Rosie Doy, Derek Burroughs, John Scott

Transcription

1 HE ABC OF COMMUNIY EMERGENCY CARE MENAL HEALH- CONSEN, HE LAW AND DEPRESSION- MANAGEMEN IN EMERGENCY SEINGS See end of artile for authors affiliations Correspondene to: R Doy, r.doy@uea.a.uk Rosie Doy, Derek Burroughs, John Sott Emerg Med J 2005; 22: doi: /emj his artile has been written with referene to the mental health legislation in England. Variations in this legislation our in other ountries of the UK. Pratitioners working in other ountries of the UK will require knowledge of the speifi legislation for their ountry. Mental health problems present in between 30% and 60% of primary are onsultations. 1 One in six men and one in four women will suffer from a mental illness at some point in their lives. 2 3 GPs, for example, find that at least 30% (or 1.5 days per week) of their working week onerns mental health onsultations. For depression alone, prevalene amongst the adult population in the UK varies between per thousand for men and from per thousand for women. he standards of the Mental Health National Health Servie Framework (MHNSF) aim to support more onsistent aess and delivery of primary are servies inluding out of hours and non-sheduled are at times of omplex need and mental health risis. Mental health presentations in primary are are frequently omplex and do not always fit easily into diagnosti ategories. 4 his artile will speifially onsider depression and deliberate self harm; patients with psyhoses will be onsidered in a seond paper to follow. ARICLE OBJECIVES o larify definitions of mental disorder o onsider key aspets of the Mental Health At (1983) and assessment of valid onsent and apaity o disuss the reognition of primary survey positive patients and those with omplex but not immediately life threatening presentations (primary survey negative patients) o desribe mental health assessment and differential diagnoses with speifi referene to depression and deliberate self harm o disuss alternatives to admission, treatment, and options for referral COMMON SIGNS AND SYMPOMS, DEFINIIONS, AND HE MENAL HEALH AC Just as in other aspets of illness, adequate and aurate desription of the signs and symptoms aids ommuniation and patient are. his is espeially important in the field of mental health emergenies, where there an be signifiant diffiulty with definitions of mental illness. here is also greater potential for onflit between the individual human right of autonomy and the professional duty of are to at in the patient s best interest. Patients who are have mental disorder requiring immediate treatment most ommonly onsent to that treatment or even if they do not onsent they may be often treated under Common Law in the patients best interest (although this has been reently hallenged, see below). Approximately 90% of those admitted to Mental Health Hospitals are admitted as informal patients, only 10% nationally are admitted under a Setion of the Mental Health At (MHA), against their will. Key to the understanding of the MHA is the definitions of mental disorder. Mental Disorder:... mental illness, arrested or inomplete development of mind, psyhopathi disorder, and any other disorder or disability of mind. he 4 sub-ategories of Mental Disorder are further defined. 1. Mental Illness:... here is no legal definition but there are many terms and definitions, see for example JRCALC Clinial Pratie Guidelines (June 2004) 5 or the International Classifiation of Diseases, version 279 Emerg Med J: first published as /emj on 23 Marh Downloaded from on 7 September 2018 by guest. Proteted by opyright.

2 DOY, BURROUGHS, SCO Mental illness may be defined as a number of onditions typially involving impairment of an individual s normal ognitive (thinking), emotional, or behavioral funtioning. Mental illness may be preipitated by biopsyhosoial, biohemial, normal, and traumati life events, geneti or other fators, inluding infetion or head injury. he following are some of the potential harateristis of mental illness presentations: impairment of intelletual funtions shown by a failure of memory, disorientation, diffiulties in omprehension, or learning apaity; persistent alteration of mood affeting the patient s daily life delusional beliefs abnormal pereptions (halluinations) assoiated with delusional beliefs and thinking patterns disordered thinking (ognition), whih prevents the patient exerising judgment and pereiving the onsequene of their ations Box 1 Common Signs and Symptoms of Mental Illness Changes in the nature of mood (affet) Disorders of pereption halluinations and illusions Disorders of thinking (ognition) delusions, negative thinking et Patient s appearane and behaviour Speeh and ommuniation 2. Severe Mental Impairment:... a state of arrested or inomplete development of mind, whih inludes severe impairment of intelligene and soial funtioning, and is assoiated with abnormally aggressive or seriously irresponsible ondut on the part of the person onerned 3. Mental Impairment:... a state of arrested or inomplete development of mind (not amounting to severe mental impairment), whih inludes signifiant impairment of intelligene and soial funtioning and is assoiated with abnormally aggressive or seriously irresponsible ondut on the part of the person onerned 4. Psyhopathi Disorder:... a persistent disorder or disability of mind (whether or not inluding signifiant impairment of intelligene), whih Abbreviations ASW: Approved Soial Worker CRH: risis resolution and home treatment terms DSH: deliberate self harm MHA: Mental Health At MHNSF: Mental Health National Health Servie Framework PICU: Psyhiatri Intensive Care Unit results in abnormally aggressive or seriously irresponsible ondut on the part of the person onerned IMPORANCE OF HE DEFINIIONS he definitions are legal terms, but the diagnosis of a type of Mental Disorder is a matter for linial judgement. Use of alohol and other substanes might sometimes ause a Mental Disorder, whih is within the sope of the At, but use of these substanes in itself is not within the sope of the At. Only a small number of professionals are involved in applying the MHA, prinipally Approved Soial Workers (ASWs), GPs, and dotors approved under Setion 12 of the At (either psyhiatrists or others with experiene in mental health who have been ertified by the Department of Health). Eah professional ompleting a reommendation for detention performs a detailed assessment of the patient s mental state and irumstanes. If any one of them feels there is insuffiient evidene to reommend detention, the person annot be kept in hospital. (Mental health law is urrently under review, the draft Mental Health Bill is urrently reeiving detailed srutiny (and engendering great debate) prior to enatment in due ourse. he MHA (1983) therefore is the urrent mental health legislative guidane.) In an emergeny situation the Polie have powers of arrest under setion 136 of the MHA. Under setion 136 the Polie may remove the patient to a plae of safety for detention for up to 72 hours. he patient may be detained within that time period by anyone aepting ustody from the Polie, and a plae of safety an inlude an NHS hospital, Polie station, mental health nursing home, residential home for the mentally disordered, Soial Servies residential aommodation, or any other suitable plae if the oupier is willing. It is important to note that Setion 136 does NO inlude the power to impose treatment without onsent. he patient has the right to onsult a soliitor in private and to have a person of their hoie present. POSSIBLE ACIONS FOR REAMEN OF A PAIEN WIH MENAL DISORDER In situations where a person is suffering from, Mental Disorder and refuses intervention for that mental disorder, then the authority for intervention may be the MHA (1983) he presene of Mental Disorder does not in itself render the individual unable to give valid onsent. Valid onsent is Possible ations for treatment of a patient with mental disorder Patient gives onsent Patient does not onsent but is inapaitated or unable to give onsent and will omply with treatment (dotrine of neessity-see below) Patient does not onsent, and will not omply with treatment suggestions REA REA Consider use of MHA Consider ontating Family/arers GP Psyhiatri team Polie Mental Health Soial Workers Emerg Med J: first published as /emj on 23 Marh Downloaded from on 7 September 2018 by guest. Proteted by opyright.

3 HE ABC OF COMMUNIY EMERGENCY CARE always situation speifi. An individual who has Mental Disorder may be able to give valid onsent for some things, but not for others. Use of the MHA is stritly defined. Informal patients are either: Admitted and treated with their valid onsent. Or: Inapaitated and unable to give valid onsent, so: Admitted and treated under the Common Law dotrine of: Neessity Ating in the patient s Best Interests Under a Duty of Care. If an inapaitated patient dissents, and the dissent is persistent and purposeful then an assessment should be made for ompulsory treatment under the MHA. A reent ruling by the European Court of Human Rights, 5 th Otober 2004, regarding the Bournewood ase may have signifiant impat on the use of Common Law to admit and treat inapaitated adults. At the time of writing the UK Government is onsidering their position regarding this ruling. Most importantly, unless the patient has been detained under a relevant setion of the MHA (urrently setion 3), if they have apaity they may legally refuse treatment, even if they are suffering from a mental disorder. Even if detained under setion 3, only treatment for the mental disorder an be legally imposed in a patient with apaity. reatment for a physial disorder whih is not assoiated with the mental illness annot be imposed under these irumstanes. ASSESSMEN OF VALID CONSEN he onepts of valid onsent and Common Law are important in this area of pratie. It is an underlying priniple of medial are that onsent should always be sought before any intervention is ommened. Failure to orretly determine the patient s ability to give valid onsent may lead to harges of assault, or battery, or worse. However, there is often a diffiult onflit between the patient s right to determine their own treatment and the professional responsibility to at in the patient s best interests. Failure to intervene and are for a patient who annot give valid onsent may lead to harges of negligene. A good understanding of the Law and how to apply it to pratie empowers not only the pratitioner, but also the patients with whom we work. How then do we determine where our legal authority omes from when working with patients? Initially we must attempt to gain our authority from the patient, via their valid onsent. Valid onsent omprises three omponents. he absene of any one omponent will render the onsent invalid. here are three omponents of valid onsent: Box 2 Components of valid onsent: Competene/apaity Dislosure of Information Voluntariness 1. Is the patient ompetent, or, does the patient have apaity to onsent? Competene and apaity are used interhangeably in this ontext. Assessment of a patient s apaity to make a deision about their own health are, is a matter of linial judgement, guided by urrent professional pratie and subjet to legal requirements. It is the personal responsibility of any health are professional proposing treatment to determine the patient has apaity to give valid onsent. An individual is presumed to have apaity to deide on a partiular treatment. his is termed a positive presumption of apaity. he Capaity test: Is the person able to take in and retain information material to the deision, espeially as to the likely onsequenes of having, or not having the treatment? Or: Is the patient unable to weigh the information in the balane, as part of the proess of arriving at the deision? It is important to remember that apaity will be affeted by ommon trauma situations suh as, shok, pain, or fear. 2. he seond omponent of valid onsent is Dislosure of Information. We must give the patient adequate information so that they an make an informed hoie. he law requires that we inform the patient of the broad terms of the nature of the proedure. We learly annot tell them all the details, but we must ensure they have adequate information on whih to base a deision. 3. he third omponent of valid onsent is voluntariness. We must ensure that neither we, nor anyone else, put undue pressure on the patient to omply with our wishes to intervene. here will be many instanes where are or treatment is needed, it is obvious that the patient is an adult, but is unable to give valid onsent. hey may be unonsious, traumatised or perhaps have ongoing dementia, or a mental disorder. Given that no one else an give valid onsent for another adult, Common Law omes into effet. If the adult patient does not meet the riteria for valid onsent then the Common Law dotrine of, neessity applies. We must be able to demonstrate that our interventions are neessary, neessary to save life or prevent deterioration of the situation. We must be able to demonstrate that our interventions are in he patient s best interests and be able to demonstrate we have a, Duty of Care to the patient. If we an demonstrate that all three riteria are present, and we are satisfied that we annot, for whatever reasons, obtain valid onsent from the adult patient, then Common Law empowers us, and gives us the authority for intervention. Indeed in these situations, if we do not intervene, then we may be held to be negligent in Law. he government has reently published a Capaity Bill in whih they intend to move some of these powers from Common Law to Statute Law. hey also intend to make other provisions for the are and treatment of inapaitated adults. his is unlikely to beome Law before PRIMARY SURVEY A mental illness may ause a patient to take an overdose or injure themselves in suh a way that they develop immediately life threatening ABCD problems. hese problems are overed in other artiles. 281 Emerg Med J: first published as /emj on 23 Marh Downloaded from on 7 September 2018 by guest. Proteted by opyright.

4 DOY, BURROUGHS, SCO 282 An immediately life threatening situation that may arise is where the patient is saying they are going to kill themselves or harm others but will not omply with treatment. he reation to this problem will depend on a large number of variables inluding your assessment of the problem and the help available. Enlisting the support of family and arers is often the simplest and best way to resolve suh onflits. However, if this does not work you will have to all for assistane. his may be the patient s own primary are team or the mental health team. In extreme situations where you judge that there is an immediate threat to the wellbeing of the patient or others you should all the polie. he MHA, in Setion 63, states that the detained (or setioned ) patient s onsent is not needed for medial treatment for mental disorder (when this is under the diretion of the Responsible Medial Offier.) his is detailed as being: (a) immediately neessary to save the patient s life; or (b) whih (not being irreversible) is immediately neessary to prevent a serious deterioration of his ondition; or () whih (not being irreversible or hazardous) is immediately neessary to alleviate serious suffering by the patient; or (d) whih (not being irreversible or hazardous) is immediately neessary and represents the minimum interferene neessary to prevent the patient from behaving violently or being a danger to himself or to others. However, the MHA does not neessarily permit the ompulsory treatment of a physial disorder in a patient who is not onsenting. Box 3: Primary Survey Is the patient threatening to kill or seriously harm themselves? Is the patient a risk or danger to themselves or to others? Is the patient through lak of appreiation of the onsequenes likely to ome to harm? Is the patient, through lak of apaity, vulnerable to abuse from others? Has the patient beome autely onfused? SECONDARY SURVEY If it is obvious that the patient is going to have to be assessed by another professional then only a brief evaluation will be required. However, the following steps need to be taken to ensure the patient is suffering from a mental illness and not a physial disorder. Aute infetions, intoxiations, drug withdrawal syndromes, diabetes, and neurologial onditions are ommon physial onditions that may present with symptoms of mental illness/disorder. An aute onfusional state may present very rapidly, espeially in older patients, this may result from hest or urinary trat infetions as well as in the older person who has experiened reent life hange, or who is suffering from dementia. Ensure the patient is not suffering from a physial disorder. Box 4 Mental Health Assessment Presenting problem History of presenting problem Previous medial history Drug history / allergies/ onordane Past psyhiatri history Previous ontat with servies Carer information Brief physial examination (vital signs inluding temperature if possible) Appearane Behaviour Cognition, onentration, and attention span Ideation, i.e. beliefs and level of insight Energy and motivation (free) hoie and volition Risk- to self, to others, of deliberate self harm (DSH), or neglet Impulsivity Co-morbidity- drugs/ alohol Soial fators and support inluding family history Preipitating fators Coping strategies Box 4 summarises the assessment of a patient with psyhiatri symptoms. Effetive and sensitive mental health assessment involves a person-entered onsultation style. A therapeuti relationship is entral to this, as is gaining the patient s trust and showing the patient that you reognise their distress and experiene. Some key priniples for the mental health interview are identified in Box 5 below. Consultation skills that improve identifiation of emotional distress inlude frequent eye ontat, relaxed posture, use of open questions at the beginning of the onsultation, use of minimal verbal prompts while atively listening, and avoiding giving information too early in the onsultation Box 5 he Mental Health Patient-Centered Interview Atively listen and be alert to your observations Allow the patient to explain the problem in their own words Be non-judgemental Use fousing tehniques to enable the patient to gain selfontrol Seek larifiation use of paraphrasing, refletion, and summarising Sharing impressions Use of silene Pitfall Jumping to onlusions alk to the family and get their viewpoint Emerg Med J: first published as /emj on 23 Marh Downloaded from on 7 September 2018 by guest. Proteted by opyright.

5 HE ABC OF COMMUNIY EMERGENCY CARE At the end of the assessment you should be able to judge if the patient has A physial disorder A disorder of mood (ommonly depression) Aute anxiety or pani Aute onfusion A psyhoti disorder Or is a threat to themselves or others he ations required will depend on your assessment of the severity of the ondition; the options are disussed in the setion on treatment and referral. HE DEPRESSED PAIEN Depression is the most ommon mental disorder in primary are. he term depression overs a range of mental health diagnoses and problems. hese problems are distinguished by lowered mood and a loss or derease of interest and pleasure in daily life and experienes. Additionally, there are disorders of thinking, problem-solving, and behavioural and physiologial symptoms. 7 It is not easy to disriminate between normal mood variations, dysthymia and ylothymi (see Box 7) episodes and mild to moderate linial depression. Box 6 lists the diagnosti riteria for severe depression. Box 6 Reognition and Classifiation of Severe (Major) Clinial Depression At least five of the following symptoms are onsistently experiened by the lient on a daily basis over a 2 week period: Persistent sad mood Loss of interest or pleasure in ativities that were one enjoyed Signifiant weight loss or gain without dieting, inreased or redued appetite Insomnia or hypersomnia Psyhomotor agitation or retardation Fatigue or listlessness; loss of energy Feelings of worthlessness and inappropriate guilt Redued ability to onentrate, make deisions or think Reurrent thoughts of death or suiidal ideation Pitfalls False or early reassurane Being overwhelmed by the patient s feelings and avoiding responding empathially It is not lear how effetive pratitioners are at preventing suiide. A number of patient s who suessful ommit suiide will have onsulted a health are professional in the immediately preeding period. At least 30% see their GP in the 4 weeks prior to their deaths. 8 Improving the reognition of severe depression and its treatment has been the fous of several studies and training pakages for GPs; though the long term data shows little sustained differene. It is often helpful to support the patient in telling their story - what a typial day is like, what makes it better or worse and listening arefully not only to what they say but how they express their narrative. he patient with depression may be at risk of suiide. Box 7 Differential Diagnoses Mood Disorders Clinial Depression Severe Moderate Mild Bipolar Disorder (Mani Depression) Dysthymi episodes- Chroni low grade depression (for at least 2 years) Cylothymia yling variations in mood; muh less extreme than in Mani Depression Seasonal Affetive Disorder Post-Natal Depression Psyhoti depression SUICIDE RISK Patients with mental illness have an inreased risk of suiide. In fat eah year people with depression aount for two thirds of all deaths from suiide nationally. Risk assessment tools and rating sales an be very helpful, for example, the Suiide and Self-Harm Risk Assessment Sale: Suiide risk & Self-Harm Risk Assessment Sale Sex male 1 Age,19 or.45 years 1 Depression/hopelessness 1 Previous attempts 1 Exessive alohol/drugs 1 Rational thinking (loss of) 1 Separated widowed divored 1 Organised or serious attempt 1 No soial support 1 Stated future intent 1 Sore (3 low risk, 3 6 medium risk,.6 high risk. his is a guide only and should not be used to replae linial judgement. (See JRCALC guidelines A6). REAMEN AND REFERRAL Prior to the MHNSF the traditional management of the at risk suiidal patient was by admission to an aute mental Box 8 Additional Risk Fators for Suiide Up to 4 weeks following disharge from servies Reent self harm; history of violent self harm (half of those who ommit suiide will have self-harmed in the past ) Depression- as mood lifts Choie of method Young Asian women Some oupations and soial groups- dentists, dotors; farmers, unemployed, homeless or living alone, students, divored, separated or widowed (men) Relationship problems Chroni illness: inluding HIV/AIDS, aner, diabetes, post stroke espeially when ommuniation entres affeted, Parkinson s Disease, Huntington s Disease, and Alzheimer s Disease (where some insight remains) Care givers without adequate soial support/ finanesespeially arers of those who are severely ognitively impaired Chroni pain 283 Emerg Med J: first published as /emj on 23 Marh Downloaded from on 7 September 2018 by guest. Proteted by opyright.

6 DOY, BURROUGHS, SCO 284 Ask about suiide. Gentle questioning inluding: Do you feel that you don t want to go on any more? Have you thought about what you would do? Have you developed a plan? How lose do you think you are to trying to kill yourself? Pitfall Believing the patient when they say they will not try to kill or harm themselves health unit. In non-sheduled and out of hours are, this is problemati due to bed shortages, high aute in-patient bed oupany (often in exess of 100%) and implementing MHA proesses for detaining at risk patients unwilling to agree to admission. Currently there is growth in managing these patients in the ommunity and many Crisis Resolution and Home reatment eams (CRHs) have been developed to offer intensive ommunity-based interventions in the patient s own home (MHNSF target of 335 CRHs by this year). Where suh teams exist, a referral both in hours and out of hours to the loal CRH should be made. he CRH will undertake a omprehensive mental health and risk assessment. As appropriate, a treatment, support, or monitoring pakage will be implemented. Other alternatives to admission that may be available inlude aute day hospital are, risis beds, the Community Mental Health team and the Primary Care Gateway (Link) Worker or 24 hour and weekend help and support lines. Servies are, however, very variable from PC to PC. In some areas Psyhiatri Intensive Care Unit (PICU) beds may be available for urgent admission, in others assertive outreah or assertive ommunity treatment or other intensive ase management servies may be available. Box 9 reatment Options 1. Admission to Hospital: severe depression espeially when suiide has been attempted or serious suiide ideation is present and the patient requires lose or onstant observation 2. ED and EAU Mental Health Assessment Liaison eam: full psyhosoial assessment (as reommended by NICE, 2004) and referral or brief interventions offered as appropriate; may offer speifi alohol and substane misuse servie 3. Home reatment and Crisis Resolution via loal mental health OOH servies: full psyhosoial assessment and servie provision for the patient with mental illness who an be supported/ treated at home without admission 4. Mediation: Fluoxetine or Paroxetine may be presribed for moderate to severe depression; Risperidone for psyhosis and agitated onfusion; Chlorpromazine and Haloperidol for psyhosis, onfusion, and behavioural disorders 5. alking reatments: Referral to mental health team/ GP NO appropriate for people with severe depression Box 10 Priniples of Effetive Shared and OOH Care: Develop risis are plans with agreed ontat points for known patients and ensure they are available to OOH servies Agree OOH arrangements and ensure they are available to all relevant team members inluding loums Clarify riteria for referral and disharge between primary and seondary are; between OOH and mental health risis teams Develop mental health registers in primary are Joint inter-professional and multi- ageny eduation, e.g. suiide assessment and risk management Consistent and regular ommuniation with regular liaison meetings; systemati review of shared are and omplex patients Robust reord-keeping Rotations between OOH servies Regular audit Liaison nurses in emergeny and MAU departments of aute general hospitals are also useful resoures for both inpatient and primary are pratitioners. DIFFERENIAING BEWEEN SUICIDE AND DELIBERAE SELF-HARM (DSH) he MHNSF indiates that overall the rate of suiide is dropping. 9 Men are three times more likely than women to ommit suiide; women are three to four times more likely to present with deliberate self-harm by overdosing, utting, or other means. 10 Whilst suiide is rare, the average PC (population of 100,000) would have about 10 suiides per annum. he term deliberate self-harm (DSH) indiates that the person hurts themselves, either to signal distress, in risis and where oping strategies are limited, and to release/ manage overwhelming feelings. 11 So, whilst there may be no intention to kill themselves the person who is self-harming does inrease the risk of death with eah oasion of this behaviour. NICE identify that there are 150,000 attendanes at A&E eah year resulting from DSH therefore being one of the top five auses of aute medial admission. Box 11 Why does the lient self-harm? Four main themes regarding motivation emerge from experiential and empirial researh evidene. 1. handling and expressing overwhelming feelings 2. esaping numbness/ unreality and onfirming one s existene 3. obtaining or maintaining a sense of ontrol 4. ontinuing past abusive patterns (Adapted from Doy, 2003) Pitfall Diminishing the behaviour and judging it as (only) attentionseeking Behaviour always has a meaning- we often do not appreiate what it means for the person Emerg Med J: first published as /emj on 23 Marh Downloaded from on 7 September 2018 by guest. Proteted by opyright.

7 HE ABC OF COMMUNIY EMERGENCY CARE At times of risis it is easy to disempower the person who has self-harmed by dismissing their often frustrating and repetitive behaviour as manipulative. Suh lients are often overwhelmed and haoti with limited oping strategies, low self-esteem, and pereptions of a lak of ontrol and safety in their lives. Pratitioners who have first ontat with people who have intentionally self- harmed should: undertake a psyhosoial and needs assessment at triage or initial assessment undertake risk assessment assume apaity unless there is evidene to the ontrary offer full information and seek valid onsent reognise the distress assoiated with deliberate self-harm and treat the person with respet Make appropriate referrals If the lient is not primary survey positive use of patiententered onsultation skills (see Box 5) and suitable referral and signposting will be appropriate. Box 12 Relevant Servies and help lines Bristol Crisis Line (National part-time help line) Community Mental Health eam CRH Mental Health Liaison Nurses- ED; MAU National Self-Harm Network Primary Care Gateway (Link) Workers It is important to provide the patient with alternatives to self-harming inluding help-line ontat and for pre-hospital workers to onsider referral for psyho-therapy. Many soial are or voluntary agenies may be effetive in supporting the patient with relationship, aommodation, finanial, substane misuse, abuse, and violene issues. As an be seen, mental health and its management in ommunity settings is omplex. he key hallenges inlude developing ompetene in assessment and risk assessment, in larifying roles and servies in the OOH/emergeny ontexts and drawing up lear and agreed guidelines and ommuniation hannels. SUMMARY his paper has onsidered definitions of mental disorder and key aspets of the MHA with partiular emphasis on valid onsent. Mental illness, its assessment and referral pathways within the pre-hospital setting have been onsidered, with partiular emphasis on depression and deliberate self harm. A future artile will onsider psyhoses, personality disorders and dementia in more detail. Mental illness is hugely debilitating for many patients; taking huge toll on their families and arers. Detailed assessment and early referral an help in the early diagnosis of mental disorder (leading to greatly enhaned prognosis); and to early intervention in relapse or risis situations. he development of mental health CRHs and ED liaison teams, the advent of the Primary Care Gateway (Link) Worker and of the Emergeny Care Pratitioner is supporting enhaned referral and greater oherene within the patient pathway. It is hoped that this paper will enable pre-hospital are pratitioners to identify and assess the person with depression with greater onfidene and to be aware of additional referral pathways available for these patients.... Authors affiliations R Doy, D Burroughs, Shool of Nursing and Midwifery, University of East Anglia, UK J Sott, East Anglian Ambulane NHS rust, UK FURHER READING 1 Department of Health. Referene Guide to Consent for Examination or reatment. London: DH, Hatton C, Blakwood R. In: Leture Notes on Clinial Skills, 4 th edn., Oxford: Blakwell Siene, (Chapter 6) Joint Royal Colleges Ambulane Liaison Committee, 2004: Clinial Pratie Guidelines version 3. 0, University of Warwik/JRCALC available from 4 Mynors-Wallis L, Moore M, Maguire J, et al. Shared Care in Mental Health. Oxford: Oxford University Press, National Institute of Clinial Exellene. he NICE website ontains linial guidelines for depression and anxiety, also for shizophrenia and self-harm 6 he Mental Health At 1983: Guidane for general pratitioners: medial examinations. 7 Medial reommendations under the At, BMA World Health Organisation, 1992 ICD-10 Classifiation of mental and behavioural disorders. Geneva: WHO. REFERENCES 1 MACA. First National Survey of Mental Health in Primary Care, MJM: Pfizer Department of Health. Modern Standards and Servie Models: Mental Health. London: NHSE, National Institute of Clinial Exellene, 2004a: Depression: the management of depression in primary and seondary are. (aessed 27 Feb 2005). 4 Mynors-Wallis L, Moore M, Maguire J, et al. Shared Care in Mental Health. Oxford: Oxford University Press, Joint Royal Colleges Ambulane Liaison Committee. Clinial Pratie Guidelines version 3.0, University of Warwik/ASA/JRCALC World Health Organisation. ICD-10 Classifiation of mental and behavioural disorders. Geneva: WHO, World Health Organisation. WHO Guide to Mental Health in Primary Care. London: Royal Soiety of Mediine Ltd, Evans J. Suiide, Deliberate self-harm, and severe depressive illness. In: Elder A, Holmes J, eds. Mental Health in Primary Care. Oxford: OUP, Department of Health. National Suiide Prevention Strategy for England. London: DH, Doy R. Women and Deliberate Self-Harm. In: Boswell G, Poland F, eds. Women s Minds, Women s bodies: An Interdisiplinary Approah to Women s Health. Basingstoke: Palgrave Mamillan, Burstow B. Radial Feminist herapy: Working in the Context of Violene. London: Sage, National Institute of Clinial Exellene, 2004b: Self-harm: he short-term physial and psyhologial management and seondary prevention of selfharm in primary and seondary are. (last aessed 28 July). 13 National Institute of Clinial Exellene 2004: Sope: Self-harm: he shortterm physial and psyhologial management and seondary prevention of self-harm in primary and seondary are. (last aessed 28 July). 285 Emerg Med J: first published as /emj on 23 Marh Downloaded from on 7 September 2018 by guest. Proteted by opyright.