Transcript The management of patients in psychiatry

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The management of
patients in psychiatry
Dr Hannah Theodorou
MEDED Psychiatry PACES Revision Day
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Take a logical approach- it’s not as
hard as you think!
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Managing the suicidal patient
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Assessment and management of risk
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Presenting management plans to the examiner
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Where to manage the patient
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Mental Capacity Act
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Mental Health Act
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Managing the suicidal patient
“These
are routine questions we ask
everyone”.
‘Given
how depressed you’ve felt
recently, have you felt so bad that you
thought life wasn’t worth living?’
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Managing the suicidal patient

‘How do you see the future?’
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‘Do you feel hopeless?’

‘Do you ever feel as if you don’t want to carry on?’
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‘Do you sometimes feel like you don’t want to wake up in the
morning?’
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‘Have you ever had thoughts of harming yourself ?’
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Managing the suicidal patient
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If a patient has had specific thoughts, ask:
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‘What particular thoughts went through your mind?’
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‘Have you made any plans?’
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‘How close have you come?’
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‘What has stopped you doing anything?’
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‘Have you actually tried to harm yourself ?’
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Assessing someone presenting
with self harm
Antecedents
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Impulsive or planned eg hoarding pills, last acts eg wills or goodbye
letters, attempts to avoid being found, disinhibiting factors eg drugs or
alcohol, prevailing mood eg did the act relieve anxiety or distress?
Psychotic symptoms eg command hallucinations
Behaviour

Method chosen, actual lethality of this method, perceived lethality of the
method, drugs or alcohol to have additive effect
Consequences
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How were they found, how did they end up in hospital, regret about
attempt or regret about failure of attempt, compliance with medical
intervention
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Risk factors for completed suicide:
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Male
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Living alone
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Unemployed
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Older age
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Substance/ alcohol problem
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Pre-existing mental illness (depression/ SCZ)
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Past history of DSH
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No confidantes/ social supports
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Command Hallucinations
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FH of suicide/ mental illness/ substance misuse
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Breaking down risk
1. Risk to self
• Deliberate
• Non-deliberate e.g.
vulnerable, self- neglect
2. Risk to others
• Deliberate
• Non-deliberate, e.g.
reckless driving,
accidental fires
3.Time line
• Short term
• Medium term
• Long term
4. Level
• High
• Medium
• Low
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Confirm the diagnosis
 “The
first step of my management would be to
confirm the diagnosis. I would do this by:
 Completing
a full history and physical
examination,
 Obtaining a collateral history
 And performing relevant investigations (may
include FBC, urine dipstick, drug screen)
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Management of mental health
disorders
 The
three main options
available are:
 Medical therapy
 Psychological
Therapies
 Social support
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Where can the patient be
managed?
GP
Most patients
CHMT
Care coordinators
CRT
Inpatient
Crisis
Resolution
Teams
PSYCHIATRIC
Psychological
Therapies
Day Hospital
Special Teams
e.g. Substance
Misuse
Early
Intervention
Team
Assertive
Outreach Team
MEDICAL:
Mental Health
Liaison
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Mental Capacity Act

Key principles of the act:
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All individuals over 16 are presumed to have capacity unless
proved otherwise
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Having a mental disorder does not mean a patient has not got
capacity
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Capacity has to be assessed for each individual situation/
decision
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The clinician or person assessing capacity must take all
reasonable measures to maximize capacity e.g. providing
interpreters, learning difficulty specialists.
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Assessing Capacity
All 4 of the following must be met:
1.
2.
3.
4.
The patient can understand the information
The patient can weigh up their decision (aware of the
consequences of refusal)
The patient can retain the information
The patient can communicate the decision back to you
ALWAYS record any assessments regarding capacity in the
patient’s notes, including the areas they failed on e.g. unable to
retain the information
Remember- if the patient is making what you believe to be an
unwise decision or one that might result in death, if they are
deemed to have capacity you must respect their decision.
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Assessing capacity
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If a patient does not have capacity:
 You must determine best interests, taking into account the
patient’s wishes before they did not have capacity. You
should also take into account the views of carers, family
and other health professionals if appropriate.
 When acting in someone’s best interests you want to used
the least restrictive intervention (one that impacts the least
on their rights and freedom)
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Mental Capacity Act
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Advance directives
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The act permits patients to make advance decisions about refusing
treatment should they lose capacity. Where an advance decision is
related to life sustaining treatment it must be written signed and
witnessed. There must also be an express statement that the decision
stands even if life is at risk e.g. in the case of Jehovah’s witnesses
refusing blood transfusion in life-threatening haemorrhage.
Lasting power of attorney
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Under the act a person may appoint someone to act as an attorney on
their behalf (lasting power of attorney) allowing them to make health
and welfare decisions amongst others for them in the event they were
to lose capacity in the future. This must be correctly registered though
in the office of the public guardian. The patient must have full
capacity when this decision is made.
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Mental Health Act (1983)
For the act to apply the patient fulfill the following criteria:
1.
Suffering from a mental disorder. There are some notable exceptions to
the act not counted as a mental disorder. You cannot section someone for
learning disability alone, drug abuse including alcohol or due to
disorders of sexual preference. As part of the 2007 update the law now
covers the personality disorders.
2.
Disorder of a nature or degree that warrants admission to hospital.
Nature relates to the course that the disease is likely to take for example
how long the symptoms will last and if they are likely to recur. Degree
refers to the current episode and the manifestations of the disorder this
occasion therefore this is usually used in the acute setting.
3.
A risk to his/her health or safety and/or other people's safety
4.
Unwilling or unable to accept hospitalisation voluntarily (informal
admission).
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The sections of the MHA
Section
Purpose
Applicant
Recommendation
Duration
2
Assessment.
Treatment can be
given, although once
this is the solo
objective it must be
converted to a
Section 3.
Treatment. Patient
must have a
diagnosis, and being
treated for an
improvement in
condition or to prevent
deterioration.
Emergency
(community)
Emergency
(inpatient)
Emergency (police)removal to a place of
safety
Urgent detention in
absence of a doctor
Approved mental
health professional
(AMHP)
2 doctors (fully
registered)- see notes
below.
28 days.
AMHP
As above.
6 months.
N/A
1 doctor
72 hours
N/A
1 doctor
72 hours
N/A
Police officer
72 hours
N/A
Registered mental
health nurse
6 hours
3
4
5(2)
136
5(4)