Mental Health Concerns in a Mental Health Concerns in a Palliative Care Setting- Palliative Care Setting-

When should I be worried?When should I be worried?

Jan Helbert Consultant PsychologistJan Helbert Consultant Psychologist Bradford Hospitals FTBradford Hospitals FT

Martin Thornton Learning & DevelopmentMartin Thornton Learning & Development Primary Care Mental HealthPrimary Care Mental HealthBradford and Airedale Community Health ServicesBradford and Airedale Community Health Services

Introduction to mental health Introduction to mental health (depression and self harm/suicide)(depression and self harm/suicide)

Increase knowledge and confidence Increase knowledge and confidence Screening and assessment in Screening and assessment in

palliative care patients and their carerspalliative care patients and their carers Knowledge of different teams and Knowledge of different teams and

services and how to accessservices and how to access

Learning Outcomes

Mental Health IssuesMental Health IssuesPsychological DistressPsychological Distress

AnxietyAnxiety DepressionDepression Deliberate self Deliberate self

harmharm Psychotic IllnessPsychotic Illness Organic brain Organic brain

syndromesyndrome

Communication & Communication & relationship issuesrelationship issues

Alcohol & drug Alcohol & drug related problemsrelated problems

Personality Personality disordersdisorders

Depression and Anxiety in Palliative Care

10-15% of patients with advanced 10-15% of patients with advanced illness experience levels of anxiety illness experience levels of anxiety and depression serious enough to and depression serious enough to warrant intervention by specialist warrant intervention by specialist psychological/mental health servicespsychological/mental health services

Why should we be Why should we be concerned?concerned?

Need to address psychological needs Need to address psychological needs routinelyroutinely

Lots of opportunities to engage people Lots of opportunities to engage people when we can all make a difference.when we can all make a difference.

Acknowledging distress is often first Acknowledging distress is often first step (all levels of severity)step (all levels of severity)

Can work towards reducing risksCan work towards reducing risks

Focussing on what we know Focussing on what we know are particularly difficult are particularly difficult

situationssituations

DepressionDepression

Self Harm/SuicideSelf Harm/Suicide

DepressionDepression

Depression or distressed, miserable or Depression or distressed, miserable or low in moodlow in mood

When does depression become a When does depression become a serious concernserious concern

Common Common Symptoms of of DepressionDepression

Sad, AnxiousSad, Anxious Loss of InterestLoss of Interest Decreased Decreased

energy/fatiguedenergy/fatigued Poor concentrationPoor concentration Decision makingDecision making SleepSleep

AppetiteAppetite Hopelessness Hopelessness

pessimismpessimism Guilt, Guilt,

worthlessness, worthlessness, helplessnesshelplessness

Thoughts of Thoughts of death/suicidedeath/suicide

Kind of things someone with severe depression might say…

‘‘Anxious’Anxious’ ‘‘A living nightmare, never felt so bad in my A living nightmare, never felt so bad in my

life…must be something better than this…life…must be something better than this…would be better if I wasn’t here’would be better if I wasn’t here’

‘‘In a prison. I don’t know if I can get out’In a prison. I don’t know if I can get out’ ‘‘Big black hole of horror’Big black hole of horror’ ‘‘Cant make up my mind be realistic’Cant make up my mind be realistic’ ‘‘As if I have a different brain. I’m not in charge As if I have a different brain. I’m not in charge

of myself’of myself’ ‘‘Hopeless, tired of living, frightened of dying’Hopeless, tired of living, frightened of dying’ ‘‘No appetite’No appetite’

What can we offer someone ‘in What can we offer someone ‘in a space of perceived a space of perceived

hopelessness’hopelessness’ Can feel overwhelmed…..Can feel overwhelmed….. Can be very hard to listen to the distress….Can be very hard to listen to the distress…. If we can do its important to really listen and If we can do its important to really listen and

pay real attention to the persons pay real attention to the persons experience…experience…

Involves opening a space for sharing, Involves opening a space for sharing, talking, silence, trying to be alongside…talking, silence, trying to be alongside…

Where we can try and really understand and Where we can try and really understand and make sense of the distress……make sense of the distress……

Approaching a ScreeningApproaching a Screening

EngagementEngagement

Approach as you would with physical Approach as you would with physical symptomssymptoms

Try and understand what's causing Try and understand what's causing it….it….

Depression, what would the Depression, what would the questions be? be?

2 screening questions may be:2 screening questions may be:(Patient Health Questionnaire PHQ9)(Patient Health Questionnaire PHQ9)

1 During the last month have you been 1 During the last month have you been bothered by feeling down, depressed or bothered by feeling down, depressed or hopeless?hopeless?

2 During the last month have you been 2 During the last month have you been bothered by having little interest or pleasure bothered by having little interest or pleasure in doing things?in doing things?

Screening DistressScreening Distress

Try and gain a picture of what its like Try and gain a picture of what its like for this person at this time?for this person at this time?

Severity, frequency, duration, triggers, Severity, frequency, duration, triggers, alleviating factorsalleviating factors

Explore the causesExplore the causes Explore coping mechanisms and Explore coping mechanisms and

strengthsstrengths Is help required? What help?Is help required? What help?

When to have alarm bellsWhen to have alarm bells

SeveritySeverity Not improvingNot improving Hopelessness pessimismHopelessness pessimism Ideas to self harmIdeas to self harm IntentIntent

Case Study 1Case Study 1 You are visiting a patient for an initial You are visiting a patient for an initial

assessment. Her husband died assessment. Her husband died unexpectedly about a year ago. The unexpectedly about a year ago. The patients illness is advanced but stable. patients illness is advanced but stable. Before you enter the room the patients Before you enter the room the patients daughter tells you her mother has been very daughter tells you her mother has been very low and said to her that she would be better low and said to her that she would be better off dead and has been asking if anyone off dead and has been asking if anyone would help her.would help her.

How would you respond?How would you respond? How would you assess?How would you assess? What would influence the outcome of your What would influence the outcome of your

assessment? assessment?

Case Study 2Case Study 2 Staff have let you know that the patient Staff have let you know that the patient

you are seeing has been very low and you are seeing has been very low and tearful. She usually enjoys spending time tearful. She usually enjoys spending time with her grandchildren although has with her grandchildren although has been avoiding this. They have been a been avoiding this. They have been a central part of her life. She starts telling central part of her life. She starts telling you about her concerns that her house you about her concerns that her house hasn’t been built properly and that she hasn’t been built properly and that she thinks the foundations aren't right and thinks the foundations aren't right and this means the house is going to fall this means the house is going to fall down. She doesn’t seem able to dismiss down. She doesn’t seem able to dismiss this thought.this thought.

How would you respond?How would you respond? How would you assess?How would you assess? What would influence the outcome of What would influence the outcome of

your assessment?your assessment?

Case Study 3Case Study 3 You are working with a middle aged You are working with a middle aged

gentleman who has told you that he doesn't gentleman who has told you that he doesn't wish to suffer at the end of his life and that wish to suffer at the end of his life and that he plans to end his life when he starts to he plans to end his life when he starts to loose his independence and rely on others loose his independence and rely on others for his care. He seems to tell you this in a for his care. He seems to tell you this in a calm way. He tells you at present that he is calm way. He tells you at present that he is still able to enjoy time with his children.still able to enjoy time with his children.

How would you respond?How would you respond? How would you assess?How would you assess? What would influence the outcome of your What would influence the outcome of your

assessment?assessment?

  Positive Symptoms

Disordered thinking – Thoughts jump

- Thoughts blocked

- Seem to talk nonsense

Delusions - False beliefs or thoughts with no

basis on reality

Hallucinations –(False or imagined sensations) Hearing, seeing or feeling things that are not there. Hear voices that may comment on their behaviour or give them commands

Signs/Symptoms Psychosis

Negative Symptoms

Blunted (or flat) Affect. Does not show feelings or emotions facially

May avoid eye contact

Few gestures and movements

May not respond to normal conversation

Lack energy

Show little initiative

Lack pleasure or interest in past enjoyable activities

Signs/Symptoms Psychosis

SummarySummary

EngagementEngagement Ask directly about experiencesAsk directly about experiences Do feel depressedDo feel depressed Have you had any thoughts that could Have you had any thoughts that could

harm yourself? harm yourself? Try to understand cause of distressTry to understand cause of distress Identifies strengths and coping….Whats Identifies strengths and coping….Whats

been a help before?been a help before? What does the person want?What does the person want? Make a decision about whether you need to Make a decision about whether you need to

involve and try to discuss thisinvolve and try to discuss this

Primary Care =GP, Practice Nurse etc

Primary Care Mental Health Team(PCMHT)

Social PrescribersHealth Trainers

Mild to Moderate

Community Mental Health Team (CMHT)

Moderate to Severe

Intensive Home Treatment Service

Simplifies Care Pathway