Mental Health Assessment Skills

• Introduction to Mental Health:

  • Prevalence 1 in 4
  • High risk of mortality
  • Stigma and discrimination
  • Affect mental state, emotion, cognition, behaviour, psychological and social wellbeing thus associated with risks
  • Conditions include - depression, anxiety, schizophrenia bipolar disorder, dementia, drugs and alcohol abuse, personality disorder
  • Mental Health Services provide medical, psychological and social care through a Care Programme Approach
  • MH services: Outpatient (CMHC), Crisis team, psychiatric liaison, inpatient acute, PICU, rehab, EIT, HTT, charities
• Effective communication skills are essential for good outcome:

  • Cochrane review: Therapeutic relationship, trust, confidence, patients respect, increased shared understanding, increase patient satisfaction, increased treatment adherence, empowering, reduces hospital admission, improved quality of life, reduced litigation, healthcare professional wellbeing, reduced errors
  • •Poor outcome: social isolation, exclusion, unemployment, poor physical health, poor staff morale
• Communication Skills:

  • Focus in MH - Empathy, Non-judgemental, Respectful, Succinct,

   Accurate, Reassuring, Therapeutic, Culturally Sensitive, Parity of esteem

  • Form of communication - verbal, non verbal communication, written communication
  • Communication Barriers - Symptoms, language culture, impaired cognition, influence of drugs and alcohol, learning disability, anger, lack of skills, lack of time, work pressures, negative attitudes, stigma

                                           
• Communication Skills:

  • Questioning:
  • Open - e.g. How are you feeling - Allows patient to express
  • Closed - e.g. do you experience any sleep problems - saves time, useful to clarify or confirm information
  • Leading - e.g. you sleep well, don't you - you say you are alright but appearing tearful
  • Listening - Activate with ears, eyes, feelings - what and how said, content
  • Statements - encouraging, empathic, discouraging, informative, summarising, clarifying
  • Allow free talk/flexibility
  • Control situations, demands, inquisitive, long silences
  • Avoids technical terms
• Consultation in MH:

  • Framework - the national practice standards for pharmacy consultation skills
  • 1.1 Undertake the consultation in a supportive environment, taking account of safety, comfort, confidentiality, dignity, respect… positive, patient centred, rapport
  • Calgary-Cambridge model
  • Motivational interview - encourage change
  • Goal/prepare/structure/time
  • Environment - safe, no distraction, furniture, facilities, privacy
  • Position - SOLER (sitting open posture lean eye relax)
  • Method of recording
• Assessment:

  • Assist with or formulate a diagnosis to  guide interventions, answer questions, elicit relevant details of past and present
  • General – including physical health, ‘problem screening checklist’, social problems
  • The psychiatric history
  • Mental state examination
  • Risks
  • Capacity
  • Tools
• The psychiatric History:

  • Introduction
  • Inform/explain purpose, focus, structure, time, notes taking, confidentiality
  • Consent
  • Identify the patient – demographic data
  • Identify presenting problem
  • History of the presenting problem
  • Personal history
  • Past psychiatric history
  • Previous medical history                           
  • Drug history
  • Premorbid personality                                                       
  • Social history
  • Habits/dependencies
  • Forensic history
  • Substance misuse*
  • Risk  and capacity*
  • MSE*
  • DOL S*
  • AoDL *
• The Psychiatric History:

  • Introduction – greet, introduce self, friendly, sit down
  • Inform/explain - purpose, focus, structure, time, notes taking, confidentiality
  • Consent to assessment
  • Reassure – confidentiality, share of information
  • Identify the patient – demographic data
  • Identify presenting problem – Ask what brought you here, precipitating factors, social stressors explore each complaint – when, life events, how, effect of the problem, sought any help
• The Psychiatric History - Part 2:

  • History of the presenting problem
  • Past psychiatric history – have you had any mental health problems or experienced  any psychiatric symptoms in the past? Diagnoses, level of functioning, treatment
  • Previous medical history – what is your physical health like? Any serious medical condition? Treatment
• The psychiatric history:

  • Drug history – medication, allergies, benefit, side-effects, adherence, monitoring
  • Personal history – childhood, school, occupation, relationships, sexual history
  • Premorbid personality – How would people who know you would describe? Obsessional, Paranoid, schizoid, inadequate, antisocial
  • Habits/dependencies*– do you smoke, drink alcohol, or take any drugs which the doctor has not prescribed
  • Forensic history – have you been involved or done anything that could have got you in trouble with the police
• The Psychiatric History:

  • Present social situation – housing, social support, finances
  • MSE*
  • MMSE* - assessment of cognition
  • Risk * - self and others
  • Capacity*
  • DOLS*
  • AoDL*

  *explore further
• Assessment Tools:

  • Psychosis - Brief Psychiatric Rating Scale
  • Depression - Depression Anxiety Stress Scales, Beck Depression Inventory, MDRS, PHQ - 9
  • Anxiety - (ASQ-15) OR GAD - 7
  • Bipolar - MDQ, YMRS
  • Dementia - MMSE, ADAScog
• Mental State Examination:

  • Aim is to observe and describe at the time of assessment
  • Appearance and Behaviour - level of consciousness, general impression, face, dress, motor, attitude, reaction
  • Speech - rate, volume, content, pressured, fluency, language, mute, poverty
  • Mood - Subjective/objective, affect, intensity, fearful
  • Thought - form, content, delusional, poverty, ideas, beliefs
  • Perception - hallucinations - visual, auditory, olfactory, gustatory, tactile
  • Cognition - consciousness, memory, orientation, concentration
  • Insight - awareness of problems, illness, accept help
• Mini Mental State Examination:

  • Cognition
  • Orientation
  • Registration
  • Attention and calculation
  • Recall
  • Language
  • Copying
• Anxiety:

  • Interference with normal function, distress, intense and prolonged reaction
  • Look out for: tense expression, shaking, worried look, agitation, over - arousal, sweating, over breathing
  • Ask - triggers, duration, physical symptoms, physical cause
  • GAD, OCD, Panic, Phobia
• Depression:

  • Severe low mood and persistent
  • ICD10: symptoms must be present for at least 2 weeks
  • Look for anxiety, self neglect, affect, psychomotor retardation, signs of self harm
  • Ask about sustained low mood, anhedonia, anergia, diurnal variation, loss of interest in hobbies, poor concentration or memory, poor sleep, loss of appetite and weight, feelings of guilt and worthlessness, hopelessness/suicide ideation, negative thoughts and ruminations
  • Assess risk of suicide
  • Tools: MADRS, DASS, PH-Q
  • Management: Severity, baseline physical monitoring  including TFT
• Mania/Hypomania:

  • Elevated mood
  • Impaired functions
  • Look out for overactivity, bizarre and dishevelled, pressure of speech, disinhibition, flight of ideas, irritability, elated mood, stimulants, delusions
  • Ask about excessive and or reckless spending, reduced need for sleep, overambitious plans, grandiose ideas, past episodes, lack of insight
• Psychosis:

  • Psychosis – persistent hallucinations, delusions, no insight, abnormal thoughts, abuse of drugs, schizophrenia, mania, dementia, severe depression
  • Look for: self neglect, physical signs of delusions; hallucinations – distraction by voices or seeing things; paranoia
  • Ask:  about odd experiences, plot or conspiracy
• Dementia:

  • State of confusion, clouding of consciousness (differential diagnosis - delirium)
  • Look for self neglect, bewildered affect, impaired speech
  • Ask: memory, activities of daily living, cognitive problems
  • MMSE (see tool. NB: not used in isolation)
• Drug and Alcohol:

  • Psychoactive substances - Mental conditions - amphetamines, LSD, stimulants, BDZ
  • NICE guidance: diagnosis, assessment, management of alcohol abuse
  • Lab tests/screening
  • Management: psychosocial, pharmacological, withdrawal, somatic symptoms, relapse prevention
  • Services for referral: e.g. BDAS, Signpost, Beresford
• Alcohol:

  • Tools: CIWA, AUDIT, SADQ, CAGE
  • Look for drunkedness, signs of chronic alcohol abuse, pattern, behaviour, tolerance, withdrawal, abstinence, relapse, complications
  • Ask what is drunk, how much, what, how often, where, when, what triggers drinking, binges, any period of abstinence, predisposing factors, any help sought, complications
• Risk - Self, others, vulnerable:

  • Risk factors - age, sex, living situation, education, employment, mental conditions, substance misuse, recent incident, disengagement, non-adherence, stress, intimidating/violent behaviour, severity, frequency, pattern, physical health, self neglect, abuse – financial, physical, emotional
  • History
  • Mental State
  • Intent
  • Planning
  • Formulation
  • Management
• Suicide:

  • Assess - Non vernal cues, signs of deliberate self harm, sociodemographic risk factors, intentions, actions, recent event
  • Stages - hopelessness - suicidal feeling - suicidal wish - rumination - plan - attempt
  • Tools - SUICiDAL, SADPERSONA
  • Develop a management plan
  • Supervision, safety from all means, environmental, refer to crisis, psychiatrist, inform relevant people, safeguards, involve family members
• Suicide - Questions to ask - If not attempted yet:

  • Do you still get pleasure out of life
  • Do you feel hopeful
  • Are you able to face each day
  • Do you ever wish you would not wake up
  • Have you ever thought of ending your life
  • Are you able to resist the thought of suicide
  • Have you tried anything
  • How likely are you to kill yourself
  • Is there anything that might make you feel worse
  • What might stop you from trying to kill yourself
• Suicide - Questions to ask - if person has attempted suicide:

  • Had you actively prepared
  • What precautions did you take to avoid intervention
  • Did you communicate your intention
  • What methods did you use
  • Did you believe the act would be final
  • Do you regret surviving
  • How many times have you attempted
• Mental Capacity:

  • Mental Capacity Act 2005 - protects and empowers people who lack ability to make decision about care, treatment, welfare, finances due to an impairment or disturbance of brain function
  • Code of practice - legal framework for acting and making decisions on behalf of individuals - 5 statutory principles
  • Assessment of capacity must be continuous and ongoing
  • Deemed unable to make decision:
  • Can not understand relevant information
  • Can not retain the relevant information long enough
  • Can not evaluate the relevant information as part of the decision making process
• Mental Capacity - Part 2:

  • Can not communicate their decision
  • Independent mental capacity advocate assessment
  • Best interest considerations
  • Documentation
• Deprivation of liberty safeguards:

  • Protect those who lack capacity to make decisions about where they receive care/treatment, need to be accommodated that may be depriving them of their liberty
  • Medical doctors/ mental health assessor and best interest assessors decision
  • Power to stop patients from leaving, make decision on patients behalf
  • Urgent authorisation 7-14 days
  • Standard authorisation - representative appointed
  • Request for assessment is made to local authority
  • Assessments carried out by 2 people - best interest assessor, mental health assessor
  • Can be appealed
• Deprivation of liberty safeguards:

  • Assessment involves - Two assessors to assess criteria  are met
  • Age – Is the person aged 18 years or over?•Mental health – Does the person have a ‘mental disorder’?
  • Mental capacity – Does the person lack ‘capacity’ (the ability) to make their own decisions about treatment or care in the place that is applying for the authorisation?
  • Best interests – Is a deprivation of liberty taking place? If so, is it:
  • In the person's best interests
  • Needed to keep the person safe from harm
• Deprivation of liberty safeguards - part 2:

  • a reasonable response to the likelihood of the person suffering harm (including whether there are any less restrictive options and if they are more appropriate)?
  • Eligibility – Is the person already liable to detention under the Mental Health Act 1983, or would they meet the requirements for detention under this Act? 
• Deprivation of liberty safeguards - part 3:

  • No refusals – Does the authorisation contradict or conflict with any advance decision the person has made refusing treatment, or with any decisions made by, for example, a court-appointed deputy or someone with Lasting power of attorney?
  • Local health authority for authorisation
• Activities of daily living:

  • They are a series of basic activities performed by individuals on a daily basis necessary for independent living at home or in the community
  • 5 basic criteria:
  • Personal hygiene - bathing/showering, grooming, nail care, and oral care
  • Dressing - the ability to make appropriate clothing decisions and physically dress/undress oneself
  • Eating - the ability to feed oneself, though not necessarily the capability to prepare food
• Activities of daily living - part 2:

  • Maintaining continence - both the mental and physical capacity to use a restroom, including the ability to get on and off the toilet and cleaning oneself
  • Transferring/Mobility- moving oneself from seated to standing, getting in and out of bed, and the ability to walk independently from one location to another
• Formulating a Diagnosis:

  • Consider key symptoms
  • Differential - physical investigation
  • ICD10/DSMIV
  • Consult with specialists
  • NB: patients may not like, believe or object being 'labelled' with mental health conditions
• Management Plan:

  • Consider desired outcome - cure, reduce symptoms, disability, improve social situation
  • Review info, evidence, severity of the symptoms, urgency of situation
  • Consider NICE guidance, know your local services, consult with specialists, discuss management plan with patient/carer, short and long term goal, patient and public safety, further investigation
  • Prescribe treatment - within your remit - review medication
  • Social prescribing - advice lifestyle measures, education
  • Refer - crisis team, drugs and alcohol services
  • Monitor/follow up