MENTAL HEALTH AND INTELLECTUAL DISABILITY. Presented by The Junction Works Ltd

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1 MENTAL HEALTH AND INTELLECTUAL DISABILITY Presented by The Junction Works Ltd

2 Myth or Reality Questionnaire Sharing knowledge is the best way to overcome preconceptions about mental illness 2

3 Introduction Agenda Promoting Good Mental Health Prevalence and Definitions of Mental Disorders Anxiety, Depression, Suicide Bipolar Disorder, Schizophrenia Access to Services Q&A Evaluations 3

4 Mental Health Continuum Everyone s mental health constantly fluctuates up and down the continuum to varying degrees. Where are you on the continuum? 4

5 Prevalence What do you think is the prevalence of Mental Health disorders in the normal population? Referring only to disorders causing major disruption to a person's behaviour, emotions or thinking. 5

6 The Mental Health of Australians Reference: Mental Health First Aid Training and Research Program. Orygen Research Centre, University of Melbourne;

7 The Mental Health of Australians by Age /Gender Reference: The Mental Health of Australians, Andrews et al, Mental Health Branch, Commonwealth Department of Health and Aged Care, April

8 People with Intellectual Disability and Mental Illness What are the Facts? We know that our clients with an ID are at a greater risk of having a mental disorder than the general population (Brown, 2000) a rate of mental disorders that is 4 times higher than the general population a prevalence of mental disorders of about 40% of ID population Less than 10% of clients with an ID and mental disorder received mental health intervention over a 14 year period (Einfeld, et al, 2006) 8

9 Mental Illness Illness is a term with a medical basis Medical overtones of disease (something enduring) The word illness implies a major disruption to a person's behaviour, emotions or thinking Implied (physical) cause in meaning of illness Mental illness is also a legal term (Mental Health Act) 9

10 Mental disorder - Mental disorder used by World Health Organisation Meaning of disorder implies treatment focus and recovery Preferred option because it is without the medical overtones Meaning of Disorder implies episodes can come and go in a person's life which better represents the facts/evidence. Better reflects that the exact causes of mental illness are unclear and that several contributing factors have been identified as predisposing people towards developing a problems. 10

11 Causes of Mental Disorders 11

12 Example: Causes of Schizophrenia Reference: 12

13 Anxiety 13

14 When does Anxiety become a Disorder? Affects person s functioning in social, occupational or other domains (difficult to control the anxiety) Characterised by a recurrent, marked fear, out of proportion to threat, excessive worry more days than not in 6 month period. 14

15 Types of Anxiety Disorders 15

16 Anxiety Disorders About 1 in 10 people are affected in their lifetime Specific phobias e.g. spiders Generalised anxiety Panic disorder Social phobia Agoraphobia Obsessive compulsive disorder (OCD) Acute stress disorder Post traumatic stress disorder (PTSD) 16

17 Anxiety Disorders and PWID Anxiety present has to be over and above what you would expect from the primary diagnosis (e.g. autism) for a disorder to be diagnosable. Difficult to diagnose anxiety due to communication and cognitive limitations e.g. Repetitive use of language, Autistic features can mimic signs of anxiety Symptoms of anxiety may be masked by the sedating effects of psychotropic medication Anxiety may look a lot like challenging behaviour (not typical anxiety) e.g. anxiety overshadowed by signs of aggression, or self-harming 17

18 Treatments for Anxiety Medications Antidepressants (eg, Prozac, Zoloft) Benzodiazepines (e.g. Valium) Psychological Cognitive behavioural therapy (CBT) Graded Exposure Therapy Relaxation techniques alone or as part of CBT or graded exposure 18

19 What can I do to support my Client with Anxiety? Support during transition Reassure your client when appropriate Be a good listener non judgemental Model relaxation strategies and encourage daily practice Encourage your client to set some small goals Achievements, no matter how small, can help the individual to feel better about themselves Use social stories/pictures/routines to assist in education about their anxiety in conjunction with psychologist Be patient! 19

20 Depression 20

21 Depression: Workbook Activity Question 1: How might depression be thought of as separate from just sadness? Question 2: What are some of the signs of depression you might notice in people with Intellectual Disability that you support? Taken from: You Won t Die Laughing by Patricia Cameron-Hill and Dr Shayne Yates

22 Depression: Causes and Treatments 22

23 Treatments for Depression See Participant Handout for table listing effective treatments available for depression Medical: Antidepressants (eg, Prozac, Zoloft); Electroconvulsive therapy (ECT), hospitalisation for safety and establishment of medication Psychological: Cognitive Behaviour Therapy (CBT) % effectiveness, no serious side effects, lower relapse rates. 23

24 Depression: Seeking Help 24

25 Depression, help seeking and suicide risk Depression is the leading cause of suicide Reasons why people with depression don t seek help - People won t understand (I feel all alone) - I m the problem. I don t deserve any help - Stigma: Your just feeling sorry for yourself - Insight: I don t have depression. It s just the blues 25

26 Encouraging seeking help Take depression seriously Provide a message of hope (role-play) 26

27 What else can I do? Additional ways you can assist a client: Check in regularly Encourage maintaining a routine Encourage interaction with others Encourage exercise / keeping active Keep data on sleep and eating Assist them to learn to manage stress If at risk, check in about suicidal thoughts 27

28 Suicide Awareness 28

29 WHAT ARE THE FACTS ABOUT SUICIDE IN AUSTRALIA 2011 ABS data indicates that 2,273 people committed suicide that year 29

30 Suicide and PWID Research Findings Causes/Risk factors for ID pop. are the same as the general population 23% reported having thought about suicide before attempting 11% reported having thought about suicide and knew how they would go about doing it (had a plan) In 23% of the cases family and staff did not know the person had suicidal thoughts 30

31 Risk factors that increase the probability of suicidal behaviour: Untreated Mental Health: Untreated mental illness (including depression, bipolar disorder, schizophrenia, and others) is the cause for the vast majority of suicides. Life Circumstances: Stressful life events - recent loss of significant person, relationship breakdown, legal crisis, interpersonal conflict Previous Attempts to Commit Suicide: Increased risk of success if previous attempts made have failed 31

32 High Risk Warning Signs Has a plan Has access to the means Anticipates death (Giving possessions away, I wont be around so I won t plan ahead) Is organizing death around the plan (Writing suicidal notes, Saying good-bye) Research has shown that at least two-thirds communicated their intention at some point before committing suicide. Attempts to communicate the intention are not always direct! 32

33 Responding to Warning Signs Communication about taking ones life can be indirect: I feel like chucking in the towel What s the point? I wish I wasn t here. I just can t take it anymore I wish I was dead Here take this; I won t be needing this anymore The only way to find out about whether someone is contemplating suicide is to ask. 33

34 Responding to Warning signs continued If you are concerned ask the person in a direct way if they are thinking of suicide and if they have any plans Key Points to remember: A direct question about suicide often lowers anxiety/suicidal thoughts A suicidal person often neither wants to die / is fully intent on dying Asking this won t put any ideas or plans in their head that were not there already. 34

35 1. Let the person know you are concerned Tell them you are worried about them Reinforce you are there to help 2. ASK them if they are thinking about suicide of have made any plans. How might we ask someone if they are feeling suicidal? Steps to remember in a crisis 35

36 Bipolar Affective Disorder 36

Bipolar Disorder: Myths and Clarifications Bipolar depression symptoms are over three times more common than mania Bipolar disorder is not primarily about manic symptoms.

37 Bipolar Disorder: Myths and Clarifications Bipolar depression symptoms are over three times more common than mania Bipolar disorder is not primarily about manic symptoms. Episodes of mania are relatively rare. Rapid cycling patterns. When mixed episodes occur, a frequent cycle (rapid change from mania to depression) is considered to be a cycle of up to 4 times per calendar year. Reference: 37

38 Types Bipolar 1 More likely to experience increased severity and psychotic symptoms. History of hospitalisations Bipolar 2 generally have episodes of hypomania that last for a short time with no psychosis e.g. hours or at most a few days Cyclothymia mild symptoms. People with this condition can be fully functioning and the condition may go undiagnosed. 38

39 Video Bipolar (Mania episode) 39

40 Mania The mood changes must last for at least a week, or be so severe that hospitalization is required. Not always a happy high; may be an irritable high Excessive engagement in pleasurable activities without thought to their distressing consequences Causes impairment in social or occupational functioning SEXUAL ISSUES are amongst the most common, but least discussed symptoms 40

41 Hypomania Less severe phase than a manic episode. Can occur prior to a full manic episode. The symptoms of bipolar mania and hypomania are the same - what is different is the DURATION and INTENSITY of the bipolar symptoms. In hypomania, the symptoms must last for at least 4 days and are not serious enough to require hospitalization. 41

42 Depression Feeling sadness or emptiness Losing interest or pleasure in one's usual enjoyments Changes in appetite (up OR down), and/or substantial and unplanned loss of weigh or weight gain Insomnia Excessive tiredness or sleepiness, and/or lack of energy Restlessness and agitation Indecision "Fuzzy" thinking, problems concentrating, or memory loss Thoughts of self harm or suicide 42

43 Bipolar and Intellectual Disability Cognitive symptoms of mania are seen less often (e.g. inflated self-esteem, grandiosity). Racing thoughts may present as the person jumping from topic to topic, moving from one activity to another before completion, racing around. Pressured speech may present as; increase vocalisation (rate or volume) or gesturing, repetitive questioning, increase in perseveration / monologues. Mania behaviour presents as; irritable mood, overactivity, decreased sleep. Persistently elevated mood may present as inappropriate laughing or singing, excessively giddy or silly, intrusive, getting into other s space. 43

44 Treatment Guidelines for Bipolar Acute Phase Disorder Stabilisation of the episode - goal is to achieve remission Rapid control of agitation, aggression and impulsivity to ensure safety of patients and those around them Maintenance Phase Reduction of cycling frequency and mood instability Improve overall functioning Consider adherence issues to prescribed medications Engage in education about relapse prevention Reference: Practice guidelines for the treatment of patients with bipolar disorder. American Journal of Psychiatry,

45 Medications Mood stabiliser drugs tend to be used for long-term maintenance to reduce the frequency, duration and severity of episodes. Mood stabilisers are so far limited to: Lithium Lamictal Zyprexa Sodium Valproate Other drugs associated with treatment are used because of their effectiveness against Depression or Mania and not both. 45

46 Medications Mood stabilisers (and) Antidepressants (e.g. zoloft) in combination with stabiliser Antipsychotics for treatment of psychotic symptoms (e.g. risperidone, quetiapine) in combination with mood stabiliser Reference: 46

47 What can I do to support my client with Bipolar Disorder? Monitor and encourage medication compliance Know when to get help early Educate carers about warning signs (symptoms of mania / depression). Listen with understanding, don t confront their reality. Get help early in a relapse. Hospitalisation during manic or depressive episodes where appropriate Referral for relapse prevention support when stable 47

48 Schizophrenia 48

49 Onset of Schizophrenia Onset varies according to gender Prodromal symptoms Chronicity varies Main Symptom Types in Schizophrenia Positive Symptoms cluster Negative Symptoms cluster 49

50 Overview of Positive Symptoms Positive Symptoms: An excess or distortion of normal functions. Hallucinations a sensory perception (hearing, sight, touch, taste, smell) that seems real to the person but there is no stimulation of the relevant sensory organ Delusions strongly held false beliefs (i.e. no basis in reality). Thought disorder confusion. Usually evident through the persons speech, e.g. incomprehensible speech Reference: 50

51 Video: Simulation of Psychosis 51

52 Responding to Psychosis Talk clearly and slowly Give the person time Do not make promises that cannot be kept Do not pretend that you can see or hear the hallucinations or delusions. Acknowledge what the person says, but, try not to agree or disagree Reassure them if they are worried Comply with reasonable requests. Do not try to reason with the person about their delusions and hallucinations 52

53 Negative Symptoms Schizophrenia also characterised by negative symptoms, which are seen to be a reduction or loss of normal functions. Loss of drive (i.e. no motivation or initiative) / loss of skills Loss of ability to feel pleasure Difficulty expressing emotion flat Social withdrawal / reduced speech Poor concentration, memory, planning and organising 53

54 Positive Symptoms in PWID Thought content is often less bizarre Behaviour Examples: New avoidance or fears Increases accusations of others Sudden refusal of routine medications 54

55 Negative Symptoms in PWID Negative symptoms difficult to assess due to the effect of developmental delay on life skills Negative symptoms may be mistaken as laziness or deliberate non-compliance and not as part of the illness Negative symptoms may be confused with depression or difficult to detect in people with long-term social withdrawal 55

56 Treatment and Care in Schizophrenia Medications Typical and Atypical antipsychotics Side effects Other supports What can I do to support my client? Supporting a connection with reality Guiding active participation 56

57 Access to mental health services in the community 57

58 How could people with an intellectual disability be disadvantaged? 1. Discuss a person you support that has a MH concern and unmet MH service need? 2. Discuss some of the obstacles they face with access to MH support? 3. Discuss ways you might attempt to improve outcomes/overcome barriers to MH support? 58

59 Getting the most from community psychiatry Most mental health needs are met in the community. We should talk about how to get the most from consultations with a psychiatrist for your client? 59

60 Hospital Settings 60

61 Emergency Departments are useful only in emergencies! Try and avoid emergency presentations. There is a better chance of a successful consultation with a booked outpatient service. The assessment and management in emergency of a mental health crisis aims to assist the person through a period of immediate or imminent risk of harm. Primary responsibility for security of patients whilst on the hospital premises remains with the management of the hospital 61

62 Discharge requirements from in-patient units 1. Transfer of Care plan 2. Transfer/Discharge Summary The person being discharged must have suitable accommodation and a means of returning home 62

63 MENTAL HEALTH ADMISSIONS Admission can be either involuntary or voluntary There are strict rules regarding the detention, review and discharge for each type of admission. Voluntary Admissions A person may be admitted to a mental health facility as a voluntary patient whether or not the person is a mentally ill person or a mentally disordered person. A person under guardianship may be admitted to a mental health facility as a voluntary patient if the guardian of the person makes a request to an authorized medical officer. 63

MENTAL HEALTH ADMISSIONS Involuntary detention of a person The person must be certified as mentally disordered. No other care of a less restrictive kind is appropriate.

64 MENTAL HEALTH ADMISSIONS Involuntary detention of a person The person must be certified as mentally disordered. No other care of a less restrictive kind is appropriate. If an authorised medical officer is of the view that the person is not mentally disordered they must not continue to detain them. A detained person can be admitted as a voluntary patient as soon as they are discharged if this is deemed appropriate. 64

65 Community Treatment Orders A community treatment order is a legal order made by the Mental Health Review Tribunal. When dealing with criminal matters a CTO may be made by a magistrate. A CTO authorises the compulsory treatment in the community of a person, by the implementation of a treatment plan. Force cannot be used to administer medication to someone on a CTO. A CTO can be applied for when a person is in hospital prior to their discharge, in detention prior to their release, or when they are already in the community by their treating team / GP. A CTO can be made in the absence of the person e.g. if they refuse to attend or accept treatment 65

66 Mental Health Care Planning Planning for emergencies does not happen at emergency departments. Planning happens in the community once discharged at an appropriate forum. It is essential that planning has been previously undertaken at the earliest time and when the client is in stable health. 66

67 Mental Health Care Plan Protocols around admission, in patient support & discharge Clarify acute phase signs & symptoms Clarify working relationship with mental health services Risk management plans e.g. when admission is required 67

68 Mental Health Care Plan To address procedures to ensure services to clients are appropriate To address accountability for service provision to a particular client To address consistency in how a client s progress is monitored 68

69 Thank you for your participation 69

Treatment Options for Bipolar Disorder Contents

Keeping Your Balance Treatment Options for Bipolar Disorder Contents Medication Treatment for Bipolar Disorder 2 Page Medication Record 5 Psychosocial Treatments for Bipolar Disorder 6 Module Summary 8