Essential Skills For mental health care Dr Jim Crabb 14 th September 2007

Quiz ?

Substance misuse: Alcohol Safe amounts of alcohol- men 3 standard drinks / day 21 standard drinks / week Safe amounts of alcohol- women 2 standard drinks / day 14 standard drinks / week Do not binge Have alcohol free days

Substance misuse: Drugs Illicit drugs Marijuana (cannabis, wee) Cocaine Heroin Medicines Sleeping tablets Pain killers

Substance misuse: key features Everyday use Binging Addiction / dependency Most important thing in their life Tolerance Lack of control Withdrawal reaction Can not live without it

Substance misuse Who does it affect More common in men and young people What are the causes Initially it feels good Deal with stress Family history

Assessing someone when you suspect substance misuse Ask everyone you see if they take alcohol or drugs Look out for Accidents and injuries Burning pains in the stomach Repeated sickness Sleep difficulties Sexual problems Depression or anxiety

CAGE questions Has anyone told you to Cut down? Has anyone made you Angry by asking you to drink less? Have you ever felt Guilty about your drinking? Have you ever had a drink in the morning to help you to open your Eyes? How much do they drink? Do they get a withdrawal reaction? Does the withdrawal reaction go away when they use alcohol or drugs? Assessing someone when you suspect substance misuse

Safety questions Food / drink Hurting themselves or others Things to look for Jaundice Nervousness Smell and general appearance Injury Things to do Test for confusion Physical health check Get the whole story Assessing someone when you suspect substance misuse

Substance misuse: treatment Stop slowly to avoid withdrawal reaction Treat withdrawal reactions fast If you can treat withdrawal reactions with Thiamine Diazepam Folic acid ……over 7 days See training manual for doses

Substance misuse: treatment Long term treatment Let them work out their risks Brainstorm!! Medicines Avoid addictive medicines Stop substance misuse before treating physical or mental illness with medicines Talking cures Group therapy Problem solving Relaxation techniques Coping strategies Crisis plan

Substance misuse: treatment Building the best life possible Sleep hygiene Find enjoyable things to do If they still want to drink alcohol or take drugs Take as little as possible Set a limit Do not drink or take drugs alone Take non-alcoholic drinks in between Mix alcohol (don’t drink straight) Drink water to quench thirst Do things that do not involve alcohol or drugs (Church) Do not share needles Do not admit to hospital

Substance misuse: What next? Never drink when: Driving Operating machinery Under legal age Pregnant / breast feeding Always encourage people to give up and never give up on them!

Psychosis What are the key features of psychosis? Brainstorm! Who gets psychosis 1 / 100 (age 20-30) What is the cause? A physical illness Alcohol or drug use Some medicines

Assessing someone when you suspect psychosis Activity!! Get into 4 groups Brainstorm: Group 1 / 2 What questions to ask during the assessment? Group 3 / 4 What would the mental state examination show?

Psychosis: Treatment Medicines Check for physical illness Check current medicines Anti-psychotics (olanzepine) Injections (modecate) Side effects Ask someone to make sure they are taking their medicine

Psychosis: Treatment Talking cures Use medicines for several weeks first Coping strategies are helpful Listening to music Dealing with stress Building the best life possible Use medicines for several weeks first Managing expressed emotion Relapse prevention plan

Psychosis: What next? Stay on medicine for at least 2 years after they get better Stop medicine slowly over several months

Break time

Mood disorders: Depression What are the key features of depression? Brainstorm! Who gets depression? 1 / 5 people More common in women years of age What is the cause? A stressful event A lack of people around to support Alcohol or drug use

Mood disorders: Depression Activity!! Get into 4 groups Brainstorm: Group 1 / 2 What questions to ask during the assessment? Group 3 / 4 What would the mental state examination show?

Depression: Treatment Use medicine if: They want to hurt themselves or someone else They do not get better after a few weeks of talking cures They have little or no other support Speak to a doctor if they have depression with psychotic features Good medicines are Amitriptyline, imipramine, sertraline, fluoxetine

Depression: Treatment Talking cures Counselling Problem solving Relaxation Crisis planning Coping strategies Different ways of looking at a situation Building the best life possible Getting the right balance Rebuilding a persons life Sleep hygiene & exercise Working with a persons family Relapse prevention

Depression: What next Usually depression lasts between 3-6 months Stay on medicine for 6 months after getting better (if first episode) Stay on medicine for 2 years after getting better (if 2+ episode) Stop medicine slowly

Mood disorders: Mania and manic depression What are the key features? Brainstorm! Who gets it? 1 / 100 people years of age What is the cause? Family history A stressful event Alcohol or drug use Physical illness (HIV, epilepsy, head injury, overactive thyroid) Medicines (TB medicine, anti-depressants, steroids, painkillers)

Mood disorders: Mania and manic depression Activity!! Get into 4 groups Brainstorm: Group 1 / 2 What questions to ask during the assessment? Group 3 / 4 What would the mental state examination show?

Mania and manic depression: Treatment Treat any physical illness that may be the cause Check their current medicines Stop any anti-depressants Medicines Olanzapine, sodium valproate, carbamazepine Combine medicine only after trying one first

Mania and manic depression: Treatment Try medicine for several weeks first Talking cures Counselling and problem solving Relaxation Crisis planning Coping strategies Different ways of looking at a situation Building the best life possible Getting the right balance Rebuilding a persons life Sleep hygiene Working with a persons family Relapse prevention

Mania and manic depression: What next Usually lasts between 3-6 months Stay on medicine for 2 years after getting better Stop medicine slowly Provide advice for women of child bearing age

Lunch time

Mental retardation What are the key features? Brainstorm! Who gets it? 2 / 100 people mild form 5 / 1000 severe form What is the cause? Mother with a serious infection during pregnancy Problems during child birth Serious physical illness in a child (cerebral malaria) Inherited conditions

Mental retardation Activity!! Get into 4 groups Brainstorm: Group 1 / 2 What questions to ask during the assessment? Group 3 / 4 What would the mental state examination show?

Mental retardation: Treatment Check sight and hearing Thyroid function test Only use medicines if Seizures Under active thyroid gland No cure Always do a physical health check

Mental retardation: Treatment Talking cures Family should talk to the child Relaxation exercises can help Building the best life possible Teach simple tasks Move onto more complex tasks Step by step Give rewards and praise Education

Mental retardation: What next Community support group No herbal cures With love and support a person with mental retardation can have a happy life!

Emergencies due to medicine Acute dsytonic reactions A severe reaction to antipsychotic medicine Who gets it? 1 / 10 who take antipsychotic medicine Starts 2 days after taking medicine for the first time Features Stiff neck, tongue or jaw Eyes roll Back arch Treatment Stop medicine Give anti-cholinergic medicine Restart antipsychotic after 2 days (lower dose or change medicine)

Emergencies due to medicine Antipsychotic induced Parkinsonism (AIP) A side effect of antipsychotic medicine Who gets it? 1 / 5 who take antipsychotic medicine Starts 4 weeks after taking medicine Features Arms, legs shake Feel stiff Treatment Lower the dose of medicine or Change to a different type of medicine Give anti-cholinergic medicine

Emergencies due to medicine Akathisia A side effect of antipsychotic and antidepressant medicine Who gets it? 4 / 10 who take antipsychotic / antidepressant medicine Features Feel restless / unable to sit still Treatment Lower the dose of medicine or Change to a different type of medicine Give propranolol

Emergencies due to medicine Tardive dyskinesia (TD) A long term side effect of antipsychotic medicine Who gets it? 1 / 10 who take antipsychotic medicine for years Features Slow writhing movements to tongue, lips, jaw or body Treatment Lower the dose of medicine to lowest possible dose Change to a different type of antipsychotic (Olanzapine) Stop anti-cholinergic medicine Add propranolol

Emergencies due to medicine Neuroleptic malignant syndrome (NMS) Serotonoergic syndrome (SS) A rare and serious side effect of antipsychotic medicine (NMS) or antidepressant medicine (SS) Who gets it? 1 / 1000 who take antipsychotic or antidepressant medicine Features Fever, high pulse, high / low blood pressure, symptoms of delirium, shake, stiff arms, pass urine uncontrollably Treatment Stop all medicine and admit to hospital CK and WCC blood tests IV and benzodiapine, dantrolene Do not prescribe same medicine again

Emergencies due to medicine Discontinuation syndrome Can occur if a medicine for mental illness is stopped suddenly Features Dizziness, headache, nausea, vomiting, lack of energy, restlessness, diarrhoea, body pains Treatment Advise people never to stop medicine suddenly Make a plan for when medicine runs out Discuss any difficulties associated with medicine eg side effects

Managing violence and aggression Brainstorm What are the warning signs? How to calm someone Safe distance Don’t get trapped Stay calm, controlled and confident Make eye contact but do not stare Talk and listen Correct any misunderstanding Plan how you can get help if needed If they are still aggressive Give strong and simple directions Call the police Consider using restraining medicines (Haloperidol 10-20mg) Only use one medicine and follow guidelines in ES Afterwards Talk about how this can be avoided

Managing violence and aggression Activity Get into groups of 3 or 4 A Patient A nurse One or two observers Role play

Managing your own mental health Helping people can be hard work Watch out for signs of stress Problems sleeping Impatience or irritability Tension, aches, pains Drinking alcohol Inability to relax and have fun Have fun past times (listening to music) Take breaks Sleep, eat and exercise Talk to others – set up a group Look after yourself – you deserve it!!

Evaluation Evaluation of aims Quiz Quiz answers Feedback questionnaire Essential skills Breakdown

Quiz Day 1 Which of the following would you ask everyone you see for the first time who might have a mental illness? (‘Golden Questions’?) Do you have problems sleeping at night? Have you been feeling sad or unhappy recently? Have you lost interest in your daily activities? All of the above

Quiz Day 1 When we assess a persons appearance, what they say and how they behave; we call this the: Physical health examination Mental state examination Safety questions History of the presenting complaint

Quiz Day 1 The bio-social treatment model involves the use of: Healthy food and exercise Medicine only Psychological treatment only Medicine, social treatment and psychological treatment

Quiz Day 1 Medicine for mental illness should be used when: You are not sure what kind of mental illness the person has The person has a serious mental illness The persons family request it All of the above

Quiz Day 1 True or false? By showing warmth, empathy and treating someone with respect you can help them to get better? True or False

Quiz Day 1 If a person has more than one type of mental illness you should Treat the least serious illness first Treat both illnesses at the same time Treat the most serious illness first Treat the illness that requires the cheapest medicines

Quiz Day 1 1.True or false? The most important cause of delirium is physical illness? True or False

Quiz Day 1 Which of the following is a key feature of partial seizures? Full loss of consciousness Jerky movement in one part of the body Shouting Passing of urine

Quiz Day 1 What are the best medicines for the long term treatment of epilepsy? Diazepam with thiamine Sodium valproate with carbamazepine Sodium valproate or carbamazepine Chlorpromazine / largactil

Quiz Day 1 1.True or false? Medicines should be used to treat dementia when there is no physical cause? True or False

Quiz Day 2 Which of the following can be used to treat alcohol withdrawal reaction? Thiamine Diazepam Folic acid All of the above

Quiz Day 2 People with psychosis should: Should be kept indoors Stop their medicine as soon as they are better Stay on their medicine for 2 years after they are better Not listen to music

Quiz Day 2 Which of the following statements are true? Depression: Should be treated with a combination of medicines Should not be managed with social treatment Affects 1 in 5 people Is not treatable

Quiz Day 2 Which of the following can cause manic depression? Alcohol and drug use HIV Antidepressants All of the above

Quiz Day 2 True or false? It is possible to cure all types of mental retardation? True or False

Quiz Day 2 You should give medicine to people with mental retardation if: They have seizures and / or an under active thyroid gland They have severe mental retardation They have mild mental retardation Their family asks you to prescribe medicine

Quiz Day 2 1.True or false? If a person takes their medicine correctly, they can still have a bad reaction to the medicine? True or False

Quiz Day 2 Which of the following is a feature of discontinuation syndromes? Dizziness and headache Nausea and vomiting Restlessness and body pains All of the above

Quiz Day 2 When trying to prevent someone from becoming violent? Physically restrain them immediately Give IV haloperidol immediately Call the police Talk calmly, stay controlled and keep a safe distance

Quiz Day 2 1.True or false? Fun past times combats stress? True or False

Goodbye and thanks