Mental health conditions Flashcards
What proportion of people will have experienced a common mental health disorder in the past week?
1 in 6
How many adults in England are affected by severe mental illness (SMI) such as schizophrenia or bipolar disorder?
500,000
Why do people with SMI have an increased mortality rate and reduced life expectancy (15-20 yrs) compared with the general population?
multifactorial
iatrogenic harm from psychiatric medication
lifestyle
reduced access to health services and leisure facilities
What percentage of mental health problems are established by the age of 14?
50%
What percentage of mental health problems are established by the age of 24?
75%
How many children aged 5-16 experience a mental health issue at any one time?
1 in 10 conduct disorder (6%) anxiety disorder (3%) attention deficit hyperactivity disorder (ADHD) (2%) depression (2%)
Almost how many young people contacted Childline with suicidal thoughts between 2014/2015?
20,000
In an average group of 30 15-year-olds, how many are likely to have been bullied?
7
In an average group of 30 15-year-olds, how many could have experienced the death of a parent?
1
In an average group of 30 15-year-olds, how many are likely to have watched their parents separate?
10
In an average group of 30 15-year-olds, how many may be self-harming?
6
What proportion of mothers suffer from depression, anxiety or, in some cases, psychosis during pregnancy or in the first year after childbirth?
1 in 5
People with long-term physical health conditions suffer more complications if they also develop mental health problems. On average, this increases the cost of care by what percentage?
45%
What proportion of older people in the community are affected by depression?
1 in 5
What percentage of older people living in care homes suffer with depression?
40%
What percentage of veterans of the armed forces who experience mental health problems like post-traumatic stress disorder (PTSD) seek help from the NHS?
50%
What proportion of prisoners have a mental health, drug or alcohol problem?
up to 9 in 10
In London from 2018-2019, what percentage of people seen sleeping rough had no alcohol, drug or mental health support needs?
20%
In London from 2018-2019, what percentage of people seen sleeping rough had alcohol misuse needs?
42%
In London from 2018-2019, what percentage of people seen sleeping rough had mental health needs?
50%
In London from 2018-2019, what percentage of people seen sleeping rough had drug misuse needs?
41%
What is the stress vulnerability model proposed by Zubin and Spring (1977)?
proposes that an individual has unique biological, psychological and social elements
these elements include strengths and vulnerabilities for dealing with stress
vulnerability is a scale where resilience can reduce the impact of this predisposition and stressors
How does mental illness impact employment?
for those in contact with secondary mental health services, the employment rate was 67.4 percentage points lower than the overall rate
How does mental illness impact benefit claims?
50.9% of Employment Support Allowance Claimants have a primary condition of a mental and behavioural problem
How does mental illness impact social isolation?
psychotic disorder is more common in people living alone
evidence suggests links between mental illness, social isolation, and the challenges that people with psychotic disorder may face with maintaining relationships
How does mental illness impact housing?
54% of adults (age 18-69) receiving secondary mental health services on the Care Programme Approach were recorded as living independently, with or without support
What is depression?
a persistent low mood that can be either mild or severe
it will have varying degrees of impact upon the person, and their engagement in personal and social activities
What is the prevalence of depression in people with diabetes?
30% of people with diabetes are estimated to be affected by depression
this is set against 36% who experience diabetic distress
What is the economic cost of treating people with diabetes and depression?
£1.8 billion of additional costs can be attributed to poor mental health
What is the prevalence of depression in people with cancer?
ranges from 4-49% depending on the type of cancer
What is the economic cost of treating people with cancer and depression?
£7.6 billion a year due to premature deaths and time off work
service costs are increasing to £13 billion by 2020-21
What is the prevalence of depression in people with COPD?
varies depending on the severity of the condition
estimated to be as high as 27%
What is the economic cost of treating people with COPD and depression?
£3 billion and £1.9 billion respectively
in total, all lung conditions (including lung cancer) directly cost the NHS £11 billion annually
What is the prevalence of depression in people with CVA?
post-stroke depression is estimated to be 30%
varies from 29-36%
What is the economic cost of treating people with CVA and depression?
3-5% of all healthcare expenditure
England, Wales and Northern Ireland was £3.60 billion in the first five years after admission
What is the prevalence of depression in people with arthritis?
varies depending on the type of arthritis from 5-51%
What is the economic cost of treating people with arthritis and depression?
healthcare costs of osteoarthritis and rheumatoid arthritis will reach £118.6 billion over the next decade
What are the four levels of depression (NICE, 2009)?
subthreshold depressive symptoms
mild depression
moderate depression
severe depression
What are subthreshold depressive symptoms (NICE, 2009)?
fewer than 5 symptoms of depression
What is mild depression (NICE, 2009)?
few, if any, symptoms in excess of the 5 required to make the diagnosis
symptoms result in only minor functional impairment
What is moderate depression (NICE, 2009)?
symptoms or functional impairment are between ‘mild’ and ‘severe’
What is severe depression (NICE, 2009)?
most symptoms and the symptoms markedly interfere with functioning
can occur with or without psychotic symptoms
What are the key symptoms of depression (NICE, 2009)?
persistent sadness or low mood, and/or
marked loss of interests or pleasure
at least one of these, most days, most of the time for at least 2 weeks
If any of the key symptoms are present, what are the following associated symptoms that should then be discussed?
disturbed sleep (decreased or increased compared to usual)
decreased or increased appetite and/or weight
fatigue or loss of energy
agitation or slowing of movements
poor concentration or indecisiveness
feelings of worthlessness or excessive or inappropriate guilt
suicidal thoughts or acts
What are the criteria for general advice and active monitoring?
four or fewer of the above symptoms with little associated disability
symptoms intermittent, or less than 2 weeks’ duration
recent onset with identified stressor
no past or family history of depression
social support available
lack of suicidal thoughts
What are the criteria for active treatment in primary care?
five or more symptoms with associated disability persistent or long-standing symptoms personal or family history of depression low social support occasional suicidal thoughts
What are the criteria for referral to mental health professionals?
inadequate or incomplete response to two or more interventions
recurrent episode within 1 year of last one
history suggestive of bipolar disorder
the person with depression or relatives request referral
more persistent suicidal thoughts
self-neglect
What are the criteria for referral to specialist mental health services?
actively suicidal ideas or plans
psychotic symptoms
severe agitation accompanying severe symptoms
severe self-neglect
What are some non-pharmacological interventions for persistent subthreshold depressive symptoms or mild to moderate depression?
individual guided self-help based on the principles of CBT? computerised CBT (CCBT) a structured group physical activity programme
What are the two alternatives if an individual does not benefit from first-line non-pharmacological treatment?
an antidepressant (normally an SSRI) OR a high-intensity psychological intervention
What are four types of high-intensity psychological interventions?
CBT interpersonal therapy (IPT) behavioural activation (evidence is less robust than for CBT or IPT) behavioural couples therapy (for people who have a regular partner and where the relationship may contribute to the development or maintenance of depression, or where involving the partner is considered to be of potential therapeutic benefit)
What is the recommended treatment for moderate to severe depression?
antidepressant medication AND
a high-intensity psychological intervention (CBT or IPT)
What factors should influence the choice of intervention for moderate to severe depression?
duration of the episode of depression and the trajectory of symptoms
previous course of depression and response to treatment
likelihood of adherence to treatment and any potential adverse effects
person’s treatment preference and priorities
In what cases should antidepressant medication be considered?
past history of moderate or severe depression OR
initial presentation of sub-threshold depressive symptoms that have been present for a long period (typically at least 2 years) OR
sub-threshold depressive symptoms or mild depression that persist(s) after other interventions
List some examples of SSRIs.
sertraline, citalopram, fluoxetine
What are some adverse effects of SSRIs?
increased risk of bleeding, risk of suicidal ideation
List some examples of TCAs.
amitriptyline, imipramine, lofepramine
What is an adverse effect of TCAs?
increased risk of overdose (except lofepramine)
What is the McGurk effect?
an illusion that results from conflicting information coming from different senses, namely sight and hearing
What is solution-focused brief therapy?
developed in the 1980s by Steve de Shazer and Insoo Kim Berg in Milwaukee, USA
assumptions - the client will choose the goals for therapy and has the resources to make changes
detailed history not necessary
average length of treatment 3-5 sessions
What are the four steps of solution-focused brief therapy?
(1) What do you want?
(2) How will you know when you have it?
(3) What are you doing already to get there?
(4) What would be happening if you were a little closer to what you want?
What are the three principles of solution-focused brief therapy?
(1) If it ain’t broke, don’t’ fix it
(2) Once you know what works, do more of it
(3) If it doesn’t work, don’t do it again: do something different
What is the ‘miracle question’?
You go to bed tonight and while you are asleep a miracle happens. But you are asleep and don’t know that it has happened.
What will be the first thing you notice?
And then what?
And then what?
And what next?
Who will notice that this miracle has happened?
How will you know they have noticed?
What are the assumptions to solution-focused brief therapy?
goals for therapy are chosen by the client
clients have resources which they use to make changes
descriptions are promoted in specific, small, positive steps and favour the presence of solutions rather than the absence of problems
a detailed history is not required but if a story has never been told it may need to be heard prior to continuing (safety assessment if the client or others are at risk)
information comes from the client and language matching is used to stay connected to the client and their experience
focus on thoughts not feelings
What is a ‘scaling question’?
Imagine a scale from 0-10 where ten indicates everything you described in the Miracle Day is
happening now and zero indicates none of that is happening.
What number would indicate where you are at now?
What would make it a …..(increased number)?
What are the exceptions to solution-focused brief therapy (Wand, 2010)?
information from the exceptions help the client to devise strategies to solve or reduce the problem
clients are supported to reflect on and describe in detail what was different when the problem did not occur or what they did differently
exceptions are gleaned for potential solutions
this helps clients to develop a more optimistic view of themselves by being reminded of current and past successes
What is cognitive behavioural therapy (CBT)?
developed in the 1960s by psychiatrist Dr Aaron Beck
hypothesis - negative interpretation and behavioural response to an event causes psychological distress
detailed history taken
average length of treatment 6-9 months
What are the three key elements of CBT?
thoughts, feelings, behaviours
What is meant by ‘thoughts’?
negative automatic thoughts are the cognitive cause of distress
they are automatic, involuntary, plausible, distorted and unhelpful
What is meant by ‘feelings’?
emotions - one word such as anger, depression, fear, guilt
physical sensations - sweating, crying, lack of appetite, sleep difficulty
What is meant by ‘behaviours’?
what people do - includes what people avoid and what they do to make themselves feel better (can be safety behaviours)
What are the key characteristics of CBT?
active therapeutic relationship
psychological formulation of the problem
collaborative relationship
structure to sessions and to therapy
collaborative development of goals
examines and questions unhelpful thinking
use of a range of aids and techniques (e.g. questionnaires for change monitoring)
teaching the client to become their own therapist
use of “homework” or assignments
time-limited
audio recorded sessions
What is a case formulation?
outlines the relationship between thoughts, emotions, behaviours, physical reactions and environment
models of case formulation range from simple to complex
What are the two basic assumptions of a case formulation (Grant et al., 2010)?
emotional disorders arise from an individual’s interpretation of events
the way in which an individual behaves in relation to how they interpret events plays an important role in the maintenance of their problems
What are the three key elements of a case formulation?
core beliefs, assumptions, triggers
What is meant by ‘core beliefs’?
negative automatic thoughts about self, others and the world
the lens through which people see the world
What is meant by ‘assumptions’?
rules for living
“If… then…”
What is meant by ‘triggers’?
incidents that set off the symptoms or cause changes to one or more of the elements of psychological distress
What percentage of the UK population suffer from bipolar affective disorder?
2%
How is bipolar affective disorder classified?
DSMCI - bipolar I and bipolar II
ICD-10 - bipolar affective disorder and bipolar affective disorder in remission
How is bipolar affective disorder characterised?
episodes of depressed and elated mood
How is bipolar affective disorder diagnosed?
after a full medical history and mental state examination
this is to rule out other differential diagnoses (e.g. substance abuse, Cushing’s disease, frontal lobe dementia)
What is the risk of recurrence following an episode of bipolar affective disorder (BMJ, 2018)?
within 12 months - 50% (especially high when compared to other psychiatric disorders)
within four years - 75%
What factors can improve the prognosis for people with bipolar affective disorder?
healthcare support received in a quick and timely manner
a mixture of interventions needed to ensure that people have early access to person-centred treatment
involvement of healthcare professionals working closely with an individual to create a profile of early warning signs (Walker and Kelly, 2011)
What is psychosis?
encompasses a number of symptoms associated with significant alternations to a person’s perception, thoughts, mood, and behaviour
What are the two types of symptoms associated with psychosis?
positive symptoms and negative symptoms
What are positive symptoms of psychosis?
disorganised behaviour
speech, and/or thoughts (thought disturbance) delusions (fixed or falsely-held beliefs)
hallucinations (perceptions in the absence of stimuli)
What are negative symptoms of psychosis?
emotional blunting reduced speech loss of motivation self-neglect social withdrawal
What are psychotic symptoms?
cardinal features of psychotic disorders (the most common of which is schizophrenia)
may also be caused acutely by certain medicines, substance misuse, and certain medical conditions (e.g. sepsis)
with treatment, psychotic symptoms as a feature of a psychotic disorder may resolve fully, recur intermittently with periods of remission between, or persist
What is the aim of treatment for psychosis?
treatment is based on reducing any distressing symptoms, both positive and negative
early intervention is important in psychosis as long periods of untreated psychosis is associated with poorer health outcomes
What is the role of a care coordinator (NHS, 2015)?
a care coordinator supports the individual throughout their time in the service
this includes helping them with self-management skills, social care issues (e.g. housing or debt management) and relapse prevention work
According to the NHS (2015) guidelines for psychosis, how quickly should someone with suspected first episode of psychosis be seen for a specialist assessment?
within two weeks of referral
List three benefits to early intervention in psychosis.
decreased service use
better health and economic outcomes in both the short- and long-term
reduced risk of premature death
Is voice hearing only associated with psychosis?
no
many people in the general population experience voice hearing
voice hearing is likely to be a spectrum which includes people who experience voice hearing as a trauma response
List six risk factors for drug misuse (PHE, 2017).
family history of addiction
socioeconomic deprivation
homelessness
unemployment, poor working conditions and job insecurity
men are more likely to use illegal drugs
poor mental health is linked to drug misuse and vice versa
What is the estimated cost of alcohol abuse in the UK (PHE, 2017)?
£21 billion
What is the estimated cost of drug abuse in the UK (PHE, 2017)?
£15 billion
What is the estimated cost of lost productivity due to alcohol in the UK (PHE, 2017)?
£7.3 billion
How many working days are lost each year in the UK due to alcohol misuse alone (PHE, 2017)?
17 million
What percentage of substance abusers are in full-time employment (PHE, 2017)?
70%
What is drug dependence?
when a person’s drug use results in:
experiencing uncontrollable & unpleasant mood states or withdrawal symptoms when the drug is not taken, AND
use of the drug compulsively despite obvious adverse reactions
What is drug abuse?
recurrent or continued use of drugs in doses or ways that result in adverse consequences
What is drug tolerance?
(1) need for markedly increased amounts of the substance to achieve intoxication or desired effect
(2) markedly diminished effect of continued use of the same amount of the substance
What is drug withdrawal?
(1) the characteristic withdrawal syndrome from the substance
(2) the same (or closely related) substance being taken to relieve or avoid withdrawal symptoms
What is substance dependence according to the DSM-IV?
a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring at any time in the same 12-month period
What is the first criteria for substance dependence according to the DSM-IV?
tolerance
What is the second criteria for substance dependence according to the DSM-IV?
withdrawal
What is the third criteria for substance dependence according to the DSM-IV?
the substance is often taken in larger amounts or over a longer period than intended
What is the fourth criteria for substance dependence according to the DSM-IV?
there is a persistent desire or unsuccessful efforts to cut down or control substance use
What is the fifth criteria for substance dependence according to the DSM-IV?
a great deal of time is spent in activities necessary to obtain the substance, to use the substance, or to recover from its effects
What is the sixth criteria for substance dependence according to the DSM-IV?
important social, occupational, or recreational activities are given up or reduced because of substance use
What is the seventh criteria for substance dependence according to the DSM-IV?
the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
What is substance abuse according to the DSM-IV?
a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 1 (or more) of the following occurring within a 12-month period
the symptoms never met the DSM criteria for substance dependence
What is the first criteria for substance abuse according to the DSM-IV?
recurrent substance use resulting in a failure to fulfil major role obligations at work, school or home
What is the second criteria for substance abuse according to the DSM-IV?
recurrent substance use in situations in which it is physically hazardous
What is the third criteria for substance abuse according to the DSM-IV?
recurrent substance related legal problems
What is the fourth criteria for substance abuse according to the DSM-IV?
continued substance abuse despite having persistent or recurrent social interpersonal problems caused or exacerbated by the effects of the substance
What are the two types of dependence?
physical and psychological
What is physical dependence?
refers to the presence of physical symptoms during withdrawal (e.g. chills, aches, seizures, sleep disturbance)
these effects are usually the opposite of the direct effects induced by the drug
How long does it taken to develop physical dependence to a drug?
it usually takes several exposures to the drug within a relatively short period to produce dependence (e.g. taken daily for several days or weeks at relatively high doses)
however, dependence can occur in one dose if it is sufficiently large
What is abstinence syndrome?
refers to the physical symptoms associated with drug withdrawal
varies greatly in intensity and duration
universally unpleasant
also occurs with prescription drugs (e.g. some anti-depressants, painkillers, benzodiazepines)
can be minimised/avoided by tapering off the drug
administration of a drug antagonist will cause immediate abstinence syndrome
What is psychological dependence?
refers to psychological symptoms during withdrawal (e.g. craving, depression, anxiety)
drug use often produces pleasure or reduces psychic discomfort, absence of drug produces the opposite (displeasure and no reduction in psychic discomfort)
What is meant by the phrase: ‘Context-specific tolerance is an integral part of psychological dependence’?
substance dependence is primarily a result of having learning and memory (e.g. positive reinforcement, discriminative effects, aversive effects, and stimulus associations with drug use)
List some examples of psychological dependence.
enhances mood or performance copes better with adverse or stressful situations to help socialise to conform expansion of experimental awareness
What is secondary psychological dependence?
following physical dependence, craving may develop based on the fear of developing abstinence symptoms if the drug is not taken (instrumental conditioning involving negative reinforcement)
cues associated with taking the drug may elicit the drug, or the compensatory response would feel like an abstinence syndrome (classical conditioning)
you can have tolerance without dependence, but if you have dependence then tolerance will have developed
What is involved in the mechanism of reinforcement action?
mesolimbic system has received most attention
the release of dopamine appears to be a necessary but insufficient condition for positive reinforcement to take place
endogenous opioids may be involved in reinforcement
glutamate appears to play a critical role in drug cravings elicited by conditional stimuli
How does religion impact on dependence?
the more religious, the less the problem with drug abuse/dependence, especially if the religion bans the substance
How do sociological factors impact on dependence?
drug availability significant others labelling the person as a deviant peer influence early childhood deviance poor school adjustment weak family influence
What personality traits correlate with dependence?
sensation or novelty seeking traits
history of antisocial behaviour (e.g. nonconformity, acting out, and impulsivity)
What is comorbidity in relation to substance dependence?
the presence of substance abuse and another psychological disorder
drug use is often a form of self-medication
among alcohol abusers, 78% of men and 86% of women have at least one other psychiatric disorder
high levels of depression
pre-existing motivation factors interact with physiological and psychological conditioning factors once drug taking begin
What are the general factors involved in treatment for substance dependence?
the first step is to recognise the problem (realise that dependency has occurred and is causing detrimental consequences)
the second step is for the user to have the motivation to change
Why is treatment for substance dependence difficult?
denial - a defence mechanism whereby users do not consciously recognise that they have a problem
enabling - when significant others do things that actually encourage the person’s drug use (sometimes this means helping them avoid the harmful consequences of drug use)
What is the ‘cycle of change’?
pre-contemplation contemplation determination action maintenance re(lapse) lasting change
What is the physical treatment for substance dependence?
if the person is dependent on a legitimate prescription drug, they can be weaned off the drug slowly (assuming they recognise the problem and wish to stop)
What factors may help to prevent relapse of substance dependence?
the person is under compulsory supervision or experiences a consistent aversive reaction
the person finds a substitute dependency to compete with drug abuse
the person obtains new social supports
the person becomes a member of an inspirational group
What is the psychological treatment for substance dependence?
recognise predisposing psychological and/or sociological factors which led to drug-taking
remove user from drug-associated environmental stimuli
extinguish the conscious/unconscious association by exposing the user to the cues in the absence of the unconscious, repeatedly
What factors make psychological treatment for substance dependence more difficult?
poor self-image sees themselves as a drug user history of deviance poor socioeconomic background few education-related skills
How is medication used in the treatment of substance dependence?
substance replacement (e.g. diazepam instead of alcohol)
replacement drugs may reduce negative affectivity that caused drug abuse (e.g. antidepressants)
other drugs may serve as antagonists (acamprosate/Campral used to treat alcohol dependence; thought to stabilise the chemical balance in the brain that would be disrupted by alcoholism)
others drugs cause aversive body states when they are taken with the abused substance (e.g. disulfiram/Antabuse for alcohol)
What would be the ideal characteristics of a medication used in the treatment of substance dependence?
less toxic, with fewer side-effects decrease craving for the abused drug provide an insurmountable blockade of the effects of the abused drug block the effects of all drugs of abuse long-lasting able to take orally
What are the key factors of a substance use assessment?
thorough assessment under detection assessment process nurse’s attitude confidentiality adaptable assessment process time needs change
Why is the assessment process important?
to engage and develop a therapeutic relationship with the client
to gain an understanding of the person and their circumstances
to identify goals
to decide on the most appropriate treatment interventions
What are psychotherapeutic processes?
the patterns of conscious and unconscious thoughts, feelings and behaviour that occur in psychotherapy, in and between the therapist and client, that mediate, enable or prevent change
Why does the assessment process need to be adaptable?
the assessment could be done in a variety of different settings
people are at different stages of being ready to change
What is the current legislative framework?
MHRA - Medicines Act 1968
Home Office - Misuse of Drugs Act 1971 - recreational psychoactive drugs
regulated sales - alcohol/tobacco/solvents
unregulated sales - khat/coffee
Emerging clinical research has provided evidence to support the claim that cannabis-based treatments can have therapeutic effects for which conditions?
childhood epilepsy Alzheimer's disease cancer chronic pain multiple sclerosis
Which countries have legalised medical cannabis?
Germany Israel Australia Portugal Canada is set to become the first G7 nation to legalise recreational use
What did the World Health Organisation (WHO) (2017) state regarding the legalisation of cannabis?
publicly endorsed the medicinal qualities of cannabis
recommended to review their approach to the scheduling of Cannabidiol (CBD) oil
What did the Medicines and Healthcare Products Regulatory Agency (MHRA) (2016) state regarding the legalisation of cannabis?
“products containing Cannabidiol (CBD) used for medical purposes are a medicine”
Following recent high-profile campaigns by the parents of childhood epilepsy sufferers, what did Home Secretary Sajid Javid commission in 2018?
a review into the scheduling of cannabis-based treatments
cannabis will remain an illegal Class B substance under the Misuse of Drugs Act 1971 following the review
What happened on the 26th July 2018?
the Home Office announced that cannabis-derived medicinal products should be placed in schedule 2 of the Misuse of Drugs Regulation 2001
the effect would be to formally acknowledge their therapeutic effects and enable clinicians to prescribe related cannabis-derived medicines
What must patients demonstrate, with the support of a specialist clinician, before a license for cannabis-based prescriptions may be granted (Home Office, 2018)?
‘exceptional clinical circumstances’ to an expert panel
What did the Government’s 2017 ‘Drug Strategy’ report state?
cannabis is the most widely recorded illicit drug used by 16-59 year olds
curbing recreational use has been the Government’s primary policy since 2010
What are the health benefits of cannabis-based treatments?
reduce pain
reduce social anxiety, cognitive impairment and discomfort in patients diagnosed with generalized social anxiety disorder (SAD)
prevent Alzheimer’s disease
reduce tobacco addiction
improve sleep quality and restore respiratory stability in sleep apnoea
clear acne
regulate blood glucose and lowers insulin resistance
provide relief for IBD
prevent obesity
How do cannabis-based treatments reduce pain?
cannabis binds to CB1 receptors while reducing swelling
How do cannabis-based treatments prevent neurodegenerative disorders like Alzheimer’s disease?
cannabis helps to remove plaques that block neuron-signalling
How do cannabis-based treatments reduce tobacco addiction?
cannabis modulates the rewarding effects of nicotine
How do cannabis-based treatments help to clear acne?
cannabis inhibits lipid synthesis on the skin
How do cannabis-based treatments provide relief for IBD?
cannabis has anti-inflammatory effects
What are the patterns of substance use?
substance use is on a continuum
occasional/experimental
recreational binge dependency - psychological or physiological
What information is used in an assessment to detect substance use?
observational skills
self-report tools (e.g. DALI or semi-structured)
interviews
urinalysis
information from family/carers
past notes
other agencies involved (e.g. GP, midwife, probation officer, housing association)
What are the key components of a comprehensive substance use assessment?
current and recent use past use physical health (including sexual health) mental health social situation legal situation personal and family history risk assessment client’s perception
How can you assess current and recent substance use?
What? When? How? Where? With whom? details diary withdrawal funding observational assessment health education
Why is a diary useful?
baseline data about consumption
insight into motivations/triggers
direct feedback to client about quantifiable data regarding consumption
change according to client needs (e.g. amount, mood)
What is involved in an observational assessment?
inspect injection site - is it safe? physical appearance (e.g. underweight, disshelved/ unkempt, agitated, anxious) non-verbal communication intoxication or withdrawal any injuries
What is health education?
client consents to getting information from other sources
How can you obtain a substance use history?
when substance use began what prompted use how use developed over time impact on life periods of abstinence previous treatment timeline
What is important to remember when obtaining a substance use history?
think carefully about the language you use
be sensitive and adaptable
some people find the verb ‘use’ offensive
What are the physical effects of alcohol use?
nutritional deficiency withdrawal seizures delirium tremens cognitive impairment transient memory loss ulcers Korsakoff’s syndrome hypertension engaging in unsafe sex
What are the physical effects of stimulant use?
injecting risks
blood borne diseases when sharing crack pipes
respiratory problems
risk of fits and seizures
cardiovascular problems associated with cocaine use
prolonged periods without sleep or food
What are the physical effects of opiate use?
injecting risks infections (local and systemic) vein damage deep vein thrombosis blood borne diseases (Hep B, Hep C, HIV) by sharing equipment (spoons, filters, water) and inadequately cleaning surfaces on which injection is prepared respiratory problems if smoking
What are the physical effects of benzodiazepine use?
risks associated with crushing and injecting pills
What are the physical effects of cannabis use?
respiratory problems if smoking
What are the general factors to consider regarding the physical effects of substance use?
may be registered with a GP or engaged with health services
opiates mask pain (e.g. stomach cancer and irregular eating)
sexually transmitted diseases if exchanging drugs for sex and not using condoms
What tests can be completed to detect physical effects of substance use?
urinalysis
breathalyser
blood tests for liver function
What are some of the potential mental health effects of substance use?
suicide
deliberate self-harm
self-neglect
depression
How is sustance use related to suicide?
alcohol reduces inhibitions
alcohol increases risk of suicide when combined with other CNS depressants
lifestyle factors may contribute (e.g. lack of social support, financial problems, difficulties with police and courts, problems in relationships with close friends/relatives, feelings of hopelessness and helplessness)
factors associated with life experiences (e.g. sexual abuse, domestic violence)
people misusing drugs have access to substances which are lethal in overdose
How is sustance use related to deliberate self-harm?
alcohol use often precursor
reduces inhibitions
numbs pain
How is sustance use related to self-neglect?
not eating
neglecting personal hygiene
lack of basic amenities in accommodation/no accommodation
How is substance use related to depression?
alcohol and drugs can trigger/exacerbate depression
depression is common, independent or secondary to alcohol use
alcohol (alcoholic hallucinosis/delirium tremens), stimulants and cannabis may trigger psychotic symptoms
low mood/depression are associated with coming down from stimulants
Why is it important to gain insight into the client’s perceptions of their situation, their reasons for substance use and readiness to change?
to complement the more specific information that is obtained during assessment
to inform care planning and treatment interventions alongside other information
information obtained in the assessment will place the person on the circle of change
Why is a decision matrix useful?
it enables people to explore their reasons for using substances and identify the disadvantages of substance use
What is motivational interviewing?
a form of collaborative conversation for strengthening a person’s own motivation and commitment to change
a person-centred counselling style to address the common problem of ambivalence about change by paying particular attention to the language of change
designed to strengthen a person’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion
Why was motivational interviewing developed?
as an intervention style for facilitating behavioural and cognitive change with substance users (Miller, 1983;1995)
particular value with clients who are ambivalent about change and at the “contemplation” stage of the change process
What are the key concepts emplyed in the motivational interviewing style?
resolving ambivalence is a key to change
therapist style is a powerful determinant of client resistance and change
client motivation can be increased through a variety of therapeutic strategies
change efforts are not started before the client is committed to particular goals and change strategies
goals and treatment strategies are negotiated with the client
What proportion of adults with mental health problems are supported in primary care?
9 in 10
What is generalised anxiety disorder (GAD)?
estimated to affect 5% of the UK population
slightly more women are affected than men
more common in people aged 35-59 years
What are personality disorders?
a group of personality traits that interfere with a person’s ADLs
they are strongly associated with adverse childhood experiences
What diagnostic information is provided by the ICD-10 (2019) Classification of Mental and Behavioural Disorders for personality disorders?
“…comprise deeply ingrained and enduring behaviour patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations. They represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels, and particularly relates to others. Such behaviour patterns tend to be stable and to encompass multiple domains of behaviour and psychological
functioning. They are frequently, but not always, associated with various degrees of subjective distress and problems in social functioning and performance.”
What proportion of people in the UK have a personality disorder?
1 in 20
In which settings is the prevalence of personality disorders much higher?
criminal justice system
inpatient mental health services
What are the key features of cluster A personality disorders?
odd and eccentric
difficulty relating to others
What are the three cluster A personality disorders?
paranoid
schizoid
schizotypal
What are the key features of cluster B personality disorders?
difficulty controlling emotions
impulsive
What are the four cluster B personality disorders?
antisocial
borderline
histrionic
narcissistic
What are the key features of cluster C personality disorders?
anxious and fearful
perfectionist
What are the two cluster C personality disorders?
avoidant
dependent
What are the two most common personality disorders?
borderline personality disorder and dissocial personality disorder
Why is the diagnosis of a personality disorder seen as controversial?
some people argue that a diagnosis provides: a way to understand their experiences, a peer community, and access to services that would otherwise not be available to them
some people argue it is a diagnosis of exclusion and the stigma associated with personality disorders is highly damaging
According to NICE (2015), what treatments are recommended for borderline and antisocial personality disorders?
psychological therapies
pharmacological interventions - antipsychotic or sedative medication for short-term crisis management or treatment of comorbid conditions
What is delirium?
a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course.
it usually develops over 1-2days
a serious condition associated with poor outcomes
it can be prevented and treated if dealt with urgently (NICE, 2010)
What are some of the common risk factors for delirium?
old age severe illness dementia physical frailty admission with infection or dehydration polypharmacy surgery
What signs and symptoms indicate delirium?
an acute confusional state
a change in perception (e.g. visual or auditory hallucinations)
a change in physical function (e.g. reduced mobility, agitation, sleep disturbance)
a change in social behaviour (e.g. withdrawal, lack of co-operation for reasonable requests, alterations in mood, change in communication/attitude)
What are the three types of delirium?
hyperactive, hypoactive, mixed
What is hyperactive delirium?
abnormally alert, restless, agitated, maybe aggressive could experience hallucinations or delusions
What is hypoactive delirium?
symptoms could include abnormal sleepiness and withdrawal
could be unresponsive
What is mixed delirium?
alternate between hypoactive and hyperactive delirium
What are the differences between delirium and dementia?
delirium - treatable and reversible; sudden onset
dementia - no treatment and usually irreversible; progressive, usually over many months and years
a person can have both delirium and dementia simultaneously which makes it hard to distinguish between them
What are the two types of assessment used to diagnose delirium?
Confusion Assessment Method (CAM) - requires the presence of features 1 and 2 and either 3 or 4
4AT - a screening instrument designed for rapid initial assessment of delirium and cognitive impairment; designed for 65+ years
What is feature 1 of the CAM?
acute onset and fluctuating course
How is feature 1 usually obtained and shown?
from a family member or nurse
shown by positive responses to the following questions:
1. Is there evidence of an acute change in mental status from the patient’s baseline?
2. Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or increase or decrease in severity?
What is feature 2 of the CAM?
inattention
How is feature 2 usually obtained and shown?
by interacting with the patient, or reported by family members or staff
shown by a positive response to the following question:
3. Did the patient have difficulty focusing attention, for example being easily distractible or having difficulty keeping track of what was being said?
What is feature 3 of the CAM?
disorganised thinking
How is feature 3 usually obtained and shown?
by interacting with the patient, or reported by family members or staff
shown by a positive response to the following question:
4. Was the patient’s thinking disorganised or incoherent, such as:
rambling or irrelevant conversation,
unclear or illogical flow of ideas, or
unpredictable switching from subject to subject?
What is feature 4 of the CDM?
altered level of consciousness
How is feature 4 usually obtained and shown?
by observing the patient shown by any answer other than ‘alert’ to the following question: 5. Overall, how would you rate this patient’s level of consciousness? alert (normal) vigilant (hyperalert) lethargic (drowsy, easily aroused) stupor (difficult to arouse) coma (unarousable)
What is the first stage of the 4AT delirium assessment tool?
alertness
normal (fully alert, but not agitated) 0
mild sleepiness for <10 secs after waking, then normal 0
clearly abnormal 4
What is the second stage of the 4AT delirium assessment tool?
AMT4 - ask your patient the following: age, date of birth, name of hospital/building, current year
no mistakes 0
1 mistake 1
2 or more mistakes or untestable 2
What is the third stage of the 4AT delirium assessment tool?
attention - ask your patient to list the months of the year backwards
7 months or more correctly 0
starts, but scores <7 months/refuses to start 1
untestable (cannot start because unwell, drowsy) 2
What is the fourth stage of the 4AT delirium assessment tool?
acute change or fluctuating course - evidence of significant change or fluctuation in alertness, cognition, other mental function arising over the last 2 weeks and still evident in last 24 hrs
no 0
yes 4
What does the total score of the 4AT suggest?
4 or above - possible delirium (use the delirium pathway)
1-3 - possible cognitive impairment
0 - delirium or severe cognitive impairment unlikely (bu delirium still possible if stage 4 information incomplete)
According to NICE (2010), what should nurses do to prevent sleep disturbance in patients with delirium?
avoid nursing/medical procedures during sleeping hours, if possible
schedule medication rounds to avoid disturbing sleep
reduce noise to a minimum during sleep periods
avoid sedatives
According to NICE (2010), what should nurses do to prevent dehydration and constipation in patients with delirium?
ensure adequate fluid intake - encourage to drink and eat
monitor dietary intake - be aware of aspiration needs if applicable
ensure dentures fit properly, if applicable
According to NICE (2010), what should nurses do to prevent cognitive impairment/disorientation in patients with delirium?
provide appropriate lighting and clear signage - a clock (consider providing a 24-hour clock) and a calendar should be easily visible to the patient
talk to the patient to reorientate them by explaining where they are, who they are, and what your role is
introduce cognitively stimulating activities (e.g. reminiscence)
facilitate regular visits from family and friends
How can nurses support the family members of patients with delirium?
ensure family are given information about delirium (including causes, reversibility, and the best way to interact with their relative)
encourage family to visit and bring familiar objects from home
nurses should work within the interdisciplinary team to ensure a planned, sensitive and timely approach to informing the patient’s family about delirium and its implications for their relative, recognising the family carer’s role and likely distress (Toye et al. 2014)
What is dementia?
a syndrome in which there is deterioration in memory, thinking, behaviour and the ability to perform everyday activities
the biggest risk factor is age, but it is not a normal part of ageing (WHO, 2017)
a major cause of disability and dependency among older people worldwide
physical, psychological, social, and economical impact on carers, families and society
What is young-onset dementia (YOD)?
dementia diagnosed under the age of 65
younger people are more likely to still be working when they are diagnosed
many will have significant financial commitments
they often have children to care for and dependent parents too
their lives tend to be more active and they have hopes, dreams and ambitions to fulfill, up to and beyond their retirement
How many people are estimated to be living with YOD in the UK (Dementia UK)?
42,000
How many people are estimated to be living with dementia in the UK (PHE, 2018)?
850,000
By 2025, how many people could have dementia in the UK (PHE, 2018)?
over 1 million
By 2050, how many people could have dementia in the UK (PHE, 2018)?
over 2 million
What is the cost of dementia to the UK (PHE, 2018)?
£11.6 billion on unpaid care £5.8 billion on individual social care £4.5 billion on state social care £4.3 billion on health care £100 million on other costs
What is the Prime Minister’s challenge on dementia 2020 (Department of Health, 2015)?
sets out what this Government wants to see in place by 2020 for England to be:
(1) the best country in the world for dementia care and support and for people with dementia, their carers and families to live
(2) the best place in the world to undertake research into dementia and other neurodegenerative diseases
it also highlights the progress to date on improving dementia care, support and research
What are the most common causes of dementia?
Alzheimer’s disease - 50-70% of cases
vascular dementia - 20%
dementia with Lewy bodies - 15%
frontotemporal dementia - 5%
What are the NICE (2018) guidelines on dementia?
this guideline makes specific recommendations on Alzheimer’s disease, dementia with Lewy bodies (DLB), frontotemporal dementia, vascular dementia and mixed dementias, as well as recommendations that apply to all types of dementia
The NICE (2018) guideline includes recommendations on which areas?
involving people living with dementia in decisions about their care
assessment and diagnosis
interventions to promote cognition, independence and wellbeing
pharmacological interventions
managing non-cognitive symptoms
supporting carers
staff training and education
What is Alzheimer’s disease?
pathology - amyloid plaques and neurofibrillary tangles
symptoms - impairment in memory (particularly STM), language, and functional ability
What is vascular dementia?
pathology - mpeded oxygen supply to the brain caused by infarcts
symptoms - cognitive decline with reduced ability to concentrate and communicate; weakness in limbs; loss of coordination
What is dementia with Lewy bodies?
pathology - abnormal protein deposits in neurons
symptoms - hallucinations and disorientiation; short-term memory loss; slowed movements; attention and alertness
What is frontotemporal dementia?
pathology - degeneration of frontal and temporal lobes
symptoms - socially inappropriate behaviour; personality changes; obsessional behaviour
Where are memories made and stored in the brain?
hippocampus is underneath the cortex and involved in making new memories
short-term memories are stored in the cortex
long-term memories are stored deep in the brain
What medications are used in the management of Alzheimer’s disease?
acetylcholinesterase inhibitors
mild to moderate - donepezil (Aricept), galantamine (Reminyl), rivastigmine (Exelon)
moderate to severe - memantine (Ebixa)
What are the principal goals for dementia care?
early diagnosis in order to promote early and optimal management
optimising physical health, cognition, activity, and wellbeing
identifying and treating accompanying physical illness
detecting and treating challenging behavioural and psychological symptoms
providing information and long-term support to carers
What are the four essential elements of the person-centred care VIPS model?
valuing - people with dementia and those that care for them
individuals - people are individuals and have a unique history
perspectives - look at the world from their perspective
social - people need to live in a social environment
What is meant by the ‘values’ component of the VIPS model?
start from a position of inclusion and respect
people with dementia have periods of lucidity and insight
people with dementia still experience feelings and emotions and these are still complex and deeply held.
What is meant by the ‘individuals’ component of the VIPS model?
knowing a person’s background is important in providing care
to provide quality of care you must think about the person with dementia as a unique individual
to do this you need to understand the person’s life (e.g. their choices, talents, past experiences, the people and things that are important to them)
Why is life story work a good way to incorporate the VIPS model into dementia care?
provides information to use in conversations
gives you clues as to how a person might express their needs and emotions
you can be sensitive to past loses
easier to provide support
What is important to remember when communicating with people who have dementia?
make sure the person can see you
speak slightly slower and in a calm, positive manner
use simple sentences
yes-no questions
listen
ask people to say things in a different way if they have problems finding the right words
use body language and read their body language
do not stand too close
use appropriate physical contact to demonstrate care
use visual clues
consider the physical environment
List some of the most prevalent communication difficulties for people with dementia which arise from severe short-term memory loss.
limited attention span
impaired ability to think logically
confusion about past and present, including muddling generations
impossibility of focusing on more than one thought at a time
losing their train of thought
repeating thoughts or words over and over
given all the above, an unsurprising inability to maintain a conversational topic
What does the VERA model stand for?
Validate, Emotion, Reassure, Activity
What is meant by the ‘validate’ component on the VERA model?
accepting that the behaviour exhibited has a value to the person and is not just a symptom of dementia
What is meant by the ‘emotion’ component on the VERA model?
paying attention to the emotional content of what the person is saying
What is meant by the ‘reassure’ component on the VERA model?
this can be as simple as saying “It’ll be okay” and smiling, holding their hand
What is meant by the ‘activity’ component on the VERA model?
people with dementia need to feel occupied and active
see if you can engage them in some related activity
How many families in the UK are estimated to be caring for people with dementia (RSAS, 2016)?
700,000
What percentage of family carers of people with dementia provide in excess of 100 hrs of care per week (RSAS, 2016)?
36%
What is the financial value of the care provided by unpaid carers?
£13.9 billion
How can nurses support the carers of people with dementia?
help carers to identify what is positive
help carers to express and verbalise what is difficult
identify practical solutions that can help
maximise opportunities to enjoy and live in the moment
encourage the use of validation approaches which acknowledge the feeling being expressed even where the overall message is incomprehensible
In 2016, how many suicides were recorded in Great Britain (ONS, 2017)?
5,688
Of the suicides recorded in Great Britain in 2016, what percentage were males in comparison to females (ONS, 2017)?
males - 75%
females - 25%
What are some of the questions we should ask to assess suicidal ideation?
Do you have thoughts about death or suicide?
Do you feel that life is not worth living?
Have you made a previous suicide attempt?
Is there a family history of suicide? (NICE, 2020)
What are the red flag warning signs around suicidal ideation?
increased frequency and or intrusiveness of suicidal ideation
feelings of hopelessness about the future, feelings of guilt
sudden euphoria following low mood can be an indication that someone is planning to commit suicide and needs to be treated as a serious clinical indicator for further assessment
having a definite plan and acting on this plan (engaging in final acts such as writing a letter, collecting tablets, etc.)
How do we have discussions around suicidal ideation?
there is no evidence that asking about suicide increases the risk of suicide.
try and use open questions to get as much information as possible
beware of leading questions which invite a particular response
questions may include techniques like normalising which makes it easier for a disclosure.
“Sometimes when people are depressed, they quite commonly experience feelings of not wanting to be alive; is this something you can relate to?”
What key services can we signpost people to who have been bereaved by suicide?
Samaritans Survivors of Bereavement by Suicide (SOBS) Cruse Bereavement Care If U Care Share Foundation Child Bereavement UK Winston’s Wish Muslim Bereavement Support Services
What tools can mental health specialists use to manage suicidal ideation?
psychiatric observation levels
personal safety plans
inpatient hospitalisation
distraction techniques
What steps should you take if you suspect someone has suicidal ideation?
assess
listen none judgmentally
support the individual to get access to help (e.g. GP, primary MH workers, psychiatric liaison services, secondary MH services, places of safety, or police (in very specific circumstances)
you must inform colleagues and contact specialist MH workers
seek supervision and support after supporting someone through this situation
Why is it essential to assess for suicidal ideation in patients who have self-harmed?
around 1 in 50 people die from suicide after presenting to A&E with self-harm
What characteristics of self-harm increase the risk of suicide?
serious intent medical seriousness potential use of violent methods evidence of planning (e.g. suicide note or changes to will) precautions taken to prevent rescue
What characteristics of the person increase the risk of self-harm?
older age male gender ongoing hopelessness and intent physical health problems mental health problems other risk-taking or destructive behaviours (e.g. unprotected sexual activity, alcohol or drug use)
What circumstances of the person increase the risk of self-harm?
lower social class
high-risk employment
unemployment
recent bereavement
social isolation
harmful relationships (e.g. neglect, abuse, domestic violence)
access to the means to self-harm (e.g. supply of medications)
What are some of the questions we should ask to assess self-harm ideation?
Can you explain to me your thoughts before you self-harmed?
How did you feel after you had self-harmed?
Have you self-harmed before?
Do you have thoughts about death or suicide?
Do you feel that life is not worth living?
Is there a family history of self-harm or mental illness?
How should you assess safety in patients who have self-harmed?
assess and reduce any immediate physical risks (environmental risks and risks to physical health)
assess and reduce safeguarding risks
assess for suicidal ideation
How should you communicate with patients who have self-harmed?
use positive listening to none judgmentally build a picture of the individual’s self-harm
this may include the frequency, items used, severity, triggers, time between impulse and self-harm, and self-harm journey over time
What tools can mental health specialists use to manage self-harm ideation?
work with individual to minimise risks (e.g. infection minimisation, safety plans, ensuring the individual knows when and how to seek further support)
distraction techniques, alternatives, support boxes, positive affirmation cards
CBT and other evidence-based talking therapies
What does Sullivan (2017) believe about self-harm in hospital settings?
there should be some occasions where a person-centred approach calls for harm minimisation that allows people to self-harm in hospital
this would only be allowed after careful MDT discussions, a full assessment of individual needs, and a person-centred care plan
