The management of patients in psychiatry Dr Hannah Theodorou MEDED Psychiatry PACES Revision Day

Take a logical approach- it’s not as hard as you think! Managing the suicidal patient Assessment and management of risk Presenting management plans to the examiner Where to manage the patient Mental Capacity Act Mental Health Act

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?’

Managing the suicidal patient ‘How do you see the future?’ ‘Do you feel hopeless?’ ‘Do you ever feel as if you don’t want to carry on?’ ‘Do you sometimes feel like you don’t want to wake up in the morning?’ ‘Have you ever had thoughts of harming yourself ?’

Managing the suicidal patient If a patient has had specific thoughts, ask: ‘What particular thoughts went through your mind?’ ‘Have you made any plans?’ ‘How close have you come?’ ‘What has stopped you doing anything?’ ‘Have you actually tried to harm yourself ?’

Assessing someone presenting with self harm Antecedents 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 How were they found, how did they end up in hospital, regret about attempt or regret about failure of attempt, compliance with medical intervention

Risk factors for completed suicide: Male Living alone Unemployed Older age Substance/ alcohol problem Pre-existing mental illness (depression/ SCZ) Past history of DSH No confidantes/ social supports Command Hallucinations FH of suicide/ mental illness/ substance misuse

Breaking down risk 1. Risk to self Deliberate Non-deliberate e.g. vulnerable, self- neglect 2. Risk to others Non-deliberate, e.g. reckless driving, accidental fires 3. Time line Short term Medium term Long term 4. Level High Medium Low

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)

Management of mental health disorders The three main options available are: Medical therapy Psychological Therapies Social support

Where can the patient be managed? GP Most patients Psychological Therapies CHMT Care co-ordinators Day Hospital Special Teams e.g. Substance Misuse CRT Crisis Resolution Teams Early Intervention Team Assertive Outreach Team Inpatient PSYCHIATRIC MEDICAL: Mental Health Liaison

Mental Capacity Act Key principles of the act: All individuals over 16 are presumed to have capacity unless proved otherwise Having a mental disorder does not mean a patient has not got capacity Capacity has to be assessed for each individual situation/ decision The clinician or person assessing capacity must take all reasonable measures to maximize capacity e.g. providing interpreters, learning difficulty specialists.

Assessing Capacity All 4 of the following must be met: 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.

Assessing capacity 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)

Mental Capacity Act Advance directives Lasting power of attorney 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 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.

Mental Health Act (1983) For the act to apply the patient fulfill the following criteria: 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. 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. A risk to his/her health or safety and/or other people's safety Unwilling or unable to accept hospitalisation voluntarily (informal admission).

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. Approved mental health professional (AMHP) 2 doctors (fully registered)- see notes below. 28 days. 3 Treatment. Patient must have a diagnosis, and being treated for an improvement in condition or to prevent deterioration. AMHP As above. 6 months. 4 Emergency (community) N/A 1 doctor 72 hours 5(2) Emergency (inpatient) 136 Emergency (police)- removal to a place of safety Police officer 5(4) Urgent detention in absence of a doctor Registered mental health nurse 6 hours