Mental health SDL cases and answers Flashcards
Case 1: Theme Psychosis
Week 1 (Theme Psychosis) Scenario: A 19 year old man is brought to see his GP by his parents who have become concerned about his behaviour. He has been asking his parents repeatedly whether there is something wrong with him, and then refusing to believe them, saying strange things like, ‘there are imbalances and improbabilities underfoot’. At times it appears as if he is talking to himself. Over the previous week his parents have heard him shifting furniture in his room throughout the night.
- What questions would you ask to illicit delusions and hallucinations?
- How would you rule out an organic or substance-use related cause of psychosis?
- You suspect that this man might need to be assessed under the MHA – describe the process and how you would explain to him and his family.
- What psychopharmacological treatments could be offered to him and how would you counsel him and his family about the benefits and side effects?
Here are screening questions for hallucinations in each sensory modality:
- Have you been hearing any voices?
- Does it seem that other people are commenting on your behavior?
- Have you been seeing any visions?
- Have you been having any unusual feelings on your body or skin?
- Have you been experiencing any unpleasant smells that others don’t notice?
- Have you been experiencing any unusual bad tastes lately that others don’t notice?
Here are some screening questions for paranoid delusions and delusions of reference:
- Does it seem like people are talking about you?
- Are people paying special attention to you?
- Do you feel that people are out to get you?
- Does it ever seem that the television or radio is talking specifically to you?Tell me about that.
Here are some questions for some other, less common delusions:
- Do you feel that you have any special abilities? What are those?
- Do you feel that you have some special importance? What is that?
- Have you ever felt that you could read people’s minds or that they could read your mind?
Thought disorder can also be a prominent symptom. If hallucinations and delusions are present, but there are not observable symptoms of thought disorder in the client’s speech (tangentiality, disorganized; see Chapter 8), you might ask the following:
- Are you having difficulties getting organized?
- Planning?
- Getting things done?
- What does your home (bedroom) look like?
- Is it messy?
- Are you having any difficulties with feeling confused or having your thoughts feel scattered?
How would you rule out an organic or substance-use related cause of psychosis?
What is your differential diagnosis for new-onset psychosis?
The medical workup!!!
- A thorough history and physical examination with emphasis on the neurological and cognitive parts are the cornerstones for the initial approach to psychosis.
- To detect fluctuations in mental status typical for a toxic psychosis, repeated visits with bedside testing of cognition may be necessary.
- The extent of the laboratory workup to complement the history and physical examination is a matter of debate, and there is no agreed-on workup.14
- For test selection, test characteristics (sensitivity and specificity) as well as the prevalence of the disease are key considerations.
- f a disease is unlikely (low prior probability), a positive test result is probably a false positive, which argues against indiscriminate screening.
- Among the tests selected for screening, the most sensitive test needs to be ordered because a negative test result removes the disease from the clinician’s differential diagnosis list.
- For example, the rapid plasma reagin (RPR) is not the most sensitive test for neurosyphilis, and a negative result could be a false negative; if one were to truly want to rule out neurosyphilis, a treponemal-specific test would be needed Further complicating test selection is the unavailability of sensitive and specific tests for many diseases.
- If there is a strong clinical suspicion for a disease, its diagnosis must be actively pursued with repeated tests (eg, serial electroencephalograms [EEGs] for epilepsy). Finally, a positive finding on an examination or a positive laboratory test result alone (eg, a urine drug test positive for cannabis) does not establish causality. This point is perhaps most relevant with regard to incidental findings on a sensitive neuroimaging modality, such as a brain MRI.
- One possible medical workup is outlined in Table The suggested laboratory battery is a compromise between broad-based screening (eg, erythrocyte sedimentation rate for inflammatory conditions) and exclusion of some specific conditions that are treatable if diagnosed (eg, HIV infection, syphilis, thyroid disease, vitamin B12 deficiency). If there is clinical concern for a delirium, EEGs, arterial blood gases, or lumbar punctures become more important.
- Of note, there is no consensus regarding the need for routine brain imaging in first-episode psychosis.
- CT or MRI may be reserved for patients with an atypical clinical presentation, neurological findings, or an unusual/treatment-refractory course. A normal baseline CT or MRI scan, however, is reassuring and can help patients and families accept that medical and neurological causes of illness have been excluded.
- The appropriate role of routine genetic screening in patients with psychosis is an area in flux. Currently, only the Clinical Practice Guidelines for the Treatment of Schizophrenia by the Canadian Psychiatric Association recommends testing for a genetic syndrome, the velocardiofacial syndrome, but only if it is clinically suspected.
How will you clinically differentiate primary and secondary (or organic causes of psychosis? What key point in the clinical assessment MUST be covered.
What is recommended a part of the Medical work up for an organic cause of psychosis?
List important medications that can cause psychosis?

Question 3: You suspect that this man might need to be assessed under the MHA – describe the process and how you would explain to him and his family.
Introduction
The Mental Health Act 2016 sets out to:
- improve and maintain the health and wellbeing of people who have a mental illness who do not have the capacity to consent to treatment
- divert people from the criminal justice system if they are of unsound mind at the time of committing an unlawful act or unfit for trial
- protect the community.
The aims of the Act are to be achieved in a way that:
- safeguards the rights of people
- is least restrictive of the rights and liberties of a person who has a mental illness
- promotes the recovery of a person who has a mental illness and their ability to live in the community.
- The Objects and Principles of the Act play a critical role in determining how the Act is to be interpreted and administered.
- A person must have regard to the principles in performing a function under the Act. 7 2.2
- Objects The main objects of the Act are: to improve and maintain the health and wellbeing of persons who have a mental illness who do not have the capacity to consent to be treated
- to enable persons to be diverted from the criminal justice system if found to have been of unsound mind at the time of committing an unlawful act or to be unfit for trial, and
- to protect the community if persons diverted from the criminal justice system may be at risk of harming others.
- The main objects are to be achieved in a way that:
- safeguards the rights of persons
- is the least restrictive of the rights and liberties of a person who has a mental illness (see below)
- , and promotes the recovery of a person who has a mental illness, and the person’s ability to live in the community, without the need for involuntary treatment and care.
- A way is the least restrictive of the rights and liberties of a person who has a mental illness if the way adversely affects the person’s rights and liberties only to the extent required to protect the person’s safety and welfare or the safety of others.
- Principles The following principles apply to the administration of this Act in relation to a person who has, or may have, a mental illness:
- Same human rights the right of all persons to the same basic human rights must be recognised and taken into account a person’s right to respect for his or her human worth and dignity as an individual must be recognised and taken into account
- Matters to be considered in making decisions to the greatest extent practicable, a person is to be encouraged to take part in making decisions affecting the person’s life, especially decisions about treatment and care to the greatest extent practicable, in making a decision about a person, the person’s views, wishes and preferences are to be taken into account
- a person is presumed to have capacity to make decisions about the person’s treatment and care and other matters under this
- Support persons to the greatest extent practicable, family, carers and other support persons of a person who has a mental illness are to be involved in decisions about the person’s treatment and care, subject to the person’s right to privac
- Provision of support and information to the greatest extent practicable, a person is to be provided with necessary support and information to enable the person to exercise rights under this Act, including, for example, providing access to other persons to help the person express the person’s views, wishes and preferences
- Achievement of maximum potential and self-reliance to the greatest extent practicable, a person is to be helped to achieve maximum physical, social, psychological and emotional potential, quality of life and self-reliance Acknowledgement of needs a person’s age-related, gender-related, religious, communication and other special needs must be recognised and taken into account a person’s hearing, visual or speech impairment must be recognised and taken into account
- Aboriginal people and Torres Strait Islanders —–
- the unique cultural, communication and other needs of Aboriginal people and Torres Strait Islanders must be recognised and taken into account Aboriginal people and Torres Strait Islanders should be provided with treatment, care and support in a way that recognises and is consistent with Aboriginal tradition or Island custom, mental health and social and emotional wellbeing, and is culturally appropriate and respectful to the extent practicable and appropriate in the circumstances, communication with Aboriginal people and Torres Strait Islanders is to be assisted by an interpreter
- Persons from culturally and linguistically diverse backgrounds the unique cultural, communication and other needs of persons from culturally and linguistically diverse backgrounds must be recognised and taken into account services provided to persons from culturally and linguistically diverse backgrounds must have regard to the person’s cultural, religious and spiritual beliefs and practices to the extent practicable and appropriate in the circumstances, communication with persons from culturally and linguistically diverse backgrounds is to be assisted by an interpreter
- Minors to the greatest extent practicable, a minor receiving treatment and care must have the minor’s best interests recognised and promoted, including, for example, by receiving treatment and care separately from adults if practicable and by having the minor’s specific needs, wellbeing and safety recognised and protected Maintenance of supportive relationships and community participation to the greatest extent practicable, the importance of a person’s continued participation in community life and maintaining existing supportive relationships are to be taken into account, including, for example, by providing treatment in the community in which the person lives 4
- Importance of recovery-oriented services and reduction of stigma the importance of recovery-oriented services and the reduction of stigma associated with mental illness must be recognised and taken into account Provision of treatment and care treatment and care provided under this Act must be provided to a person who has a mental illness only if it is appropriate for promoting and maintaining the person’s health and wellbeing Privacy and confidentiality a person’s right to privacy and confidentiality of information about the person must be recognised and taken into account. The Act also establishes principles for victims of unlawful acts
Continue how to explain this to him and his mother, explaining what is meant by, EEA, Examination authority, Recommendation for assessment, treatment authority,
What is meant by involuntary patient?
Who is an involuntary patient
- An involuntary patient is: a person subject to a treatment authority a person subject to:
- a forensic order
- a person subject to a treatment support order
- a person subject to an examination authority
- a person subject to a recommendation for assessment
- a person subject to a judicial order
- a person detained while a recommendation for assessment is being made for the person, or a person who is absent without permission from another State and is detained in an authorised mental health service.
Emergency examination authorities are made under the Public Health Act, Persons subject to emergency examination authorities are not involuntary patients under the Mental Health Act 2016.
- Treatment authorities are made by authorised doctors.
- They authorise the involuntary treatment and care of a person for a mental illness, and, if necessary, detention in an authorised mental health service.
- Forensic orders are a forensic order (mental health), forensic order (disability) or forensic order (Criminal Code).
- Forensic orders (mental health) and forensic orders (disability) are made by the Mental Health Court to protect the safety of the community.
- A forensic order (mental health) allows the involuntary treatment and care of a person for a mental condition, and if necessary detention in an authorised mental health service.
- A forensic order (disability) allows the involuntary care of a person for an intellectual disability, and, if necessary, detention in the Forensic Disability Service or an authorised mental health service.
- Forensic orders (Criminal Code) are made by the Supreme Court or
- Treatment support orders are made by the Mental Health Court to protect the safety of the community in circumstances where a forensic order is not warranted.
What psychopharmacological treatments could be offered to him and how would you counsel him and his family about the benefits and side effects?
First Pharmological treatment:
Atypical antipyshcotics
- Antipsychotic medications work by altering your brain chemistry to reduce psychotic symptoms like hallucinations, delusions and disordered thinking. They also help prevent those symptoms from returning.
Antipsychotic medication facts
- Experiences vary: all antipsychotic drugs are designed to do the same thing — reduce psychotic symptoms and keep them away — but they’re known to affect people in different ways, so your experience of taking them will be unique to you.
- Antipsychotic medications are common: in 2011, nearly 350,000 Australians had at least one prescription filled for antipsychotic medication. That’s 1.6% of the population.
Antipsychotic medication myths
- Myth: ‘You can get addicted to them’
- Reality: Antipsychotic medications aren’t addictive and you won’t need to take more over time to get the same effect.
- Myth: ‘They cure you’
- Reality: Antipsychotics reduce psychotic symptoms and distress, but they’re not a cure for mental illness.
- Myth: ‘They’re happy pills’
- Reality: Antipsychotics don’t make you feel happy no matter what. You’ll still feel normal ups and downs in your emotions.
- Myth: ‘Medication is the only treatment’
- Reality: There are many other forms of help: psychological therapies, support with housing and work, physical and occupational therapy and more.
Kinds of antipsychotic medication
- Modern medications for treating psychosis are known as ‘second-generation’ or ‘atypical’ antipsychotics. Some common atypical antipsychotics include:
- aripiprazole
- clozapine
- olanzapine
- quetiapine
- risperidone
- ziprasidone
These are the names of the drugs themselves, but they’re often sold under different brand names.
- Older, ‘first-generation’ or ‘typical’ antipsychotic medications are generally only prescribed if the second-generation medications aren’t working for you.
- I’m very grateful for the medication as it allowed me to sleep for the first time in five months
— Carlo
How antipsychotic medications work
- Antipsychotics change the levels of chemicals in your brain called neurotransmitters — the chemicals that carry messages around your brain. The neurotransmitter most targeted by antipsychotics is called dopamine.
- Changing the levels of these chemicals reduces, in almost all cases, the hallucinations and delusions of psychosis. In some cases, they also improve your mood and reduce anxiety.
Talking to doctors about medication
- Here’s a list of some useful things you might want to discuss with your doctor.
Tell your doctor about:
- any other medications you’re taking
- any other physical conditions you have
- your allergies.
If your doctor suggests medication, ask:
- how long will it take to start working?
- what side-effects and benefits will it have?
- how long will you need to take it for?
- Ask your doctor what is or isn’t recommended while taking medication. For example:
- if your medication can make you drowsy, your doctor might suggest you don’t drive
- you may need to avoid alcohol with some medications. This can be a challenge if alcohol is a big part of your social life.
- Talk to your doctor about what is a safe amount to drink and whether other treatment options are available.
- if you’re planning to become pregnant, tell your doctor in case any changes need to be made.
While you’re taking medication, tell your doctor immediately about:
- any side-effects you experience
- difficulty remembering to take your medication
- any changes to your physical health.
How to take antipsychotic medication
- There are two ways to take antipsychotic medication: by mouth or as a depot (sometimes called a ‘long-acting injectable’). The dose you take each time usually starts low. As your symptoms are monitored over time, your doctor might increase it or keep it at the same level.
- Medication by mouth usually means a tablet, once or twice a day. Listen to any instructions you’re given and read the pamphlet that comes with medication to make sure you follow the right method for taking them.
- Medication by depot is when you take your medication as a regular injection. The depot sits under your skin and releases the medication over two or four weeks, so you get a steady dose. It’s the same medication as the tablet.
- Depots are used when there’s a risk you might forget or stop taking your medication, which can lead to a rapid worsening of your symptoms.
- You can choose a depot yourself, but there are circumstances where a doctor can legally require you to take medication by depot, even without your consent. That’s only done rarely, and always with your health and safety in mind.
How long until they work
- It commonly takes up to six weeks from your first dose for medication to start reducing symptoms, and several months before you feel their full effect.
- How long to take antipsychotic medication
- If your psychotic symptoms reduce or go away, it doesn’t mean your medication is unnecessary. It means your medication is working — part of its job is to stop your symptoms coming back.
- When people stop taking their medication too soon or too suddenly, they are at very high risk of having another episode.
- You should have completely recovered from psychosis and had 12 months of good mental health before even starting the discussion about stopping medication.
- To give yourself the best possible chance of recovery and good health, take your doctor’s advice and, where advised, take your medication.
If you feel you need to change your medication, always do this in consultation with your doctor.
Side-effects
- All antipsychotic medications have potential side-effects. They vary from person to person, but can include:
- drowsiness
- weight gain
- unusually dry or watery mouth
- restlessness
- trembling, especially in the limbs
- muscle stiffness
- dizziness
- eyesight problems
- moving more slowly
- changed interest in sex, problems having sex
- nausea
- constipation
- increased sweating
- pain or irregularity in menstruation.
If you’re taking antipsychotic medication, it’s very likely you will experience some side effects. Work is being done to improve medications, but at the moment it’s often necessary to live with side-effects to reduce your active psychotic symptoms.
If you start experiencing side-effects, make sure you tell your doctor about them straightaway.
Changing medications
For some people, it can take months to find the right medication — that’s normal.
If the side-effects of the medication you’re taking are too severe, or if your psychotic symptoms don’t subside, it might be possible to try other options.
Talk to your doctor. Changing medicine can take time and will need careful guidance and observation from a health professional.
Within three months of the change in his medication, Jock took over his own life. He didn’t look back
— Jock’s mother Dianne
Safety with medication
- There are a few things you can do to make sure your experience with medication is safe:
- Tell your doctor everything: your allergies, other medication you take, your alcohol, smoking and recreational drug habits, if you’re pregnant or breastfeeding, and anything else they ask. It all helps with finding the right medication plan for you.
- Store your medication carefully: medicine doesn’t like heat or damp, so keep your medication out of bathrooms and cars. Keep it in a container in a cool, dry place. Store it high to make sure children can’t reach it.
- Don’t share medication: your medication is designed for you and no one else. Don’t take anyone else’s medication and don’t let anyone take yours. It can do real harm.
- Take the right dose: taking too little or too much reduces how effective your medicine is, and can do harm. Stick to the instructions on the packet.
Limits of antipsychotic medication
- Some people with psychotic illness find that the usual antipsychotic medications don’t reduce their symptoms over time. If this happens, your doctor may suggest clozapine, a drug which is very effective but comes with a greater risk of side effects.
- Antipsychotic medications are designed to reduce and prevent the return of psychotic symptoms, including hallucinations, delusions and disordered thinking. They may not affect the other symptoms of your illness, so you may need to get other treatments for these symptoms.
- Antipsychotic medication is considered the main treatment for psychosis, but other treatments are available.
Related: Psychosis factsheet
- Other medication you might need to take
- Along with psychosis, you may experience other mental health issues, like depression, mania, anxiety, and the ‘negative’ symptoms of schizophrenia.
- So you may be prescribed anti-anxiety medications, anti-depressants or mood stabilisers along with your antipsychotics. This is relatively common — the medications are often used together
What are the key recommendations for FEP (first episode Psychosis RANZCP- Guideline recommendations
What are key psychiatric management principles when first giving antipsychotics (THINK WHAT YOU NEED TO MONITOR/SCREEN FOR)
- Discuss risks and benefits of the medication with the patient beforeinitiating treatment, if feasible, and identify target symptoms (e.g.,anxiety, poor sleep, hallucinations, and delusions) and acute sideeffects (e.g., orthostatic hypotension, dizziness, dystonic reactions,insomnia, and sedation)
- .Initiate antipsychotic medication as soon as it is feasible. It may beappropriate to delay pharmacologic treatment for patients whorequire more extensive diagnostic evaluation or who refusemedications or if psychosis is caused by substance use or acute stressreactions.3.
- Use of Antipsychotic Medications in the Acute PhaseAssess baseline levels of signs, symptoms, and laboratory values relevant to monitoring effects of antipsychotic therapy.
- Measure vital signs (pulse, blood pressure,
- temperature).
- Measure weight, height, and body mass index (BMI), which can becalculated with the formula weight in kilograms/(height in meters)2or the formula 703 ×weight in pounds/(height in inches)2or witha BMI ble
- Assess for extrapyramidal signs and abnormal involuntarymovements
- .Screen for diabetes risk factors and measure fasting blood glucose.
- Screen for symptoms of hyperprolactinemia.
- Obtain lipid panel.
- Obtain ECG and serum potassium measurement before treatmentwith thioridazine, mesoridazine, or pimozide; obtain
- ECG beforetreatment with ziprasidone in the presence of cardiac risk factors.•
- Conduct ocular examination, including slit-lamp examination, whenbeginning antipsychotics associated with increased risk ofcataracts.•Screen for changes in vision.
- Consider a pregnancy test for women with childbearing potential.
TREATING SCHIZOPHRENIA •
- Minimize acute side effects (e.g., dystonia) that can influence willingness to accept and continue pharmacologic treatment.
- Initiate rapid emergency treatments when an acutely psychotic patient is exhibiting aggressive behaviors toward self or others.
- Try talking to the patient in an attempt to calm him or her. • Restraining the patient should be done only by a team trained in safe restraint procedures.
- Use short-acting parenteral formulations of first- or secondgeneration antipsychotic agents with or without parenteral benzodiazepine.
- Alternatively, use rapidly dissolving oral formulations of secondgeneration agents (e.g., olanzapine, risperidone) or oral concentrate formulations (e.g., risperidone, haloperidol).
CASE 2
Week 2 (Theme: Mood Disorders) Scenario: A 37 year old man with a history of several depressive episodes is brought to ED by his partner. They are concerned because he has been acting unusually for the past few days – sleeping very little, spending large amounts of money, and embarking on risky business ventures. The patient is adamant that there is nothing wrong, saying he has ‘never felt better’. He takes citalopram which was recently increased to 40mg daily.
- What is the most likely diagnosis?
- Discuss the factors you would take into account when considering if this man should be treated in hospital.
- What change would you make to his current medication?
- What alternative medications could be started to treat his condition in the immediate and longer term?
- What is the prognosis for his condition? How would you explain this to him and his partner?
- Hypomania/Mania, with hx of depressive illness - Makes Type 2 bipolar likely. - Switching effect
What is the lifetime prevalence of mood disorders (Bipolar/depression) ?
Discuss the factors you would take into account when considering if this man should be treated in hospital.
What are some screening questions to ask patients with depression to screen their cognition?
Outline a general stepwise approach to depression management/treatment?
Outline strategies to implement ‘Sleep hygiene’, in depression/mood disorders
Outline, Dietary recommendations for depression/mood disorders/any condition really?
Outline strategies for implementing ‘Regular excercise” into treatment:?
Outline strategies to assist patients with quitting smoking?
Outline ways to assist patients with substance and alcohol misuse?
Outline statgeis to assist with daily functioning and routine maintenance?
Outline strategies for assisting psychoeducation??? List different online resources to assist this?
Outline stratgeies for implementing social support?