Transcript Mental Well-being Presentation by Jane Petraska

MENTAL WELLBEING
Welcome to the Practice Nurse Peer Group evening session
Presented by Jane Petraska
10 November 2015
SESSION OVERVIEW
• Mental health
• Depression & Anxiety
• Suicide
• Assessment skills
• How do I talk about these?
• What can I offer?
• Management & resources
OUTCOMES
• What do you want out of this?
• By the end of the session we hope for you to be more confident
at approaching, assessing and managing mental health with your
patients!
“Health is a state of complete
physical, mental and social wellbeing and not merely the
absence of disease.”
World Health Organisation
“Depression is currently ranked fourth among
the 10 leading causes of the global burden of
disease, it is predicted that by the year 2020, it
will have jumped to second place…
….The time for action is NOW”
Mental Health, a call for action by World Health
Ministers;
World Health Organisation
HOW COMFORTABLE ARE YOU TALKING
ABOUT MENTAL HEALTH?
• Your own?
• Others?
• Would you like to get more comfortable?
Lets talk about it!
MENTAL ILLNESS
• “The most powerful organ in the body can sometimes fail to work
properly
• It loses its ability to function to keep us healthy, safe and alive
• It can prevent us from experiencing happiness & sorrow
• What happens when the mind loses control?
• What happens when the chemicals are out of balance?
• This is what happens to our brain of those living with mental
illness (more accurately, “brain illnesses”.)
MENTAL ILLNESS
• The brain does not function as it should
• Life is out of control
• The brain alters our bodies
• Thoughts are distorted, emotions become unregulated and
behaviours change
• The most challenging phenomena we do as humans is survive
these challenges
• The toll it takes on our bodies is for some tragically too much to
bear…”
Kevin Hines
“Its just before my exam on mental health
assessment, late in the evening
…do I have anxiety?”
Note what you may feel and think in this situation?
No exam really, was that mean..?!
ANXIETY
• Anxiety symptoms are experienced by everyone at sometime.
• It is part of evolution – it is because your ancestors were good at
fight/flight and learning anxiety, that you are sitting here; the
people not sitting here had ancestors who were not so good at
this…
• But, “anxiety” can become a disabling problem.
• Caused by an over-estimation of danger and under-estimation
of ability to cope, often leading to avoidance or panic if exposed.
• We can be anxious about everything (e.g.
Generalised Anxiety
Disorder) or any specific thing (e.g. Health Anxiety)
WHAT IS DEPRESSION?
• Depression is a mental illness where you feel sad and
miserable most of the time and your mood is persistently
very low.
• Being depressed is more than feeling down for a day or two
– it usually continues for weeks or months at a time.
• Depression can range from being a mild illness, to a severe
one – where you can lose interest in life and the things you
used to enjoy.
TRIGGERS & VULNERABILITIES
• Family history, previous history
• Physical illness
• Serious life stressors
• Some medications
• A&D
• Gender
• Psychologically, the greatest risk factors are associated with
style of coping, problem-solving style and style of thought,
especially interpretation and reaction to life experiences.
WHAT ARE THE SYMPTOMS?
• Low energy
• Sleep disturbances or changes
• Feeling worthless & helpless
• Negative cognitions
• Low self-esteem
• Appetite & weight changes
• Sadness or emotional
‘numbness’
• Loss of pleasure in everyday
activities
• Decreased motor function,
slow speech, less reactive
• Anxiety or irritability
• Poor concentration &
motivation
• Changes in emotions, crying for
no reason
• Thoughts of suicide - Thinking
about death a lot
CASE DISCUSSION
Susan comes to see you for a blood pressure check, she is 46 year
old. Talking to her she tells you she hasn’t been in sooner, as she
has had a number of Tangi to attend, also there has recently been a
restructure at her work and she will soon have to re-apply for her
job. She is fidgety and avoiding eye contact, she is giving short
answers and looking at her watch.
1. How do you approach this?
2. What questions do you ask?
3. How would you word these?
CASE DISCUSSION
• How do you approach talking about anxiety/mood?
• How can you gently challenge inconsistencies?
• How can you bring a screening tool in to the consultation?
• How can you help a patient to come up with their own mental
health related care plan goals?
• How can you answer a difficult question e.g. am I “crazy”?
• Being safe and making follow up plans with the patient.
ASSESSMENT SKILLS
• Building and maintaining good rapport is essential
• Always discuss confidentiality
• Often people don’t realise or recognise themselves that they
have depression or a mental illness and it is not until you start
asking questions that you can uncover a disorder.
• Asking questions is the only real way to assess for mental illness.
Not like a physical illness where you can have a blood test or an xray. You have to ask the questions.
ASSESSMENT SKILLS…
• Acknowledge the difficulty for the patient in answering uncomfortable
•
•
•
•
•
•
questions; but tell them that the more you find out the better position you are
in to help them get the right support and treatment.
Use open ended questions, why, what, who, where, how, tell me about?
Be inquisitive
Use reflective listening skills
Challenge negative thoughts and statements
Be calm and matter of fact
Be aware of your tone and expression
• Be quiet and listen
• Don’t advise, lecture interrogate or judge
• Summarise and check for understanding
START WITH SCREENING QUESTIONS
SCREENING FOR DEPRESSION
Screening questions
Over the past month, have you often been bothered by:
1. Little interest or pleasure in doing things? Yes
No
2. Feeling down, depressed or hopeless?
No
If YES, follow through with the Kessler-10
Yes
SCREENING FOR ANXIETY
Screening question
Over the past month, have you often been bothered by:
1. Worrying a lot about everyday problems?
Yes
If YES:
• Use a screening tool – GAD-7
• Keep asking questions and gather information
• Try to build a picture
No
SUGGESTED QUESTIONS
• What has been happening lately • Tell me about what you typically
•
•
•
•
•
•
•
in your life that has been stressful
for you?
•
Who do you live with?
•
How are things at home/work? •
Who are your closest
•
supports/friends/family?
Do they know how you feel? Why •
or why not?
•
What excites you about life?
How has this changed?
Why do you think that is?
eat in a day?
How is your sleep?
What about energy levels?
Emotions, crying irritable
Mood (scale 1-10)
What do you think about most of
the time? Negative?
When was the last time you really
felt happy?
SUICIDE ASSESSMENT & MANAGEMENT
Always ask about suicide!
The P4 screener
The p4 screener assesses patients via four types of questions (4p’s):
1. Past suicide attempts
2. Plan for acting out suicide,
3. Probability of completing suicide
4. Preventative factors
Management:
High risk: Urgent referral to CAS (0800 800 717)
Low risk: Treatment, problem solve, supportive counselling, e therapy,
encourage to talk to someone, activity scheduling
SUICIDE
• More people die by suicide from the golden gate bridge than any
other manmade structure in the world
• Bridge built in 1937 Suicides estimated 1600
• More likely over 2000 but not recorded – unaccounted washed away
• 220 ft fall – equivalent of a 25 story building
• The fall takes 4 seconds
• Survival rate of 0.002%
• Fall speed is 120km p/hr
• Study done of the survivors – over the past 75 years there have been
33 survivors
• Only a fraction recovered fully from their injuries
• Many have already died of natural causes
• Only 1 went back to the bridge & ended his life
• Of the survivors 24 have come forward and expressed words to this
effect “ The second my hands left the rail I realised I had made a
mistake, I realised how much I needed to live or I didn’t want to die”
“oh God what have I done, I don’t want to die, please save me!”
• The world’s most exclusive survivors club
• Most people who are suicidal are ambivalent about death and don’t
actually want to die.
• Life is so unbearable for them, something has to change immediately
for them – will you be the one to facilitate this change?
“He who has a why to live for can bear almost any how”
Life is not primarily a quest for pleasure or a quest for power
but a quest for meaning. The great task for any person is to
find meaning in his or her life. Frankl saw three possible
sources for meaning; in work, (doing something significant),
in love (caring for another person) and in courage in difficult
times. Suffering in and of itself is meaningless; we give our
suffering meaning by the way in which we respond to it.
Forces beyond your control can take away everything you
possess except one thing, your freedom to choose how you
will respond to the situation. You cannot control what
happens in your life, but you can always control what you will
feel and do about what happens to you.
Viktor E. Frankl
SUICIDE
Helping people find meaning in their life focuses
them on their strengths, protective factors and
ultimately a reason to continue to live. By helping
others find meaning you will also provide patients
with a sense of hope for the future. Providing
patients with hope is essentially what you need to
achieve before they leave your clinic.
Yesterday is history
Tomorrow is a mystery
Today is a gift
That is why they call it the present
“Babatunde Olatunji”
SUUICIDE –WARNING SIGNS & INVITATIONS TO
TALK
• Attempted suicide before
• Mental illness
• An addiction
• A serious physical illness or pain
• Major loss or disappointment
• Major life change
• No sense of their own identity or purpose in life
• No strong relationships or limited supports
• Started or stopped medication recently for mental illness
• Lost a friend or family member to suicide
• Relationship break up or loss of custody of children
• Financial problems
• Unemployment, loss of job
• Victim of violence, bullying or sexual abuse
• A court case coming up or a recent/pending prison sentence
• Been judged, shamed or put under a lot of pressure
• Lack of support around sexuality or gender
ACTIONS
• Crying/emotional outburst
• Irritability
• Withdrawn
• Recklessness
• Self harm
• Abuse of alcohol or drugs
• Extreme behaviour changes
• Giving away possessions
• Organising or putting affairs in order
PHYSICAL
• Changes in appetite
• Lack of energy
• Physical health complaints
• Disturbed sleep
• Loss of libido
• Lack of interest/pleasure in life
• Loss of interest in appearance
FEELINGS
• Lonely
• Hopeless
• Helpless
• Sad
• Angry
• Guilty
• Worthless
• Desperate
THOUGHTS
• “Everyone will be better off without me”
• “I won’t be needing these things anymore”
• “I wish I was dead”
• “I can’t do anything right”
• “All my problems will end soon”
• “I can’t think straight anymore”
• “No one can help me now”
• “I can’t take it anymore”
• “Now I know what they were going through”
ASK ABOUT SUICIDE
Feeling suicide is a symptom of depression & these thoughts are not
happening because they have chosen them. It is because they have an illness
that is treatable and they will go away.
Even if they don’t have thoughts, they can crop up if untreated.
• Do you think you will ever get better?
• Do you have any hope for the future
• Have you thought that your life is not worth living?
• Have you thought about ending your life?
• Do you feel that your reason for living outweighs your reasons for dying?
• Do you want to die?
• What do you have in your life that makes life worth living?
• What has held you back from killing yourself thus far?
Often at this stage of your assessment you
may well discover that the patient wants help
and doesn’t want to die; you can then go on to
look at how you can help.
However if this is not the case go on to ask
about intent and plans.
Ask about intent and plan
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
If you had a way, would you try to take your own life?
If you thought you were going to die, would you take steps to save yourself?
How often do you think about dying?
How long does it usually take for the thoughts to go away?
Are thoughts about dying or taking your life overpowering to you?
How do you feel when you start thinking about taking your own life?
Have you ever thought of ways to take your own life?
Have you ever had specific thoughts or plans about taking your own life?
Have you set a time or place?
What are those plans?
Do you have access to (method; e.g., pills, poisons, medication, weapon)?
Do you think you could get (method) if you needed to?
Do you think you would die if you used (method)?
Have you done anything or taken steps to prepare to take your own life (e.g., writing
suicide note or will, arranging method, giving away possessions)?
Do you think that you could take your own life?
Do you feel ready to die?
HOW CAN YOU HELP?
Most suicides can be prevented by sensitive responses to the
person in crisis. If you think someone you know may be suicidal,
you should:
• Remain calm. In most instances, there is no rush. Sit and listen really listen to what the person is saying. Give understanding and
active emotional support for his or her feelings.
• Deal directly with the topic of suicide. Most individuals have
mixed feelings about death and dying and are open to help. Don't
be afraid to ask or talk directly about suicide.
HOW CAN YOU HELP?
• Encourage problem solving and positive actions. Remember that
the person involved in emotional crisis is not thinking clearly;
encourage him or her to refrain from making any serious,
irreversible decisions while in a crisis. Talk about the positive
alternatives which may establish hope for the future.
• Get assistance. Although you want to help, do not take full
responsibility by trying to be the sole counsel. Seek out resources
which can lend qualified help, even if it means breaking a
confidence. Let the troubled person know you are concerned - so
concerned that you are willing to arrange help beyond that which
you can offer.
HOW CAN YOU HELP?
How will you respond when they tell you how it really is for them?
• Tell them they will get better - be believable!
• Talk about the process of recovery ups & downs
• Focus on their strengths and provide hope if the conversation gets too
negative.
• Encourage and validate
• It is important to remember to tell patients that depression is an
illness that is 100% treatable and recoverable from with the right
support and the right treatment.
WHAT WILL YOU DO ABOUT THE
INFORMATION YOU GAIN?
Develop a plan and discuss this openly with the patient.
A plan will include:
• Risk assessment (determine Internal or external management)
• Encourage the patient to involve family/support people
• Inform others - clinical team
• Start medication if warranted
• Book the next appointment or follow up plans
• Refer to external agencies
• Document findings and plan
MANAGEMENT
Depression should be a highly satisfying
condition to manage in Primary Care.
The vast majority of patients will recover
fully with access to good GP team care.
WHAT ARE THE OPTIONS WITH LIMITED TIME?
1.Listen and keep in touch.
2.Following up with proactive phone call/text support.
3.Encourage self cares (sleep, nutrition, exercise)
4.Encourage your patient to build a support network
5.What you do matters less, than ensuring its followed up.
RESOURCES
Online resource
Youth
• depression.org.nz
• thelowdown.co.nz
• moodgym.anu.edu.au • sparx.org.nz
• calm.auckland.ac.nz • bigwhitewall.com
OTHER RESOURCES
• Lifeline – 0800 543 354
(for counselling and support).
• Depression Helpline – 0800 111 757
(to talk to a trained counsellor about how you are feeling)
• Chinese Lifeline – 0800 888 880
(for people who speak Mandarin or Cantonese)
• Youthline – 0800 376 633, free text 234 or email
[email protected]
(for young people, and their parents, whānau and friends).
• Alcohol Drug Helpline – 0800 787 797
(for people dealing with an alcohol or other drug problem; 10 am to
10 pm)
• Skylight – 0800 299 100
(for support through trauma, loss and grief; 9 am to 5 pm
weekdays)
• Supporting Families In Mental Illness – 0800 732 825
(for families supporting a loved one who has a mental illness)
• Mental Health Foundation – for more information about
supporting someone in distress, looking after your mental
health and working towards recovery.
• PlunketLine – 0800 933 922
(support for new parents, including mothers experiencing
PND)
• Shakti Crisis Line - 0800 742 584
(for migrant or refugee women living with family violence)
Now, to your surprise, you have a bit more time to spend
with your patients!
WHAT CAN YOU DO?
•
Activity Scheduling
•
•
Problem Solving
•
•
Benefits Of Activity Include: Distraction From Depressive
Thoughts, More Energetic And Less Tired, Clear The Mind
And Allow More Focused Thinking.
Define Problem → Possible Solutions → Decide On A Solution
→ Make A Plan And Try It Out → Check The Outcome.
Simple CBT
•
Situation → Thinking → Behaviour → Feeling.
•
Progressive Muscle Relaxation
•
•
Little Tips
•
•
Serenity Prayer, Non Religious Version, One Thing At A
Time.
Mindful Breathing
•
•
Tensing And Relaxing Each Muscle, Relaxing Time
Longer Than Tensing Time.
Practice, Practice, Practice…
Medication
•
Useful For Severe Depression.
QUESTIONS??
Evaluation forms please?
Thank you!!