Mental Health Awareness

Presenter name, position, trust

Date
 Acknowledgements

We would like to thank:

• Dr Sheila Hardy, Education Fellow at UCLPartners, and author of these materials.
• The expert reference group, steering group and project team:
Michael Benson Lead Nurse Education and Practice Development, Barnet, Enfield and Haringey Mental Health NHS Trust
Stephanie Bridger Director of Nursing, North East London NHS Foundation Trust
Eileen Bryant Primary Care Nurse Advisor, NHS England
Interim Deputy Director of Nursing and Clinical Governance, Barnet, Enfield and Haringey Mental Health NHS
Stephen Cook
Trust
Dr Rhiannon England CCG Mental Health GP Lead
Professor Peter Fonagy Director, Integrated Mental Health Programme, UCLPartners
Kate Hall Director of Education, UCLPartners
Cate Hogan Project Coordinator
Gemma Houghton Project Coordinator
Dr Henrietta Hughes Medical Director, North and East London, NHS England
Claire Johnston Director of Nursing, Camden and Islington Foundation Trust
Becky Kingsnorth Programme Manager, Adult Mental Health, UCLPartners
Dr Anna Moore Director, Integrated Mental Health Programme, UCL Partners
Dr Fiona Nolan Deputy Director of Nursing, Camden and Islington Foundation Trust
Gill Rogers Londonwide LMCs
Antony Senner Head of Development, Health Education North Central and East London
Dr Geraldine Strathdee National Clinical Director, NHS England
Jonathan Warren Director of Nursing, East London NHS Foundation Trust 2
Introductions

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Learning objectives

1. Be aware that patients attending for physical problems may have underlying distress or mental
health problems.
2. Be confident in:
• Screening patients for depression and anxiety
• Talking to a patient who has just divulged that they are distressed or concerned about a
mental health problem.
• Carrying out a biopsychosocial assessment
• Assessing the severity of depression and anxiety
• Assessing suicide risk.
3. Know how to refer patients to the appropriate mental health services.
4. Know where to signpost patients to get help with social issues such as debt and housing.
5. Understand how practice nurses can help reduce the risk of cardiovascular disease and
premature death in patients with mental illness.
6. Feel confident in assisting a patient with severe mental illness to plan their care.
7. Be aware of the medications used in mental illness.
8. Feel competent in carrying out an assessment of side effects in patients taking antipsychotic
medication.
9. Know how to refer patients with drug or alcohol problems to the appropriate services.
10. Consider how to make it easier for patients with mental illness to attend primary care.

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Underlying distress or mental health problems

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Underlying distress or mental health
problems

Adults with a mental health problem in England:

• Anxiety or depression 17.6%

• Alcohol dependence 6%
• Drug dependence 3%
• Hazardous drinking 24%
• Nicotine dependence 21% (42% of smokers have a mental
health problem)
• Severe mental illness 0.4%
• Sub-threshold mental health problems 17%

McManus S, Meltzer H, Brugha T, Bebbington P and Jenkins R. (2009) Adult

psychiatric morbidity in England, 2007: results of a household survey. Leeds:
NHS Information Centre for Health and Social Care.
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Mental health in primary care

How many patients with a mental health problem do you think are
dealt with in primary care?

90%

How many patients with a severe mental illness do you think have
no input from a mental health specialist?

30–50%

Gask L, Lester H, Kendrick T and Peveler R. (2009) Primary care mental health.
London: Royal College of Psychiatrists.

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When to consider that your patient may
have an emotional problem

If they report:
• Difficulty in managing their usual day-to-day activities
• Increased tiredness and/or problems with sleep
• Frequent short-term sickness episodes
• Problems with colleagues, family or friends
• Tearfulness
• Headaches
• Loss of humour
• Mood swings
• Change in appetite and/or eating habits
• Increase in smoking
• Increased alcohol/drug consumption

For example… 8
What is depression and anxiety?

Physical symptoms

Depression Anxiety
• Change in appetite • Change in appetite
• Change in bowel function • Change in bowel function
• Dry mouth • Dry mouth
• Palpitations • Palpitations, tachycardia, chest pain
• Indigestion • Nausea, vomiting, burping
• Feel slowed down • Increased muscle tension and weakness,
• Look unkempt tremor, and akathisia (restlessness)
• Loss of libido • Loss of libido
• Amenorrhoea • Increased menstrual flow
• Sleep disturbance • Sleep disturbance
• Headaches, giddiness, tight band round • Panting for air, tightness of the chest,
chest and head, skin-picking, hand-wringing, increased respirations, sweating, cold
general aches and pains clammy palms, sighing
• Headache, pins and needles, giddiness

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What is depression and anxiety?

Psychological symptoms

Depression Anxiety

• Thinking slow and difficult • Preoccupation with ill-health

• Poor concentration • Poor concentration
• Preoccupation with morbid thoughts • Feelings of helplessness
(death/suicide) and/or physical symptoms • Fatigue
• Feel sad, low or flat • Bizarre thoughts
• Fed up, indecisive • Wanting to run away from a feared
• Indifference, denial or lack of awareness of situation
symptoms • Irritability and restlessness
• Loss of interest in life • Thoughts of insecurity and inferiority
• Speech; slow, monotonous, monosyllabic
answers. Incessant negative talk

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Depression

• Often presents with anxiety

• Even sub-clinical presentations cause distress

• Duration for 2 weeks

• Distress
• Disabling

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Forms of anxiety

• Generalised anxiety disorder (GAD)

• Social anxiety disorder (social phobia)
• Phobias
• Panic attacks
• Obsessive compulsive disorder (OCD)

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Related modules

• Comorbidities: using a psychological approach

• Wellbeing

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Screening for depression and anxiety
and supporting patients

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Screening for depression and anxiety

Depression questions
• ‘During the last month have you often been bothered by feeling
down, depressed, or hopeless?’ Yes/No
• ‘During the last month have you often been bothered by having
little interest or pleasure in doing things?’ Yes/No
Anxiety questions:
• ‘Do you feel nervous, anxious or on edge?’ Yes/No
• ‘Do you feel unable to stop worrying?’ Yes/No
Help question:
• ‘Is this something with which you would like help?’ No/Yes, but
not today/Yes

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If a patient screens positively for anxiety or
depression:

• Listen actively
• Find out:
o How their problem is affecting them (note the person’s
mood)
o What is troubling them the most
o What helps them cope with this (offer brief advice)
• Offer empathic comment (to encourage hope)
• Ask about suicide intent

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Biopsychosocial assessment

• Current symptoms including duration and severity

• Personal history of depression
• Family history of mental illness
• The quality of interpersonal relationships with, for example,
partner, children and/or parents
• Living conditions
• Social support
• Employment and/or financial worries
• Current or previous alcohol and substance use
• Suicidal ideation
• Discussion of treatment options
• Any past experience of, and response to, treatments

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Tools used to make a detailed assessment of
depression and/or anxiety

Tools validated for primary care:

• PHQ-9 (depression)
• GAD-7 (anxiety)
• HADs (depression and anxiety)
• Beck Depression Inventory (depression)

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People most at risk of suicide

• Family history
• Previous attempt
• Underlying mental disorder
• Long-term physical condition (or pain)
• Male
• Young adult or elderly
• Alcohol or drug abuse
• Under extreme distress

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Suicide questions

1. Have you made a suicide attempt in the past?

2. Do you think that life is not worth living?
3. Do you think about harming or killing yourself?
4. Have you got a plan to kill yourself? How would you do it?
5. Do you aim to carry out this plan?
6. Have you got access to (the necessary tools) to carry out the
plan?
7. What would stop (or is stopping) you from carrying out your
plan?

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Self-harm

Prevalence:
• >11% of girls and 3% of boys aged 15–16 years self-harmed in the previous
year (Hawton 2002)
• 4.9% of adults have self-harmed (McManus et al 2009)

Self-harm is intentional damage or injury to the body. It is a way of coping with

or expressing overwhelming emotional distress.

Causes:
• Social factors
• Trauma
• Mental health conditions

Hawton K. (2002) Deliberate self harm in adolescents: Self report survey in schools in England. British
Medical Journal 325 (7374): 1207.
McManus S, Meltzer H, Brugha T, Bebbington P and Jenkins R. (2009) Adult psychiatric morbidity in
England, 2007: results of a household survey. Leeds: NHS Information Centre for Health and Social
Care.
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Self-harm

What to look out for:

• Cutting or burning their skin

• Bruising (e.g. from punching themselves)
• Poisoning themselves with tablets
• Misusing alcohol or drugs
• Deliberately starving themselves (anorexia nervosa) or binge
eating (bulimia nervosa)
• Unexplained injuries
• Depression
• Low self-esteem

Respond as you would when identifying depression and anxiety

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Services for people with mental health problems

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Services for people with mental health
problems

• Primary care

• Counselling services

• Improving Access to Psychological Therapy (IAPT)

• Third sector organisations

• Secondary care mental health services

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Local services

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National resources

Relevant services for people with mental health problems

are listed in your manual

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Related modules

• Your patient’s journey (e-learning)

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Tea break!

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Severe mental illness (SMI)

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Schizophrenia

Lifetime prevalence is 0.4%

Peak of onset is around late adolescence and early adulthood
Positive symptoms (those that are Negative symptoms (those that appear
additional to normal for the person) to take away from what the person once
• Hallucinations experienced)
• Delusions • Poor motivation
• Thought disorder • Social isolation
• Withdrawal

Cognitive symptoms Affective or mood symptoms

• Impaired attention and memory • Signs of depression and/or anxiety
• Difficulty forward planning and are common
problem solving

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Bipolar disorder

Lifetime prevalence is 1%, but it is underdiagnosed

Peak of onset is between 15 and 19 years of age
Depression Mania
• Feeling sad and hopeless • Feeling extremely happy, elated or euphoric
• Lack of energy • Talking quickly
• Finding it difficult to concentrate and • Feeling full of energy
remember things • Feeling self-important
• Loss of interest and enjoyment in everyday • Feeling full of great new ideas and having
activities important plans
• Feelings of emptiness or worthlessness • Being easily distracted
• Feelings of guilt and despair • Being easily irritated or agitated
• Feeling pessimistic about everything • Not sleeping
• Self-doubt • Not eating
• Difficulty sleeping and waking up early • Doing pleasurable things with disastrous
• Suicidal thoughts consequences, such as spending money they
haven’t got or engaging in unwise sexual
relationships

Other
• Psychosis – may have hallucinations (seeing, smelling or hearing things that aren't there)
• Self-harm can be used as a distraction from mental pain and distress

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Reducing the risk of premature death from cardiovascular disease in people with SMI

• Life expectancy is reduced by 12–19 years

• Many comorbidities but most common cause of premature

death is cardiovascular disease (CVD)

• Caused by smoking (50% smoke), unhealthy diets, low levels of

physical activity, some antipsychotic medication

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Reducing the risk of premature death from cardiovascular
disease in people with SMI

Offer patients an annual physical health check

A website has been created specifically for practice nurses. It has a

best practice manual – The Health Improvement Profile for
Primary Care (HIP-PC) – and other useful tools. These can all be
downloaded free:

http://physicalsmi.webeden.co.uk/

Attend the module ‘Physical health in mental illness’

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Making it easier for patients with SMI to attend primary
care

Late morning or afternoon appointments

Invitation letter:
• Uncomplicated
• Make clear patient can refuse treatment offered
• Date and time (be flexible if patient cannot attend)
• Named practitioner
• Not sent out too early
Telephone reminders before appointment and if does not attend to
• Patient
• Carer
• Mental health worker

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Basic care planning

Key questions:
1. Do you see a doctor, nurse or social worker at (name of
secondary care centre)?
2. Have you got housing difficulties, money or employment
problems?
3. Do you have help from anyone else?
4. What is it that keeps you well?
5. What are your main symptoms when you are unwell?
6. Can we discuss what to do if you become unwell?
7. What signs are there that you could be becoming unwell again?
8. Can we make/review a plan for when you feel you are becoming
unwell?
9. Do you have any plans for the future?
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Related modules

• Physical health in mental illness (classroom)

• Changing patients’ behaviour (classroom)

• Care planning (e-learning)

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Medications used in mental illness

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Medications used in mental illness

Common medicines you will see in primary care

Treatment for depression and/or anxiety:
• Selective serotonin reuptake inhibitors or SSRIs (fluoxetine,
citalopram, sertraline, paroxetine), Others (mirtazepine,
venlafaxine)
Drugs used for psychotic disorder:
• Antipsychotics (e.g. olanzapine, risperidone, aripiprazole,
quetiapine, clozapine)
Drugs used for bipolar disorder:
• Antipsychotics, antidepressants, ‘mood stabilisers’ (lithium,
valproate, lamotrigine, carbamazepine)
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Giving depot injections in primary care

Giving an antipsychotic depot injections is not very different from

giving a long-acting injection for a physical illness or contraception

Follow the neuroleptic injection protocol

Some of the most common drug names are:

• Flupentixol Decanoate (Psytixol®/Depixol®)
• Zuclopentixol Decanoate (Clopixol®)
• Fluphenazine (Modecate®)
• Pipothiazine (Piportil®)
• Haloperidol Decanoate (Haldol®)
• Risperidone (Risperdal Consta®)

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Monitoring side effects

• Glasgow Antipsychotic Side-effect Scale (GASS)

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Related modules

• Medications used in mental illness (e-learning)

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Specific conditions

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Alcohol problems

Alcohol use is measured in units

1 unit = 1/2 a standard glass (175ml) of wine (ABV 12%) or
1/3 of a pint of beer (ABV 5–6%)

Screening tools: AUDIT-C

Misuse:
• >28 units per week (men) or 21 (women)
• Associated with increased risk of:
o Liver disease
o Gastrointestinal bleeding
o Depression and/or anxiety
o Negative social consequences (e.g. loss of job)
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Alcohol problems

Alcohol dependence is defined by the presence of three or more

of the following:
• A strong craving to use alcohol
• Trouble in controlling alcohol use
• Withdrawal (anxiety, tremors, sweating) when drinking is
stopped
• Tolerance (able to drink large amounts of alcohol without
becoming drunk)
• Continual alcohol use despite damaging consequences

The consequences of alcohol dependence are considerable and

include CVD and stroke.

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Drug misuse

• No proactive screening in primary care

• Patients often will deny problem
• May be recognised when patients want:
o A prescription for drugs
o Help to withdraw or stabilise their drug use
o Treatment for the physical complications of drug use, such
as abscesses
o Medical acknowledgement of a drug problem because of
debt or prosecution

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Treatment of alcohol and drug problems

• Dependent on whether patient wants to stop or reduce

• Pass no judgement if they wish to continue
• Advise on the benefits of stopping (physical health, mental
health, ability to sort out social problems)
• Refer to local NHS service
• Provide self-help information

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Eating disorders

Most common:
• Anorexia
• Bulimia
Often present with a physical complaint:
• Palpitations
• Amenorrhoea
• Fits
OR
Brought in by member of family (worried about weight loss,
refusal to eat, vomiting)

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Complications caused by eating disorders

Weight loss Purging

• Amenorrhoea • Dental problems

• Dental problems • Salivary gland swelling
• Muscle weakness • Renal stones
• Renal stones • Cardiac arrhythmias
• Constipation • Fits
• Liver dysfunction

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Management of eating disorders

• Regular routine of attendance

• Education about a healthy diet and weight. Meal planning.
• Refer to dietitian (if available)
• Discuss what the benefits and disadvantages of the condition
are for the patient
• Activities to avoid bingeing
• 60mg fluoxetine maybe helpful (bulimia only)
• Monitor weight, set realistic targets agreed with patient
• Advise about local voluntary or self-help groups
• Refer to CBT/psychotherapy
• Refer to secondary care if not progressing

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Urgent referral to secondary care

• Risk of suicide
• BMI <13.5 kg/m2
• Potassium levels <2.5 mmol/l
• Low platelet levels
• Severe muscle atrophy and weakness
• Major gastrointestinal symptoms
• Other complications (alcohol or substance abuse)

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Personality disorder

Definition: the individual differs significantly from an average

person in terms of how they think, perceive, feel or relate to
others. This may lead to odd interpersonal behaviour, which can
be distressing or upsetting.

• Affects about 1 in 20 people

• Emerges in adolescence and continues into adulthood
• Can be mild, moderate or severe
• Periods of remission
• Associated with genetic and family factors

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Types of personality disorder

Type A B C

Feelings Difficulty relating to Struggle to regulate Overwhelming

others anxiety and fear

Behaviour Eccentric, odd Dramatic, Shy, withdrawn

unpredictable

Example Paranoid – person is Borderline – has Avoidant – feels

distrustful and impulses to self- inadequate, sensitive
suspicious harm, unstable to rejection
relationships with
others

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Management of personality disorder

Most people recover over time

Psychological therapies include

• Psychodynamic
• Cognitive behavioural therapy
• Interpersonal

Therapeutic communities

Medication – none licensed for personality disorder

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Postnatal depression

Occurs 4 to 6 weeks after birth but may be later

Affects 10–15% of women
Causes:
• Stress of looking after the baby
• Hormonal changes
• Money worries, poor social support or relationship problems
Higher risk if:
• Previous history of depression, bipolar disorder or
postnatal depression
• Depression or anxiety during pregnancy
Treatment as for depression described earlier
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Postpartum psychosis

Occurs within 2 weeks of birth

Affects one in every 1000

A severe episode of mental illness

Symptoms:
• Mania
• Depression
• Confusion
• Hallucinations
• Delusions

Postpartum psychosis is a psychiatric emergency

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Bereavement

Grief following:
• Death of someone close
• Significant event (loss of job or limb, breakdown of relationship)

There are four stages:

• Accepting the loss (may feel numb)
• Feeling the pain
• Becoming accustomed to the loss
• Letting go and moving on

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Bereavement

What the practice nurse can do:

• Provide the opportunity for the patient to talk

• Ask about feelings regarding the loss
• Explain it will take time to come to terms with the loss, pain will
fade slowly
• Advise to take time out if needed
• Consider depression and treat appropriately
• Refer for counselling if at risk of developing an abnormal
reaction

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Abuse

Abuse is a violation of an individual's human and civil rights by any

other person or persons (DOH 2000)

• Physical abuse
• Sexual abuse
• Psychological abuse
• Financial or material abuse
• Neglect and acts of omission
• Discriminatory abuse
• Institutional abuse

Department of Health. (2000) No secrets: Guidance on developing and

implementing multi-agency policies and procedures to protect vulnerable
adults from abuse. London: DOH.
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Abuse

Your role is that of a supportive listener

How to respond:
• Maintain a calm appearance
• Listen actively
• Don’t make promises you can’t keep
• Reassure them it is right to tell
• Recognise the bravery/strength needed to divulge the problem
• Tell them what you plan to do next

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Related modules

• Specific conditions (e-learning)

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Stress

Signs and symptoms

Feelings Thoughts
Moodiness Memory problems
Irritability or short temper Inability to concentrate
Agitation, inability to relax Poor judgement
Feeling overwhelmed Seeing only the negative
Sense of loneliness and isolation Anxious or racing thoughts
General unhappiness Constant worrying

Behaviour Physical
Eating more or less Aches and pains
Sleeping too much or too little Diarrhoea or constipation
Withdrawal Nausea, dizziness
Procrastinating or neglecting Chest pain, rapid heartbeat
responsibilities Loss of libido
Use of alcohol, cigarettes or drugs for Frequent colds
relaxation
Nervous habits (e.g. nail biting, pacing)

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Related modules

• Wellbeing (classroom)

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