Chapter 15 Mental illness assessment, management of depression and self harm; the Mental Health Act
Introduction
Mental health problems present in between 30% and 60% of primary care consultations.1 One in six men and one in four women will suffer from a mental illness at some point in their lives.2,3 GPs, for example, find that at least 30% (or 1.5 days per week) of their working week concerns mental health consultations. For depression alone, prevalence amongst the adult population in the UK varies between 17–71 per thousand for men and 25–124 per thousand for women.
Unfortunately these patient presentations in primary care are frequently complex and do not always fit easily into diagnostic categories.4 The objectives of this chapter are listed in Box 15.1.
Box 15.1 Chapter objectives
Primary survey
A mental illness may cause a patient to take an overdose or injure themselves in such a way that they develop immediately life-threatening ABCD problems. These problems are covered in Chapter 14.
An immediately life-threatening psychiatric situation is where the patient wants to kill themselves, or harm others (Box 15.2), but will not comply with treatment. Management will depend on a large number of factors – not only your assessment of the problem but also the extent and availability of local services.
Secondary survey
Medical assessment is indicated if:
Mental health assessment
While it is difficult to completely separate the mental health assessment into ‘history’ and exam sections, it aids understanding to use the SOAPC system. Effective mental health assessment requires a very sensitive consultation style to gain the patient’s trust and showing the patient that you recognise their distress and experience. Some key principles for the mental health interview are identified in Box 15.3. Consultation skills that improve identification of emotional distress include frequent eye contact, relaxed posture, use of open questions at the beginning of the -consultation, use of minimal verbal prompts while actively listening and avoiding giving information too early in the consultation.
Subjective – history
Information from carers is often of great importance in the assessment. If carers are not present and you are having difficulty, you may have to trace them and discuss the issues (preferably with consent of the patient). Box 15.4 summarises the assessment of a patient with psychiatric symptoms.
Objective information – mental state examination
Perform a brief physical exam, including noting the vital signs (especially pulse, temperature and Glasgow Coma Score). Listing the elements of a mental state examination is an excellent way to bring some structure to what can be a confusing and difficult task. These key elements are listed in Box 15.5. The assessment of social support is often of the greatest importance in deciding a management plan.
Depression
Depression is the most common mental disorder in primary care and covers a range of mental health diagnoses and problems. These are all distinguished by lowered mood and a loss or decrease of interest and pleasure in daily life and experiences. Additionally, there are disorders of thinking, problem-solving and behavioural and physiological symptoms.5 Box 15.6 lists the diagnostic criteria for severe depression but it is often difficult to discriminate between normal mood variations, dysthymia (Box 15.7) and cyclothymic (Box 15.7