1. Mental Health Concerns in a Palliative Care Setting- When should I be worried? Jan Helbert Consultant Psychologist Bradford Hospitals FT Martin Thornton Learning & Development Primary Care Mental Health Bradford and Airedale Community Health Services

2. Introduction to mental health (depression and self harm/suicide) Introduction to mental health (depression and self harm/suicide) Increase knowledge and confidence Increase knowledge and confidence Screening and assessment in palliative care patients and their carers Screening and assessment in palliative care patients and their carers Knowledge of different teams and services and how to access Knowledge of different teams and services and how to access Learning Outcomes

3. Mental Health Issues Psychological Distress Anxiety Anxiety Depression Depression Deliberate self harm Deliberate self harm Psychotic Illness Psychotic Illness Organic brain syndrome Organic brain syndrome Communication & relationship issues Communication & relationship issues Alcohol & drug related problems Alcohol & drug related problems Personality disorders Personality disorders

4. Depression and Anxiety in Palliative Care 10-15% of patients with advanced illness experience levels of anxiety and depression serious enough to warrant intervention by specialist psychological/mental health services 10-15% of patients with advanced illness experience levels of anxiety and depression serious enough to warrant intervention by specialist psychological/mental health services

5. Why should we be concerned? Need to address psychological needs routinely Need to address psychological needs routinely Lots of opportunities to engage people when we can all make a difference. Lots of opportunities to engage people when we can all make a difference. Acknowledging distress is often first step (all levels of severity) Acknowledging distress is often first step (all levels of severity) Can work towards reducing risks Can work towards reducing risks

6. Focussing on what we know are particularly difficult situations Depression Depression Self Harm/Suicide Self Harm/Suicide

7. Depression Depression or distressed, miserable or low in mood Depression or distressed, miserable or low in mood When does depression become a serious concern When does depression become a serious concern

8. Common of Depression Common Symptoms of Depression Sad, Anxious Sad, Anxious Loss of Interest Loss of Interest Decreased energy/fatigued Decreased energy/fatigued Poor concentration Poor concentration Decision making Decision making Sleep Sleep Appetite Appetite Hopelessness pessimism Hopelessness pessimism Guilt, worthlessness, helplessness Guilt, worthlessness, helplessness Thoughts of death/suicide Thoughts of death/suicide

9. Kind of things someone with severe depression might say… ‘ Anxious’ ‘ Anxious’ ‘A living nightmare, never felt so bad in my life…must be something better than this…would be better if I wasn’t here’ ‘A living nightmare, never felt so bad in my life…must be something better than this…would be better if I wasn’t here’ ‘In a prison. I don’t know if I can get out’ ‘In a prison. I don’t know if I can get out’ ‘Big black hole of horror’ ‘Big black hole of horror’ ‘Cant make up my mind be realistic’ ‘Cant make up my mind be realistic’ ‘As if I have a different brain. I’m not in charge of myself’ ‘As if I have a different brain. I’m not in charge of myself’ ‘Hopeless, tired of living, frightened of dying’ ‘Hopeless, tired of living, frightened of dying’ ‘No appetite’ ‘No appetite’

10. What can we offer someone ‘in a space of perceived hopelessness’ Can feel overwhelmed….. Can feel overwhelmed….. Can be very hard to listen to the distress…. Can be very hard to listen to the distress…. If we can do its important to really listen and pay real attention to the persons experience… If we can do its important to really listen and pay real attention to the persons experience… Involves opening a space for sharing, talking, silence, trying to be alongside… Involves opening a space for sharing, talking, silence, trying to be alongside… Where we can try and really understand and make sense of the distress…… Where we can try and really understand and make sense of the distress……

11. Approaching a Screening Engagement Engagement Approach as you would with physical symptoms Approach as you would with physical symptoms Try and understand what's causing it…. Try and understand what's causing it….

12. Depression, what would the be? Depression, what would the questions be? 2 screening questions may be: (Patient Health Questionnaire PHQ9) 1 During the last month have you been bothered by feeling down, depressed or hopeless? 2 During the last month have you been bothered by having little interest or pleasure in doing things?

13. Screening Distress Try and gain a picture of what its like for this person at this time? Try and gain a picture of what its like for this person at this time? Severity, frequency, duration, triggers, alleviating factors Severity, frequency, duration, triggers, alleviating factors Explore the causes Explore the causes Explore coping mechanisms and strengths Explore coping mechanisms and strengths Is help required? What help? Is help required? What help?

14. When to have alarm bells Severity Severity Not improving Not improving Hopelessness pessimism Hopelessness pessimism Ideas to self harm Ideas to self harm Intent Intent

15. Case Study 1 You are visiting a patient for an initial assessment. Her husband died unexpectedly about a year ago. The patients illness is advanced but stable. Before you enter the room the patients daughter tells you her mother has been very low and said to her that she would be better off dead and has been asking if anyone would help her. You are visiting a patient for an initial assessment. Her husband died unexpectedly about a year ago. The patients illness is advanced but stable. Before you enter the room the patients daughter tells you her mother has been very low and said to her that she would be better off dead and has been asking if anyone would help her. How would you respond? How would you respond? How would you assess? How would you assess? What would influence the outcome of your assessment? What would influence the outcome of your assessment?

16. Case Study 2 Staff have let you know that the patient you are seeing has been very low and tearful. She usually enjoys spending time with her grandchildren although has been avoiding this. They have been a central part of her life. She starts telling you about her concerns that her house hasn’t been built properly and that she thinks the foundations aren't right and this means the house is going to fall down. She doesn’t seem able to dismiss this thought. Staff have let you know that the patient you are seeing has been very low and tearful. She usually enjoys spending time with her grandchildren although has been avoiding this. They have been a central part of her life. She starts telling you about her concerns that her house hasn’t been built properly and that she thinks the foundations aren't right and this means the house is going to fall down. She doesn’t seem able to dismiss this thought. How would you respond? How would you respond? How would you assess? How would you assess? What would influence the outcome of your assessment? What would influence the outcome of your assessment?

17. Case Study 3 You are working with a middle aged gentleman who has told you that he doesn't wish to suffer at the end of his life and that he plans to end his life when he starts to loose his independence and rely on others for his care. He seems to tell you this in a calm way. He tells you at present that he is still able to enjoy time with his children. You are working with a middle aged gentleman who has told you that he doesn't wish to suffer at the end of his life and that he plans to end his life when he starts to loose his independence and rely on others for his care. He seems to tell you this in a calm way. He tells you at present that he is still able to enjoy time with his children. How would you respond? How would you respond? How would you assess? How would you assess? What would influence the outcome of your assessment? What would influence the outcome of your assessment?

18. Positive Symptoms  Disordered thinking – Thoughts jump - Thoughts blocked - Seem to talk nonsense  Delusions - False beliefs or thoughts with no basis on reality  Hallucinations –(False or imagined sensations) Hearing, seeing or feeling things that are not there. Hear voices that may comment on their behaviour or give them commands Signs/Symptoms Psychosis

19. Negative Symptoms  Blunted (or flat) Affect. Does not show feelings or emotions facially  May avoid eye contact  Few gestures and movements  May not respond to normal conversation  Lack energy  Show little initiative  Lack pleasure or interest in past enjoyable activities Signs/Symptoms Psychosis

20. Summary Engagement Engagement Ask directly about experiences Ask directly about experiences Do feel depressed Do feel depressed Have you had any thoughts that could harm yourself? Have you had any thoughts that could harm yourself? Try to understand cause of distress Try to understand cause of distress Identifies strengths and coping….Whats been a help before? Identifies strengths and coping….Whats been a help before? What does the person want? What does the person want? Make a decision about whether you need to involve and try to discuss this Make a decision about whether you need to involve and try to discuss this

21. Primary Care = GP, Practice Nurse etc Primary Care Mental Health Team (PCMHT) Social Prescribers Health Trainers Mild to Moderate Community Mental Health Team (CMHT) Moderate to Severe Intensive Home Treatment Service Simplifies Care Pathway