essential skills for mental health care dr jim crabb 14 th september 2007
TRANSCRIPT
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Essential SkillsFor mental health care
Dr Jim Crabb
14th September 2007
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Quiz
?
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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
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Substance misuse: Drugs
Illicit drugs• Marijuana (cannabis, wee)
• Cocaine
• Heroin
Medicines• Sleeping tablets
• Pain killers
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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
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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
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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
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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
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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
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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
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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
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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
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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!
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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
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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?
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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
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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
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Psychosis: What next?
Stay on medicine for at least 2 years after they get better
Stop medicine slowly over several months
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Break time
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Mood disorders: Depression
What are the key features of depression? Brainstorm!
Who gets depression?• 1 / 5 people
• More common in women
• 30-40 years of age What is the cause?
• A stressful event
• A lack of people around to support
• Alcohol or drug use
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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?
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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
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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
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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
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Mood disorders: Mania and manic depression What are the key features? Brainstorm! Who gets it?
• 1 / 100 people
• 20-30 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)
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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?
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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
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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
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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
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Lunch time
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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
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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?
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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
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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
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Mental retardation: What next
Community support group No herbal cures
With love and support a person with
mental retardation can have a happy life!
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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)
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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
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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
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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
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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
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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
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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
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Managing violence and aggression
Activity Get into groups of 3 or 4
• A Patient
• A nurse
• One or two observers
• Role play
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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!!
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Evaluation
Evaluation of aims Quiz Quiz answers Feedback questionnaire Essential skills
• Breakdown
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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
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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
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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
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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
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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
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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
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Quiz Day 1
1. True or false? The most important cause of delirium is physical illness? True or False
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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
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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
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Quiz Day 1
1. True or false? Medicines should be used to treat dementia when there is no physical cause? True or False
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Quiz Day 2
Which of the following can be used to treat alcohol withdrawal reaction?• Thiamine
• Diazepam
• Folic acid
• All of the above
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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
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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
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Quiz Day 2
Which of the following can cause manic depression?• Alcohol and drug use
• HIV
• Antidepressants
• All of the above
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Quiz Day 2
True or false? It is possible to cure all types of mental retardation?
True or False
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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
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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
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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
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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
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Quiz Day 2
1. True or false? Fun past times combats stress? True or False
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Goodbye and thanks