Effective crisis management

More patients with mental health conditions are now managed in primary care, making it essential for practice nurses to familiarise themselves with the identification of, and response to, a crisis or relapse

Mental health problems are more common, and more severe, among primary care patients than any other common chronic diseases such as hypertension, diabetes, arthritis and back pain.¹ The most common mental health problems seen in a typical GP practice are mixed anxiety, depression and alcohol dependency and the least commonly seen are panic disorders and psychotic illness.²

At least one in four people will experience a mental health problem at some point in their life and one in six adults have a mental health problem at any one time.³ People with psychotic illnesses account for only a small percentage of psychiatric illness in the UK population: the prevalence of bipolar disorder is about 1—2% and that of schizophrenia is 0.72%.⁴ Due to the number of people suffering from mental health problems, primary care has a vital part to play in the care of patients, with 83% of such patients stating they are likely to go to their GP for help.⁵ As a result of the changes this year to health and social care services, it is envisaged that the maintenance of patients, even those with severe mental illness, who are relatively stable with low level recurrent symptoms can be managed effectively in primary care.

For this objective to become a reality, in addition to the challenges of reducing the stigma of the mental health patient and increasing mental health knowledge and confidence, practice teams need to know how to manage a 'crisis' or relapse.

RECOGNISING A CRISIS

Whether the patient is well known or attends rarely, the nurse's role is to assess, identify and understand the key presenting symptoms. The sooner the nurse identifies the issues, the quicker any potential crisis is managed and the lower the risk of relapse to the patient.

Early Warning Signs

Early warning signs can manifest with any patient and in psychosis are usually characterised by subtle changes in thought, affect and behaviour. The most common early predictor is feelings of being unhappy, low in mood, indicated by poor sleep and appetite, depressed mood and withdrawal, rather than psychotic symptoms. This is followed by increased levels of emotional distress or disturbance, and finally by psychotic symptoms. Mental health services work with the individual patient to develop understanding of their early warning signs and have an agreed plan for each stage, which should form part of the patient's discharge summary, along with an assessment of any risks.⁶ (Table 1)

Alongside understanding the early warning signs the patient presents with, it is important as part of safety and risk assessment to identify the context of symptoms by using four domains (FIDO):7

Frequency How often are their symptoms present?

Intensity How severe/ concentrated are their symptom

Duration How long do their symptoms last?

Onset Are there any triggers, when did symptoms start?

DEALING WITH A CRISIS

Should a patient present in either early, intermediate or late stages in crisis, it is important that all members of the primary care team maintain good engagement and are aware of what is happening. The patient will need time to talk about how they are feeling, changes in their mood and, in order for an assessment to take place, to avoid areas where there are high levels of stimulation, particularly if the patient is distracted by their symptoms.

COMMUNICATION

Verbal

• Tell the patient who you are and why you are there
• Offer reassurance
• Talk to the patient about where they are and why they are there
• Use their preferred name to show a supportive and caring disposition
• Say you want to help
• Use a clear, calming voice, keeping sentences short, simple and clear
• Stay calm and be alert for colleagues and others in the area
• Call for a colleague if you are concerned about seeing the patient alone
• Avoid an authoritative or patronising approach

Non-verbal

• Maintain a calm posture
• Relax your shoulders and keep your arms down and hands open outwards
• Avoid invading the patient's personal space
• Do not smile or grimace overtly when someone is delusional or hallucinating as this may be misinterpreted
• Avoid making sudden movements and threatening postures, such as gesticulation, pointing, crossing your arms and or putting your hands on hips
• Try to keep all parties in an open space
• Try not to mirror any negative body language by the patient
• Assess the layout and environment

The main focus of dealing with is a crisis to determine at what stage the patient is and to have a clear idea of how to manage it. The patient is usually adept at managing their own crisis, particularly if it is in the early stage and they have good coping strategies. At any stage, the practice nurse needs to have confidence in the patient's crisis plan, know what mental health services are available, and have a clear understanding of where to signpost someone in crisis when they are concerned about risk.⁹

Sign Posting and Mental Health Services

The integrated care pathway for patients with mental health problems is well defined and is designed to support personal recovery. It ensures that if a patient presents in crisis and needs additional support or assessment, services are easily accessible. The referral pathway is illustrated in Figure 1.

If a patient presents in crisis and is at risk, there are several options, depending on the severity of symptoms.

• The patient may not need intervention and the crisis may subside, but if the situation deteriorates they can be sent to A&E, to be assessed by the Psychiatric Liaison Team.
• Alternatively, the patient can be referred to the local Assessment and Brief Treatment team, who will carry out an assessment and either provide an agreed brief package of care or refer the patient for further assessment and treatment.
• If the patient is a high risk, a Mental Health Act assessment may need to be carried out and the patient admitted to an inpatient acute unit for a period of assessment and treatment.

When people with serious mental illness are very unwell, experiencing an episode of psychosis or have tried to take their own life they can be offered appropriate support at home from a Crisis Resolution/Home Treatment Team, who may also provide support when the patient is discharged from hospital.

Once the crisis has been successfully managed, the patient may be discharged back to the care of their GP, although this depends on the severity of the crisis and the risks involved in the relapse. It may be necessary for the patient's care to be managed longer term by the Community Recovery Team, until the patient has sufficiently recovered.

RISK OF RELAPSE

The risk of relapse in schizophrenia can be frequent during the first years of the illness; in subsequent years it is determined by many variables, although a key component is non-compliance with medication.⁹ There are wide variations in the course of schizophrenia with some people having episodes of illness which last weeks or months with full remission between each episode. Others have a fluctuating course, with symptoms that are continuous, but increase and decrease in intensity; other patients with schizophrenia have very little variation in the symptoms of their illness over time. At one end of the spectrum, a person can have a single episode of schizophrenia followed by complete recovery; at the other, symptoms may never subside. Ten years after diagnosis, 25% of patients have completely recovered, 25% are much improved and/or relatively independent, 25% are improved but require extensive support, 15% are unimproved and 10%, unfortunately, will be dead (usually suicide).¹⁰

Recurrence rates for bipolar disorder are high even with ongoing therapy. One study found a 73% relapse rate at five years, and two thirds of patients had multiple relapses. Other estimates place the relapse rate at about 90%, with nearly half of the relapses occurring within two years. However a 10-year follow-up study of patients with bipolar disorder found that about 50% of patients had sustained improvement, whereas 30% to 40% experienced functional decline over time.¹¹

RECOVERY

Recovery in mental health is a process, not an event and patients should have the opportunity for self-management, and to participate in mainstream services to cater for both their mental and physical health needs. People with mental health problems can have worse life opportunities, partly as a direct effect of their condition, but also as a result of stigma and discrimination, driven by ignorance, fear, and negative attitudes towards mental illness. Clinicians are not exempt from these negative emotions. No Health without Mental Health outlines the importance of prompting recovery in mainstream services by removing the stigma, discrimination and health inequalities that can affect patients' recovery.³

CONCLUSION

While managing people with serious mental health problems in primary care will be a challenge in the short term, once nurses have the knowledge, confidence and competence, patients will really benefit, aiding their physical and mental health wellbeing. It is important that in caring for people with serious mental health problems we are not unduly pessimistic about recovery outcomes, but it is vital that practice nurses have the information to manage long term care, are aware of how to respond to a crisis, receive the necessary support and understand how mental health services work. Practice nurses are highly skilled in the management of long-term physical conditions, able to detect an incipient issue or crisis. The only difference in mental health is that many practice nurses may not yet have the necessary knowledge, experience, or accurate information to manage the stable patient with a psychotic illness. Providing treatment for people with mental health conditions in primary care will help to normalise their care, reduce the stigma of their illness and in turn, promote their recovery.

Louise Saxton is employed in a non-promotional, educational role as a Clinical Nurse Specialist in Mental Health by Janssen-Cilag Ltd as part of a Service to Medicine.

REFERENCES

1. WHO Guide to Mental and Neurological Health in Primary Care: A guide to mental and neurological ill health in adults, adolescents and children, 2nd Edition 2004

2. 2007 RCGP GP Curriculum Statement 13: Care of People with Mental Health Problems

3. Department of Health. No health without mental health: a cross-government mental health outcomes strategy for people of all ages. 2011. Available at: https://www.gov.uk/government/publications/the-mental-health-strategy-for-england. Accessed October 2013

4. The Role of Primary Care in Service Provision for People with Severe Mental Illness in the United Kingdom. Reilly S, Planner C, Hann M, Reeves D, Nazareth I, et al, PLoS One May 2012, Volume 77, Issue 5 ,e36468

5. Attitudes to Mental Illness 2010 Research Report JN 207028 March 2010

6. Royal College of Psychiatrists, Advances In Psychiatric Treatment Schizophrenia: Early Warning Signs Max Birchwood, Elizabeth Spencer and Dermot McGovern APT 2000, 6:93-101

7. Hagen R, Turkington D, Berge T et al. CBT for Psychosis: A symptom based approach. Abingdon, Oxon: Routledge Publishing: 2011

8. Ryan A. (Ed) Managing crisis and risk in mental health nursing, (Revised 2001) Oxford; Nelson Thomas Ltd: 1999

9. M. Alvarez-Jimenez et al. Risk factors for relapse following treatment for first episode psychosis: a systematic review and meta-analysis of longitudinal studies; Schizophrenia Research 2012; 139:116—128

10. Schizophrenia.com: Schizophrenia Facts. Available at www.schizophrenia.com/szfacts.htm (last accessed October 2013)

11. Sajatovic M. Bipolar Disorder: Disease Burden. Am J Managed 2005; 11(3) Suppl: S80-S84