Mental health and care in the community

• To examine a range of mental health problems which may affect people living in the community

• To explore the role of the community mental health nurse and other members of the team

• To discuss treatment options for patients/clients within a community care context

• To reflect on how the knowledge and experience gained in mental health services in a community placement can be applied across a range of other placement settings

Introduction

This chapter will help you to prepare for a placement within the community where you may gain experience working with nurses who care for people with mental health problems. It is a chapter for all student nurses pursuing all fields of practice pathways, as mental health and wellbeing and managing to care for patients with diagnosed mental health problems will be essential skills at exposure level for all. It is an introduction to the mental health issues to which a student may be exposed in many placements. (To focus in more detail on mental health-specific placements and learning, see Stacey et al 2012).

Major mental health problems are relatively uncommon in comparison with minor or common mental health disorders. In the 2007 household survey of adult psychiatric morbidity in England (NHS 2009), the level of common mental health disorder in the population requiring some form of treatment, was identified as 7.5% of the population. In the same publication, the prevalence of ‘psychoses’, a term which captures the majority of major mental health disorders, is 0.5%. When you compare these two percentages and given that people with major mental health problems are more likely to be admitted to hospital, it is clear that nurses working in the community are more likely to encounter people with minor, less severe mental health problems, albeit these can be quite disabling and impact significantly on the life of sufferers and their families. Table 8.1 shows common mental health and major mental health disorders.

Table 8.1

Common mental health and major mental health disorders

Common mental health disorders	Major mental health disorders
Generalised anxiety disorder (GAD) Mixed anxiety and depressive disorder Depressive episode (including mild, moderate) Phobias Obsessive-compulsive disorder (OCD) Panic disorder	Psychoses Schizophrenia Bipolar disorder Manic depressive illness Unipolar disorder Severe depression

The NHS (2009).

On placement you may be able, if the patient consents, to observe basic counselling, relaxation therapy, sleep hygiene counselling, etc. (People with mental health problems such as mild depression and anxiety-related problems are covered in more detail later in this chapter.)

Activity

At times, people with mental health problems are misunderstood; occasionally negative attitudes expressed towards such people and their behaviour, often borne out of ignorance and prejudice, can have a detrimental effect on an individual’s wellbeing.

The terminology used by mental health practitioners is often not fully understood; derogatory and stigmatising terms such as ‘crazy’, ‘mad’ or ‘having a screw loose’ are commonly used by the public to describe people with mental health problems.

Research common mental health terminology through websites such as:

http://www.open.ac.uk/inclusiveteaching/pages/understanding-and-awareness/common-terms-in-mental-health.php

http://www.mentalhealth.org.uk/help-information/mental-health-a-z/T/terminology/

from a textbook such as Mental Health Nursing (Videbeck 2009).

Discuss your findings with your mentor and reflect on how your understanding of mental health terminology varies from that used by professionals, carers and service users.

Mental health nursing in the community is often seen to be the domain of the Community Psychiatric Nurse/Community Mental Health Nurse (CPN/CMHN). While many people with a mental health problem, particularly long standing conditions such as schizophrenia or bipolar disorder, are supported by CPNs, there are a wide range of conditions, often referred to as minor mental health problems, and those who experience them are occasionally cared for and supported by other community nurses such as general practice nurses, district nurses and health visitors.

People experience a wide range of mental health problems such as mild to moderate depression, anxiety-related problems, sleep disturbance and addictive problems. Many of these people will only see their GPs for support and medication. Community nurses may have more time to spend with the individual; more time to engage in ‘talking therapies’ (Stacey et al 2012).

Activity

Prior to undertaking a placement with a mental health practitioner or nurse in the community, it would be helpful to understand more about basic counselling. The following websites are a good starting point to develop your understanding of counselling approaches:

http://www.howto.co.uk/wellbeing/counselling-skills

http://www.basic-counseling-skills.com.

It is important to note that these are only information sites and the content must be discussed with your mentor and/or personal tutors to ensure safe practice, as a student, is undertaken.

Reading the information on these sites will help give you an insight into this field and support your achievement of both generic and field-specific competencies (if undertaking a mental health nursing pathway) in the NMC Domain 2: Communication and Interpersonal Skills.

During placements with the community nursing team, it may be possible for you to spend some time with the specialist mental health nurses or attend a day care centre where you may be able to observe basic counselling skills in action.

Role of the community psychiatric nurse (CPN)/community mental health nurse (CMHN)

The following definition illustrates the key aspects of this role:

The CPN is a qualified mental health nurse who works as part of a team of professionals to provide mental health services in the community. The role of the CPN is to work with the people referred, to define what they see as the problem and to agree whether or not further action or further contact with the CPN is needed. At the end of this assessment the CPN and the client may agree an action plan to address any needs identified and the CPN will continue to work with the client until the plan is finished. CPNs have a broad knowledge of mental health problems and a wide range of skills that they can use to enable clients to work through any programmes agreed. As well as working directly with people experiencing mental health problems, the CPN will try to ensure that the needs of carers are considered. This may mean working directly with a carer or may be related to making sure that the carer is able to access the support needed from other sources.

NHS Tayside Nursing Services (http://www.nhstayside.scot.nhs.uk/services/nursing/index.shtml)

Activity

In discussion with your mentor, and through independent research, identify those mental health problems, and their key features, that community mental health nurses would predominantly play a major role in supporting.

Make sure you explore the specific reasons why certain clients will be cared for and supported by a CPN/CMHN.

Write up your research and notes on mental health problems in your on-going learning diary or portfolio.

This activity will help you to work towards achieving competencies in the NMC Domain 3: Nursing Practice and Decision Making and NMC Domain 4: Leadership, Management and Team Working.

Having observed the management and delivery of care to people with mental health problems in the community, we now explore in more detail some of the main mental health problems that people can experience. It may be worth starting with mental health as opposed to mental illness. The Mental Health Foundation describes mental health as:

• Mental Health affects us all. How we think and feel about ourselves and our lives impacts on our behaviour and how we cope in tough times.

• It affects our ability to make the most of the opportunities that come our way and play a full part amongst our family, workplace, community and friends. It’s also closely linked with our physical health.

• Whether we call it well-being, emotional welfare or mental health, it’s key to living a fulfilling life.

The Mental Health Foundation (http://www.mentalhealth.org.uk)

It can be seen from the above that mental health is about coping with life on a day-to-day basis, it is about having satisfying relationships and it is about having a realistic understanding of your own self-worth; being able to cope with uncertainty, the ability to manage both positive and negative emotions and deal with disappointment. It is clear that mental health is more than the absence of mental illness. Mental illness arises when stress, whether that be physical, social or psychological overwhelms an individual and interferes with those very aspects of living that are identified above and seen as aspects of good mental health. Therefore, when an individual is mentally ill, they may not be able to manage their emotions and their relationships can become strained or broken. A person can become unable to work or manage their affairs; their concentration can be poor and their thinking distorted or delusional.

Different types of mental illness

Psychiatric diagnoses are categorised by the Diagnostic and Statistical Manual of Mental Disorders, 4th edn., otherwise known as the DSM-IV (American Psychiatric Association 1994). The manual is published by the American Psychiatric Association and covers all mental health disorders for both children and adults. It also lists known causes of these disorders, statistics in terms of gender, age at onset and prognosis, as well as some research concerning the optimal treatment approaches. The World Health Organization has its own classification; ICD-10 (WHO 1993), which fulfils a similar purpose; both of these were revised in the early 1990s and are currently being reviewed. Classification manuals/schedules such as these are used by mental health professionals for epidemiological and research purposes to enhance their understanding of mental illness. Nonetheless, it is helpful outwith that context in providing a structure which helps patients, and professionals alike, to understand and describe mental illness.

All the following descriptions and explanations of a range of mental illnesses are followed by specific activities which will support your achievement of a number of competencies across all four NMC domains of: Professional Values; Communication and Interpersonal Skills; Nursing Practice and Decision Making and Leadership, Management and Team Working.

Students in all four fields of practice should use this chapter to learn about mental health problems and how they can gain exposure to the knowledge and skills to be able to manage care situations where patients/clients may present with the behaviours associated with each illness.

It is important to note that, although ‘labelling’ a person who has a mental illness with an attached ‘condition’ is considered inappropriate in practice, in the context of this section of the chapter, it is more related to the actual underpinning health problem that the terminology is used. This is to enable the student to understand possible symptoms and behaviour that a person may experience with these diagnosed mental health problems.

Disorders of mood such as depression and bipolar disorder

These conditions are categorised as disorders where the primary symptom is disturbance of mood, whether that be an inappropriate, limited or exaggerated expression of feelings. Elevation or depression of mood and feeling is an experience common to most people. However, to receive a diagnosis of mood disorder, one’s feelings must be extreme in terms of both level and duration. This can manifest itself by frequent and prolonged periods of crying, feelings of depression, anxiety, guilt and suicidal ideation. The corollary to this, mania or hypomania, is characterised by the opposite extreme, where someone has excessive energy and hyperactivity with severely disturbed sleep and grossly disrupted decision-making, often driven by a sense of grandiosity.

A major category within DSM-IV is bipolar disorder (manic-depression). Research has shown a strong biological component for this disorder, with environmental factors playing a role in the exacerbation of symptoms. The implication being that some people are genetically predisposed to bipolar disorder but environmental factors such as stress can play a major role in its manifestation (Elder & Mosack 2011).

Activity

In a person with a genetic or familial predisposition to bipolar disorder, illness can often be triggered by a precipitating factor, often stress, and these factors are referred to as ‘stressors’.

Consider the role of individual stress as a precipitant to a depressive episode and from your placement experience and discussion with your mentor, identify the range of potential stressors that can lead to an individual experiencing a depressive episode.

Think of factors that may be physical, psychological or social in nature.

While on placement in the community, consider the role of the environment and how it may play a part in contributing to individual stress.

This activity can help you to achieve knowledge in relation to competencies in NMC Domain 3: Nursing Practice and Decision Making, in particular Competence 3.2 and 3.7.

DSM-IV separates bipolar disorder into two types: Bipolar I and II. To receive a diagnosis of Bipolar I disorder, a person must have at least one occurrence of mania. Mania, the opposite extreme to depression, is characterised by episodes of extreme euphoria; this feeling of high is often accompanied by irresponsible behaviour such as sexual disinhibition and lavish spending, which can be quite destructive to personal relationships, business and finances. They may have elevated self-esteem, flight of ideas, insomnia and be easily distracted. The high, although it may sound appealing, is often fragile and associated with agitation and restlessness, which can result in interpersonal conflict; particularly when challenged by others. The disinhibited behaviour can at times be dangerous and can lead to harm from inappropriate use of drugs and or alcohol. The fluctuations in mood experienced by someone with Bipolar I disorder can lead to sudden swings of mood from elations to depression and vice-versa.

Bipolar II disorder is similar to Bipolar I, in that there are periods of highs that are often followed by periods of depression. The difference with Bipolar II disorder however, is that the periods of mania are less intense and are described as hypomania. People with this condition have similar symptoms but they are not as severe and may not require hospitalisation (Videbeck 2009). People with hypomania can often remain at work, maintain social relationships and therefore do not necessarily require inpatient care. In many cases, they will be seen by their GP, CPN/CMHN or other community-based nurses.

In severe cases of either mania or depression, the symptoms can be such that they will be described as psychotic (see below).

Treatment and care

Medication, commonly known as mood stabilisers, such as lithium carbonate or carbamazepine, can be typically prescribed for this disorder and is the mainstay of pharmacological treatment. Medication reduces the severity and duration of periods of low and high mood. This in turn enables some people to engage in therapy, which can be useful in helping a sufferer understand the illness and its consequences and thus be better able to know when a manic or depressive episode is imminent and to prepare for this. As with many mental health problems, poor coping skills and lack of social support will make the condition more difficult to cope with.

Student reflection

Consider what resources you had access to on placement that you could have used to learn more about medication, its specific uses, side effects and contraindications.

What strategies could you use in the future to ensure you keep up-to-date with developments in medication? Learning about medication and medication management are core skills for student nurses and they can then engage in delivery of these to patients in their care.

(See NMC (2010) Essential Skills Clusters (ESCs) 33–38, on medicine management for additional learning outcomes to be achieved.)

Prognosis for the individual

The prognosis for people with more severe cases is poor in terms of a ‘cure’ and many people need to remain on medication for the rest of their lives, with failure to adhere to prescribed medication often resulting in relapse and hospital admission. Medication does assist many people to cope with the condition for long periods without relapse. There is also some evidence to suggest manic episodes slow down because of the natural ageing process (Coryell et al 2009).

Bipolar disorder presents in varying degrees and therefore misdiagnosis and confusion with other mental health problems, particularly mood disorders, can occur. In many circumstances, counselling and family support can be of significant value to people, therefore reducing the reliance on medication.

Major depressive disorder (unipolar depression)

Research by Elder and Mosack (2011) has shown that depression is influenced by both biological and environmental factors. First-degree relatives, regardless of whether they were raised by their relative, have a higher incidence of depression supporting the influence of biological factors. Environmental factors can exacerbate a depressive disorder in significant ways. Factors include stress, lack of a support system and physical illness in self or loved one; viruses can be a significant trigger for depressions in susceptible individuals. Social factors such as legal difficulties, financial struggles and job problems can also play a major role.