Transcript Mental Health Care Pathway

Mental Health
Care Pathway
Coping
with
daily
living
problems
Psychological
Therapy Services
(IAPT)
Primary
care
Care pathways
Mental health
services
General hospital
services
Other
agencies
i
Commissioning
for
mental health
Service Pathways
Hants Oxon
Coping
with
daily
living
problems
MENTAL HEALTH
Self-help
& Caring
Exit from
services
MENTAL HEALTH
(prototype)
Mental Health
Care Pathway
Mental health
Services
Children
Self-help
& Caring for
mental health
problems
Coping with
daily
living
problems
Primary care
Mental health
General hospital
Services and
Mental health
Adults
Older people Learning disability Diagnoses
How do I contact
Psychological
Therapy Services
(IAPT)?
How do I find
mental health
Services?
Other agencies
which work with
mental health
services
Search
Care pathways
for mental health
problems
Help
Exit
from
services
Service pathways
through mental
health services
Please insert UK postcode for
locaised information
Comments: [email protected]
[email protected]
Web-links that are provided as part of this programme are ones which we hope you will find useful but their inclusion should not imply that the relevant web content is endorsed by NHS
South Central or other NHS organisations supporting the development of this programme.
Permission to use pathways developed by South London and Maudsley FT (SLAM) is awaited.
Developed by David Kingdon for NHS South Central with contributions from many individuals
What is a mental health problem?
There is often confusion about what is a mental health problem, mental disorder or mental illness.
– A disorder (or problem) could be described as any condition that causes distress or disability
(physical or mental). However whether someone presents, or rarely is presented, for help or
requires reduction in their responsibilities e.g. time off work, varies greatly from person to person
and in relation to the cause of the disorder.
– Society has standards and mechanisms for deciding whether someone is ill or not – usually
relying on the General Practitioner to make that decision.
– For example, depression is a disorder but need not be an illness. It can be very severe, e.g.
after a bereavement, but the individual may request very limited support or intervention. On the
other hand, relatively ‘mild’ depression may present and treatment may be appropriate in
someone with limited coping abilities and little social support. It may be agreed that they are ill
and psychological intervention, for example, be reasonable. Similarly for physical conditions, a
bruise might be described as a disorder but not an illness – though it could become one if it
causes swelling or severe discomfort.
Web-links that are provided as part of this programme are ones which we hope you will find useful
but their inclusion should not imply that the relevant web content is endorsed by NHS South
Central or other NHS organisations supporting the development of this programme.
Comments:
specific service websites will often have email addresses for comments, if not these
can be made to [email protected]
comments on the website can be made to [email protected]
Developed by David Kingdon ([email protected]) for NHS South Central with contributions from many individuals
for which grateful thanks
Getting access to mental health
services
•
Emergency
–
–
•
Urgent
–
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–
•
Where there is immediate risk to life or serious physical injury, the emergency services should be
contacted using 999.
Examples would be where someone has taken or seriously threatening to take an overdose of
medication or made another suicidal action especially where they are showing signs of its effects,
e.g. slurring or sleepiness (ask for ambulance); or where someone is threatening aggression,
holding a weapon or committing or about to commit an assault (ask for police).
Where someone is very distressed or may be talking about harming themselves or someone else,
immediate attention may be necessary
If they are currently under the care of mental health services, contact should be made with those
services (local services can be located through NHS Choices ) or their general practitioner or NHS
Direct.
If not under the care of services, contact should be through the person’s general practitioner (or
NHS Direct ) or if the person is in a public place (not their own home), the police can be contacted
and may intervene.
A relative of a patient can ask local mental health services for a Mental Health Act assessment by
a psychiatrist and approved mental health practitioner
Routine
–
–
–
Most services accept referrals from General Practitioners and so these referrals usually occur after
discussion about mental health care needs at an appointment with a GP (local services can be
located through NHS Choices ).
Some services accept self-referral (e.g. Psychological Therapy Services , Drugs & Alcohol or Early
Intervention in Psychosis teams)
Some people are referred from the Courts, Prisons or by the Police.
Contact with services
• General hospital
– Some people present to Emergency Departments with mental
health problems, e.g. after self-harming or accidents.
– They may also present to specialist out-patient clinics or as inpatients and require treatment, in collaboration with their family
doctor and, sometimes, referral to specialist mental health
services.
• Criminal Justice Service (Police, Probation, Courts or
Prisons)
– The police may be called and can act where mental health
issues arise especially where there is concern about harm to
others or self in public (and sometimes private) places.
– Courts and prisons may also refer to mental health services
including through specialised liaison services.
Primary Care
(including general practitioner or family doctor services)
• GPs provide front-line mental health care
as part of their service to their patients.
• Most people with mental health problems
will therefore never require help from
specialist mental health or psychological
treatment services.
• However where it is necessary, such
referrals are possible.
Quality & Outcomes Framework
Primary Care
Explanation of symptoms or sign-posting
may be sufficient.
Consider watchful waiting for emotional
difficulties.
NO ACTION
Holistic assessment including both
mental and physical state.
Consider carer perspective
Consider diagnosis especially early
intervention in psychosis
ASSESSMENT
REFERRAL
INTERVENTION
Access local psychological
therapy services (IAPT) or
mental health services
If referral refused by patient,
consider discussion with
local CMHT or early
intervention team
Consider relapse prevention
and sign-posting
EPISODE
COMPLETION
Watchful waiting & self-help resources
Where appropriate, agree shared care with mental
health services – especially where non-cooperation
is issue.
Medication or brief psychological intervention – see
care pathways &/or:
Resource: The management of patients with physical and
psychological problems in primary care: a practical guide
Underpinning values
10 Essential Shared Capabilities.
•
Working in Partnership.
•
Respecting Diversity.
•
Practising Ethically.
•
Challenging Inequality.
•
Promoting Recovery.
•
Identifying People’s Needs and Strengths.
•
Providing Service User Centred Care.
•
Making a Difference.
•
Promoting Safety and Positive Risk Management.
•
Personal Development and Learning.
Partner Agencies
Statutory:
• Police
Voluntary:
• National
–
–
–
–
–
–
–
–
–
–
– Hampshire
– Thames Valley
• Councils
– Hampshire
– Oxfordshire
– Southampton
• General Hospitals
•
• Southampton University Hospital Trust
• Royal Hampshire County Hospital
• Basingstoke Hospital
– Oxfordshire
• Radcliffe
Local
–
–
–
–
– Hampshire
•
AgeUK
Alcohol Concern
Alzheimers society
Centre for Mental Health
MENCAP
Mental Health Foundation
MIND
RETHINK
Voluntary Services
YOUNG MINDS
MIND (Oxon Solent)
Restore (Oxon)
No Limits (Soton)
Voluntary Services (Oxon Soton)
Housing & Employment
–
–
City limits (Soton)
Shelter
Assistance with coping
with life’s problems
Patient rated outcome measure
Cultural
support
General
practical
advice
Caring
for others
Leisure
activities
Mental
distress
Spiritual
issues
Education
Patient rated outcome measure
Relationships
Memory
problems
Drugs &
Alcohol
Work
DropBy
Physical
health
Housing
issues
Money
For further help:
Mental Health
Care Pathways
Housing issues
• National organisations
– Shelter
– Crisis
– Homeless Link
• Gateways to homelessness services:
– Homeless Healthcare Services (Soton)
– Street Homeless Prevention Team (Soton)
• ‘No-One Left Out: Communities Ending Rough Sleeping’
• Mental health and homelessness good practice guide
• Asylum seekers
GENERAL HOSPITAL
SERVICES
• Ambulance Services
• Emergency Department
– Access to mental health services
– Management of Deliberate Self-Harm
• Perinatal (mother & baby) mental health care
• Psychological medicine (General hospital liaison)
• Mental Health Act , Mental Capacity & Deprivation of
liberty (DOLS) guidance
• Specific conditions
– Dementia & Delirium
– Physically unexplained symptoms
– Other mental health conditions
Local Hospitals
Care pathways
• These are ways of describing the care needed for
specific mental health conditions.
• Broadly these are:
– Emotional difficulties, usually presenting with distress
– Psychosis, where there is some confusion or disagreement with
others about what is really happening
– Memory difficulties, where these may be from changes to the
brain
– Developmental difficulties where development has been held
back in learning disability or is a problem, e.g. with behaviour
– Substance misuse - drug or alcohol problems
• Much fuller information is given in books & leaflets or
diagnostic systems.
Care pathways
Psychosis
R&D OASIS
Memory
Difficulties
Emotional
difficulties
Values
Developmental
difficulties
Substance
misuse
Self-diagnosis
Payment-by-Results
R&D – studies actively recruiting
Global outcome measure
Patient rated outcome measure
Global outcome measure
Patient rated outcome measure
R&D
Care pathways
Psychosis
R&D OASIS
Memory
difficulties
Learning
disability
Anxiety/depression
& related
conditions
Eating
disorders
Emotional
difficulties
Developmental
difficulties
Bipolar disorder
‘Rapid cycling’
R&D OASIS
Borderline Personality
Disorder
Other:
Incl. Autism (ASD),
ADHD, Conduct disorder.
Substance
misuse
Values
Drugs
Alcohol
i
Payment-by-Results
R&D – studies actively recruiting
Global outcome measure
Patient rated outcome measure
Global outcome measure
Patient rated outcome measure
R&D
Care Pathways –
Anxiety/depression & related conditions
Anxiety
Anxiety/
depression, etc
(diagnosis)
Somatising
‘physically
unexplained’
PTSD
OCD & Body
Dysmorphic
Disorder’
NICE guideline
NICE guideline
Review
NICE
priorities
Anxiety/
depression
etc
pathway
IAPT Guidance
NICE guideline
Review
NICE
priorities
NICE guideline
Review
NICE
priorities
Self-help
& caring
Specific outcome measures
Specific outcome measures
Depression
Review
NICE
priorities
Referral to
Psychological
Therapy
Services (IAPT)
Specialist
mood
disorder
service
Community
pathway
Medication
review
Review
NICE
priorities
Confirm
diagnosis
Assessment
& risk
management
Not require
Mental Health
Service
intervention
Requires
Mental Health
Service
intervention
Acute
care
pathway
Requires
maintenance
support
Psychol
-ogical
review
NICE guidelineS
PbR clusters
Exit
from
services
Assertive
outreach/
Recovery
team
CMHT
Self-help
& caring
Asylum seekers
Specific outcome measure
Specific outcome measure (CORE & IAPT)
Care Pathway – Anxiety/Depression
& related conditions
SERVICE PATHWAYS
Hampshire
Values
Learning disability
services
Transitional protocols
Child & Adolescent
Services
(electronic record)
Service pathways
Transitional protocol
Acute care
Community
Liaison
Perinatal
Acute care
Community
Adult services
Transitional protocol
QUALITY
Essentials
CQUIN
Standards
& Survey
National
Patient
Safety
Agency
Recovery
Older people’s
services
Liaison
Early
Intervention
Memory assessment
Forensic services
Substance
misuse services
Finance
Training
Global outcome measures
Patient rated outcome measure
Global outcome measures
Patient rated outcome measure
Information
HR
MENTAL HEALTH SERVICE
PATHWAYS
Values
Learning disability
services
Transitional protocols
Child & Adolescent
Services
(electronic record)
Transitional protocol
Acute care
Service pathways
Community
Recovery
Adult services
Liaison
Perinatal
Transitional protocol
QUALITY
Essentials
CQUIN
Standards
& Survey
National
Patient
Safety
Agency
Older people’s
services
Acute care
Community
Liaison
Memory assessment
Forensic services
Substance
misuse services
Training
Global outcome measures
Patient rated outcome measure
Global outcome measures
Patient rated outcome measure
Information
MENTAL HEALTH SERVICE
PATHWAYS
Values
Learning disability
services
Child & Adolescent
Services
(electronic record)
Transitional protocol
Acute care
Service pathways
QUALITY
Essentials
CQUIN
Standards
& Survey
National
Patient
Safety
Agency
Community
Recovery
Adult services
Liaison
Older people’s
services
Acute care
Perinatal
Community
Liaison
Memory assessment
Forensic services
Substance
misuse services
Training
Policies
Global outcome measures
Patient rated outcome measure
Global outcome measures
Patient rated outcome measure
Information
Care Pathways –
Memory
DifficultiesR&D
Early Memory
Difficulties
Review
priorities
Memory
assessment
pathway
Review
priorities
Moderate need
pathway
Review
priorities
High need pathway
Review
priorities
High physical
or engagement
need pathway
Review
priorities
(diagnosis)
Global outcome measure – HoNOS 65+
Global outcome measure – HoNOS 65+
Memory Difficulties
Mental
health
pathway
Self-help
& caring
Quality & Outcomes
Framework (mental health)
Check your local
surgery results
Resources
RCGP forum
Early intervention in psychosis
DIALOG
How satisfied are you with your mental health?
How satisfied are you with your physical health?
How satisfied are you with your job situation?
How satisfied are you with your accommodation?
How satisfied are you with your leisure activities?
How satisfied are you with your friendships?
How satisfied are you with your partner/family?
How satisfied are you with your personal safety?
How satisfied are you with your medication?
How satisfied are you with the practical help you receive?
How satisfied are you with consultations with mental
health professionals?
Recovery Star
1.
2.
3.
4.
5.
6.
7.
8.
Couldn’t be worse
Displeased
Mostly dissatisfied
Mixed
Mostly satisfied
Pleased
Couldn’t be better
No response
Additional help required? Yes/No
…………………………………….
SUBSTANCE MISUSE
Books
Talk-to-Frank (drugs)
Drinkaware
Alcoholics Anonymous
Alcohol Concern
NHS Choices
Royal College of
Psychiatrists
PSYCHOSIS
Books
Hearing Voices Network
RETHINK
MIND
NHS Choices
Royal College of
Psychiatrists
Self-help
EMOTIONAL
DIFFICULTIES
Books
NHS Choices
Computerised CBT
Royal College of
Psychiatrists
GENERAL
INFO
Books
NHS Choices
MIND
MENCAP
RETHINK
Choice and Medication
Royal College of
Psychiatrists
MEMORY
DIFFICULTIES
Books
Dementia gateway
NHS Choices
Royal College of
Psychiatrists
Carers
Books
Al-Anon (alcohol carers support)
Alcohol Concern
Caring (finance, etc)
Care choices
Choice and Medication
Confidentiality and sharing information
Dementia gateway
Mental health care (psychosis)
Mental health first aid
NHS Carers Direct
Princess Royal Trust for Carers
RETHINK
Royal College of Psychiatrists
Memory difficulties
Emotional difficulties
Developmental
difficulties
Psychosis
Substance
misuse
Developed by SLAM
Acute care pathway
CRHT
REFERRAL
INITIATING
INPATIENT
TREATMENT
CARE
PICU
Acute Pathway
Quality & Performance
Dashboard
DISCHARGE
Acute care pathway
REFERRAL
Single point of access & rapid response
by Crisis Resolution Home Treatment
Team (CRHT)
Assessment involving SU, carer and
relevant others (risk issues including
safeguarding children and adults)
Consider Mental Health Act , Capacity &
Deprivation of liberty (DOLS)
Assess at home whenever possible
REFERRAL OUTCOME
Admission to hospital
CRHT care
Refer to CMHT or maintenance by
current team
Engage other services/signpost
Discharge to GP
PICU Inpatient
CRHT
BUILD ON INITIAL
ASSESSMENT
(INCLUDING RISK)
AND BEGIN
RECOVERY AND
STRENGTHS
FOCUSSED
THERAPEUTIC
APPROACH WITH
SERVICE USER
INVOLVEMENT
Acute care pathway
INITIATING CARE
Communicate with referrer, home acute unit & GP
Assertive Engagement
Gate Keeping
Engage Carer /carer support worker
Maintain contact with care co-ordinators (community pathway)
Obtain case notes or electronic equivalent
Confirm admission objectives
Commence discharge planning with projected discharge date,
housing needs & care Plan
HoNOS on admission
Consider input required from social, advocacy and other agencies
Complete admission checklist
‘Meet and Greet’ establish consent to admission
Immediate risk assessment/support level/ward environment
Orientation to ward
Identify physical needs (e.g. check Body mass index [BMI])
If detained read rights
Acute care pathway
TREATMENT
Assertive engagement, intensive
support
Time limited intervention,
medication review if needed.
Manage self-harm & hostility
(include incident & complaint
reporting)
Practical help with basics of daily
living and crisis plan
Use of Crisis beds when available
Engage Carer/care support worker
Maintain contact with care
coordinator (community pathway)
Investigations
Formulate problems/diagnosis on
bio-psycho-social model
Consider medication and other
interventions including ECT
Side effect monitoring, improve
concordance & Wellness Recovery
Action Plan (WRAP)
Supplement assessment which may
include the intervention of other
professionals, e.g. forensic
Commence interventions to include
psychological in broad sense (include
CBT, interventions to enhance
resilience, crisis planning, relapse
prevention, problem-solving, anxiety
management)
Regular MDT review
Consider input required from social
care, advocacy and other agencies
Senior/Professionals’ review
Ward round/Consultant review
Consider involvement of & early
discharge to CRHT
Manage physical health care needs
Acute care pathway
DISCHARGE
Engage Carer/care support worker
Agree discharge date
Prepare for discharge/transfer
Consider active involvement of CRHT & input
required from social care, work and other
agencies
CPA joint review with care
coordinator/community consultant including
relapse prevention plan
Use of step-down/Crisis beds when available
Consider trial leave
Complete discharge checklist
HoNOS on discharge
Agree follow-up: Outpatient, CRHT & Care Coordinator (<48hr [high suicide risk] or <7-day)
Discharge summary (within 2 weeks)
Community pathway
REFERRAL
CMHT
INITIATING
TREATMENT
CARE
Community Pathway
Quality & Performance
Dashboard
DISCHARGE
Community pathway
REFERRAL
Provide single point of access
Rapid response proportional to urgency
Assessment involving patient, carer and
relevant others (also risk issues
including safeguarding children and
adults)
REFERRAL OUTCOMES
Brief intervention (include Discharge
Liaison Team involvement).
Enter acute care pathway
Refer to specialist team (Early Intervention,
Substance Use, Assertive, Rehabilitation)
Accept referral & allocate care coordinator &/or to outpatient care;
engage other services/signpost
Discharge to GP
CMHT
BUILD ON INITIAL
ASSESSMENT
(INCLUDING RISK)
HoNOS AT INITIAL
CONTACT.
BEGIN
RECOVERY AND
STRENGTHS
FOCUSSED
THERAPEUTIC
APPROACH WITH
SERVICE USER
INVOLVEMENT
Community Pathway
INITIATING CARE
Arrange appointment
Assertive Engagement
Engage Carer /carer support worker
Develop treatment objectives & timescale
Commence Care Planning
Consider input required from social care, work, advocacy,
housing and other care agencies
Identify physical needs (e.g. check Body mass index [BMI])
Consider need for psychiatric review
Mental Health Act (on Section 17 leave, 37(41) or
Community Treatment Order)
Consider self-directed support (personalisation) & Wellness
Recovery Action Plan (WRAP)
Communicate with referrer & GP
Community pathway
TREATMENT
Formulate problems/diagnosis on
bio-psycho-social model
Time limited intervention,
medication review if needed.
Practical help with basics of daily
living and crisis plan
Consider need for psychiatric
review & review medication needs
Consider fitness to drive or use
machinery
Supplement assessment which
may include the intervention of
other professionals, e.g.
psychologist, occupational
therapist
Reconsider self-directed support
(personalisation)
Commence interventions to include
psychological in broad sense
(include CBT, DBT, interventions to
include resilience, crisis planning,
relapse prevention, problem
solving, stress management)
CPA review (repeat HoNOS)
Report & manage any complaints
Consider input required from social
care, work and other agencies
Physical needs reassessment
Continue to assess risk, MHA
& need for acute pathway
Side-effect monitoring, improve
concordance
Caseload & clinical supervision
Review NICE guideline for condition
Regular communication with GP,
accommodation provider & carer
Community pathway
DISCHARGE/TRANSFER
Consider whether criteria for recovery pathway
met
Engage Carer/carer support worker
Consider input required from social care and
other agencies
Agree discharge date
Prepare for discharge/transfer
CPA review with relapse prevention plan
HoNOS on discharge
Communicate with GP
OPMH Community pathway
REFERRAL
CMHT
INITIATING
TREATMENT
CARE
Community Pathway
Quality & Performance
Dashboard
DISCHARGE
DropBy
OPMH Community pathway
Assessment
REFERRAL
Provide single point of access
Rapid response proportional to urgency
Assessment involving patient, carer and
relevant others (also risk issue
including safeguarding children
,adults)
RISK ASSESSMENT, HoNOS
REFERRAL OUTCOMES
•
•
•
•
•
Brief intervention (include Liaison
Team involvement).
Accept referral & allocate care coordinator
Engage other services/signpost
Enter inpatient pathway
Discharge to GP
CMHT
Multidisciplinary
review.
Initiate other
assessmentspsychology,
occupational
therapy,
nursing ,medical
Review of Risk.
Initiate care
planning.
Liaise with partner
organisationsAdult Services,
Community
Healthcare.
OPMH Community Pathway
INITIATING CARE
Arrange appointment, either at home or community base
Engage Carer /carer support worker
Identify further assessments needed- psychological,
cognitive assessment, occupational therapy, physical
health assessment.
Consider need for psychiatric review including
Mental Health Act assessment .
Identify need for investigations, blood test or scanning.
Consider referral to Adult Services, care agencies,
advocacy, work
Develop treatment objectives & timescale
Commence Care Planning
Consider self-directed support (personalisation)
Communicate with referrer & GP
OPMH Community pathway
TREATMENT
•Formulate problems/diagnosis.
•Identify interventions and time
frame. (Care Planning)
•Practical help with basics of daily
living and crisis plan
•Consider psychiatric review &
review medication
•Consider fitness to drive or use
machinery
•Reconsider self-directed support
(personalisation)
•Psychological interventions
including cognitive work, CBT,
crisis planning, relapse prevention,
problem solving, stress
management
•
•
•
•
•
•
•
•
•
•
Occupational interventions to
support independent living
Consider input required from adult
services, work and other agencies
CPA review (repeat HoNOS)
Physical needs reassessment
Ongoing Risk Assessment
Consider MHA & need for acute
pathway
Side effect monitoring, improve
concordance
Caseload & clinical supervision
Report & manage any complaints
Review NICE guideline for
condition
Regular communication with GP,
accommodation provider & carer
OPMH Community pathway
DISCHARGE/TRANSFER
Consider whether criteria for discharge are met
Engage Carer/carer support worker
Consider input required from Adult Services
and other agencies
Agree discharge date
Prepare for discharge/transfer
CPA review with relapse prevention plan
HoNOS on discharge
Communicate with GP
Eating Disorder
Service Pathway
INTERVENTIONS
Outpatient, day care (12 weeks) or Inpatient (Acute Care Pathway or General
Hospital)
1st session measures:
CPA review
Physical monitor with relevant investigations (coordinated with GP)
Guided self-help: 4 month – 6 direct contacts
Nutritional advice
Group work
Medication review
Psychological interventions: Family therapy, Group work, DBT modified, individual &
group; Inter-personal therapy – 24 sessions: CBT – 20 sessions
CAT – 16, 24, or 32 sessions: Measure CORE-10
REFERRAL
Waiting list
INTERVENTIONS
REFERRAL
Screening: Assess comorbidities jointly with CMHT
Inform referrer
Comprehensive Assessment involving service user, carer and relevant others (include mental
health, social functioning & risk issues - including physical); relevant measures.
Consider Mental Health Act & Deprivation of liberty (DOLS)
Team discussion; choose treatment options; discuss & agree with service user
REFERRAL OUTCOME
Taken onto waiting list by Eating disorder service
Refer to CMHT or maintenance by current team
Engage other services/signpost Discharge to GP
DISCHARGE
Engage Carer/care support worker
Agree discharge date
Prepare for discharge/transfer
Consider active involvement of CRHT & input required from social
care, work and other agencies
CPA joint review with care coordinator/community consultant
including relapse prevention plan
HoNOS on discharge
Agree follow-up: Outpatient, CRHT & Care Co-ordinator
Discharge summary (within 2 weeks)
REVIEW
NICE
PRIORITIES
DISCHARGE
Early Intervention in Psychosis
Service Pathway
First presentation
for assessment of
psychosis
(aged 14-35)
24 hour access
Provide service & self-help materials
Complete specific outcome measures:
PANSS, GAF, HADS, Drake.
Follow COMMUNITY & PSYCHOSIS
PATHWAYS
Focus on psychological and family
work.
Carer support
Assertive care coordination
Medication management
Urgent
ACUTE
CARE
PATHWAY
REFERRA
L
OUTCOME
REFERRA
L
Non-Urgent
(within 7 days)
EIP
ASSESSMENT
ASSESSMENT
BY EIT
(up to 6 months)
TAKEN ON BY
EIT
(up to 36 months)
NO PSYCHOSIS
Refer on to
CMHT or other
mental health
service or back
to GP or
referrer
Early
intervention
Sites
[IRIS,
EPPIC]
General Hospital Liaison
REFERRALS FROM WARDS AND THE
EMERGENCY DEPARTMENT
Accepted from medical staff
responsible for the patient between:
09:00 – 17:00hrs, Monday to Friday for
18 – 65 year olds
If the referral is received after 16:00:There will be provision of initial advice
and assessment if there is a clinical
crisis
Referrals from the Emergency
Department to the Home Treatment
Service if the patient is expected to
become medically fit for discharge later
in the evening
Assess in working hours if there is no
need for urgent specialist mental health
input. Advice will be provided to
General Hospital staff to guide
management if the patient deteriorates
REFERRAL
PROCESS
(in-patient &
outpatient)
REFERRALS OUTSIDE THE WORKING
HOURS OF THE TEAM
Only patients requiring crisis/urgent clinical advice or
assessment by a mental health specialist after initial
assessment and attempts at management by the
responsible medical team will be accepted outside working
hours. It is expected that the referral will be made by a
doctor of at least middle grade seniority.
Referrals from General Hospital wards:
The referring doctor should contact the the duty
psychiatric service (nurse bleep holder in Antelope House
(bleep 1504)). The call will be passed to the senior
psychiatrist on call who will provide telephone advice and,
if necessary, come to see the patient.
Referrals from the Emergency Department:
The referring doctor should contact the Crisis
Resolution/Home Treatment Service
Crisis referrals from General Hospital out-patient clinics or
occupational health
Mental health assessment should be arranged by the
patient’s GP or rarely Emergency Department, who can
then access community mental health resources if
Service Pathway
REFERRALS TO PSYCHOLOGICAL MEDICINE OUT-PATIENT CLINIC
Referrals for routine out-patient assessment can be accepted for patients aged 18-65 years requiring ongoing out-patient or in-patient follow up from
General Hospital.
Referrals to the out-patient clinic should be made by letter from the Consultant (or Specialty trainee after discussion with the consultant) responsible for
the patient detailing reasons for referral and summary of physical health issues. It is helpful to attach recent clinic letters (the service does not have
access to eDOCs).
If the referral cannot be seen due to another service being thought more appropriate or lack of capacity in the service then this decision will be
communicated by letter to the referrer and GP. Patients requiring urgent out-patient assessment (for example due to active suicidal ideas or acute
psychotic symptoms) cannot be seen by the service. This initial mental health assessment needs to be undertaken by the GP.
Advice for General Hospital staff regarding patients already receiving treatment from another mental health should be sought from that mental health
team. If it is thought that a specialist assessment from the Psychological Medicine team would be helpful due to the complexity of interaction between
physical and mental health issues then the specific reasons for referral to the service and the details of the existing mental health team need to be
included in the referral letter. The letter should also be copied to the community mental health team.
The following problems are suitable for referral: Prolonged or severe adjustment disorder impairing physical, occupational or social functioning; Moderate
depression or anxiety disorder impairing functioning or self care of the physical health condition; Somatoform and dissociative disorders resulting in
frequent admissions or attendance to the Emergency Department or out-patients; Psychological issues impacting on self care e.g. poor adherence;
Psychological problems affecting physical health or health care utilisation where the patient does not yet accept referral to psychological therapy services
but agrees to attend the Psychological Medicine clinic.
The following problems should be managed via the GP (who may refer to community mental health services); Urgent referrals – e.g. strong suicidal ideas,
active psychosis; Mental health problems in patients who will not be receiving ongoing care from General Hospital; Mild depression or anxiety; Depression
or anxiety disorders unrelated to the physical health condition; Substance misuse; Somatoform or other medically unexplained symptoms not resulting in
frequent presentation to General Hospital
REFERRAL
CRITERIA
REFERRAL
ROUTE
REFERRAL CRITERIA
All patients admitted after self harm (overdose, self laceration, attempted hanging, jumping from a
height, gunshot wound): Organic psychosis: Schizophrenia and other functional psychosis where
the disorder is affecting management in General Hospital: Depression or anxiety interfering with
physical healthcare or recovery: Adjustment reactions interfering with physical healthcare or
recovery: Eating disorders leading to admission: Behavioural disturbance if mental health issues
are thought relevant: Somatoform, dissociative and fictitious disorders if there is frequent
attendance or co-morbid physical disease requiring ongoing in-patient or out-patient care from
General Hospital: Diagnostic dilemmas where mental disorder is a possibility: Patients where
psychological factors are thought to be affecting communication or other aspects of care by
General Hospital staff: Capacity advice if mental health issues are thought relevant or the decision
is complex and the General Hospital consultant wants further advice after their own assessment:
Alcohol and other substance misuse if other mental health problems are present (e.g. severe
depression remaining after detoxification, hallucinations remaining after detoxification)
The following types of problems should not be referred but be highlighted to the GP for
management after discharge: Mild depression or anxiety: Pre-existing mental illness not affecting
care in General Hospital: Alcohol and other substance misuse
TEAM
RESPONSE
General Hospital Liaison
Service Pathway
TEAM RESPONSE TO REFERRALS
REFERRAL ROUTE
Referrals should be made by faxed referral form with letter (unless assessment after admission for self harm) which should
always include:-reason for referral / question asked of the Psychological Medicine team; mental state assessment and
other reasons leading to suspicion of mental illness or psychological problems impairing management within General
Hospital: reason for treatment in General Hospital: a summary of physical management and past admissions: results of
recent investigations
If it is unclear whether a patient needs to be referred, or the referrer wants to discuss the referral for other reasons, then
they should telephone the department. If there is no clinician present in the team base at the time, admin staff will record the
name and contact details of the referrer and arrange for a clinician to ring back.
In crisis situations, the referral can be made solely by telephone discussion with a clinician in the team
Prioritisation of referrals: Initially on the basis of clinical urgency and risk and secondly on location in General Hospital in
order: Emergency Department, Acute Medical Unit, other wards.
The team aims to respond within the following time frame: Crisis: 1 hour (usually within 30 minutes): Urgent: same day (if
the referral is received late in the day then response is likely to be by telephone advice that day and direct assessment the
next day): Routine: 3 days (usually within 1 working day)
REFERRAL
PROCESS
REFERRAL
CRITERIA
TRANSFER TO GENERAL HOSPITAL FROM
A MENTAL HEALTH IN-PATIENT UNIT
HPFT Clinical Policy 57 & SUHT details expectations and
responsibilities for HPFT and General Hospital staff for patients
transferred to General Hospital for physical healthcare from a
mental health in-patient unit.
If a patient needs constant (1:1) observation due to their mental
health needs in General Hospital then the responsibility for
providing this is local mental health trust if the patient was
transferred from a MHT bed. Responsibility lies with General
Hospital if the patient was admitted from the community or
another acute hospital.
Mental health act issues.
On receipt of referral admin staff will check if the patient is already known to local mental health
services, obtain any recent mental health correspondence and notify clinical staff of the referral.
If the clinician receiving a referral requires more clinical information to prioritise response then
they will contact the referrer or other mental health teams as required. If the patient will not be
seen the same day then a clinician will telephone the referrer to check that the patient is settled
and, if appropriate, give advice regarding how to contact out of hours services should the clinical
situation deteriorate. If the referrer is unavailable then the clinician will liaise with ward nursing
staff.
If referrers telephone the team for advice or to discuss a referral admin staff are expected to take
down the following information: Name of patient; Hospital and NHS numbers; Age; Name of the
referrer and bleep or other contact number; Ward location; Is it an acute crisis needing immediate
discussion with a practitioner?
Supervision policy.
REFERRAL
ROUTE
MENTAL HEALTH
INTERVENTION
COMMUNICATION AND DOCUMENTATION
Team members have a responsibility to follow team practices
regarding documentation.
Document the clinical assessment, risk assessment, formulation, and management plan in the
General Hospital notes and retain a photocopy for DPM notes; Discuss with DPM team as
necessary; Recording of risk and clinical assessment has to be accurate; Ask patient to
complete consent form to receive a copy of correspondence to GP; Complete the checking of
information, ethnicity and accommodation forms; Ensure admin staff have recorded the referral
on the daily referral log sheet; Complete contact record for computerised notes (RiO) which
admin staff then enter; Brief letter to the GP faxed on the day of assessment for self harm; Full
assessment letter at time of discharge from the team for patients seen for reasons other than
self harm; Complete audit assessment form post discharge (Appendix 6); Dictate letter to the
referrer, GP, patient and other professionals involved in the patient’s care after all initial and
final out-patient appointments. Letters should also be sent after each appointment with
medical staff and at intervals or if significant new information arises during intensive
psychosocial interventions undertaken by practitioners.
USE OF THE MENTAL HEALTH ACT
IN THE GENERAL HOSPITAL
•
•
•
•
•
•
•
•
If a patient is transferred from a mental health in-patient unit whilst detained under the Mental Health Act (MHA),
responsibility remains with the mental health trust if the patient has been transferred under section 17 leave. The
doctor responsible for the patient’s mental health care (Responsible Clinician as defined by the MHA) remains the
Consultant Psychiatrist, or other professional if they are the RC, in the mental health unit. DPM clinical staff will
liaise with the in-patient unit regarding mental health assessment and will complete a weekly summary to fax to
the mental health unit for discussion of the patient in ward rounds.
If a patient is detained under the MHA whilst in General Hospital, then General Hospital has legal responsibility for
mental health care. They will therefore have responsibility for arranging tribunals etc.
The section papers need to be formally received by the site co-ordinator in SGH for the section to be valid.
Section 5(2) is a doctor’s holding power and can be applied by any fully registered medical practitioner (not FY1
doctor) to detain any admitted patient (not anyone in the Emergency Department) who the doctor suspects of
having a mental illness necessitating detention under a more prolonged section of the MHA. When the section is
placed, the site co-ordinator should be involved and they should notify the Approved Mental Health Practitioners
(AMHPs) in Southampton Home Treatment Service so that a full MHA assessment can be arranged. The section
5(2) lasts up to 72 hours.
Sections 2 and 3 of the MHA enable detention for 28 days for assessment or 6 months for treatment of a mental
disorder. They only provide legal power to treat physical problems if these are a direct cause or consequence of
the mental disorder.
The site co-ordinators will fax a notification of sectioning using section 2 or 3 of the MHA to the Department of
Psychological Medicine the next working day. The Liaison Psychiatrist (LP - Dr Butler) will take on the MHA role of
Responsible Clinician for adults aged 18-65 years. For older adults a clinician in DPM needs to speak to the
relevant OPMH Consultant to take on the Responsible Clinician role. For leave periods, LP (Dr Butler) will have
notified the team of the Consultant Psychiatrist covering the Responsible Clinician role.
For section 2 or 3, only the Responsible Clinician (LP or other nominated Consultant Psychiatrist) can allow leave
from General Hospital grounds (which needs a section 17 leave form completing) or discharge of the section.
As for other patients, clinicians in DPM have a responsibility to advise General Hospital on levels of observation,
psychiatric treatment and other management of the mental health problems for patients detained under the MHA
in General Hospital.
OPMH Medication Management
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Depression treatment guidelines for Older Adults
Antidementia drug treatment guidelines
Guidelines for Rapid Tranquilisation for Older Adults
Prescribing Lithium
Oral Antipsychotics
Prescribing guidelines for treatment of behavioural problems in Dementia
DVLA Guidelines on fitness to drive
Choice and Medication (UK Psychiatric Pharmacists Information site)
Medicines Control, Administration and Prescribing Policy
Antibiotic Prescribing Guidelines
Cholesterol Guidelines
Clozapine initiation – inpatient & community
Prescribing guidelines for BPD (under development)
Risperdal Consta forms &monitoring guidance for clients receiving treatment for
psychosis
ECT
OPMH Community intervention
•
Health Care Support worker
–
–
–
•
•
•
Social Worker
–
–
–
–
–
•
Assessment
Care Planning
Intervention
Liaison
Memory Nurse
–
–
–
–
–
•
–
–
–
–
–
Assessment
Care Planning
Care Coordination
Intervention, individual and group
Liaison
Psychiatrist
Psychiatric assessment
Risk management
Diagnosis
Medication management
Care coordination
Psychologist
–
–
–
–
–
•
Assessment
Care Planning
Care Coordination
Intervention
Liaison
Day Therapy Nurse
–
–
–
–
–
Assessment
Care Planning
Care Coordination
Intervention
Liaison
Acute Hospital Liaison
–
–
–
–
•
Assessment
Care Planning
Care Coordination
Intervention
Liaison
Nursing and Residential Home
Liaison
–
–
–
–
–
•
Social needs Assessment
Care Planning
Care Coordination
Care Management
Liaison
Community mental Health Nurse
–
–
–
–
–
•
Engagement
Social intervention
Documentation
Psychological assessment
Cognitive Assessment
Care Coordination
Psychological intervention
Psychological formulation, training & supervision
Occupational therapist
–
–
–
–
–
–
Assessment
Occupational Assessment including AMPS
Care Planning
Care Coordination
Intervention
Liaison
Care Pathway – Emotional difficulties
(‘borderline personality disorder’)
Requires
Mental Health
Service
intervention
Confirm
diagnosis
Psychosis
pathway
Specialist
service
Review
Problem
-solving
guidance
Community
pathway
Medication
review
Review
NICE
priorities
Psychol
-ogical
review
Requires
maintenance
support
Assessment
& risk
management
Acute
care
pathway
Not require
Mental Health
Service
intervention
Exit
from
services
Assertive
outreach/
Recovery
team
CMHT
NICE guideline CG78
PbR cluster
Self-help
& caring
Emergence
Specific outcome measure
Specific outcome measure (CORE)
Prominent
psychotic
symptoms
Requires
Mental Health
Service
intervention
Consider
diagnosis
Assessment
& risk
management
Not require
Mental Health
Service
intervention
Co-existing
‘borderline p.d.’
‘Emotional
difficulties’ pathway
Co-existing
substance
misuse
Substance
misuse pathway
Early
intervention
Community
pathway
Review
Medication
review
NICE
priorities
Psycho
social
review
Requires
maintenance
support
Acute
care
pathway
NICE guideline CG82
(for co-existing drug misuse – awaited)
PbR clusters
Exit
from
services
Assertive
outreach/
Recovery
team
CMHT
Self-help
& caring
Specific outcome measure
Specific outcome measures (Positive & Negative symptoms)
Care Pathway – Psychosis
Co-existing
substance
misuse
Requires
Mental Health
Service
intervention
Consider
diagnosis
Assessment
& risk
management
Not require
Mental Health
Service
intervention
Perinatal
period
Early
intervention
Community
pathway
Substance
misuse
pathway
Review
Medication
review
NICE
priorities
Psycho
social
review
Requires
maintenance
support
Acute
care
pathway
NICE guideline CG38
PbR clusters
Exit
from
services
Assertive
outreach/
Recovery
team
CMHT
Self-help
& caring
Specific outcome measures
Specific outcome measures (Mania & Depression)
Care Pathway – Bipolar Disorder
Dementia
Affecting
Independent
Living
Requires
Mental Health
Service
intervention
Consider
diagnosis
Assessment
& risk
management
Not require
Mental Health
Service
intervention
Dementia
Affecting
Independent
Living
Pathway
Review
Psychological
and
carers support
Precription
and
review of
medication
Review
Memory
Assessment
Service
Criteria
Memory
Matters
Requires
maintenance
support
Exit
from
services
Community
pathway
Memory
Assessment
Service
NICE guideline CG42
PbR cluster 18
Memory
Clinic
CMHT
Self-help
& caring
Specific outcome measures – HoNOS 65+
Specific outcome measure - HoNOS 65+
Care Pathway –
Early Memory Difficulties
PbR Cluster 18
Care Pathway – Memory Assessment Service
(Cognitive impairment -Low need)
Multi-Professional
Care Planning
Prescription
and
monitoring of
medication
Memory
Matters
Memory problems
not affecting
Independent living
Review
Care Pathway
Criteria
Exit form
services
Carer
Support
Clinical
assessment
Care Pathway
Criteria & Risk
assessment
Memory problems
affecting
Independent living
Memory Problems not
requiring Mental
Health service
intervention
Community
Pathway
(Moderate
need)
NICE guideline for
Dementia – CG 42
Self-help
& caring
Specific outcome measure HoNOS 65+
Specific outcome measure HoNOS 65+
Psychological
support
PbR Cluster 19
Care Pathway – Complicated cognitive impairment or
Dementia (Moderate Need)
High or
moderate
Multilevel of
Professional
Moderate
need?
Care
Planning
Memory problems
affecting
Independent living
Clinical
assessment
Care Pathway
Criteria & Risk
Assessment
Memory problems
not affecting
Independent living
Psychological
and
occupational
therapy
interventions
Prescription
and
monitoring of
medication
Review
Care Pathway
Criteria
Joint working
with partner
organisations
Exit form
services
Additional
care provided
at home
Carer
Support
NICE guideline for
Dementia – CG 42
Memory
assessment
service pathway
Self-help
& caring
Specific outcome measure HoNOS 65+
Specific outcome measure HoNOS 65+
High
Complicated
Dementia with
high level of
need Pathway
PbR Cluster 20
Care Pathway – Complicated cognitive impairment
or Dementia (High Need)
Psychological/
therapeutic
Interventions
High level
of physical Need/
engagement? no
Continuing
Health Care
Assessment
Memory problems affecting
Independent living (high need)
MultiProfessional
care
planning
Prescription
and
monitoring of
medication
Additional
care provided
at home
Psychiatric
inpatient
assessment
Review
Care Pathway
Criteria
Acute hospital
treatment
Clinical &
social care
assessment
Care Pathway
Criteria & Risk
Assessment
Memory problems
affecting
Independent living
(moderate need)
Adult Services
respite
Carer
Support
NICE guideline for
Dementia – CG 42
Community
Pathway
(Moderate need)
Self-help
& caring
Exit form
services
Specific outcome measure HoNOS 65+
Specific outcome measure HoNOS 65+
Yes
Complicated Dementia
with high level of
physical
need/Engagement
Pathway
PbR Cluster 21
Care Pathway – Cognitive Impairment or Dementia
(High Physical Need/Engagement)
Psychological/therapeutic
Interventions
Medication for behaviour
that challenges
Continuing
Health Care
Assessment
Memory problems
affecting Independent
living (High Physical
need/Engagement)
Clinical &
social care
assessment
Care Pathway
Criteria & Risk
Assessment
End of Life Care
Pathway
Intensive home care
support
Psychiatric inpatient
assessment
Acute hospital treatment
Review
Care Pathway
Criteria
Nursing or Residential
home placement
Carer Support
Complicated
Dementia with
high level of need
Pathway
Memory problems
affecting
Independent living
(High need)
NICE guideline for
Dementia – CG 42
Self-help
& caring
Exit form
services
Specific outcome measure HoNOS 65+
Specific outcome measure HoNOS 65+
Multi-Professional
care planning
Care Pathway – Eating disorders
Co-existing
‘borderline p.d.’
‘Emotional
difficulties’ pathway
Co-existing
substance
misuse
Substance
misuse pathway
Requires
Mental Health
Service
intervention
Consider
diagnosis
Assessment
& risk
management
Not require
Mental Health
Service
intervention
BMI calculator
Eating
Disorder
Service
Community
pathway
Medication
review
REVIEW
NICE
PRIORITIES
Psycho
social
review
Requires
maintenance
support
Acute
care
pathway
NICE guideline (CG9)
Payment-by-results
(Cluster 6)
Exit
from
services
Assertive
outreach/
Recovery
team
CMHT
Self-help
& caring
Specific outcome measure
Specific outcome measures
SCOFF (screening questionnaire)
Medication Management
•
•
•
•
•
•
•
•
•
•
•
Antibiotic Prescribing Guidelines
Cholesterol Guidelines
Choice and Medication (UK Psychiatric Pharmacists Information site)
Clozapine initiation – inpatient & community
DVLA Guidelines on fitness to drive
Guidelines for Rapid Tranquilisation
Medicines Control, Administration and Prescribing Policy
Oral Antipsychotics
Prescribing guidelines for BPD (under development)
Prescribing Lithium
Risperdal Consta forms &monitoring guidance for clients receiving
treatment for psychosis
User info
Choice and Medication
MIND
ECT
Psychosocial interventions
• Cognitive therapy (CBT, CAT)
– 6, 12, 16, 20, 24, 1 & 2 yr sessions
• Dialectical behaviour therapy (DBT)
– 48 group session group & 51 individual
sessions
• Psychodynamic psychotherapy
– Group & 20 sessions, 1 & 2 yr
• Arts therapies (Art, music, dance)
– 20 sessions
• Family & Couples therapy
– 3, 6 & 10 sessions
• Problem-solving, Motivational interviewing;
Assertiveness & Social Skills Training, Anger,
& Anxiety management
All pathways
(psychosis)
Emotional difficulties
Emotional difficulties
Psychosis
All pathways
All pathways
All eligible patients should be offered PI. Patient choice, non-response to previous therapy
& medication, and severity determine ‘dosage’ and expertise of therapist.
Community intervention
•
Support worker
•
– Engagement
– Social intervention
– Documentation
– Caseload 10-20
•
Care coordinator
–
–
–
–
•
•
•
Psychologist
Roles (include above)
–
–
–
–
–
– Caseload 2-300 (estimate)
•
Roles (include above)
– Assessment
– Intervention
– Liaison
Caseload 30 (CMHT)
Caseload 15 (EIP)
Caseload 10 (AOT)
Team (CRHT)
Psychiatrist
Roles
•
Psychiatric assessment
Risk management
Diagnosis
Medication management
Care coordination
Roles
– Psychological intervention
– Psychological formulation, training
& supervision
PbR Clusters & Care Pathways1
•
Clusters represent stages in CPs
– Emotional difficulties:
•
•
•
•
•
•
•
•
•
1: Common Mental Health Problems (low severity)
2: Common Mental Health Problems (low severity with greater need)
3: Non-Psychotic (Moderate Severity)
4: Non-Psychotic (Severe)
5: Non-Psychotic (very severe)
7: Enduring Non-Psychotic Disorders (high disability)
15. Severe Psychotic Depression
6: Non-Psychotic Disorders of overvalued ideas [Eating disorders & OCD]
8: Non-Psychotic Chaotic and Challenging Disorders [ ‘Borderline PD’]
– Psychosis:
•
•
•
•
•
•
•
10: First Episode in Psychosis
14: Psychotic Crisis
11: Ongoing Recurrent Psychosis (low symptoms)
12: Ongoing or Recurrent Psychosis (high disability)
13: Ongoing or Recurrent Psychosis (high symptom and disability)
16: Dual Diagnosis = ‘Psychosis with drug abuse’
17: Psychosis and Affective Disorder Difficult to Engage
– Memory difficulties:
•
•
•
•
18: Cognitive impairment (low need)
19: Cognitive impairment or Dementia Complicated (Moderate need)
20: Cognitive impairment or Dementia Complicated (High need)
21: Cognitive impairment or Dementia (High physical or engagement needs)
1Cluster
9 is blank
Mental Health Training
•
•
•
•
•
•
General practice
Management
Mental health practitioner
Nursing
Occupational Therapist
Psychiatry
• Psychology
• Social work
basic CPD GMC
basic CPD
basic CPD
basic CPD NMC
basic CPD
basic CPD GMC
MRCPsych course (Wsx)
basic CPD
basic CPD GSCC
• Medical students
Portal (Soton) OSCE
HPFT
Training
Borderline Personality Disorder
Bipolar Affective Disorder
Antenatal and Postnatal (CG45)
Anxiety Disorders
Depression
Post Traumatic Stress Disorder
Obsessive-Compulsive and
Body Dysmorphic Disorders
Eating disorders
Perinatal
bipolar
disorder
NICE
guidelines
Bipolar
Care pathway
Perinatal
Service
pathway
NICE guidelines
Bipolar CG38
Perinatal CG45
Developed
by
SLAM 2010
Five ways to well-being
1. Connect… With the people around you. With family, friends, colleagues and neighbours. At
home, work, school or in your local community. Think of these as the cornerstones of your life and
invest time in developing them. Building these connections will support and enrich you every day.
2. Be active… Go for a walk or run. Step outside. Cycle. Play a game. Garden. Dance.
Exercising makes you feel good. Most importantly, discover a physical activity you enjoy and that
suits your level of mobility and fitness.
3. Take notice… Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the
changing seasons. Savour the moment, whether you are walking to work, eating lunch or talking to
friends. Be aware of the world around you and what you are feeling. Reflecting on your experiences
will help you appreciate what matters to you.
4. Keep learning… Try something new. Rediscover an old interest. Sign up for that course.
Take on a different responsibility at work. Fix a bike. Learn to play an instrument or how to cook your
favourite food. Set a challenge you enjoy achieving. Learning new things will make you more
confident as well as being fun.
5. Give … Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your
time. Join a community group. Look out, as well as in. Seeing yourself, and your happiness, as
linked to the wider community can be incredibly rewarding and creates connections with the people
around you.
See also; PANSS
SCHIZOPHRENIA GUIDELINES CG1
(2009)