participant manual introduction to agitation, delirium

English-haiti

Introduction to Agitation,

Delirium, and Psychosis

Curriculum for Psychologists/social Workers

PartiCiPant manual

Partners in health (Pih) is an independent, non-profit organization founded over twenty years ago in haiti with a mission to provide the very best medical care in places that had none, to accompany patients through their care and treatment, and to address the root causes of their illness. today, Pih works in fourteen countries with a comprehensive approach to breaking the cycle of poverty and disease — through direct health-care delivery as well as community-based interventions in agriculture and nutrition, housing, clean water, and income generation.

Pih’s work begins with caring for and treating patients, but it extends far beyond to the transformation of communities, health systems, and global health policy. Pih has built and sustained this integrated approach in the midst of tragedies like the devastating earthquake in haiti. through collaboration with leading medical and academic institutions like harvard medical school and the Brigham & Women’s hospital, Pih works to disseminate this model to others. through advocacy efforts aimed at global health funders and policymakers, Pih seeks to raise the standard for what is possible in the delivery of health care in the poorest corners of the world.

Pih works in haiti, russia, Peru, rwanda, sierra leone, liberia lesotho, malawi, Kazakhstan, mexico and the united states. For more information about Pih, please visit www.pih.org.

many Pih and Zanmi lasante staff members and external partners contributed to the development of this training. We would like to thank giuseppe raviola, mD, mPh; rupinder legha, mD ; Père Eddy Eustache, ma; tatiana therosme; Wilder Dubuisson; shin Daimyo, mPh; noor Beckwith; lena Verdeli, PhD; Ketnie aristide; leigh Forbush, mPh; and Jenny lee utech.

this training draws on the following sources: american Psychiatric association. (2013). Diagnostic and statistical manual of mental Disorders (5th ed.). Washington, DC: american Psychiatric association; Eapen, V., graham, P., & srinath, s. (2012). Where there is no Child Psychiatrist: a mental health Care manual. rCPsych Publications; mental illness Fellowship Victoria. (2013). understanding psychosis; raviola, Kahn, Jarvis. (2015). the Psychiatry Quality Program, Boston Children’s hospital; sherman, m. (2008). support and Family Education: mental health Facts for Families, http://www.ouhsc.edu/safeprogram/; starling, J., Feijo, i. (2012). schizophrenia and Other Psychotic Disorders of Early Onset. in iaCaPaP textbook of Child and adolescent mental health. geneva: international association for Child and adolescent Psychiatry and allied Professions; targum, s. D., & Busner, J. (2007). the Clinical global impressions scale: applying a research tool in Clinical Practice. Psychiatry, 4(7), 28; Winters, n., hanson, g., & stoyanova, V. (2007). the Case Formulation in Child and adolescent Psychiatry. Child and adolescent Psychiatric Clinics of north america, 16(1), 111–132; World health Organization. (2010). mhgaP intervention guide. geneva: World health Organization; World health Organization. (2010). mental Disorders Fact sheet 396, http://www.who.int/mediacentre/factsheets/fs396/en/.

We would like to thank grand Challenges Canada for their financial and technical support of this curriculum and of our broad mental health systems-building in haiti.

© text: Partners in health, 2015 Photographs: Partners in health Design: Katrina noble and Partners in health

II Partners In Health | PartiCiPant hanDBOOK

Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

This manual is dedicated to the thousands of health workers whose tireless efforts

make our mission a reality and who are the backbone of our programs to save lives

and improve livelihoods in poor communities. Every day, they work in health centers,

hospitals and visit community members to offer services, education, and support, and

they teach all of us that pragmatic solidarity is the most potent remedy for pandemic

disease, poverty, and despair.

IIIPartners In Health | PartiCiPant hanDBOOK


Table of Contents

Introduction to Agitation, Delirium, and Psychosis

introduction ...........................................................................1

Objectives .............................................................................2

Epidemiology, the treatment gap and stigma ........................4

Diagnosis of severe mental Disorders ....................................8

the Psychosis system of Care and the Four Pillars of Emergency management of agitation, Delirium and Psychosis ......................................................................17

safety and management of agitated Patients .................... 22

medical Evaluation and management of agitation, Delirium, and Psychosis .......................................................28

Biopsychosocial Clinical Formulation ....................................30

medication management for agitation, Delirium, and Psychosis ......................................................................36

Psychotherapy and Family & Patient Education ....................40

Clinical Outcome measures – Cgi and WhODas ................44

Follow-up and Documentation ............................................51

using mhgaP for Psychosis and Bipolar Disorder .................52

review ...............................................................................54

notes ...................................................................................59

IV Partners In Health | PartiCiPant hanDBOOK


Annex

Psychosis Care Pathway .......................................................61

Psychiatric Differential Diagnosis information sheet ............62

agitation, Delirium and Psychosis Checklist .........................65

agitated Patient Protocol ....................................................66

agitation, Delirium and Psychosis Form ...............................67

medication Card for agitation, Delirium, and Psychosis .......68

medical Evaluation Protocol for agitation, Delirium, and Psychosis ......................................................................71

suicidality screening instrument ..........................................73

suicidality treatment guidelines ..........................................74

safety Plan ..........................................................................76

Clinical global impressions scale (Cgi) ...............................77

WhODas 2 – 12 item Version ............................................79

Partners In Health | PartiCiPant hanDBOOK 1


Introduction to Agitation, Delirium, and Psychosis

INTRODUCTION

Psychotic disorders refer to a category of severe mental illness that produces a loss of contact

with reality, including distortions of perception, delusions, and hallucinations. The most common

psychotic disorders are schizophrenia and bipolar disorder, which affect a combined 81 million

people. However, these two conditions do not account for all psychotic disorders. Despite the

immense burden of illness from psychotic disorders, about 80% of people living with a mental

disorder in low-income countries do not receive treatment.1 Stigma and discrimination against

people living with severe mental illness often result in a lack of access to health care and social

support. Human rights violations including being tied up, locked up, or left in inhumane facilities

for years; are all common.

Before a psychotic disorder can be diagnosed, however, patients require comprehensive medical

evaluation to ensure that medical problems are not the root cause of the symptoms. The term

“agitated” is often misused to describe patients who appear psychotic and are, therefore,

immediately referred to mental health. However, oftentimes these patients are actually

suffering from delirium, a state of mental confusion that can resemble a psychotic disorder but

is actually caused by a potentially severe medical illness. Patients who are delirious are often

injected with high doses of haloperidol to quell their “agitation” and they frequently do not

receive any medical evaluation or care. Unfortunately, this misdiagnosis and mismanagement

can lead to death.

Fortunately, psychotic disorders are treatable and for some, completely curable. With the right

training and system of coordinated care, people with psychosis can receive effective treatment

and lead rich, productive lives. In this training, psychologists and social workers will learn how

to manage agitated patients safely and effectively and will also learn how to properly diagnosis

psychotic disorders caused by mental illness.

1. World health Organization. (Oct 2014). mental Disorders Fact sheet 396. retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/

2 Partners In Health | PartiCiPant hanDBOOK


By the end of this training, psychologists and social workers will understand how to work

hand-in-hand with community health workers, nurses and physicians to provide high-quality,

humane medical and mental health care for agitated, delirious, and psychotic patients.

ObjeCTIves

By the end of this training, you will be able to:

a. Describe the epidemiology of psychotic disorders and the corresponding treatment gap.

b. Describe the various ways that psychosis may be viewed by the community and by health providers.

c. Describe the impact of stigma on patient care and outcomes.

d. Identify key clinical information related to the diagnosis of various psychotic disorders.

e. Develop a basic mental health differential diagnosis using the Differential Diagnosis Information Sheet.

f. Describe the psychosis care pathway and its collaborative care approach.

g. Outline the main roles of physicians, psychologists, social workers, nurses and community health workers in the system of care.

h. Explain the four pillars of emergency management of agitation, delirium and psychosis.

i. Describe how a psychologist/social worker should use the biopsychosocial model when managing a patient with agitation, delirium or psychosis.

j. Describe the identification, triage, referral, and non-pharmacological management of an agitated patient through the use of the Agitated Patient Protocol and Agitation, Delirium and Psychosis Form.

k. Explain how to screen for suicidal ideation and manage suicidal patients consistent with their severity and risk level.

l. Define medical delirium.

m. Describe the importance of proper medical evaluation for an agitated, delirious or psychotic patient.

n. Explain the process of carrying out a medical evaluation for an agitated, delirious or psychotic patient.

o. Explain how to gather information for a complete mental health history.

p. Describe how to create a biopsychosocial clinical formulation to guide a patient’s treatment.

q. Explain the collaboration between the physician and the psychologist/social worker in managing medication for agitation, delirium and psychosis.

r. Describe the physician’s use of the Medication Card for Agitation, Delirium and Psychosis.



s. Explain the core psychotherapy approaches for patients with severe mental illness.

t. Describe how to educate patients and family members about the effects and management of psychosis and bipolar disorders.

u. Explain the core psychotherapy approaches for patients with severe mental illness.

v. Describe how to educate patients and family members about the effects and management of psychosis and bipolar disorders.

w. Explain the process of follow-up for people living with psychotic disorders and severe mental illness.

x. Describe the importance of documentation during patient follow-up.

y. Describe how to use mhGAP for the management of psychosis and bipolar disorder.

z. Describe how to use mhGAP for the management of self-harm/suicide.



Epidemiology, the Treatment Gap, and Stigma

Severe Mental Illness

Severe mental illnesses are illnesses of longer duration, longer treatment and have significant impact on the activities of daily living. They include psychosis and mood disorders.

What is psychosis?

Psychosis is a syndrome. A syndrome is defined as the association of several clinically recognizable signs and symptoms which may have multiple causes.

Psychosis results in dysfunction in several domains:

• Cognition (disorganized thinking and speech, memory problems)

• Perception (hallucinations)

• Behavior (social withdrawal, catatonia)

• Emotion (decreased emotion)

There are some psychiatric disorders that mimic psychosis, which can include PTSD, acute stress, intellectual development disorder, and autism spectrum disorder.

schizophrenia

Schizophrenia is characterized by profound disruptions in:

• thinking, affecting language

• perception

• the sense of self

It often includes psychotic experiences, such as hearing voices, visual hallucinations or delusions. Patients with schizophrenia often first begin to show symptoms of psychosis when they are teenagers. Prior to developing schizophrenia, patients may show subtle non-specific signs such as depression, social withdrawal, and irritability.

Schizophrenia affects more than 21 million people worldwide. The prevalence ranges from 1 – 7 per 1,000 people. People with schizophrenia have a 20% reduction in life expectancy.2




bipolar Disorder

Bipolar disorder is a mood disorder that can include symptoms of depression, mania and/or psychosis. Manic episodes involve elevated or irritable mood swings, over-activity, pressure of speech, inflated self-esteem, and a decreased need for sleep. Some people with bipolar disorder experience mixed episodes that involve both symptoms of mania and depression at the same time or alternating frequently during the same day. Bipolar disorder usually starts during adolescence and early adulthood.

Bipolar disorder affects about 60 million people worldwide. It is the sixth leading cause of disability in the world. People with bipolar disorder have a reduced life expectancy of 9 – 20 years.3




Treatment Gap

Health systems have not yet adequately responded to the burden of mental disorders. As a consequence, there is a wide gap between the need for treatment and its provision all over the world. In low- and middle-income countries, between 76% and 85% of people with mental disorders receive no treatment for their disorder. In high-income countries, between 35% and 50% of people with mental disorders receive no treatment for their disorder.4

stigma

Stigma refers to negative or prejudicial thoughts about someone based on a particular characteristic or condition, in this case someone with a severe mental illness.

As clinicians, it is not acceptable to have stigmatizing thoughts or behaviors toward people with severe mental illnesses. It the clinicians’ responsibility to overcome these feelings to be able to treat patients with dignity and respect.


Statistics taken from World Health Organization Mental Disorders Fact Sheet #396

81 million + People living with severe mental illness

12 –19 million

People living with severe mental illness who receive treatment

Treatment Gap! 62– 69 million

People living with severe mental illness who receive no treatment



The Zanmi Lasante psychosis system of care aims to diminish Haiti’s treatment gap by safely and effectively treating people living with severe mental illness in a community-based system of care. Psychologists and social workers have the opportunity to close the treatment gap and reduce the stigma related to psychosis by building on the coherent system of care already developed for depression and epilepsy. Psychologists and social workers have the opportunity to help some of the most vulnerable and marginalized people living in communities — those living with mental illness.

sTIGmA ROle PlAy

sTORy

a patient is brought by his family to the emergency room. he is very talkative and focuses mainly on vodou and religion. the emergency nurse fears that he is violent and does not wish to touch him because she thinks he may hit her. the nurse does not check vital signs or provide any medical care. instead the nurse calls the psychologist/social worker on the phone and says “a mental health patient is here.” in the meantime, the patient is totally dehydrated, and has both a high fever and pulse that go undetected. his family reports he has never behaved this way before and only became “a crazy person” after a dog bit him. For more than two hours, the patient and his mother wait and no one comes to them for help.

sCRIPT

Family member (Participant 2): Brings in sick patient to the emergency room.

Patient (Participant 1): arrives to emergency room in the arms of a family member. Begins to talk a lot about vodou and religion in the emergency room.

Nurse (Participant 3): acts scared because he might be violent. Calls psychologist/social worker to say a mental health patient is here.

Patient (Participant 1): has a fever and becomes dehydrated. Does not look well.

Family member (Participant 2): reports to nurse that patient has never behaved this way before and only became “a crazy person” after a dog bit him. Becomes frustrated that a lot of time has passed and no one has helped them.



Diagnosis of Severe Mental Disorders

The Different Signs and Symptoms Associated with Psychosis

The different signs and symptoms associated with psychosis are divided into two categories: positive and negative.

“Positive” symptom – something is present that shouldn’t be:

• Hallucinations

• Delusions

• Disorganized speech

• Disorganized or catatonic behavior

“Negative” symptom – disruption to normal emotion or behavior:

• Flattening of affect

• Social withdrawal

• Loss of motivation

• Cognitive impairments

Phases of Psychosis

There are three distinct phases of psychosis that psychologists/social workers will see throughout their work with psychotic patients: the prodromal phase, the acute phase and the stable phase.

1. Prodromal phase – the time between the first disturbance of normal thinking, feeling or behavior and the onset of psychosis

2. Acute phase – the period when psychotic symptoms are present (delusions, hallucinations, thought disorder)

3. Stable phase – symptoms start to remit and recovery begins

Psychosis: Mimics

There are some medical problems that seem like psychosis:

• Delirium

• Psychiatric Disorder due to a General Medical Condition

• Substance-Induced Psychotic Disorder

• Post-Partum Psychosis

Delirium is a disturbance in attention and awareness due to a medical illness. A medical delirium can appear like psychosis; however it is not a psychotic disorder!



There are some psychiatric disorders that seem like psychosis.

• Transient Hallucinations

• Acute Stress/PTSD

• Obsessive-Compulsive Disorder

• Autism Spectrum Disorder

• Personality Disorder

Severe Depression with Psychotic Features

Patients who show at minimum six of the following symptoms of depression with psychosis over a period of two weeks:

• depressed mood most of the day nearly every day

• noticeably increased or decreased sex drive

• loss of interest or pleasure in all, or almost all, activities most of the day nearly every day

• significant weight loss or weight gain, OR decrease or increase in appetite nearly every day

• insomnia OR hypersomnia nearly everyday

• psychomotor agitation OR retardation nearly every day

• fatigue OR loss of energy nearly every day

• feelings of worthlessness OR excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

• diminished ability to think or concentrate, OR indecisiveness, nearly every day

• recurrent thoughts of death, recurrent ideas about suicide without a specific plan, or a suicide attempt or specific plan for committing suicide

• delusions or hallucinations

• increased and intense daydreaming



Bipolar Disorder

Bipolar disorder is diagnosed when a patient has at least one manic episode.

At least one manic episode

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

• During the period of mood disturbance, three (or more) of the following symptoms have persisted and have been present to a significant degree:

– Inflated self-esteem or grandiosity.

– Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

– More talkative than usual or pressure to keep talking.

– Insomnia or hypersomnia nearly every day.

– Psychomotor agitation or retardation nearly every day

– Flight of ideas or subjective experience that thoughts are racing.

– Distractibility Increase in goal-directed activity or psychomotor agitation.

– Excessive involvement in pleasurable activities that have a high potential for painful consequences.

Bipolar disorder usually starts during adolescence and early adulthood. It is not common that bipolar disorder develops in children who have no family risk factors and it is rare that it develops in people over 60 years (except when associated with another disease). Some people with bipolar disorder experience mixed episodes that involve both symptoms of mania and depression at the same time or alternating frequently during the same day. Some people may have as many maniac as depressive episodes, while others may experience one type of episode (usually depression). If you are not sure which episodes the patient has had, document it as bipolar unipolar.

Hypomania is a less severe form of mania, with similar symptoms, but less severe. Hypomania has a less of a negative impact on the daily activities of the person. Around half of people initially diagnosed with bipolar disorder achieve syndromal recovery within six weeks, and nearly all achieve it within two years, with nearly half regaining their prior occupational and residential status in that period. However, nearly half of people go on to experience a new episode of mania or major depression within the next two years.



Brief Psychotic Disorder

Presence of 1 or more symptoms for duration of at least 1 day but less than 1 month:

• Hallucinations

• Delusions

• Disordered thoughts and speech

• Severely disorganized behavior

Schizophreniform Disorder

Two or more symptoms, each present for a significant portion of time during a 1 – 6 month period:

• Hallucinations

• Delusions



• Negative symptoms

The main difference between brief psychotic disorder, schizophreniform disorder and schizophrenia is the duration of the symptoms/episode. Schizophreniform can be diagnosed if symptoms are present for 1 – 6 months only.

Psychosis Not Otherwise Specified (NOS)

A person shows significant distress or impairment in important areas of functioning due to psychotic symptoms BUT does not meet the full criteria for a schizophrenic or other-psychotic disorder diagnosis.



Schizophrenia

Schizophrenia is thought to be caused by physical changes in the brain, however it may begin after a stressful event.

Two or more of the following present for at least a month:

• Hallucinations

• Delusions



• Negative symptoms

– Deterioration in social, educational or work functioning

– Duration of illness of at least six months

– Not due to another mental illness such as a mood disorder, or a medical condition.

Schizophrenia may begin at any time but most commonly it begins in the mid- to late teens or early 20s. Prior to developing schizophrenia, patients may show subtle nonspecific signs such as depression, social withdrawal, and irritability. Patients can have periods of stability with or without treatment during which their symptoms are absent or minimal.

Among adults, hallucinations are viewed as synonymous with psychosis and as harbingers of serious psychopathology. In children, however, hallucinations can be part of normal development or can be associated with non-psychotic psychopathology, psychosocial stressors, drug intoxication, or physical illness. The first clinical task in evaluating children and adolescents who report hallucinations is to sort out those that are associated with severe mental illness from those that derive from other causes.

Delusional Disorder

Diagnostic criteria:

• Non-bizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, deceived by spouse or lover, or having a disease) of at least 1 month’s duration.

• Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the delusional theme.

• Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.

• If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.

• The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.



Differential Diagnosis Case Studies

*For all cases assume that a medical illness has already been ruled out by the physician. All the patients referred to you have been determined to have a mental illness.

CAse 1

a mother has brought her 12-year-old girl to the health facility. she says that her daughter is often unfocused, seemingly “far away.” the daughter sometimes wakes up in the middle of the night screaming. the girl refuses to enter any cars. through questioning the mother, you find out that this has been happening for 7 weeks. the girl has had difficulty falling asleep, has been sleeping poorly, and reports that sometimes she sees “shadows of people” at night who are not there. the mother reveals that their son died in a car accident about two months ago, and that the daughter was in the car when it happened. after performing a mental status exam, taking a history and asking the patient a few questions about her friends and school, you see she has no evident problems with cognition or emotion. there is no history of mental illness in the family.

1. Is the girl, in your opinion, psychotic? Why or why not?

2. What diagnosis might you present to the girl? Why?



CAse 2

a 22-year-old woman is brought in by her husband. he says that his wife has been acting strangely recently. he reports that she has refused to get out of bed for the past week and has been crying frequently. he was worried she was depressed. however, yesterday she got out of bed extremely happy and was so energized cleaning the house she didn’t sleep at night. You observe the wife chatting excitedly with other people in the waiting room. she says she feels wonderful and doesn’t know why her husband brought her here. the husband reports that over the past few days she has been spending the family’s money on nonessential items and that he is worried that this is putting the family at risk.

1. Is the woman, in your opinion, psychotic? Why or why not?

2. What diagnosis might you present to the woman? Why?



CAse 3

a 20-year-old man is brought in by his friend. the friend says that recently, the patient started saying that his neighbor is watching him all the time. the patient cannot stop talking about the neighbor’s spying. the patient describes that he even hears what the neighbor is saying about him in his mind. When you ask how long this has been happening for, the friend says almost three months.

1. Is the man, in your opinion, psychotic? Why or why not?

2. What diagnosis might you present to the man? Why?



CAse 4

a 25 year-old man is brought in by a neighbor. this patient has disorganized behavior and has not bathed recently. he is mumbling words under his breath and is not able to speak in complete sentences. You try to have a conversation with the patient, but cannot easily communicate. You ask the neighbor how long he has been like this. the neighbor responds that he has been like this for a few years already, but this is the first time that he is seeing a psychologist/social worker. the neighbor says that the man cannot work because of his mental state and sometimes the man is aggressive and yells threats to no one in particular. What diagnosis might you present to the man?

1. Is the man, in your opinion, psychotic? Why or why not?

2. What diagnosis might you present to the man? Why?



The Psychosis System of Care and the Four Pillars of Emergency Management of Agitation, Delirium, and Psychosis

The Psychosis System of Care

Psychologists’ and social workers’ main roles in the Zanmi Lasante system of care are:

a. to ensure safety for the patient and others through correct agitation management

b. to make a preliminary diagnosis of delirium/medical illness or mental illness in coordination with the physician

c. to provide psychotherapy and psychoeducation to patient and families

d. to coordinate care with the physician and CHW

Psychologists/social workers are just one important element in the collaborative care approach; to provide the quality care they need to work closely with other team members that include physicians, nurses and community health workers.

Four Pillars of the emergency management of Agitation, Delirium and Psychosis

There are three types of patients that will come looking psychiatric, although not all of them will have a psychiatric illness:

• Patient is agitated

• Patient has a medical illness

• Patient has a psychiatric illness

Any decision around mental health or a treatment plan should include these four elements, in this order:

1. Safety

a. Determine the risk of suicide

b. Understand the exposure to violence

c. Determine the risk of violence

2. Medical Health

a. You cannot diagnose a mental illness without eliminating all medical causes

b. Take vital signs, perform a physical and neurological exam, lab tests (RPR, HIV, hemogram), in some cases consider a scan



3. Mental Health

a. Plan the assessment and ongoing treatment

b. Psychotherapy, pharmacology

c. Create a safety plan

4. Follow-up

a. Next appointment at the clinic

b. Which providers are involved in the patient’s care (CHW, psychologist/social worker, nurse, physician)?

Each pillar will be informed by the psychologist/social worker’s use of the biopsychosocial model.

biopsychosocial model

Medical providers need to approach the treatment and management of psychotic disorders and severe mental illness from a biopsychosocial approach, because there are biological, psychological and social factors involved in the development of mental disorders.

A biopsychosocial approach to mental health treatment will:

• Assist with understanding the condition

• Assist with structuring assessment and guiding intervention

• Inform multidisciplinary practices

World health Organization: World mental health report, 2001: p. 20

Biological factors

Psychological factors

mental and behavioural

disorders

social factors



bIO PsyCHO sOCIAl

• medical comorbidities

• genetic factors, family history

• medications (sensitivity, medication interactions, side-effects)

• Drug or alcohol use

• temperament

• Personality

• Weaknesses

• Defense mechanisms (response to stressful situations)

• Past trauma and losses

• support from family and friends

• Education and employment

• religious and spiritual beliefs

• socioeconomic stressors

• Exposure to stigmatization

• Explanatory model, system of beliefs

• Different coping strategies

CAse 1

CAse: biopsychosocial Considerations

a 37-year-old man patient is brought by his family to the emergency room. he is very talkative and shouts about vodou and religion as he runs around the emergency room.

the emergency nurses fear that he is violent and do not wish to touch him because he may be contagious. they do not check vital signs or provide any medical care. instead they call the psychologist and say “a mental health patient is here.” in the meantime, the patient is totally dehydrated and has a high fever that goes undetected.

his family reports he has never behaved this way before and only became “a crazy person” after a dog bit him two weeks ago. since then he has been unable to work and care for his wife and two children. Other family members have to stay with him, thereby losing daily wages.



thE FOur Pillars OF EmErgEnCY managEmEnt OF agitatiOn, DElirium, anD PsYChOsis

1. sAFeTy

violence:

• is the patient agitated or violent currently? (use the agitated Patient Protocol)

• What is the history of violence? When did it happen, how severe was it?

• is the patient being exposed to violence/abuse?

suicide:

• is the patient suicidal currently? actively or passively?

• What is the history of suicide? Past attempts with medical severity, past suicidal ideation? When did it happen?

management:

• how is safety being managed? is 1:1 present?

• how is risk being decreased?

2. meDICAl

medical evaluation of Psychosis:

• must do a physical and neurological exam, vital signs, weight, laboratory tests (hemogram, hiV and rPr for all patients; renal and hepatic panels if available; CD 4 count for all hiV patients).

• Consider a Ct scan if the patient has a clear neurological deficit.

Consider Delirium:

• Disturbance of consciousness with reduced ability to focus, sustain or shift attention; change in cognition/development of perceptual disturbance not due to dementia; disturbance develops over a short period of time (hours to days) and fluctuates during the day; evidence from the history, physical exam or lab tests that the disturbance is caused by a medical problem.

• treatment is aimed at underlying medical problem and avoiding diazepam.

Consider epilepsy (Post-Ictal Psychosis):

• the family reports the development of psychosis/agitation after seizures.

• treatment is anti-epileptic.

medication management:

• use the medication card to dose and prescribe.

• Provide fluids and do an EKg for all hospitalized/emergency room patients receiving haloperidol.

• Check for medication side-effects; do aims.

• Check vital signs and weight for all patients



3. meNTAl HeAlTH

Diagnosis:

• Work with a psychologist/social worker, use the Differential Diagnosis information sheet.

• reconsider the diagnosis at each visit.

Psychoeducation and support:

• Provide education to patients and families regarding psychosis and medication.

medication management:

• use medication Card for agitation, Delirium and Psychosis; consider diagnosis.

4. FOllOW-UP

Date of next appointment/visit:

• Follow-up based on acuity; for hospitalized patients, daily or several times a day; for outpatients, can be every 1– 2 days or weekly for more acute patients and every 2 – 4 weeks for stable patients.

• involve community health workers in the care.



Safety and Management of Agitated PatientsSafety is the first pillar when dealing with an agitated, delirious or psychotic patient.

Agitation

Is agitation a disease? Agitation is not a disease, there are many causes:

• Delirium (medical): mental retardation, thyroid abnormalities, dementia, seizures, hypoglycemia, anti-cholinergic intoxication and urinary tract infection, HIV encephalopathy, various states of intoxication and withdrawal

• Psychiatric problems: psychosis, mania, trauma

• Emotional/psychological trauma

Agitation spectrum

There is a spectrum of agitation and patients can fall anywhere on the spectrum.

Forms to manage Agitated Patients

The Agitated Patient Protocol will assist clinicians in properly managing different levels of agitation.

The Agitation, Delirium, and Psychosis Form assists physicians in recording vital information related to determining if an agitated patient is delirious or psychotic.

Agitation (mild) Aggression (moderate) violence (severe)

• wringing hands• pacing/moving restlessly• frequent demands• loud, rapid speech• low frustration tolerance

• verbal threats• yelling, cursing• does not respond to

verbal redirection• does not respond to

increased staff presence

• destroying property• making a fist, physically

threatening (e.g. hitting, kicking, biting)

• harming people



When managing an Agitated Patient: safety and Talking First!

Often psychologists/social workers and other health providers are unsure what to do when there is an agitated patient. By talking to the patient, the nurse can evaluate the risk of violence, begin the medical evaluation and calm the patient.

How to ensure safety:

• Do not see the patient alone (ask for security). Remain calm. Remember that patients do not suddenly become violent; their behavior occurs along a spectrum.

• Maintain a safe physical distance from the patient. Do not allow the exit to be blocked. Keep large furniture between you and patient.

• Remove all objects that can be used to harm (needles, sharp objects, other small objects). Check whether the patient has a history of violence or substance abuse.

• Talking to the patient is safe and effective. Do not yell. Keep your voice calm, quiet and friendly.

• Make eye contact to show that you care about the patient. Show sympathy and empathy (‘I understand that you are scared, but I am here to help. We will not hurt you’).

Intramuscular Medication and Physical Restraint

When should providers give medication intra-muscularly?

From a human rights perspective, you always want the least restrictive approach and use the fewest interventions necessary. We only give medication intramuscularly to a severely agitated patient who is at risk of imminent self-harm or is harming those around him. We only administer medication intramuscularly when a severely agitated patient refuses oral medication or is unable to comprehend the request to take oral medication. We must remember that administering an intramuscular injection is invasive and can cause physical pain. It can also potentially lead to physical harm towards providers.

In what situations should clinicians use physical restraint?

The goal is to use the least restrictive means necessary. The rights of a person must take priority, in balance with the safety of those around them. Physical restraint can be considered if:

• If calming measures have been tried AND

• The patient has been offered an oral medication and refused AND

• The patient reaches a state of severe agitation where there is a significant worry about harm to self and others AND

• It is felt that all alternatives have been tried



Gathering Information and a Brief Assessment

Physicians and nurses should try to obtain as much history about the patient as possible to better inform the management of the patient’s agitation. It is helpful to obtain this information from the patient, if possible, but also from family members or anyone who has accompanied the patient.

• What happened?

• How did this start?

• Has this happened before?

• Has the person suffered from a mental illness in the past?

• Does the person drink a lot of alcohol?

• Has the person been taking medicines lately?

• Has the person had any recent physical illnesses?

Although it would be ideal to obtain information about the agitated patient (whether from the patient or someone else), it is not always possible, depending on the level of agitation.

ROle PlAys

ROle PlAy 1: Agitated Patient

a 55-year-old man is brought to the clinic by concerned neighbors. they report that he has been talking to himself, yelling at people for no reason, and making threatening comments. they refer to him as ‘crazy’ and report that he has no friends or family. in the clinic he is disorganized and confused.

ROle PlAy 2: Agitated Patient

a 24-year-old woman is brought to the emergency room by her boyfriend and brother. she is angry, yelling and screaming. her brother has to physically hold her in order to prevent her from lunging at her boyfriend. the brother reports that the patient’s behavior changed several days ago following an argument with her boyfriend in which she accused him of cheating.



Suicide Risk

The identification and triage of patients who may have suicidal ideation is one of the most important aspects of the clinical history and evaluation. It is important that each agitated or psychotic-appearing patient with a concern of self-harm is screened for suicidality. Psychologists/social workers have the responsibility within the system of care to evaluate and properly screen patients for suicidality. The physician, when managing an agitated patient will ask and then record on the Agitated Patient Form if that patient has a history of suicide attempts. If the patient does have a history of suicide attempts, the psychologist/social worker will immediately use the Suicidality Screening Instrument to determine the patient’s level of risk. If it is not immediately apparent if the patient has a history of suicide attempts, but there is a concern about the patient’s self-harm (whether past or present), the psychologist/social worker should also administer the Suicidality Screening Instrument.

Safety Plan

All patients who are screened for suicidality, whether low risk or high risk, need a safety plan. A safety plan is a plan, collaboratively developed by the patient and psychologist/social worker, which assists patients to decrease their risk of suicide.

The plan’s six essential components:

1. Recognize warning signs of a suicidal crisis about to happen

2. Identify and employ internal coping strategies without needing to contact another person

3. Utilize contacts with people as a means of distraction from suicidal thoughts & urges

4. Contact friends or family members who can help resolve a crisis & with whom suicidality can be discussed

5. Contact mental health professionals or agencies

6. Reduce potential use of lethal means

The most important aspect of the safety plan is its accessibility and ease of use. A safety plan will not be helpful if there are obstacles in the plan that the patient cannot overcome. The psychologist/social worker’s role is to discuss feasibility of the plan’s steps with the patient so the patient is prepared.



ROle PlAy 1

Psychologist/social Worker: hello Emmanuel.

Patient: hello.

Psychologist/social Worker: i’d like to ask you a few additional questions to be sure that you are safe. Part of my job here in the health facility is to help people feel safe, and to help all of the physicians and nurses to ensure the safety of people we see here. Please know that you can trust me, and that i would like to be helpful to you.

Patient: OK.

Psychologist/social Worker: sometimes, when things are particularly difficult, some people have thoughts of not wanting to live. have you ever wished you were dead in the past two weeks?

Patient: no.

Psychologist/social Worker: have you ever wished you were dead in the past year?

Patient: Yes.

Interview continues because patient said yes.

Psychologist/social Worker: have you had any thoughts of killing yourself in the past two weeks?

Patient: no.

Psychologist/social Worker: have you had any thoughts of killing yourself in the past year?

Patient: Yes. things were just so hard!


Psychologist/social Worker: have you been thinking of ways to do this in the past two weeks?

Patient: no.

Psychologist/social Worker: have you been thinking of ways to do this in the past year?

Patient: no. i never decided to do anything.

Interview ends because patient said no to each column of a question



ROle PlAy 2

Psychologist/social Worker: hello Katrina.

Patient: hello.

Psychologist/social Worker: i’d like to ask you a few additional questions to be sure that you are safe. Part of my job here in the hospital/clinic is to help people feel safe, and to help all of the physicians and nurses to ensure the safety of people we see here. Please know that you can trust me, and that i would like to be helpful to you.

Patient: OK.

Psychologist/social Worker: have you ever wished you were dead in the past two weeks?

Patient: Yes.

Psychologist/social Worker: have you ever wished you were dead in the past year?

Patient: Yes.


Psychologist/social Worker: have you had any thoughts of killing yourself in the past two weeks?

Patient: Yes. i don’t want to live anymore, but i know my family would feel so bad.

Psychologist/social Worker: have you had any thoughts of killing yourself in the past 12 months?

Patient: (nods).


Psychologist/social Worker: have you been thinking of ways to do this, now or in the past two weeks?

Patient: Yes, i think a lot about it.

Psychologist/social Worker: have you been thinking of ways to do this, in the past year?

Patient: Yes, i guess i’ve been thinking about it for a long time.


Psychologist/social Worker: Do you have any intention to act on these thoughts?

Patient: i’m not sure…

Psychologist/social Worker: We are here to help you, you are not alone. i would like to work with you to develop a plan to support you given that things are so difficult currently.

Interview ends as clinician develops a plan to support the patient based on the rest of the history obtained.



Medical Evaluation and the Management of Agitation, Delirium, and PsychosisOnce a clinician has calmed an agitated patient, the physician and psychologist/social worker need to determine if the patient is psychotic or has a medical delirium.

Definition of Agitation, Delirium and Psychosis

Agitation is a symptom to describe behavior. It is not a disease. It is not a mental illness.

Delirium is a medical emergency. It is not a mental illness. It occurs when medical illness results in mental confusion. Delirious patients are confused and off-center and have an increased chance of death. It also has an additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception).The disturbance develops over a short period of time (usually hours to a few days) and tends to fluctuate in severity during the course of a day. Delirium is often misdiagnosed as psychosis or other psychiatric illnesses.

There are many causes for delirium including:

• Infections (HIV/AIDS, neurosyphilis, malaria)

• Metabolic disorders (electrolyte disorders, especially hypo/hyperglycemia related to diabetes)

• Drug intoxication/Alcohol withdrawal

• Medications (corticosteriods, cycloserine, phenobarbital, efavirenz, high doses of antihistamines, isoniazid)

• Malnutrition/Vitamin deficiencies

• Brain diseases (dementia, stroke, head injury with bleed)

• Malignancy

• Post-Ictal Psychosis

– Takes place between seizures

– Usually follows a ‘lucid’ interval that lasts from hours to days following a seizure

– Characterized by delusions, hallucinations, and aggressive behavior

– Primary treatment is anti-epileptic medication

• Hypertension



Psychosis is a syndrome. A syndrome is defined as the association of several clinically recognizable signs and symptoms which may have multiple causes. It can be a sign of medical illness or mental illness. It is not always a mental illness! It results in dysfunction in thinking, perception (hallucinations) and behavior (decreased social and professional activity).

Treatment is aimed at a complete medical evaluation and treatment first, then a complete mental health evaluation and treatment, if necessary.

Standard Medical Evaluation for Agitation, Delirium and Psychosis

• History (epilepsy, delirium, substance abuse, medications)

• Vital Signs

• Physical Exam

• Neurological Exam

• Mental Status Exam

• Laboratory Tests (at least CBC, RPR, VIH, CD4 if HIV+)

• Additional Tests (CT Scan, EEG, lumbar puncture)



Biopsychosocial Clinical FormulationIf after a medical evaluation, it has been concluded that a patient has a mental illness, the psychologist/social worker will complete the Initial Mental Health Evaluation Form. This includes recording a complete mental health history and creating a biopsychosocial clinical formulation for a patient.

Information to Obtain from Patient/Family

Based on the Zanmi Lasante Initial Mental Health Evaluation Form, obtain:

• Identification/demographic information

• Chief complaint (CC), in patient’s own words

• History of present illness (HPI)

• Psychiatric review of systems (ROS)

– Use of screening tools to help identify possible disorders

– Plus systematic interview to be able to identify disorders/diagnoses

• Past Psychiatric History (PPH), including hospitalizations

• Past Medical History (PMH)

– Head injury

– Loss of consciousness

• Active medical problems

Questions to Ask to Obtain History

• How long has the problem been present (hours, weeks, days, months, years), has it ever happened before?

• How has it affected your life?

• Are you currently being treated for this?

• Have you had any similar problems to the current one before?

• Any recent illness?

• Do you have any physical problems that are bothering you?

• Do you have any allergies?

• Are you aware of a family history of mental health problems, including your siblings, parents or grandparents?

• Is there any family history of depression, anxiety, alcohol or drug abuse, schizophrenia, bipolar disorder or suicide?

• How would you describe your childhood?



• Were there any behavioral problems for you as a child?

• Did you have difficulty at home or at school, as a child or as a teenager?

• What is your highest level of education?

• How have you and your family been doing financially?

• Do you and your family have enough to eat?

• Do you have any problems sleeping at night?

• Have you lost interest in your daily activities?

• Have you been seeing or hearing things that other people cannot hear?

• Have you been feeling sad or unhappy recently?

• Have you been scared or frightened recently?

• How much alcohol have you been drinking recently?

• Have you been able to do the activities you want to, without feeling that your mood or your thinking does not allow you to?

Biopsychosocial Clinical Formulation

A biopsychosocial clinical formulation is a working hypothesis which attempts to explain the biological, psychological and sociocultural factors which have combined to create and maintain the presenting clinical problem. It is a guide to treatment planning and helps communicate providers’ impressions to other providers, and to a patient and their family. A clinical formulation is not a summary of the clinical data. A formulation must contain a theory about the etiology of the patient’s problems, related developmental status and strengths.

Creating a biopsychosocial formulation:

• The biological factors include things such as genetics, general medical conditions and drugs.

• The psychological factors include a person’s coping strategies, personality and stressors including past trauma, loss and prolonged grieving.

• The social factors include a person’s living situation, their support (both family and friends), finances, situation at work/school, etc.

• It is important to take note of areas of significant strength, competency and mastery. Areas of strength can be used as initial areas of intervention in supporting a person.



bIOPsyCHOsOCIAl ClINICAl FORmUlATION exAmPle

Peterson is a 21-year-old male living in mirebalais who lives with his parents and presented to the hospital with a chief complaint of “hearing voices.” From a biological perspective there is a family history of a similar problem (his father), and he also experienced head trauma in a motorcycle accident several years ago. From a psychological perspective, Peterson has experienced significant shame about his illness, which has significantly affected his self-esteem. he and his family believe that these symptoms are related to a curse that was cast on the family. From a social perspective, they also are poor, Peterson’s father drinks alcohol excessively, and at times there is domestic violence. Peterson has strengths in that he has been a good student at school, he goes to church, and he participates in a musical group.



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bIOPsyCHOsOCIAl FORmUlATION CAses

CAse 1

a 22-year-old woman, Darline, is brought in by her husband to the health facility in Cange. he says that his wife has been acting strangely. he reports that she has refused to get out of bed for the past week and has been crying frequently. Darline is usually very active in church but hasn’t gone the past two weeks. he was worried she was depressed. however, yesterday she got out of bed extremely happy and was so energized cleaning the house she didn’t sleep at night. You observe Darline chatting excitedly with other people in the waiting room. she says she feels wonderful and doesn’t know why her husband brought her here. When you ask Darline if there is any family history of mental illness she declines to reply. she asks you angrily what you are trying to suggest. she says that nothing is wrong with her, although she does admit she was feeling sad last week. the husband mentions that he is worried and frustrated because she hasn’t been able to work as much the past two weeks because of her condition, and that it’s straining the family finances. When asked about her physical health, Darline states she has no health problems. her husband reports that this is the first time that Darline has acted this way.

biopsychosocial formulation:



bIOPsyCHOsOCIAl FORmUlATION CAses (continued)

CAse 2

a 20-year-old man, James, is brought in by his friend, simon. simon says that recently James started saying that his neighbor is watching him; James cannot stop talking about it. James thinks that the neighbor is a spy. James lives with his aunt and used to go to school. James was a good student, but he stopped going to school because he couldn’t concentrate. James reports that he hears what the neighbor is saying about him in his mind. the neighbor says “i’m watching you. i’m going to get you.” When you ask how long this has been happening for, James says almost three months. James is so scared that he can’t sleep at night. When you ask about his family history, James says he has never met his father, and he hasn’t seen his mother since she was hospitalized at mars and Kline in 2011. simon reports that James’ girlfriend broke up with James because she was scared of how James was acting. James has begun to use alcohol to relax because he is nervous all the time about his neighbor.

biopsychosocial formulation:



Medication Management for Agitation, Delirium, and PsychosisOnce a medical evaluation has been performed, a physician must decide if pharmacological treatment is necessary. Physicians are responsible for prescribing antipsychotics but they must work with psychologists to determine the likely diagnosis.

Prescribing Principles for Agitation, Delirium and Psychosis

The primary tools that can be used to guide prescribing practices are:

• Zanmi Lasante Formulary

• Epilepsy Medication Card

• Agitated Patient Protocol

• Medication Card for Agitation, Delirium, and Psychosis

Haloperidol and risperidone are the primary medications for the management of agitation, delirium, and psychosis. Risperidone has fewer side-effects and should be tried before haloperidol, unless the patient is violent or aggressive and could benefit from the sedation of haloperidol. Begin with a low dose and increase gradually.

Carbamazepine should typically be prescribed before valproate as a long-term mood stabilizer.

Valproate is particularly for patients with long-standing aggression or violence, and should never be prescribed to a pregnant woman (and avoided for women of child-bearing age).

Diazepam is only used in agitated patients and those going through alcohol withdrawal.

Children, the elderly, pregnant and breast-feeding patients are special populations. Please consult with the mental health team before prescribing for them. For suicidal patients, give a small supply of the medication to a family member to prevent possible overdose.



Psychoeducation about Medication

It is incredibly important to speak to patients and their family members in language that they understand, depending on their education level and knowledge. Do not speak to patients and family members in jargon or complex medical language.

Make sure to explain to the patient/family:

• What the medication is for

• How to take the medication properly

• Common side-effects

• Toxic side-effects and when to seek immediate medical care

• How long it takes for medication to work How long it takes for medication to work

TIP: To know if the patient/family actually understands the information you are providing about taking the medication, ask the patient/family member to repeat back to you how to take the medication.

Additional information about prescribing principles:

• It is important to take the medication regularly and not miss a dose.

• Do not double up on a dose if a dose is missed.

• It is important to continue to take medication even if symptoms improve.

• Symptoms may worsen if medication is discontinued.

• If any problems of concern develop, contact a member of the treatment team (community health worker, psychologist/social worker or physician) by phone, or return to the hospital for evaluation.

AIMS (Abnormal Involuntary Movement Scale)

The AIMS is a 12-item scale that the clinician administers and scores. The clinician observes the patient and asks questions about involuntary movements due to tardive dyskinesia. If one can catch tardive dyskinesia early, one can intervene.

• Facial and oral movements

• Extremity movements

• Truncal movements

• Patient awareness of movements

The AIMS should be used at the beginning of treatment, and then every six months. It can be done in less than 10 minutes. The clinician tracks the numerical score over time (every six months).



meDICATION RevIeW WORksHeeT

Use the Medication Card for Agitation, Delirium, and Psychosis, and the Agitated Patient Protocol.

1. Which three medications on the medication card can Zamni lasante physicians prescribe without consulting the mental Health team?

2. Which two medications on the medication card should NOT be routinely prescribed by Zamni lasante physicians for bipolar disorder or other forms of mental illness?

3a. A 63-year-old man arrives in the emergency room. He is violent and out of control, pushing people and running around. He has been brought in by his wife and son, who report he has never behaved this way before. What level of agitation does he have (mild, moderate or severe)?



meDICATION RevIeW WORksHeeT (continued)

3b. According to the Agitated Patient Protocol Form, which medication should the physician give the patient? Give the medication name, dose, and form.

4. you are working in the emergency room of a local clinic when a father brings his 19-year-old daughter in. she is totally rigid, unable to walk, unable to turn her head, and unable to open her mouth. Her father has to carry her. He reports that she was taken to a psychiatric facility after becoming violent following a break-up with her boyfriend. At the facility, she was given multiple injections. How would you work with the physician to treat this case?



Psychotherapy and Family & Patient EducationThere are a variety of approaches for treating mental illnesses, many of which can be useful for treating patients with severe mental illness, like psychosis or bipolar disorder.

• Interpersonal Therapy (IPT)

• Cognitive Behavioral Therapy (CBT)

• Behavioral Activation (BA)

• Breathing/muscle relaxation techniques, stress management

• Group therapy

• Family therapy

• School-based mental health and psychosocial interventions

Supportive Therapy

Appropriate for two kinds of patients:

• Chronic illness, low level of functioning: bipolar disorder, schizophrenia, chronic major depressive disorder

• Person in crisis

Interventions:

Permit venting, acknowledge and validate, accept, give hope, educate, give permission to (temporarily) accept the sick role, normalize, help problem-solve, advise, reality test, role play, request family meeting.

Interpersonal Therapy

Interpersonal therapy can be helpful for some patients with severe mental illness because their illnesses often cause problems in their social relationships.

• Psychological treatment designed to help a person identify and address problems in their relationships with family, friends, partners and other people.

• Works on improving symptoms through a focus on interpersonal functioning.

Family-Focused Therapy

Family-focused therapy can be one of the most helpful types of therapy for patients with severe mental illness.



Family dynamics are often stressed when a member of the family has a severe mental illness. Families may blame the patient for their symptoms, or be hostile towards the patient. Often, families feel helpless and hopeless to control the illness. Unfortunately, this stressful home environment can lead to the worsening of the patient’s symptoms, creating a cycle of stress in the home. Family-focused therapy emphasizes the importance of building family support through education, problem solving techniques and communication skills.

Family-Focused Therapy:

• Create a shared understanding of severe mental illness (bipolar disorder, schizophrenia) in the family which will:

– Maintain a low-key atmosphere

– Support the patient taking medication and monitoring it

– Separate the patient from the illness

• Communication skills training

• Problem-solving skills training

– Identify the precipitating life events that provoke worse symptoms

– Conduct a relapse prevention drill –> how to identify, what to do

Psychoeducation

All of the therapy approaches previously mentioned include educating the patient and their family. Because of the importance of psychoeducation, all Zamni Lasante health providers have a role in delivering psychoeducation. Psychologists and social workers will practice psychotherapy that includes psychoeducation components, while the other cadres of health workers will provide basic education around severe mental illness.

GeNeRAl messAGes TO sHARe WITH PATIeNTs AND FAmIlIes

• a patient’s symptoms can improve with treatment and they can even recover.

• it is important to continue with work, social, and school activities as much as possible.

• the patient has a right to be involved in making decisions about their treatment.

• it is important to exercise, eat healthy, and maintain good personal hygiene.

• Families should not tie up or lock up patients. instead, bring them to the clinic/hospital or ask the ChW for help/support.

• information about medication:

– it is important to take the medication regularly and not miss a dose.

– Do not double up on a dose if a dose is missed.

– it is important to continue to take medication even if symptoms improve.

– symptoms may worsen if medication is discontinued.



PsyCHOsIs-sPeCIFIC messAGes

• Psychosis is a medical condition that is treatable.

• Psychosis is not contagious.

• Patients with psychosis are often stigmatized and mistreated.

• many patients recover from psychosis with medication and therapy and return to their normal functioning.

• the patient may hear voices or may firmly believe things that are untrue.

• the patient often does not agree that he or she is ill and may sometimes be hostile.

• if there is a return/worsening of symptoms the patient should come back for re-assessment.

• the patient should be included in family and social activities.

• Family members should avoid expressing criticism or hostility towards the patient.

• the patient may have difficulties recovering or functioning in high-stress working or living environments.

bIPOlAR-sPeCIFIC messAGes

• it is important for the patient to maintain a regular sleep cycle (e.g. going to bed at the same time every night, trying to sleep the same amount as before illness, avoiding sleeping much less than usual). Difficulty sleeping, if it is persistent, can be helped with medication.

• relapses can be prevented, by recognizing when a patient’s symptoms return, such as sleeping less, spending more money or feeling much more energetic than usual. the patient should come back for treatment when this occurs.

• a patient in a manic state can lack insight into the illness and may even enjoy the euphoria and improved energy, so carers must be part of relapse prevention.

• alcohol and other psychoactive substances should be avoided.



CAse sTUDy 1

• gerard is a 25-year-old man with bipolar disorder. he is a patient of yours that you have seen for the past year and the physician has prescribed him carbamazepine.

• his mother, amelie, has accompanied gerard to the health center.

• amelie says that gerard stopped taking his medication a week ago. she says he has been acting “crazy.” gerard confirms that he stopped taking his medication, but says he did so to see if he was cured.

• the psychologist/social worker counsels gerard and his mother.

CAse sTUDy 2

• rose is a 21-year-old who has been accompanied to the health center by her older sister and a community health worker. rose is clearly agitated, having visual hallucinations and speaking to someone who is not there.

• the older sister tells the psychologist/social worker that for the past three days she has been like this. the older sister says that someone has put a spell on her.

• the community health worker says that rose has a fever and that rose’s mother is also sick with a fever.

• the psychologist/social worker counsels rose’s sister and community health worker about rose’s condition and the process of determining if this is a medical illness or psychiatric illness.

CAse sTUDy 3

• Jean is a 19-year-old man who is disheveled and was brought to the clinic by his brother.

• Jean’s brother explains that Jean has stopped going out with friends and refuses to leave his house. Jean hasn’t attended his university classes in a month. Jean’s brother sometimes sees Jean talking to himself.

• Jean refuses to speak to the psychologist/social worker. the psychologist/social worker shares general mental health messages with Jean and his brother.

CAse sTUDy 4

• ronald is a 55-year-old man who is brought to the clinic by his wife and son.

• ronald’s wife, Esther, explains that ronald went out last night and spent all their money. he was up all night, repeating that he was the King of haiti. she said he has had many of these types of days since they first met 25 years ago. ronald’s son is very angry that ronald has spent all their money and demands that the psychologist fixes ronald’s disturbed mind.

• the psychologist/social worker counsels Esther and her son.



Clinical Outcome Measures — CGI and WHODASEffective care is that which has been shown to improve functioning and quality of life. Effective care may be based on several different types and levels of evidence, and it reflects the best care a system can offer at any given point. To measure effective care, the Zamni Lasante system of care will use the Clinical Global Impressions Scale (known as “CGI”) and the World Health Organization Disability Assessment Schedule (known as “WHODAS”).

Clinical Global Impressions Scale (CGI)

The Clinical Global Impressions Scale (CGI) is an easily adopted tool that measures the effect of treatment over time. It is a global assessment of current symptoms, behavior, and the impact of illness on functioning. Its goal is to allow the clinician to rate the severity of illness (CGI-S), change over time (CGI-I), and efficacy of medication.

It evaluates the following elements:

• Current symptoms

• Behavior

• Impact of illness on functioning

It rates the following elements:

• Severity of illness

• Change over time

• Efficacy of medication

CGI – Severity

Psychologists/social workers determine the CGI Severity by assessing how ill the patient is at the time of interview relative to the psychologist’s /social worker’s past experience with patients who have the same diagnosis. The psychologist/social worker will judge the level of mental illness that the patient has experienced over the past 7 days.



CAse 1

a 38-year-old, well-groomed, female patient, who is a successful professional, reports a one-month unprecipitated depressive episode that seems to be worsening. she is currently experiencing early morning awakening, loss of pleasure in her usual activities, feelings of guilt, reduced appetite, tearfulness, and depressed mood. she has found herself weeping several times over the past week, but cannot identify a reason. she is continuing to work, but found herself fighting back tears at an important meeting and believes her work may be less sharp than it had been in the past. no one has noticed, but she is concerned that the depression is worsening and may result in a significant impact on work. she is worried that she may lose her “edge.” she denies suicidal ideation. she has no previous psychiatric history.

CAse 2

a 34-year-old, male patient with a diagnosis of paranoid schizophrenia has been in treatment at Zanmi lasante for the past several years, having started medication treatment more than ten years ago after a hospitalization at mars and Kline. according to his community health worker and physician, he had been stable on his medication regimen for the past year, but recently stopped taking his medication and would not cite a reason. he attended his church twice this past week, but missed four other days which he usually would have attended. after receiving a call from a family member, the community health worker went to his home and drove him to the hospital for evaluation and possible hospitalization. the community health worker reports he has become increasingly threatening and difficult to manage at home, and has been seen responding to auditory hallucinations, including taking cover in attempts to hide from “enemies.” in the past week, he obeyed a command hallucination to “go after” a neighbor, but was physically circumvented from harming the neighbor by three community health workers, who physically restrained him. the community health worker reported that although the patient was passively cooperative about coming to the clinic, he did not speak with her at all during the trip. in the clinic office, he is guarded and suspicious. he mumbles under his breath, but refuses to elaborate as to what he has said or to whom it was directed. twice he makes a fist and raises his arm threateningly in the direction of the physician, but then puts his hand back in his lap. he appears disheveled and is not groomed; he has not changed his clothing over the past week, which his community health worker reports is a new behavior for him.



CGI – Improvement

• At Initial Evaluation: If the patient has been in treatment previously, rate CGI-I based on the history and compared to the patient’s condition prior to treatment. Otherwise, select 0, “not assessed.”

• Follow-Up Appointment: Rate CGI-I by comparing the current condition to the patient’s condition at the initiation of the current treatment plan. Assess how much the patient’s illness has changed relative to a baseline state at the beginning of the treatment plan based on the first evaluation. Rate total improvement whether or not in your judgment it is due to treatment.

CAse 1

a patient who has been in treatment and receiving an ssri for an anxiety disorder for four months comes in for a medication check. the patient’s Cgi-s at the visit at which ssri medication was initiated (“baseline” visit) was 4 (moderate). at today’s visit, the patient reports that the anxiety symptoms have decreased considerably. the patient is now able to sleep 7 to 8 hours each night, with no initial insomnia. this represents a significant change from baseline, at which time the patient spent 2 to 3 hours each night trying to fall asleep, with a nightly total of 4 to 5 hours of fitful sleep. the patient reports having felt excessively anxious this week about running out of gas and about a burglar entering the house. the estimated time spent engaged in these anxious thoughts was less than one hour per day, compared to an estimated 3 to 4 hours per day at baseline. the patient drove over a bridge this week, which was described as somewhat difficult and fear-provoking, but manageable. at baseline, the subject was wholly avoidant of bridges, which caused him to drive 30 minutes out of his way each day to get to work.

CAse 2

the anxious patient in the previous example (Cgi-i Case 1) returns one month later. he reports that he is now afraid of leaving his house without accompaniment. this is a new development for him. he is anxious and worried all day long. he called work and told them he had the flu. in reality, he was afraid to leave his house. he has only left the house three times this week, including his visit to the clinic today, all accompanied by his wife. he felt panicky on all three occasions. although he denies any lightheadedness or other symptoms suggesting impending syncope, he reports worrying constantly about “passing out” in front of a moving car or bus. he is fearful that he will forget the name of a well-known friend or relative should they call him on the phone. he is sleeping only 1 to 2 hours a night. his wife reports that she has “never seen him so bad.” he cries in the interview and admits he has considered “ending it all” to make the pain go away.



CGI – Side-Effects

The side-effects scale scores a patient’s level of side-effects from medication on a scale of 0 – 3. The closer the number is to zero, the better. Medication side-effects will be monitored by physicians using the Abnormal Involuntary Movements Scale (AIMS). The psychologist/social worker’s role is not to actively check or identify side-effects. Rather, the CGI Side-Effects scale is simply used to serve as an additional tracking tool, and to double-check what the physician has found in his AIMS evaluation.

World Health Organization Disability Assessment Schedule

The WHODAS is another tool that psychologists/social workers will use to track patients’ progress over time. There are six domains of functioning in the WHODAS that will be discussed with the patient and then recorded.



WHODAs ROle PlAy

Psychologist/social Worker: “i now want to ask you a few questions. the interview is about difficulties people have because of health conditions. By health condition i mean diseases or illnesses, or other health problems that may be short or long lasting; injuries; mental or emotional problems; and problems with alcohol or drugs. Do you understand what i mean by health condition?”

Patient: “Yes.”

Psychologist/social Worker: “remember to keep all of your health problems in mind as you answer the questions. When i ask you about difficulties in doing an activity think about: increased effort, discomfort or pain, slowness, changes in the way you do the activity. When answering, i’d like you to think back over the past 30 days.”

Patient: “OK.”

Psychologist/social Worker: “i would also like you to answer these questions thinking about how much difficulty you have had, on average, over the past 30 days, while doing the activity as you usually do it. use this scale when responding: none, mild, moderate, severe, extreme or cannot do.”

Patient: “OK.”

Psychologist/social Worker: “in the past 30 days, how much difficulty did you have in: standing for long periods such as 30 minutes?”

Patient: “i am always standing.”

Psychologist/social Worker:

1.

(What should you say to the patient to obtain an answer of none, mild, moderate, severe, extreme or cannot do?)

Patient: “i did not have any difficulty.”

2. how would you record this answer on the WhODas scale? Which category would you circle?

a. none

b. mild

c. moderate

d. severe

e. Extreme or cannot do



WHODAs ROle PlAy (continued)

Psychologist/social Worker: “in the past 30 days, how much difficulty did you have in: taking care of your household responsibilities?”

Patient: “What type of household responsibilities?”


3.

(What should you say to the patient to clarify what you mean?)

Patient: “i had no difficulty.”

Psychologist/social Worker: “in the past 30 days, how much difficulty did you have in: learning a new task, for example learning how to get to a new place?”

Patient: “i haven’t learned any new tasks.”


4.

(What should you say to the patient to probe about whether this question is not applicable?)

Psychologist/social Worker: “in the past 30 days, how much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?”

Patient: “i always go to church but i don’t like going to other community activities.”


5.

(What should you say to the patient to obtain an answer of none, mild, moderate, severe, extreme or cannot do? Remind the patient these questions are based on his health status.)

Patient: “i can go to everything — it’s just that i don’t want to. i suppose my answer is none.”



WHODAs ROle PlAy (continued)

Psychologist/social Worker: “in the past 30 days, how many days were these difficulties present?”

Patient: “Oh, i don’t know. i can’t say.”


6.

(What should you say to the patient to obtain the number of days?)

Patient: “i guess i could estimate that four days a month these difficulties were present.”



Follow-Up and DocumentationThe Psychosis Care Pathway only works with functional follow-up and documentation.

Patients should be seen for follow-up appointments every one-to-two weeks if their symptoms are acute or if medications are being started, adjusted or stopped. Patients with psychosis whose symptoms are stable can be seen once a month or once every three months.

Follow Up Chart

HOW TO DeTeRmINe A PATIeNT’s ImPROvemeNT IN symPTOms

WHy Is DOCUmeNTATION ImPORTANT?

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Using mhGAP for Psychosis and Bipolar DisorderThe mhGAP Intervention Guide is a document developed by the World Health Organization that outlines the diagnosis and management of various mental health disorders. It is designed to serve as a guide for clinicians around the world. It is an important resource to help guide decision-making for non-specialist providers such as physicians. The effective training of non-specialists is how the global treatment gap will be narrowed.

The mhGAP chapters on psychosis and bipolar disorder can be used to guide assessment and management of all these different disorders. mhGAP organizes psychotic disorders separately from bipolar disorder because bipolar disorder is considered a mood disorder. However, both bipolar disorder and depression can have psychotic features.

Questions to Ask about Psychosis

Sometimes it is not obvious what symptoms a patient may have. By asking these questions, the physician may be able to better determine if a patient has psychotic features.

• “Have you ever heard voices, even when nobody is present? Do you currently hear voices? Are you bothered or harassed by these voices? What did the voices tell you? Can other people hear the voices too? Do you think that I can hear them?”

• “Have you ever seen things that may not actually be present?”

• “Have you ever felt that your mind or body was being secretly controlled or somehow controlled against your will?”

• “Have you ever felt that others wanted to hurt you or really get you for some special reason, maybe because you had secret or special powers of some sort?”

Determining Chronic vs. Acute Psychosis

By asking the patient or carer about the onset of the psychotic episode and any prior episodes, participants will be able to determine if the person has acute psychosis or chronic psychosis. This is important because it can have an impact on the duration of treatment with antipsychotic medication. For acute psychosis, the provider will want to stop the medication at some point to see if the patient can recover without the medication. Medication can have potentially significant side-effects, and we want to minimize the use of medication as much as possible.

the red box in the middle of page 18 in mhgaP emphasizes the importance of ruling out medical delirium before prescribing any medication to someone with acute psychosis — just as you learned about earlier during this training.



Self-Harm and Suicide

During your work with depressed patients, epileptic patients and psychotic patients, you might come across a patient that has self-injurious behavior or suicidal ideation. It is critical to assess safety and risk of suicide for all patients for whom there is a mental health concern. By asking someone if they are thinking about hurting or killing themselves, psychologists/social workers will not increase the risk of the patient doing so. Asking about thoughts of self-harm is an important responsibility of every provider: physician, nurse, community health worker, social worker and psychologist. For the physician assessing a patient for self-harm, mhGAP can assist the physician to take the appropriate next steps.

No matter the condition of the patient, it is important not to leave the patient alone. Self-harm and suicide can be attempted by anyone who might have mental health issues, including depression, epilepsy, psychosis and bipolar disorder.

Supplementary Resources

mhGAP Intervention Guide http://www.who.int/mental_health/publications/mhGAP_intervention_guide/en/



Review: Case Studies

CAse sTUDy 1

a 40-year-old woman is brought into the health facility by her two sons. she is barely able to walk and is clearly confused. she cannot follow simple commands. her sons said she has been fatigued and feverish for the past few days. the patient is mildly agitated, clearly frustrated with her sons. You, the nurse and the physician are available to evaluate and manage the patient.

1. What would you do with the nurse to manage the patient’s agitation? What form would you use to guide you?

2. How would you support the physician in evaluating the agitated patient? What forms would you help the physician manage during the medical evaluation?

the physician has concluded that the patient likely needs further neurological testing to determine if the patient has a neurological problem. the patient also has a confirmed fever above 38 C. the two sons said that they are sad that she is now “crazy” and want to know how you can cure her.

3. What would you say to the two sons?



CAse sTUDy 2

a 27-year-old man, Pierre, is brought into the health center by two community health workers. he is yelling that the community health workers are trying to kill him. he lunges at anyone who tries to get close to him, screaming that he will kill everyone.

1. Is this patient agitated. What level of agitation does the patient have?

2. What do you do to manage the behavior and environment? Who do you collaborate with?

3. What forms would you use to assist you to manage this agitated patient?

after a few minutes of speaking calmly with the patient you leave the room, and identify someone to keep an eye on the patient to ensure his safety and that of others (1:1). You have been able to calm the patient without giving any medications and the physician has done an initial medical evaluation. the patient denies wanting to hurt himself or others. his lab tests have come back normal and the physician says he is not suffering from medical delirium.

4. What would you do next? What forms would you be utilizing to guide your work?



CAse sTUDy 2 (continued)

You see the patient for an initial mental health evaluation and the patient reports that he has been hearing voices that tell him that everyone wants to kill him. he is disheveled and it is apparent he has not bathed in many days. You ask the community health workers about the patient, and they say that he is typically locked in the house by his family. however, the community health workers were able to convince the family to let him come to the health facility. the community health workers say the patient has been this way for a few years. You are unable to get further information from the patient as his speech is disorganized and tangential.

5. What diagnosis would you give the patient? Why? Where would you record the diagnosis?

6. What clinical formulation would you record on the Initial mental Health evaluation Form?

7. What type of psychotherapy would you consider beginning with the patient during the next visit? Why?



CAse sTUDy 2 (continued)

8. After diagnosis, how would you collaborate with the physician that day?

9. What would be the follow-up plan for this patient? What other providers would you include, and what would their role be?



CAse sTUDy 3

this past year you began seeing a young, 18-year-old woman with a recent episode of psychosis. she was prescribed risperidone. today during her monthly follow-up visit, approximately 8 months since the initiation of medication, you notice that she appears restless, frequently wringing her hands and looking upset.

1. What forms will you use or complete during your follow-up visit?

During her appointment, when you ask her how things are going, she begins to cry and tells you that things are not going well. she recently broke up with her boyfriend and cannot find a job to support herself.

2. How would you counsel her? What are some key messages you would give her during this time of stress?

You are worried that this stress could trigger a relapse.

3. How would you collaborate with other providers to ensures she is adherent to her medication and has social support during this time of stress?

59Partners In Health | PartiCiPant hanDBOOK | ANNEx

NOTes

60 Partners In Health | PartiCiPant hanDBOOK | ANNEx

Annex


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1

DIFFeReNTIAl D IAGNOsIs INFORmATION sHeeT FOR seveRe meNTAl D IsORDeRs

CONDITION symPTOms DIAGNOsTIC HINTs GeNeRAl mANAGemeNT

medical symptoms or Psychosis Caused by medical Conditions

Delirium new onset abnormal mental status •abnormal physical exam, vital signs or laboratory studies

•abnormal mental status examination

•seek medical source of illness

•Follow medical Evaluation Protocol for agitation, Delirium and PsychosisPsychotic Disorder

Due to a general medical Condition

Psychosis is the direct physiological consequence of a medical condition

•Psychotic symptoms

•Evidence of a contributing medical illness

substance-induced Psychotic Disorder

Prominent hallucinations or delusions •Evidence of recent substance intoxication or withdrawal

Post-Partum Psychosis

new onset psychosis in a female following childbirth

•recent childbirth

mental Health Related symptoms that are not Psychosis

transient hallucinations

anomalous experiences, may occur in a person in a state of good mental and physical health, even in the apparent absence of a trigger (stress, fatigue, intoxication, etc.)

•Common in children and youth

•Ensure safety of patient: assess for self-harm

•seek to understand patient’s explanatory model, and to assess internal level of distress

•Obtain Biopsychosocial history

• identify potential stressors

•Consult traditional healer if currently involved in management

acute stress, anxiety, and trauma-related problems

stress and traumatic experiences can result in unusual sensory and perceptual experiences that can mimic psychosis

•significant trauma history

Conversion Disorder usually in response to stress, a person can develop blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation

• identification of stressor

•Poor insight into emotional stressors

Obsessive-compulsive disorder

Excessive thoughts (obsessions) that can lead to repetitive behaviors (compulsions), with a potential component of disordered thinking

•specific area of focus

autism spectrum disorders

a serious developmental disorder that impairs the ability to communicate and interact

•longstanding history of unstable interpersonal relationships

Personality Disorder a deeply ingrained and maladaptive pattern of behavior of a specified kind, typically manifest by the time one reaches adolescence and causing long-term difficulties in personal relationships or in functioning in society

•longstanding history of unstable interpersonal relationships

•Poor insight


2


episodic Psychosis or mania

Depression with psychotic features (mood Disorder, depressed)

a primary depression with psychotic symptoms. •Depressive symptoms before psychotic symptoms






•Consider co-morbid mental health diagnoses.

•Both depression and psychosis are treated with distinct medications

•antidepressant medications (fluoxetine, amitryptiline) can cause mania in a person with Bipolar Disorder

Bipolar Disorder (mood Disorder, manic or depressed)

marked by alternating periods of elation and depression; some develop mania without depression, others can develop hypomania with depression

•Period of mania, or hypomania with depression

Brief psychotic disorder (less than one month)

a sudden, short-term episode of psychotic thinking and behavior which occurs with a stressful event; can be informed by social and cultural factors

•Person returns to functioning

schizophreniform Disorder (schizophrenia symptoms 1-6 months)

symptoms of schizophrenia are present for a significant portion of the time within a 1-month period, but signs of disruption are not present for the full six months required for the diagnosis of schizophrenia

•Do not make diagnosis of schizophrenia if symptoms are less than 6 months

Psychosis not Otherwise specified (nOs)

Psychotic symptoms about which there is inadequate information to make a diagnosis

•Examples include: psychosis of a few days or weeks duration, post-partum psychosis, and situations in which diagnosis is unclear

Differential Diagnosis Information sheet For severe mental Disorders (Continued)


3


Continous Psychosis

schizophrenia (greater than 6 months)

Dsm 5 criteria1

two (or more) of the following, each present for a significant portion of time during a 1-month period. at least one of these must be (1), (2), or (3):

1. Delusions2. hallucinations3. Disorganized speech 4. grossly disorganized or catatonic behavior5. negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one of the above symptoms is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts or two or more voices are conversing with each other

social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning, such as work, interpersonal relations, or self-care, are markedly below the level achieved before the onset.

Duration: Continuous signs of the disturbance persist for at least 6 months. this 6-month period must include at least 1 month of symptoms and may include periods of prodromal or residual symptoms.

exclusions:

•schizoaffective and mood disorder exclusion

•substance/general medical condition exclusion

•Pervasive developmental disorder- the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least a month

•Consider age at onset

•Consider prodromal period before onset of initial symptoms





•take conservative approach to medication


•Consider co-morbid mental health diagnoses

Delusional disorder (plausible, circumscribed delusions)

associated with one or more nonbizarre delusions of thinking such as expressing beliefs that can occur in real life, provided no other symptoms of schizophrenia are present

•Delusion is usually realistic

1 Dsm-5 Diagnostic criteria for schizophrenia. american Psychiatric association: Diagnostic and statistical manual of mental disorders, fifth edition, Washington, DC, 2013, american Psychiatric association.

Differential Diagnosis Information sheet For severe mental Disorders (Continued)

65Partners In Health | PartiCiPant hanDBOOK | ANNEx 65

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luat

ion

(onc

e ca

lm)

INIT

IAl

evA

lUA

TIO

N (

ON

Ce

CA

lm)

q

Com

plet

e Ps

ycho

sis

Che

cklis

t w

ith C

hW

/nur

se

q

Com

plet

e Zl

Dsi

q

Doc

umen

t in

initi

al m

enta

l hea

lth E

valu

atio

n Fo

rm

q

spea

k w

ith p

atie

nt a

nd t

WO

fam

ily m

embe

rs &

rev

iew

phy

sici

an’s

agi

tate

d Pa

tient

For

m t

o co

mpl

ete

initi

al m

enta

l hea

lth e

valu

atio

n

q

Ensu

re v

itals

, wei

ght,

and

labs

are

che

cked

q

acc

ompa

ny p

atie

nt t

o se

e ph

ysic

ian

(see

s al

l psy

chot

ic, s

uici

dal,

viol

ent

case

s)

q

hel

p ph

ysic

ian

follo

w c

heck

list

q

mak

e pr

elim

inar

y di

agno

sis

of d

eliri

um/m

edic

al il

lnes

s or

men

tal i

llnes

s w

ith

the

phys

icia

n

q

if p

atie

nt n

eeds

med

ical

car

e, c

oord

inat

e w

ith p

hysi

cian

s, if

pat

ient

has

ps

ycho

tic d

isor

der,

sche

dule

fol

low

-up

with

in o

ne w

eek

q

Do

psyc

hoed

ucat

ion

and

supp

ort

rela

ted

to m

edic

atio

n an

d ps

ycho

sis

q

Com

plet

e C

gi/

Wh

OD

as,

reg

istr

y, C

heck

list

FOll

OW

-UP

q

use

men

tal h

ealth

Fol

low

-up

Form

q

see

whe

ther

pat

ient

is im

prov

ing

(che

ck m

enta

l sta

tus

exam

, fun

ctio

ning

, pa

tient

and

fam

ily r

epor

t)

q

Che

ck m

edic

atio

n co

mpl

ianc

e, s

ide

effe

cts

q

Ensu

re v

itals

, wei

ght,

and

labs

are

che

cked

q

acc

ompa

ny p

atie

nt t

o se

e ph

ysic

ian;

hel

p ph

ysic

ian

follo

w a

gita

tion,

Del

irium

an

d Ps

ycho

sis

Che

cklis

t

q

Plan

fol

low

-up

for

1– 2

wee

ks; c

oord

inat

e w

ith C

hW

q

Do

psyc

hoed

ucat

ion

and

supp

ort

for

med

icat

ion

and

psyc

hosi

s

q

Com

plet

e C

gi/

Wh

OD

as,

reg

istr

y, a

gita

tion,

Del

irium

and

Psy

chos

is C

heck

list

AG

ITA

TeD

PA

TIeN

T

q

ale

rt e

ither

psy

chol

ogis

t/so

cial

w

orke

r

q

acc

ompa

ny p

atie

nt t

o em

erge

ncy

room

q

ref

er t

o a

gita

ted

Patie

nt

Prot

ocol

q

man

age

envi

ronm

ent

q

talk

to

patie

nt; s

uppo

rt f

amily

q

Do

vita

l sig

ns a

saP

q

Prep

are

oral

and

im m

edic

atio

ns

if ne

eded

q

arr

ange

1:1

if n

eede

d

q

mon

itor

antip

sych

otic

sid

e ef

fect

s, r

epor

t to

phy

sici

an

q

Con

tinue

to

follo

w p

atie

nt c

lose

ly

(at

leas

t ev

ery

15 m

in c

heck

)

q

ass

ist d

octo

r in

med

ical

eva

luat

ion

and

care

(vi

tal s

igns

, lab

tes

ts,

EKg

, flui

ds)

q

Prov

ide

psyc

hoed

ucat

ion

and

supp

ort

to p

atie

nt a

nd f

amily

q

Doc

umen

t al

l wor

k in

nur

sing

fo

rms

INIT

IAl

evA

lUA

TIO

N (

ON

Ce

CA

lm)

q

Det

erm

ine

whe

ther

pat

ient

may

be

psy

chot

ic

q

acc

ompa

ny p

atie

nt t

o se

e ps

ycho

logi

st/s

W; s

uppo

rt

colla

bora

tion

with

phy

sici

an

q

if p

sych

osis

is d

iagn

osed

, pro

vide

ps

ycho

educ

atio

n an

d su

ppor

t

q

Befo

re d

isch

arge

, ens

ure

the

patie

nt h

as a

fol

low

-up

appt

with

ps

ycho

logi

st/s

W

FOll

OW

-UP

q

Do

vita

l sig

ns, w

eigh

t at

eac

h vi

sit

q

Che

ck la

bs w

hen

nece

ssar

y

q

Doc

umen

t in

men

tal h

ealth

Fo

llow

-up

Form

AG

ITA

TeD

PA

TIeN

T

q

ale

rt e

ither

psy

chol

ogis

t/so

cial

wor

ker

q

Follo

w a

gita

ted

Patie

nt P

roto

col t

o de

term

ine

leve

l of

agita

tion

and

to p

resc

ribe

med

icat

ion

if ne

cess

ary

q

Con

tinue

med

ical

eva

luat

ion:

phy

sica

l/ne

uro

exam

, vita

l sig

ns, l

ab t

ests

q

use

med

icat

ion

Car

d to

mon

itor

antip

sych

otic

si

de e

ffec

ts (

cons

ider

EK

g, fl

uids

)

q

Doc

umen

t in

agi

tate

d Pa

tient

For

m

INIT

IAl

evA

lUA

TIO

N (

ON

Ce

CA

lm)

q

rev

iew

initi

al m

enta

l hea

lth E

valu

atio

n

Form

with

psy

chol

ogis

t/sW

to

diag

nose

de

liriu

m/m

edic

al il

lnes

s or

men

tal d

isor

der

q

Do

com

plet

e m

edic

al e

valu

atio

n: v

ital s

igns

, ph

ysic

al/n

euro

exa

m, l

ab t

ests

. use

med

ical

Ev

alua

tion

Prot

ocol

for

agi

tatio

n, D

eliri

um

and

Psyc

hosi

s

q

if p

atie

nt h

as a

psy

chot

ic d

isor

der

or d

eliri

um,

use

med

icat

ion

Car

d to

dos

e

q

Do

base

line

aim

s ex

am

q

Doc

umen

t ev

eryt

hing

in in

itial

men

tal h

ealth

Ev

alua

tion

Form

q

Prov

ide

med

icat

ion

to la

st u

ntil

next

app

t

q

Do

psyc

hoed

ucat

ion

abou

t m

edic

atio

n

q

Plan

fol

low

-up

with

psy

chol

ogis

t/sW

FOll

OW

-UP

q

rev

iew

the

men

tal h

ealth

Fol

low

-up

Form

with

ps

ycho

logi

st/s

W t

o se

e if

patie

nt is

impr

ovin

g

q

Do

phys

ical

/neu

ro e

xam

q

Che

ck w

eigh

t/vi

tals

eac

h vi

sit;

lab

test

s an

d a

ims

ever

y 6

mon

ths

q

use

med

icat

ion

Car

d to

che

ck f

or s

ide

effe

cts

and

to a

djus

t do

se a

s ne

eded

q

Prov

ide

med

icat

ion

to la

st u

ntil

next

app

t

q

Dis

cuss

dis

cont

inua

tion

of a

ntip

sych

otic

with

m

enta

l hea

lth t

eam

q

Doc

umen

t pr

oper

ly in

men

tal h

ealth

Fo

llow

-up

Form

q

Do

psyc

hoed

ucat

ion

abou

t m

edic

atio

n

q

Plan

fol

low

-up

with

psy

chol

ogis

t/sW

P


AG

ITA

Te

D P

AT

IeN

T P

RO

TO

CO

l

THR

OU

GH

OU

T v

IsIT

: Ass

essm

ent

•R

eFeR

to

Med

ical

Eva

luat

ion

Prot

ocol

s

for

Agi

tati

on, D

elir

ium

and

Psy

chos

is

•R

eCO

RD

on

Agi

tati

on, D

elir

ium

and

Psyc

hosi

s Fo

rm

sAFe

Ty F

IRsT

!

•D

o no

t se

e th

e pa

tient

alo

ne

(ask

for

sec

urity

). r

emai

n

calm

. rem

embe

r th

at p

atie

nts

do n

ot s

udde

nly

beco

me

viol

ent;

the

ir be

havi

or o

ccur

s

alon

g a

spec

trum

.

•m

aint

ain

safe

phy

sica

l dis

tanc

e

from

pat

ient

. Do

not

allo

w

exit

to b

e bl

ocke

d. K

eep

larg

e

furn

iture

bet

wee

n yo

u an

d

patie

nt.

•r

emov

e al

l obj

ects

tha

t ca

n

be u

sed

to h

arm

(ne

edle

s,

shar

p ob

ject

s, o

ther

sm

all

obje

cts)

. Che

ck w

heth

er

patie

nt h

as a

his

tory

of

viol

ence

or

subs

tanc

e ab

use.

•ta

lkin

g to

pat

ient

is s

afe

and

effe

ctiv

e. D

o no

t ye

ll. K

eep

your

voi

ce c

alm

, qui

et, a

nd

frie

ndly

.

•m

ake

eye

cont

act

to s

how

you

care

abo

ut t

he p

atie

nt.

show

sym

path

y an

d em

path

y

(“i u

nder

stan

d yo

u ar

e sc

ared

,

but

i am

her

e to

hel

p. i

will

not

hurt

you

.”)

sTeP

1:

Det

erm

ine

leve

l of

agi

tati

on b

y ob

serv

ing

pati

ent

beha

vior

sTeP

2:

man

age

agit

atio

n

Rem

embe

r:

•sa

fety

: tal

k fir

st, d

o no

t m

edic

ate

first

•m

edic

al H

ealt

h: v

ital s

igns

, phy

sica

l exa

m,

men

tal s

tatu

s, e

xam

to

asse

ss f

or d

eliri

um, l

abs

and

stud

ies

•m

enta

l Hea

lth:

tak

e hi

stor

y

•Fo

llow

-Up:

con

tact

psy

chol

ogis

t/so

cial

wor

ker

mIl

D A

gita

tion

q

wrin

ging

/tap

ping

of

hand

s

q

paci

ng, m

ovin

g re

stle

ssly

q

freq

uent

req

uest

s/de

man

ds

q

loud

or

rapi

d sp

eech

q

low

fru

stra

tion

tole

ranc

e

1. m

anag

e b

ehav

ior/

envi

ronm

ent

q

use

cal

m v

oice

, sim

ple

lang

uage

,

soft

voi

ce, s

low

mov

emen

ts

q

ask

“h

ow c

an i

help

?” a

nd

prob

lem

sol

ve w

ith p

atie

nt;

be e

mpa

thic

q

rem

ove

pote

ntia

lly h

arm

ful

obje

cts

from

are

a

q

ask

abo

ut h

unge

r/th

irst

q

Dec

reas

e st

imul

atio

n/ar

rang

e 1:

1

q

Off

er v

erba

l sup

port

and

unde

rsta

ndin

g

q

allo

w t

he p

atie

nt t

o sh

ow

ange

r/fr

ustr

atio

n

q

Cal

m s

taff

q

if a

gita

tion

due

to d

eliri

um,

cons

ider

hal

dol 1

– 2

mg

PO;

not

in e

lder

ly

1. m

anag

e b

ehav

ior/

envi

ronm

ent

2. C

onsi

der

OR

Al

med

icat

ions

q

Off

er P

O m

edic

atio

ns fi

rst

if

(hal

dol 5

mg

+ d

iphe

nhyd

ram

ine

50 m

g O

r D

iaze

pam

10

mg)

q

if p

atie

nt r

efus

es P

O, g

ive

im

med

icat

ions

(h

aldo

l 5 m

g +

diph

enhy

dram

ine

25 m

g O

r

Dia

zepa

m 1

0 m

g)

q

Wai

t 30

min

utes

; if

patie

nt

rem

ains

agi

tate

d, c

an g

ive

½ t

he

orig

inal

dos

e

q

use

med

icat

ion

Car

d to

mon

itor

side

eff

ects

1. m

anag

e b

ehav

ior/

envi

ronm

ent

2. C

onsi

der

OR

Al

med

icat

ions

3. C

onsi

der

INTR

Am

UsC

UlA

R

med

icat

ions

q

hal

dol 5

–10

mg

im +

diph

enhy

dram

ine

25 m

g im

Or

dia

zepa

m 1

0 m

g im

q

Wai

t 30

min

utes

; if

patie

nt

rem

ains

agi

tate

d, c

an r

e-do

se

with

½ t

he o

rigin

al d

ose

q

use

med

icat

ion

Car

d to

mon

itor

side

eff

ects

q

Deb

rief

with

sta

ff

q

Con

sult

men

tal h

ealth

tea

m if

etio

logy

is p

sych

iatr

ic

mO

DeR

ATe

Agi

tati

on q

verb

al t

hrea

ts

q

yelli

ng/c

ursi

ng

q

does

not

res

pond

to

verb

al

redi

rect

ion

q

does

not

res

pond

to

incr

ease

d

staf

f pr

esen

ce

sev

eRe

Agi

tati

on q

dest

royi

ng p

rope

rty

q

phys

ical

agg

ress

ion

(e.g

.,

hitt

ing,

kic

king

, biti

ng)

q

self-

inju

rious

beh

avio

r (e

.g.,

bitin

g ha

nd, h

ead

bang

ing)


AGITATION, Del IR IUm AND PsyCHOsIs FORm

1. sAFeTy (Use AGITATeD PATIeNT PROTOCOl)

Patient is: q not agitated (But appears psychotic) q agitated (mild) q aggressive (moderate) q Violent (severe)

History of violence: q no q Yes: Describe violent behavior ________________________________________________________________ When did it take place:__________________________________________________________________

q manage Behavior/Environment Completed Does patient need a 1:1? q no q Yes:___________

2. meDICAl HeAlTH (Use meDICAl evAlUATION PROTOCOl)

Vital signs: temp:______ Pulse:______ BP:______ rr:______ O2:______ Weight:______

Physical exam Neurological exam

hEEnt: q normal q abnormal:___________ Cranial nerves: q normal q abnormal:___________

Cardiac: q normal q abnormal:___________ motor strength: q normal q abnormal:___________

Pulmonary: q normal q abnormal:___________ sensory: q normal q abnormal:___________

abdominal: q normal q abnormal:___________ reflexes: q normal q abnormal:___________

skin/Extremities: q normal q abnormal:___________ gait/Coordination: q normal q abnormal:___________

mental status exam laboratory Tests Ordered

q alert q sleepy q unable to arouse q hemogram q CD4 q hepatic Panel

thought Process: q normal q Confused:___________ q rPr q tB q renal Panel

Can Follow simple Commands: q no q Yes q hiV q urinalysis q malaria

hallucinations: q no q Yes:__________ Family History of mental Illness: q no q Yes

Orientation: Person q no q Yes medical History: q hiV/aiDs (CD4:_____) q tB

Place q no q Yes q htn q head injury (with loss of consciousness)

time/Date q no q Yes q Epilepsy q Dementia q Other:___________

Friend/Family member q no q Yes Alcohol Use: q no q Yes: q Daily?

Current medications (names and doses):___________________________ Drug Use: q no q Yes:___________

Delirium

q Disturbance of consciousness with reduced ability to focus, sustain or shift attention.

q a change in cognition or the development of a perceptual disturbance (hallucinations) that is not better accounted for by a preexisting, established or evolving dementia.

q the disturbance develops over a short period of time (usually hours to days) and fluctuates during the day

q there is evidence from the history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.

q no q Yes (Patient must meet all four criteria above to make diagnosis)

3. meNTAl HeAlTH

History of mental illness: q no q Yes:___________________________________________________________________________________

Has the patient gone to m&k/beudet/other psych facility? q no q Yes:_____________________________

Is this the first episode of agitation? q no q Yes:_______________ History of suicide attempt: q no q Yes:__________________

Post-Ictal Psychosis: q no q Yes (episodes of agitation/psychosis only take place after epileptic seizure)Antipsychotic medication (Use Agitated Patient Protocol; give dose and indicate whether PO/Im):

q risperidone:_______________ q haloperidol:_______________ q Other: Diphenhydramine:_______________

4. FOllOWUP

q Psychologist contacted about patient

Presumed Etiology of agitation/Psychosis: q medical Problem/Delirium: _______________ q mental health Problem:_______________

has haloperidol been given?: q no q Yes q Fluids ordered/given q EKg ordered/done

notes: _________________________________________________________________________________________________________________

Patient Name:________________________ sex:____ Phone:_____________ Provider:_________________ Date: dd/mm/yy


1

me

DIC

AT

ION

CA

RD

FO

R A

GIT

AT

ION

, D

el

IRIU

m,

AN

D P

sy

CH

Os

Is

RIs

PeR

IDO

Ne

HA

lOPe

RID

Ol

DIA

ZePA

mC

AR

bA

mA

ZePI

Ne

vA

lPR

OA

Te

1st

Cho

ice:

“A

typi

cal”

Ant

ipsy

chot

ic/M

ood

stab

ilize

r

Use

for

: Psy

chos

is (

wit

h or

wit

hout

man

ia)

2nd

Cho

ice:

“Ty

pica

l”

Ant

ipsy

chot

ic/M

ood

stab

ilize

r

Use

for

: Agg

ress

ive

or v

iole

nt

psyc

hosi

s (w

ith

or w

itho

ut m

ania

)

Ben

zodi

azep

ine

Use

for

: Alc

ohol

wit

hdra

wal

,

acut

e ag

itat

ion

wit

h or

wit

hout

ant

i-ps

ycho

tic

3rd

Cho

ice:

Moo

d st

abili

zer

Do

not

pres

crib

e w

itho

ut

cons

ulti

ng m

enta

l hea

lth

team

Use

for

: man

ia w

itho

ut

psyc

hosi

s

4th

choi

ce: M

ood

stab

ilize

r

Do

not

pres

crib

e w

itho

ut

cons

ulti

ng m

enta

l hea

lth

team

Use

for

: man

ia w

itho

ut

psyc

hosi

s (l

ongs

tand

ing

aggr

essi

on o

r vi

olen

ce in

mal

es)

DO

NO

T U

se IF

•C

autio

n if

child

/ado

lesc

ent

•Pr

ior

hist

ory

of d

ysto

nia

on

antip

sych

otic

med

icat

ion

•C

hild

ren

(18

or y

oung

er)

•Pa

tient

is d

eliri

ous

•Pr

egna

nt/b

reas

tfee

ding

wom

en

•C

hild

ren

(18

or y

oung

er)

•El

derly

(65

or

olde

r)

•Bl

ood

diso

rder

•Ep

ileps

y: a

bsen

ce s

eizu

res

•C

autio

n if

child

•W

omen

of

child

-bea

ring

age/

preg

nant

wom

en

•li

ver

dise

ase

•C

autio

n if

child

mU

sT C

ON

sUlT

m

eNTA

l H

eAlT

H

TeA

m

•Fo

r ps

ycho

sis

due

to d

emen

tia

(incr

ease

d ris

k of

dea

th)

•C

hild

ren

18 o

r yo

unge

r

•Pr

egna

nt w

omen

•Fo

r ps

ycho

sis

due

to d

emen

tia

(incr

ease

d ris

k of

dea

th)

•Pr

egna

nt w

omen

•Fo

r tr

eatm

ent

of a

ll m

enta

l

illne

ss (

excl

udin

g ep

ileps

y)

•Pr

egna

nt o

r br

east

feed

ing

wom

en

•Fo

r tr

eatm

ent

of a

ll m

enta

l

illne

ss (

excl

udin

g ep

ileps

y)

star

ting

Dos

e (A

dult

)Ta

ke a

t ni

ght

due

to s

edat

ive

effe

cts

•Bi

pola

r/Ps

ycho

sis

– 0.

5 – 1

mg

•D

eliri

um –

0.2

5 –

0.5

mg

Take

at

nigh

t du

e to

sed

ativ

e ef

fect

s

•Bi

pola

r/Ps

ycho

sis

mod

erat

e sx

s: 0

.5 –

2.5

mg

seve

re s

xs: 2

.5 –

5 m

g

•a

lway

s pr

escr

ibe

diph

enhy

dram

ine

25 –

50

mg

daily

with

hal

oper

idol

•D

eliri

um: 0

.5 –

2.5

mg

at n

ight

(Con

side

r lo

w-d

ose

of

rispe

ridon

e fir

st)

•A

ggre

ssiv

e/v

iole

nt P

atie

nts:

see

Agi

tate

d Pa

tien

t Pr

otoc

ol

see

agi

tate

d Pa

tient

Pro

toco

l

for

guid

elin

es r

egar

ding

use

.

200

mg

twic

e da

ily20

0 –

250

mg

twic

e da

ily

*Pat

ient

s re

ceiv

ing

valp

roic

acid

may

req

uire

a z

idov

udin

e

dosa

ge r

educ

tion

to m

aint

ain

unch

ange

d se

rum

zid

ovud

ine

conc

entr

atio

ns

“ste

p” o

f up

titr

atio

na

ntip

sych

otic

s re

quire

4 –

6 w

eeks

to

reac

h fu

ll ef

fect

. if

ther

e ar

e sa

fety

conc

erns

, phy

sici

ans

can

incr

ease

dose

s m

ore

quic

kly

(eve

ry 3

– 7

day

s)

by 0

.5 m

g in

crem

ents

. Del

irium

:

incr

ease

by

0.25

mg

incr

emen

ts.

ant

ipsy

chot

ics

requ

ire 4

– 6

wee

ks t

o

reac

h fu

ll ef

fect

. if

ther

e ar

e sa

fety

conc

erns

, phy

sici

ans

can

incr

ease

dose

s m

ore

quic

kly

(eve

ry 3

– 7

day

s)

by 2

.5 m

g in

crem

ents

.

see

agi

tate

d Pa

tient

Pro

toco

l

for

guid

elin

es r

egar

ding

use

.

200

mg

tota

l dai

ly25

0 –

500

mg

tota

l dai

ly

max

imum

Dos

e2

mg

Dos

es a

bove

2 m

g da

ily m

ust

be

revi

ewed

with

the

men

tal h

ealth

tea

m.

10 m

g

Dos

es a

bove

10

mg

daily

mus

t be

revi

ewed

with

the

men

tal h

ealth

team

.

10 m

g

Dos

es a

bove

10

mg

daily

mus

t be

rev

iew

ed w

ith t

he

men

tal h

ealth

tea

m.

800

mg

(for

men

tal i

llnes

s)

Dos

es a

bove

800

mg

mus

t

be r

evie

wed

with

the

men

tal

heal

th t

eam

.

1000

mg

(for

men

tal i

llnes

s)

Dos

es a

bove

100

0 m

g m

ust

be r

evie

wed

with

the

men

tal

heal

th t

eam

.


2

med

icat

ion

Car

d fo

r A

gita

tion

, Del

iriu

m, a

nd P

sych

osis

(co

ntin

ued)

RIs

PeR

IDO

Ne

HA

lOPe

RID

Ol

DIA

ZePA

mC

AR

bA

mA

ZePI

Ne

vA

lPR

OA

Te

Toxi

citi

es*i

f ra

sh, s

top

med

icat

ion

and

retu

rn t

o ho

spita

l

seri

ous

Dys

toni

a (e

spec

ially

of

phar

ynx,

eye

s, n

eck—

tem

pora

ry b

ut p

oten

tially

fat

al),

Tard

ive

Dys

kine

sia

(per

man

ent)

, Aka

this

ia (

rest

less

ness

), D

iabe

tes,

Car

diac

arrh

ythm

ia le

adin

g to

tor

sade

s de

s po

inte

s

Ris

k of

sei

zure

if d

iaze

pam

with

draw

n w

ithou

t ta

per

afte

r re

gula

r us

e at

hig

her

dose

Ras

h, li

ver

failu

re, d

ecre

ased

whi

te b

lood

cou

nt

(Car

bam

azep

ine

can

caus

e hy

pona

trem

ia)

(Val

proa

te c

an c

ause

ser

ious

bir

th d

efec

ts in

pre

gnan

cy)

Com

mon

•se

datio

n

•W

eigh

t g

ain

•la

ctat

ion

•a

men

orrh

ea

•En

ures

is (

for

boys

)

•se

datio

n

•h

eavy

ton

gue

•st

iffne

ss

•a

rrhy

thm

ia (

for

patie

nts

rece

ivin

g

mor

e th

an 1

0 m

g da

ily)

•se

datio

n

•D

epen

denc

e (s

houl

d no

t

be g

iven

for

long

per

iods

of t

ime)

Fatig

ue, d

izzi

ness

, nau

sea/

vom

iting

, inc

oord

inat

ion,

dou

ble

visi

on

(Car

bam

azep

ine

decr

ease

s ef

ficac

y of

ora

l con

trac

eptiv

es;

Valp

roat

e ca

uses

tre

mor

)

mon

itor

ing

•Ba

selin

e: a

ims,

wei

ght,

fas

ting

gluc

ose,

hem

ogra

m, h

epat

ic p

anel

(if a

vaila

ble)

•Ev

ery

visi

t: w

eigh

t, v

ital s

igns

•Ev

ery

6 m

onth

s: a

ims,

fas

ting

gluc

ose,

hep

atic

pan

el, h

emog

ram

•Ba

selin

e: a

ims,

wei

ght,

fas

ting

gluc

ose,

hem

ogra

m, h

epat

ic

pane

l (if

avai

labl

e)

•Ev

ery

visi

t: w

eigh

t, v

ital s

igns

•Ev

ery

6 m

onth

s: a

ims,

fast

ing

gluc

ose,

hep

atic

pan

el,

hem

ogra

m

•m

onito

r fo

r si

gns

of

seda

tion

•m

onito

r fo

r de

pend

ence

(nee

d fo

r in

crea

sed

dose

to a

chie

ve s

ame

effe

ct)

lFts

, CBC

, sod

ium

Wei

ght

gain

, lFt

s, C

BC

hiV

pat

ient

s re

ceiv

ing

valp

roic

acid

may

req

uire

a z

idov

udin

e

dosa

ge r

educ

tin t

o m

aint

ain

unch

ange

d se

rum

zid

ovud

ine

conc

entr

atio

ns.

Tape

ring

/D

isco

ntin

uing

if t

here

is a

life

-

thre

aten

ing/

toxi

c si

de

effe

ct, s

top

imm

edia

tely

.

•C

onsu

lt w

ith

the

men

tal h

ealt

h

team

bef

ore

tape

ring

med

icat

ion.

som

e pa

tien

ts m

ay n

eed

to

cont

inue

ris

peri

done

inde

fini

tely

.

•if

the

pat

ient

has

oth

er s

igni

fican

t

side

eff

ects

, con

side

r de

crea

sing

the

dose

slo

wly

(by

0.2

5 –

0.5

mg

incr

emen

ts)

and

mon

itorin

g cl

osel

y.

Can

als

o co

nsid

er c

hang

ing

to

halo

perid

ol.

•C

onsu

lt w

ith

the

men

tal h

ealt

h

team

bef

ore

tape

ring

med

icat

ion.

som

e pa

tien

ts m

ay n

eed

to

cont

inue

hal

oper

idol

inde

fini

tely

.

•if

the

pat

ient

has

oth

er s

igni

fican

t

side

eff

ects

, con

side

r de

crea

sing

the

dose

slo

wly

(by

2.5

mg

incr

emen

ts)

and

mon

itorin

g

clos

ely.

Can

als

o co

nsid

er

chan

ging

to

rispe

ridon

e.

•O

nly

used

for

the

man

agem

ent

of

agita

ted/

viol

ent

patie

nts

and

alco

hol w

ithdr

awal

.

•it

sho

uld

not

be

cont

inue

d fo

r m

ore

than

seve

ral d

ays.

red

uce

by s

teps

abo

ve e

very

2 –

4 w

eeks

.

red

uce

by s

teps

abo

ve e

very

2 –

4 w

eeks

.

•Fo

r de

liriu

m, s

top

the

med

icat

ion

afte

r m

edic

al il

lnes

s is

tre

ated

.

•Fo

r ch

roni

c ps

ycho

sis

due

to m

enta

l illn

ess:

if t

he p

atie

nt is

sho

win

g

impr

ovem

ent

in s

ympt

oms

and

has

no m

ajor

sid

e ef

fect

s, d

o no

t st

op t

he

med

icat

ion.

•Fo

r ac

ute

psyc

hosi

s du

e to

men

tal i

llnes

s: c

onsi

der

slow

ly t

aper

ing

the

med

icat

ion

afte

r pa

tient

is s

ympt

om-f

ree

for

3 –

6 m

onth

s.

bre

astf

eedi

ngD

o no

t pr

escr

ibe

to p

regn

ant

or

brea

stfe

edin

g pa

tient

s w

ithou

t

cons

ultin

g w

ith t

he m

enta

l hea

lth

team

; giv

e fo

lic a

cid

4 m

g Q

D

thro

ugh

preg

nanc

y.

Do

not

pres

crib

e to

pre

gnan

t or

brea

stfe

edin

g pa

tient

s w

ithou

t

cons

ultin

g w

ith t

he m

enta

l hea

lth

team

; giv

e fo

lic a

cid

4 m

g Q

D

thro

ugh

preg

nanc

y.

Con

trai

ndic

ated

Do

not

pres

crib

e (f

or m

enta

l

illne

ss)

to p

regn

ant

or

brea

stfe

edin

g pa

tient

s w

ithou

t

cons

ultin

g th

e m

enta

l hea

lth

team

; giv

e fo

lic a

cid

4 m

g Q

D

thro

ugh

preg

nanc

y.

Do

not

initi

ate.

if a

lread

y on

,

mak

e su

re t

akin

g 4

mg

folic

acid

QD

.


3

TR

eA

Tm

eN

T F

OR

AN

TIP

sy

CH

OT

IC m

eD

ICA

TIO

N s

IDe

eF

Fe

CT

s

esP

(ex

TRA

PyR

Am

IDA

l sy

mTO

ms)

TAR

DIv

e D

ysk

INes

IAN

eUR

Ole

PTIC

mA

lIG

NA

NT

syN

DR

Om

e (N

ms)

AC

UTe

Dy

sTO

NIA

Ak

ATH

IsIA

man

ifes

tati

onm

uscl

e rig

idity

(po

tent

ially

incl

udin

g:

eye

mus

cles

, thr

oat,

neck

, ton

gue,

bac

k)

EM

ER

GEN

CY

Psyc

hom

otor

res

tless

ness

invo

lunt

ary

orof

acia

l mov

emen

ts (

may

be p

erm

anen

t)

Con

fusi

on, d

eliri

um, s

tiffn

ess

(like

a

lead

pip

e), s

wea

ting,

hyp

erpy

rexi

a,

auto

nom

ic in

stab

ility

, dro

olin

g,

elev

ated

WBC

, ele

vate

d C

PK, d

eath

EM

ER

GEN

CY

Trea

tmen

tD

iphe

nhyd

ram

ine

50 –

75

mg

im o

r

PO d

aily

seve

ral l

iters

of

iV o

r PO

flui

ds d

aily

Prop

rano

lol 1

0 –

20 m

g ti

D

Can

als

o de

crea

se t

he d

ose

of

med

icat

ion

Dis

cont

inue

neu

role

ptic

or

low

er d

ose

Con

side

r V

itam

in C

(50

0 –

1000

mg/

d)

+ V

itam

in E

(12

00 –

160

0 iu

/d)

1. D

isco

ntin

ue o

ffen

ding

med

icat

ion.

2. m

edic

al e

valu

atio

n an

d su

ppor

t

(con

side

r iV

flui

ds)

3. h

ospi

taliz

e

4. C

onsi

der

dopa

min

e ag

onis

ts o

r

dant

role

ne t

o im

prov

e ou

tcom

e.

Toxi

citi

esse

riou

sa

naph

ylax

is, a

nem

ia, a

rrhy

thm

iaa

rrhy

thm

ia, b

ronc

hosp

asm

, ste

vens

-

John

son

synd

rom

e

Com

mon

Dro

wsi

ness

, diz

zine

ss, h

eada

che,

dry

mou

th, t

achy

card

ia, c

onst

ipat

ion,

blur

red

visi

on

Fatig

ue, d

izzi

ness

, nau

sea,

dep

ress

ion,

inso

mni

a


1

me

DIC

Al

ev

Al

UA

TIO

N P

RO

TO

CO

ls

FO

R A

GIT

AT

ION

, D

el

IRIU

m A

ND

Ps

yC

HO

sIs

sU

mm

AR

y

PR

OT

OC

Ol

In

A C

lIn

IC/H

OS

PIT

Al

SE

TT

Ing

sTeP

1a:

Is P

erso

n A

gita

ted?

Pati

ent

is c

onsi

dere

d ag

itat

ed if

the

y ar

e an

y of

the

follo

win

g:

•V

iole

nt, a

ggre

ssiv

e

•Ye

lling

, thr

eate

ning

•m

anic

, del

usio

nal (

has

untr

ue, fi

xed

belie

fs)

•h

allu

cina

ting

•a

cute

ly p

aran

oid

•W

ringi

ng o

f ha

nds,

pac

ing,

tap

ping

han

d

•r

apid

spe

ech,

rai

sing

voi

ce

•Fr

eque

nt r

eque

sts,

low

fru

stra

tion

tole

ranc

e

sTeP

1b:

Det

erm

ine

leve

l of

Agi

tati

on a

nd m

anag

e•

Ref

er t

o A

gita

ted

Pati

ent

Prot

ocol

to

guid

e ag

itat

ion

man

agem

ent

depe

ndin

g on

sym

ptom

s an

d se

veri

ty

•u

se c

alm

voi

ce

•g

ive

verb

al s

uppo

rt

•D

ecre

ase

stim

uli

•a

sk, “

how

can

i he

lp?”

•a

lert

sta

ff

•K

eep

your

self

safe

•u

se W

hO

mhg

aP

(p.7

4) f

or s

elf-

har

m/s

uici

de a

sses

smen

t

if ne

cess

ary

box

1: s

tand

ard

med

ical

eva

luat

ion

for

Agi

tati

on/D

elir

ium

/Psy

chos

is

•Br

ief

his

tory

–m

edic

al h

isto

ry

–a

lcoh

ol/s

ubst

ance

abu

se

–C

urre

nt m

edic

atio

ns

–h

isto

ry o

f m

enta

l illn

ess

•V

ital s

igns

, phy

sica

l exa

m

•n

euro

logi

cal E

xam

•m

enta

l sta

tus

Exam

–O

rient

atio

n

–a

lert

ness

–C

onfu

sion

box

2: D

elir

ium

1. D

istu

rban

ce o

f co

nsci

ousn

ess;

red

uced

abili

ty t

o fo

cus,

sus

tain

or

shift

att

entio

n.

2. a

cha

nge

in c

ogni

tion

or t

he d

evel

opm

ent

of a

per

cept

ual d

istu

rban

ce (

hallu

cina

tions

)

that

is n

ot d

ue t

o a

pree

xist

ing,

est

ablis

hed

or e

volv

ing

dem

entia

.

3. t

he d

istu

rban

ce d

evel

ops

over

a s

hort

perio

d of

tim

e (u

sual

ly h

ours

to

days

) an

d

fluct

uate

s du

ring

the

day

4. t

here

is e

vide

nce

from

the

his

tory

, phy

sica

l

exam

inat

ion

or la

bora

tory

find

ings

tha

t

the

dist

urba

nce

is c

ause

d by

the

dire

ct

phys

iolo

gica

l con

sequ

ence

s of

a g

ener

al

med

ical

con

diti

on.

NO

THeN

yes

sTeP

2: P

erfo

rm m

edic

al A

sses

smen

t (s

ee b

ox 1

, ReF

eR t

o an

d R

eCO

RD

info

rmat

ion

on A

gita

ted

Pati

ent

Form

, inc

ludi

ng):

•sa

fety

: tal

k fir

st, d

o no

t m

edic

ate

first

•m

edic

al H

ealt

h: t

ake

vita

l sig

ns, p

hysi

cal e

xam

, men

tal s

tatu

s ex

am t

o as

sess

for

del

irium

•m

enta

l Hea

lth:

tak

e hi

stor

y

•Fo

llow

-Up:

con

tact

psy

chol

ogis

t

•C

ontin

ue e

valu

atio

n an

d tr

eatm

ent

of u

nder

lyin

g

med

ical

con

ditio

n.

•C

onsi

der

low

-dos

e an

tipsy

chot

ic f

or d

eliri

um

(see

med

icat

ion

card

)

•C

onsu

lt m

enta

l hea

lth t

eam

/psy

chol

ogis

t

abn

orm

al m

enta

l sta

tus

exam

or

mee

ts c

riter

ia f

or

delir

ium

(se

e b

ox 2

)

see

Page

2 f

or c

onti

nuat

ion

of m

edic

al A

sses

smen

t

yes

NO


2

med

ical

eva

luat

ion

Prot

ocol

s fo

r A

gita

tion

, Del

iriu

m a

nd P

sych

osis

sum

mar

y (c

onti

nued

)

•tr

eat

alco

hol w

ithdr

awal

with

10

mg

iV/i

m

diaz

epam

, rep

eat

afte

r 15

min

s as

nee

ded

until

res

pons

e, t

hen

repe

at in

6 h

ours

.

•m

onito

r re

spira

tory

rat

e to

avo

id o

verd

ose

•m

alar

ia s

mea

r an

d co

nsid

er e

mpi

ric

trea

tmen

t fo

r m

alar

ia

•lu

mba

r pu

nctu

re a

nd c

onsi

der

empi

ric r

x

with

app

ropr

iate

ant

ibio

tic m

edic

atio

n

Con

side

r C

T be

fore

lP

if a

sym

met

ric

pupi

ls o

r

abno

rmal

ext

ra-o

cula

r m

ovem

ent

or g

ait.

•lP

, as

abov

e

•C

onsi

der

empi

ric r

x w

ith a

ppro

pria

te

antib

iotic

med

icat

ion

Con

side

r tr

eatm

ent

for

toxo

plam

osis

or c

ryto

cocc

us.

•C

onsi

der

addi

tiona

l tes

ts: r

enal

pan

el, l

iver

pane

l, ch

est

x-ra

y

•tr

eat

acco

rdin

gly

trea

t fo

r ne

uros

yphi

lis w

ith p

enic

illin

•Fu

rthe

r ne

urol

ogic

al t

estin

g (s

ee b

ox 3

)

•C

onsi

der

Ct,

EEg

, or

lP

•C

onsu

lt w

ith s

peci

alis

ta

bnor

mal

neu

rolo

gic

exam

rec

ent

onse

t an

d

tem

pera

ture

> 3

8 C

hiV

+ w

ith C

D4

coun

t <

200

Posi

tive

rPr

abn

l glu

cose

, ele

ctro

lyte

s,

or o

ther

evi

denc

e of

med

ical

illn

ess

(see

box

4)

ris

k fa

ctor

s fo

r dr

ug o

r

alco

hol w

ithdr

awal

or

into

xica

tion?

(se

e b

ox 5

)

Con

side

r a

prim

ary

psyc

hotic

dis

orde

r

Perf

orm

men

tal H

ealt

h A

sses

smen

t

and

Con

sult

men

tal H

ealt

h Te

am

On

med

icat

ion

caus

ing

psyc

hosi

s? (

see

box

6)

Det

erm

ine

whe

ther

his

tory

of

psyc

hosi

s an

d m

edic

atio

n us

e co

inci

de.

Con

side

r di

scon

tinui

ng m

edic

atio

n.

yes yes

yes

yes

yes

yes

yes

yes

THeN

THeN

box

4: C

omm

on s

yste

mic

Con

diti

ons

that

can

Cau

se/C

ontr

ibut

e to

Psy

chos

is

•m

alar

ia

•El

ectr

olyt

e ab

norm

aliti

es (

sodi

um, c

alci

um)

•m

alnu

triti

on, t

hiam

ine

defic

ienc

y

•th

yroi

d di

seas

e

•a

lcoh

ol w

ithdr

awal

•h

ypox

ia

box

6: m

edic

atio

ns t

hat

can

Cau

se/C

ontr

ibut

e

to P

sych

osis

•C

ortic

oste

riods

•C

yclo

serin

e

•is

onia

zid,

Efa

vire

nz

•C

ortic

oste

roid

s

•Ph

enob

arbi

tal

•h

igh

dose

s of

ant

i-ch

olin

ergi

c m

edic

atio

n

box

3: N

euro

logi

cal C

ondi

tion

s th

at C

ause

or

Con

trib

ute

to P

sych

osis

•te

rtia

ry s

yphi

lis

•En

ceph

ilitis

•D

emen

tia (

hiV

, alz

heim

ers)

•Pa

rkin

sons

•Br

ain

tum

ors

or o

ther

mas

s le

sion

s (t

B,

lym

phom

a, t

oxop

lasm

osis

)

box

5: A

lcoh

ol W

ithd

raw

al

•h

isto

ry o

f he

avy

alco

hol u

se (

last

drin

k

24 –

28

hour

s pr

ior

to s

ympt

oms)

•se

vere

alc

ohol

with

draw

al:

–W

ithin

a f

ew h

ours

: with

draw

al

trem

ors,

nau

sea,

vom

iting

, sw

eatin

g,

anxi

ety

–W

ithin

a f

ew d

ays:

hal

luci

natio

ns,

seiz

ures

, fev

er, d

isor

ient

atio

n,

hype

rten

sion

Con

tinu

atio

n of

med

ical

Ass

essm

ent

NO

NO

NO

NO

NO

NO

NO


level ReACHeD IN THe PAsT TWO Weeks? IN THe PAsT yeAR?

1. Passive no Yes no Yes

Ask: Do you have any thoughts of ending your life, even if they are not clear in your mind?

Possible Response: i think about it from time to time, but i’ve never acted upon it...i would make my family feel too bad...god would not forgive me

Description:

2. Non-specific Active no Yes no Yes

Ask: Do you want to die? Do you often think or talk about death?

Possible Response: desire/wish to be dead…prefer to be dead…think frequently/talk about death…god would rather have me

Description:

3. methods but no Intent to Act no Yes no Yes

Ask: if you would do it, how would you do it?

Possible Response: bleach, pesticide, herbicide, battery acid, hang themselves, medication overdose, stop taking medication, a knife, a gun

Description:

4. Intent to Act no Yes no Yes

Ask: Do you intend to act on these thoughts?

Possible Response: i will kill myself but i do not know when… i do not think i can do so now…but it’s too much for me, i cannot yet

Description:

5. Planification no Yes no Yes

Ask: have you started planning the details about how you will kill yourself?

Danger signs: there is a sudden change in attitude, withdraws from everything; not interested in anything; say: “when i am not here anymore”; seeks to implement the plan, write a note (on paper).

Description:

6. Attempted no Yes no Yes

Ask: have you tried to do something that could hasten the end of your life? have you stopped preserving your life, like not eating and not taking medication?

Danger signs: realized did not want to die after the attempt failed, but it often gets worse again after a few days; might have some injuries or marks.

Description:

low: Current = 0 Past = 0

medium: Current = 1–2 yes Or Past = 1 or more yes

High: Current = 3 or more yes Or Past = 3 or more yes

Total “yes” in past two weeks

Total “yes” in past year

ZANmI lAsANTe — meNTAl HeAlTHsUICIDAlITy sCReeNING INsTRUmeNT


1

For All Patients

act 1. Ensure that the environment will be private, safe and non-threatening.

2. Begin the process of ensuring that the patient will be able to access necessary medication.

3. always work with the patient to develop a safety Plan.

say 4. use the patient’s name often, give hope, insist that there are other options, and declare your intent to help.

5. start iPt and collect iP inventory.

6. Provide psychoeducation about depression, suicidality, psychopharmacology, therapy and Zl resources.

7. identify specific current supports and potentially welcome supports (e.g. neighbors, clergy). (Write this on the copy of your Safety Plan, on the back side).

Contact 8. always contact at least one person close to the patient to support and monitor them.

9. Contact as many of the current and potential supports as a patient will permit

• You should utilize the clergy early and heavily for supporting, home visiting, and monitoring patients

•When involving anyone, ensure that you preserve confidentiality if possible and define these:

1. Depression, suicidality

2. the needs of such patients

3. how others can help

4. how others can hurt

team 10. Consult and involve colleagues to help.

social Worker Psychologist Community health Worker Doctor

Follow up

11. if the patient has a higher risk level, continue to the guidelines below.

Provider: location: Date: / / last name: _________________________ First name: nickname: File #:

ZANmI lAsANTe — meNTAl HeAlTH sUICIDAlITy TReATmeNT GUIDelINes


2

For patients with meDIUm risk, include these additional aspects in your care.

act 1. maintain a high index of suspicion for understatement and concealed ideation. Be sure of your assessment.

say 2. ascertain what caused the ideation to increase in seriousness and specificity and/or what caused it to occur.

3. seek agreement or at least acceptance that individuals in that patient’s milieu may need to be notified explicitly.

Contact 4. Close family should be informed quickly and explicitly of the patient’s suicidality.

team 5. at least one social worker and psychologist should cooperate closely on all cases with greater than low risk.

Follow up

6. if the patient is medium risk, schedule follow-up within 7 days. Date Time if the patient is high risk, continue to the guidelines below.

For patients with HIGH risk, include these additional aspects in your care.

act 1. Ensure safety and calm. remove potential weapons. Obtain help and apply physical/chemical restraint if necessary.

2. seek to admit patient to the emergency room or another service with beds for at least 24 hours.

3. Determine who will be available to watch the patient and when so that they are not left unattended.

name time name time

name time name time

name time name time

say 4. Despite the potential necessity of negating the patient’s autonomy, do as much as possible to preserve dignity.

Contact 5. any and all accessible individuals from the patient’s milieu (you are justified in breaching confidentiality here).

6. any and all potentially influential individuals (neighborhood elder, clergy, Freemason).

team 7. mD: make sure no attempt has been made occultly, and rule out remediable organic processes (especially pain).

8. any available clinical staff can be called upon to help in monitoring - if necessary, other patients can be as well.

Follow up

9. Keep the patient admitted and under continuous monitoring (e.g. 4x/hr).

10. Frequently re-assess risk level.

11. if the patient leaves or can’t be kept, follow through with continued intensive psychosocial activation.

ZANmI lAsANTe — meNTAl HeAlTH sUICIDAlITy TReATmeNT GUIDelINes


ZANmI lAsANTe — meNTAl HeAlTH sAFeTy PlAN

sTeP 1 Warning signs that a crisis is developing (such as thoughts, images, moods, situations, behavior):

1. 2.

3. 4.

5. 6.

sTeP 2 internal coping strategies – activities that i can do without others to distract myself from my problems, such as relaxation techniques:

1. 2.

3. 4.

5. 6.

sTeP 3 People and social environments that offer distractions and support:

name telephone

name telephone

name telephone

Where Where

step 4 People and social environments that offer distractions and support:

name telephone __________________________________________

name telephone __________________________________________

name telephone __________________________________________

sTeP 5 Professionals and agencies i can contact during a crisis:Community health Worker telephone __________________________________________

ajan sante telephone __________________________________________

social Worker telephone __________________________________________

Psychologist telephone __________________________________________

Doctor telephone __________________________________________

spiritual healer telephone __________________________________________

Emergency room/hospital telephone __________________________________________

sTeP 6 making the environment safe:

I, , will follow the steps when I’m in a crisis,and one thing more important to me than anything else that will help me live is…


1

Date:

name: Psychologist / sW:

Patient iD: age:

male/ Female (circle one) Phone #1:

town: Phone #2:

District: session#:

Date recieved patient info:

I. Severity of Illness

Considering your total clinical experience with this particular population, how mentally ill has the patient been over the past 7 days?

Tip: Compare relative to your past experience with patients who have the same diagnosis considering your total clinical experience with this population.

0 = Not assessed

1 = Normal, not at all ill. symptoms of disorder have not been present in the past seven days.

2 = borderline mentally ill. subtle or suspected symptoms within the past seven days. no definable impact on behavior or function.

3 = mildly ill. Clearly established symptoms causing minimal, if any, distress or difficulty in social or occupational function.

4 = moderately ill. Overt symptoms causing noticeable, but modest, functional impairment or distress. there is evidence of functional interference in multiple settings. some symptoms may warrant medication.

5 = markedly ill. intrusive symptoms that distinctly impair social or occupational function or cause intrusive levels of distress. Functional interference due to symptoms is obvious to others.

6 = severely ill. Disruptive pathology; behavior and function are frequently influenced by symptoms. Dysfunction may require assistance from others.

7 = Among the most extremely ill patients. Pathology drastically interferes in many life functions. Patient may need to be hospitalized. Rating (number 0–7)

C l I N I C A l G l O b A l I m P R e s s I O N s s C A l e


2

II. Improvement

Compared to the patient’s baseline condition before treatment, how much has the patient changed?

Tips: For initial evaluation: if the patient has been in treatment previously, rate Cgi improvement based on the history and compared to the patient’s condition prior to treatment. Otherwise, leave blank.

Progress notes: rate improvement by comparing the current condition to the patient’s condition at the initiation of the current treatment plan. assess how much the patient’s illness has changed relative to a baseline state at the beginning of the treatment plan based on the first evaluation. rate total improvement whether or not in your judgment it is due to treatment.

0 = Not assessed

1 = very much improved. nearly all better; good level of functioning; minimal symptoms; represents a very substantial change.

2 = much improved. notably better with significant reduction of symptoms; increase in the level of functioning but some symptoms remain.

3 = minimally improved. slightly better with little or no clinically meaningful reduction of symptoms. may represent very little change in basic clinical status, level of care, or functional capacity.

4 = No change. symptoms remain essentially unchanged.

5 = minimally worse. slightly worse but may not be clinically meaningful; may represent very little change in basic clinical status or functional capacity.

6 = much worse. Clinically significant increase in symptoms and diminished functioning.

7 = very much worse. severe exacerbation of symptoms and loss of functioning.

Rating (number 0–7)

III. Side Effects

select the terms that best describe the degree of side effects of medication treatment.

0 = None

1 = Do not significantly interfere with patient’s functioning.

2 = significantly interfere with patient’s functioning.

3 = Outweighs therapeutic effects with patient’s functioning. Rating (number 0–3)

Clinical Global Impressions scale Continued...


Page 4 of 5 (12-item, interviewer-administered)

12

Interview

Section 3 Preamble

Say to respondent:

The interview is about difficulties people have because of health conditions.

Hand flashcard #1 to respondent

By health condition I mean diseases or illnesses, or other health problems that may be short or long lasting; injuries; mental or emotional problems; and problems with alcohol or drugs.

Remember to keep all of your health problems in mind as you answer the questions. When I ask you about difficulties in doing an activity think about...

Point to flashcard #1

• Increased effort

• Discomfort or pain

• Slowness

• Changes in the way you do the activity.

When answering, I’d like you to think back over the past 30 days. I would also like you to answer these questions thinking about how much difficulty you have had, on average, over the past 30 days, while doing the activity as you usually do it.

Hand flashcard #2 to respondent

Use this scale when responding.

Read scale aloud:

None, mild, moderate, severe, extreme or cannot do.

Ensure that the respondent can easily see flashcards #1 and #2 throughout the interview

Please continue to next page...

WHODAS-03(23Nov09).book Page 4 Tuesday, November 24, 2009 1:30 PM

WHODAS 2.0WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0


Page 5 of 5 (12-item, interviewer-administered)

12

Interview

Section 4 Core questions

Show flashcard #2

This concludes our interview. Thank you for participating.

In the past 30 days, how much difficulty did you have in:

None Mild Moderate Severe Extreme or cannot do

S1 Standing for long periods such as 30 minutes?

1 2 3 4 5

S2 Taking care of your household responsibilities?

1 2 3 4 5

S3 Learning a new task, for example, learning how to get to a new place?

1 2 3 4 5

S4 How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?

1 2 3 4 5

S5 How much have you been emotionally affected by your health problems?

1 2 3 4 5

In the past 30 days, how much difficulty did you have in:

None Mild Moderate Severe Extreme or cannot do

S6 Concentrating on doing something for ten minutes?

1 2 3 4 5

S7 Walking a long distance such as a kilometre [or equivalent]?

1 2 3 4 5

S8 Washing your whole body? 1 2 3 4 5

S9 Getting dressed? 1 2 3 4 5

S10 Dealing with people you do not know? 1 2 3 4 5

S11 Maintaining a friendship? 1 2 3 4 5

S12 Your day-to-day work/school? 1 2 3 4 5

H1 Overall, in the past 30 days, how many days were these difficulties present? Record number of days ____

H2 In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?

Record number of days ____

H3 In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?

Record number of days ____




Flashcard 1

Health conditions:• Diseases, illnesses or other health problems

• Injuries

• Mental or emotional problems

• Problems with alcohol

• Problems with drugs

Having difficulty with an activity means:

• Increased effort

• Discomfort or pain

• Slowness

• Changes in the way you do the activity

Think about the past 30 days only.




WHODAS 2.0

WORLD HEA

LTH ORG

ANIZATION

DISABILITY ASSESSM

ENT SC

HED

ULE 2.0

Flas

hcar

d 2

1

No

ne

2

Mild

3

Mo

der

ate

4

Sev

ere

5

Ext

rem

e o

r ca

nn

ot

do

WH

OD

AS-

03(2

3Nov

09).b

ook

Pag

e 7

Tue

sday

, Nov

embe

r 24,

200

9 1

:30

PM

Partners In Health888 Commonwealth Avenue, 3rd Floor, boston, mA 02215 www.pih.org

participant manual introduction to agitation, delirium

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