Mental Health or Mental illness Part 1

Mental Health or Mental illness? A mental illness is a health problem that significantly affects how a person feels, thinks, behaves and interacts with other people. It is diagnosed according to standardised criteria. The term mental disorder is also used to refer to these health problems Mental health is “a state of complete physical, mental and social wellbeing and not merely the absence of disease” WHO Mental Illness Facts and Statistics: 1 in 5 (20%) Australians will have a mental illness in any 12-month period – 11.5% have one disorder – 8.5% two or more “75% of all severe mental illness begins before the age of 24 years, with the peak onset between 18-24 years of age” (Government of Western Australia, Mental Health Commission Strategic Plan 2020, p. 32) Australia's suicide rate in 2010-11 was almost double the country's annual road toll in 2013 – 1193 (road toll) vs 2, 282 (suicide) – >6 people per day commit suicide in Australia (a further 30 attempt) Lifetime prevalence for mental illness (16-85yrs) is over 45% Anxiety disorders are most common affecting 14% of adults annually, depression 6% ~3% Australians affected by psychotic illness ~2% affected by eating disorders ~5% affected by substance use disorders Annual cost of mental illness in Australia is around $20 billion Estimated 85% of the homeless are mentally ill 1 in 4 young Australians say they are ‘unhappy with their life’ Recovery Principles: • National framework for recovery-oriented mental health services defines personal recovery as being able to create and live a meaningful and contributing life in a community of choice with or without the presence of mental health issues • Uniqueness of the individual • Real choices • Attitudes and rights • Dignity and respect • Partnership and communication • Evaluating recovery Consumer lived experience: Recovery “...is lived and experienced by individuals; what recovery orientated services do is provide supports and interventions to facilitate people in recovering” (Fossey, 2012) Recovery cannot be ‘done’ to or for someone by health professionals – uphold hope Does not mean that health professionals have no value in recovery- orientated practice Individuals will have their own definition of recovery Reshaping of one’s personal identity through a holistic sense of self that includes psychiatric disability but does not focus on the psychiatric disability as a defining aspect of life Family and carer lived experience: Lived experience is lay knowledge and can only be known by living through something. A person who has not had the experience cannot know what it 'feels like'. Experiential knowledge “...consists of statements, stories or narratives reflecting some aspect of an individual's experience that he or she values and trusts as knowledge." Recovery: • Traditional concepts of mental illness: o Degenerative, life long and permanently disabling o Medication is the focus of recovery o A diagnosis of mental illness does not correlate with successful, independent living o Consumers are passive recipients of care • Contemporary concepts of mental illness: o Recovery is a non-linear process o Treatment in the community is best-practice o Practitioners acknowledge the need for balance between reduction of symptoms with acceptable medication regimes o An inability to return to premorbid levels of functioning does not equate to failure Working within a Recovery framework: Providing a culture of hope Promoting autonomy & self-motivation Collaborative partnerships and meaningful engagement Focus on strengths Holistic and personalised care Involvement of family, carers, support people and significant others Community participation & citizenship Responsiveness to diversity Reflection & learning Recovery works when we: Align people with the right support at the right time for however long they need it Refrain from judgement – give equal help regardless of who the individual is Adopt a holistic approach Treat individuals with respect, dignity & equity Advocate for consumers to take on competent roles Protect rights Provide support only when necessary Encourage consumers to use services and supports Educate consumers to access these Staff services with workers who support these core values Historical approaches to care: • Containment and marginalisation • The asylum o Coercive treatments o Inhumane approaches • Early 20th century o Freud, Jung, postmodernism • Post WW2 o Pharmacological advances o Medical model • Human rights perspective • Deinstitutionalisation o Mainstreaming with general health care o Multidisciplinary care Model of Care: • A model of healthcare is a system or structure that has been formally developed to organise, guide and explain the way in which health professionals deliver healthcare within a particular setting • Should not be confused with a ‘service model’, ‘nursing models of care’, ‘nursing models of practice’... Contribution of the medical model: • Frameworks for diagnosis o DSM5, ICD10 • Treatment decisions • Illness/disease driven model • Clinical leadership • Focus for pharmacological research Moving to a recovery model: Recovery: Recovery enables people to address the experience of loss and grief that are major components of mental illness o Loss of employment o Loss of friends/family/support networks o Loss of identity o Loss of independence o Loss of control over destiny o Loss of confidence Principles of Recovery- Model of Practice: Promote recovery o Grounded in appreciation of recovery (hope, power, purpose, skills & connection) Strengths based o Discover and focus on consumer strengths Community focused o Occurs in community context, focuses on connections Person driven o Fosters choice and self-determination Culturally responsive o Sensitive to social and cultural needs Reciprocity in relationships o Allows for enhanced sense of value Grounded in life context o Appreciate the consumer’s unique life story and sense of self Addresses socioeconomic context o Identifies and minimises barriers as a result of poverty, housing etc. Relationally mediated o Relationships are central Optimises natural supports o Fosters connections and supports Recovery Oriented Services Uphold hope for the consumer Understand and allow for individualised recovery Engage consumers in an active sense of self Protect the rights of service users Understand and support family perspectives o Recovery oriented nurses must have self-awareness and respectful communication skills o In the context of mental illness, recovery is influenced by clinical care, but means more than the absence of symptoms Seminal Theorists: Andresen, Oades & Caputi (2011): four processes: finding and maintaining hope, reestablishing a positive identity, building a meaningful life and taking responsibility and control. Glover (2012) five recovery processes: from passive to active sense of self, from hopelessness to hope, from other’s control to self-control, from alienation to discovery and from disconnectedness to connectedness. Le Boutillier, Leamy, Bird, Davidson, Williams and Slade (2011) identified similar but differently worded processes Stigma, Stereotyping and discrimination: Stereotypes- widely held but fixed, over-simplified beliefs about particular people or things Discrimination- unjust or prejudicial treatment of a group or class of people o Also recognition & understanding of differences (positive discrimination or preferential treatment) Stigma- a sign of disgrace associated with particular circumstance, quality or people The lives of people with mental health conditions are often plagued by stigma as well as discrimination. Stigma is a negative stereotype. Stigma is a reality for many people with a mental illness and they report that how others judge them is one of their greatest barriers to a complete and satisfying life. Goffman (1986) important early theorist Stigma applied to people experiencing mental health problems: Based on fear of those experiencing mental health problems Dangerous Unpredictable Socially inappropriate Poor prognosis Evident in popular culture and perpetuated in every day language The power of language: Language often feeds directly into stigma Language is powerful, contested and in a state of change Language can diminish personhood by labelling e.g. “The schizophrenic” rather than person diagnosed with. Person –first language can be awkward. Criticised as being ‘politically correct’ Language affects others’ perceptions of the subject. Term ‘mentally ill’ much more negative than person experiencing. Features of current Australian Mental Health Services: Australian funding as a percentage of the Health budget has changed little over the past 10 years (4.9% 2004-05, 5.25% 2014-15) and is not aligned with its burden of health (12%) (AIHW (2016) General focus of care remains hospital-based services (inpatient, outpatient clinics or ED) (AIHW (2016) GP services represent primary care – other community based Medicare funded services difficult to find (some additional funds in 2017 budget associated with NDIS) Model of Service Delivery: As evident from funding – strongly medical. This emphasises diagnosis and treatment essentially medication. Diagnosis contested as validity and reliability of classification system is primarily based on a consensus model with a significant absence of bio-markers. (Pickersgill 2014) Medication treatment primarily symptomatic rather than curative. (Evans, Nizette & O’Brien, 2017) Assessment in Mental Health: Mental Health assessment operates in the absence of clear bio-markers. Emphasises systematised and comprehensive observation based on therapeutic relationship and use of collaborative information. Mental Health Assessment includes three separately reported components: o Mental state examination o Risk assessment o Substance use history Mental Health Assessment: Broadest assessment, incorporating detailed history, including: reason for referral/presentation person’s response to referral presenting problem history of presenting problem mental health history family history substance use history medical history social and developmental history trauma cultural/spiritual needs forensic history mental state examination (assessment) clinical formulation/summary risk assessment diagnosis/problem list care plan Mental State Examination (Assessment): Snap shot of point of time Systematic, ordered report 1. Behaviour and appearance 2. Affect and mood 3. Thought and speech (rate, form and content) 4. Perception 5. Orientation, cognition, sensorium 6. Memory 7. Insight and judgement Risk Assessment: Controversial component of clinical practice (Clancy, Happell & Moxham, 2014) Draws from comprehensive assessment – not a distinct form of assessment, but continuous process of dynamic and changeable factors. Risk assessment tools not highly reliable. Common areas of assessment: o Risk of violence o Risk of self-harm o Risk of suicide o Risk of neglect o Risk of victimisation/exploitation o Risk of absconding Substance Use Assessment: Rates of co-existing mental illness and substance use are very high (Gilbert et al. 2014). Substance use may have precipitated mental illness or substance use may perpetuate mental illness. Assessment requires information of particular substances, amount used, patterns of use, time of last use, prior withdrawal symptoms (if any).Include prescribed medications and tobacco. Specific tools include screening questionnaires such as AUDIT.People can be concerned regarding reporting to police of illicit substance use. Confidentiality important. Strengths Assessment: Personal resources Includes personal strategies developed to prevent and/or respond to issues, pleasurable activities to reduce stress and provide distraction, family members and friends (Available), spiritual beliefs, problem-solving skills EXPLORING THE CONTEXT FOR PRACTICE- LEGAL AND ETHICAL CONSIDERATIONS Changes in Legal perspectives: Asylums  deinstitutionalisation  Restrictive interventions (e.g. custodial care)  consumer movement  recovery framework  Legal framework implemented Contemporary Perspectives: Least restrictive treatment  community –focused care Influences in practice: o Increased effectiveness/availability of psychotropic medications o Classification of mental illness o NMHC (commissioner 2012- commenced the reduced of seclusion and restraint) o UN appointed expert on torture Juan E. Mendez (2013)  called for “an absolute ban on all coercive and non-consensual measures, including restraint and solitary confinement of people with psychological or intellectual disabilities in places of deprivation of liberty, including psychiatric and social care institutions” Victorian MHA 2014: Legislative documents: o Protects individual’s rights- statement of rights o Governs treatment o Provides direction to legal requirements for health professions Established procedures: o Independent review by the mental Health Tribunal (MHT)- compulsory treatments/electroconvulsive therapy (ECT) Definitions: Patient: person being treated under VHMA Designated Mental Health Service: approved MH service Authorised Person: Ambulance paramedic, police officer, medical practitioner employed by a designated MHS & a mental health practitioner Mental Health Practitioner: Registered nurse, registered psychologist, registered occupational therapist or social worker employed by designated MHS Authorised Witness: Registered medical practitioner, mental health practitioner, and anyone who can sign a statutory declaration Supported Decision Making: Central to the promotion of recovery-oriented practice.enables and supports compulsory patients to make decisions about their treatment and to determine their individual path to recovery. MHA supports this by: o Advance statement (s.19-22)- a formal statement of treatment preferences that much be regarded in Tx decision making. Advanced statements (AS): o Allows for consumers the opportunity to have their treatment wishes respected o Can be made any time o Is effective from the time it is made until it is revoked o Must be in writing (signed & dated) o Witnessed by an authorised witness o Where the AS has not been adhered to:  AP must be clear the treatment in the AS is not clinically appropriate  AP must provide written response if requested  Consumer can make a complaint if not satisfied with the AP response  “Advance Statements give me a chance to have my wishes about treatment respected” (State of Victoria, DoH 2014).  AS supports the notion of recovery oriented practices by providing consumer choiceTension remains with the duty of care and supported decision making  “As a carer, it helps me to know how best to advocate for my loved one during [a relapse]” (State of Victoria, DoH 2014). Nominated Person (NP): NP (s. 23-27): a person who is nominated by the consumer to:Receive information and support the treatment preferences of the person. Helps the person to exercise their rights and views.Must be willing to be available to support the individual.Does not need to be a carer/ family member but can be if the individual requests this. Second Opinion (s.78): provides another opinion to assess treatment criteria and or review of treatment provides recommended changes if requiredsupports and provides written information for the individual & nominated person. promotes self determination and dialogue about Treatment, must be regarded in clinical decision making. o Can be provided by:  Another psychiatrist from the same treatment service  A psychiatrist from different treatment service  A private psychiatrist  The second opinion service Capacity: Individuals are presumed to have capacity Capacity: (s.68) is the ability of a person to make a particular treatment decision at a particular point in time (to give informed consent) The person has capacity to make a decision if he or she: o Understands the information given o Is able to remember the information o Is able to use or weigh up the information o Is able to communicate the decision Determining Capacity: The person has: o Been given adequate information to make an informed decision o Been given a reasonable opportunity to make the decision o Given consent freely without undue pressure/coercion o Not withdrawn consent or indicated any intention to withdraw consent  Capacity should be rechecked prior to any treatment or care Consent to treatment: Some individuals may not have capacity to give consent to treatment or have refused informed consent In these circumstances: o Authorised Psychiatrist may make treatment decisions o Some decisions will require mental health tribunal (mental health tribunal) e.g. ECT o Where this is the case consideration to the:  Advance statement  Views of nominated person/guardian/carer and parents if <18 yrs.  Second opinion Compulsory Assessment & Treatment: Assessment orders (s.28) Temporary treatment orders (s.45) Treatment Orders (s.52) o Use and duration to be minimised Criteria for Assessment Order (s.29): The person appears to have a mental illness; and because the person appears to have a mental illness, the person appears to need immediate treatment to prevent- (i) serious deterioration in the persons mental or physical health; or (ii) serious harm to the person or to another person; and If the person is subject to an Assessment Order, the person can be assessed; and There is no less restrictive means reasonably available to enable the person to be assessed Assessment Orders (AO): Requirements for the consideration of compulsory mental health treatment Made by a registered medical practitioner or mental health practitioner o Person must have been assessed within the last 24 hours o Considers information communicated by other (collateral) o Community or inpatient assessment order Authorises for a person to be compulsorily examined by an Authorised Psychiatrist to determine whether the treatment criteria apply (Inc. taking to and detaining in a DNHS where required) Valid for 24 hours; can be extended 2x up to 72 hours Inpatient AO allows 72 hours for transport; 24 hour clocks starts when received at DMHS Provide copy of the AO and statement of rights to the person and nominated person