CSB 341

Topics
 Introduction
 Inter-agency collaboration
 Epidemiology
 EEO
 Childhood and developmental disorders in MH
 Substance use and MH
 Geriatric MH
 Social and cultural aspects of MH
 Consumer & Individual experiences
 Suicide

Week 1

 20% ambulance call outs are to mental health

 minimal 24/7 services outside of business hours except for hospital.
 Stigma: a mark of disgrace associated with a particular circumstance, quality,
or person

Is there stigma of mental health in paramedic practice?

o Verbal abuse
o Mistreatment
o Negative or non-verbal actions
o Inter-disciplinary mistreatment
o Adopting the negative stance to match the mentor or generalised
feelings of ambulance culture

Multidisciplinary teams – triad

Multiple teams are responsible for helping people with acute/chronic mental health
concerns  protect their health, well being and safety
 QAS
 QPS
 QH

Epidemiology and service systems

 1/5 Australians in 12 month period

 proportion increased from 19995-2005  real increase? Or increase in self
report? Or both?
 3rd highest burden of disease – behind cancer and cardiovascular. 2 nd in
aboriginal population – behind cardiovascular
 4th most common reason for seeing GP
 1/9 GP encounters
 leading cause of “healthy life” lost due to disability
 In 2007, 45% of Australians aged between 16-85 had at sometime in their life
experienced a mental disorder
 More than 22% of population in QLD
 Rate of 11:100000 for suicide in QLD – higher than national (10:100000)
  Most common reported long term health conditions of socially and
economically disadvantaged people
 Highest rate = Unemployed
 3/100 will experience a psychotic illness such as schizophrenia, bipolar, drug
induced psychosis
 comorbidities common
 Anxiety disorders most common – 1/7
 Mental disorder  3 days out of role per 4 week period  3x higher than
those with no mental illness
 Rate of deaths decreased – underlying cause is substance abuse
 Mental Health services – funded by
o Australian government
o State governments  largest role
o Private health insurers

Fourth national Mental Health Plan

Priority 1: Social inclusion and recovery

Priority 2: Prevention and early intervention
Priority 3: service access, coordination & continuity of care
Priority 4: quality improvement and innovation
Priority 5: Accountability

Providers of Mental Health Services

 Public mental health service – provide in each of 20 Queensland health

districts
o Primary health care providers = GP, community health workers,
nurses, allied health professionals, school health nurse, counsellors
 Private mental health service
o Psychiatrists
o Mental health nurses
o Clinical psychologists
o Social workers
 Non-government organisations
o Not for profit
o Carer groups
o Support groups
EEO

Authorizes the temporary detention of a person who is experiencing a mental illness

where their actions may result in harm to themselves or someone else

Enables the health service to have six (6) hours in which to conduct the assessment
of the person involuntarily.

 An EEO is completed when the Officer reasonably believes:

1. The person has a mental illness, and

2. Because of the illness they are at imminent risk of physical harm

sustained to themselves or others, and

3. Proceeding with a justice examination order would cause a dangerous

delay, and

4. The person needs an examination at the Authorised Mental Health

service

 Indications:

1. Where EEO criteria are met and a patient gives consent to go to hospital
but there is concern that the patient may not understand the nature and
effect of their decision.

2. Where EEO criteria are met an a pt refuses transport.

Mental Illness is characterised by a clinically significant disturbance of thought, mood

perception or memory.

A person must not be considered to have a mental illness because of one of the
following

o Religious, cultural, political, philosophical belief

o Member of particular racial group

o Particular economic or social status

o Particular sexual preference

o Sexual promiscuity

o Immoral or indecent conduct

o Drugs or alcohol
 o Intellectual disability

o Antisocial or criminal behaviour

o Family conflict

o Previously been treated for mental illness.

May have mental illness caused by alcohol or as well as intellectual disability

Mental Status Assessment Guide

Appearance  Grooming Thought Form  Amount

 Posture  Rate
 Build  Derailment
 Clothing  Flight of ideas
 Cleanliness

Behaviour  Eye contact Thought content  Disturbances

 Mannerisms  Delusions
 Gait  Suicidal
 Activity level  obsessions

Speech  Rate Perception  Illusions

 Volume  Thought
 Pitch insertion
 Tone  Broadcasting
 Flow  hallucinations
 Pressure

Mood  Anxious Insight &  Cognition

 Depressed judgment  Illness
 Cheerful  Understanding
 Cause & effect

Affect  Restrictive
 Blunted
 labile
Week 2

Postpartum

Postpartum = one hour following delivery of the placenta  six weeks of infants life.
Perinatal period = conception  end of postnatal first year

Postpartum mood disorders

 Blues
 Depression
 Psychosis
Postpartum PTSD
Post partum anxiety

Co-morbidity between depression & anxiety disorders

Incidence Onset Symptoms

Postpartum blues 50-85% Within first week Fluctuating mood
Tearfulness
Anxiety
Postpartum 10-15% Within first 3 Depressed mood
depression months Excessive anxiety
Insomnia
Postpartum 0.1-0.2% Dramatic, within Agitation
psychosis first 2 weeks Irritability
Depressed or
elated mood
Delusions
Disorganised
behaviour

Postpartum Blues

 Affective instability
 High prevalence  almost seen as normal
 Rapidly fluctuating mood, tearfulness, irritability, anxiety
  Peak 4th or 5th day after delivery  may last few hours or days  gone by 2
weeks

Postpartum depression

 More pervasive and significantly interferes with mothers ability to care for her
child
 Depressed mood, tearfulness, irritability, loss of interest in ususal activities,
insomnia, fatigue, loss of appeteite
 Ambivalent or negative feelings towards the infant
 Doubts re ability to care for child
 Suicidal ideation frequent however suicide rates low

Postpartum psychosis

 Sudden in first 2-3 weeks

 Loss of contact with reality
 False ideas about current events and about themselves  delusions
o Child is defective or has special powers or satan or god
 Hallucinations
 Stop eating
 Inability to sleep, inability to relax
 Urgency about accomplishing atsks
 More energy that should
 Agitated and anxious
 Poor judgement
 Alienation
 Paranoia
 Risk of infanticide & suicide high –(egosyntonic)
 Treatment = antipsychotic drugs and hospitalisation
 50% are without previous psychiatric hospitalisations
 some first and only

Postpartum PTSD

 complicated prior delivery eg prolonged, severe pain, loss of control feelings,

 can effect ability to breastfeed, may impair parent child bonding.

Postpartum Anxiety

 hand in hand with Postpartum depression

 present with generalised anxiety, panic disorder or hypochondriasis
 obsessions or thoughts of harming or smothering the child  distressing so
go out of way to protect the child (egodystonic)

Leigh article
 13% prevalence of antenatal & postnatal depression
  mothers suffering from PND were less attached to infant  more demanding
from 3months and experienced parenting stress for up to 3 years
 antenatal depression  strongest risk factor for PND
o low self esteem
o antenatal anxiety
o low social support
o negative cognitive style
o major life events
o low income
o Hx of abuse
 Antenatal depression dominant mediator between risk factors and PND
 Only identified factor for parenting stress was concurrent PND  reciprocal
relationship

Childhood Mental Health Issues

Childhood development – issues can arise when any stage of development is

unusual

Attachment theory
 enduring emotional bond developed during first year of life
 parent-child attachment is a central aspect of social and emotional
development
 during separation  need patience, comfort, consistency and continuation of
regular routines to continue to feel secure

Types of attachment
1. secure
2. ambivalent insecure attachment
3. avoidant insecure attachment
4. disorganised insecure attachment

Trauma
 can interrupt emotional regulation  heightened stress response &
maladaptive coping.

Disorders of childhood
 infancy
o sleep, feeding and eating disorders
o pervasive development disorders
o relationship problems
o developmental disorders
o anxiety disorders or separation anxiety
o motor skills disorders
 childhood
o externalising behaviours eg ADD, ADHD
o oppositional defiant disorder ODD
o conduct disorder CD
 o somatisation = expressing psychological distress through physical
symptoms

Psychiatric evaluation of an infant or child

 Appearance
 Behaviour
 Speech
 Mood
 Affect
 Thought form
 Thought content
 Perception
 Insight & judgement
Not small adults  gain info by speaking to child.
Varying levels of compliance and cooperation
Ensure child answers not parent or care-giver

Autism

 A neuro-developmental disorder that is typically diagnosed by age 3 and is a

life long disability
 Impact on 3 areas of life
o Social development
o Communication skills
o Restricted interests
 Can be mild – severe
 Often have a co-existing mental health disorder that may be undiagnosed 
negative impact on academic performance and sustainability
 Research has indicated that persons with ASD have increased risk of
psychiatric disorders  67-70% meet criteria for an additional mental health
disorder described within DSM-IV
 Diagnosis of autism precludes making a formal diagnosis of other psychiatric
disorders including ADHD, OCD, & social anxiety disorder  impossible to
receive comorbid clinical diagnosis.

Comorbidity:
 ADHD most common - ~50%
 Anxiety - >40%
o Phobias
o Social anxiety
o Generalised anxiety
o Panic disorder
o OCD
o Tourette syndrome
 Depression & mood disorders
o Depression
o Bipolar

Factors effecting comorbidity risk

 Associated medical conditions and syndromes
 o Fragile X syndrome
o Prader-Willis syndrome
o Seizure disorders
 Familial genetic factors
o Bipolar
o OCD
 Psychosocial factors  increased risk
o Peer rejection
o Low levels of social support
o Academic difficulties
o Cognitive and processing limitations
o Awareness of difficulties (around puberty)  anxiety and depression
Factors that hinder identification and diagnosis
 Diagnostic overshadowing  contributing new behaviours to the ASD, ruling
out possibility of another disorder
 Baseline exaggeration  new behaviours just an exacerbation of ASD
 Applicability of current diagnostic criteria to ASD pts is questionable  due to
intellectual/communication difficulties. Symptoms may look different is ASD.

Potential indicators of an underlying mental health issue in ASD

 ADHD  ASD more likely exhibit the inattentive subtype rather than
hyperactive.
 Anxiety
o Avoidance of new people/tasks
o Increase in performance of rituals
o Increase in resistance to transitions, change in routine
o Narrowing of focus of attention on special interest
o Withdraes from social situations
o Low frustration tolerance  tantrums
o Perfectionistic behaviour
o Seeks constant reassurance
o Specific phobias
o OCD
 Depression
o Increased agitation, self injury, temper outbursts
o Increased tearfulness
o Loss of interest
o Resistance to participating
o Tantrums, meltdowns, aggression
o Self – depreciating comments
o Deliberate, potentially lethal acts
 Bipolar
o Elated mood regardless of circumstances
o Aware at night and active
o Feel they do and achieve more
o May create new tasks
o Increase in preoccupation
o Increase in ritualistic or compulsive activities
o Increase in intrusiveness
o Hallucinations, delusions, paranoia
Kessler paper
 Childhood adversities (interpersonal loss, parental maladjustment,
maltreatment, physical illness) significantly predict first onset of all classes of
mental health disorder
 Maladaptive family functioning ie parental mental illness, child abuse, neglect
is strongest predictor of mental health disorders.

Scott paper
 Childhood adversity arising from problems with family functioning was
significantly associated with all types of mental illness  can explain 32%
 Childhood trauma upsets the orderly psychological and biological cascaded of
development, leaving the affected individual at an increased risk of a wide
range of adverse mental health outcomes.
 Childhood adversities appear to contribute to the increased prevalence of
mental health disorders by 2 mechanisms
1. More new cases ie greater inflow
2. Less recovery ie less outflow
 Adults who have mental health issues due to CA are more likely to expose
their children to CA

Essex paper
 Studied patterns of childhood mental health symptoms from K-5  develop a
screening procedure to detect those most likely to have MH issues
 Combination of recurring and comorbid symptoms that strongly distinguishes
children likely to suffer pervasive impairment by early adolescence
 Children most in need of treatment are not receiving
 Many families do not follow through with recommendations

People with intellectual disability & mental health

As defined by DSV-V
= deficits in intellectual functions such as
 Reasoning
 Problem solving
 Abstract thinking
 Judgement
 Academic learning
 Learning from experience
= deficits in adaptive functioning that fail to meet developmental and socio-cultural
standards for personal independence and social responsibility
 Limit functioning in one or more activities of daily life
o Communication
o Social participation
o Independent living

Levels of severity defined on basis of adaptive function not IQ scores

Prevalence = 3%  60% with severe communication limitations

Highly likely to have limitations in 3 core activities of daily life
 1. Self care
2. Mobility
3. Communication
ASD most prevalent developmental disability 1:160

Health issues
 Nutrition
 Lack of exercise
 Polypharmacy
 pain
 Biology associated with syndrome  structural abnormalities to brain,
epilepsy
 Devaluing, isolation, loneliness
 Access problems
 High comorbidity
o GORD
o Dental
o Infectious
o Genetic
o Constipation
o Sensory impairment

 Psychological factors
o Impaired memory
o Low stress thresholds
o Poor self image
o Immature
o Lack of emotional support
 Social factors
o Conflicts
o Difficulties developing relationships
o Problems finding employment
o Patronisation by others
o Lack of integration in wider community

Increased risk of developing mental health problems

 Nature of disability  links, greater risk with some syndromes
 Brain trauma  psychiatric problems
 More likely to encounter traumatic events  more vulnerable to MH
 Social restrictions, fewer opportunities to gain life experience  puts mental
health at risk
 Low socioeconomic status
 Limited social networks
 Trauma/abuse
 Limited choice and control
 Limited functional expressive communication
 Stigmatisation

lower quality of life
mental health
poorer health outcomes
Communication
 Individuals with communication difficulties often have to make numerous
attempts to be acknowledged  may resort to overt means to gain attention
 Behaviours that result in achieving the desired outcome will be used more
often

Week 3

Schizophrenia

General information
Psychosis syndrome characterised by long duration,
 Positive symptoms
o hallucinations
 Auditory
 Any sense effected
o delusions - Fixed false belief unshared by others
 Can be personal
 Persecution (threatened or conspiracy)
 Passivity (thoughts controlled by external force)
 Grandiose, sexual or religious themes
o Thought disorder
 Distorted or illogical speech
 Thoughts start in one direction and suddenly move in another
without any logical connection
o Lack of insight – failure to recognise symptoms are caused by illness
 Negative symptoms – decrease in drive and volition
o Emotional blunting
o Social withdrawal
o Paucity of speech
o Loss of motivation and initiative
o Self-neglect
 Primary and secondary symptoms
o Primary negative – emotional blunting
 o Secondary negative – social withdrawal due to paranoid delusions

Spectrum disorders
 Schizophrenia
 Schizoaffective disorder
 Schizophreniform disorder
 Schizotypal
 Schizoid personality disorder
 Acute psychotic disorder

Epidemiology
Who?
 Men
o Higher rates
o Earlier age at onset (late teens – mid 20s)
o More negative symptoms
 Rare in children <13
Incidence/prevalence?
 1:100

Aetiology
 multifactorial  multigene interaction + environmental influences
 multiple environmental risk factors
o genetic
o cannabis use
o urban residence
o obstetric complications
o paediatric trauma
o CNS infections
o Psychosocial stress – intolerance of normal stress
Pathophysiology
 Altered brain function
o Increased dopamine synthesis, dopamine release
o Hyper and hypo activity in different brain regions
 Reduced grey matter
History
 Chief concern
o Unusual behaviours
 Hearing voices
 Articulating strange beliefs
 Disorganised speech and thought
 Disorganised social behaviour
 Social withdrawal
 Flattened affect
 Hx of present illness
o Acute onset of symptoms
o Changes in behaviour
 o Social problems
o Anxiety and depression
o Psychotic behaviours
 Medication Hx
 Social Hx
o Social withdrawal
o Substance use
o Hx of self harm
 Family Hx
Physical
 Neuro
o Lack of insight
o Auditory hallucinations
o Ideas of reference (belief that something/ someone is specific to
patient, talking about – pt may recognise belief is unfounded if
questioned))
o Delusions of reference (unrealistic belief that external events are
somehow about the patient – not altered when confronted)
o Suspiciousness
o Thoughts spoken aloud
 Assess for cognitive impairment

Diagnosis
 Rule out medical illness that may cause delirium or psychotic symptoms such
as
o Substance abuse
o Dementia
o Hypoglycaemia
 Consider other psychiatric conditions
o Bipolar
o ASD
o OCD
o Delusional disorder
o Major depression
Treatment
 Antipsychotics
o thought to normalise symptoms by affecting the brain neurotransmitters
dopamine and serotonin.
o Control positive symptoms like hallucinations and delusions
o 1st generation (typical)
 Eg. Fluphenazine dacanoate (modecate) & haloperidol via depot
 Linked to progressive grey matter loss in brain
 Side effects tardive dyskinesia, dysdiadokinesia =
extrapyramidal symptoms
o 2nd generation (atypical)
  eg clozapine
 less potential to cause EPS.
 Resolve TD due to decrease in abnormal motor movements.
 Adverse effects – chest pain, dry mouth  ulcers, T2DM
 Psychosocial treatment – non-pharmacological
o Cognitive behavioural therapy – successful is attend regularly
o Family orientated interventions
o Electroconvulsive therapy
 causes chemical changes in the brain
 multiple treatments necessary
Complications & prognosis
 increased risk of suicide
 increased risk of violent crime
 spontaneous dyskinesia
 comorbidities – weight gain, diabetes.

Bipolar disorder

General information
 A mood disorder previously known as manic-depressive disorder
 characterised by fluctuations between episodes of mania, hypomania and/or
depressive states
 can effect relationships, careers and general functional capacity
 During the manic stage, the patient may have feelings of euphoria, often out
of proportion with life events, elevated energy levels including a decreased
need for sleep and extreme emotions. They may engage in reckless or bizarre
behaviour and can become aggressive when they perceive something is
interfering with their ambitions. Delusions and hallucinations, both visual and
auditory, can also occur
 Depressive states more common
 Types
o bipolar type 1
 at least 1 episode of mania
o bipolar type 2
 at least one episode of depression and 1 hypomanic (< mania)
o rapid cycling
 >= 4 episodes in 12 months
 interspersed with partial or full remission
o mixed
 feeling of depression while manic
Epidemiology
Who?
 Onset <25
1. BP1 18, = M/F
2. BP2 22, > F

Incidence/prevalence?
 2:100
Aetiology
 Linked to brain chemicals – neurotransmitters that regulate mood particularly
serotonin and noradrenaline  balancing issue
 Risk factors
o Family Hx
o Diagnosis of depression
o Environmental
 Life events
 Childhood adversities
 Cannabis use
 Presence of other psychiatric conditions common
o Anxiety
o Panic disorder
o OCD
o Substance abuse

Pathophysiology
 Interacting genetic and environmental risk factors
o Genetic
o Environmental
 Life events & Chronic stressors  precipitate a mood episode
 Childhood adversities
History
 Chief concern
o Symptoms of depression or mania
o Irritability, aggressiveness, hyperactivity, mood swings
 Hx of present illness
o Manic and depressive episodes may be precipitated by stressful life
events or other mental trauma
o Depressive episodes - Ask about
 Depression or hopelessness in last month
 Little interest in activities
 Change in appetite
 Insomnia or hypersomnia
 Suicidal thoughts
 Indecision
o Manic episodes – ask about
 Current reduced need for sleep
 Current elevated mood
  Increased irritability
 Increased activity
 Excessive involvement in pleasurable activities with
adverse consequences
 Inflated self esteem or grandiosity
 Increased rapid speech, jumps in topic
 Flights of ideas & racing thoughts
 Distractibility
 Medication Hx
 Family Hx
 Social Hx
o Hyper-sexuality
o Overspending or spending sprees
o Poor judgement
o Drug use/abuse
Physical
 Signs of mania and hypomania may include
o Hyperactivity, restlessness
o Affect may be euphoric, irritable, elated
o Distractibility
o Rapid speech, flight of ideas
o Over confidence, grandiosity
o Impaired judgement (reckless behaviour)
o Loss of normal social inhibitions (overfamiliarity, provocative, intrusive)
 Signs of depression include
o Obvious distress, downcast eyes
o Slow or agitated movements and speech
o Negative themed speech content – world, self, relationships

Diagnosis
 Consider bipolar with pts presenting with depression <25 or family Hx
 Eliminate other causes
 Consider other psychiatric conditions
o Schizophrenia
o ASD
o OCD
o Delusional disorder
o Major depression
Treatment
 Medications – mood stabilizing drugs
o Valproate
o Lithium
o SSRIs
o Antipsychotics – Olanzapine
o thought to normalise symptoms by affecting the brain neurotransmitters
dopamine and serotonin.
 Psychosocial treatment – non-pharmacological
o Electroconvulsive therapy
 causes chemical changes in the brain
 multiple treatments necessary
 o Counselling
o Family focussed therapy
o Cognitive behavioural therapy
o Focus on
 Identify early warning signs
 Acceptance of illness
 Adherence with medicine
 Cope with environmental stressors
 Enhancing family rraltionships and communication
 Reduce substance abuse
Complications & prognosis
 Self harm
 Legal problems
 Financial problems
 Relationship/social problems
 Poor work or school performance
Comorbidities
 Substance abuse – alcohol, Benzodiazepams
Increased suicide risk

Anxiety disorder

General information
 Characterised by chronic unfocussed worry and stress
 Often accompanied by
o insomnia,
o restlessness,
o muscle tension,
o concentration problems
 different types
o Generalised – worry about everyday aspects of life, realistic or not
o OCD – compelled to ritually check
o Phobias – intense irrational fears about particular things or situations
o Panic disorders – frequent sudden attacks of intense fear
o Social anxiety disorder – intense anxiety associated with social
situations
o PTSD – follows a traumatic event.
Epidemiology
 More common in
o Women
 o Caucasians
o Older adults
o Widowed, separated or divorced
Aetiology
 Risk factors
o Environmental
 Life events
 Financial
 Death of somebody
 Relationship breakup
 Being in an unpredictable new situation
o Physical health problems
o Drug/alcohol use
Pathophysiology
 Proposed neurobiological model
o Hyperactive amygdala  hyperactive autonomic nervous system and
cortisol secretion 
 increased serotonin uptake
 decreased functional coonectiovity between prefrontal cortex
and anterior cingulate cortex
 decreased hippocampus volume
o neural changes result in further increased anxiety and disruption in
emotional regulation
 Interacting genetic and environmental risk factors
o Genetic
o Environmental
 Life events & Chronic stressors

History
 Chief concern
o Feelings of worry and concern that are
 Excessive
 Persistent
 Unfocussed
 Hard to control
 Associated with clinically significant distress and
functional impairment
 Hx of present illness
o Age of onset – 10-14 in children and adolescents, 30 in adults
o Associated symptoms
 Restlessness
 Fatigue
 Concentration difficulties
 Irritability
 Muscle tension
 Sleep disturbances
 Medication Hx
  Family Hx
 Social Hx
Physical
 Tachycardia possible
 Other signs include
o Nervousness
o Trembling
o Diaphoresis
Diagnosis
 Excessive anxiety and worry occurring more days than not for 6 months about
a number of events or activities.
 Other psychiatric conditions
o Bipolar
o Psychotic disorder
Treatment
 Medications – antidepressants
o SSRIs
 Psychosocial treatment – non-pharmacological
o Counselling
o Cognitive behavioural therapy
Complications & prognosis
 Increased risk of suicidal behaviour
 Increased risk of onset of cardiovascular disease
 Substance abuse

Depression

General information
 Characterised by consistent low mood, lack of positive affect, loss of interest in
usual pleasurable activities
 Causes significant impairment for >= 2 weeks
 different types
o dysthymia – less severe but more persistent
o perinatal – during preganancy and/or following birth
o bipolar
o seasonal affective disorder (SAD) – only during certain seasons
Epidemiology
 More common in women
 6%
Aetiology
 Genetic predisposition
 Risk factors
 o Environmental
 Life events, childhood adversities
 Financial
 Death of somebody
 Relationship breakup
 Being in an unpredictable new situation
o Physical health problems, trauma
o Drug/alcohol use, cannabis use
Pathophysiology
 Neurotransmitter defects – serotonin, tryptophan, noradrenaline and
dopamine
 Chemical imbalance
 Structural and functional changes in brain

History
 Chief concern
o Sad, anxious agitated or tearful
o Difficulty concentration
o Loss of sexual interest
o Suicidal thoughts
o Loss of interest in pleasurable activities
o Feelings of worthlessness. Hopelessness, excessive guilt
o Psychomotor retardation or agitation ( decreased physical activity)
o Sleep disturbances
o Weight loss or gain
 SIGECAPS
o Sleep disorder
o Interest deficit
o Guilt
o Energy deficit
o Concentration deficit
o Appetite disorder
o Psychomotor retardation or agitation
o Suicidality.

 Hx of present illness
o onset – may be gradual or abrupt
 Medication Hx
 Family Hx
 Social Hx
Physical
o Neuro – Mental Status assessment
o General physical
 Fatigue
 Sleep disturbances
 Cognitive diff
 stress

Diagnosis
 >5 of above symptoms for > 2 weeks
  Other psychiatric conditions
o Bipolar
o Psychotic disorder
Treatment
 Medications – antidepressants
o SSRIs
 Psychosocial treatment – non-pharmacological
o Counselling
o Cognitive behavioural therapy
Complications & prognosis
 Increased risk of suicidal behaviour
 Increased risk of onset of cardiovascular disease
 Substance abuse

Dementia

General information
 Clinical syndrome of acquired impairment in neuropsychological and
behavioural areas sufficient to impair social or occupational functioning
including change in
o Long and short term memory
o Language
o Speech
o Visuospatial ability
o Mood and personality
 Rapidly progressive dementia – develops within 12 months of cognitive
symptoms
 Early onset - <65
  Delirium – fluctuating, acute confusional state
Epidemiology
 Incidence associated with age
o 7:1000 65-69
o 85:1000 >= 85
Aetiology
 neurodegenerative causes
o cortical degenerative dementias
 Alzheimer
 Frontotemporal
o Dementia associated with movement disorders
 Parkinson’s
 Dementia with Lewy bodies
 Huntington disease
 Vascular causes
o Binswanger disease
o Stroke
 Inflammatory causes
o Lupus
o Behcet syndrome
o Multiple sclerosis
 Traumatic causes
o TBI
o Dementia pugilistic (sports injuries eg boxing)
 Other causes
o HIV
o Prion
o Limbic encephalitis
o Hippocampal sclerosis

Pathophysiology

History
 Chief complaint
o Impaired memory
 Ask about
o Comorbidities
o Head trauma
o Stroke
o Medication use
o Functional impairment
 Dressing
 Bathing
 Eating
  Toileting
 Managing money
 Preparing meals
 Taking meds
 Performing household tasks
Physical
 Mental status assessment
Diagnosis
Treatment
 Cholinergic – Acetylcholinesterase inhibitors.
 Memantine
 Drugs to treat symptoms of dementia such as
o Agitation
o Depression
o Anxiety
o Sleep disturbances
 Cognitive stimulation and reality orientation therapy – stimulate persons mind
and remind them who they are, where they are and what they are doing
Complications & prognosis
 Eating problems
 Infections
 Decline in visual processing

Week 4

Indigenous mental health

Well Being Centre

 Combines modern and traditional
 Set up to destigmatise MH in the community
 Preventative
 Key is talk about their feelings
 Take them on visits out to the bush or beach  makes them feel better
 In the community they say they feel terrible compared to on the bush
  Home like environment – friendly, less stressful
 Give health workers ability to make more formal assessment of pts MH
 Home visits – destigmatise – indicate to them that its just part of who they are
and its OK.

Care Coordination and Supplementary Service program (CCSS)

 Aims to improve the health outcomes for indigenous people with chronic
disease thru better access to coordinated multidisciplinary care.
 Program is funded by the dept. of health and ageing & is an example of a
partnership between 4 Medicare locals
o Metro north Brisbane
o Greater metro south Brisbane
o West Moreton Oxley
o Gold coast
 The Institute for Urban Indigenous Health deliver the CCSS program
 Difficulty understanding medical lingo  help having someone attend
appointments with them
 Improvement due to better access to healthcare
 Transport to and from appointments.

Aboriginal and Torres Straight Islander Health Workers

 Can relate because they are indigenous  makes pt feel more comfortable
 A&TI = 3rd world health problems & inequality
 Health workers
o Reflect A&TI view
o Look at physical, spiritual and emotional and cultural wellbeing of pt.
o Deliver clinical services
o Help promote case management
 Challenges rest of Australia to see a need for holistic and culturally safe
approach.
 Focusses on individual, family and community in holistic way
 Look at whole well being – social, cultural & spiritual and how it impacts on
someone’s health
 Help pt understand what is said
 Improve health literacy of pts
 Improve cultural sensitivity of mainstream hospital environments
 Advocate on pts behalf
 Liaise with Drs and nurses re cultural aspects they might need to think about.
 Training of Dr and nursing staff

 Some pts it’s the first time away from their community
o Shame
o Fear
o uncomfortable
 Out in community
o Program outside usual medical setting
o Share info re healthy living
 Enable people to recognise health problems they may have

Community Restorative Centre (CRC)

  Aboriginal or Torres Strait Islander  more likely than other Australians to
spend some time in gaol
 28 per cent of Australian prisoners are Indigenous and the numbers are
growing. Over the past 15 years, the rate of incarceration of Australia's first
people has increased by 57 per cent.
 To combat the problem, a new report is calling for a radical rethink of mental
health services in Aboriginal communities. The study looked at Indigenous
prisoners in New South Wales with a diagnosed mental illness or cognitive
impairment and it traced their interactions with the law over 30 years.
 The researchers also spoke to communities in the Northern Territory and
found that a failure to identify a mental health issue early in life led to a
predictable path of contact with police, then the court system, and finally, jail.
 The report finds that thousands of Indigenous people are being warehoused
in jails across the country, rather than receiving treatment or community
support
 CRC builds support into the community - often the first time that that really
targeted, intensive support has been there for these men and women.
 In UNSW report, there were very few who didn't have some kind of disability,
either mental or cognitive.
 of the Aboriginal people who had been in juvenile detention, not one of them
did not have a disability. So every single one of them had a mental or
cognitive disability and most had complex support needs, had many
diagnoses, many problems.

When mental Illness enters the family – helping a loved one with a mental illness

 Families sense a problem – see signs

o symptoms
 mood – down, tearful, cry
 thinking – trouble concentrating, jumbled thoughts, paranoid
 behaviour – different, sleeping patterns change, eating habits,
odd behaviour, isolate themselves
o Time – persisting symptoms – weeks – months. Don’t het better on
their own
 Safety concern? Are they at risk of harming themselves or someone else?
 Families see it is obvious but have a hard time trusting what they see.
o Write down what they see
o Validate with someone that what they are seeing is actually going on
 The illness gets in the way of the person recognising they have a problem

Solutions
1. Don’t go it alone
a. Many others experiencing the same
b. Consult others – dr, clergy, other families
c. Consult National Alliance on Mental Illness (NAMI)
2. Don’t get into fights
a. Tried reason and persuasion  no success
b. Amplified voices, yelling  evokes equal and opposite reaction - not
helpful
c. Alternatives
 i. Listening – what do they gain from their behaviour?
ii. Leverage – use the support you provide as leverage to seek
help, negotiate
3. Learn the rules of the mental health system and how to bend them
a. Need to be vocal advocates for you family member
b. Get past privacy rules
4. It’s a marathon not a sprint
a. There will be problems along the way
b. Treatment takes time
c. Recovery is not a straight line
d. Tests morals and determination of all involved
e. Never give up.

Crisis Communication Strategies

 Active listening
 Verbal
 Non-verbal
 Need to be more solution focused and directive than usual
 Patience
 Impatience can be viewed as lack of interest
 Slow down
 Limit self disclosure – often used in attempt to show empathy but pts don’t
see it as that
 Suicide risk –
 Identify persons’ level of risk by
1. Plan – how defined?
2. Means – do they have what they need?
3. Timeframe – establish intended time of attempt. Shorter time
frame  increased risk
4. History – attempted before?
 Ask
1. Do you have any medical/psychiatric illness?
2. Have you ever tried to commit suicide before?
3. Do you know anyone who has committed suicide?
4. Have there been any recent triggers or events that have initiated
suicidal thoughts?
 Don’t leave person alone
 Listen to story & identify risk
 Problem solve if applicable

 Thought disorder
 Don’t reinforce delusions or hallucinations but don’t openly dispute
 Side step issues –“that needs to be worked out”
 Talk slowly
 Repeat questions if necessary
 Allow person to pace or move if restless
 Crisis management plans
 3 components
1. Objectives
 How long
  Specific triggers
 Supports?
 Identify each individuals intended outcomes – patients
objectives, clinicians objectives and any discrepancies
2. Planning and action
 Identify current MH supports
 Problem solve a plan that addresses key needs
3. Outcomes
 Realistic outcomes – don’t make promises can’t keep
 Access to definitive care
 Creation of a safety plan with review
Confidentiality:
 Info related to involuntary pt may be given to guardian, family member
or primary caregiver if
 If the info is reasonably required for ongoing care
 If that person will be involved in the care
 Health Records
 Permits disclosure to reduce or prevent
o Serious or imminent threat to persons life or safety
o A serious threat to public health safety or welfare

Aggression
 Factors contributing to aggression –
o Internal
o External
 Aggression
o Organic disorders
o Psychiatric illness
o Substance abuse
 Hostile v instrumental aggression
o Hostile
1. Impulsive
2. HOT
3. Unplanned
4. Driven by anger
5. Reactive
o Instrumental aggression
1. Premeditated
2. COLD
3. Goal directed
4. More proactive than hostile

 HOT
o Threats are part of escalation – commonly caused by fear, frustration,
confusion
o Recognized by
1. Minor movements
2. Verbal abuse and threats
3. Major motor movements
4. Aggression
5. Exhaustion
  COLD
o Threats are part of manipulation and control
o Common in personality disorder
o Attempt to get needs met

The assault cycle:

 Phase 1: the triggering event
 Phase 2: Escalation
 Phase 3: Crisis – verbal or physical demonstration
 Phase 4: recovery
 Phase 5: post depression Crisis  regret.
De-escalation
 The gradual resolution of a potentially violent and/or aggressive situation thru
the use of verbal and physical expressions of empathy, alliance and non-
confrontational limit setting that is based on respect.
 Principles
o Maintaining autonomy and dignity of patient
o Using self knowledge to achieve goals
o Being self aware
o Intervening early
o Providing options and choice
o Avoiding physical confrontations
 Strategies
o Verbal
 Allow time for response
 Allocate one person to communicate
 Active listening
 Calm, respectful language
 Open – ended sentences
 Avoid challenges and promises you can’t keep
 be firm but compassionate
 Calm, lowered tone of voice
 Cold threats
o Set clear firm boundaries on behaviour & offer alternatives
o Give less time to listening when person acting inappropriately
 Hot Threats
o Give time to cool down
 Psychological de-escalation strategies
o Offer limited choices to allow pt to retain sense of control
o Encourage pt to gain control over their behaviour
o Try to identify and understand reasons for their behaviour
o Use distraction and redirection
o Suggest more appropriate behaviour
o Allow person an “out” so they can back down without losing face
 Physical de-escalation strategies
o Calmer personal space
o Approach with caution
o Don’t startle patient
o Be aware of exits
o Remove dangerous objects from your person and be aware of
environment
 o Encourage pt to sit
o Open body language, eye contact
o Show interest in what they are saying
o Be respectful

Hunter Paper - Disadvantage and discontent: A review of issues relevant to the

mental health of rural and remote Indigenous Australians

 Indigenous residents of remote and rural Australia experience high levels of

mental health disorder and social and emotional problems often unrecognized
and not addressed by the health system
 Ensuring equitable access to mental health services is a priority
 Data on indigenous mental health is poor
 Existing data indicates significantly higher morbidity and mortality (suicide)
among indigenous Australians
 Indigenous residents of rural and remote communities are at particular risk
due to pervasive social disadvantage and poor access to social and health
services.
 AIHW – indigenous 2x rate of non-indigenous for hospitalization for mental
and behavioral disorders
 Psychosocial development challenged by rapid changes in family structure
and function over the last 4 decades
 High arrest rate
 Realities of remote and rural areas – hardship, sufferance and invisibility (high
level of unrecognized and untreated illness)

Meehan paper - Trends in the use of Emergency Examination Orders in Queensland

since the implementation of the Mental Health Intervention Project.

 Mental Health Intervention Project – 2005 – improve interagency collaboration

in the management of mental health crisis situations
 Use of EEOs increased by 262% since 2002
o Increasing focus on community care
o Poorly organized/ resourced mental health services
o Waiting time at ED for police is < 30 mins  take to ED rather than
watch house
o Overuse of EEOs for “problem” patients
o Many inappropriate  need for more training in criteria
  Police generate 2/3 of EEO
 Providing alternative accommodation/treatment options for those under
influence of alcohol and drugs may help reduce inappropriate use of EEOs
and in turn demand for emergency department services

Richmond paper - Verbal de-escalation of the agitated patient: consensus statement

of the American Association for Emergency Psychiatry Project BETA De-escalation
Workgroup

 Restraints and involuntary medication have been replaced by non-coercive

approach.
 3 step approach
1. pt verbally engaged
2. collaborative relationship established
3. pt is verbally de-escalated out of the agitated state
 helping pt calm himself
 4 main objectives when working with an agitated pt
1. ensure safety of pt, staff and bystanders
2. help pt manage his emotions and distress and maintain or regain control of
his behaviour
3. avoid the use of restraint when possible
4. avoid coercive interventions that escalate agitation
 10 domains of de-escalation
1. respect personal space
2. do not be provocative
3. establish verbal contact – introduce yourself and provide orientation and
reassurance
4. be concise and keep it simple – repetition – repeat message till it is heard.
5. Identify wants and feelings
6. Listen closely to what the pt is saying – use active listening, Millers law (to
understand what another person is saying you must assume it to be true and
try to imagine what it could be true of)
7. Agree or agree to disagree
8. Lay down the law and set clear limits – limits must be reasonable
9. Offer choices and optimism
10. Debrief the pt and staff
 Can empower the patient to stay in control while building trust with caregivers.

Shaban paper: Paramedics’ clinical judgment and mental health assessments in

emergency contexts: Research, practice, and tools of the trade.

 Increasing needs to
o Improve mental health skills of all healthcare professionals
 o Improve coordination of services provided to consumers of mental
health services
o Foster greater community interest and involvement in mental health
issues
 Paramedics face increasing challenges.
o Decentralization of mental health services  increased attendance at
ED
o 10-fold increase

Shaban paper: Mental health and mental illness in paramedic practice: A warrant for
research and inquiry into accounts of paramedic clinical judgment and decision-
making.

 Mental health act 2000 – allows for involuntary assessment, treatment and
protection of persons with mental illness while safe guarding their rights
 Research required to make paramedics more equipped to manage mental
health patients

Aboriginal mental health

Aboriginal people have a diverse culture with a rich and compelling history. The
impact of colonisation, legislation and the stolen generation created significant
hardships for Aboriginal Australians. These problems continue today and impact on
Aboriginal people and their mental health.
Issues for Aboriginal people include:
o continued grief and loss in the Aboriginal community
o living in continual poverty
o loss of identity and culture
o chronic disease
o low self-esteem and self-worth
o incarceration
o premature death
o poor education outcomes
o overcrowding in family homes
o substance use problems

Managing mental health problems

The impact of history continues today with problems such as anxiety, post-traumatic
stress disorder and depression becoming more common in Aboriginal communities
across Western Australia.
Successfully engaging Aboriginal people in support services requires a “whole of
family” approach to working with Aboriginal people and their families.

The wellbeing of an individual is linked to the wellbeing of all significant others within
the family unit
What we know

 Indigenous Australians experience persistently poorer health outcomes for

their entire lives than non-Indigenous Australians.
 Indigenous people also experience poorer social and emotional wellbeing
outcomes than non-Indigenous Australians. For instance, among Indigenous
adults high or very high levels of psychological distress are nearly 3 times the
rate of non-Indigenous adults. Rates of intentional self harm among young
Indigenous people aged 15–24 years are 5.2 times the rate of non-Indigenous
young people.
 Ten per cent of the health gap between Indigenous and non-Indigenous
Australians in 2003 has been linked to mental health conditions; another 4%
of the gap is attributable to suicide.
 Indigenous views of mental health and social and emotional wellbeing are
very different to those of non-Indigenous Australians. This affects the way in
which policies, programs, early prevention and intervention initiatives need to
be framed, formulated, implemented, measured and evaluated.
 The provision of mental health services for Indigenous people is both
inadequate and inappropriate, and changes need to be implemented
immediately (NMHC 2012).
 Current funding for dedicated Indigenous mental health programs and
services is limited. Existing interventions focus on supporting families to
prevent child abuse and neglect, harmful alcohol and substance misuse, and
suicide.
 Programs that show promising results for Indigenous social and emotional
wellbeing are those that encourage self-determination and community
governance, reconnection and community life, and restoration and community
resilience.
 Do not be provocative
Week 5

Mental health in the elderly

 Involves developing an appreciation of the complex interactions that occur

between the aging process, medical factors and the social, psychological,
spiritual and cultural issues of late life

 Proportion of people in Australia increase to over 26% in 2051

 6-8% over 85

 challenging because presentation in this age group is often atypical and

frequently there are coexistent physical conditions that further complicate
assessment and management

 Depression
o 10-15%
o 10% anxiety
o 34% aged care residents
o genetics + neurochemistry + adverse life events = depression
o neurotransmitter hypothesis – serotonin depletion
o risk factors
 physical health problems
 chronic pain
 side effects from medications
 losses – relationship, death, work, income, mobility, flexibility
 social isolation
 change in living arrangements
 admission to hospital
 anniversaries
o symptoms often present in dementia
o treatable – longer it is left the harder to treat
 Dementia
o Normally age related
o Present in over 100 different diseases
 50% Alzheimer’s
 20% vascular
 15% combination of the two
o disruption to
  memory
 orientation
 judgment and problem solving
 community affairs
 activities of daily living
 personal care
o 5% of 65-80
o 20% >80
o Alzheimer’s higher in women
o vascular higher in men
o duration 2-20 years
o death usually a result of systemic infection

o neurological changes
 neurofibrillary angles
 plaques
 disruption of Tau proteins
 Ach
o Macroscopic changes
 Brain atrophy
 Widening of sulci
 Enlargement of ventricles
o Cortical impact
 Amnesia
 Aphasia
 Apraxia
 Agnosia
 Abnormal affect
 Acalculia
 Impaired abstraction
o Forgetfulness
o Normal language but abnormal speech
o Slowed cognition
o Apathy and depression
o Stooped posture, tremor, abnormal gait
o Aim of treatment – reduce excess disability

 Delirium
o A disturbance of consciousness that is accompanied by a change in
cognition that cannot be better accounted for by a pre-existing or
evolving dementia
o Develops over a short period of time – hours- days
o Reduction of clarity of awareness, inability to focus, distractibility
o 15-30% elderly patients
o highest amongst AIDS, terminal illness and after surgical procedures
o nursing home residents - >60%
o adverse outcomes
 prolonged hospital stay
 increased mortality while in hospital
 increased risk of developing complications in hospital
 increased risk of placement in residential home
  increased risk of developing dementia

Differences between delirium, dementia & depression.

delirium dementia depression

onset acute insidious variable
course fluctuating progressive Diurnal variation
consciousness Altered, clouded Clear until late Clear
attention inattention normal Poor
thinking Disorganized, Difficulty with Intact, low self
incoherent abstract thought worth,
hopelessness
perception Misinterpretation, Ususlaly normal Can have complex
hallucinations, delusions,
delusions paranoid
psychosis
MMSE = Mini Distracted, Struggles, tries to Lacks motivation “I
Mental State difficulty find correct reply don’t know”
Examination completing MMSE

Suicide and suicidality

Defining suicide
 suicide is complex
 the action of killing oneself intentionally
 the human act of intentionally self inflicting one’s life cessation
 is influenced by ecological and environmental characteristics, social fabric,
individual predispositions and current circumstances
o not just one factor
o social support networks
 causes are multifactorial
o interlinked
o cumulative
o often repetitive over period of time
o pushing an individual thru stages of helplessness and worthlessness
o based around support systems of individual
 has 4 elements
 1. a suicide has taken place if death occurs
2. it must be of one’s own doing (excludes assisted suicide)
3. the agency of suicide can be active (hanging, OD) or passive (suicide
by police)
4. implies intentionally ending one’s own life
 Suicide attempt
o A non habitual act with non fatal outcome
o Taking the risk to die or inflict bodily harm
o Initiated and carried out with the purpose of bringing about wanted
changes
 suicidal behaviour
o Suicide ideation (thinking, thoughts)
o Suicide attempt (deliberate self harm, self mutilation, non-fatal suicidal
behaviour
o Completed suicide – (committed suicide, successful suicide)
 Suicide continuum
o Lowest
 Totally not
 Suicide ideation (fleeting)
 Suicide ideation (chronic)
 Suicide like gesture
 Diffuse risky lifestyle
 Suicide plan (vague)
 Suicide plan (specific)
 Non serious attempt (low lethality/attempt)
 Serious attempt (high lethality/attempt)
o Completed suicide
 Self mutilation – a direct and deliberate destruction or alteration of body tissue
without conscious suicidal intent.

History of suicide

 Been recorded since we’ve been recording history

 Ranged from not frowned upon to being a criminal act
 1983 – suicide decriminalized in all of Australia

Suicide statistics

 Australia
o 2012 – 11:100000
o 2011 – 9.9:100000
o increase in rate or increase in reporting??
 Male complete more often than females – 3/5 are men
 Twice as many suicides as road related death
 10th leading cause of death in men
 2.5-3 x for ATI
 200 attempts a day – one every 10 minutes
 250/day make a plan
 1000/day think about t
 ambulance attendance
o 600 completed
 o 11000 attempts
o 14000 suicide ideation

Paramedic interventions

 Look at risk factors

o Social and demographic
 Age & gender
 Socioeconomic disadvantage
 Ethnicity
 Unemployment
 Occupation (building industry, military)
 Financial problems
 Work related stress
o Mental health/medical factors
 Previous suicidal behaviour – attempts
 Previous psychiatric care (recently discharged)
 Major depression, bipolar
 Alcohol abuse/ dependence
 Drug abuse/dependence
 Schizophrenia
 Disorders – borderline, conduct, antisocial
 Other – chronic illness, terminal, comorbidity
o Individual personality factors
 Genetic
 Neuroendocrine & biological processes
 Personality traits
 characteristics such as
 rigid thinking
 hopelessness
 impulsivity
 neuroticism
o Environmental factors
 Life events
 Access to methods
 Legal problems, custody, incarceration
 Contagious factors
 Media influences – copycat, societal suicide
o Family & childhood experiences
 Parental psychopathology – greater risk
 Family discord, parental conflict
 Parental loss – separation rather than death
 Parental care – sexual, physical, emotional abuse
 Paramedic perceptions
o Frustration, futility and legitimacy of care
o First contact in pre-hospital environment
o Lasting impression
o Harnessing professionalism and opportunities to contribute to the care
of self harm
o First point of contact in their house  can have bearing on future
 positive interaction
 People who self harm
o Want empathy
o Non judgmental
o Support

Myths and facts

 False statements
o People who talk about suicide don’t complete
 Always take seriously
o Suicide happens without warning
 Always some warning signs, often seen in hindsight
o Suicidal people have full intent of dying
 Many are undecided
 Many just want to end the suffering
 Ambivalence
o Asking a person about suicide will push them to complete
o Improvement following suicide means risk is low
 Most occur days or weeks after improvement
 Person has more energy and can think more clearly & has
motivation to follow through
o Once a person attempts, the pain and shame wil stop them doing it
again
 Every time depressed the risk returns
o Sometimes a singe tragic or bad event can cause a person to complete
suicide
 Not a single event
 Involves many factors
Assessment

 SADPERSONS risk scale

o S = male sex
o A = age - <19, >45
o D = depression
o P = previous attempts
o E = excess alcohol / substace abuse
o R = rational thinking loss
o S = social supports lacking
o O = organized plan
o N = no spouse
 o S = sickness – cancer, terminal illness, AIDS

 HEADS
o Past?
o H = Health and home situation
o E = education / employment
o A = activities / ambitions / affect
 Sitting at home all the time?
 Future thinking?
 Depressed looking?
o D = drugs / alcohol
o S = suicide
 Methods
 Thoughts
 Risk taking behaviour
 Past behaviour
 Psychiatric history
 Coping mechanisms

Ask
 Are you thinking about self harm or suicide right now?
 Do you have a plan?
 Do you have the means to carry out the plan?
 Have you attempted in the past?
 What has prevented you from following through?
 What do you typically do when you have suicidal thoughts? (coping
strategies)

 Be direct – talk openly and matter of factly about suicide

 Be willing to listen, allow expression of feelings and accept the feelings

 Be non-judgmental

 Don’t debate whether suicide is right or wrong or whether feelings are good or
bad

 Don’t lecture on the value of life

 Don’t act shocked – puts distance between you and your patient
Week 6
A Farm with a Difference
 Australia – 200 000 aged between 16-24 have drug and alcohol abuse
problems
 Of these 25% have a mental health problem
 = DUAL DIAGNOSIS
 use of cannabis, speed, alcohol, prescription drugs
 feel that life has no meaning, nothing to show for it, felt like he shouldn’t be
here  attempted suicide
 Triple Care Farm - Mission Australia – for troubled youth
o 3 month residential rehab
o to kick habit and recover their mind
o significant reduction in their substance abuse  engage in work and
education after leaving
 significant number of youth don’t get help
 overstretched services
 young people cotinine to fall through the cracks – told they need to go on
detox before getting help for their MH problem  the 2 very interrelated

Homelessness
 shortage of long stay accommodation and support services for people with
mental illness  homeless shelters inundated with people with mental illness
 big factor in causing shortage of beds in homeless shelters 80% mentally ill
 closure of asylums  no where to go
 challenges on streets
o safety – attack while sleeping
o keeping belongings safe
 research has shown that its unlikely someone will recover from a mental
illness if they don’t have stable accommodation and support.

Unemployment
 condition all consuming  forcing out of workforce to become "invisible part
of society”
  too sick to work – consumes life
 challenges getting back into workforce
o number of years out
o questioned by employers – account for the years
o longer out of work the less likely they are to return
 mental illness is the leading cause of long term work incapacity
 cost is 10.9 billion to companies
o not from absenteeism
o from present-eeism – turn up to work but are unproductive
 broken bone, hurt back  duties altered to suit their capability Not so for
mental illness
 disclosing mental illness may work against them
 things to help get back to work
o flexible working hours
o trusted psychiatrist
o supportive manager and working environment
 volunteering is a good way to start to get back in

Substance abuse and mental health

 25% of people with anxiety disorder or other affective disorders have a

substance abuse problem
 64% of psychiatric patients have a current or previous addiction of some kind
 90% of males with schizophrenia have substance abuse problem
 which came first??
 Dual diagnosis
o Socially alienated from friends and family
o Won’t cooperate with health care provider
o Very emotional
o Homeless or move frequently
o Likely to be hospitalized or attend ED frequently
o Respond well to programs that address both the mental illness and the
substance abuse
o Diagnosis is difficult because it isn’t always clear which problem is
causing the most severe symptoms
 Commonly abused substances
o Alcohol
 Lead to problems in relationships
 Disturbing thoughts
 Aggression & violence
 Physical health problems
 Paranoia
 Loss of confidence
o Tobacco
o Cannabis
 Significantly increase paranoia
 Diminishes ability to think clearly and solve problems
 Affects memory
 Interferes with metabolism of other drugs
 increases risk of hallucinations
  May exacerbate depression
 Reduces volition and pleasure in normal activities
 Increase risk of panic and anxiety attacks
 Research suggests that there would be 8-10% less cases of
schizophrenia if cannabis wasn’t being used
o Benzos
 Temazepam
 Diazepam
 Oxazepam
 Alprazolam
 Nitrazepam
 Generally safe and effective in short term
 Cognitive impairments commonly occur
 Sometimes a contrary reverse action can occur eg State of
panic may worsen
 Prone to cause dependence, withdrawal syndrome
o Amphetamines
 Can exacerbate MH issues
 Known to initiate depression
 Increases paranoia
 Delusions and hallucinations
 Brain damage in prolonged use
 Use for a few days  no sleep, not eating, stimulant  come off
 crash  hungry, agitated, sleep pattern so disturbed 
depression  not feeling good so use drug again.
 Vulnerability – stroke and mental illness – may not be expressed
if hadn’t taken the amphetamine
 Other drug use – to help come down from amphetamine
o Heroin
 Methadone
 Morphine
 Pethidine
 Codeine
 Symptoms often exacerbated
 Feel disorganized and out of control
 Interfere with effectiveness of other psychotropic drugs
 Exacerbates hallucinations and delusional beliefs
 Overdose and death
o Inhalants
 Usually household or industrial products
 Hallucination, paranoia
 Confusion
 Memory disturbance
 Depression
 Anxiety, panic attacks
 Loss of person, place & time

Mental Health System issues

Changes proposed
 An integrated health care package that means people suffering from mental
illness will have Medicare access to a larger range of services free of charge.
 changes would help deliver a "stepped-care" approach to mental health that
was more efficient because it ensured patients received the level of care
 needed for their conditions, rather than a "one-size fits all" treatment.
 Should result in better care for mentally ill and less strain on paramedic and
ED services.

Self care for paramedics - Rebuilding foundations – building resilience

 Definition of a traumatic event:

One which causes you to experience unusually strong reactions that have the
potential to interfere with your normal functioning either at the time or later
 Effect may be significantly subconscious but manifest emotionally &/or
physically
 Reactions to traumatic experiences are “scattered feelings like a jigsaw with
so many pieces missing” (Embleton 1995)
 No clarity of thought – sense of confusion, disorganization, disbelief and
fragmentation – as differing emotions and thoughts attempt to surface 
feeling uncomfortable  push back emotions and thoughts
 Factors contributing to pushing back of emotions
o Perceived expectations of colleagues
o Internal expectations of self
o Invalidation from colleagues / managers

Limbic system
 Located between cortex and brain stem
 Key to degree of recovery from psychologically traumatic experiences.
o Amygdala
 Functions to retrieve and process emotional aspects of memory
– from across one’s lifespan
 Emotions don’t require conscious thought to be brought in –
emotions come forth in response to a trigger
o Hippocampus
 Functions to bring coherence, sequencing and narrative to
experience  registers timing of events
 When recall a memory you recall beginning middle and end
 Functioning important in reduction of a traumatic stress
response as hippocampus is responsible for marking an end to
a traumatic or threatening event.

Cortex
Can decide not
threatening after
amygdala has triggered

sympathetic response
Internal impulses  No Hippocamapus
Amygdala Responsible for
Thalamus  Draws on emotional sequencing vent in
memory – is it a real memory – marking end to
threat? event
External impulses  Yes
SNS High level of stress
fight or flight response hormones cortisol and
adrenaline can impede
function of hippocampus
  amygdala not
adequately stimulated to
stop SNS triggering.

 In traumatic event, hippocampus may not be able to determine the end of the
threatening episode so person still feels unsafe.
 PTSD
o = hippocampus unable to mark the ned of a traumatic event  SNS
continues to function as if the threat was still there.
o = a persistent reaction in the present to a threatening experience in the
past

3 main categories of reactions

1. Hyper-arousal
2. Avoidance and numbing
3. Intrusive recollections

1. Hyper-arousal
o SNS response – fight or flight - Preparation to keep safer from threat
o Visual distortion – tunnel vision
o Auditory distortion
o Time distortion
o Impact on concentrating and reasoning – normal cognition is impeded
o Memories
o Distortion of trust – all seem threatening
o Other
 Irritability
 Anger
 Sleep difficulties
 Tachycardia
 Palpitations
 Sweating
 Nausea
 GI upset
o Normal in immediacy of trauma but a problem if prolonged
o Need hippocampus to register that threat is over – otherwise amygdala
will go on responding as if the trauma continues again and again

2. Avoidance and Numbing

o Emotional blunting – spaced out, surreal.
o Subconscious avoidance of the real grief, sadness, anger or fear  too
 overwhelming if it came forth
o Inability to recall – blanks in memories  subconscious mind
disassociates the most confronting aspects from self
o Black humour – lighten context of situation by laughter
o Avoidance of reminders – not wanting tio engage in any activity that
may trigger reminders of the traumatic event  controls potential to
have emotions activated again
o Excess alcohol intake  escape strategy  brief relief, short term 
dependence
o Detachment/estrangement – restricted emotional connection in
relationships

3. Intrusive Recollections
o Thoughts and emotions that push their way into your consciousness
when you’d prefer not to be thinking about the incident
o Processing of the experience
o Accommodate new meaning  essence of post traumatic growth
o Ruminations – going over and over the event, trying to make some
sense of it
o Flashbacks – triggers cause visuals and emotional distress
o Dream – intrusive rumination while sleeping.

Factors effecting the outcome to potentially traumatic events

1. Personal
characteristics
 Sense of self
 Worldview
 Values and beliefs

2. Nature of the 3. Reactions and 5.Spectrum of personal

event processing adaptation
 Loss  Hyper-arousal  Post traumatic growth
 No warning  Avoidance  Resilience
 Grotesque  Intrusive recollections  Depression
 Terror  Anxiety
 Personal proximity Intentional processing  PTSD
 Inhumanity
 Loss of control
4. Coping
environment
 Degree of social, peer
and family support
 Workplace attitudes to
emotional expression
 Positive  trauma
effected person gains
 sense of safety and
calmness &
understanding from
others

Post Traumatic growth

Positive change in individual experiences as a result of a struggle with a traumatic

event.
 Changes in relating to others
 Perceptions of new possibilities
 Changes in one’s sense of personal strength
 Spiritual and religious changes
 New appreciation for life

Facilitating personal growth and resilience

2 key tasks to cultivating PTG and reducing the potential for negative post trauma
outcomes
1. Finding FELT sense of safety
2. Processing confronting aspects of the experience to bring acceptable
meaning to the event – talking an important part of processing

Personal role on facilitating PTG

 Maintain wide stress buffer  increases ability to cope.

 SANER
o S = Self awareness and self compassion
 Ability to notice and have conscious knowledge of your own
character, feelings and emotion
 Realize something has had an emotional impact on you
 Self compassion – have understanding kindness to yourself
 Acknowledge internal reactions and emotions as being an important
part of who you are
o A = Acknowledgement and Validation
 Know your reactions are valid and a normal response
o N = Normalise
 Remind yourself confusing states are normal
 A sign the experience had meaning to you
o E = Expression of the experience
 Express yourself regarding the experience – talk, write
o R = resolution or referral
 Get help if it doesn’t resolve

Psychological first aid to support colleagues

 Ensure people feel safe and secure

 o Assists in reduction of hyper-arousal and provides a psychological climate
in which psychological processing can take place
 Provide practical assistance if needed
o Helping impacted person – till they can get back on task
 Provide information about current and potential reactions that the person may
experience
o This is normalizing & validating and prepares person for feelings they may
experience over the coming days
 Promote the use of social supports
o Being available to talk to, or help them get in contact with someone
 Provide information on how to access further help if needed – ancillary supports
available
 Follow up – a phone call
o to get a sense of how the person is doing or more help needed.