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English-haiti
Introduction to Agitation,
Delirium, and Psychosis
Curriculum for Psychologists/social Workers
PartiCiPant manual
Partners in health (Pih) is an independent, non-profit organization founded over twenty years ago in haiti with a mission to provide the very best medical care in places that had none, to accompany patients through their care and treatment, and to address the root causes of their illness. today, Pih works in fourteen countries with a comprehensive approach to breaking the cycle of poverty and disease — through direct health-care delivery as well as community-based interventions in agriculture and nutrition, housing, clean water, and income generation.
Pih’s work begins with caring for and treating patients, but it extends far beyond to the transformation of communities, health systems, and global health policy. Pih has built and sustained this integrated approach in the midst of tragedies like the devastating earthquake in haiti. through collaboration with leading medical and academic institutions like harvard medical school and the Brigham & Women’s hospital, Pih works to disseminate this model to others. through advocacy efforts aimed at global health funders and policymakers, Pih seeks to raise the standard for what is possible in the delivery of health care in the poorest corners of the world.
Pih works in haiti, russia, Peru, rwanda, sierra leone, liberia lesotho, malawi, Kazakhstan, mexico and the united states. For more information about Pih, please visit www.pih.org.
many Pih and Zanmi lasante staff members and external partners contributed to the development of this training. We would like to thank giuseppe raviola, mD, mPh; rupinder legha, mD ; Père Eddy Eustache, ma; tatiana therosme; Wilder Dubuisson; shin Daimyo, mPh; noor Beckwith; lena Verdeli, PhD; Ketnie aristide; leigh Forbush, mPh; and Jenny lee utech.
this training draws on the following sources: american Psychiatric association. (2013). Diagnostic and statistical manual of mental Disorders (5th ed.). Washington, DC: american Psychiatric association; Eapen, V., graham, P., & srinath, s. (2012). Where there is no Child Psychiatrist: a mental health Care manual. rCPsych Publications; mental illness Fellowship Victoria. (2013). understanding psychosis; raviola, Kahn, Jarvis. (2015). the Psychiatry Quality Program, Boston Children’s hospital; sherman, m. (2008). support and Family Education: mental health Facts for Families, http://www.ouhsc.edu/safeprogram/; starling, J., Feijo, i. (2012). schizophrenia and Other Psychotic Disorders of Early Onset. in iaCaPaP textbook of Child and adolescent mental health. geneva: international association for Child and adolescent Psychiatry and allied Professions; targum, s. D., & Busner, J. (2007). the Clinical global impressions scale: applying a research tool in Clinical Practice. Psychiatry, 4(7), 28; Winters, n., hanson, g., & stoyanova, V. (2007). the Case Formulation in Child and adolescent Psychiatry. Child and adolescent Psychiatric Clinics of north america, 16(1), 111–132; World health Organization. (2010). mhgaP intervention guide. geneva: World health Organization; World health Organization. (2010). mental Disorders Fact sheet 396, http://www.who.int/mediacentre/factsheets/fs396/en/.
We would like to thank grand Challenges Canada for their financial and technical support of this curriculum and of our broad mental health systems-building in haiti.
© text: Partners in health, 2015 Photographs: Partners in health Design: Katrina noble and Partners in health
II Partners In Health | PartiCiPant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
This manual is dedicated to the thousands of health workers whose tireless efforts
make our mission a reality and who are the backbone of our programs to save lives
and improve livelihoods in poor communities. Every day, they work in health centers,
hospitals and visit community members to offer services, education, and support, and
they teach all of us that pragmatic solidarity is the most potent remedy for pandemic
disease, poverty, and despair.
IIIPartners In Health | PartiCiPant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Table of Contents
Introduction to Agitation, Delirium, and Psychosis
introduction ...........................................................................1
Objectives .............................................................................2
Epidemiology, the treatment gap and stigma ........................4
Diagnosis of severe mental Disorders ....................................8
the Psychosis system of Care and the Four Pillars of Emergency management of agitation, Delirium and Psychosis ......................................................................17
safety and management of agitated Patients .................... 22
medical Evaluation and management of agitation, Delirium, and Psychosis .......................................................28
Biopsychosocial Clinical Formulation ....................................30
medication management for agitation, Delirium, and Psychosis ......................................................................36
Psychotherapy and Family & Patient Education ....................40
Clinical Outcome measures – Cgi and WhODas ................44
Follow-up and Documentation ............................................51
using mhgaP for Psychosis and Bipolar Disorder .................52
review ...............................................................................54
notes ...................................................................................59
IV Partners In Health | PartiCiPant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Annex
Psychosis Care Pathway .......................................................61
Psychiatric Differential Diagnosis information sheet ............62
agitation, Delirium and Psychosis Checklist .........................65
agitated Patient Protocol ....................................................66
agitation, Delirium and Psychosis Form ...............................67
medication Card for agitation, Delirium, and Psychosis .......68
medical Evaluation Protocol for agitation, Delirium, and Psychosis ......................................................................71
suicidality screening instrument ..........................................73
suicidality treatment guidelines ..........................................74
safety Plan ..........................................................................76
Clinical global impressions scale (Cgi) ...............................77
WhODas 2 – 12 item Version ............................................79
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Introduction to Agitation, Delirium, and Psychosis
INTRODUCTION
Psychotic disorders refer to a category of severe mental illness that produces a loss of contact
with reality, including distortions of perception, delusions, and hallucinations. The most common
psychotic disorders are schizophrenia and bipolar disorder, which affect a combined 81 million
people. However, these two conditions do not account for all psychotic disorders. Despite the
immense burden of illness from psychotic disorders, about 80% of people living with a mental
disorder in low-income countries do not receive treatment.1 Stigma and discrimination against
people living with severe mental illness often result in a lack of access to health care and social
support. Human rights violations including being tied up, locked up, or left in inhumane facilities
for years; are all common.
Before a psychotic disorder can be diagnosed, however, patients require comprehensive medical
evaluation to ensure that medical problems are not the root cause of the symptoms. The term
“agitated” is often misused to describe patients who appear psychotic and are, therefore,
immediately referred to mental health. However, oftentimes these patients are actually
suffering from delirium, a state of mental confusion that can resemble a psychotic disorder but
is actually caused by a potentially severe medical illness. Patients who are delirious are often
injected with high doses of haloperidol to quell their “agitation” and they frequently do not
receive any medical evaluation or care. Unfortunately, this misdiagnosis and mismanagement
can lead to death.
Fortunately, psychotic disorders are treatable and for some, completely curable. With the right
training and system of coordinated care, people with psychosis can receive effective treatment
and lead rich, productive lives. In this training, psychologists and social workers will learn how
to manage agitated patients safely and effectively and will also learn how to properly diagnosis
psychotic disorders caused by mental illness.
1. World health Organization. (Oct 2014). mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
By the end of this training, psychologists and social workers will understand how to work
hand-in-hand with community health workers, nurses and physicians to provide high-quality,
humane medical and mental health care for agitated, delirious, and psychotic patients.
ObjeCTIves
By the end of this training, you will be able to:
a. Describe the epidemiology of psychotic disorders and the corresponding treatment gap.
b. Describe the various ways that psychosis may be viewed by the community and by health providers.
c. Describe the impact of stigma on patient care and outcomes.
d. Identify key clinical information related to the diagnosis of various psychotic disorders.
e. Develop a basic mental health differential diagnosis using the Differential Diagnosis Information Sheet.
f. Describe the psychosis care pathway and its collaborative care approach.
g. Outline the main roles of physicians, psychologists, social workers, nurses and community health workers in the system of care.
h. Explain the four pillars of emergency management of agitation, delirium and psychosis.
i. Describe how a psychologist/social worker should use the biopsychosocial model when managing a patient with agitation, delirium or psychosis.
j. Describe the identification, triage, referral, and non-pharmacological management of an agitated patient through the use of the Agitated Patient Protocol and Agitation, Delirium and Psychosis Form.
k. Explain how to screen for suicidal ideation and manage suicidal patients consistent with their severity and risk level.
l. Define medical delirium.
m. Describe the importance of proper medical evaluation for an agitated, delirious or psychotic patient.
n. Explain the process of carrying out a medical evaluation for an agitated, delirious or psychotic patient.
o. Explain how to gather information for a complete mental health history.
p. Describe how to create a biopsychosocial clinical formulation to guide a patient’s treatment.
q. Explain the collaboration between the physician and the psychologist/social worker in managing medication for agitation, delirium and psychosis.
r. Describe the physician’s use of the Medication Card for Agitation, Delirium and Psychosis.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
s. Explain the core psychotherapy approaches for patients with severe mental illness.
t. Describe how to educate patients and family members about the effects and management of psychosis and bipolar disorders.
u. Explain the core psychotherapy approaches for patients with severe mental illness.
v. Describe how to educate patients and family members about the effects and management of psychosis and bipolar disorders.
w. Explain the process of follow-up for people living with psychotic disorders and severe mental illness.
x. Describe the importance of documentation during patient follow-up.
y. Describe how to use mhGAP for the management of psychosis and bipolar disorder.
z. Describe how to use mhGAP for the management of self-harm/suicide.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Epidemiology, the Treatment Gap, and Stigma
Severe Mental Illness
Severe mental illnesses are illnesses of longer duration, longer treatment and have significant impact on the activities of daily living. They include psychosis and mood disorders.
What is psychosis?
Psychosis is a syndrome. A syndrome is defined as the association of several clinically recognizable signs and symptoms which may have multiple causes.
Psychosis results in dysfunction in several domains:
• Cognition (disorganized thinking and speech, memory problems)
• Perception (hallucinations)
• Behavior (social withdrawal, catatonia)
• Emotion (decreased emotion)
There are some psychiatric disorders that mimic psychosis, which can include PTSD, acute stress, intellectual development disorder, and autism spectrum disorder.
schizophrenia
Schizophrenia is characterized by profound disruptions in:
• thinking, affecting language
• perception
• the sense of self
It often includes psychotic experiences, such as hearing voices, visual hallucinations or delusions. Patients with schizophrenia often first begin to show symptoms of psychosis when they are teenagers. Prior to developing schizophrenia, patients may show subtle non-specific signs such as depression, social withdrawal, and irritability.
Schizophrenia affects more than 21 million people worldwide. The prevalence ranges from 1 – 7 per 1,000 people. People with schizophrenia have a 20% reduction in life expectancy.2
2. World health Organization. (Oct 2014). mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
bipolar Disorder
Bipolar disorder is a mood disorder that can include symptoms of depression, mania and/or psychosis. Manic episodes involve elevated or irritable mood swings, over-activity, pressure of speech, inflated self-esteem, and a decreased need for sleep. Some people with bipolar disorder experience mixed episodes that involve both symptoms of mania and depression at the same time or alternating frequently during the same day. Bipolar disorder usually starts during adolescence and early adulthood.
Bipolar disorder affects about 60 million people worldwide. It is the sixth leading cause of disability in the world. People with bipolar disorder have a reduced life expectancy of 9 – 20 years.3
3. World health Organization. (Oct 2014). mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Treatment Gap
Health systems have not yet adequately responded to the burden of mental disorders. As a consequence, there is a wide gap between the need for treatment and its provision all over the world. In low- and middle-income countries, between 76% and 85% of people with mental disorders receive no treatment for their disorder. In high-income countries, between 35% and 50% of people with mental disorders receive no treatment for their disorder.4
stigma
Stigma refers to negative or prejudicial thoughts about someone based on a particular characteristic or condition, in this case someone with a severe mental illness.
As clinicians, it is not acceptable to have stigmatizing thoughts or behaviors toward people with severe mental illnesses. It the clinicians’ responsibility to overcome these feelings to be able to treat patients with dignity and respect.
4. World health Organization. (Oct 2014). mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/
Statistics taken from World Health Organization Mental Disorders Fact Sheet #396
81 million + People living with severe mental illness
12 –19 million
People living with severe mental illness who receive treatment
Treatment Gap! 62– 69 million
People living with severe mental illness who receive no treatment
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
The Zanmi Lasante psychosis system of care aims to diminish Haiti’s treatment gap by safely and effectively treating people living with severe mental illness in a community-based system of care. Psychologists and social workers have the opportunity to close the treatment gap and reduce the stigma related to psychosis by building on the coherent system of care already developed for depression and epilepsy. Psychologists and social workers have the opportunity to help some of the most vulnerable and marginalized people living in communities — those living with mental illness.
sTIGmA ROle PlAy
sTORy
a patient is brought by his family to the emergency room. he is very talkative and focuses mainly on vodou and religion. the emergency nurse fears that he is violent and does not wish to touch him because she thinks he may hit her. the nurse does not check vital signs or provide any medical care. instead the nurse calls the psychologist/social worker on the phone and says “a mental health patient is here.” in the meantime, the patient is totally dehydrated, and has both a high fever and pulse that go undetected. his family reports he has never behaved this way before and only became “a crazy person” after a dog bit him. For more than two hours, the patient and his mother wait and no one comes to them for help.
sCRIPT
Family member (Participant 2): Brings in sick patient to the emergency room.
Patient (Participant 1): arrives to emergency room in the arms of a family member. Begins to talk a lot about vodou and religion in the emergency room.
Nurse (Participant 3): acts scared because he might be violent. Calls psychologist/social worker to say a mental health patient is here.
Patient (Participant 1): has a fever and becomes dehydrated. Does not look well.
Family member (Participant 2): reports to nurse that patient has never behaved this way before and only became “a crazy person” after a dog bit him. Becomes frustrated that a lot of time has passed and no one has helped them.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Diagnosis of Severe Mental Disorders
The Different Signs and Symptoms Associated with Psychosis
The different signs and symptoms associated with psychosis are divided into two categories: positive and negative.
“Positive” symptom – something is present that shouldn’t be:
• Hallucinations
• Delusions
• Disorganized speech
• Disorganized or catatonic behavior
“Negative” symptom – disruption to normal emotion or behavior:
• Flattening of affect
• Social withdrawal
• Loss of motivation
• Cognitive impairments
Phases of Psychosis
There are three distinct phases of psychosis that psychologists/social workers will see throughout their work with psychotic patients: the prodromal phase, the acute phase and the stable phase.
1. Prodromal phase – the time between the first disturbance of normal thinking, feeling or behavior and the onset of psychosis
2. Acute phase – the period when psychotic symptoms are present (delusions, hallucinations, thought disorder)
3. Stable phase – symptoms start to remit and recovery begins
Psychosis: Mimics
There are some medical problems that seem like psychosis:
• Delirium
• Psychiatric Disorder due to a General Medical Condition
• Substance-Induced Psychotic Disorder
• Post-Partum Psychosis
Delirium is a disturbance in attention and awareness due to a medical illness. A medical delirium can appear like psychosis; however it is not a psychotic disorder!
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
There are some psychiatric disorders that seem like psychosis.
• Transient Hallucinations
• Acute Stress/PTSD
• Obsessive-Compulsive Disorder
• Autism Spectrum Disorder
• Personality Disorder
Severe Depression with Psychotic Features
Patients who show at minimum six of the following symptoms of depression with psychosis over a period of two weeks:
• depressed mood most of the day nearly every day
• noticeably increased or decreased sex drive
• loss of interest or pleasure in all, or almost all, activities most of the day nearly every day
• significant weight loss or weight gain, OR decrease or increase in appetite nearly every day
• insomnia OR hypersomnia nearly everyday
• psychomotor agitation OR retardation nearly every day
• fatigue OR loss of energy nearly every day
• feelings of worthlessness OR excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
• diminished ability to think or concentrate, OR indecisiveness, nearly every day
• recurrent thoughts of death, recurrent ideas about suicide without a specific plan, or a suicide attempt or specific plan for committing suicide
• delusions or hallucinations
• increased and intense daydreaming
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Bipolar Disorder
Bipolar disorder is diagnosed when a patient has at least one manic episode.
At least one manic episode
• A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
• During the period of mood disturbance, three (or more) of the following symptoms have persisted and have been present to a significant degree:
– Inflated self-esteem or grandiosity.
– Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
– More talkative than usual or pressure to keep talking.
– Insomnia or hypersomnia nearly every day.
– Psychomotor agitation or retardation nearly every day
– Flight of ideas or subjective experience that thoughts are racing.
– Distractibility Increase in goal-directed activity or psychomotor agitation.
– Excessive involvement in pleasurable activities that have a high potential for painful consequences.
Bipolar disorder usually starts during adolescence and early adulthood. It is not common that bipolar disorder develops in children who have no family risk factors and it is rare that it develops in people over 60 years (except when associated with another disease). Some people with bipolar disorder experience mixed episodes that involve both symptoms of mania and depression at the same time or alternating frequently during the same day. Some people may have as many maniac as depressive episodes, while others may experience one type of episode (usually depression). If you are not sure which episodes the patient has had, document it as bipolar unipolar.
Hypomania is a less severe form of mania, with similar symptoms, but less severe. Hypomania has a less of a negative impact on the daily activities of the person. Around half of people initially diagnosed with bipolar disorder achieve syndromal recovery within six weeks, and nearly all achieve it within two years, with nearly half regaining their prior occupational and residential status in that period. However, nearly half of people go on to experience a new episode of mania or major depression within the next two years.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Brief Psychotic Disorder
Presence of 1 or more symptoms for duration of at least 1 day but less than 1 month:
• Hallucinations
• Delusions
• Disordered thoughts and speech
• Severely disorganized behavior
Schizophreniform Disorder
Two or more symptoms, each present for a significant portion of time during a 1 – 6 month period:
• Hallucinations
• Delusions
• Disordered thoughts and speech
• Severely disorganized behavior
• Negative symptoms
The main difference between brief psychotic disorder, schizophreniform disorder and schizophrenia is the duration of the symptoms/episode. Schizophreniform can be diagnosed if symptoms are present for 1 – 6 months only.
Psychosis Not Otherwise Specified (NOS)
A person shows significant distress or impairment in important areas of functioning due to psychotic symptoms BUT does not meet the full criteria for a schizophrenic or other-psychotic disorder diagnosis.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Schizophrenia
Schizophrenia is thought to be caused by physical changes in the brain, however it may begin after a stressful event.
Two or more of the following present for at least a month:
• Hallucinations
• Delusions
• Disordered thoughts and speech
• Severely disorganized behavior
• Negative symptoms
– Deterioration in social, educational or work functioning
– Duration of illness of at least six months
– Not due to another mental illness such as a mood disorder, or a medical condition.
Schizophrenia may begin at any time but most commonly it begins in the mid- to late teens or early 20s. Prior to developing schizophrenia, patients may show subtle nonspecific signs such as depression, social withdrawal, and irritability. Patients can have periods of stability with or without treatment during which their symptoms are absent or minimal.
Among adults, hallucinations are viewed as synonymous with psychosis and as harbingers of serious psychopathology. In children, however, hallucinations can be part of normal development or can be associated with non-psychotic psychopathology, psychosocial stressors, drug intoxication, or physical illness. The first clinical task in evaluating children and adolescents who report hallucinations is to sort out those that are associated with severe mental illness from those that derive from other causes.
Delusional Disorder
Diagnostic criteria:
• Non-bizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, deceived by spouse or lover, or having a disease) of at least 1 month’s duration.
• Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the delusional theme.
• Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.
• If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.
• The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Differential Diagnosis Case Studies
*For all cases assume that a medical illness has already been ruled out by the physician. All the patients referred to you have been determined to have a mental illness.
CAse 1
a mother has brought her 12-year-old girl to the health facility. she says that her daughter is often unfocused, seemingly “far away.” the daughter sometimes wakes up in the middle of the night screaming. the girl refuses to enter any cars. through questioning the mother, you find out that this has been happening for 7 weeks. the girl has had difficulty falling asleep, has been sleeping poorly, and reports that sometimes she sees “shadows of people” at night who are not there. the mother reveals that their son died in a car accident about two months ago, and that the daughter was in the car when it happened. after performing a mental status exam, taking a history and asking the patient a few questions about her friends and school, you see she has no evident problems with cognition or emotion. there is no history of mental illness in the family.
1. Is the girl, in your opinion, psychotic? Why or why not?
2. What diagnosis might you present to the girl? Why?
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
CAse 2
a 22-year-old woman is brought in by her husband. he says that his wife has been acting strangely recently. he reports that she has refused to get out of bed for the past week and has been crying frequently. he was worried she was depressed. however, yesterday she got out of bed extremely happy and was so energized cleaning the house she didn’t sleep at night. You observe the wife chatting excitedly with other people in the waiting room. she says she feels wonderful and doesn’t know why her husband brought her here. the husband reports that over the past few days she has been spending the family’s money on nonessential items and that he is worried that this is putting the family at risk.
1. Is the woman, in your opinion, psychotic? Why or why not?
2. What diagnosis might you present to the woman? Why?
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
CAse 3
a 20-year-old man is brought in by his friend. the friend says that recently, the patient started saying that his neighbor is watching him all the time. the patient cannot stop talking about the neighbor’s spying. the patient describes that he even hears what the neighbor is saying about him in his mind. When you ask how long this has been happening for, the friend says almost three months.
1. Is the man, in your opinion, psychotic? Why or why not?
2. What diagnosis might you present to the man? Why?
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
CAse 4
a 25 year-old man is brought in by a neighbor. this patient has disorganized behavior and has not bathed recently. he is mumbling words under his breath and is not able to speak in complete sentences. You try to have a conversation with the patient, but cannot easily communicate. You ask the neighbor how long he has been like this. the neighbor responds that he has been like this for a few years already, but this is the first time that he is seeing a psychologist/social worker. the neighbor says that the man cannot work because of his mental state and sometimes the man is aggressive and yells threats to no one in particular. What diagnosis might you present to the man?
1. Is the man, in your opinion, psychotic? Why or why not?
2. What diagnosis might you present to the man? Why?
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
The Psychosis System of Care and the Four Pillars of Emergency Management of Agitation, Delirium, and Psychosis
The Psychosis System of Care
Psychologists’ and social workers’ main roles in the Zanmi Lasante system of care are:
a. to ensure safety for the patient and others through correct agitation management
b. to make a preliminary diagnosis of delirium/medical illness or mental illness in coordination with the physician
c. to provide psychotherapy and psychoeducation to patient and families
d. to coordinate care with the physician and CHW
Psychologists/social workers are just one important element in the collaborative care approach; to provide the quality care they need to work closely with other team members that include physicians, nurses and community health workers.
Four Pillars of the emergency management of Agitation, Delirium and Psychosis
There are three types of patients that will come looking psychiatric, although not all of them will have a psychiatric illness:
• Patient is agitated
• Patient has a medical illness
• Patient has a psychiatric illness
Any decision around mental health or a treatment plan should include these four elements, in this order:
1. Safety
a. Determine the risk of suicide
b. Understand the exposure to violence
c. Determine the risk of violence
2. Medical Health
a. You cannot diagnose a mental illness without eliminating all medical causes
b. Take vital signs, perform a physical and neurological exam, lab tests (RPR, HIV, hemogram), in some cases consider a scan
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
3. Mental Health
a. Plan the assessment and ongoing treatment
b. Psychotherapy, pharmacology
c. Create a safety plan
4. Follow-up
a. Next appointment at the clinic
b. Which providers are involved in the patient’s care (CHW, psychologist/social worker, nurse, physician)?
Each pillar will be informed by the psychologist/social worker’s use of the biopsychosocial model.
biopsychosocial model
Medical providers need to approach the treatment and management of psychotic disorders and severe mental illness from a biopsychosocial approach, because there are biological, psychological and social factors involved in the development of mental disorders.
A biopsychosocial approach to mental health treatment will:
• Assist with understanding the condition
• Assist with structuring assessment and guiding intervention
• Inform multidisciplinary practices
World health Organization: World mental health report, 2001: p. 20
Biological factors
Psychological factors
mental and behavioural
disorders
social factors
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
bIO PsyCHO sOCIAl
• medical comorbidities
• genetic factors, family history
• medications (sensitivity, medication interactions, side-effects)
• Drug or alcohol use
• temperament
• Personality
• Weaknesses
• Defense mechanisms (response to stressful situations)
• Past trauma and losses
• support from family and friends
• Education and employment
• religious and spiritual beliefs
• socioeconomic stressors
• Exposure to stigmatization
• Explanatory model, system of beliefs
• Different coping strategies
CAse 1
CAse: biopsychosocial Considerations
a 37-year-old man patient is brought by his family to the emergency room. he is very talkative and shouts about vodou and religion as he runs around the emergency room.
the emergency nurses fear that he is violent and do not wish to touch him because he may be contagious. they do not check vital signs or provide any medical care. instead they call the psychologist and say “a mental health patient is here.” in the meantime, the patient is totally dehydrated and has a high fever that goes undetected.
his family reports he has never behaved this way before and only became “a crazy person” after a dog bit him two weeks ago. since then he has been unable to work and care for his wife and two children. Other family members have to stay with him, thereby losing daily wages.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
thE FOur Pillars OF EmErgEnCY managEmEnt OF agitatiOn, DElirium, anD PsYChOsis
1. sAFeTy
violence:
• is the patient agitated or violent currently? (use the agitated Patient Protocol)
• What is the history of violence? When did it happen, how severe was it?
• is the patient being exposed to violence/abuse?
suicide:
• is the patient suicidal currently? actively or passively?
• What is the history of suicide? Past attempts with medical severity, past suicidal ideation? When did it happen?
management:
• how is safety being managed? is 1:1 present?
• how is risk being decreased?
2. meDICAl
medical evaluation of Psychosis:
• must do a physical and neurological exam, vital signs, weight, laboratory tests (hemogram, hiV and rPr for all patients; renal and hepatic panels if available; CD 4 count for all hiV patients).
• Consider a Ct scan if the patient has a clear neurological deficit.
Consider Delirium:
• Disturbance of consciousness with reduced ability to focus, sustain or shift attention; change in cognition/development of perceptual disturbance not due to dementia; disturbance develops over a short period of time (hours to days) and fluctuates during the day; evidence from the history, physical exam or lab tests that the disturbance is caused by a medical problem.
• treatment is aimed at underlying medical problem and avoiding diazepam.
Consider epilepsy (Post-Ictal Psychosis):
• the family reports the development of psychosis/agitation after seizures.
• treatment is anti-epileptic.
medication management:
• use the medication card to dose and prescribe.
• Provide fluids and do an EKg for all hospitalized/emergency room patients receiving haloperidol.
• Check for medication side-effects; do aims.
• Check vital signs and weight for all patients
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
3. meNTAl HeAlTH
Diagnosis:
• Work with a psychologist/social worker, use the Differential Diagnosis information sheet.
• reconsider the diagnosis at each visit.
Psychoeducation and support:
• Provide education to patients and families regarding psychosis and medication.
medication management:
• use medication Card for agitation, Delirium and Psychosis; consider diagnosis.
4. FOllOW-UP
Date of next appointment/visit:
• Follow-up based on acuity; for hospitalized patients, daily or several times a day; for outpatients, can be every 1– 2 days or weekly for more acute patients and every 2 – 4 weeks for stable patients.
• involve community health workers in the care.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Safety and Management of Agitated PatientsSafety is the first pillar when dealing with an agitated, delirious or psychotic patient.
Agitation
Is agitation a disease? Agitation is not a disease, there are many causes:
• Delirium (medical): mental retardation, thyroid abnormalities, dementia, seizures, hypoglycemia, anti-cholinergic intoxication and urinary tract infection, HIV encephalopathy, various states of intoxication and withdrawal
• Psychiatric problems: psychosis, mania, trauma
• Emotional/psychological trauma
Agitation spectrum
There is a spectrum of agitation and patients can fall anywhere on the spectrum.
Forms to manage Agitated Patients
The Agitated Patient Protocol will assist clinicians in properly managing different levels of agitation.
The Agitation, Delirium, and Psychosis Form assists physicians in recording vital information related to determining if an agitated patient is delirious or psychotic.
Agitation (mild) Aggression (moderate) violence (severe)
• wringing hands• pacing/moving restlessly• frequent demands• loud, rapid speech• low frustration tolerance
• verbal threats• yelling, cursing• does not respond to
verbal redirection• does not respond to
increased staff presence
• destroying property• making a fist, physically
threatening (e.g. hitting, kicking, biting)
• harming people
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
When managing an Agitated Patient: safety and Talking First!
Often psychologists/social workers and other health providers are unsure what to do when there is an agitated patient. By talking to the patient, the nurse can evaluate the risk of violence, begin the medical evaluation and calm the patient.
How to ensure safety:
• Do not see the patient alone (ask for security). Remain calm. Remember that patients do not suddenly become violent; their behavior occurs along a spectrum.
• Maintain a safe physical distance from the patient. Do not allow the exit to be blocked. Keep large furniture between you and patient.
• Remove all objects that can be used to harm (needles, sharp objects, other small objects). Check whether the patient has a history of violence or substance abuse.
• Talking to the patient is safe and effective. Do not yell. Keep your voice calm, quiet and friendly.
• Make eye contact to show that you care about the patient. Show sympathy and empathy (‘I understand that you are scared, but I am here to help. We will not hurt you’).
Intramuscular Medication and Physical Restraint
When should providers give medication intra-muscularly?
From a human rights perspective, you always want the least restrictive approach and use the fewest interventions necessary. We only give medication intramuscularly to a severely agitated patient who is at risk of imminent self-harm or is harming those around him. We only administer medication intramuscularly when a severely agitated patient refuses oral medication or is unable to comprehend the request to take oral medication. We must remember that administering an intramuscular injection is invasive and can cause physical pain. It can also potentially lead to physical harm towards providers.
In what situations should clinicians use physical restraint?
The goal is to use the least restrictive means necessary. The rights of a person must take priority, in balance with the safety of those around them. Physical restraint can be considered if:
• If calming measures have been tried AND
• The patient has been offered an oral medication and refused AND
• The patient reaches a state of severe agitation where there is a significant worry about harm to self and others AND
• It is felt that all alternatives have been tried
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Gathering Information and a Brief Assessment
Physicians and nurses should try to obtain as much history about the patient as possible to better inform the management of the patient’s agitation. It is helpful to obtain this information from the patient, if possible, but also from family members or anyone who has accompanied the patient.
• What happened?
• How did this start?
• Has this happened before?
• Has the person suffered from a mental illness in the past?
• Does the person drink a lot of alcohol?
• Has the person been taking medicines lately?
• Has the person had any recent physical illnesses?
Although it would be ideal to obtain information about the agitated patient (whether from the patient or someone else), it is not always possible, depending on the level of agitation.
ROle PlAys
ROle PlAy 1: Agitated Patient
a 55-year-old man is brought to the clinic by concerned neighbors. they report that he has been talking to himself, yelling at people for no reason, and making threatening comments. they refer to him as ‘crazy’ and report that he has no friends or family. in the clinic he is disorganized and confused.
ROle PlAy 2: Agitated Patient
a 24-year-old woman is brought to the emergency room by her boyfriend and brother. she is angry, yelling and screaming. her brother has to physically hold her in order to prevent her from lunging at her boyfriend. the brother reports that the patient’s behavior changed several days ago following an argument with her boyfriend in which she accused him of cheating.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Suicide Risk
The identification and triage of patients who may have suicidal ideation is one of the most important aspects of the clinical history and evaluation. It is important that each agitated or psychotic-appearing patient with a concern of self-harm is screened for suicidality. Psychologists/social workers have the responsibility within the system of care to evaluate and properly screen patients for suicidality. The physician, when managing an agitated patient will ask and then record on the Agitated Patient Form if that patient has a history of suicide attempts. If the patient does have a history of suicide attempts, the psychologist/social worker will immediately use the Suicidality Screening Instrument to determine the patient’s level of risk. If it is not immediately apparent if the patient has a history of suicide attempts, but there is a concern about the patient’s self-harm (whether past or present), the psychologist/social worker should also administer the Suicidality Screening Instrument.
Safety Plan
All patients who are screened for suicidality, whether low risk or high risk, need a safety plan. A safety plan is a plan, collaboratively developed by the patient and psychologist/social worker, which assists patients to decrease their risk of suicide.
The plan’s six essential components:
1. Recognize warning signs of a suicidal crisis about to happen
2. Identify and employ internal coping strategies without needing to contact another person
3. Utilize contacts with people as a means of distraction from suicidal thoughts & urges
4. Contact friends or family members who can help resolve a crisis & with whom suicidality can be discussed
5. Contact mental health professionals or agencies
6. Reduce potential use of lethal means
The most important aspect of the safety plan is its accessibility and ease of use. A safety plan will not be helpful if there are obstacles in the plan that the patient cannot overcome. The psychologist/social worker’s role is to discuss feasibility of the plan’s steps with the patient so the patient is prepared.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
ROle PlAy 1
Psychologist/social Worker: hello Emmanuel.
Patient: hello.
Psychologist/social Worker: i’d like to ask you a few additional questions to be sure that you are safe. Part of my job here in the health facility is to help people feel safe, and to help all of the physicians and nurses to ensure the safety of people we see here. Please know that you can trust me, and that i would like to be helpful to you.
Patient: OK.
Psychologist/social Worker: sometimes, when things are particularly difficult, some people have thoughts of not wanting to live. have you ever wished you were dead in the past two weeks?
Patient: no.
Psychologist/social Worker: have you ever wished you were dead in the past year?
Patient: Yes.
Interview continues because patient said yes.
Psychologist/social Worker: have you had any thoughts of killing yourself in the past two weeks?
Patient: no.
Psychologist/social Worker: have you had any thoughts of killing yourself in the past year?
Patient: Yes. things were just so hard!
Interview continues because patient said yes.
Psychologist/social Worker: have you been thinking of ways to do this in the past two weeks?
Patient: no.
Psychologist/social Worker: have you been thinking of ways to do this in the past year?
Patient: no. i never decided to do anything.
Interview ends because patient said no to each column of a question
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
ROle PlAy 2
Psychologist/social Worker: hello Katrina.
Patient: hello.
Psychologist/social Worker: i’d like to ask you a few additional questions to be sure that you are safe. Part of my job here in the hospital/clinic is to help people feel safe, and to help all of the physicians and nurses to ensure the safety of people we see here. Please know that you can trust me, and that i would like to be helpful to you.
Patient: OK.
Psychologist/social Worker: have you ever wished you were dead in the past two weeks?
Patient: Yes.
Psychologist/social Worker: have you ever wished you were dead in the past year?
Patient: Yes.
Interview continues because patient said yes.
Psychologist/social Worker: have you had any thoughts of killing yourself in the past two weeks?
Patient: Yes. i don’t want to live anymore, but i know my family would feel so bad.
Psychologist/social Worker: have you had any thoughts of killing yourself in the past 12 months?
Patient: (nods).
Interview continues because patient said yes.
Psychologist/social Worker: have you been thinking of ways to do this, now or in the past two weeks?
Patient: Yes, i think a lot about it.
Psychologist/social Worker: have you been thinking of ways to do this, in the past year?
Patient: Yes, i guess i’ve been thinking about it for a long time.
Interview continues because patient said yes.
Psychologist/social Worker: Do you have any intention to act on these thoughts?
Patient: i’m not sure…
Psychologist/social Worker: We are here to help you, you are not alone. i would like to work with you to develop a plan to support you given that things are so difficult currently.
Interview ends as clinician develops a plan to support the patient based on the rest of the history obtained.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Medical Evaluation and the Management of Agitation, Delirium, and PsychosisOnce a clinician has calmed an agitated patient, the physician and psychologist/social worker need to determine if the patient is psychotic or has a medical delirium.
Definition of Agitation, Delirium and Psychosis
Agitation is a symptom to describe behavior. It is not a disease. It is not a mental illness.
Delirium is a medical emergency. It is not a mental illness. It occurs when medical illness results in mental confusion. Delirious patients are confused and off-center and have an increased chance of death. It also has an additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception).The disturbance develops over a short period of time (usually hours to a few days) and tends to fluctuate in severity during the course of a day. Delirium is often misdiagnosed as psychosis or other psychiatric illnesses.
There are many causes for delirium including:
• Infections (HIV/AIDS, neurosyphilis, malaria)
• Metabolic disorders (electrolyte disorders, especially hypo/hyperglycemia related to diabetes)
• Drug intoxication/Alcohol withdrawal
• Medications (corticosteriods, cycloserine, phenobarbital, efavirenz, high doses of antihistamines, isoniazid)
• Malnutrition/Vitamin deficiencies
• Brain diseases (dementia, stroke, head injury with bleed)
• Malignancy
• Post-Ictal Psychosis
– Takes place between seizures
– Usually follows a ‘lucid’ interval that lasts from hours to days following a seizure
– Characterized by delusions, hallucinations, and aggressive behavior
– Primary treatment is anti-epileptic medication
• Hypertension
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Psychosis is a syndrome. A syndrome is defined as the association of several clinically recognizable signs and symptoms which may have multiple causes. It can be a sign of medical illness or mental illness. It is not always a mental illness! It results in dysfunction in thinking, perception (hallucinations) and behavior (decreased social and professional activity).
Treatment is aimed at a complete medical evaluation and treatment first, then a complete mental health evaluation and treatment, if necessary.
Standard Medical Evaluation for Agitation, Delirium and Psychosis
• History (epilepsy, delirium, substance abuse, medications)
• Vital Signs
• Physical Exam
• Neurological Exam
• Mental Status Exam
• Laboratory Tests (at least CBC, RPR, VIH, CD4 if HIV+)
• Additional Tests (CT Scan, EEG, lumbar puncture)
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Biopsychosocial Clinical FormulationIf after a medical evaluation, it has been concluded that a patient has a mental illness, the psychologist/social worker will complete the Initial Mental Health Evaluation Form. This includes recording a complete mental health history and creating a biopsychosocial clinical formulation for a patient.
Information to Obtain from Patient/Family
Based on the Zanmi Lasante Initial Mental Health Evaluation Form, obtain:
• Identification/demographic information
• Chief complaint (CC), in patient’s own words
• History of present illness (HPI)
• Psychiatric review of systems (ROS)
– Use of screening tools to help identify possible disorders
– Plus systematic interview to be able to identify disorders/diagnoses
• Past Psychiatric History (PPH), including hospitalizations
• Past Medical History (PMH)
– Head injury
– Loss of consciousness
• Active medical problems
Questions to Ask to Obtain History
• How long has the problem been present (hours, weeks, days, months, years), has it ever happened before?
• How has it affected your life?
• Are you currently being treated for this?
• Have you had any similar problems to the current one before?
• Any recent illness?
• Do you have any physical problems that are bothering you?
• Do you have any allergies?
• Are you aware of a family history of mental health problems, including your siblings, parents or grandparents?
• Is there any family history of depression, anxiety, alcohol or drug abuse, schizophrenia, bipolar disorder or suicide?
• How would you describe your childhood?
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
• Were there any behavioral problems for you as a child?
• Did you have difficulty at home or at school, as a child or as a teenager?
• What is your highest level of education?
• How have you and your family been doing financially?
• Do you and your family have enough to eat?
• Do you have any problems sleeping at night?
• Have you lost interest in your daily activities?
• Have you been seeing or hearing things that other people cannot hear?
• Have you been feeling sad or unhappy recently?
• Have you been scared or frightened recently?
• How much alcohol have you been drinking recently?
• Have you been able to do the activities you want to, without feeling that your mood or your thinking does not allow you to?
Biopsychosocial Clinical Formulation
A biopsychosocial clinical formulation is a working hypothesis which attempts to explain the biological, psychological and sociocultural factors which have combined to create and maintain the presenting clinical problem. It is a guide to treatment planning and helps communicate providers’ impressions to other providers, and to a patient and their family. A clinical formulation is not a summary of the clinical data. A formulation must contain a theory about the etiology of the patient’s problems, related developmental status and strengths.
Creating a biopsychosocial formulation:
• The biological factors include things such as genetics, general medical conditions and drugs.
• The psychological factors include a person’s coping strategies, personality and stressors including past trauma, loss and prolonged grieving.
• The social factors include a person’s living situation, their support (both family and friends), finances, situation at work/school, etc.
• It is important to take note of areas of significant strength, competency and mastery. Areas of strength can be used as initial areas of intervention in supporting a person.
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bIOPsyCHOsOCIAl ClINICAl FORmUlATION exAmPle
Peterson is a 21-year-old male living in mirebalais who lives with his parents and presented to the hospital with a chief complaint of “hearing voices.” From a biological perspective there is a family history of a similar problem (his father), and he also experienced head trauma in a motorcycle accident several years ago. From a psychological perspective, Peterson has experienced significant shame about his illness, which has significantly affected his self-esteem. he and his family believe that these symptoms are related to a curse that was cast on the family. From a social perspective, they also are poor, Peterson’s father drinks alcohol excessively, and at times there is domestic violence. Peterson has strengths in that he has been a good student at school, he goes to church, and he participates in a musical group.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
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34 Partners In Health | PartiCiPant hanDBOOK
Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
bIOPsyCHOsOCIAl FORmUlATION CAses
CAse 1
a 22-year-old woman, Darline, is brought in by her husband to the health facility in Cange. he says that his wife has been acting strangely. he reports that she has refused to get out of bed for the past week and has been crying frequently. Darline is usually very active in church but hasn’t gone the past two weeks. he was worried she was depressed. however, yesterday she got out of bed extremely happy and was so energized cleaning the house she didn’t sleep at night. You observe Darline chatting excitedly with other people in the waiting room. she says she feels wonderful and doesn’t know why her husband brought her here. When you ask Darline if there is any family history of mental illness she declines to reply. she asks you angrily what you are trying to suggest. she says that nothing is wrong with her, although she does admit she was feeling sad last week. the husband mentions that he is worried and frustrated because she hasn’t been able to work as much the past two weeks because of her condition, and that it’s straining the family finances. When asked about her physical health, Darline states she has no health problems. her husband reports that this is the first time that Darline has acted this way.
biopsychosocial formulation:
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
bIOPsyCHOsOCIAl FORmUlATION CAses (continued)
CAse 2
a 20-year-old man, James, is brought in by his friend, simon. simon says that recently James started saying that his neighbor is watching him; James cannot stop talking about it. James thinks that the neighbor is a spy. James lives with his aunt and used to go to school. James was a good student, but he stopped going to school because he couldn’t concentrate. James reports that he hears what the neighbor is saying about him in his mind. the neighbor says “i’m watching you. i’m going to get you.” When you ask how long this has been happening for, James says almost three months. James is so scared that he can’t sleep at night. When you ask about his family history, James says he has never met his father, and he hasn’t seen his mother since she was hospitalized at mars and Kline in 2011. simon reports that James’ girlfriend broke up with James because she was scared of how James was acting. James has begun to use alcohol to relax because he is nervous all the time about his neighbor.
biopsychosocial formulation:
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Medication Management for Agitation, Delirium, and PsychosisOnce a medical evaluation has been performed, a physician must decide if pharmacological treatment is necessary. Physicians are responsible for prescribing antipsychotics but they must work with psychologists to determine the likely diagnosis.
Prescribing Principles for Agitation, Delirium and Psychosis
The primary tools that can be used to guide prescribing practices are:
• Zanmi Lasante Formulary
• Epilepsy Medication Card
• Agitated Patient Protocol
• Medication Card for Agitation, Delirium, and Psychosis
Haloperidol and risperidone are the primary medications for the management of agitation, delirium, and psychosis. Risperidone has fewer side-effects and should be tried before haloperidol, unless the patient is violent or aggressive and could benefit from the sedation of haloperidol. Begin with a low dose and increase gradually.
Carbamazepine should typically be prescribed before valproate as a long-term mood stabilizer.
Valproate is particularly for patients with long-standing aggression or violence, and should never be prescribed to a pregnant woman (and avoided for women of child-bearing age).
Diazepam is only used in agitated patients and those going through alcohol withdrawal.
Children, the elderly, pregnant and breast-feeding patients are special populations. Please consult with the mental health team before prescribing for them. For suicidal patients, give a small supply of the medication to a family member to prevent possible overdose.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Psychoeducation about Medication
It is incredibly important to speak to patients and their family members in language that they understand, depending on their education level and knowledge. Do not speak to patients and family members in jargon or complex medical language.
Make sure to explain to the patient/family:
• What the medication is for
• How to take the medication properly
• Common side-effects
• Toxic side-effects and when to seek immediate medical care
• How long it takes for medication to work How long it takes for medication to work
TIP: To know if the patient/family actually understands the information you are providing about taking the medication, ask the patient/family member to repeat back to you how to take the medication.
Additional information about prescribing principles:
• It is important to take the medication regularly and not miss a dose.
• Do not double up on a dose if a dose is missed.
• It is important to continue to take medication even if symptoms improve.
• Symptoms may worsen if medication is discontinued.
• If any problems of concern develop, contact a member of the treatment team (community health worker, psychologist/social worker or physician) by phone, or return to the hospital for evaluation.
AIMS (Abnormal Involuntary Movement Scale)
The AIMS is a 12-item scale that the clinician administers and scores. The clinician observes the patient and asks questions about involuntary movements due to tardive dyskinesia. If one can catch tardive dyskinesia early, one can intervene.
• Facial and oral movements
• Extremity movements
• Truncal movements
• Patient awareness of movements
The AIMS should be used at the beginning of treatment, and then every six months. It can be done in less than 10 minutes. The clinician tracks the numerical score over time (every six months).
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
meDICATION RevIeW WORksHeeT
Use the Medication Card for Agitation, Delirium, and Psychosis, and the Agitated Patient Protocol.
1. Which three medications on the medication card can Zamni lasante physicians prescribe without consulting the mental Health team?
2. Which two medications on the medication card should NOT be routinely prescribed by Zamni lasante physicians for bipolar disorder or other forms of mental illness?
3a. A 63-year-old man arrives in the emergency room. He is violent and out of control, pushing people and running around. He has been brought in by his wife and son, who report he has never behaved this way before. What level of agitation does he have (mild, moderate or severe)?
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meDICATION RevIeW WORksHeeT (continued)
3b. According to the Agitated Patient Protocol Form, which medication should the physician give the patient? Give the medication name, dose, and form.
4. you are working in the emergency room of a local clinic when a father brings his 19-year-old daughter in. she is totally rigid, unable to walk, unable to turn her head, and unable to open her mouth. Her father has to carry her. He reports that she was taken to a psychiatric facility after becoming violent following a break-up with her boyfriend. At the facility, she was given multiple injections. How would you work with the physician to treat this case?
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Psychotherapy and Family & Patient EducationThere are a variety of approaches for treating mental illnesses, many of which can be useful for treating patients with severe mental illness, like psychosis or bipolar disorder.
• Interpersonal Therapy (IPT)
• Cognitive Behavioral Therapy (CBT)
• Behavioral Activation (BA)
• Breathing/muscle relaxation techniques, stress management
• Group therapy
• Family therapy
• School-based mental health and psychosocial interventions
Supportive Therapy
Appropriate for two kinds of patients:
• Chronic illness, low level of functioning: bipolar disorder, schizophrenia, chronic major depressive disorder
• Person in crisis
Interventions:
Permit venting, acknowledge and validate, accept, give hope, educate, give permission to (temporarily) accept the sick role, normalize, help problem-solve, advise, reality test, role play, request family meeting.
Interpersonal Therapy
Interpersonal therapy can be helpful for some patients with severe mental illness because their illnesses often cause problems in their social relationships.
• Psychological treatment designed to help a person identify and address problems in their relationships with family, friends, partners and other people.
• Works on improving symptoms through a focus on interpersonal functioning.
Family-Focused Therapy
Family-focused therapy can be one of the most helpful types of therapy for patients with severe mental illness.
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Family dynamics are often stressed when a member of the family has a severe mental illness. Families may blame the patient for their symptoms, or be hostile towards the patient. Often, families feel helpless and hopeless to control the illness. Unfortunately, this stressful home environment can lead to the worsening of the patient’s symptoms, creating a cycle of stress in the home. Family-focused therapy emphasizes the importance of building family support through education, problem solving techniques and communication skills.
Family-Focused Therapy:
• Create a shared understanding of severe mental illness (bipolar disorder, schizophrenia) in the family which will:
– Maintain a low-key atmosphere
– Support the patient taking medication and monitoring it
– Separate the patient from the illness
• Communication skills training
• Problem-solving skills training
– Identify the precipitating life events that provoke worse symptoms
– Conduct a relapse prevention drill –> how to identify, what to do
Psychoeducation
All of the therapy approaches previously mentioned include educating the patient and their family. Because of the importance of psychoeducation, all Zamni Lasante health providers have a role in delivering psychoeducation. Psychologists and social workers will practice psychotherapy that includes psychoeducation components, while the other cadres of health workers will provide basic education around severe mental illness.
GeNeRAl messAGes TO sHARe WITH PATIeNTs AND FAmIlIes
• a patient’s symptoms can improve with treatment and they can even recover.
• it is important to continue with work, social, and school activities as much as possible.
• the patient has a right to be involved in making decisions about their treatment.
• it is important to exercise, eat healthy, and maintain good personal hygiene.
• Families should not tie up or lock up patients. instead, bring them to the clinic/hospital or ask the ChW for help/support.
• information about medication:
– it is important to take the medication regularly and not miss a dose.
– Do not double up on a dose if a dose is missed.
– it is important to continue to take medication even if symptoms improve.
– symptoms may worsen if medication is discontinued.
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PsyCHOsIs-sPeCIFIC messAGes
• Psychosis is a medical condition that is treatable.
• Psychosis is not contagious.
• Patients with psychosis are often stigmatized and mistreated.
• many patients recover from psychosis with medication and therapy and return to their normal functioning.
• the patient may hear voices or may firmly believe things that are untrue.
• the patient often does not agree that he or she is ill and may sometimes be hostile.
• if there is a return/worsening of symptoms the patient should come back for re-assessment.
• the patient should be included in family and social activities.
• Family members should avoid expressing criticism or hostility towards the patient.
• the patient may have difficulties recovering or functioning in high-stress working or living environments.
bIPOlAR-sPeCIFIC messAGes
• it is important for the patient to maintain a regular sleep cycle (e.g. going to bed at the same time every night, trying to sleep the same amount as before illness, avoiding sleeping much less than usual). Difficulty sleeping, if it is persistent, can be helped with medication.
• relapses can be prevented, by recognizing when a patient’s symptoms return, such as sleeping less, spending more money or feeling much more energetic than usual. the patient should come back for treatment when this occurs.
• a patient in a manic state can lack insight into the illness and may even enjoy the euphoria and improved energy, so carers must be part of relapse prevention.
• alcohol and other psychoactive substances should be avoided.
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CAse sTUDy 1
• gerard is a 25-year-old man with bipolar disorder. he is a patient of yours that you have seen for the past year and the physician has prescribed him carbamazepine.
• his mother, amelie, has accompanied gerard to the health center.
• amelie says that gerard stopped taking his medication a week ago. she says he has been acting “crazy.” gerard confirms that he stopped taking his medication, but says he did so to see if he was cured.
• the psychologist/social worker counsels gerard and his mother.
CAse sTUDy 2
• rose is a 21-year-old who has been accompanied to the health center by her older sister and a community health worker. rose is clearly agitated, having visual hallucinations and speaking to someone who is not there.
• the older sister tells the psychologist/social worker that for the past three days she has been like this. the older sister says that someone has put a spell on her.
• the community health worker says that rose has a fever and that rose’s mother is also sick with a fever.
• the psychologist/social worker counsels rose’s sister and community health worker about rose’s condition and the process of determining if this is a medical illness or psychiatric illness.
CAse sTUDy 3
• Jean is a 19-year-old man who is disheveled and was brought to the clinic by his brother.
• Jean’s brother explains that Jean has stopped going out with friends and refuses to leave his house. Jean hasn’t attended his university classes in a month. Jean’s brother sometimes sees Jean talking to himself.
• Jean refuses to speak to the psychologist/social worker. the psychologist/social worker shares general mental health messages with Jean and his brother.
CAse sTUDy 4
• ronald is a 55-year-old man who is brought to the clinic by his wife and son.
• ronald’s wife, Esther, explains that ronald went out last night and spent all their money. he was up all night, repeating that he was the King of haiti. she said he has had many of these types of days since they first met 25 years ago. ronald’s son is very angry that ronald has spent all their money and demands that the psychologist fixes ronald’s disturbed mind.
• the psychologist/social worker counsels Esther and her son.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Clinical Outcome Measures — CGI and WHODASEffective care is that which has been shown to improve functioning and quality of life. Effective care may be based on several different types and levels of evidence, and it reflects the best care a system can offer at any given point. To measure effective care, the Zamni Lasante system of care will use the Clinical Global Impressions Scale (known as “CGI”) and the World Health Organization Disability Assessment Schedule (known as “WHODAS”).
Clinical Global Impressions Scale (CGI)
The Clinical Global Impressions Scale (CGI) is an easily adopted tool that measures the effect of treatment over time. It is a global assessment of current symptoms, behavior, and the impact of illness on functioning. Its goal is to allow the clinician to rate the severity of illness (CGI-S), change over time (CGI-I), and efficacy of medication.
It evaluates the following elements:
• Current symptoms
• Behavior
• Impact of illness on functioning
It rates the following elements:
• Severity of illness
• Change over time
• Efficacy of medication
CGI – Severity
Psychologists/social workers determine the CGI Severity by assessing how ill the patient is at the time of interview relative to the psychologist’s /social worker’s past experience with patients who have the same diagnosis. The psychologist/social worker will judge the level of mental illness that the patient has experienced over the past 7 days.
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CAse 1
a 38-year-old, well-groomed, female patient, who is a successful professional, reports a one-month unprecipitated depressive episode that seems to be worsening. she is currently experiencing early morning awakening, loss of pleasure in her usual activities, feelings of guilt, reduced appetite, tearfulness, and depressed mood. she has found herself weeping several times over the past week, but cannot identify a reason. she is continuing to work, but found herself fighting back tears at an important meeting and believes her work may be less sharp than it had been in the past. no one has noticed, but she is concerned that the depression is worsening and may result in a significant impact on work. she is worried that she may lose her “edge.” she denies suicidal ideation. she has no previous psychiatric history.
CAse 2
a 34-year-old, male patient with a diagnosis of paranoid schizophrenia has been in treatment at Zanmi lasante for the past several years, having started medication treatment more than ten years ago after a hospitalization at mars and Kline. according to his community health worker and physician, he had been stable on his medication regimen for the past year, but recently stopped taking his medication and would not cite a reason. he attended his church twice this past week, but missed four other days which he usually would have attended. after receiving a call from a family member, the community health worker went to his home and drove him to the hospital for evaluation and possible hospitalization. the community health worker reports he has become increasingly threatening and difficult to manage at home, and has been seen responding to auditory hallucinations, including taking cover in attempts to hide from “enemies.” in the past week, he obeyed a command hallucination to “go after” a neighbor, but was physically circumvented from harming the neighbor by three community health workers, who physically restrained him. the community health worker reported that although the patient was passively cooperative about coming to the clinic, he did not speak with her at all during the trip. in the clinic office, he is guarded and suspicious. he mumbles under his breath, but refuses to elaborate as to what he has said or to whom it was directed. twice he makes a fist and raises his arm threateningly in the direction of the physician, but then puts his hand back in his lap. he appears disheveled and is not groomed; he has not changed his clothing over the past week, which his community health worker reports is a new behavior for him.
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CGI – Improvement
• At Initial Evaluation: If the patient has been in treatment previously, rate CGI-I based on the history and compared to the patient’s condition prior to treatment. Otherwise, select 0, “not assessed.”
• Follow-Up Appointment: Rate CGI-I by comparing the current condition to the patient’s condition at the initiation of the current treatment plan. Assess how much the patient’s illness has changed relative to a baseline state at the beginning of the treatment plan based on the first evaluation. Rate total improvement whether or not in your judgment it is due to treatment.
CAse 1
a patient who has been in treatment and receiving an ssri for an anxiety disorder for four months comes in for a medication check. the patient’s Cgi-s at the visit at which ssri medication was initiated (“baseline” visit) was 4 (moderate). at today’s visit, the patient reports that the anxiety symptoms have decreased considerably. the patient is now able to sleep 7 to 8 hours each night, with no initial insomnia. this represents a significant change from baseline, at which time the patient spent 2 to 3 hours each night trying to fall asleep, with a nightly total of 4 to 5 hours of fitful sleep. the patient reports having felt excessively anxious this week about running out of gas and about a burglar entering the house. the estimated time spent engaged in these anxious thoughts was less than one hour per day, compared to an estimated 3 to 4 hours per day at baseline. the patient drove over a bridge this week, which was described as somewhat difficult and fear-provoking, but manageable. at baseline, the subject was wholly avoidant of bridges, which caused him to drive 30 minutes out of his way each day to get to work.
CAse 2
the anxious patient in the previous example (Cgi-i Case 1) returns one month later. he reports that he is now afraid of leaving his house without accompaniment. this is a new development for him. he is anxious and worried all day long. he called work and told them he had the flu. in reality, he was afraid to leave his house. he has only left the house three times this week, including his visit to the clinic today, all accompanied by his wife. he felt panicky on all three occasions. although he denies any lightheadedness or other symptoms suggesting impending syncope, he reports worrying constantly about “passing out” in front of a moving car or bus. he is fearful that he will forget the name of a well-known friend or relative should they call him on the phone. he is sleeping only 1 to 2 hours a night. his wife reports that she has “never seen him so bad.” he cries in the interview and admits he has considered “ending it all” to make the pain go away.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
CGI – Side-Effects
The side-effects scale scores a patient’s level of side-effects from medication on a scale of 0 – 3. The closer the number is to zero, the better. Medication side-effects will be monitored by physicians using the Abnormal Involuntary Movements Scale (AIMS). The psychologist/social worker’s role is not to actively check or identify side-effects. Rather, the CGI Side-Effects scale is simply used to serve as an additional tracking tool, and to double-check what the physician has found in his AIMS evaluation.
World Health Organization Disability Assessment Schedule
The WHODAS is another tool that psychologists/social workers will use to track patients’ progress over time. There are six domains of functioning in the WHODAS that will be discussed with the patient and then recorded.
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WHODAs ROle PlAy
Psychologist/social Worker: “i now want to ask you a few questions. the interview is about difficulties people have because of health conditions. By health condition i mean diseases or illnesses, or other health problems that may be short or long lasting; injuries; mental or emotional problems; and problems with alcohol or drugs. Do you understand what i mean by health condition?”
Patient: “Yes.”
Psychologist/social Worker: “remember to keep all of your health problems in mind as you answer the questions. When i ask you about difficulties in doing an activity think about: increased effort, discomfort or pain, slowness, changes in the way you do the activity. When answering, i’d like you to think back over the past 30 days.”
Patient: “OK.”
Psychologist/social Worker: “i would also like you to answer these questions thinking about how much difficulty you have had, on average, over the past 30 days, while doing the activity as you usually do it. use this scale when responding: none, mild, moderate, severe, extreme or cannot do.”
Patient: “OK.”
Psychologist/social Worker: “in the past 30 days, how much difficulty did you have in: standing for long periods such as 30 minutes?”
Patient: “i am always standing.”
Psychologist/social Worker:
1.
(What should you say to the patient to obtain an answer of none, mild, moderate, severe, extreme or cannot do?)
Patient: “i did not have any difficulty.”
2. how would you record this answer on the WhODas scale? Which category would you circle?
a. none
b. mild
c. moderate
d. severe
e. Extreme or cannot do
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WHODAs ROle PlAy (continued)
Psychologist/social Worker: “in the past 30 days, how much difficulty did you have in: taking care of your household responsibilities?”
Patient: “What type of household responsibilities?”
Psychologist/social Worker:
3.
(What should you say to the patient to clarify what you mean?)
Patient: “i had no difficulty.”
Psychologist/social Worker: “in the past 30 days, how much difficulty did you have in: learning a new task, for example learning how to get to a new place?”
Patient: “i haven’t learned any new tasks.”
Psychologist/social Worker:
4.
(What should you say to the patient to probe about whether this question is not applicable?)
Psychologist/social Worker: “in the past 30 days, how much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?”
Patient: “i always go to church but i don’t like going to other community activities.”
Psychologist/social Worker:
5.
(What should you say to the patient to obtain an answer of none, mild, moderate, severe, extreme or cannot do? Remind the patient these questions are based on his health status.)
Patient: “i can go to everything — it’s just that i don’t want to. i suppose my answer is none.”
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WHODAs ROle PlAy (continued)
Psychologist/social Worker: “in the past 30 days, how many days were these difficulties present?”
Patient: “Oh, i don’t know. i can’t say.”
Psychologist/social Worker:
6.
(What should you say to the patient to obtain the number of days?)
Patient: “i guess i could estimate that four days a month these difficulties were present.”
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Follow-Up and DocumentationThe Psychosis Care Pathway only works with functional follow-up and documentation.
Patients should be seen for follow-up appointments every one-to-two weeks if their symptoms are acute or if medications are being started, adjusted or stopped. Patients with psychosis whose symptoms are stable can be seen once a month or once every three months.
Follow Up Chart
HOW TO DeTeRmINe A PATIeNT’s ImPROvemeNT IN symPTOms
WHy Is DOCUmeNTATION ImPORTANT?
•
•
•
•
•
•
•
•
•
•
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Using mhGAP for Psychosis and Bipolar DisorderThe mhGAP Intervention Guide is a document developed by the World Health Organization that outlines the diagnosis and management of various mental health disorders. It is designed to serve as a guide for clinicians around the world. It is an important resource to help guide decision-making for non-specialist providers such as physicians. The effective training of non-specialists is how the global treatment gap will be narrowed.
The mhGAP chapters on psychosis and bipolar disorder can be used to guide assessment and management of all these different disorders. mhGAP organizes psychotic disorders separately from bipolar disorder because bipolar disorder is considered a mood disorder. However, both bipolar disorder and depression can have psychotic features.
Questions to Ask about Psychosis
Sometimes it is not obvious what symptoms a patient may have. By asking these questions, the physician may be able to better determine if a patient has psychotic features.
• “Have you ever heard voices, even when nobody is present? Do you currently hear voices? Are you bothered or harassed by these voices? What did the voices tell you? Can other people hear the voices too? Do you think that I can hear them?”
• “Have you ever seen things that may not actually be present?”
• “Have you ever felt that your mind or body was being secretly controlled or somehow controlled against your will?”
• “Have you ever felt that others wanted to hurt you or really get you for some special reason, maybe because you had secret or special powers of some sort?”
Determining Chronic vs. Acute Psychosis
By asking the patient or carer about the onset of the psychotic episode and any prior episodes, participants will be able to determine if the person has acute psychosis or chronic psychosis. This is important because it can have an impact on the duration of treatment with antipsychotic medication. For acute psychosis, the provider will want to stop the medication at some point to see if the patient can recover without the medication. Medication can have potentially significant side-effects, and we want to minimize the use of medication as much as possible.
the red box in the middle of page 18 in mhgaP emphasizes the importance of ruling out medical delirium before prescribing any medication to someone with acute psychosis — just as you learned about earlier during this training.
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
Self-Harm and Suicide
During your work with depressed patients, epileptic patients and psychotic patients, you might come across a patient that has self-injurious behavior or suicidal ideation. It is critical to assess safety and risk of suicide for all patients for whom there is a mental health concern. By asking someone if they are thinking about hurting or killing themselves, psychologists/social workers will not increase the risk of the patient doing so. Asking about thoughts of self-harm is an important responsibility of every provider: physician, nurse, community health worker, social worker and psychologist. For the physician assessing a patient for self-harm, mhGAP can assist the physician to take the appropriate next steps.
No matter the condition of the patient, it is important not to leave the patient alone. Self-harm and suicide can be attempted by anyone who might have mental health issues, including depression, epilepsy, psychosis and bipolar disorder.
Supplementary Resources
mhGAP Intervention Guide http://www.who.int/mental_health/publications/mhGAP_intervention_guide/en/
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Review: Case Studies
CAse sTUDy 1
a 40-year-old woman is brought into the health facility by her two sons. she is barely able to walk and is clearly confused. she cannot follow simple commands. her sons said she has been fatigued and feverish for the past few days. the patient is mildly agitated, clearly frustrated with her sons. You, the nurse and the physician are available to evaluate and manage the patient.
1. What would you do with the nurse to manage the patient’s agitation? What form would you use to guide you?
2. How would you support the physician in evaluating the agitated patient? What forms would you help the physician manage during the medical evaluation?
the physician has concluded that the patient likely needs further neurological testing to determine if the patient has a neurological problem. the patient also has a confirmed fever above 38 C. the two sons said that they are sad that she is now “crazy” and want to know how you can cure her.
3. What would you say to the two sons?
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CAse sTUDy 2
a 27-year-old man, Pierre, is brought into the health center by two community health workers. he is yelling that the community health workers are trying to kill him. he lunges at anyone who tries to get close to him, screaming that he will kill everyone.
1. Is this patient agitated. What level of agitation does the patient have?
2. What do you do to manage the behavior and environment? Who do you collaborate with?
3. What forms would you use to assist you to manage this agitated patient?
after a few minutes of speaking calmly with the patient you leave the room, and identify someone to keep an eye on the patient to ensure his safety and that of others (1:1). You have been able to calm the patient without giving any medications and the physician has done an initial medical evaluation. the patient denies wanting to hurt himself or others. his lab tests have come back normal and the physician says he is not suffering from medical delirium.
4. What would you do next? What forms would you be utilizing to guide your work?
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CAse sTUDy 2 (continued)
You see the patient for an initial mental health evaluation and the patient reports that he has been hearing voices that tell him that everyone wants to kill him. he is disheveled and it is apparent he has not bathed in many days. You ask the community health workers about the patient, and they say that he is typically locked in the house by his family. however, the community health workers were able to convince the family to let him come to the health facility. the community health workers say the patient has been this way for a few years. You are unable to get further information from the patient as his speech is disorganized and tangential.
5. What diagnosis would you give the patient? Why? Where would you record the diagnosis?
6. What clinical formulation would you record on the Initial mental Health evaluation Form?
7. What type of psychotherapy would you consider beginning with the patient during the next visit? Why?
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Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers
CAse sTUDy 2 (continued)
8. After diagnosis, how would you collaborate with the physician that day?
9. What would be the follow-up plan for this patient? What other providers would you include, and what would their role be?
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CAse sTUDy 3
this past year you began seeing a young, 18-year-old woman with a recent episode of psychosis. she was prescribed risperidone. today during her monthly follow-up visit, approximately 8 months since the initiation of medication, you notice that she appears restless, frequently wringing her hands and looking upset.
1. What forms will you use or complete during your follow-up visit?
During her appointment, when you ask her how things are going, she begins to cry and tells you that things are not going well. she recently broke up with her boyfriend and cannot find a job to support herself.
2. How would you counsel her? What are some key messages you would give her during this time of stress?
You are worried that this stress could trigger a relapse.
3. How would you collaborate with other providers to ensures she is adherent to her medication and has social support during this time of stress?
59Partners In Health | PartiCiPant hanDBOOK | ANNEx
NOTes
60 Partners In Health | PartiCiPant hanDBOOK | ANNEx
Annex
61Partners In Health | PartiCiPant hanDBOOK | ANNEx
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62 Partners In Health | PartiCiPant hanDBOOK | ANNEx
1
DIFFeReNTIAl D IAGNOsIs INFORmATION sHeeT FOR seveRe meNTAl D IsORDeRs
CONDITION symPTOms DIAGNOsTIC HINTs GeNeRAl mANAGemeNT
medical symptoms or Psychosis Caused by medical Conditions
Delirium new onset abnormal mental status •abnormal physical exam, vital signs or laboratory studies
•abnormal mental status examination
•seek medical source of illness
•Follow medical Evaluation Protocol for agitation, Delirium and PsychosisPsychotic Disorder
Due to a general medical Condition
Psychosis is the direct physiological consequence of a medical condition
•Psychotic symptoms
•Evidence of a contributing medical illness
substance-induced Psychotic Disorder
Prominent hallucinations or delusions •Evidence of recent substance intoxication or withdrawal
Post-Partum Psychosis
new onset psychosis in a female following childbirth
•recent childbirth
mental Health Related symptoms that are not Psychosis
transient hallucinations
anomalous experiences, may occur in a person in a state of good mental and physical health, even in the apparent absence of a trigger (stress, fatigue, intoxication, etc.)
•Common in children and youth
•Ensure safety of patient: assess for self-harm
•seek to understand patient’s explanatory model, and to assess internal level of distress
•Obtain Biopsychosocial history
• identify potential stressors
•Consult traditional healer if currently involved in management
acute stress, anxiety, and trauma-related problems
stress and traumatic experiences can result in unusual sensory and perceptual experiences that can mimic psychosis
•significant trauma history
Conversion Disorder usually in response to stress, a person can develop blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation
• identification of stressor
•Poor insight into emotional stressors
Obsessive-compulsive disorder
Excessive thoughts (obsessions) that can lead to repetitive behaviors (compulsions), with a potential component of disordered thinking
•specific area of focus
autism spectrum disorders
a serious developmental disorder that impairs the ability to communicate and interact
•longstanding history of unstable interpersonal relationships
Personality Disorder a deeply ingrained and maladaptive pattern of behavior of a specified kind, typically manifest by the time one reaches adolescence and causing long-term difficulties in personal relationships or in functioning in society
•longstanding history of unstable interpersonal relationships
•Poor insight
63Partners In Health | PartiCiPant hanDBOOK | ANNEx
2
CONDITION symPTOms DIAGNOsTIC HINTs GeNeRAl mANAGemeNT
episodic Psychosis or mania
Depression with psychotic features (mood Disorder, depressed)
a primary depression with psychotic symptoms. •Depressive symptoms before psychotic symptoms
•Ensure safety of patient: assess for self-harm
•seek to understand patient’s explanatory model, and to assess internal level of distress
•Obtain Biopsychosocial history
• identify potential stressors
•Consult traditional healer if currently involved in management
•Consider co-morbid mental health diagnoses.
•Both depression and psychosis are treated with distinct medications
•antidepressant medications (fluoxetine, amitryptiline) can cause mania in a person with Bipolar Disorder
Bipolar Disorder (mood Disorder, manic or depressed)
marked by alternating periods of elation and depression; some develop mania without depression, others can develop hypomania with depression
•Period of mania, or hypomania with depression
Brief psychotic disorder (less than one month)
a sudden, short-term episode of psychotic thinking and behavior which occurs with a stressful event; can be informed by social and cultural factors
•Person returns to functioning
schizophreniform Disorder (schizophrenia symptoms 1-6 months)
symptoms of schizophrenia are present for a significant portion of the time within a 1-month period, but signs of disruption are not present for the full six months required for the diagnosis of schizophrenia
•Do not make diagnosis of schizophrenia if symptoms are less than 6 months
Psychosis not Otherwise specified (nOs)
Psychotic symptoms about which there is inadequate information to make a diagnosis
•Examples include: psychosis of a few days or weeks duration, post-partum psychosis, and situations in which diagnosis is unclear
Differential Diagnosis Information sheet For severe mental Disorders (Continued)
64 Partners In Health | PartiCiPant hanDBOOK | ANNEx
3
CONDITION symPTOms DIAGNOsTIC HINTs GeNeRAl mANAGemeNT
Continous Psychosis
schizophrenia (greater than 6 months)
Dsm 5 criteria1
two (or more) of the following, each present for a significant portion of time during a 1-month period. at least one of these must be (1), (2), or (3):
1. Delusions2. hallucinations3. Disorganized speech 4. grossly disorganized or catatonic behavior5. negative symptoms, i.e., affective flattening, alogia, or avolition
Note: Only one of the above symptoms is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts or two or more voices are conversing with each other
social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning, such as work, interpersonal relations, or self-care, are markedly below the level achieved before the onset.
Duration: Continuous signs of the disturbance persist for at least 6 months. this 6-month period must include at least 1 month of symptoms and may include periods of prodromal or residual symptoms.
exclusions:
•schizoaffective and mood disorder exclusion
•substance/general medical condition exclusion
•Pervasive developmental disorder- the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least a month
•Consider age at onset
•Consider prodromal period before onset of initial symptoms
•Ensure safety of patient: assess for self-harm
•seek to understand patient’s explanatory model, and to assess internal level of distress
•Obtain Biopsychosocial history
• identify potential stressors
•take conservative approach to medication
•Consult traditional healer if currently involved in management
•Consider co-morbid mental health diagnoses
Delusional disorder (plausible, circumscribed delusions)
associated with one or more nonbizarre delusions of thinking such as expressing beliefs that can occur in real life, provided no other symptoms of schizophrenia are present
•Delusion is usually realistic
1 Dsm-5 Diagnostic criteria for schizophrenia. american Psychiatric association: Diagnostic and statistical manual of mental disorders, fifth edition, Washington, DC, 2013, american Psychiatric association.
Differential Diagnosis Information sheet For severe mental Disorders (Continued)
65Partners In Health | PartiCiPant hanDBOOK | ANNEx 65
AG
ITA
TIO
N,
De
lIR
IUm
AN
D P
sy
CH
Os
Is C
He
Ck
lIs
T
Dat
e __
____
____
____
____
____
____
dd
/mm
/yy
CH
WP
SYC
HO
LO
GIS
T/S
OC
IAL
WO
RK
ER
NU
RS
ES
PH
YS
ICIA
N
AG
ITA
TeD
PA
TIeN
T
q
acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
imm
edia
tely
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
q
if s
uici
dal/
viol
ent,
acc
ompa
ny
patie
nt a
nd f
amily
to
the
clin
ic
imm
edia
tely
q
Dec
reas
e ris
k an
d re
info
rce
safe
ty
if ris
k fo
r su
icid
e or
vio
lenc
e
q
Com
plet
e th
e in
itial
Vis
it Fo
rm
q
use
the
ZlD
si
q
Do
psyc
hoed
ucat
ion
q
giv
e th
e r
efer
ral F
orm
and
initi
al
Vis
it Fo
rm t
o ps
ycho
logi
st/s
W
FOll
OW
-UP
q
if s
uici
dal/
viol
ent,
acc
ompa
ny
patie
nt a
nd f
amily
to
the
clin
ic
imm
edia
tely
q
Dec
reas
e ris
k an
d re
info
rce
safe
ty
if ris
k fo
r su
icid
e or
vio
lenc
e
q
Doc
umen
t w
ith t
he m
enta
l h
ealth
Fol
low
-up
Form
q
use
the
ZlD
si
q
Do
psyc
hoed
ucat
ion
q
giv
e th
e r
efer
ral F
orm
and
initi
al
Vis
it Fo
rm t
o ps
ycho
logi
st/s
W
q
Do
follo
w-u
p of
pat
ient
in
the
com
mun
ity (
chec
k pa
tient
ad
here
nce,
sid
e ef
fect
s,
enco
urag
e pa
tient
s to
do
fo
llow
-ups
)
AG
ITA
TeD
PA
TIeN
T
q
acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
q
ref
er t
o th
e a
gita
ted
Patie
nt P
roto
col;
supp
ort
nurs
e an
d ph
ysic
ian
q
Col
lect
info
rmat
ion
from
pat
ient
and
fam
ily
q
arr
ange
1:1
if n
eede
d
q
rem
ain
at b
edsi
de u
ntil
patie
nt is
sta
ble
q
Follo
w p
atie
nt 2
x/da
y, g
ive
phon
e nu
mbe
r to
pat
ient
’s fa
mily
& n
urse
/phy
sici
an
q
usi
ng a
gita
tion,
Del
irium
and
Psy
chos
is C
heck
list,
ens
ure
med
icat
ions
giv
en a
nd
med
ical
car
e pr
ovid
ed b
y nu
rse/
mD
q
giv
e pa
tient
/fam
ily p
sych
oedu
catio
n an
d su
ppor
t
q
ass
ess
& m
anag
e so
cioe
cono
mic
bur
den
of il
lnes
s
q
Proc
eed
to in
itial
eva
luat
ion
(onc
e ca
lm)
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
q
Com
plet
e Ps
ycho
sis
Che
cklis
t w
ith C
hW
/nur
se
q
Com
plet
e Zl
Dsi
q
Doc
umen
t in
initi
al m
enta
l hea
lth E
valu
atio
n Fo
rm
q
spea
k w
ith p
atie
nt a
nd t
WO
fam
ily m
embe
rs &
rev
iew
phy
sici
an’s
agi
tate
d Pa
tient
For
m t
o co
mpl
ete
initi
al m
enta
l hea
lth e
valu
atio
n
q
Ensu
re v
itals
, wei
ght,
and
labs
are
che
cked
q
acc
ompa
ny p
atie
nt t
o se
e ph
ysic
ian
(see
s al
l psy
chot
ic, s
uici
dal,
viol
ent
case
s)
q
hel
p ph
ysic
ian
follo
w c
heck
list
q
mak
e pr
elim
inar
y di
agno
sis
of d
eliri
um/m
edic
al il
lnes
s or
men
tal i
llnes
s w
ith
the
phys
icia
n
q
if p
atie
nt n
eeds
med
ical
car
e, c
oord
inat
e w
ith p
hysi
cian
s, if
pat
ient
has
ps
ycho
tic d
isor
der,
sche
dule
fol
low
-up
with
in o
ne w
eek
q
Do
psyc
hoed
ucat
ion
and
supp
ort
rela
ted
to m
edic
atio
n an
d ps
ycho
sis
q
Com
plet
e C
gi/
Wh
OD
as,
reg
istr
y, C
heck
list
FOll
OW
-UP
q
use
men
tal h
ealth
Fol
low
-up
Form
q
see
whe
ther
pat
ient
is im
prov
ing
(che
ck m
enta
l sta
tus
exam
, fun
ctio
ning
, pa
tient
and
fam
ily r
epor
t)
q
Che
ck m
edic
atio
n co
mpl
ianc
e, s
ide
effe
cts
q
Ensu
re v
itals
, wei
ght,
and
labs
are
che
cked
q
acc
ompa
ny p
atie
nt t
o se
e ph
ysic
ian;
hel
p ph
ysic
ian
follo
w a
gita
tion,
Del
irium
an
d Ps
ycho
sis
Che
cklis
t
q
Plan
fol
low
-up
for
1– 2
wee
ks; c
oord
inat
e w
ith C
hW
q
Do
psyc
hoed
ucat
ion
and
supp
ort
for
med
icat
ion
and
psyc
hosi
s
q
Com
plet
e C
gi/
Wh
OD
as,
reg
istr
y, a
gita
tion,
Del
irium
and
Psy
chos
is C
heck
list
AG
ITA
TeD
PA
TIeN
T
q
ale
rt e
ither
psy
chol
ogis
t/so
cial
w
orke
r
q
acc
ompa
ny p
atie
nt t
o em
erge
ncy
room
q
ref
er t
o a
gita
ted
Patie
nt
Prot
ocol
q
man
age
envi
ronm
ent
q
talk
to
patie
nt; s
uppo
rt f
amily
q
Do
vita
l sig
ns a
saP
q
Prep
are
oral
and
im m
edic
atio
ns
if ne
eded
q
arr
ange
1:1
if n
eede
d
q
mon
itor
antip
sych
otic
sid
e ef
fect
s, r
epor
t to
phy
sici
an
q
Con
tinue
to
follo
w p
atie
nt c
lose
ly
(at
leas
t ev
ery
15 m
in c
heck
)
q
ass
ist d
octo
r in
med
ical
eva
luat
ion
and
care
(vi
tal s
igns
, lab
tes
ts,
EKg
, flui
ds)
q
Prov
ide
psyc
hoed
ucat
ion
and
supp
ort
to p
atie
nt a
nd f
amily
q
Doc
umen
t al
l wor
k in
nur
sing
fo
rms
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
q
Det
erm
ine
whe
ther
pat
ient
may
be
psy
chot
ic
q
acc
ompa
ny p
atie
nt t
o se
e ps
ycho
logi
st/s
W; s
uppo
rt
colla
bora
tion
with
phy
sici
an
q
if p
sych
osis
is d
iagn
osed
, pro
vide
ps
ycho
educ
atio
n an
d su
ppor
t
q
Befo
re d
isch
arge
, ens
ure
the
patie
nt h
as a
fol
low
-up
appt
with
ps
ycho
logi
st/s
W
FOll
OW
-UP
q
Do
vita
l sig
ns, w
eigh
t at
eac
h vi
sit
q
Che
ck la
bs w
hen
nece
ssar
y
q
Doc
umen
t in
men
tal h
ealth
Fo
llow
-up
Form
AG
ITA
TeD
PA
TIeN
T
q
ale
rt e
ither
psy
chol
ogis
t/so
cial
wor
ker
q
Follo
w a
gita
ted
Patie
nt P
roto
col t
o de
term
ine
leve
l of
agita
tion
and
to p
resc
ribe
med
icat
ion
if ne
cess
ary
q
Con
tinue
med
ical
eva
luat
ion:
phy
sica
l/ne
uro
exam
, vita
l sig
ns, l
ab t
ests
q
use
med
icat
ion
Car
d to
mon
itor
antip
sych
otic
si
de e
ffec
ts (
cons
ider
EK
g, fl
uids
)
q
Doc
umen
t in
agi
tate
d Pa
tient
For
m
INIT
IAl
evA
lUA
TIO
N (
ON
Ce
CA
lm)
q
rev
iew
initi
al m
enta
l hea
lth E
valu
atio
n
Form
with
psy
chol
ogis
t/sW
to
diag
nose
de
liriu
m/m
edic
al il
lnes
s or
men
tal d
isor
der
q
Do
com
plet
e m
edic
al e
valu
atio
n: v
ital s
igns
, ph
ysic
al/n
euro
exa
m, l
ab t
ests
. use
med
ical
Ev
alua
tion
Prot
ocol
for
agi
tatio
n, D
eliri
um
and
Psyc
hosi
s
q
if p
atie
nt h
as a
psy
chot
ic d
isor
der
or d
eliri
um,
use
med
icat
ion
Car
d to
dos
e
q
Do
base
line
aim
s ex
am
q
Doc
umen
t ev
eryt
hing
in in
itial
men
tal h
ealth
Ev
alua
tion
Form
q
Prov
ide
med
icat
ion
to la
st u
ntil
next
app
t
q
Do
psyc
hoed
ucat
ion
abou
t m
edic
atio
n
q
Plan
fol
low
-up
with
psy
chol
ogis
t/sW
FOll
OW
-UP
q
rev
iew
the
men
tal h
ealth
Fol
low
-up
Form
with
ps
ycho
logi
st/s
W t
o se
e if
patie
nt is
impr
ovin
g
q
Do
phys
ical
/neu
ro e
xam
q
Che
ck w
eigh
t/vi
tals
eac
h vi
sit;
lab
test
s an
d a
ims
ever
y 6
mon
ths
q
use
med
icat
ion
Car
d to
che
ck f
or s
ide
effe
cts
and
to a
djus
t do
se a
s ne
eded
q
Prov
ide
med
icat
ion
to la
st u
ntil
next
app
t
q
Dis
cuss
dis
cont
inua
tion
of a
ntip
sych
otic
with
m
enta
l hea
lth t
eam
q
Doc
umen
t pr
oper
ly in
men
tal h
ealth
Fo
llow
-up
Form
q
Do
psyc
hoed
ucat
ion
abou
t m
edic
atio
n
q
Plan
fol
low
-up
with
psy
chol
ogis
t/sW
P
66 Partners In Health | PartiCiPant hanDBOOK | ANNEx
AG
ITA
Te
D P
AT
IeN
T P
RO
TO
CO
l
THR
OU
GH
OU
T v
IsIT
: Ass
essm
ent
•R
eFeR
to
Med
ical
Eva
luat
ion
Prot
ocol
s
for
Agi
tati
on, D
elir
ium
and
Psy
chos
is
•R
eCO
RD
on
Agi
tati
on, D
elir
ium
and
Psyc
hosi
s Fo
rm
sAFe
Ty F
IRsT
!
•D
o no
t se
e th
e pa
tient
alo
ne
(ask
for
sec
urity
). r
emai
n
calm
. rem
embe
r th
at p
atie
nts
do n
ot s
udde
nly
beco
me
viol
ent;
the
ir be
havi
or o
ccur
s
alon
g a
spec
trum
.
•m
aint
ain
safe
phy
sica
l dis
tanc
e
from
pat
ient
. Do
not
allo
w
exit
to b
e bl
ocke
d. K
eep
larg
e
furn
iture
bet
wee
n yo
u an
d
patie
nt.
•r
emov
e al
l obj
ects
tha
t ca
n
be u
sed
to h
arm
(ne
edle
s,
shar
p ob
ject
s, o
ther
sm
all
obje
cts)
. Che
ck w
heth
er
patie
nt h
as a
his
tory
of
viol
ence
or
subs
tanc
e ab
use.
•ta
lkin
g to
pat
ient
is s
afe
and
effe
ctiv
e. D
o no
t ye
ll. K
eep
your
voi
ce c
alm
, qui
et, a
nd
frie
ndly
.
•m
ake
eye
cont
act
to s
how
you
care
abo
ut t
he p
atie
nt.
show
sym
path
y an
d em
path
y
(“i u
nder
stan
d yo
u ar
e sc
ared
,
but
i am
her
e to
hel
p. i
will
not
hurt
you
.”)
sTeP
1:
Det
erm
ine
leve
l of
agi
tati
on b
y ob
serv
ing
pati
ent
beha
vior
sTeP
2:
man
age
agit
atio
n
Rem
embe
r:
•sa
fety
: tal
k fir
st, d
o no
t m
edic
ate
first
•m
edic
al H
ealt
h: v
ital s
igns
, phy
sica
l exa
m,
men
tal s
tatu
s, e
xam
to
asse
ss f
or d
eliri
um, l
abs
and
stud
ies
•m
enta
l Hea
lth:
tak
e hi
stor
y
•Fo
llow
-Up:
con
tact
psy
chol
ogis
t/so
cial
wor
ker
mIl
D A
gita
tion
q
wrin
ging
/tap
ping
of
hand
s
q
paci
ng, m
ovin
g re
stle
ssly
q
freq
uent
req
uest
s/de
man
ds
q
loud
or
rapi
d sp
eech
q
low
fru
stra
tion
tole
ranc
e
1. m
anag
e b
ehav
ior/
envi
ronm
ent
q
use
cal
m v
oice
, sim
ple
lang
uage
,
soft
voi
ce, s
low
mov
emen
ts
q
ask
“h
ow c
an i
help
?” a
nd
prob
lem
sol
ve w
ith p
atie
nt;
be e
mpa
thic
q
rem
ove
pote
ntia
lly h
arm
ful
obje
cts
from
are
a
q
ask
abo
ut h
unge
r/th
irst
q
Dec
reas
e st
imul
atio
n/ar
rang
e 1:
1
q
Off
er v
erba
l sup
port
and
unde
rsta
ndin
g
q
allo
w t
he p
atie
nt t
o sh
ow
ange
r/fr
ustr
atio
n
q
Cal
m s
taff
q
if a
gita
tion
due
to d
eliri
um,
cons
ider
hal
dol 1
– 2
mg
PO;
not
in e
lder
ly
1. m
anag
e b
ehav
ior/
envi
ronm
ent
2. C
onsi
der
OR
Al
med
icat
ions
q
Off
er P
O m
edic
atio
ns fi
rst
if
(hal
dol 5
mg
+ d
iphe
nhyd
ram
ine
50 m
g O
r D
iaze
pam
10
mg)
q
if p
atie
nt r
efus
es P
O, g
ive
im
med
icat
ions
(h
aldo
l 5 m
g +
diph
enhy
dram
ine
25 m
g O
r
Dia
zepa
m 1
0 m
g)
q
Wai
t 30
min
utes
; if
patie
nt
rem
ains
agi
tate
d, c
an g
ive
½ t
he
orig
inal
dos
e
q
use
med
icat
ion
Car
d to
mon
itor
side
eff
ects
1. m
anag
e b
ehav
ior/
envi
ronm
ent
2. C
onsi
der
OR
Al
med
icat
ions
3. C
onsi
der
INTR
Am
UsC
UlA
R
med
icat
ions
q
hal
dol 5
–10
mg
im +
diph
enhy
dram
ine
25 m
g im
Or
dia
zepa
m 1
0 m
g im
q
Wai
t 30
min
utes
; if
patie
nt
rem
ains
agi
tate
d, c
an r
e-do
se
with
½ t
he o
rigin
al d
ose
q
use
med
icat
ion
Car
d to
mon
itor
side
eff
ects
q
Deb
rief
with
sta
ff
q
Con
sult
men
tal h
ealth
tea
m if
etio
logy
is p
sych
iatr
ic
mO
DeR
ATe
Agi
tati
on q
verb
al t
hrea
ts
q
yelli
ng/c
ursi
ng
q
does
not
res
pond
to
verb
al
redi
rect
ion
q
does
not
res
pond
to
incr
ease
d
staf
f pr
esen
ce
sev
eRe
Agi
tati
on q
dest
royi
ng p
rope
rty
q
phys
ical
agg
ress
ion
(e.g
.,
hitt
ing,
kic
king
, biti
ng)
q
self-
inju
rious
beh
avio
r (e
.g.,
bitin
g ha
nd, h
ead
bang
ing)
67Partners In Health | PartiCiPant hanDBOOK | ANNEx
AGITATION, Del IR IUm AND PsyCHOsIs FORm
1. sAFeTy (Use AGITATeD PATIeNT PROTOCOl)
Patient is: q not agitated (But appears psychotic) q agitated (mild) q aggressive (moderate) q Violent (severe)
History of violence: q no q Yes: Describe violent behavior ________________________________________________________________ When did it take place:__________________________________________________________________
q manage Behavior/Environment Completed Does patient need a 1:1? q no q Yes:___________
2. meDICAl HeAlTH (Use meDICAl evAlUATION PROTOCOl)
Vital signs: temp:______ Pulse:______ BP:______ rr:______ O2:______ Weight:______
Physical exam Neurological exam
hEEnt: q normal q abnormal:___________ Cranial nerves: q normal q abnormal:___________
Cardiac: q normal q abnormal:___________ motor strength: q normal q abnormal:___________
Pulmonary: q normal q abnormal:___________ sensory: q normal q abnormal:___________
abdominal: q normal q abnormal:___________ reflexes: q normal q abnormal:___________
skin/Extremities: q normal q abnormal:___________ gait/Coordination: q normal q abnormal:___________
mental status exam laboratory Tests Ordered
q alert q sleepy q unable to arouse q hemogram q CD4 q hepatic Panel
thought Process: q normal q Confused:___________ q rPr q tB q renal Panel
Can Follow simple Commands: q no q Yes q hiV q urinalysis q malaria
hallucinations: q no q Yes:__________ Family History of mental Illness: q no q Yes
Orientation: Person q no q Yes medical History: q hiV/aiDs (CD4:_____) q tB
Place q no q Yes q htn q head injury (with loss of consciousness)
time/Date q no q Yes q Epilepsy q Dementia q Other:___________
Friend/Family member q no q Yes Alcohol Use: q no q Yes: q Daily?
Current medications (names and doses):___________________________ Drug Use: q no q Yes:___________
Delirium
q Disturbance of consciousness with reduced ability to focus, sustain or shift attention.
q a change in cognition or the development of a perceptual disturbance (hallucinations) that is not better accounted for by a preexisting, established or evolving dementia.
q the disturbance develops over a short period of time (usually hours to days) and fluctuates during the day
q there is evidence from the history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.
q no q Yes (Patient must meet all four criteria above to make diagnosis)
3. meNTAl HeAlTH
History of mental illness: q no q Yes:___________________________________________________________________________________
Has the patient gone to m&k/beudet/other psych facility? q no q Yes:_____________________________
Is this the first episode of agitation? q no q Yes:_______________ History of suicide attempt: q no q Yes:__________________
Post-Ictal Psychosis: q no q Yes (episodes of agitation/psychosis only take place after epileptic seizure)Antipsychotic medication (Use Agitated Patient Protocol; give dose and indicate whether PO/Im):
q risperidone:_______________ q haloperidol:_______________ q Other: Diphenhydramine:_______________
4. FOllOWUP
q Psychologist contacted about patient
Presumed Etiology of agitation/Psychosis: q medical Problem/Delirium: _______________ q mental health Problem:_______________
has haloperidol been given?: q no q Yes q Fluids ordered/given q EKg ordered/done
notes: _________________________________________________________________________________________________________________
Patient Name:________________________ sex:____ Phone:_____________ Provider:_________________ Date: dd/mm/yy
68 Partners In Health | PartiCiPant hanDBOOK | ANNEx
1
me
DIC
AT
ION
CA
RD
FO
R A
GIT
AT
ION
, D
el
IRIU
m,
AN
D P
sy
CH
Os
Is
RIs
PeR
IDO
Ne
HA
lOPe
RID
Ol
DIA
ZePA
mC
AR
bA
mA
ZePI
Ne
vA
lPR
OA
Te
1st
Cho
ice:
“A
typi
cal”
Ant
ipsy
chot
ic/M
ood
stab
ilize
r
Use
for
: Psy
chos
is (
wit
h or
wit
hout
man
ia)
2nd
Cho
ice:
“Ty
pica
l”
Ant
ipsy
chot
ic/M
ood
stab
ilize
r
Use
for
: Agg
ress
ive
or v
iole
nt
psyc
hosi
s (w
ith
or w
itho
ut m
ania
)
Ben
zodi
azep
ine
Use
for
: Alc
ohol
wit
hdra
wal
,
acut
e ag
itat
ion
wit
h or
wit
hout
ant
i-ps
ycho
tic
3rd
Cho
ice:
Moo
d st
abili
zer
Do
not
pres
crib
e w
itho
ut
cons
ulti
ng m
enta
l hea
lth
team
Use
for
: man
ia w
itho
ut
psyc
hosi
s
4th
choi
ce: M
ood
stab
ilize
r
Do
not
pres
crib
e w
itho
ut
cons
ulti
ng m
enta
l hea
lth
team
Use
for
: man
ia w
itho
ut
psyc
hosi
s (l
ongs
tand
ing
aggr
essi
on o
r vi
olen
ce in
mal
es)
DO
NO
T U
se IF
•C
autio
n if
child
/ado
lesc
ent
•Pr
ior
hist
ory
of d
ysto
nia
on
antip
sych
otic
med
icat
ion
•C
hild
ren
(18
or y
oung
er)
•Pa
tient
is d
eliri
ous
•Pr
egna
nt/b
reas
tfee
ding
wom
en
•C
hild
ren
(18
or y
oung
er)
•El
derly
(65
or
olde
r)
•Bl
ood
diso
rder
•Ep
ileps
y: a
bsen
ce s
eizu
res
•C
autio
n if
child
•W
omen
of
child
-bea
ring
age/
preg
nant
wom
en
•li
ver
dise
ase
•C
autio
n if
child
mU
sT C
ON
sUlT
m
eNTA
l H
eAlT
H
TeA
m
•Fo
r ps
ycho
sis
due
to d
emen
tia
(incr
ease
d ris
k of
dea
th)
•C
hild
ren
18 o
r yo
unge
r
•Pr
egna
nt w
omen
•Fo
r ps
ycho
sis
due
to d
emen
tia
(incr
ease
d ris
k of
dea
th)
•Pr
egna
nt w
omen
•Fo
r tr
eatm
ent
of a
ll m
enta
l
illne
ss (
excl
udin
g ep
ileps
y)
•Pr
egna
nt o
r br
east
feed
ing
wom
en
•Fo
r tr
eatm
ent
of a
ll m
enta
l
illne
ss (
excl
udin
g ep
ileps
y)
star
ting
Dos
e (A
dult
)Ta
ke a
t ni
ght
due
to s
edat
ive
effe
cts
•Bi
pola
r/Ps
ycho
sis
– 0.
5 – 1
mg
•D
eliri
um –
0.2
5 –
0.5
mg
Take
at
nigh
t du
e to
sed
ativ
e ef
fect
s
•Bi
pola
r/Ps
ycho
sis
mod
erat
e sx
s: 0
.5 –
2.5
mg
seve
re s
xs: 2
.5 –
5 m
g
•a
lway
s pr
escr
ibe
diph
enhy
dram
ine
25 –
50
mg
daily
with
hal
oper
idol
•D
eliri
um: 0
.5 –
2.5
mg
at n
ight
(Con
side
r lo
w-d
ose
of
rispe
ridon
e fir
st)
•A
ggre
ssiv
e/v
iole
nt P
atie
nts:
see
Agi
tate
d Pa
tien
t Pr
otoc
ol
see
agi
tate
d Pa
tient
Pro
toco
l
for
guid
elin
es r
egar
ding
use
.
200
mg
twic
e da
ily20
0 –
250
mg
twic
e da
ily
*Pat
ient
s re
ceiv
ing
valp
roic
acid
may
req
uire
a z
idov
udin
e
dosa
ge r
educ
tion
to m
aint
ain
unch
ange
d se
rum
zid
ovud
ine
conc
entr
atio
ns
“ste
p” o
f up
titr
atio
na
ntip
sych
otic
s re
quire
4 –
6 w
eeks
to
reac
h fu
ll ef
fect
. if
ther
e ar
e sa
fety
conc
erns
, phy
sici
ans
can
incr
ease
dose
s m
ore
quic
kly
(eve
ry 3
– 7
day
s)
by 0
.5 m
g in
crem
ents
. Del
irium
:
incr
ease
by
0.25
mg
incr
emen
ts.
ant
ipsy
chot
ics
requ
ire 4
– 6
wee
ks t
o
reac
h fu
ll ef
fect
. if
ther
e ar
e sa
fety
conc
erns
, phy
sici
ans
can
incr
ease
dose
s m
ore
quic
kly
(eve
ry 3
– 7
day
s)
by 2
.5 m
g in
crem
ents
.
see
agi
tate
d Pa
tient
Pro
toco
l
for
guid
elin
es r
egar
ding
use
.
200
mg
tota
l dai
ly25
0 –
500
mg
tota
l dai
ly
max
imum
Dos
e2
mg
Dos
es a
bove
2 m
g da
ily m
ust
be
revi
ewed
with
the
men
tal h
ealth
tea
m.
10 m
g
Dos
es a
bove
10
mg
daily
mus
t be
revi
ewed
with
the
men
tal h
ealth
team
.
10 m
g
Dos
es a
bove
10
mg
daily
mus
t be
rev
iew
ed w
ith t
he
men
tal h
ealth
tea
m.
800
mg
(for
men
tal i
llnes
s)
Dos
es a
bove
800
mg
mus
t
be r
evie
wed
with
the
men
tal
heal
th t
eam
.
1000
mg
(for
men
tal i
llnes
s)
Dos
es a
bove
100
0 m
g m
ust
be r
evie
wed
with
the
men
tal
heal
th t
eam
.
69Partners In Health | PartiCiPant hanDBOOK | ANNEx
2
med
icat
ion
Car
d fo
r A
gita
tion
, Del
iriu
m, a
nd P
sych
osis
(co
ntin
ued)
RIs
PeR
IDO
Ne
HA
lOPe
RID
Ol
DIA
ZePA
mC
AR
bA
mA
ZePI
Ne
vA
lPR
OA
Te
Toxi
citi
es*i
f ra
sh, s
top
med
icat
ion
and
retu
rn t
o ho
spita
l
seri
ous
Dys
toni
a (e
spec
ially
of
phar
ynx,
eye
s, n
eck—
tem
pora
ry b
ut p
oten
tially
fat
al),
Tard
ive
Dys
kine
sia
(per
man
ent)
, Aka
this
ia (
rest
less
ness
), D
iabe
tes,
Car
diac
arrh
ythm
ia le
adin
g to
tor
sade
s de
s po
inte
s
Ris
k of
sei
zure
if d
iaze
pam
with
draw
n w
ithou
t ta
per
afte
r re
gula
r us
e at
hig
her
dose
Ras
h, li
ver
failu
re, d
ecre
ased
whi
te b
lood
cou
nt
(Car
bam
azep
ine
can
caus
e hy
pona
trem
ia)
(Val
proa
te c
an c
ause
ser
ious
bir
th d
efec
ts in
pre
gnan
cy)
Com
mon
•se
datio
n
•W
eigh
t g
ain
•la
ctat
ion
•a
men
orrh
ea
•En
ures
is (
for
boys
)
•se
datio
n
•h
eavy
ton
gue
•st
iffne
ss
•a
rrhy
thm
ia (
for
patie
nts
rece
ivin
g
mor
e th
an 1
0 m
g da
ily)
•se
datio
n
•D
epen
denc
e (s
houl
d no
t
be g
iven
for
long
per
iods
of t
ime)
Fatig
ue, d
izzi
ness
, nau
sea/
vom
iting
, inc
oord
inat
ion,
dou
ble
visi
on
(Car
bam
azep
ine
decr
ease
s ef
ficac
y of
ora
l con
trac
eptiv
es;
Valp
roat
e ca
uses
tre
mor
)
mon
itor
ing
•Ba
selin
e: a
ims,
wei
ght,
fas
ting
gluc
ose,
hem
ogra
m, h
epat
ic p
anel
(if a
vaila
ble)
•Ev
ery
visi
t: w
eigh
t, v
ital s
igns
•Ev
ery
6 m
onth
s: a
ims,
fas
ting
gluc
ose,
hep
atic
pan
el, h
emog
ram
•Ba
selin
e: a
ims,
wei
ght,
fas
ting
gluc
ose,
hem
ogra
m, h
epat
ic
pane
l (if
avai
labl
e)
•Ev
ery
visi
t: w
eigh
t, v
ital s
igns
•Ev
ery
6 m
onth
s: a
ims,
fast
ing
gluc
ose,
hep
atic
pan
el,
hem
ogra
m
•m
onito
r fo
r si
gns
of
seda
tion
•m
onito
r fo
r de
pend
ence
(nee
d fo
r in
crea
sed
dose
to a
chie
ve s
ame
effe
ct)
lFts
, CBC
, sod
ium
Wei
ght
gain
, lFt
s, C
BC
hiV
pat
ient
s re
ceiv
ing
valp
roic
acid
may
req
uire
a z
idov
udin
e
dosa
ge r
educ
tin t
o m
aint
ain
unch
ange
d se
rum
zid
ovud
ine
conc
entr
atio
ns.
Tape
ring
/D
isco
ntin
uing
if t
here
is a
life
-
thre
aten
ing/
toxi
c si
de
effe
ct, s
top
imm
edia
tely
.
•C
onsu
lt w
ith
the
men
tal h
ealt
h
team
bef
ore
tape
ring
med
icat
ion.
som
e pa
tien
ts m
ay n
eed
to
cont
inue
ris
peri
done
inde
fini
tely
.
•if
the
pat
ient
has
oth
er s
igni
fican
t
side
eff
ects
, con
side
r de
crea
sing
the
dose
slo
wly
(by
0.2
5 –
0.5
mg
incr
emen
ts)
and
mon
itorin
g cl
osel
y.
Can
als
o co
nsid
er c
hang
ing
to
halo
perid
ol.
•C
onsu
lt w
ith
the
men
tal h
ealt
h
team
bef
ore
tape
ring
med
icat
ion.
som
e pa
tien
ts m
ay n
eed
to
cont
inue
hal
oper
idol
inde
fini
tely
.
•if
the
pat
ient
has
oth
er s
igni
fican
t
side
eff
ects
, con
side
r de
crea
sing
the
dose
slo
wly
(by
2.5
mg
incr
emen
ts)
and
mon
itorin
g
clos
ely.
Can
als
o co
nsid
er
chan
ging
to
rispe
ridon
e.
•O
nly
used
for
the
man
agem
ent
of
agita
ted/
viol
ent
patie
nts
and
alco
hol w
ithdr
awal
.
•it
sho
uld
not
be
cont
inue
d fo
r m
ore
than
seve
ral d
ays.
red
uce
by s
teps
abo
ve e
very
2 –
4 w
eeks
.
red
uce
by s
teps
abo
ve e
very
2 –
4 w
eeks
.
•Fo
r de
liriu
m, s
top
the
med
icat
ion
afte
r m
edic
al il
lnes
s is
tre
ated
.
•Fo
r ch
roni
c ps
ycho
sis
due
to m
enta
l illn
ess:
if t
he p
atie
nt is
sho
win
g
impr
ovem
ent
in s
ympt
oms
and
has
no m
ajor
sid
e ef
fect
s, d
o no
t st
op t
he
med
icat
ion.
•Fo
r ac
ute
psyc
hosi
s du
e to
men
tal i
llnes
s: c
onsi
der
slow
ly t
aper
ing
the
med
icat
ion
afte
r pa
tient
is s
ympt
om-f
ree
for
3 –
6 m
onth
s.
bre
astf
eedi
ngD
o no
t pr
escr
ibe
to p
regn
ant
or
brea
stfe
edin
g pa
tient
s w
ithou
t
cons
ultin
g w
ith t
he m
enta
l hea
lth
team
; giv
e fo
lic a
cid
4 m
g Q
D
thro
ugh
preg
nanc
y.
Do
not
pres
crib
e to
pre
gnan
t or
brea
stfe
edin
g pa
tient
s w
ithou
t
cons
ultin
g w
ith t
he m
enta
l hea
lth
team
; giv
e fo
lic a
cid
4 m
g Q
D
thro
ugh
preg
nanc
y.
Con
trai
ndic
ated
Do
not
pres
crib
e (f
or m
enta
l
illne
ss)
to p
regn
ant
or
brea
stfe
edin
g pa
tient
s w
ithou
t
cons
ultin
g th
e m
enta
l hea
lth
team
; giv
e fo
lic a
cid
4 m
g Q
D
thro
ugh
preg
nanc
y.
Do
not
initi
ate.
if a
lread
y on
,
mak
e su
re t
akin
g 4
mg
folic
acid
QD
.
70 Partners In Health | PartiCiPant hanDBOOK | ANNEx
3
TR
eA
Tm
eN
T F
OR
AN
TIP
sy
CH
OT
IC m
eD
ICA
TIO
N s
IDe
eF
Fe
CT
s
esP
(ex
TRA
PyR
Am
IDA
l sy
mTO
ms)
TAR
DIv
e D
ysk
INes
IAN
eUR
Ole
PTIC
mA
lIG
NA
NT
syN
DR
Om
e (N
ms)
AC
UTe
Dy
sTO
NIA
Ak
ATH
IsIA
man
ifes
tati
onm
uscl
e rig
idity
(po
tent
ially
incl
udin
g:
eye
mus
cles
, thr
oat,
neck
, ton
gue,
bac
k)
EM
ER
GEN
CY
Psyc
hom
otor
res
tless
ness
invo
lunt
ary
orof
acia
l mov
emen
ts (
may
be p
erm
anen
t)
Con
fusi
on, d
eliri
um, s
tiffn
ess
(like
a
lead
pip
e), s
wea
ting,
hyp
erpy
rexi
a,
auto
nom
ic in
stab
ility
, dro
olin
g,
elev
ated
WBC
, ele
vate
d C
PK, d
eath
EM
ER
GEN
CY
Trea
tmen
tD
iphe
nhyd
ram
ine
50 –
75
mg
im o
r
PO d
aily
seve
ral l
iters
of
iV o
r PO
flui
ds d
aily
Prop
rano
lol 1
0 –
20 m
g ti
D
Can
als
o de
crea
se t
he d
ose
of
med
icat
ion
Dis
cont
inue
neu
role
ptic
or
low
er d
ose
Con
side
r V
itam
in C
(50
0 –
1000
mg/
d)
+ V
itam
in E
(12
00 –
160
0 iu
/d)
1. D
isco
ntin
ue o
ffen
ding
med
icat
ion.
2. m
edic
al e
valu
atio
n an
d su
ppor
t
(con
side
r iV
flui
ds)
3. h
ospi
taliz
e
4. C
onsi
der
dopa
min
e ag
onis
ts o
r
dant
role
ne t
o im
prov
e ou
tcom
e.
Toxi
citi
esse
riou
sa
naph
ylax
is, a
nem
ia, a
rrhy
thm
iaa
rrhy
thm
ia, b
ronc
hosp
asm
, ste
vens
-
John
son
synd
rom
e
Com
mon
Dro
wsi
ness
, diz
zine
ss, h
eada
che,
dry
mou
th, t
achy
card
ia, c
onst
ipat
ion,
blur
red
visi
on
Fatig
ue, d
izzi
ness
, nau
sea,
dep
ress
ion,
inso
mni
a
71Partners In Health | PartiCiPant hanDBOOK | ANNEx
1
me
DIC
Al
ev
Al
UA
TIO
N P
RO
TO
CO
ls
FO
R A
GIT
AT
ION
, D
el
IRIU
m A
ND
Ps
yC
HO
sIs
sU
mm
AR
y
PR
OT
OC
Ol
In
A C
lIn
IC/H
OS
PIT
Al
SE
TT
Ing
sTeP
1a:
Is P
erso
n A
gita
ted?
Pati
ent
is c
onsi
dere
d ag
itat
ed if
the
y ar
e an
y of
the
follo
win
g:
•V
iole
nt, a
ggre
ssiv
e
•Ye
lling
, thr
eate
ning
•m
anic
, del
usio
nal (
has
untr
ue, fi
xed
belie
fs)
•h
allu
cina
ting
•a
cute
ly p
aran
oid
•W
ringi
ng o
f ha
nds,
pac
ing,
tap
ping
han
d
•r
apid
spe
ech,
rai
sing
voi
ce
•Fr
eque
nt r
eque
sts,
low
fru
stra
tion
tole
ranc
e
sTeP
1b:
Det
erm
ine
leve
l of
Agi
tati
on a
nd m
anag
e•
Ref
er t
o A
gita
ted
Pati
ent
Prot
ocol
to
guid
e ag
itat
ion
man
agem
ent
depe
ndin
g on
sym
ptom
s an
d se
veri
ty
•u
se c
alm
voi
ce
•g
ive
verb
al s
uppo
rt
•D
ecre
ase
stim
uli
•a
sk, “
how
can
i he
lp?”
•a
lert
sta
ff
•K
eep
your
self
safe
•u
se W
hO
mhg
aP
(p.7
4) f
or s
elf-
har
m/s
uici
de a
sses
smen
t
if ne
cess
ary
box
1: s
tand
ard
med
ical
eva
luat
ion
for
Agi
tati
on/D
elir
ium
/Psy
chos
is
•Br
ief
his
tory
–m
edic
al h
isto
ry
–a
lcoh
ol/s
ubst
ance
abu
se
–C
urre
nt m
edic
atio
ns
–h
isto
ry o
f m
enta
l illn
ess
•V
ital s
igns
, phy
sica
l exa
m
•n
euro
logi
cal E
xam
•m
enta
l sta
tus
Exam
–O
rient
atio
n
–a
lert
ness
–C
onfu
sion
box
2: D
elir
ium
1. D
istu
rban
ce o
f co
nsci
ousn
ess;
red
uced
abili
ty t
o fo
cus,
sus
tain
or
shift
att
entio
n.
2. a
cha
nge
in c
ogni
tion
or t
he d
evel
opm
ent
of a
per
cept
ual d
istu
rban
ce (
hallu
cina
tions
)
that
is n
ot d
ue t
o a
pree
xist
ing,
est
ablis
hed
or e
volv
ing
dem
entia
.
3. t
he d
istu
rban
ce d
evel
ops
over
a s
hort
perio
d of
tim
e (u
sual
ly h
ours
to
days
) an
d
fluct
uate
s du
ring
the
day
4. t
here
is e
vide
nce
from
the
his
tory
, phy
sica
l
exam
inat
ion
or la
bora
tory
find
ings
tha
t
the
dist
urba
nce
is c
ause
d by
the
dire
ct
phys
iolo
gica
l con
sequ
ence
s of
a g
ener
al
med
ical
con
diti
on.
NO
THeN
yes
sTeP
2: P
erfo
rm m
edic
al A
sses
smen
t (s
ee b
ox 1
, ReF
eR t
o an
d R
eCO
RD
info
rmat
ion
on A
gita
ted
Pati
ent
Form
, inc
ludi
ng):
•sa
fety
: tal
k fir
st, d
o no
t m
edic
ate
first
•m
edic
al H
ealt
h: t
ake
vita
l sig
ns, p
hysi
cal e
xam
, men
tal s
tatu
s ex
am t
o as
sess
for
del
irium
•m
enta
l Hea
lth:
tak
e hi
stor
y
•Fo
llow
-Up:
con
tact
psy
chol
ogis
t
•C
ontin
ue e
valu
atio
n an
d tr
eatm
ent
of u
nder
lyin
g
med
ical
con
ditio
n.
•C
onsi
der
low
-dos
e an
tipsy
chot
ic f
or d
eliri
um
(see
med
icat
ion
card
)
•C
onsu
lt m
enta
l hea
lth t
eam
/psy
chol
ogis
t
abn
orm
al m
enta
l sta
tus
exam
or
mee
ts c
riter
ia f
or
delir
ium
(se
e b
ox 2
)
see
Page
2 f
or c
onti
nuat
ion
of m
edic
al A
sses
smen
t
yes
NO
72 Partners In Health | PartiCiPant hanDBOOK | ANNEx
2
med
ical
eva
luat
ion
Prot
ocol
s fo
r A
gita
tion
, Del
iriu
m a
nd P
sych
osis
sum
mar
y (c
onti
nued
)
•tr
eat
alco
hol w
ithdr
awal
with
10
mg
iV/i
m
diaz
epam
, rep
eat
afte
r 15
min
s as
nee
ded
until
res
pons
e, t
hen
repe
at in
6 h
ours
.
•m
onito
r re
spira
tory
rat
e to
avo
id o
verd
ose
•m
alar
ia s
mea
r an
d co
nsid
er e
mpi
ric
trea
tmen
t fo
r m
alar
ia
•lu
mba
r pu
nctu
re a
nd c
onsi
der
empi
ric r
x
with
app
ropr
iate
ant
ibio
tic m
edic
atio
n
Con
side
r C
T be
fore
lP
if a
sym
met
ric
pupi
ls o
r
abno
rmal
ext
ra-o
cula
r m
ovem
ent
or g
ait.
•lP
, as
abov
e
•C
onsi
der
empi
ric r
x w
ith a
ppro
pria
te
antib
iotic
med
icat
ion
Con
side
r tr
eatm
ent
for
toxo
plam
osis
or c
ryto
cocc
us.
•C
onsi
der
addi
tiona
l tes
ts: r
enal
pan
el, l
iver
pane
l, ch
est
x-ra
y
•tr
eat
acco
rdin
gly
trea
t fo
r ne
uros
yphi
lis w
ith p
enic
illin
•Fu
rthe
r ne
urol
ogic
al t
estin
g (s
ee b
ox 3
)
•C
onsi
der
Ct,
EEg
, or
lP
•C
onsu
lt w
ith s
peci
alis
ta
bnor
mal
neu
rolo
gic
exam
rec
ent
onse
t an
d
tem
pera
ture
> 3
8 C
hiV
+ w
ith C
D4
coun
t <
200
Posi
tive
rPr
abn
l glu
cose
, ele
ctro
lyte
s,
or o
ther
evi
denc
e of
med
ical
illn
ess
(see
box
4)
ris
k fa
ctor
s fo
r dr
ug o
r
alco
hol w
ithdr
awal
or
into
xica
tion?
(se
e b
ox 5
)
Con
side
r a
prim
ary
psyc
hotic
dis
orde
r
Perf
orm
men
tal H
ealt
h A
sses
smen
t
and
Con
sult
men
tal H
ealt
h Te
am
On
med
icat
ion
caus
ing
psyc
hosi
s? (
see
box
6)
Det
erm
ine
whe
ther
his
tory
of
psyc
hosi
s an
d m
edic
atio
n us
e co
inci
de.
Con
side
r di
scon
tinui
ng m
edic
atio
n.
yes yes
yes
yes
yes
yes
yes
yes
THeN
THeN
box
4: C
omm
on s
yste
mic
Con
diti
ons
that
can
Cau
se/C
ontr
ibut
e to
Psy
chos
is
•m
alar
ia
•El
ectr
olyt
e ab
norm
aliti
es (
sodi
um, c
alci
um)
•m
alnu
triti
on, t
hiam
ine
defic
ienc
y
•th
yroi
d di
seas
e
•a
lcoh
ol w
ithdr
awal
•h
ypox
ia
box
6: m
edic
atio
ns t
hat
can
Cau
se/C
ontr
ibut
e
to P
sych
osis
•C
ortic
oste
riods
•C
yclo
serin
e
•is
onia
zid,
Efa
vire
nz
•C
ortic
oste
roid
s
•Ph
enob
arbi
tal
•h
igh
dose
s of
ant
i-ch
olin
ergi
c m
edic
atio
n
box
3: N
euro
logi
cal C
ondi
tion
s th
at C
ause
or
Con
trib
ute
to P
sych
osis
•te
rtia
ry s
yphi
lis
•En
ceph
ilitis
•D
emen
tia (
hiV
, alz
heim
ers)
•Pa
rkin
sons
•Br
ain
tum
ors
or o
ther
mas
s le
sion
s (t
B,
lym
phom
a, t
oxop
lasm
osis
)
box
5: A
lcoh
ol W
ithd
raw
al
•h
isto
ry o
f he
avy
alco
hol u
se (
last
drin
k
24 –
28
hour
s pr
ior
to s
ympt
oms)
•se
vere
alc
ohol
with
draw
al:
–W
ithin
a f
ew h
ours
: with
draw
al
trem
ors,
nau
sea,
vom
iting
, sw
eatin
g,
anxi
ety
–W
ithin
a f
ew d
ays:
hal
luci
natio
ns,
seiz
ures
, fev
er, d
isor
ient
atio
n,
hype
rten
sion
Con
tinu
atio
n of
med
ical
Ass
essm
ent
NO
NO
NO
NO
NO
NO
NO
73Partners In Health | PartiCiPant hanDBOOK | ANNEx
level ReACHeD IN THe PAsT TWO Weeks? IN THe PAsT yeAR?
1. Passive no Yes no Yes
Ask: Do you have any thoughts of ending your life, even if they are not clear in your mind?
Possible Response: i think about it from time to time, but i’ve never acted upon it...i would make my family feel too bad...god would not forgive me
Description:
2. Non-specific Active no Yes no Yes
Ask: Do you want to die? Do you often think or talk about death?
Possible Response: desire/wish to be dead…prefer to be dead…think frequently/talk about death…god would rather have me
Description:
3. methods but no Intent to Act no Yes no Yes
Ask: if you would do it, how would you do it?
Possible Response: bleach, pesticide, herbicide, battery acid, hang themselves, medication overdose, stop taking medication, a knife, a gun
Description:
4. Intent to Act no Yes no Yes
Ask: Do you intend to act on these thoughts?
Possible Response: i will kill myself but i do not know when… i do not think i can do so now…but it’s too much for me, i cannot yet
Description:
5. Planification no Yes no Yes
Ask: have you started planning the details about how you will kill yourself?
Danger signs: there is a sudden change in attitude, withdraws from everything; not interested in anything; say: “when i am not here anymore”; seeks to implement the plan, write a note (on paper).
Description:
6. Attempted no Yes no Yes
Ask: have you tried to do something that could hasten the end of your life? have you stopped preserving your life, like not eating and not taking medication?
Danger signs: realized did not want to die after the attempt failed, but it often gets worse again after a few days; might have some injuries or marks.
Description:
low: Current = 0 Past = 0
medium: Current = 1–2 yes Or Past = 1 or more yes
High: Current = 3 or more yes Or Past = 3 or more yes
Total “yes” in past two weeks
Total “yes” in past year
ZANmI lAsANTe — meNTAl HeAlTHsUICIDAlITy sCReeNING INsTRUmeNT
74 Partners In Health | PartiCiPant hanDBOOK | ANNEx
1
For All Patients
act 1. Ensure that the environment will be private, safe and non-threatening.
2. Begin the process of ensuring that the patient will be able to access necessary medication.
3. always work with the patient to develop a safety Plan.
say 4. use the patient’s name often, give hope, insist that there are other options, and declare your intent to help.
5. start iPt and collect iP inventory.
6. Provide psychoeducation about depression, suicidality, psychopharmacology, therapy and Zl resources.
7. identify specific current supports and potentially welcome supports (e.g. neighbors, clergy). (Write this on the copy of your Safety Plan, on the back side).
Contact 8. always contact at least one person close to the patient to support and monitor them.
9. Contact as many of the current and potential supports as a patient will permit
• You should utilize the clergy early and heavily for supporting, home visiting, and monitoring patients
•When involving anyone, ensure that you preserve confidentiality if possible and define these:
1. Depression, suicidality
2. the needs of such patients
3. how others can help
4. how others can hurt
team 10. Consult and involve colleagues to help.
social Worker Psychologist Community health Worker Doctor
Follow up
11. if the patient has a higher risk level, continue to the guidelines below.
Provider: location: Date: / / last name: _________________________ First name: nickname: File #:
ZANmI lAsANTe — meNTAl HeAlTH sUICIDAlITy TReATmeNT GUIDelINes
75Partners In Health | PartiCiPant hanDBOOK | ANNEx
2
For patients with meDIUm risk, include these additional aspects in your care.
act 1. maintain a high index of suspicion for understatement and concealed ideation. Be sure of your assessment.
say 2. ascertain what caused the ideation to increase in seriousness and specificity and/or what caused it to occur.
3. seek agreement or at least acceptance that individuals in that patient’s milieu may need to be notified explicitly.
Contact 4. Close family should be informed quickly and explicitly of the patient’s suicidality.
team 5. at least one social worker and psychologist should cooperate closely on all cases with greater than low risk.
Follow up
6. if the patient is medium risk, schedule follow-up within 7 days. Date Time if the patient is high risk, continue to the guidelines below.
For patients with HIGH risk, include these additional aspects in your care.
act 1. Ensure safety and calm. remove potential weapons. Obtain help and apply physical/chemical restraint if necessary.
2. seek to admit patient to the emergency room or another service with beds for at least 24 hours.
3. Determine who will be available to watch the patient and when so that they are not left unattended.
name time name time
name time name time
name time name time
say 4. Despite the potential necessity of negating the patient’s autonomy, do as much as possible to preserve dignity.
Contact 5. any and all accessible individuals from the patient’s milieu (you are justified in breaching confidentiality here).
6. any and all potentially influential individuals (neighborhood elder, clergy, Freemason).
team 7. mD: make sure no attempt has been made occultly, and rule out remediable organic processes (especially pain).
8. any available clinical staff can be called upon to help in monitoring - if necessary, other patients can be as well.
Follow up
9. Keep the patient admitted and under continuous monitoring (e.g. 4x/hr).
10. Frequently re-assess risk level.
11. if the patient leaves or can’t be kept, follow through with continued intensive psychosocial activation.
ZANmI lAsANTe — meNTAl HeAlTH sUICIDAlITy TReATmeNT GUIDelINes
76 Partners In Health | PartiCiPant hanDBOOK | ANNEx
ZANmI lAsANTe — meNTAl HeAlTH sAFeTy PlAN
sTeP 1 Warning signs that a crisis is developing (such as thoughts, images, moods, situations, behavior):
1. 2.
3. 4.
5. 6.
sTeP 2 internal coping strategies – activities that i can do without others to distract myself from my problems, such as relaxation techniques:
1. 2.
3. 4.
5. 6.
sTeP 3 People and social environments that offer distractions and support:
name telephone
name telephone
name telephone
Where Where
step 4 People and social environments that offer distractions and support:
name telephone __________________________________________
name telephone __________________________________________
name telephone __________________________________________
sTeP 5 Professionals and agencies i can contact during a crisis:Community health Worker telephone __________________________________________
ajan sante telephone __________________________________________
social Worker telephone __________________________________________
Psychologist telephone __________________________________________
Doctor telephone __________________________________________
spiritual healer telephone __________________________________________
Emergency room/hospital telephone __________________________________________
sTeP 6 making the environment safe:
I, , will follow the steps when I’m in a crisis,and one thing more important to me than anything else that will help me live is…
77Partners In Health | PartiCiPant hanDBOOK | ANNEx
1
Date:
name: Psychologist / sW:
Patient iD: age:
male/ Female (circle one) Phone #1:
town: Phone #2:
District: session#:
Date recieved patient info:
I. Severity of Illness
Considering your total clinical experience with this particular population, how mentally ill has the patient been over the past 7 days?
Tip: Compare relative to your past experience with patients who have the same diagnosis considering your total clinical experience with this population.
0 = Not assessed
1 = Normal, not at all ill. symptoms of disorder have not been present in the past seven days.
2 = borderline mentally ill. subtle or suspected symptoms within the past seven days. no definable impact on behavior or function.
3 = mildly ill. Clearly established symptoms causing minimal, if any, distress or difficulty in social or occupational function.
4 = moderately ill. Overt symptoms causing noticeable, but modest, functional impairment or distress. there is evidence of functional interference in multiple settings. some symptoms may warrant medication.
5 = markedly ill. intrusive symptoms that distinctly impair social or occupational function or cause intrusive levels of distress. Functional interference due to symptoms is obvious to others.
6 = severely ill. Disruptive pathology; behavior and function are frequently influenced by symptoms. Dysfunction may require assistance from others.
7 = Among the most extremely ill patients. Pathology drastically interferes in many life functions. Patient may need to be hospitalized. Rating (number 0–7)
C l I N I C A l G l O b A l I m P R e s s I O N s s C A l e
78 Partners In Health | PartiCiPant hanDBOOK | ANNEx
2
II. Improvement
Compared to the patient’s baseline condition before treatment, how much has the patient changed?
Tips: For initial evaluation: if the patient has been in treatment previously, rate Cgi improvement based on the history and compared to the patient’s condition prior to treatment. Otherwise, leave blank.
Progress notes: rate improvement by comparing the current condition to the patient’s condition at the initiation of the current treatment plan. assess how much the patient’s illness has changed relative to a baseline state at the beginning of the treatment plan based on the first evaluation. rate total improvement whether or not in your judgment it is due to treatment.
0 = Not assessed
1 = very much improved. nearly all better; good level of functioning; minimal symptoms; represents a very substantial change.
2 = much improved. notably better with significant reduction of symptoms; increase in the level of functioning but some symptoms remain.
3 = minimally improved. slightly better with little or no clinically meaningful reduction of symptoms. may represent very little change in basic clinical status, level of care, or functional capacity.
4 = No change. symptoms remain essentially unchanged.
5 = minimally worse. slightly worse but may not be clinically meaningful; may represent very little change in basic clinical status or functional capacity.
6 = much worse. Clinically significant increase in symptoms and diminished functioning.
7 = very much worse. severe exacerbation of symptoms and loss of functioning.
Rating (number 0–7)
III. Side Effects
select the terms that best describe the degree of side effects of medication treatment.
0 = None
1 = Do not significantly interfere with patient’s functioning.
2 = significantly interfere with patient’s functioning.
3 = Outweighs therapeutic effects with patient’s functioning. Rating (number 0–3)
Clinical Global Impressions scale Continued...
79Partners In Health | PartiCiPant hanDBOOK | ANNEx
Page 4 of 5 (12-item, interviewer-administered)
12
Interview
Section 3 Preamble
Say to respondent:
The interview is about difficulties people have because of health conditions.
Hand flashcard #1 to respondent
By health condition I mean diseases or illnesses, or other health problems that may be short or long lasting; injuries; mental or emotional problems; and problems with alcohol or drugs.
Remember to keep all of your health problems in mind as you answer the questions. When I ask you about difficulties in doing an activity think about...
Point to flashcard #1
• Increased effort
• Discomfort or pain
• Slowness
• Changes in the way you do the activity.
When answering, I’d like you to think back over the past 30 days. I would also like you to answer these questions thinking about how much difficulty you have had, on average, over the past 30 days, while doing the activity as you usually do it.
Hand flashcard #2 to respondent
Use this scale when responding.
Read scale aloud:
None, mild, moderate, severe, extreme or cannot do.
Ensure that the respondent can easily see flashcards #1 and #2 throughout the interview
Please continue to next page...
WHODAS-03(23Nov09).book Page 4 Tuesday, November 24, 2009 1:30 PM
WHODAS 2.0WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0
80 Partners In Health | PartiCiPant hanDBOOK | ANNEx
Page 5 of 5 (12-item, interviewer-administered)
12
Interview
Section 4 Core questions
Show flashcard #2
This concludes our interview. Thank you for participating.
In the past 30 days, how much difficulty did you have in:
None Mild Moderate Severe Extreme or cannot do
S1 Standing for long periods such as 30 minutes?
1 2 3 4 5
S2 Taking care of your household responsibilities?
1 2 3 4 5
S3 Learning a new task, for example, learning how to get to a new place?
1 2 3 4 5
S4 How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
1 2 3 4 5
S5 How much have you been emotionally affected by your health problems?
1 2 3 4 5
In the past 30 days, how much difficulty did you have in:
None Mild Moderate Severe Extreme or cannot do
S6 Concentrating on doing something for ten minutes?
1 2 3 4 5
S7 Walking a long distance such as a kilometre [or equivalent]?
1 2 3 4 5
S8 Washing your whole body? 1 2 3 4 5
S9 Getting dressed? 1 2 3 4 5
S10 Dealing with people you do not know? 1 2 3 4 5
S11 Maintaining a friendship? 1 2 3 4 5
S12 Your day-to-day work/school? 1 2 3 4 5
H1 Overall, in the past 30 days, how many days were these difficulties present? Record number of days ____
H2 In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?
Record number of days ____
H3 In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?
Record number of days ____
WHODAS-03(23Nov09).book Page 5 Tuesday, November 24, 2009 1:30 PM
WHODAS 2.0WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0
81Partners In Health | PartiCiPant hanDBOOK | ANNEx
Flashcard 1
Health conditions:• Diseases, illnesses or other health problems
• Injuries
• Mental or emotional problems
• Problems with alcohol
• Problems with drugs
Having difficulty with an activity means:
• Increased effort
• Discomfort or pain
• Slowness
• Changes in the way you do the activity
Think about the past 30 days only.
WHODAS-03(23Nov09).book Page 6 Tuesday, November 24, 2009 1:30 PM
WHODAS 2.0WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0
82 Partners In Health | PartiCiPant hanDBOOK | ANNEx
WHODAS 2.0
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Partners In Health888 Commonwealth Avenue, 3rd Floor, boston, mA 02215 www.pih.org
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