laypeople in each state and territory, although their title and make-up are different from state to state (e.g. in New South Wales and Queensland the panel is known as the Mental Health Review Tribunal, in Victoria it is known as the Mental Health Review Board, in South Australia it is known as the Guardianship Board and in Tasmania it is known as the Guardianship and Administration Board). These boards and tribunals assist when a person may be unable to make decisions for themselves due to mental illness and dangerousness. They are commonly involved when consumers wish to appeal detention orders placed on them by their treating psychiatrist. All mental health consumers need to be provided with information about their rights and details of advocacy groups on admission to a psychiatric inpatient facility. In New Zealand, in accord with the Treaty of Waitangi, section 5 of the New Zealand Mental Health Act requires that the cultural identity of consumers is respected and attended to (Muir-Cochrane et al 2012). Consumers may not be involuntarily held under mental health legislation, in any jurisdiction, on the following grounds: ■ political, religious or personal beliefs ■ sexual preference ■ criminal behaviour ■ illegal drug use ■ intellectual disability. Consumers who are held against their will in a psychiatric inpatient facility must be provided with written and verbal information explaining all procedures, as well as their legal rights and how they can appeal the decision, in a language they understand. 141

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Compulsory community treatment

Compulsory mental health care in the community has existed for more than two decades in Australia and New Zealand, and is enacted under community treatment orders (CTOs). These orders are a response to the coercive nature of involuntary hospitalisation and are an attempt to increase engagement of consumers with services, reduce relapse and promote recovery (Muir-Cochrane et al 2012). Most CTOs require that consumers accept treatment and, if they do not do so, they can be removed to a psychiatric treatment facility. The advantages of CTOs are thought to include improved social functioning, reduced rates of relapse and increased quality of life.

Role of ambulance officers and police officers

Ambulance officers and the police are frequently involved in transporting people for the purposes of assessment and treatment, and have particular responsibilities that include transporting people if it appears they may have an illness that the person has caused themselves or is at significant risk to themselves or the public, or property. In South Australia, under the Mental Health Act 2009, authority is given to police and ambulance officers to search, restrain and use reasonable force in transporting those thought to be suffering from a mental illness for assessment and treatment, thereby extending current existing powers.

Summary of rights of people with a mental illness

In 1991 the United Nations established principles for protecting people with a mental illness. These include the right to: confidentiality about their personal information voluntary treatment wherever possible ■ information about mental health Acts to be given in a verbal and written form that the person can understand ■ no treatment being given without informed consent ■ receive appropriate medical treatment ■ least restrictive care and that restraint will only be used as a last resort ■ make a complaint ■ specific conditions of treatment if a person is involuntarily held ■ live and work in the community (adapted from Singh 2012). ■ ■

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In Australia and New Zealand, mental health legislation is based on human rights and additional individual rights. Rights include the right to: ■ access to legal representation ■ access to a copy of the Mental Health Act ■ a right of appeal ■ a second psychiatric opinion.

Ethical issues in mental health care Ethics in health care refers to determining the right thing to do in difficult circumstances in accordance with the standards and competencies of your health profession. All health workers are expected to be aware of the professional standards, ethical codes and competencies related to the focus of their practice (see Chapter 2). Ethical codes provide guidance to health professionals in regard to their obligations to the public and the boundaries of their practice. Box 12.1 lists the main terms in ethics in mental health settings.

Exceptions to confidentiality

An exception to confidentiality is termed the Tarasoff rule, which is based on a famous American case that resulted in the death of a woman whose ex-boyfriend had confided to his treating psychologist that he would kill her, which subsequently happened. Under the law at that time, the psychologist was not required to inform authorities or the person in potential danger. After a number of appeals to the original decision, a therapist now has a duty to protect an intended victim where information is disclosed in the context of a health setting.

The ethics of physical restraint of consumers

Physical restraint of consumers is used to control behaviour of people with a mental illness. As described earlier, mental health law allows the police and ambulance officers to restrain and use reasonable force to contain and transport people for treatment. Restraint must be exercised within a context of the least restrictive environment (to protect a consumer’s autonomy), as well as the duty of care that must be extended by the health professional or police officer. Duty of care is a legal term referring to the obligations required by people in a workplace that they adhere to a standard of reasonable care in their day-to-day work. In health care and social care, this includes a need to: ■ act in the best interests of others ■ not act or fail to act in a way that could cause harm 143

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Box 12.1

Summary of main terms in ethics in mental health settings

Privacy. Information provided to health professionals is safeguarded and kept private from the general public. Privacy refers to spoken and written material, and all forms of health care records (e.g. prescriptions, x-rays, case notes).

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Confidentiality. Health professionals ought to keep information secret about people in their care unless it needs to be shared for the purposes of giving care and in this case personal information may be passed on.

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Veracity. Health professionals should tell the truth to people in their care and not withhold or mislead in regard to information giving.

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Autonomy. This refers to a person’s self-determination and ability to make decisions for themselves.

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Informed consent. This refers to the provision of information about the nature of the person’s illness, the therapeutic procedures, care and treatment, including the risks, benefits and outcomes of various treatment options.

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Paternalism. This refers to decisions made by medical practitioners or other health professionals that are deemed to be in the best interests of the person in the context of their illness. This is a controversial issue and a common ethical dilemma, as when the principle of paternalism is applied the principle of autonomy may be overridden.

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Beneficence. Health workers should attempt to ‘do good’ to people in their care.

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Nonmaleficence. Above all, health workers should do no harm. Health professionals have a duty of care to not cause harm to consumers in their care and to prevent or avoid harm occurring.

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Justice. Care should be provided that is fair and given equally to others.

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always act within your own competence and do not do something that you cannot do safely. Therefore, if needing to physically hold or lift a person, you must have the skills and knowledge to undertake the activity. If you do not, you could be in breach of your duty of care. The use of any form of restraint (i.e. physical, such as physical holding, shackles or confinement as in seclusion) including chemical restraint (the administration of medication to control a person’s behaviour) must be used as a last resort when all other options (e.g. talking, diversion) have been exhausted. Restraint should occur for the shortest possible time and there must be careful adherence to procedures.

■

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Comparison of individual and professional views

Based on the following case study, Table 12.1 compares individual and professional views of ethical principles in mental health. CASE STUDY:

Ethical decision making Jane is an 18-year-old woman who has been taken by ambulance to an emergency department in Adelaide, South Australia. Her mother called emergency services when Jane admitted taking 30 paracetamol tablets. Jane was unwilling to go to hospital but paramedics insisted using their rights to transfer a person to hospital for assessment if they believe a person may be suffering from a mental illness. Jane has asked ambulance staff not to tell her mother of her suicidal ideation or previous self-harming (cutting) behaviour. Jane is unwilling to stay in hospital and despite health professionals seeking her consent to stay in hospital, she refuses and is detained under the relevant mental health legislation for treatment. Comment Confidentiality requires that the health professionals do not inform the mother about this information, as the daughter has requested. The consumer is an adult in a legal sense, and so has autonomy regarding her decisions. Duty of care also requires that the ambulance officers inform the treating medical and mental health team of her suicidal ideation. TABLE 12.1  Individual and professional views of ethical principles in mental health Ethical principle

Jane’s view

Mental health professional’s view

Human rights issues

Autonomy

‘I want to stay at home and decide for myself about what treatment if any I need.’

‘Jane is extremely depressed and does not have the capacity to make decisions in her best interests.’

The right to determine one’s own health decisions

Beneficence

’To “do good”, you should assist me make my own decisions and let me stay at home.’

’To “do good”, we must ignore Jane’s stated wishes and prevent her from harming herself.’

The right to choose between different treatment options Continued

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TABLE 12.1—cont’d Ethical principle

Jane’s view

Mental health professional’s view

Human rights issues

Nonmaleficence

‘If you admit me to hospital, you will be “doing me harm”.’

‘If we do not admit Jane, we will cause greater harm by allowing her physical condition to deteriorate and running the risk that she will attempt suicide.’

The right to freedom of movement

Justice

‘I have the same right as anyone else to make my own decisions. Other people can’t be forced to go to hospital if they don’t want to.’

‘While Jane is not able to make the best decisions for her health, we must make them for her.’

The right to refuse treatment

Adapted from Happell et al 2008 p 92

Conclusion

There are many competing issues for carers, consumers and health professionals when caring for people with a mental illness and these are not easily resolved in many cases. This chapter has provided an overview of the central issues regarding ethics, mental health law and people with a mental illness. The challenge remains to treat people with a mental illness with the least restriction on their autonomy while ensuring they receive the best possible care to encourage recovery and stability in their lives. REFERENCES Happell, B., Cowin, L. S., Roper, C., et al. (2008). Introducing mental health nursing: a consumer-oriented approach. Sydney: Allen & Unwin. Muir-Cochrane, E., O’Brien, A., & Wand, T. (2012). The Australian and New Zealand politico-legal context. In R. Elder, K. Evans & D. Nizette (Eds.), Psychiatric and mental health nursing (3rd edn). Sydney: Elsevier. Singh, B. (2012). The active participants in mental health services. In G. Meadows, B. Singh & M. Grigg (Eds.), Mental health in Australia. Melbourne: Oxford University Press. World Medical Association. (2006). Statement on ethical issues concerning patients with mental illness. Online. Available: 1 Nov 2013. 146

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WEB RESOURCES Code of Ethics for Nurses in Australia. The code of ethics has been developed for the nursing profession in Australia. It is relevant to all nurses at all levels and areas of practice, including those encompassing clinical, management, education and research domains. Guardianship and Administration Board (SA). ; Guardianship and Administration Board (Tasmania). These boards can make decisions for the benefit of people who have a disability and who are unable to make reasonable judgements about lifestyle and financial matters. Institute for Criminal Justice Ethics. The Resource Library of this website contains hundreds of pages of resources, ranging from applied and professional ethics through to police codes (sorted by state and department), as well as links to major restorative justice sites. Mental health legislation: Australian Capital Territory Mental Health (Treatment and Care) Act. (1994). ; New South Wales Mental Health Act. (2007). ; Northern Territory Mental Health and Related Services Act. (2009). ; Queensland Mental Health Act. (2000). ; South Australian Mental Health Act. (2009). ; Tasmanian Mental Health Act. (1996). ; Victorian Mental Health Act. (1986). (amended): ; Western Australian Mental Health Act. (1996). . Nursing Council of New Zealand Codes of Conduct. As the statutory authority, the council governs the practice of nurses. The council sets and monitors standards in the interests of the public and the profession. The council’s primary concern is public safety. This link takes you to the council’s available publications. Royal College of Psychiatrists. This is a British website with readable, user-friendly and accurate information about mental health problems.

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13

 

Settings for mental health care

Introduction

Mental health services in developed countries have undergone major reform in recent decades and the World Health Organization (2013) has called for this reform to be worldwide. Reform has led to the mainstreaming of mental health services (i.e. providing mental health care within the general health system, not within separate psychiatric services) and a shift from the traditional biomedical treatment approach to a model in which recovery is the focus (National Mental Health Commission 2012, New Zealand Ministry of Health 2012). Reform policy directs that ‘People with mental health problems and mental illness will have timely access to high quality, coordinated care appropriate to their condition and circumstances, provided by the most appropriate services’ (Commonwealth of Australia 2009 p 16) and the World Health Organization (2009 p 1) recommends that ‘mental health care is available at the community level for anyone who may need it’. In Australia and New Zealand, the reform agenda has led to the transformation and expansion of the settings in which mental health care is delivered. This chapter provides an overview of these settings.

Mental health care

Contemporary mental health services provide a wide range of interventions and programs including: assessment and treatment; emergency and crisis care; prevention and early intervention programs; mental health promotion initiatives; support for consumers and families who have ongoing mental health needs; and rehabilitation and recovery programs. Services that embrace a recovery framework also emphasise mental health and do not just focus on treating the symptoms of the person’s mental illness. Mental health services are provided in diverse settings by a broad range of health workers, including allied health professionals, care workers, general practitioners (GPs), mental health nurses, psychiatrists and 148

Chapter 13  Settings for mental health care

psychologists. Services and programs are delivered in both public and private hospitals, by government and non-government organisations and in both community and institutional settings.

Community settings

The preferred contemporary setting for providing mental health care is in the community (Elder et al 2012, World Health Organization 2013). Community mental health services include primary care, mental health promotion, acute treatment and community support services, and may be provided by public and/or private sector organisations (Commonwealth of Australia 2009, New Zealand Ministry of Health 2012).

Case management

The predominant model of public sector mental health care, which is provided at a community level, is case management (Elder et al 2012 p 444). In the public sector, case management is mostly undertaken by mental health services, while in the private sector GPs and other private practitioners perform this function. The core functions of case management include: ■ assessment ■ planning ■ linking ■ monitoring ■ evaluation (Elder et al 2012 pp 444–448). Generally, public sector community mental health services are structured into multidisciplinary teams that provide mental health care to specific population groups. While the structure of these teams and the names of the teams differ between health services, most community mental health services provide three types of intervention: ■ crisis intervention ■ treatment for people with acute mental illness ■ ongoing care for people with enduring mental illness.

Assessment and crisis intervention teams

Assessment and crisis intervention services provide a single point of first contact with the mental health team and are generally available 24 hours a day, seven days a week. Referrals are accepted from any source. These services provide community-based mobile emergency response, crisis 149

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assistance, initial assessment, short-term case management, admission to psychiatric inpatient units and referral for treatment within the community.

Community treatment teams

Community treatment services provide community-based multidisciplinary case management and consultancy services to people with a mental illness and their family or carers. In addition to providing treatment for the mental illness, emphasis is placed on assisting people with mental illness to develop skills in self-care and independent living in their own environment, thereby encouraging integration within the community. They have a crisis and case management role, which means that the consumer is engaged with one mental health professional throughout the episode of care—that is, both crisis and ongoing case management.

Mobile assertive care teams

Mobile assertive care services provide intensive and medium-term support to people with a severe and disabling mental illness. The services are available over seven days and provide: intensive, mobile, community-based management; specialist care regarding self-care, medication and treatment options; close liaison with other support services; linkage and advocacy with external agencies or services; and carer support and education.

General practitioners

GPs are frequently the first point of contact for people with mental health problems or mental illness. GPs can refer the person either to a private mental health practitioner or to the local public mental health service. Also, people who have been treated by public sector mental health services will often be discharged into the care of their GP for ongoing case management.

Private practitioners

Psychiatrists, psychologists, mental health nurse practitioners and other allied health professionals in private practice provide treatment, counselling and case management services. Generally, private health insurance is required to access these services, though some private services are publicly funded. In Australia, seeing a psychologist in private practice attracts a Medicare payment if the GP develops a ‘GP mental health care plan’ for the person (Department of Health and Ageing 2013a). In New Zealand, psychologists and mental health nurses can deliver mental health services 150

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in primary care settings under the ‘Primary mental health initiative’ (Dowell et al 2009).

The Mental Health Nurse Incentive Program

Another model of case management in Australia is the Mental Health Nurse Incentive Program. It was established in 2007 by the federal government and provides a non-MBS (Medical Benefit Scheme) incentive payment to general practices, private psychiatric services and other appropriate community providers to employ mental health nurses to help provide coordinated clinical care for people in the community who have severe mental illness and complex needs (Department of Health and Ageing 2013b). To work under this scheme a registered nurse needs to be credentialled as a mental health nurse with the Australian College of Mental Health Nurses (ACMHN 2013). They are employed to work with consumers, their families and carers in a range of settings—including GP practices, private clinics, the community and private homes—to provide coordinated clinical care for people living in the community who have mental health disorders or a mental illness. Mental health nurses employed through this initiative provide a range of services to enhance continuity of care, which are geared towards each person’s particular needs. Services include: ■ case management ■ therapeutic interventions ■ regular review of the person’s mental state ■ medication monitoring and management ■ provision of information about physical health care to consumers and carers ■ provision of education and acting as a resource in regard to mental health and mental illness to other professionals within the practice (ACMHN 2013).

Hospital@home

Hospital@home is a community-based service that provides acute mental health care in a person’s home as an alternative to traditional inpatient treatment. It enables the person to avoid hospital altogether, or be discharged from hospital sooner. Consumers referred to a mental health hospital@home program are people who have been assessed in a hospital emergency department or by 151

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the consultation-liaison psychiatric service as meeting the criteria for admission to an inpatient psychiatric unit, and who have sufficient personal coping skills and support to be able to receive the treatment for their mental illness in their own home from a mobile community mental health team. The team may visit the person and their family/carer several times a day to provide treatment and support. The service is also available to those in mental health inpatient units who are assessed as being well enough to go home but not well enough to use the ordinary support services available in the community (Department of Health 2013, Flinders Medical Centre 2006).

Non-government organisations

Non-government organisations (NGOs) play a significant role in providing psychosocial and support services to people with a mental illness, including employment, accommodation, support, information, day and residential programs and family respite. NGOs are generally run by notfor-profit organisations with the support of government funding. This sector has grown significantly over the past decade. NGOs provide centre-based psychiatric disability support services to assist people with severe and enduring mental illness to: improve their quality of life; participate to their maximum extent in social and recreational activities; pursue education and employment opportunities; and achieve an optimal level of independent living in the community. Programs also provide community access, community development and outreach support. NGOs provide leadership and are frequently at the forefront of: innovations in service delivery; workforce culture change; effective partnerships with consumers, carers, families and communities; and putting recovery into action (Department of Health 2011, New Zealand Ministry of Health 2012).

Mutual support/self-help/information/ advocacy groups

Mutual support/self-help/information/advocacy groups offer peer-based support, information and social action services to people with a mental illness and their families and carers. The Mental Illness Fellowship of Australia and Supporting Families in Mental Illness New Zealand are examples of these organisations. In addition to providing support, friendship and psychoeducation for their members, these organisations play a significant role in lobbying for appropriate services for people with a mental illness and challenging the 152

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stigma associated with mental illness, and the consequent discrimination experienced by consumers and carers.

Hospital settings

Public and private hospitals provide treatment for mental illness in specialised mental health inpatient units and in general hospital settings. Consumers admitted to inpatient units may be voluntary or involuntary (compelled to accept treatment under the relevant mental health Act).

Acute inpatient units

Acute inpatient units provide care for people requiring hospitalisation. Care is provided 24 hours a day by a multidisciplinary team of medical and allied health professionals, including mental health nurses, psychiatrists, psychologists, social workers and occupational therapists. Inpatient units are located in specialised psychiatric hospitals and within acute general hospitals. They provide individual treatment, as well as a comprehensive activities program designed to meet a range of individual needs. The goals of inpatient therapy include: ■ containment ■ structure ■ support ■ involvement ■ validation ■ symptom management ■ maintaining links with the person’s family or others ■ developing or maintaining links with the community (Elder et al 2012 pp 444–448).

Secure/extended care inpatient facilities

Secure/extended care inpatient facilities provide a safe, supportive environment for people with a serious mental illness and whose behaviours may put themselves or others at risk. The units provide intensive inpatient treatment and care to consumers who have persistent severe symptoms that limit their capacity to live in the community.

Intermediate care centres

Intermediate care centres are ‘step up–step down’ facilities that provide care for consumers living in the community who are experiencing early warning signs of a relapse, and for consumers leaving hospital who require 153

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a transition before returning home. The care is recovery focused and delivered by a nurse-led multidisciplinary team in a home-like, supportive environment. There is also a focus on improving the person’s connection with local community services such as health, housing, employment and recreation (SA Health 2013).

Consultation-liaison psychiatry

Consultation-liaison psychiatry provides assessment, consultation and referral for general hospital patients. The service is delivered by mental health nurses, psychiatrists and allied mental health professionals who provide expert consultation and support to non-mental health professionals in hospital emergency departments, wards and clinics regarding the mental health care of general hospital patients. Services are provided for consumers with a primary medical condition (e.g. an elderly person who develops a delirium post-general anaesthetic). Services are also available for consumers who have a known mental illness associated with or complicated by a medical problem (e.g. a person who develops metabolic syndrome after taking an atypical antipsychotic medication). Services provided by a consultation-liaison psychiatry service include: psychiatric assessment and diagnostic service for inpatients, including risk assessment ■ advice on managing difficult behaviours ■ advice on the acute psychiatric management of people who have attempted suicide or self-harm ■ recommendations regarding interventions and treatments ■ support, guidance and education in relation to those people referred to non-mental health staff ■ advice on psychopharmacology and psychological interventions ■ opinions pertaining to relevant legislation including mental health legislation ■ assessing capacity to consent to or refuse treatment ■ in-service education for staff on mental health issues ■ participating in mental health projects, policy development and research ■ support and advice to local GPs ■ specialty consultation-liaison training for psychiatric registrars, mental health nurses and allied health professionals (St Vincent’s Hospital Sydney nd). ■

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Chapter 13  Settings for mental health care

Special populations

In addition to the mental health settings outlined above, mental health care is also delivered by specialised services that focus on the needs of particular populations. These include services specifically for children and adolescents; youth (e.g. Headspace 2013); the elderly; prisoners; indigenous peoples; refugees and immigrants; people with specific diagnoses (e.g. Spectrum 2013); people with drug and alcohol problems; and people in particular geographic areas (e.g. regional, remote and rural populations). These services are also offered across a variety of settings within the community and within institutions.

Conclusion

Contemporary health policy directs mental health service providers to deliver care for people with a mental illness that is responsive to consumers’ and carers’ needs and promotes positive outcomes and facilitates sustained recovery (Commonwealth of Australia 2009 p 16). To enable this outcome, consumers and carers need access, in a timely manner, to the most appropriate clinical and community services. Settings for delivering mental health care are diverse and include the community and health care institutions. While care in the community is advocated as the preferred setting in which to deliver mental health care, at times, some people will require inpatient care. Finally, decisions about where to deliver care need to be person-centred and based on the needs of the consumer and their family/carers. REFERENCES Australian College of Mental Health Nurses (ACMHN). (2013). The mental health nurse incentive program. Online. Available: 22 Aug 2013. Commonwealth of Australia. (2009). Fourth national mental health plan: an agenda for collaborative government action in mental health 2009–2014. Canberra: Commonwealth of Australia. Department of Health and Ageing. (2013a). Better access to mental health care. Online. Available: 22 Aug 2013. Department of Health and Ageing. (2013b). Mental Health Nurse Incentive Program. Online. Available: 22 Aug 2013. Department of Health. (2011). Framework for recovery-oriented practice. Mental Health. Melbourne: Drug and Alcohol Division, Department of Health. Online. Available: 21 Aug 2013. Department of Health. (2013). Hospital in the home. Online. Available: 22 Aug 2013. 155

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Dowell, A., Garrett, S., Collings, S., et al. (2009). Evaluation of the primary mental health initiatives: summary report 2008. Wellington: New Zealand Ministry of Health. Elder, R., Sharrock, J., Maude, P., et al. (2012). Settings for mental health care. In R. Elder, K. Evans & D. Nizette (Eds.), Psychiatric and mental health nursing (4th edn). Sydney: Elsevier. Flinders Medical Centre. (2006). Mental health hospital@home program. Online. Available: 22 Aug 2013. Headspace. (2013). National Youth Mental Health Foundation. Online. Available: 22 Aug 2013. National Mental Health Commission. (2012). National Mental Health Commission’s strategies and actions 2012–2015. Canberra: Australian Government. Online. Available: 21 Aug 2013. New Zealand Ministry of Health. (2012). Rising to the challenge: The mental health and addiction service plan 2012–2017. Online. Available: 22 Aug 2013. SA Health. (2013). Intermediate Care Centres. Online. Available: 22 Aug 2013. Spectrum. (2013). The personality disorder service for Victoria. Online. Available: 22 Aug 2013. St Vincent’s Hospital Sydney. (nd). Consultation liaison psychiatry. Online. Available: 22 Aug 2013. World Health Organization. (2009). WHO’s framework on mental health, human rights and legislation. Geneva: WHO. World Health Organization. (2013). Draft comprehensive mental health action plan 2013–2020. Geneva: WHO. Online. Available: 22 Aug 2013.

WEB RESOURCES Australian Government. . The federal government’s mental health and wellbeing homepage provides access to information about mental health reform, legislation, policy, resources, initiatives and publications. Health boards and departments of health. See your local health board or state or territory health department website for specific details of the mental health services provided and the settings in which these services are delivered. Mental Illness Fellowship of Australia Inc. . The fellowship is a not-for-profit non-government organisation that provides self-help, support and advocacy for people with serious mental illnesses, their families and friends. Fact sheets describe mental health service delivery frameworks for Australian states and territories. 156

Chapter 13  Settings for mental health care

New Zealand Ministry of Health. . The ministry’s mental health homepage provides access to information about mental health legislation, policy, resources, publications and how to access mental health care. World Health Organization (WHO). . The WHO mental health homepage is a resource for information about policy, programs, projects and WHO publications in the mental health and mental illness field.

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Appendix 1

Surviving clinical placement!

Self-organisation

Tips for self-organisation include: ■ Research your placement before you go. Find out what you will be expected to do on your first day. ■ Make sure your immunisations, ID and police clearances are all in order before you begin your placement. ■ Invest in a good pair of shoes to increase comfort and safety, if you will be on your feet a lot. ■ Read as much as you can to prepare yourself for the placement. ■ Focus your learning by writing objectives for the placement. ■ Use a diary on your phone, computer, iPad, notebook, etc. to record relevant information. ■ Prioritise tasks on a needs basis; don’t drop everything when you are asked to do something, unless it is clearly an emergency. ■ Find out about commonly used abbreviations in the organisation. ■ Be responsible for your own learning.

Communication

Tips for effective communication include: ■ Arrive and leave on time. ■ Ask about the dress code (if not in uniform) and stick to it. ■ Be polite and respectful at all times. ■ If you are not able to attend the placement contact the organisation well in advance. ■ Record your supervisor/facilitator’s contact details and keep them in a safe place. ■ Identify and discuss your learning goals for the placement with your supervisor/facilitator including how these can be achieved. ■ Actively seek out your supervisor/facilitator and ask for feedback. 158

Appendix 1

Clarify expectations about your role and what you are there to achieve. ■ Don’t engage in gossip or in-house politics. ■ Don’t be afraid to say ‘I don’t know’. ■ Don’t be afraid to ask questions. There is no such thing as a stupid question. ■ Actively seek feedback on your work. ■ Make the effort to get to know other members of the team. ■ Get involved in your allocated team, and talk to all the people in the multidisciplinary team. ■ Use your initiative! Offer your opinion. Share your knowledge of research into clinical practice. ■ Don’t take things personally. ■ If you are feeling vulnerable, talk to someone about it. ■ Don’t agree to keep a confidence with people for whom you are providing care. ■ Don’t give out personal details such as your mobile telephone number or address to people for whom you are providing care. ■

Work/life balance

Tips for work/life balance include: ■ Have fun. ■ Smile. ■ Have regular contact with your peers. This will enhance your own experience. ■ Don’t drink too much coffee or alcohol. ■ Get lots of sleep. ■ Avoid taking work home. ■ Exercise regularly. ■ Learn from your mistakes. You are a ‘newby’! Making mistakes is okay.

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Appendix 2

Who does what in mental health?

Multidisciplinary teams in mental health

A multidisciplinary team is composed of members from different health care professions with specialised skills and expertise in mental health. The members collaborate to make treatment recommendations that facilitate quality patient care. Multidisciplinary teams form one aspect of providing a streamlined patient journey by developing individual treatment plans that are based on ‘best practice’. Multidisciplinary teams provide treatment that is focused on both the physical and the psychological needs of the person diagnosed with a mental illness.

Consumer and carer workers

These workers are employed by mental health services and have a personal, lived experience of mental illness and recovery, or care for a person living with a mental illness. They can provide information and education about mental illness, recovery and support services to consumers and their families, friends and carers. Consumer and carer workers work in partnership with clinical staff to promote hope and recovery. Because of their life experience, such workers have expertise that professional training cannot replicate. They have job titles such as consumer and carer consultant or peer support worker.

Community visitor

A community visitor is a person appointed by justice departments in Australia and New Zealand to visit inpatient and residential mental health environments and help people in these settings understand their rights. Community visitors regularly visit these facilities to promote the rights of the consumers and residents, protect their interests and ensure no one is taking advantage of them.

Mental health nurse

A mental health nurse has formal qualifications in mental health nursing with a focus on caring for people with mental health problems. A 160

Appendix 2

credentialled mental health nurse is a specialist mental health nurse with specific skills and knowledge in mental health nursing. The Credential for Practice Program is an initiative of the Australian College of Mental Health Nurses and has established the only nationally consistent recognition for specialist mental health nurses.

Mental health support worker

A mental health support worker usually has certificate or diploma qualifications in mental health and provides mental health counselling and support to individuals, families and groups in the community. Mental health workers provide treatment referrals for clients as well as assistance with community education, support and other activities.

Social worker

A social worker has formal qualifications in social work and works with individuals and groups who need assistance with social, economic, domestic, employment and emotional issues. The aim of care is to increase wellbeing and quality of life.

Psychiatrist

Psychiatrists are doctors who specialise in preventing, diagnosing and treating mental illness. A psychiatrist is a qualified medical doctor with additional training in psychiatry. Psychiatrists can prescribe medication, while psychologists cannot.

Psychologist

A psychologist has formal qualifications in psychology (the study of the mind and human behaviour) who can evaluate, diagnose and treat behaviour and mental processes. Clinical psychologists use talking therapies (e.g. cognitive behaviour therapy and psychotherapy) to alleviate symptoms of emotional distress.

Occupational therapist

An occupational therapist has formal qualifications in occupational therapy and works with individuals and groups to achieve the fullest potential through using purposeful activities and interventions.

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Appendix 3

Working with people with challenging behaviours The importance of establishing boundaries to sustain a therapeutic relationship with consumers was discussed in Chapter 3. Many people using health and social services exhibit challenging behaviours for a variety of reasons. For example: ■ frequent presentations to emergency departments ■ frequent calls to ambulance or police ■ repeated overdose of prescription or non-prescription medicines ■ alcohol and substance intoxication ■ aggressive and/or violent outbursts. It is important to remember that when people are in crisis they may behave in ways that we consider unacceptable but that they find helpful, or these behaviours may be the only ones that they have available to them at that time. People diagnosed with a personality disorder are often negatively labelled and the phrase ‘they’re just a PD’ is commonly heard in health and social service settings. This involves a judgment that the person with this diagnosis is not really sick but is deliberately misbehaving or does not deserve treatment. As described in Chapter 6, people with personality disorders have legitimate mental health problems and exhibit behaviours that are difficult or unhelpful in an effort to manage their distress. Health professionals need to take care not to engage in unhelpful behaviours themselves in reacting to stressful interpersonal situations. People with a personality disorder respond to supportive and consistent care that accepts their distress but that also focuses on their existing strengths and the skills they can use to manage their distress. The core aim of treatment of people with a personality disorder is to maintain a therapeutic working relationship and work with them to reduce their distress and facilitate better coping.

Helpful behaviours

Helpful behaviours for interacting with consumers who present challenges include: 162

Appendix 3

Have a clear management plan that the whole team agrees to and regularly review and revise goals. ■ Be positive and maintain an attitude of hope. ■ Set appropriate limits and boundaries about acceptable and unacceptable behaviours. ■ Be honest and open with the person. ■ Respond to the person, not the diagnosis/label. ■ Set realistic and achievable goals with the person. ■ Have an agreed written care plan with the person for times of crisis. ■ Use clinical supervision to work on interpersonal issues associated with working with a person (Cleary & Horsfall 2012). ■

Behaviours to avoid Avoiding using the following behaviours can help health professionals be non-judgmental and more helpful to those in their care: ■ wanting to rescue the person ■ believing that you are the only one who can help the person ■ offering to see the person outside your working hours ■ being defensive and/or verbally retaliating as a result of feeling ‘attacked’ by the person ■ trying to be the person’s friend ■ agreeing to keep information provided by the person secret from the rest of the multidisciplinary team ■ avoiding the person ■ being over-controlling of the person’s behaviour ■ using sarcasm or cynical comments in relating with the person ■ being jealous of the attention the person receives ■ feeling that your skills are of no worth in the care of this person.

Finally

Remember, the core aim of treatment with people with a personality disorder is to maintain a therapeutic working relationship and work with them to reduce their distress and facilitate better coping. REFERENCE Cleary, M., & Horsfall, J. (2012). Personality disorders. In R. Elder, K. Evans & D. Nizette (Eds.), Psychiatric and mental health nursing (3rd edn). Sydney: Elsevier.

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Appendix 4

Prescription abbreviations

Abbreviation

Latin term

English meaning

ac

ante cibum

before food

pc

post cibum

after food

am

ante meridiem

morning

pm

post meridiem

night

om

omne mane

every morning

on

omne nocte

every night

qd

quo diem

once a day

bid

bis in die

twice a day

tid

ter in die

3 times a day

qid

quater in die

4 times a day

od

oculus dexter

right eye

os

oculus sinister

left eye

po

per os

by mouth

au

auro utro

both ears

gt

gutta

drop

prn

pro re nata

as needed

qh

quaque hora

every hour/hourly

q2h

quaque 2 hora

every 2 hours

q3h

quaque 3 hora

every 3 hours

q4h

quaque 4 hora

every 4 hours

q6h

quaque 6 hora

every 6 hours

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Appendix 4

Abbreviation

Latin term

English meaning

q8h

quaque 8 hora

every 8 hours

qd

quaque die

every day

stat

statim

immediately

nr

non repetatur

no repeats

ud

ut dictum

as directed

These terms are often written on the medication prescription, the medication chart or referral letter written by health professionals. If in doubt, check with a pharmacist or the prescribing doctor.

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Appendix 5

Top tips for people taking psychiatric medication The following tips can be given to people taking medication: ■ Ask your pharmacist to go through what the medication is for, when to take it and any possible side effects. ■ Ask your doctor or pharmacist how you will know that the drug is working for you. ■ If you are not sure about any aspect of your medication, ask your pharmacist or health professional to explain. ■ Find out what medicines (e.g. cough/cold medicines, antiinflammatories) will interact with your medication because these may make you feel unwell. ■ Identify two people who can support you with taking your medication (e.g. a friend, relative, carer, health professional). ■ Think about where you can safely keep your medication. A cool, dry place that is not in direct sunlight is best. Some medications need to be kept in the fridge. Follow the storage directions. ■ You might get some side effects (e.g. dry mouth, headache, frightening dreams, agitation, fever, insomnia) before you start to feel better. Talk to your doctor or health professional about them. ■ If things don’t seem right for you, speak to your health professional. ■ Choose a regular time to take your medication and set your mobile phone/watch/alarm to remind you. ■ Be honest with yourself and your health professional about any other (prescribed, over-the-counter or illicit) drugs that you might be taking. ■ If you miss a dose, don’t panic, but don’t double up; wait until the next dose and continue as normal. ■ Don’t stop taking your medication suddenly. This can make you feel very unwell. ■ Getting well will take time (two to four weeks if you have started antidepressants). Try to be patient. 166

Appendix 5

Consider using a dosette or Webster pack so you can easily take the medication at specific times of the day. ■ Keep a list of your medication in your purse/wallet and give a copy to a friend. ■ If you have out-of-date medicines return them to the pharmacist for disposal (taking old medications can make you ill). ■

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Appendix 6

Mental health terminology

Acceptance and commitment therapy: a psychological intervention that uses acceptance and mindfulness strategies to influence behaviour change through psychological flexibility. Activity groups: part of psychosocial rehabilitation programs where organised activities such as art, walking and discussion are designed to engage people to construct a therapeutic milieu and to help with socialising techniques and imitative behaviour. Acute dystonic reaction: one of the side effects of traditional antipsychotic medication. Can include the consumer having painful muscle spasms in the head, back and torso, which can last minutes or hours; these occur suddenly and can cause fear in the person. Adjustment disorder: an exaggerated emotional or behavioural response to a significant life change or stressor, such as a relationship break-up, bereavement, divorce or illness. Adulthood: a series of cognitive, social, psychological and physical changes that occur after adolescence until the final stages of one’s life. Affect: the observable behaviours associated with changes in a person’s mood, such as crying and looking dejected. Ageism: the systematic stereotyping of and discrimination against people because of their age alone and/or making assumptions about how people are viewed throughout the life span. Aggression: actions or behaviours ranging from violent physical acts such as kicks or punches, through to verbal abuse, insults and non-verbal gestures. The overall emotion projected is anger. Agoraphobia: anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help might not be available. Agranulocytosis: a blood disorder characterised by severe depletion of white blood cells, rendering the body almost defenceless against infection. 168

Appendix 6

Akathisia: one of the side effects of traditional antipsychotic medication; involves the person not being able to stay or remain still, being restless and suffering from leg aches. Ambivalence: an individual’s tendency to hold conflicting views and feelings, such as love and hate, making meaningful decision making difficult. Amnesia: an inability to remember events from a particular period. There are a number of different amnesias, including localised amnesia, selective amnesia, generalised amnesia and systematised amnesia. Anhedonia: loss of the feelings of pleasure previously associated with favoured activities. Anorexia nervosa: a disorder characterised by a refusal to maintain minimal, normal body weight for one’s age and height; an intense fear of gaining weight; disturbed perception of body shape and size; and amenorrhoea in post-menarcheal females. Antianxiety medication: medication used when anxiety for the person becomes debilitating. Benzodiazepines are the drug of choice for shortterm treatment of anxiety states. Anticholinergic: side effects of traditional antipsychotic medication, including dry mouth, blurred vision, orthostatic hypotension, tachycardia, urinary retention and nasal congestion. Antidepressant medication: medication that enhances the transmission of neurochemicals, particularly serotonin and noradrenaline, by blocking the reuptake of the neurotransmitters at the synapse, inhibiting their metabolism and destroying and/or enhancing activity of the receptors. Antipsychotic medication: also known as neuroleptic and typical antipsychotics, these drugs were introduced in the 1950s and revolutionised the treatment of mental illness. Traditional anti­psychotics are dopamine antagonists that reduce the ‘positive’ symptoms of schizophrenia and can affect the ‘negative’ symptoms. Anxiety: a common human experience that is a normal emotion felt in varying degrees by everyone; also a state in which individuals experience feelings of uneasiness, apprehension and activation of the autonomic nervous system in response to a vague, non-specific threat. Assertiveness: a communication skill that enhances one’s interpersonal effectiveness and allows one the choice of how to respond to others. An assertive person protects the rights of each party and achieves goals without hurting others. This results in self-confidence and the ability to express oneself appropriately in emotional and social situations. 169

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Attachment: the strong bond or connection one feels for particular people in one’s life. It is usually associated with the primary bond between infant and mother, which can influence one’s self-concept, relationships and life experiences. Autism: a person’s tendency to retreat into an inner fantasy world, resulting in socially isolating or withdrawing behaviours and loss of contact with reality. Avolition: loss of motivation, resulting in impairment in goal-directed activities. Behaviour therapy: therapy used to determine what causes and maintains certain behaviours. It is used to develop treatment plans with specific goals and identifies what will be done to achieve goals, how goal achievement will be measured and a timeline for goal achievement. Behavioural theories: theories that emphasise the importance of the environment in shaping and changing behaviour in individuals. Bereavement: the experience of grief and mourning following the loss of someone or something of significance to the person. Biomedical model: a theoretical model that holds that behaviour is influenced by physiology, with normal behaviour occurring when the body is in a state of equilibrium and abnormal behaviour being a consequence of physical pathology. Biopsychosocial model of assessment: a comprehensive assessment of all aspects of information concerning the person, including biological, psychological, sociological, developmental, spiritual and cultural information. Bipolar disorder: a diagnosis outlined in DSM-5 when a person has previously experienced at least one manic episode and a depressive episode. Body image assessment: assessment of components of body image, including body image distortion, body image avoidance and body image dissatisfaction. Body image avoidance: a disturbance of cognition and affect that leads to repetitive body checking and avoidance of social situations that provoke anxiety about the body. Body image dissatisfaction: a disturbance of cognition and affect that leads to a negative evaluation of physical appearance. Body image distortion: a disturbance of perception in which people describe their body or parts of it as large or fat, despite concrete evidence to the contrary. 170

Appendix 6

Body mass index (BMI): a mathematical formula based on the height and weight of a person that is used to help determine the degree of starvation or obesity. Bulimia nervosa: a disorder characterised by binge-eating behaviour, eating much larger amounts of food than would normally be eaten in one sitting and inappropriate, compensatory weight-loss behaviours, such as self-induced vomiting and purging. Burnout: a syndrome in which health care workers lose concern and feeling for people under their care, becoming detached and distancing themselves from the consumer; characterised by emotional exhaustion, depersonalisation and decreased personal accomplishment. CALD: refers to people from backgrounds that are culturally and linguistically different from mainstream society. Care plan: a mental illness management and mental health recovery plan developed in partnership between a consumer and a mental health professional (and a carer if appropriate). Carer: a partner, family member or friend who provides care for a person with a mental illness. Case management: a model of care in which the health professional acts as the key worker and collaborates with the consumer to manage the consumer’s mental illness. Catastrophising: when a person feels inappropriate guilt and thinks of themselves as incompetent, faulty, unlovable and a failure. Catatonia: a severe and debilitating condition with disorganisation of motor behaviour and inability to relate to external stimuli; one of the subtypes of schizophrenia. Caucasian: light-skinned people of European origin. Challenging behaviour: unusual or disturbed maladaptive behaviours that can include: stereo­typical or repetitive behaviours (e.g. body rocking); ‘acting out’ behaviours (e.g. yelling out); self-injurious behaviours (e.g. scratching at own skin); or aggression towards others. Child and adolescent mental health services: comprehensive services including specialist assessment and treatment options, usually only available in main centres. Child behaviour checklist: checklist used by many services in Australia; places stronger emphasis on general and specific behaviours and problems than on the categories of disorders as described in DSM-5. 171

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Childhood: the early years of life in which foundations are laid for future development and outcomes. Circumstantiality: a disturbance in form of thought in which speech is indirect and longwinded (adapted from Treatment Protocol Project 2004). Clanging: a disturbance in form of thought in which words are chosen for their sounds rather than their meanings; includes puns and rhymes. Classification of mental disorders: classification enables information to be provided concerning the patterns of behaviour, thoughts and emotions of consumers. Clinical supervision: a positive process that involves reflection of clinical interactions and interventions by one clinician to another more experienced clinician for support, professional development, education and development of clinical practice skills. Code of ethics: guidelines for members of professional groups as to the nature of proper ethical conduct and their obligations to the public. Coexisting disorder: having more than one disorder at the same time, most commonly a mental health disorder and a substance use disorder. Similar terms are comorbidity and dual diagnosis. Cognitive behaviour therapy (CBT): therapy that aims to help people develop more efficient coping mechanisms by equipping them with strategies that promote logical ways of thinking about and responding to everyday situations. Cognitive restructuring: a collaborative mental health professional–consumer intervention that aims to monitor and reduce distressing negative cognitions (thoughts), especially in people who are depressed. Collective culture: a society in which the smallest social unit is the family and the person’s strongest identity is as a member of the group. Collusion: when a person in care attempts to persuade individual staff members to endorse their way of behaving. Community care: health services available from community mental health centres and emphasising the multidisciplinary team; includes services such as counselling, follow-up treatment, referrals and supported accommodation. Comorbidity: having more than one disorder at the same time, most commonly a mental health disorder and a substance use disorder, but can include a physical disorder such as obesity or diabetes. Similar terms are coexisting disorder and dual diagnosis. 172

Appendix 6

Competence: when a consumer can or should decide and/or be permitted to decide for themselves; beyond this point another or others will need to, or should, decide for the consumer. Competency skills: in order to protect the public, a specific framework that describes the expected skill base of all practitioners within a specific discipline is set by regulatory bodies and professional nursing organisations. Complicated grief: a grief reaction that is ongoing and problematic for the person, often because of the nature of the relationship, the unexpected nature of the loss or because the person has few social supports. Compulsions: repetitive behaviours (e.g. handwashing, checking) or mental acts (e.g. praying, counting), the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification. Confidentiality: a primary principle of the therapeutic relationship; involves maintaining confidential information about a consumer within the treatment team. Consultation-liaison psychiatry: a service in which nursing, medical and allied mental health professionals provide expert consultation to nonmental health professionals in general hospital settings regarding the mental health care of consumers. Consumer: someone who has the lived experience of mental distress and who has received care from mental health professionals. Containment: to provide a place of safety, the hospital and confinement can be seen as a refuge from self-destructiveness and an opportunity to reassure the person and others that illness will not overwhelm them. Continuous care: long-term, ongoing, supportive care of people with access to a range of services, usually commenced by committed staff and in the discharge planning process. Coping: the way one deals with change, conflict and demands in life, which can be influenced by factors such as our feelings, thoughts, beliefs and values. Countertransference: the response of the therapist to the consumer. Having strong feelings for the consumer, either negative or positive, might be a cue that one is experiencing countertransference. Crisis: an event(s) that changes one’s day-to-day existence and creates a sense of one’s life being out of control, feeling that one is vulnerable and that events are unpredictable; can involve a significant loss for the person. 173

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Crisis intervention: involvement of assessment, planning, intervention and resolution of a crisis. Cultural awareness: refers to an awareness of one’s own cultural heritage and to differences between groups. Cultural competence: occurs when health professionals possess a set of qualities, such as awareness, acceptance and respect for difference, that enables them to deliver care in a culturally safe manner. Cultural respect: allows the individual mental health professional to value the contribution that culturally appropriate interventions can make to the therapeutic environment. Cultural safety: occurs when the consumer perceives health care is delivered in a manner that preserves and respects their cultural heritage. Cultural sensitivity: acceptance of the legitimacy of difference. Culture: a socially defined, dynamic and ever-changing phenomenon that incorporates the history, beliefs, language, practices, dress and customs that are shared by a group of people, and that influences the behaviour and values of the members. Defence mechanisms: unconscious processes whereby anxiety experienced by the person’s ego is reduced. Deinstitutionalisation: closure of major psychiatric hospitals and expansion of community-based care for consumers, including relocation of inpatient psychiatric beds into general hospitals. Delirium: a syndrome that constitutes a characteristic pattern of signs and symptoms that reduce clarity of awareness and impair the person’s ability to focus, sustain or shift attention; tends to develop quickly and fluctuates during the course of the day. Delirium tremens (DTs): a major withdrawal syndrome in which the person presents with a number of complaints, which can include agitation, disorientation, high fever, paranoia, visual hallucinations, coarse tremors and seizures. Delusion: a false, fixed belief that is inconsistent with one’s social, cultural and religious beliefs and that cannot be logically reasoned with. Dementia: a progressive illness that involves cognitive and non-cognitive abnormalities and disorders of behaviour; presents as a gradual failure of brain function. It is not a normal part of life or ageing. Democratisation: creating an environment in which staff and consumers feel free to express themselves without fear of rejection and to participate in decision making to the extent of one’s abilities. 174

Appendix 6

Dependence: a maladaptive pattern of substance abuse leading to significant impairment or distress and manifested in tolerance, withdrawal and increasing consumption, to the point where obtaining the substance becomes the main focus for the individual; can be physical and/or psychological. Depersonalisation: a sense of personal reality being lost or altered, of being estranged from oneself, as if in a dream, or that one’s actions are mechanical or otherwise detached from the body or mind. Depot antipsychotic medication: long-acting, injectable forms of traditional antipsychotic medication used when the consumer is unable to take oral medication, if intestinal absorption is questioned or when there might be a medication adherence or compliance problem. Depression: a disorder characterised by depressed mood, with feelings of hopelessness and helplessness, lack of pleasure or interest, appetite disturbance, sleep disturbance and fatigue. Derailment: a disturbance in form of thought in which thoughts do not progress logically and ideas are unconnected, shifting between subjects; also known as loosening of association (adapted from Treatment Protocol Project 2004). Derealisation: a phenomenon in which the person’s sense of the object world is altered. The person might perceive objects to be bigger or smaller than they really are, or that once familiar objects now seem strange. Detoxification: the process by which an alcohol-dependent or drugdependent person recovers from intoxication in a supervised manner so that withdrawal symptoms are minimised. Developmental theories: theories that highlight the importance of the early months and years of one’s life in laying a solid foundation for mental health and wellbeing in adulthood. Dialectical behaviour therapy (DBT): similar to cognitive behaviour therapy but actively incorporates social skills training; moves between validation and acceptance of the person. Disability: an individual’s impairment in one or more areas of functioning. Disability services: a variety of services for people with intellectual disabilities, including those living at home with relatives, in shared accommodation, group homes, community-based services, non-government organisation accommodation and residential institutions. 175

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Dissociation: being focused on one’s own internal thoughts, and being unaware of the external environment (e.g. daydreaming is considered a mild form of dissociation). Distractible speech: a disturbance in form of thought in which nearby stimuli cause repeated changes in the topic of speech. Dosette box: a container to help organise scheduled mediations by time and day of administration. DSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5th edition, published by the American Psychiatric Association. This classification system assesses people across five domains, which help with treatment planning and outcomes. Dual diagnosis: having more than one disorder at the same time—most commonly a mental health disorder and a substance use disorder. Similar terms are coexisting disorder and comorbidity. Dual disability: having a comorbid intellectual or developmental disability. Dualism: a philosophical position derived from the Cartesian idea that there is a mind–body duality, the body being separate from the soul or moral features (mind). Duty of care: the taking of reasonable care by a nurse to avoid acts or omissions that one can reasonably foresee would be likely to injure another. Early intervention: early diagnosis and treatment of mental illness to minimise the impact of the illness and its consequences. Eating disorders: complex and serious disorders that involve physical, psychological, social, family and individual factors, characterised by serious disturbance of eating behaviours. It includes anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified. Echolalia: a disturbance in form of thought in which other people’s words or phrases are echoed, often in a ‘mocking’ tone; not the same as repetition of the person’s own words (perseveration). Egocentrism: focusing on oneself to a degree that other people’s needs are beyond one’s awareness. Ego dystonic: when a person’s symptoms are experienced as distressing to themselves. Electroconvulsive therapy (ECT): the application of metal electrodes to the head through which an electric current is delivered. The electrodes can be placed unilaterally or bilaterally. ECT remains a controversial 176

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intervention in psychiatry, although it is widely accepted as an effective intervention in treating severe depression. Empathy: the capacity for understanding and appreciating the feelings, ideas and experiences of another. It involves cognition (taking the perspective of another), emotion and the physical act of observing, listening and attending. Engagement: the process of establishing rapport with a person through interactions based on acknowledging and developing a relationship based on trust. Ethical conduct: principles for the practice of ethical conduct by health professionals, including issues of autonomy, beneficence, non-maleficence and justice. Ethnicity: a common, shared view about one’s ancestry. Ethnocentrism: the belief that our own cultural values constitute the human norm and that difference is deviant and wrong. Externalising problems: problems that include antisocial or under-controlled behaviour, such as delinquency or aggression. Extrapyramidal side effects: side effects of antipsychotic drugs on the extrapyramidal motor system. They include acute dystonia, Parkinsonism, akathisia and tardive dyskinesia. Family therapy: an approach to treatment that is based on the idea that when a family member has a problem it usually involves the whole family. Family therapists aim to effect change in the entire family system. Fear: a response to a known threat that manifests in the same way as anxiety. Flight of ideas: a disturbance in form of thought in which the person’s ideas are too rapid for them to express, and so their speech is fragmented and incoherent (adapted from Treatment Protocol Project 2004). Forensic patient: a person who has committed a crime while mentally ill and is remanded in custody in an approved mental health service within a prison, remand centre or forensic psychiatric hospital. Form of thought: the amount and rate of production of thought, continuity of ideas and language. Disturbances in form of thought include circumstantiality, clanging, derailment (loosening of associations), distractible speech, echolalia, flight of ideas, illogicality, incoherence, irrelevance, neologisms, perseveration, tangentiality, thought blocking, thought disorder and word approximations. For descriptions of each, see individual entries in this glossary. 177

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Fugue: in a long-term dissociative state, the person is unable to remember the past and may also be confused about their identity and unable to remember their name or their occupation. Generalised anxiety disorder (GAD): excessive anxiety and worry concerning events or activities (apprehensive expectation). This occurs occurring more days than not for a period of at least six months and the person finds it difficult to control. Geriatric Depression Scale (GDS): assessment tool designed to assist in making a diagnosis of depression, referral for treatment and to provide a baseline assessment with which to measure the outcome of treatments. Gillick competence: the ability of young people to consent to medical treatment or seek medical consultation as seen in their cognitive ability to make an informed judgment to give consent for treatment. Glasgow Coma Scale (GCS): a standardised system for assessing the degree of conscious impairment in the critically ill and for predicting the duration and ultimate outcome of coma, primarily in people with head injury. Grief: the affective (emotional) component of mourning, including the painful affects associated with the loss (e.g. sadness, anger, guilt, shame and anxiety). Group cohesion: an important component in creating a climate of support and involvement. Sharing among the staff and consumers of daily duties and unit resources helps communalism and cohesion to occur. Group therapy: the engagement of two or more people in therapy at the same time. Interactions with others in a group situation, especially people who come together with others who experience the same or similar difficulties, have been shown to have positive and beneficial effects. Hallucination: a sensory perception/experience that occurs without external/environmental stimuli. Types of hallucinations include visual, olfactory, tactile, auditory, somatic and gustatory. Harm reduction: the guiding principle used to identify a range of strategies that target the consequences of drug use rather than the drug itself. Health of the Nation Outcome Scales (HoNOS): designed in Britain, this scale is used to gather information concerning key areas of mental 178

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health and social functioning for service monitoring and outcome measurement. Health promotion: the process of enabling people to increase control over and to improve their health. It can involve a range of educational, political, social and environmental strategies. Helping relationship: a therapeutic interaction facilitating exploration of responses following a major and significant personal loss leading to a consumer experiencing grief. Holism: a theory of the whole person, recognising the importance of the interrelationships between biological, psychological, social and spiritual aspects of a person. Hope: a state of mind that anticipates positive expectations of personally meaningful goal achievement. Hospital@home: a community-based service that provides acute mental health care in the consumer’s home as an alternative to traditional inpatient treatment. Hypochondriasis: a disorder in which the person is intensely preoccupied with their bodily functions and can report any of a wide range of symptoms. The person focuses on what the symptoms might signify and can misinterpret ordinary bodily functions as symptoms of a serious physical illness. Hypomania: a form of elevated mood that is less severe than mania. ICD-10: International Statistical Classification of Diseases and Related Health Problems, 10th revision, published by the World Health Organization; provides a comprehensive listing of clinical diagnoses, each with its own numerical code. Ideas of reference: belief that an insignificant or incidental object or event has special significance or meaning for that person. Identity: part of one’s self-concept; develops over time and contributes to one’s overall sense of self. Illicit drugs: drugs that are classified as illegal. Illogicality: a disturbance in form of thought in which the conclusions reached in a person’s speech are illogical (adapted from Treatment Protocol Project 2004). Incoherence: a disturbance in form of thought in which there is verbal rambling with no clear main idea. Incongruent affect: a mismatch between a person’s thoughts and their emotional expression in a given situation. 179

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Indigenous Australian: a person who identifies as being Aboriginal or Torres Strait Islander. Individualist culture: a society in which the smallest social unit is the individual and the person’s identity is as an individual within the group. Informed consent: consent that is (among other requirements) voluntary and specific and comes from a competent person. Insane: coming from the Latin word ‘insana’ meaning not of right mind; the equivalent Greek term is ‘mania’. Intellectual disability: a disability typified by major limitations in intellectual functioning and in conceptual, social and practical adaptive skills that originates before the age of 18. Consumers and disability service professionals in Australia prefer this term rather than the older term ‘mental retardation’. Internalising problems: problems that include inhibited or over-controlled behaviours such as anxiety or depression. Interpersonal therapy (IPT): therapy that targets relationships as a key factor in the contribution and maintenance of mental health problems such as eating disorders. Intoxication: a reversible state that occurs when a person’s intake exceeds their tolerance and produces behavioural and/or physical changes. Involuntary admission: compulsory or involuntary detention in an approved psychiatric institution in the best interests of the person, for treatment that will alleviate the person’s symptoms of mental illness. Irrelevance: a disturbance in form of thought in which a person’s replies to questions are not related to the topic being discussed (adapted from Treatment Protocol Project 2004). La belle indifference: ‘beautiful indifference’ where the person shows a marked indifference to or unconcern about their symptoms, even if the symptom is blindness or paralysis. Learned helplessness: both a behavioural state and a personality trait of one who believes their control over a situation has been lost. It can also relate to hopelessness and powerlessness; an inability to escape an intolerable situation, leading to the ultimate mode of adaptation: subjugation and acceptance. Least-restrictive alternative: the option of least restriction for the individual (e.g. community-based care or institution-based treatment), with consideration of the person’s level of autonomy, their acceptance and cooperation and potential for harm to self and to others. 180

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Limit setting: explaining to people what behaviours are acceptable and what is unacceptable, and informing them of the consequences of breaking the rules. It aims to offer the person a degree of control over their behaviour by setting firm, fair and consistent limits or rules. Lived experience: the experience of living with a particular phenomenon (e.g. mental illness). Loss: being parted from someone or something that the person values. Major depressive disorder: a condition involving seriously depressed mood and other symptoms defined by DSM-5 that affect all aspects of a person’s bodily system and interferes significantly with their daily living activities. Mania: a state of euphoria that results in extreme physical and mental overactivity. Māori: an indigenous New Zealander. Medication adherence/compliance: the taking of medication for ongoing treatment of the person’s illness. Failure to take medication is often the cause of relapse and readmission to hospital, and can be caused by factors such as: the medication having an adverse impact on the consumer’s life; side effects; insight into the illness; and lack of education about the medication. Mental health: the experience of having a positive sense of self and having access to personal and social resources with which to fully engage in life and respond to life’s challenges. Mental health assessment: a comprehensive, holistic assessment based on the person’s developmental, family, social, medical, recreational and employment history. It includes a mental state examination and history of current functioning and presenting problems. The person and family members or carers may contribute perspectives to this assessment. Other standardised assessments (such as specific cognitive or family assessments) may form a part of a comprehensive mental health assessment. Mental health disorders: conditions in which a person cannot cope and function as previously, causing considerable personal, social and financial distress, and affecting health care funding, implementation of service provision and community resources. Mental health policy: health policy based on the World Health Organization guiding principles of access, equity, effectiveness and efficiency for all people with mental health issues. 181

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Mental health promotion: a population health approach to mental health that attends to the mental health status and needs of the whole population. It emphasises a continuum of care from universal prevention to long-term, individual care with early intervention and treatment. Mental health reform: refers to the deinstitutionalisation of mental health care, the integration of mental health into general health care, and providing mental health services within a recovery framework. Mental illness: an illness, diagnosed by DSM-5 or ICD-10 criteria, that significantly interferes with a person’s cognitive, emotional or social abilities. Mental state examination/assessment (MSE/MSA): a semi-structured interview with a person to assess the person’s current neurological and psychological functioning across several dimensions such as perception, affect, thought content, form of thought and speech. Mentoring: process aimed at promoting growth and development in clinicians by means of partnerships with other clinicians in the workplace, involving problem solving, feedback, support and relationship building. Milieu: a physical environment including the social, emotional, interpersonal, professional and managerial elements that comprise a particular setting. Milieu therapy: therapy that involves the environment in the treatment process, the participation of the consumer and staff in decision making, the use of a multidisciplinary team, open communication and individualised goal setting with consumers. Mindfulness: focused attention or awareness in the present moment; observing and ‘being’ without judgment. Mini-Mental State Examination (MMSE): a brief questionnaire used to screen for cognitive impairment. Misconceptions: misinformation and misunderstanding about the origins, course and treatment of mental health problems and mental disorders. Motivational interviewing: an adaptation of the Socratic style of interviewing; proceeds from the assumption that change is produced collaboratively and cannot be imposed from outside. Mourning: the behavioural component of bereavement that includes biological reactions and behavioural, cognitive and defensive responses to the loss. 182

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Multidisciplinary team (MDT): a team of individuals from multiple disciplines, such as nurses, psychologists, psychiatrists, social workers and occupational therapists, working together to provide a holistic team approach to care. Narrative therapy: a counselling approach that centres people as experts of their own experience and views problems as separate to people. It is non-blaming and based on curiosity and respectful questioning and exploration of a person’s story. Nature versus nurture debate: a continuing discussion concerning the effects of biological phenomena and inheritance (nature) and the individual’s environment and experiences in the world (nurture) and whether both are vital, inseparable, interdependent components of personality development that influence human behaviour. Negative symptoms of schizophrenia: this includes symptoms such as blunting of affect, avolition and anhedonia. Neologisms: disturbance in form of thought in which a person creates new words or expressions that have no meaning to anyone else (adapted from Treatment Protocol Project 2004). Neuroleptic malignant syndrome: a rare disorder that resembles a severe form of Parkinsonism with coarse tremor and catatonia, fluctuating in intensity, accompanied by signs of autonomic instability and stupor; risk of death is high. Neuroleptic medication: see also ‘antipsychotic medication’; the term ‘neuroleptic’ is used to indicate the movement and posture disorder caused as part of the extrapyramidal side effects of some antipsychotic drugs. ‘Antipsychotic medication’ is the preferred term because the atypical antipsychotics have very little extrapyramidal action. Neurosis: a term of mainly historical interest that was used in reference to madness caused by nervous system disease. Since Freud’s time, ‘neurosis’ has been used to refer to non-psychotic disorders characterised mainly by anxiety. NHMRC: Australia’s National Health and Medical Research Council. Non-government organisations (NGOs): services that operate outside mainstream government authority and at a community level to support consumers and carers with a range of special needs (e.g. Association of Relatives and Friends of the Mentally Ill (ARAFMI)). Normalisation: a humanistic model of care in which people with an intellectual disability are given the same rights and opportunities as any other person, even if the support of appropriate services is needed. 183

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Observation: experienced staff maintain a continuous watchful presence in a non-threatening, non-intrusive manner to set reasonable limits on behaviour. Obsessions: recurrent, persistent thoughts, impulses and images that are intrusive and inappropriate, and cause marked anxiety or distress in a person. Obsessive-compulsive disorder: recurrent obsessions or compulsions that are severe enough to be time consuming or cause marked distress or significant impairment in a person. Panic attack: a discrete period of intense fear or discomfort in the absence of real danger. Panic disorder: the presence of recurrent, unexpected panic attacks followed by concern about having another panic attack or significant behavioural change related to the attacks. Parasuicide: any non-fatal serious act of self-harm with or without suicidal intent. Parkinsonism: one of the side effects of traditional antipsychotic medication, with the person exhibiting a rigid, mask-like facial expression, shuffling gait and drooling. Partnership: a model of mental health service delivery in which the person receiving care and the health professional work together to plan and implement the mental health care plan. Perseveration: a disturbance in form of thought in which the person persistently repeats the same word or ideas; often associated with organic brain disease (adapted from Treatment Protocol Project 2004). Personality: expression of our feelings, thoughts and patterns of behaviour that evolve over time. Personality disorder: a diagnosis that occurs when manifestations of personality in an individual start to interfere negatively with the individual’s life or with the lives of those close to them. Personality traits: aspects of our personality that make us unique and interesting, and differentiate us from each other. Pharmacokinetics: the study of the actions of drugs within the body, including the mechanisms of absorption, distribution, metabolism and excretion. Positive symptoms of schizophrenia: tends to include signs and symptoms such as delusions, hallucinations and motor disturbance. 184

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Preceptoring: a preceptoring relationship is usually based in the clinical environment and occurs when someone is new to an area (e.g. a new employee or student) and a preceptor is allocated. This is usually an experienced clinician who has been prepared for the preceptoring role, which involves guidance, helping to develop confidence and skills and facilitates the new person becoming a member of the team. Primary gain: results in relief from psychological pain, anxiety and conflict (e.g. having physical symptoms gives legitimacy to feeling unwell). Primary health care: strategies and interventions for reducing the prevalence and impact of mental health problems in the community; includes increasing detection, promotion, prevention, early intervention and effective treatment. Professional boundaries: limitations that need to be agreed upon in therapeutic relationships between the consumer and the mental health professional. These boundaries define acceptable and expected behaviour for both the mental health professional and the person that ensure a ‘safe’ environment based on ethical practice. Protective factors: factors that reduce the likelihood that an illness will occur (e.g. having a supportive family and social network). Psychodynamic psychotherapy: an in-depth counselling technique that aims to reduce psychic tension through revealing unconscious content. It assumes that a person’s functioning may be maladaptive due to an unconscious issue arising from the past. Psychoeducation: education concerning the mental health status and treatment given for a person’s mental illness. It is aimed at promoting wellness and providing an opportunity for the person to gain insight into their condition. Psychosis: a condition in which a person has impaired cognition, emotional, social and communicative responses and interpretation of reality. Psychotropic medications: a collection of pharmacological agents in current psychiatric use, including antianxiety sedatives, antidepressants and mood-stabilising, neuroleptic and antipsychotic drugs. Recovery: the journey undertaken by a person with a mental illness that is defined by and determined by that person. Reflective practices: processes that allow a health professional to examine both their practice (actions) and the accompanying cognitions (thoughts) and affective meanings (feelings) in relation to their values, biases and knowledge in the context of a particular situation. 185

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Rehabilitation: working with mentally ill people to reintegrate them back into the community. Relapse prevention: programs that aim to teach consumers a set of cognitive and behavioural strategies to enhance their capacity to cope with high-risk situations that could otherwise precipitate relapse. Resilience: a person’s innate ability to achieve good outcomes in spite of adversity, serious threats and risks. Resocialisation: re-establishing social support networks and peer support through group therapy and individual goal setting. Risk assessment/management: identifying and estimating risk so that structured decisions can be made as to how best to manage risk behaviour. Risk factors: factors that increase vulnerability to mental illness (e.g. social inequities or discrimination). Rumination: repetitive and increasingly intrusive negative thoughts and ideas that can eventually interfere with other thought processes. Schizophrenia: a disorder characterised by major disturbance in thought, perception, thinking and psychosocial functioning; a severe mental illness. Secondary gain: the attention and support provided by others for a physical illness that can involve any benefit other than relief from anxiety. Self-awareness: the process of becoming aware of and examining one’s own personal beliefs, attitudes and motivations, and recognising how these may affect others. Self-disclosure: to make knowledge about oneself known to others; to publicly divulge information about one’s own life. Self-harm: behaviour occurring along a continuum, from pulling one’s own hair out, cutting, piercing, burning oneself, through to suicide. These behaviours are a mode of self-regulation for the person, and can be comforting and confirming in a world that is out of control from their perspective. Self-help: listening to one’s own self-wisdom; can also involve seeking assistance and support from others who have had similar experiences to learn coping skills, tap into resources and find useful information. Social justice: a belief that fairness and equity are a right for all, regardless of the person’s social position. 186

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Socratic questioning: a common technique for encouraging motivation that helps the person to come to an alternative belief of their own. Somatisation: a psychological process whereby anxiety or psychological conflict is translated into physical complaints, although no mechanism has been found. Splitting staff: an attempt by a person to split their treatment team by appealing to individual members, by sharing ‘secrets’ and suggesting that the staff member is the ‘only one’ who understands or is approachable. Standards of practice: standards that describe the expected performance of mental health professionals providing mental health care. They represent the commitment to accountability of mental health professionals. For example, mental health nursing standards of practice include a rationale and attributes for each standard, performance criteria and clinical indicators of practice. Stigma: a notion that mental illness is something to be avoided, hidden away or feel shame about. Strengths: a person’s resilience, aspirations, talents and uniqueness; what a person can do and do well. Strengths-focused care: a model of care delivery that focuses on the person’s abilities rather than their disabilities or illness. Stress: a psychological response to any demand or stressor; can be experienced as negative (distress) or positive. Individuals can respond differently to the same stressor. Stress management: managing the effects of the stress one is experiencing by changing the situation, increasing one’s ability to deal with the situation, changing one’s perception of the situation, and/or changing one’s behaviour. Substance abuse: the use of drugs or alcohol in a way that disrupts prevailing social norms; these norms vary with culture, gender and generations. Suicide: a serious act of self-harm where the person has acted with the intention of ending their life. Suicide survivor: family or friends of a person who has suicided. Sundowning effect: an increase in behavioural problems for the person, occurring in the evening hours and beginning around sunset. Tangata whaiora: a Māori term that refers to mental health service consumers or people seeking wellness. 187

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Tangentiality: a disturbance in form of thought in which the individual gives irrelevant or oblique replies to questions. The reply might refer to the topic but not give a complete answer. Tardive dyskinesia: stereotypical involuntary movement of the tongue, lips and feet; results from prolonged use of traditional antipsychotics. Teamwork: involves shared purpose (person focus) coordination of effort and sharing of resources and flexibility and cooperation in care delivery. Therapeutic alliance: the development of the trusting, beneficial and understanding partnership that needs to exist between a mental health professional and a consumer for a therapeutic relationship to develop. Therapeutic communication: demonstrating care, genuine concern and empathy in the patient as a person by attending, listening, understanding and acknowledging them. Therapeutic relationship: a professional relationship in which the consumer’s needs are central. Thought blocking: a disturbance in form of thought in which there are abrupt gaps in a person’s flow of thoughts that are not caused by anxiety, poor concentration or being distracted (adapted from Treatment Protocol Project 2004). Thought disorder: a disturbance of the form in which an individual expresses their thoughts (structure, grammar, syntax, logic) or sometimes the content of their thoughts (adapted from Treatment Protocol Project 2004). Transference: when a person transfers beliefs, feelings, thoughts or behaviours that occurred in one situation, usually in their past, to a situation that is happening in the present; traditionally referred to a person with unconscious feelings or beliefs about someone in their past transferring these feelings or beliefs onto their therapist. Treaty of Waitangi: a New Zealand agreement signed in 1840 between the British Crown and Māori chiefs. It is New Zealand’s founding document and is a broad statement of principles on which the British and Māori agreed to found the nation state and establish a government in New Zealand. Triage assessment: a process for decision making that occurs when alternatives for acute care are being considered. A comprehensive assessment is undertaken, including the person’s symptoms and current situation. 188

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Uncomplicated grief: the distressing, normal emotional reaction to a loss (see also grief ). Voluntary admission: admission of individuals, with their full permission, who require treatment in an approved mental health setting because of the severity of their mental illness, and also for people suffering from an acute episode of a mental illness. Whānau: a Māori language word for extended family. Withdrawal: usually, but not always, associated with substance dependence. Most individuals going through withdrawal have a craving to readminister the substance to reduce the symptoms. It is the development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged. Word approximations: when words are used in an unconventional way but are understandable in the context of the conversation. REFERENCE Treatment Protocol Project. (2004). World Health Organization. Sydney: Collaborating Centre for Evidence in Mental Health Policy.

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Further reading and resources Further reading on mental health

Burroughs, A. (2003). Running with scissors: a memoir. New York: Picador. Harris, R. (2008). The happiness trap. London: Robinson. Persaud, R. (Ed.) (2007). The mind: a user’s guide. London: Bantam Press. Richards, K. (2013). Madness: a memoir. Melbourne: Penguin. Swados, E. (2005). My depression: a picture book. New York: Hyperion.

App resources in mental health

The PsychCentral blog has a list of top 10 mental health apps at . These are based on established interventions but do not make claims about their impact. 1 BellyBio 2 Operation Reach Out 3 eCBT Calm 4 Deep Sleep with Andrew Johnson 5 WhatsMyM3 6 DBT Diary Card and Skills Coach 7 Optimism 8 iSleepEasy 9 MagicWindow-Living Pictures 10 Relax Melodies

Web resources on mental health

Anxieties.com. This website provides free anxiety self-help. ARAFMI: Mental Health Carers Australia. This organisation has a network across Australian states and territories providing a diverse range of services and support to families and friends of people with a mental illness. Services include respite care, support groups, counselling (telephone and in person), psychoeducation and workshops. Australian Bipolar. This is a bipolar information website. Australian College of Mental Health Nurses. The college is the peak professional body for mental health nurses in Australia. It is the only organisation that solely represents mental health nurses. The college engages with its members and key stakeholders to advance mental health nursing across the country. 190

Further reading and resources

Australian Drug Information Network (ADIN). ADIN provides a central point of access to internet-based alcohol and drug information provided by prominent organisations in Australia and internationally. It is funded by the Australian Government Department of Health and Ageing as part of the National illicit drug strategy and is managed by the Australian Drug Foundation. Beyond Blue. Beyond Blue is a national, independent, notfor-profit organisation working to address issues associated with depression, anxiety and related substance abuse disorders in Australia. Beyond Blue works in partnership with health services, schools, workplaces, universities, media and community organisations, as well as people living with depression, to bring together their expertise on depression. Black Dog Institute. The institute is a not-for-profit, educational, research, clinical and community-oriented facility offering specialist expertise in depression and bipolar disorder. Carers Association of SA. Carers provide unpaid care and support to family members and friends who have a disability, mental illness, chronic condition, terminal illness or who are frail. More than one in eight Australians provide care of this kind. The purpose of the Carers Association of SA is to improve the lives of carers by providing important services such as counselling, advice, advocacy, education and training. The association also promotes the recognition of carers to governments, businesses and the public. Carers Australia. The purpose of Carers Australia, and the network of carers’ associations in each state and territory, is to improve the lives of carers, and provide important services such as counselling, advice, advocacy, education and training. They also promote the recognition of carers to governments, businesses and the public. COMIC (Children of Mentally Ill Consumers). COMIC was formed at a forum held in 2000 and is composed of a group of ‘adult children’ who share a common interest for children of mentally ill consumers. The group shares a common perception of the past failure by the mental health services to acknowledge them as children with unique needs and offer support. COMIC has begun to lobby and advocate for the rights of children of mentally ill consumers and their parents because of the lack of acknowledgment, education and assistance by mental health services. depressioNET. depressioNET is committed ‘around the clock’ to improving the mental health and wellbeing of people affected by depression through providing an internet-based service offering hope and understanding, information and support. Headspace. This website is for young people with mental health issues in New Zealand, as well as their families and schools. Mental Health Foundation of New Zealand. The foundation’s work focuses on making mental health everybody’s business. Its work is diverse and expansive, with campaigns and services that cover all aspects of mental health and wellbeing. A holistic approach is taken to mental health. The foundation provides free information and training, and is an advocate for policies and services that support people with experience of mental illness, and also their families/whānau and friends. 191

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Mental Illness Fellowship of Australia. The fellowship commenced informally in 1986 as an association of the various state and territory Schizophrenia Fellowships, which were then in existence. It was formed primarily to provide a point of contact, a place to exchange information, lobby and to provide mutual support. Mental Health in Multicultural Australia (MHMA). This website provides national leadership in building greater awareness of mental health and suicide prevention among Australians from culturally and linguistically diverse (CALD) backgrounds. Royal Australian and New Zealand College of Psychiatrists (RANZCP). RANZCP is the principal organisation representing the medical specialty of psychiatry in Australia and New Zealand. It is responsible for training, examining and awarding the Fellowship of the College qualification to medical practitioners. SANE Australia. SANE Australia is a national charity working for a better life for people affected by mental illness. Schizophrenia.com. This is a non-profit community organisation providing in-depth information, support and education related to schizophrenia. Supporting Families in Mental Illness New Zealand. This website provides education, advocacy and support for family/whānau of people experiencing a major mental illness. Victorian Mental Health Carers Network. The network is the Victorian peak body of organisations and individuals who support carers of people with mental health issues. It comprises: carers or former carers linked with carer groups; representatives of statewide carer organisations with a significant carer focus; workers from carer support programs; and carer-related academics. Victoria’s mental health services. This website provides information on Victoria’s mental health services as well as other information about mental health and illness. World Health Organization (Program and Projects; Mental Health; Disorders Management—Depression). ; World Health Organization (Programs and Projects; Mental Health; Disorders Management—Schizophrenia). These sites provide suggested reading about mental illness.

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Index Page numbers followed by ‘f ’ indicate figures, ‘t’ indicate tables and ‘b’ indicate boxes. A Abnormal Involuntary Movements Scale see AIMS Aboriginal Health Council of Western Australia, Cultural Safety Training Program, 50 abstract thinking, 42 acceptance and commitment therapy (ACT), 119 access (national practice standard), 22 acute care setting, general health care for mental illness in, 4 acute inpatient units, 153–154 intermediate care centres, 153–154 secure/extended care inpatient facilities, 153 acute trauma, 86–88 after crisis has passed and, 87–88 ADHD see attention deficit with hyperactivity disorder aetiology of ADHD, 69–70 of anorexia nervosa, 71 of anxiety disorders, 60 of dementia, 78 of intellectual disability, 72 of personality disorders, 74 of PTSD, 64 of schizophrenia, 65 affect descriptors for, 38t in MSE, 38 aggression, 88–90 scales of, 88–89 agoraphobia, 62

AIMS (Abnormal Involuntary Movements Scale), 111 akathisia, 105t–106t alcohol intoxication, 94–97 alcohol withdrawal, 96–97 alprazolam, 99 Alzheimer’s Australia, 78 Alzheimer’s dementia, 77 ambulance officers, role of, 142 amisulpride, 104t amitriptyline, 101t anorexia nervosa, 70–71 bingeing/purging type, 70 criteria for, 70 mental health symptoms of, 71 physical symptoms of, 71 restricting type, 70 anticholinergic drugs, 104–107 anticonvulsants, 109–110 antidepressants, 98, 100 commonly used, 101t MAOIs, 100, 103 SNRIs, 100–102 SSRIs, 100–101 tricyclic, 100, 102–103 antipsychotics, 98, 103–104, 104t action of, 104 depot, 108 EPSEs of, 104, 105t–106t PRN, 108 anxiety disorders, 60 anxiolytics, 98–99 drug interactions, 99 appearance in MSE, 36–37 aripiprazole, 104t 193

Index

assessment, 26, 32–46, 33f medical history in, 45 of mental health, 32–46, 33f mental health practice and, 26 presenting information in, 43–45 psychiatric history in, 45 risk assessment in, 45 social history and, 45 of substance abuse, 95 of suicidal/self-harming behaviour, 86b see also mental state assessment; risk assessment attention deficit with hyperactivity disorder (ADHD), 68–70 AUDIT alcohol assessment scale, 80, 95 auditory hallucinations, 41 Australian Aboriginal peoples, 49–50 Cultural Safety Training Program, Aboriginal Health Council of Western Australia, 50 working with Aboriginal and Torres Strait Islander people, families and communities (national practice standard), 22 see also indigenous peoples Australian Government Department of Health and Ageing website, 76 Australian mental health and wellbeing survey, 2, 2t autism spectrum disorder, 73 autonomy, 144 B bad news, delivering, 134 Barker, Phil, 15 behavioural psychotherapy, 117 behaviours ADHD, 69 in MSE, 37–38 suicidal/self-harming, 85–86 beneficence, 144 benzhexol, 107 194

benzodiazepines, drug interactions, 99 benztropine, 107 bereavement, 129t assisting in, 134–135 models and theories of, 129–130 professional support for, 134–135 biomedical approach, 10, 10t bipolar disorder, 67 types of, 67 body mass index (BMI), 122, 124b boundaries, professional, 28–31 tips for setting, 30b breastfeeding, medications during, 112 brief psychotic disorder, 66 bromazepam, 99 bulimia nervosa, 71–72 criteria for, 72 physical and psychological symptoms of, 72 C CAGE alcohol screening test, 80, 95 CALD backgrounds see culturally and linguistically diverse backgrounds Canadian Mental Health Alliance, 16 carbamazepine, 108–110 case management, 25 of mental health care, 149 CBT see cognitive behavioural therapy childbirth and mood disorders, 67–68 chlorpromazine, 104t citalopram, 101 clang association, 40 clonazepam, 99 clozapine, 104t, 122 cluster A personality disorders, 74, 75t cluster B personality disorders, 74, 75t cluster C personality disorders, 74, 75t cognitive behaviour therapy (CBT), 63

Index

cognitive therapy, 117 colonisation, 133 communication and information management (national practice standard), 22 community mental health care in, 149 mental illness in, extent of, 2–3 protective factors associated with, 11–12 community treatment orders (CTOs), 142 community treatment teams, 150 compassionate care, 27 complicated grief, 130–131 compulsions, 40 compulsory community treatment, 142 compulsory mental health care, 142 concentration, 42 confidentiality, 144 exceptions to, 143 conscious awareness in MSE, 41–42 consciousness, 41–42 constipation, side effect, 107t consultation-liaison psychiatry, 154 conversation in MSE, 38 co-occurring medical problems, 121–127, 123t extent of problem and, 121–122 mental illness, risk for, 3 physical illness, risk for, 3–4 poor physical health and, 124–125 prevention of, 122, 124b creative therapies, 119 crisis intervention teams, 149–150 CTOs see community treatment orders cultural awareness, 50–51 cultural competence, 51, 52b cultural diversity, 48 cultural issues, 34 cultural safety, 47, 50–51 practice, 50–51, 51t

Cultural Safety Training Program, Aboriginal Health Council of Western Australia, 50 cultural sensitivity, 50–51 culturally and linguistically diverse (CALD) backgrounds, 48–49, 51–53 culturally inclusive environment, 51, 52b culture, 47 mental health and, 47–58 social groups and, 47, 48b working with interpreters and, 53, 54b–56b D debriefing after violence of aggression, 90 delirium, 76–77 differences between delirium, dementia and depression, 77t delusions, 39–40 dementia, 77–78 assessment scales for, 78 differences between delirium, dementia and depression, 77t drugs to manage, 110–111 depersonalisation, 41 depot antipsychotic medication, 108 depression differences between delirium, dementia and depression, 77t pre-, and postnatal, 68 see also antidepressants derealisation, 41 de-escalation, 90 diabetes mellitus, co-occurring, 122 diagnosis of ADHD, 69 of mental illness, 49b Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), 60 diagnostic classifications, 60 195

Index

diagnostic criteria delirium, 76–77 intellectual disability, 72 schizophrenia, 65 substance abuse disorders, 79–80 dialectical behaviour therapy, 118 diazepam, 98–99 disenfranchised loss, 132–133 donepezil, 110 dos and don’ts of dealing with acute trauma, 88b of dealing with aggression and violence, 91b–92b of dealing with alcohol or drug intoxication, 96b of dealing with panic attacks, 94b of dealing with psychotic people, 93b for delivering bad news, 135b of suicidal/self-harming behaviour assessment, 87b drowsiness, side effect, 107t drug intoxication, 94–97 see also substance abuse disorders drug-induced psychosis, 66 dry mouth, side effect, 107t DSM-5 see Diagnostic and Statistical Manual of Mental Disorders, 5th edition duty of care, 143–144 dystonia, 105t–106t E eating disorders, 70–72 echolalia, 40 Edinburgh Postnatal Depression Scale, 68 elderly see older people emergencies, psychiatric and associated, 83–97 environment culturally inclusive, 51, 52b recovery and, 24 safe, 27 see also settings 196

EPSEs see extrapyramidal side effects escitalopram, 101 ethical practice and professional development responsibilities (national practice standard), 23 ethics, 140–147 case study, 145b in mental health care, 143–145, 144b, 145t–146t of physical restraint of consumers, 143–144 explanatory models of mental illness, 49–50 extrapyramidal side effects (EPSEs), 104, 105t–106t F families family therapy, 118 MSA and talking to, 34 working with, 16–17 flunitrazepam, 99 fluoxetine, 101 flupenthixol, 104t fluphenazine, 104t fluvoxamine, 101 Framework for recovery-oriented practice, 13, 14t friends, MSA and talking to, 34 G galantamine, 110 general practitioners (GPs), 150 people with mental health problems and engaging, 125b generalised anxiety disorder, 61 symptoms of, 61 GPs see general practitioners grandiose delusions, 39 grief, 128–139, 129t complicated, 130–131 health professionals and, 135–137, 136b–137b supportive strategies for, 131b

Index

uncomplicated, 130 understanding, 128–129 unhelpful strategies for, 132b gustatory hallucinations, 41 H hallucinations, 40–41 haloperidol, 104t health professionals delivering bad news and, 134, 135b grief and, 135–137, 136b–137b mental health and, 1–8 mental health promotion and, 13–15 people with mental health problems and engaging, 125b health promotion and prevention (national practice standard), 23 history, 26, 36b holistic mental health assessment, 26 hospital settings, 153 Hospital@home, 151–152 I ICD-10 see International Statistical Classification of Diseases and Related Health Problems, 10th revision illusions, 41 imipramine, 101t immediate past recall, 43 Impact of Events Scale, 64 increased appetite, side effect, 107t indigenous peoples Australian, 53 loss for, 133–134, 134t working with, 51–53 working with Aboriginal and Torres Strait Islander people, families and communities (national practice standard), 22 individual planning (national practice standard), 22 informed consent, 144 insight in MSE, 42

integration and partnership (national practice standard), 22 intellectual disability, 72–73 assessment tools for, 72–73 treatment of, 72 intermediate care centres, 153–154 International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD10), 60 interpreters, working with, 53, 54b guidelines for conducting interview and, 55b–56b J judgement in MSE, 43 justice, 144 K Kübler-Ross, Elisabeth, 129 L lamotrigine, 108 laws, 140–147 mental health, 140–143 literacy, mental health, 22 lithium, 108 toxicity, 109, 110b Liverpool University Neuroleptic Side Effect Rating Scale see LUNSERS logical thought, 40 loose associations, 40 lorazepam, 99 loss, 128–139, 129t for indigenous peoples, 133–134, 134t across life span, 133 mental illness and, 132–133 models and theories of, 129–130 in special circumstances, 131–134 suicide and, 133 understanding, 128–129 LUNSERS (Liverpool University Neuroleptic Side Effect Rating Scale), 111 197

Index

M major depressive disorder, 66–67 management of co-occurring medical problems, 122, 124b of medications, 98–115, 113b of panic attacks, 92–94 of substance abuse, 94–97 of suicidal/self-harming behaviour, 85–86 MAOIs see monoamine oxidase inhibitors medical history, 45 medications categories of, 98–110 concordance, 114b dementia, 110–111 general management issues, 111–112 managing, 98–115, 113b special populations and, 112–113 meeting diverse needs (national practice standard), 22 memory in MSE, 43 mental health definition of, 1 health professionals and, 1–8 Mental Health Act, New Zealand, 141 mental health care, 4, 148–149 case management, 149 for chronic physical illness, 4 community settings for, 149 compulsory, 142 ethical issues in, 143–145, 144b ethical principles in, 145t–146t settings, 148–157 Mental Health Nurse Incentive Program, 151 mental health nurse incentive program (MHNIP), 24–25 mental health plans, 1 mental health practice, 21–31 assessment and, 26 guiding principles, 23–24 198

history and, 26 scope of, 25 settings and models for care, 24–25 mental health professionals competent, 17–18 National practice standards for the mental health workforce, 24 recovery competencies for, 17–18 Recovery competencies for New Zealand mental health workers, 24 Mental health statement of rights and responsibilities, 22 mental illness in community, extent of, 2–3 culture and risk of, 48–49 definition of, 1 explanatory models of, 49–50 health care for, 4, 5b loss for people living with, 132–133 overview of, 59–82 prevention of, 21 rights of people with, 142–143 Mental Illness Fellowship of Australia, 152 mental state assessment (MSA) cultural issues in, 34 reasons for, 33–34 talking to family, friends and, 34 mental state examination (MSE), 32–33 basics and purpose of, 35–36 case study, 44b components of, 36–43, 37f essential skills for, 34–35 settings for, 34 see also Mini-Mental State Examination mental wellness, 15–16 metabolic syndrome, co-occurring, 122, 124b MHNIP see mental health nurse incentive program

Index

Mini-Mental State Examination (MMSE), 78 Mini Psychiatric Assessment Schedule for Adults with Developmental Disabilities (Mini PAS-ADD), 72–73 Minnesota Multiphasic Personality Inventory, 76 MMSE see Mini-Mental State Examination MOAS see Modified Overt Aggression Scale mobile assertive care teams, 150 models for care, 24–25 Modified Overt Aggression Scale (MOAS), 88–89 monoamine oxidase inhibitors (MAOIs), 100, 103 mood disorders, 66–68 childbirth and, 67–68 mood in MSE, 39 mood stabilisers, 98, 108–109 motivational interviewing, 119 mourning, 129t understanding, 128–129 MSA see mental state assessment MSE see mental state examination multidisciplinary team, 25, 27 mutual support/self-help/information/ advocacy groups, 152–153 N narrative therapy, 118 National Mental Health Promotion and Prevention Working Party, 12–13 National Perinatal Depression Initiative, 68 national practice standards, 21, 22t–23t National practice standards for the mental health workforce, 24 National standards for mental health services 2010, 24

National Survey of Mental Health and Wellbeing, 59 nausea, side effect, 107t neuroleptic malignant syndrome, 107 New Zealand Māori, 49–50 cultural safety and, 50 see also indigenous peoples NGOs see non-government organisations nitrazepam, 99 non-government organisations (NGOs), 152 nonmaleficence, 144 NOSIE see Nurses’ Observation Scale for Inpatient Evaluation Nurses’ Global Assessment of Suicide Risk, 85 Nurses’ Observation Scale for Inpatient Evaluation (NOSIE), 88–89 O obsessions, 40 obsessive-compulsive disorder (OCD), 62–63 common themes of, 63t prevalence of, 63 olanzapine, 104t, 122 older people disorders in, 76–78 medications for, 113 other mental disorders in, 78 olfactory hallucinations, 41 orientation, 42 oxazepam, 99 P panic attacks, managing, 92–94 panic disorder, 61 prevalence of, 61 PANSS see Positive and Negative Symptoms Scale Parkinsonism, 105t–106t paroxetine, 101, 101t 199

Index

paternalism, 144 Peplau, Hildegard, 13 perceptions in MSE, 40–41 pericyazine, 104t persecutory delusions, 39 perseveration, 40 personal values of practitioner, 27 personality disorders, 73–76 assessment tools, 76 groups, 74, 75t person-centred approach, 27 see also recovery framework phenelzine, 101t phenomenon, 10 phobias, 62 physical activity in MSE, 37–38 physical assault, 86–88 physical health factors affecting poor, 124–125 strategies for improving, 125–126 physical illness co-occurring, risk for, 3–4 mental health care for chronic, 4 physical restraint of consumers, 143–144 police officers, role of, 142 Positive and Negative Symptoms Scale (PANSS), 66 positive risk taking, 18 postnatal depression, 68 post-traumatic stress disorder (PTSD), 63–64 assessment scales for, 64 postural hypotension, side effect, 107t practitioners essentials of, 27–31 personal and professional values of, 27 self-awareness of, 27–28 working alliance, 28 see also health professionals pregnancy, medications during, 112 prenatal depression, 68 primary care focus, 126 200

primary care setting general health care for mental illness in, 4, 5b mental health care for chronic physical illness in, 4 primary health care, 59–60 privacy, 144 private practitioners, 150–151 PRN antipsychotic medication, 108 professional values of practitioner, 27 prognosis of anorexia nervosa, 70 of dementia, 78 of generalised anxiety disorder, 61 OCD, 63 of personality disorders, 74 PTSD, 64 of schizophrenia, 65 promotion of mental health, 13–15, 21 protective factors community, 11–12 family and peers, 11–12 individual, 11–12 recovery and, 10–11 psychiatric and associated emergencies, 83–97 psychiatric history in mental health assessment, 45 psychodynamic psychotherapy, 116–117 psychoeducation, 22 psychotic people, dealing with, 92 PTSD see post-traumatic stress disorder Q quality improvement (national practice standard), 22 quetiapine, 104t R rapport, developing, 29b reboxetine, 101t recent past recall, 43

Index

recovery environment and, 24 Recovery competencies for New Zealand mental health workers, 17, 24 recovery framework, 9–20 competencies for mental health workers, 17–18 mental health and, 18 person-centred, 10, 10t protective factors and, 10–11 risk and, 18 risk factors and, 10–11 working with families and, 16–17 working with individuals and, 15–16 recovery-oriented mental health services, 12–13 delivery of, 12–13 providing, 13–15 Tidal Model and, 15 religious delusions, 40 remote past recall, 43 resilience, developing, 30b respect, 27 responding, 29b Rethink model, 15–16 rights, responsibilities, safety and privacy (national practice standard), 22 rights of people with mental illness, 142–143 risk, recovery and, 18 risk assessment, 45, 83 questions for, 84b reason for, 83–85 suicide, 85 risk factors for aggression and violence, 90 mental illness diagnosis and, 49b recovery and, 10–11 for suicide, 85b risperidone, 104t rivastigmine, 110 Rowland Universal Dementia Assessment Scale (RUDAS), 78

S safe environment, 27 schizoaffective disorder, 66 schizophrenia, 64–66 assessment scales for, 66 negative symptoms of, 65–66 positive symptoms of, 65 schizophreniform, 66 scope of practice, 25 secure/extended care inpatient facilities, 153 selective serotonin reuptake inhibitors (SSRIs), 100–101 self-awareness of practitioners, 27–28 serotonin discontinuation syndrome, 101–102 serotonin noradrenaline reuptake inhibitors (SNRIs), 100–102 serotonin syndrome, 102b sertraline, 101, 101t settings, 24–25 community mental health care, 149 hospital, 153 mental health care, 148–157 mental health care, contemporary, 149 for MSE, 34 primary care, 4, 5b see also acute care setting, general health care for mental illness in; primary care setting sexual assault, 86–88 side effects of anticonvulsants, 111b of antipsychotics, 107, 107t of anxiolytics, 100b assessment tools for, 111 EPSEs, 104, 105t–106t LUNSERS, 111 of mood stabilisers, 109b SNRIs see serotonin noradrenaline reuptake inhibitors social history in mental health assessment, 45 201

Index

sodium valproate, 108 solution-focused therapy, 119 special populations medications for, 112–113 mental health care settings and, 155 SSRIs see selective serotonin reuptake inhibitors Statement on ethical issues concerning patients with mental illness, World Medical Association’s, 140 Stolen Generation, 133 substance abuse disorders, 79–80 assessment scales for, 80 suicide loss following, 133 myths about, 85–86 risk assessment for, 85 sunburn sensitivity, side effect, 107t Supporting Families in Mental Illness New Zealand, 152 T tactile hallucinations, 41 talking therapies, 116–120 see also specific therapies Tarasoff rule, 143 tardive dyskinesia, 105t–106t teamwork, 22 temazepam, 99 therapeutic milieu, 24 therapeutic relationship, 13 therapy, 116 see also specific therapies thought broadcasting, 40 thought content in MSE, 39–40 thought form in MSE, 39 thought insertion, 40 thought process in MSE, 40 thought withdrawal, 40 Tidal Model, 15 commitments guiding, 15 topiramate, 109–110 202

Torres Strait Islander peoples, 49–50 working with Aboriginal and Torres Strait Islander people, families and communities (national practice standard), 22 see also indigenous peoples transitions in care (national practice standard), 22 tranylcypromine, 101t trazodone, 101t treatment and support (national practice standard), 22 Treaty of Waitangi, 50 tricyclic antidepressants, 100, 102–103 overdose, 103b trifluoperazine, 104t type 2 diabetes, 122 U uncomplicated grief, 130 V valproate, 109–110 vascular dementia, 77 venlafaxine, 101t veracity, 144 Victorian Department of Health, 18 violence, 88–90 conditions associated with, 89b potential, determining, 89–90 visual hallucinations, 41 vulnerable populations, 3–4 W web resources ADHD, 70 for bipolar disorder, 67 for dementia, 78 for intellectual disability, 73 for personality disorders, 76 for substance abuse disorders, 80

Index

weight gain, side effect, 107t Western medicine, 49–50 WHO see World Health Organization word salad, 40 Worder, William, 149 working alliance, 27–28 building strengths in, 29b developing and maintaining, 29b initiating, 29b working with Aboriginal and Torres Strait Islander people, families and communities (national practice standard), 22

working with people, families and carers in recovery-focused ways (national practice standard), 22 World Health Organization (WHO), 1 World Medical Association, 140 Y young people disorders in, 68–70 medications for, 112

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