Essential SkillsFor mental health care

Dr Jim Crabb

13th September 2007

Introduction

Introductions Housekeeping Our aims, your aims Agenda Quiz Questions

Assessing someone

Important questions to ask• Personal details

• Presenting complaint

• History of the presenting complaint

• Golden questions

• Medical history

• Physical illness & allergies

• Safety questions

The mental state examination

Appearance Behaviour Speech Mood Thoughts Perception Cognition Insight

The physical health check

Pulse Temperature Blood pressure Capillary refill test Breathing rate Physical examination Urine tests Blood tests Alcohol tests

Get the whole story

Ask permission Speak to their family Speak to the person on their own

Bio-psycho-social treatment model

1. Medicines

2. Talking cures (psychological treatments)

3. Building the best life possible (social treatment)

1) Medicine

Use medicine when:• You know exactly what the mental illness is

• It is a serious mental illness

• It is a common mental illness that has not improved despite psychological / social treatment

Do not use medicine:• Just because the family expect it

• Because you do not know what else to do

1) Medicines: golden rules Stick to the lowest dose and the right dose Use one medicine Be patient Do not stop taking the medicine suddenly Managing side effects Use the right medicine Some medicines should not be mixed Medicines and pregnancy / breast feeding Medicines and children Medicines and the physically weak Medicine and alcohol Medicine and food

2) Talking cures a) Problem solving b) Relaxation c) Crisis planning d) Counselling e) Coping strategies f) Looking at a situation differently The therapeutic alliance

• Showing warmth• Showing empathy• Showing positive regard

a) Problem solving work

Derry’s story• Not enough money to buy food

• Owes his friends money

• Does not have a girlfriend

The plan• Wash and shave at a friends house

• Borrow clothes

• Work for free / work for food

• The plan worked! Derry was offered a job!

a) Problem solving

Activity!! Get into 4 groups Read your case study Make a plan Present your ideas

b) Relaxation: Activity!!

2) Talking cures

c) Crisis planning d) Counselling e) Coping strategies f) Looking at a situation differently The therapeutic alliance

• Showing warmth

• Showing empathy

• Showing positive regard

3) Building the best life possible

Getting the right balance• Daily routine

• Sleep hygiene

• Diet

• Exercise

• Pleasant activities

• Work Working with a persons family Managing stress Relapse prevention

Break time

The types of mental illness

Mental illness due to a physical illness.

This is called organic mental illness.

Mental illness due to the use of alcohol or illicit drugs. This is called substance misuse.

Where a person loses touch with reality.This is called psychosis.

Where a person is too sad or too happy.The mood disorders.

Where a person is worried or afraid The anxiety disorders.

Organic mental illness: Delirium

What are the key features• Partial loss consciousness

• Disorientated

• Not able to sleep

• Strange / odd behaviour

• Restless, aggressive, suspicious, fearful

• Forgetful

• Lack concentration

• Visual auditory hallucinations

• Sudden onset over days or hours

Organic mental illness: Delirium Who gets delirium

• Anybody with a physical illness• Very old, young

What causes delirium• Dehydration• Fever, infection• Abnormal levels sugar / salt• Head injury• Substance misuse• Medicine

Delirium activity!!

If you suspect delirium Group 1: What questions would you ask? Group 2: What would the mental state

examination show? Group 3: What would the physical observations

show? Group 4: Once diagnosed, what would you do

with this person?

Present ideas

Delirium treatment

Treat the physical illness• Monitor physical observations

• Give fluids

• Treat infection

• Lower dose medicines for mental illness

At the same time• Keep away from noise

• Reassure and remind

• Care for by one person

Lunch time

Organic mental illness: Epilepsy

What are the key features? Generalised seizures

• Becomes unconscious

• Fall down

• Bite tongue

• Become stiff and shake

• Eyeballs roll upwards

• Froth at the mouth

• Pass urine

• Lips become blue

• Feel drowsy afterwards

Organic mental illness: Epilepsy

What are the key features?• Partial seizures

• Awake but not aware• Aura• Jerky movements in one part of their body• Smack lips• Repeated movements

• Hysterical seizures• Fall to the ground and shake• Will not

• become unconscious• Bite tongue• Pass urine

Organic mental illness: Epilepsy Who gets epilepsy

• 1 / 100 people

• Under 30 years

• More common in men and people with mental retardation

What causes epilepsy• Withdrawal from alcohol

• Infection

• Abnormal levels of salt / sugar

• Bleeding / tumour in the head

• Delirium

Assessing someone when you suspect epilepsy

Questions to ask: Brainstorm!! Things to do

• Test for confusion

• Physical health check

• Check blood sugar – give sugary drink

• Make sure it was a seizure not a faint

What to do if someone has a seizure

Make the area safe Recovery position

• Remove objects in their mouth

• Loosen belts / ties

• Do not restrain

• Do not give medicine

• Protect the head

• Wait 5 minutes

• If not recovering….

What to do if someone has a seizure

Give medicines1. Insert airway

2. 100mg thiamine plus 50% dextrose soln

3. 10mg diazepam (wait 5 min)

4. 5mg diazepam (wait 5 min)

5. Repeat 5mg diazepam until• Seizure stops

• You have given 20mg diazepam

What to do if someone has a seizure

Check physical observations Move with a sheet

Long term treatment

Medicines• 2+ generalised or partial seizures

• Best medicines to use

• Sodium valproate

• Carbamazepine

• Side effects

• Hysterical seizures

• Do not give anti-psychotics or anti-depressents

Talking cures

Long term treatment

Building the best life possible• Sleep and wake at regular times

• Avoid alcohol

• Avoid extreme physical exercise

• Avoid stress

• Avoid triggers: flashing lights What next?

• Take medicines

• Do not swim alone, drive, operate heavy machines

• Tell doctor if planning children

Organic mental illness: Dementia

The key features of dementia• Forgetful

• Wander

• Angry and irritable

• Strange behaviour

• Make little sense

• Sexually inappropriate Who gets dementia?

• Over 65

• Younger people with HIV

Dementia

Cause• Disease of the brain

• Stroke

• Infection

• Alzheimer's disease

• Under active thyroid gland

• Drinking too much alcohol

• Low vitamin levels (folate, B12)

Assessing when you suspect dementia

What questions should you ask? Activity! What should you look for and do?

• Test for confusion

• Check sight and hearing

• Check to see if a physical illness is causing it

• Depression or dementia?

Treating dementia

Medicines• Treat the physical illness

• If no physical illness present: avoid medicines

• Haloperidol can be used to calm (short term)

Talking cures• Counselling

• Warmth and empathy

• Speak slowly, use simple words

Treating dementia

Building the best life possible• Work out a daily time table

• Keep tasks simple

• Give regular sight / hearing tests

• Identity bracelet

• Signs around the home

• Lock doors to prevent wandering

• Medicine What next

• Talk to the family - be honest.

Quiz

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See you tomorrow