CLINICAL PROTOCOL FOR COMMON MENTAL HEALTH PROBLEMS INCLUDING SUICIDAL INTENT

Transcription

1 CLINICAL PROTOCOL FOR COMMON MENTAL HEALTH PROBLEMS INCLUDING SUICIDAL INTENT RATIONALE Mental health problems can affect anyone. One in four people in the United Kingdom (UK) will have suffered from a mental health condition at some stage of their lives. Without support and treatment, mental health problems can have a serious effect on the individual and those around them. Every year in the UK, more than 250, 000 people are admitted to psychiatric hospitals and over 4,000 people commit suicide. There is no single cause of mental health problems and the reasons they develop are complex (National Institute for Health and Clinical Excellence [NICE] 2011). TARGET GROUP The procedure applies to all registered and support clinical staff employed by the Trust who have patient contact as part of their role. TRAINING All staff in the Trust are required to comply with mandatory training as specified in the Trusts mandatory training matrix. Clinical staff are also required to comply with service specific mandatory training as specified within their service training matrix. RELATED POLICIES Please refer to relevant Trust policies and procedures OVERVIEW OF COMMON MENTAL HEALTH PROBLEMS Mental health problems can take many different forms and affect people in different ways. Mental health problems are more common in certain groups, such as: People with poor living conditions People from ethnic minority groups People with Long Term Conditions Homeless people Offenders During the perinatal period

2 Mental health problems are more common in certain people, e.g. women are more likely than men to have anxiety disorders and depression, drug and alcohol addictions are more common in men, and men are also more likely to commit suicide. The perinatal period is a vulnerable time for women especially if they have a previous history of perinatal depression. Mental health problems can develop as a result of previous or existing difficult life events, physical illness, excessive consumption of alcohol, and use of prescribed or non-prescribed medication can contribute to an individual s mental health problem or, cause an exacerbation in people who are already vulnerable. CLINICAL ASSESSMENTS Community nursing and specialist nursing staff are expected to assess mental health as part of their holistic assessment. The mental health assessment tools highlighted in this protocol are to be used when clinically indicated. All patients with a Long Term Condition should be offered a mental health assessment. Allied health professionals and other clinical staff should also be mindful of patients presenting with a low mood as they may need referring to their General Practitioner. DEPRESSION Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Living with depression is difficult for those who suffer from it and for an individual s family, friends, and colleagues. It can be difficult to assess and diagnose depression, and to recommend the most appropriate treatment option for the individual. The symptoms of depression can be complex. Depression commonly interferes with an individual s work, social life and family life. There are many other symptoms, which can be psychological, physical and social. Psychological symptoms include: continuous low mood or sadness feelings of hopelessness and helplessness low self-esteem tearfulness feelings of guilt feeling irritable and intolerant of others lack of motivation and little interest in things difficulty making decisions 2

3 lack of enjoyment suicidal thoughts or thoughts of harming yourself feeling anxious or worried reduced sex drive Physical symptoms include: slowed movement or speech change in appetite or weight (usually decreased, but sometimes increased) constipation unexplained aches and pains lack of energy or lack of interest in sex changes to the menstrual cycle disturbed sleep patterns (for example, problems going to sleep or waking in the early hours of the morning) Social symptoms include: not doing well at work taking part in fewer social activities and avoiding contact with friends reduced hobbies and interests difficulties in home and family life Depression can happen suddenly as a result of physical illness, experiences dating back to childhood, unemployment, bereavement, family problems or other life-changing events. Examples of chronic illnesses linked to depression include heart disease, back pain and cancer. Pituitary damage, a treatable condition which frequently follows head injuries, may also lead to depression (NICE 2009). Mild depression Depression is described as mild when it has a limited negative effect on a person s daily life. For example, an individual may have difficulty concentrating at work or the motivation to do the things they normally enjoy. Major depression Major depression interferes with an individual s daily life - eating, sleeping and other everyday activities. Some people may experience only one episode but it is more common to experience several episodes in a lifetime. It can lead to hospital admission, as the person may be assessed as having the potential to cause harm to themselves. Bi-polar disorder The mood swings in bi-polar disorder can be extreme - from highs, where the individual feels extremely elated and indestructible, to lows, where they may experience complete despair, lethargy and suicidal feelings. Sometimes people have very severe symptoms where they cannot make sense of their world and do things that seem odd or illogical. Assessment Tool: - Depression in Adults Patient Health Questionnaire (PHQ-9) When depression is suspected following assessment or contact with a patient, Trust staff should assist the patient to complete the Trust s Depression in Adults Patient Health 3

4 Questionnaire (PHQ-9), and evidence this within the patients health records and forward the results to the GP (CQC 2010: DH 2010). Post-natal Depression Post-natal depression can leave new mothers feeling completely overwhelmed, inadequate and unable to cope. They may have problems sleeping, panic attacks or an intense fear of dying (NICE 2007). They may also experience negative feelings towards their child. It affects one in ten mothers and usually begins two to three weeks after the birth. Postnatal depression sufferers can also suffer with the following symptoms: Have no appetite or over-eat for comfort Unable to cope with their new life and baby Feelings of anxiety Feelings of guilt Are afraid to be alone with their baby Suicidal thoughts Following NICE guidance Trust staff who holistically assess new mothers as part of their job role should ask the following two questions: During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things? Assessment Tool: - Edinburgh Postnatal Depression Scale (EPDS) Additionally, Trust staff who assess new parents and children as part of their job role e.g. health visitors should complete the Trust s Edinburgh Postnatal Depression Scale (EPDS) to ascertain the severity of depression following an initial assessment, when it is deemed appropriate and with the patients consent. Consent should also be obtained to share the results with the patients GP, if consent is not given and there is a real risk identified in Question 10, following further discussion and risk assessment, the health professional would need to share without consent. On completion of the questionnaire, it must be filed within the patient s notes appropriately along with documentation stating that the assessment has taken place (CQC 2010; DH 2010). The results must also be forwarded to the GP with the patient s consent. ANXIETY Anxiety is associated with the thought of a threat or something going wrong in the future, rather than something happening right now. There are several conditions for which anxiety is the main symptom; panic disorders, phobias and post-traumatic stress disorder can all cause severe anxiety. The symptoms of anxiety often develop slowly and can vary in severity from person to person. Some people experience only one or two symptoms, while others experience many more. 4

5 These include: Increased heart rate Irregular heart rhythm Breathing gets very fast Muscles feel weak Increased perspiration Churning stomach Loose bowels Difficulty concentrating Feelings of dizziness Feeling frozen to the spot Reduced appetite Hot and cold sweats Dry mouth Tense muscles. These are all a result of the body preparing to respond to an emergency. It increases the blood flow to the muscles, increases blood sugar and focuses the mind on the thing that maybe causing the feelings of anxiety. With anxiety, individuals may suffer from longer-term effects, such as: Increased sense of fear Irritability Trouble sleeping Headaches Trouble getting on with work and planning for the future Problems having sex Loss of self-confidence. As with most conditions that affect mental health, the exact cause of this condition is not fully understood. Some people develop the condition for no apparent reason. Others may develop more anxious feelings following a major stressful incident. Assessment Tool: - Generalised Anxiety Disorder Assessment: Trust staff with the necessary competencies should complete the Trust s Generalised Anxiety Disorder Assessment (GAD 7) as an aid to ascertain whether an individual is suffering from anxiety problems following a holistic assessment. On completion of the questionnaire, it must be filed within the patient s notes appropriately, along with documentation stating that the assessment has taken place (CQC 2010; DH 2010). The results should be forwarded to the GP accordingly along with the patient s consent. DEMENTIA Dementia is a decline in mental ability which affects memory, thinking, problem-solving, concentration and perception. Dementia occurs as a result of the death of brain cells or damage in parts of the brain that deal with our thought processes. 5

6 Dementia is a syndrome (a group of related symptoms) that is associated with an ongoing decline of the brain and its abilities. These include: memory thinking language understanding judgement There are several types of dementia: Alzheimer's disease, where small clumps of protein, known as plaques, begin to develop around brain cells. This disrupts the normal workings of the brain. Vascular dementia, where problems with blood circulation result in parts of the brain not receiving enough blood and oxygen. Dementia with Lewy bodies, where abnormal structures, known as Lewy bodies, develop inside the brain. Frontotemporal dementia, where the frontal and temporal lobes (two parts of the brain) begin to shrink. Unlike other types of dementia, frontotemporal dementia usually develops in people who are under 65. It is much rarer than other types of dementia. Dementia occurs as a result of the death of brain cells or damage in parts of the brain that deal with our thought processes. This may follow other problems like: lack of blood/oxygen supply to these brain areas head injury pressure on the brain e.g. from a tumour hydrocephalus neurological disease e.g. Parkinson's disease, Creutzfeld Jakob disease (CJD) infection e.g. AIDS vitamin deficiency a long period of excessive alcohol intake People with dementia may become apathetic, have problems controlling their emotions or behaving inappropriately in social situations. Aspects of their personality may change or they may see or hear things that other people do not, or have false beliefs. Most cases of dementia are caused by damage to the structure of the brain. People with dementia usually need help from friends or relatives, including help in making decisions (DH 2009). The symptoms of vascular dementia can develop suddenly and quickly worsen, or they can develop gradually over many months. Symptoms include: increasing difficulties with tasks and activities that require concentration and planning memory loss depression changes in personality and mood 6

7 periods of mental confusion low attention span urinary incontinence stroke-like symptoms, such as muscle weakness or paralysis on one side of the body visual hallucinations wandering during the night slow and unsteady gait Confirming a diagnosis of dementia can be difficult, particularly when the condition is in its early stages. This is because many of the symptoms of dementia can be caused by other conditions. In order for dementia to be diagnosed correctly, a number of different tests and assessments will have to be conducted by a GP or other relevant health professional including: a review of an individual s personal history including education and employment a medical history overview a comprehensive assessment of mental abilities a range of tests, including blood tests to rule out other possible causes of symptoms, such as a vitamin B deficiency imaging scans, such as a CT scan or magnetic resonance imaging (MRI) scan, which can provide information about the physical state and structure the brain? a review of any medication being taken by the individual, in case these are contributing to their symptoms Assessment Tool: - General Practitioner Assessment of Cognition (GPCOG) Initially, Trust staff should complete a General Practitioner Assessment of Cognition (GPCOG) when there are suspicions relating to an individual s cognitive performance following a holistic assessment. On completion of the questionnaire, it must be filed within the patient s notes appropriately, documentation stating that the assessment has taken place, and the results forwarded to the GP accordingly along with the patient s consent (CQC 2010; DH 2010). In line with the National Dementia Strategy and with the consent of the patient when there are concerns relating to an individual s cognitive performance following an initial holistic assessment or when any memory deterioration is evident, staff need to complete or consider referral for a General Practitioner (GP) Assessment of Cognition (GPCOG) SELF-HARM Self-harm is when somebody intentionally damages or injures their body. Self-harm is more common than many people realise, especially among younger people. In most cases, people who self-harm do it to help them cope with unbearable and overwhelming emotional issues, caused by problems such as: Social factors such as being bullied, having difficulties at work or school, or having difficult relationships with friends or family Trauma such as physical or sexual abuse, or the death of a close family 7

8 member or friend Mental health conditions such as depression or borderline personality disorder These issues can lead to a build-up of intense feelings of anger, hopelessness and selfhatred. Although some people who self-harm are at a high risk of ending their lives, many people who self-harm do not want to end their lives. In fact, the self-harm may help them cope with emotional distress so they don t feel the need to kill themselves. There are many different ways people can intentionally harm themselves, such as: Cutting or burning their skin Punching themselves Poisoning themselves with tablets Misusing alcohol or drugs Deliberately starving themselves (anorexia nervosa) or binge eating (bulimia nervosa) People often try to keep self-harm a secret because of shame or fear of discovery. For example, they may cover up their skin and avoid discussing the problem It is important for anyone who self-harms to see their GP. They can treat any physical injury and recommend further assessment if necessary. SUICIDAL INTENT Many people with a mental illness have thoughts of suicide, or attempt suicide. Suicide is the main cause of premature death in people with mental health problems, but many suicides can be prevented. Suicide risk is affected by life events, and the way a person is affected by these events. Someone s social situation and history also affect risk. Different factors might make some people more vulnerable than others. However, risk factors might include: Something upsetting or life-changing happening such as a relationship breakdown or bereavement Social isolation and living alone A history of being abused Feelings of shame Mental health conditions, such as depression, psychotic illnesses or personality disorder Alcoholism, or misusing alcohol, or prescription or non-prescription drugs Having a physical health condition, especially if this causes pain or serious disability Previous suicide attempts, or having a family history of suicide Recent discharge from hospital if someone has a mental health condition Loss of job or income Having a stressful job Being unemployed or retired 8

9 In the UK, suicide is over three times more common amongst men than women. However, women are considerably more likely to attempt suicide or to self-harm than men are. A person may choose to end their lives to: Escape what they see as an impossible situation Relieve unbearable thoughts or feelings Convey their feelings to other people Relieve physical pain or incapacity Someone considering suicide may feel that there is nothing that can be done to rid themselves of the problems that are causing their suicidal thoughts. They may find it difficult to reason through their problem and instead concentrate on feelings of hopelessness. Examples of the kind of thoughts that could be leading someone to consider suicide include: I have let myself down What is the point in living I will never find a way out of my problem Things will never get better for me Nobody cares When a health professional is in discussion with a patient who expresses suicidal thoughts, it is important to reassure the person that these feelings are temporary and that they can get help, including help from a doctor. It is rare for someone to be certain that they want to end their own life. Most people will be undecided about suicide, seeing some pros and cons of living and dying. A lot of people seek help before attempting suicide by telling other people about their feelings or by selfharming to show people that they are in emotional pain. If someone discloses thoughts of self-harm / suicide / harm to others follow the Suicidal Intent Flow Chart (Appendix 1) and complete a risk assessment (Appendix 2) All assessment forms can be found on the staff intranet OBSESSIONAL COMPULSIVE DISORDER Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by uncontrollable, unwanted thoughts and repetitive, ritualised behaviours that the person feels compelled to perform. 9

10 PSYCHOSIS There are four main symptoms associated with a psychotic episode: hallucinations delusions confused and disturbed thoughts a lack of insight and self-awareness WHERE TO GET ADVICE FROM Trust staff need to contact relevant specialist service and Line Manager if guidance is required. Liaise with the patient s General Practitioner if further advice is needed. INCIDENT REPORTING Clinical incidents or near misses must be reported via the Trust s incident reporting system. SAFEGUARDING ADULTS In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adults Policy and discuss with their Line Manager and document outcomes. EQUALITY ASSESSMENT During the development of this protocol the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place. 10

11 REFERENCES Care Quality Commission (2010) Essential Standards of Quality and Safety. Department of Health (2010), Essence of Care. Department of Health (2009) Living well with dementia: A National Dementia Strategy. National Institute for Health and Clinical Excellence (2011) Common mental health disorders: Identification and pathways to care. National Institute for Health and Clinical Excellence (2009) Depression: Treatment and management of depression in adults, including adults with a chronic physical health problem. National Institute for Health and Clinical Excellence (2007) Anxiety: Management of anxiety (panic disorder with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. National Institute for Health and Clinical Excellence (2007) Antenatal and postnatal mental health: Clinical management and service guidance. National Institute for Health and Clinical Excellence (2004) Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care NHS Choices. Self-harm information prescription NHS Choices. Suicide information prescription Rethink Mental Illness. Helping someone with suicidal thoughts Wirral Community NHS Trust (2013) Clinical Protocol for the Early Detection and Management of Postnatal Depression 11

12 CONTROL RECORD Title Clinical Protocol for Common Mental Health Problems including Self Harm and Suicide Intent Purpose To develop staffs awareness and knowledge in relation to common mental health problems. Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Caroline Hewitt Document Librarian QGS Groups consulted with :- Clinical Policies and Procedures Group Infection Control Approved Not Applicable Date formally approved by Quality, Patient Experience and Risk Group January 2014 Method of distribution Intranet Archived Date: d April 2012 Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 Quality and N First version Governance Service Version 2 Quality and Governance Service Governance R Addition of Self-Harm and Suicidal Intent 12

13 APPENDIX 1 Suicidal Intent Flow Chart Client discloses thoughts of self-harm/suicide/harm to others. Explore this with client, covering core domains included on risk assessment Does the client have an active plan (i.e. a plan that he/she intends to act on immediately or in the very short term?) Yes If the client is present, stay with them and ring: Line manager Client s GP Out of normal office hours: Ring on call duty manager Call for an ambulance to take the client to Accident and Emergency If client is on telephone, act as above. Ring for ambulance if immediate help is required. Further advice available from: Central Advice and Duty Team ( ; Out of Hours ) No Send letter to GP detailing time/date/purpose of contact with client and summary of information disclosed, attaching risk assessment, and requesting an urgent review Complete client clinical record, including notes of all contact with patient and other health care professionals, copy of letters and risk assessment. Make up a new client file if none currently exists. If there are children involved contact Safeguarding 13

14 APPENDIX 2 RISK ASSESSMENT OF SUICIDAL INTENT Client s Name Date of Birth NHS Number Suicidal Intent (please tick all that apply) Wishes to be dead: Fleeting or fixed: Frequency: Current perception: Hopelessness/view of future: Plan Where: When: How: Means: Immediate intention: Measures to prevent detection: Background Events leading up to crisis/in last few months/past history of self-harm or suicide Factors which make suicide more or less likely Male: Drugs/alcohol: Mental illness: Other: Coping Mechanisms What has worked in the past? What has stopped them from carrying out suicide, now or in the past? Networks of support? Management Advice given Full name: Signed: Designation: Date: Time: Location: 14