Mental Health Conditions PDF

Mental Health Conditions By Louise Roberts OVERVIEW Patients displaying changes in behaviour which are indicative of changes in mental health status and potential mental illness are common in the out-of-hospital setting and they present paramedics with unique clinical and management challenges. Changes in behaviour can be caused by alterations in the body's physiology due to organic causes such as infection or can be a result of mental illness. Patients presenting with altered behaviour require a specific approach to assessment, including the Mental State Assessment and Examination. These patients often have physical injuries as a result of their inability to adequately protect themselves from harm. Patients who are demonstrating that they are likely to come to harm can be involuntarily transported to hospital under legal provisions. Introduction According to the World Health Organization (WHO, 2013), mental health is a state of emotional and social wellbeing in which a person can fulﬁl their abilities, cope with the normal stressors of life, work productively and make a contribution to their community. Changes in mental health status and functioning may occur over the course of an individual's life. These changes fall across a spectrum of severity, from common mental health problems, which cause distress but are short-lived, to more severe mental illnesses. Mental illnesses are deﬁned as those which cause signiﬁcant 'disturbances in thinking, perception and behaviour’ (Dogra et al., 2017). They are characterised by having a longer duration, impaired functioning in at least one area of the individual's life and have a detrimental impact on the person's ability to cope (Bloch et al., 2017; Mindframe National Media Initiative, 2012). It is widely recognised that deﬁning mental illness and their associated characteristics (see Box 52.1) is often diﬃcult, and struggles to separate psychopathology from normal variances in human behaviour such as sadness after a loss and shyness (Stein et al., 2010). In the past 10 years research is starting to shed light on the relationship between physiological changes in the body and their association with the development of mental illness. Research has been broadly focused on the eﬀects of genetics, changes in neuroanatomy and physiology, neurotransmi ers, the immune system, the endocrine system and the relationship with the gut microbiome, speciﬁcally in its eﬀects on mood, in the development of mental illness (Bloch et al., 2017). BOX 52.1 Characteristics of a mental/psychiatric disorder Features A mental/psychiatric disorder is a behavioural or psychological syndrome or pa ern that occurs in an individual: the consequences of which must be clinically signiﬁcant distress (e.g. a painful symptom) or disability (i.e. impairment in one or more important areas of functioning)—that is, they must not be merely an expected response to common stressors and losses (e.g. the loss of a loved one) or a culturally sanctioned response to a particular event (e.g. trance states in religious rituals) that reﬂects an underlying psychobiological dysfunction that is not solely a result of social deviance or conﬂicts with society. Other considerations It must have diagnostic validity using one or more sets of diagnostic validators (e.g. prognostic signiﬁcance, psychobiological disruption, response to treatment). It must also have clinical utility (e.g. contribute to be er conceptualisation of diagnoses or to be er assessment and treatment). Source: Stein et al. (2010). This chapter provides an assessment framework as part of the paramedics’ tool box to understand and assess changes in behaviour and assist with diﬀerential diagnosis. The challenge for paramedics is to consider the broad causes of altered behaviour which can be due to a primary mental health problem, a non-mental health issue (e.g. a physical/organic cause such as hypoglycaemia) or an interaction of both. Paramedics need to ensure that the non-mental health causes of these presentations are considered, explored and treated, and a holistic assessment is done so as not to discount either mental or physical health issues. It should be noted that within the mental health sector the term 'mental health consumer’ or persons with 'lived experience’ is used in preference to 'patient’. For the sake of consistency within this text, however, the collective term 'patient’ is used. Prevalence of out-of-hospital and emergency department mental health presentations In any single year, 1 in 5 Australian adults will experience a mental illness: in 2014–15, 17.5% of Australians self-reported having a mental or behavioural condition (Australian Bureau of Statistics [ABS], 2015). Anxiety-related and mood (aﬀective) disorders were the most frequently reported with 11.2% and 9.3% respectively of the population experiencing these conditions within a 12-month period (ABS, 2015). Broadly, the most common presentations of mental illness in the out-ofhospital se ing are anxiety and mood (or aﬀective) disorders, presentations of self-harm, suicide ideations and suicide a empts, psychosis and schizophrenia, and drug and alcohol issues. Accurate statistics regarding the number of mental health presentations a ended by Australian and New Zealand paramedics are diﬃcult to obtain due to misleading categorisation of jobs at dispatch, uncertainty regarding the individual's diagnosis at the point of assessment (Roberts & Henderson, 2009) and diﬃculties linking out-of-hospital data with hospital patient care records. More recent data here in Australia has tried to address these issues by examining patient records directly. The data focused on paramedic a endance to self-harm and mental health-related presentations in Australia from 2013 and showed Ambulance Victoria a ended over 15,000 cases related to anxiety and more than 6000 cases of depression, over 6000 suicide a empts and 2000 cases of self-injury in a 12-month period (Lloyd et al., 2015). Similar prevalence rates were found in other Australian states, which demonstrates the vital role paramedics play in providing care and treatment for those in the community with mental health problems and illness. To add to this picture emergency departments (EDs) nationally in Australia managed an estimated 273,439 presentations with a mental health-related principal diagnosis during 2015–16 (3.7% of all ED occasions of service, excluding the Australian Capital Territory) (AIHW, 2017). According to the AIHW 12.8% of presentations were classiﬁed as emergency (requiring care within 10 minutes), with 77.5% of mental healthrelated presentations classiﬁed on initial assessment as being either urgent (requiring care within 30 minutes) or semi-urgent (requiring care within 60 minutes) (AIHW, 2017). Current reporting and trends recognised globally suggest that these ﬁgures are only likely to increase in the coming years, due to the mainstreaming of mental health services and a steadily increasing demand for services, which has not been met by increases in funding (Lowthian et al., 2011S. As such, paramedics need to be well educated in the areas of mental health and risk assessments and have a working knowledge of the primary diagnoses likely to present to emergency services. The mental health system: why the increase in the out-of-hospital attendance to those with mental health concerns Since the early 1970s the human rights movement and the advent of medications to manage more severe mental illness such as antipsychotics underpinned the movement of people from institutionalised (inpatient) care to community mental health care (deinstitutionalisation). More recently there has been a signiﬁcant push in public policy to reduce seclusion and restraint practices, promote and embed the principle of least-restrictive practice and move mental health services to the general health system and the community. The trend towards earlierdischarge inpatient units (short-stay units), hospital avoidance, signiﬁcant losses in mental health beds and funding (Bradbury et al., 2017S and greater provision of community and primary mental health care has moved the demand for service to the out-of-hospital and primary healthcare se ings (e.g. greater involvement of general practitioners, community mental health services, non-government organisations and emergency services) (Jespersen et al., 2016). While community treatment is the preferred option when possible, there is still a need to transport patients whose mental illness has unexpectedly exacerbated to require ED or psychiatric inpatient unit care. Admission to the ED allows for further medical assessment to rule out other causes of changed behaviour as well as a specialist psychiatric assessment to determine the most appropriate treatment option for the patient at that time. Possible outcomes include admission to treat an organic cause, admission to a psychiatric inpatient unit or discharge back home with follow-up by community mental health services. In other instances paramedics, depending on their assessment and the circumstances, may use alternative referral pathways such as local mental health teams, mental health triage consultation, mental health liaisons in either the ambulance operation centres or the ED or transport the patient directly to an inpatient mental health facility. The referral pathways vary according to speciﬁc local guidelines, laws and collaborations between available services. Concepts of recovery and the biopsychosocial model of care Mental illness eﬀects an individual's ability to function whether it is changes in the body's physiology, psychology or social and occupational functioning (see Box 52.2). Therefore, understanding the aetiology of the illness or identifying one clear causative factor becomes more diﬃcult and often not as crucial as the context and the story from the person themselves. To be able to provide context and understanding and build the eﬀective therapeutic relationship paramedics need to understand the concepts of recovery and the biopsychosocial model of care. BOX 52.2 Biological, psychological and social factors that may impact on mental health Biological Genetics, nutritional status, general state of health or, in more speciﬁc cases, structural abnormalities in the brain or variable levels of neurotransmi ers such as dopamine, serotonin, noradrenaline, GABA. Psychological Early experiences (childhood), personality, intelligence, a itudes and values, self-image and self-esteem, temperament, coping skills, stress and others. Social Family relationships, social supports, social skills, cultural background, as well as other environmental factors such as employment and others. Note: Some of the items identiﬁed can be considered within multiple categories. Paramedics are in a unique position to observe patients in their home environment, to identify community and social supports, facilitate engagement and communication between health professional and patient, and act as an advocate during the clinical handover of vital information if further care is required. An exclusive focus on the patient's physiological signs and symptoms may result in the loss of meaningful and crucial information, which might prolong the patient's episode of care. While the biomedical model of illness and treatment has distinct advantages in the out-of-hospital ﬁeld, where timely intervention is crucial and the linking of signs and symptoms to speciﬁc diagnostic criteria and treatment pathways is useful, it fails to account for broader factors which inﬂuence health outcomes. For example, depression is three times more likely after a patient suﬀers an acute myocardial infarction (AMI), despite there being no speciﬁc physical link that directly ties the damage of myocardial cells to decreased release of serotonin in the brain (Lichtman et al., 2008). Similarly, depressive symptoms after an AMI are predictors of increased mortality and worse health status, despite there being no direct physiological link between brain and cardiac function (Mallik et al., 2006). The biomedical model also fails to account for the importance of the patient–practitioner relationship in terms of successful recovery (the therapeutic relationship). The biopsychosocial model To provide a basis for understanding the determinants of disease and arriving at rational treatments and pa erns of health care, a medical model must also take into account the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive eﬀects of illness, that is, the physician role and the health care system. This requires a biopsychosocial model. Engel (1977) The biopsychosocial model on the other hand suggests that illness is the result of a complex interplay of psychological, social and biological factors, each of which should be considered in our assessment and treatment of the patient (Engel, 1977). While the biomedical model seeks to separate the biological factors from other factors, the biopsychosocial approach asserts that no single factor can be considered in isolation. Rather, the biological, social and psychological aspects of an individual's life aﬀect each other so that changes in one area will have an impact in another. This relationship is represented in Figure 52.1. FIGURE 52.1 The integrated relationship between the biological, psychological and social domains identified by Engel. The advantage of the biopsychosocial model is that it allows us to view a person as a whole being and provides a framework to understand the wide range of factors which may aﬀect health and individual variation. This ensures that important factors in the individual's health status are not missed. It also lends itself to multidisciplinary treatment models, with a combination of social, physical and psychological treatments being recognised and included in care provision. Unfortunately the model is not as prescriptive in terms of its assessment and treatment. Additionally, it has been argued that a further separation of biology and psychology can be arbitrary, if not misleading (Tavakoli, 2009). Regardless of the theoretical debate, a basic understanding of the biopsychosocial model is important for paramedics, as it directs mental health assessment and treatment models and provides a framework for communication between mental health disciplines. The recovery approach ‘Recovery’ is broadly deﬁned as a ‘deeply personal, unique process of changing one's a itudes, values, goals, skills and/or roles. It is a way of living a satisfying, hopeful and contributing life even within the limitations caused by illness’ (Anthony, 1993, p. 14). The challenging question for paramedics is what does this actually mean and how do we understand and apply this concept to practice in the out-of-hospital se ing? The recovery approach focuses on the relationship between the clinician and the patient. A key principle is the ability to listen and support the person with the lived experience of mental illness. Their perspective and voice is fundamental to creating a therapeutic relationship which moves from a 'deﬁcit’ framework (the person is unable, incapable or lacks capacity) to one that acknowledges the person has abilities and strengths and can contribute to their own care planning, and should be supported in doing so as much as possible (Leonhardt et al., 2017). The idea of recovery acknowledges that every individual is diﬀerent and due to illness may have challenges in making their own decisions and looking after themselves, but should be treated with respect, dignity and in the leastrestrictive and most-inclusive manner possible (Isaacs et al., 2017). Recovery also strongly points to the social systems and environmental factors which shape a person's life. Recovery suggests you can aim towards creating a positive and contributing life even though you have or are experiencing changes in mental health, social and family circumstances, work or personal environments, or trauma and stress. This leads us to consider the holistic nature of care, 'person-centred’ care and the biopsychosocial model of health. Pathophysiology As mentioned, the causes of mental illness are complex and involve biological, social and psychological factors which interrelate to create changes in behaviour that are disruptive and distressing for the person. Biological factors involve genetic, neurochemical, neuroendocrine, immunology and inﬂammation basis for mental illness as well as changes in brain function and structure. Gene studies, for example, have shown hereditability and the role of multiple genes is signiﬁcant in the development of mental illness. These studies have shown roughly half the risk of developing addiction and depression is hereditary. Genes and their interaction with the environment play an important role in the development of schizophrenia with the general population lifetime risk at around 1% compared to 10% in those with a family history (Bloch et al., 2017). Recently more research has been done into the role of the neurotransmi ers dopamine, serotonin, norepinephrine (noradrenaline) and their post-synapsis receptors and their association with depression and its development. Neurotransmi ers such as serotonin and gammaaminobutyric acid (GABA), the chief inhibitory neurotransmi er in the brain, interact with the emotional centres in the brain such as the amygdala, pre-frontal cortex, hippocampus, thalamus and hypothalamus and play a major role in how anxiety develops (Nuss, 2015). Advances in scanning techniques such as functional magnetic resonance imaging (fMRI) have allowed researchers to map and record brain function and structure in those with mental illness. Changes in volume and function of the pre-frontal cortex (e.g. in schizophrenia) are thought to be signiﬁcant and contribute to the development of psychosis (Bloch et al., 2017). The relationship between the endocrine system and the brain and the role of the immune system and inﬂammation are two areas currently creating a lot of interest in the quest to understand the development of mental illness. The hypothalamic–pituitary–adrenal (HPA) axis particularly plays a large role in regulating the body's stress response and is thought to be integral to the development and presentation of anxiety (Graeﬀ, 2017). Recent evidence investigating immune cells and their signalling indicates they also play a crucial role in the pathophysiology of major depressive disorder (MDD) and bipolar disorder (BD). The release of neuroactive cytokines, particularly interleukins, is altered in these disorders and creates neuroinﬂammation within the microglia cells within the central nervous system (Bha acharya et al., 2016). Psychological factors relate to those factors which are central to the person's personality, early life experiences and coping mechanisms, and how they view themselves and their world (see Box 52.2). Social factors are those which explore how the person interacts and engages with others such as their relationships, support networks, employment and cultural background Definitions In the mental health arena the classiﬁcation of mental illness is based in the International Classiﬁcation of Diseases (ICD) or the Diagnostic and Statistical Manual of Mental Health Disorders Fifth edition (DSM-5) (American Psychiatric Association, 2013). Both provide a guide to how mental health is identiﬁed and its characteristics. The following outlines the common presentations seen in the community and out-of-hospital environment. Table 52.1 provides symptoms, common medications and recommendations for out-of-hospital management of all the following conditions. Table 52.1 Common mental illnesses encountered by paramedics Anxiety disorders are one of the most common mental health issues seen in the community with approximately 14% of Australian adults experiencing an anxiety disorder over a 12-month period (AIHW, 2017). There are a number of diﬀerent types of anxiety disorders (panic a acks and panic disorders, generalised anxiety disorder, phobias, substance/medication-induced anxiety disorder) but all involve the person experiencing fear (the emotional response to a perceived or real imminent threat) and/or anxiety (anticipation of future threat) with associated behaviours that are prolonged and do not appear to match the level of threat or the situation. Anxiety disorders are characterised by the body's autonomic responses (ﬂight, ﬁght and freeze) such as increased heart rate (palpitations) and breathing rate, sweating, nausea, trembling, widened eyes and dilated pupils, feeling dizzy or lightheaded, tingling and y p p g y g g g numbness in extremities, and a feeling of being outside yourself (depersonalisation). A patient may also demonstrate or describe avoidance behaviours associated with the situation or objects which trigger their anxiety (DSM-5). Mood disorders are very common, with more than 1 million Australians reporting a past depressive episode. MDD is characterised by disturbances in mood and behaviour. Typical symptoms of a depressive episode include lowered mood, changes in appetite (signiﬁcant increase or decrease) and sleep (insomnia or hypersomnia), loss of interest or pleasure in usual activities, lowered motivation and energy, social withdrawal and diﬃculty concentrating. Suicidal thoughts may also be present. To meet the diagnostic criteria for MDD, symptoms must occur over a 2-week period and impact on the person's ability to perform everyday tasks. Understanding and identifying MDD is extremely important, as it can be a debilitating disorder that has strong links to suicidal ideation (thoughts of suicide) and a empted suicide (DSM-5). Bipolar disorder is the name used to describe a set of conditions that involve prolonged 'mood swings’ that impair functioning, the most severe of which is bipolar I (Black Dog Institute, 2010). Individuals with bipolar I experience long periods of high mood or mania, followed in most cases by periods of depression. First onset of the disorder typically occurs either in the late teens or in middle to late adulthood, and like many mental illnesses it is more likely to occur at times of heightened stress. PRACTICE TIP Ask! What is the reason for the call-out today? How long has X been an issue for you? What changes or symptoms have you noticed? Can you identify anything that may have triggered this change? What have you tried so far to manage X? Has anything been useful in the treatment of X? Are you on any medications? What support do you have? Key symptoms of a manic episode include high energy levels, irritability, grandiosity, racing thoughts, decreased sleep and increased engagement in pleasurable or risky activities (e.g. indiscriminate spending or sexual activity). Psychosis is an umbrella term used to describe a group of conditions that are characterised by disturbances in thoughts, sensory perception, beliefs and understanding of the world around you and the associated behaviour. Psychosis involves a loss of contact with reality (Kuipers et al., 2014). The majority of patients with psychosis experience their ﬁrst episode in adolescence or early adulthood. The lifetime risk of developing a psychotic disorder is diﬃcult to calculate as it relies on individuals presenting to centres where the diagnosis can be made and, as with many mental illnesses, suﬀerers may actively avoid such services or be unable to access them for signiﬁcant periods of time although unwell. While classed as a low-prevalence mental illness, accounting for around 3% of cases presenting to Australian specialised mental health services (Department of Health, 2010a), the severity and impact of psychotic disorders means that suﬀerers are likely to come into contact with the hospital sector when they are acutely unwell (Frost et al., 2002). Psychosis may be caused by illness such as schizophrenia, organic causes such as drug intoxication or metabolic causes such as diabetes (Queensland Ambulance Service, 2008). When someone is experiencing a psychotic episode for the ﬁrst time, a deﬁnitive diagnosis may be diﬃcult to identify, as diagnoses require observation and in some symptoms need to be prevalent for at least 1 month during a 6-month period (DSM-5). Common symptoms of a psychotic disorder include hallucinations, delusions and formal thought disorder. A hallucination is deﬁned as a sensory experience that occurs in the absence of any external stimuli (Davidson et al., 2004). Hallucinations may occur in one or more of the ﬁve senses (i.e. they may be visual, auditory, tactile, gustatory or olfactory in nature). Auditory hallucinations tend to be the most common followed by visual hallucinations. Delusions are ﬁrmly held beliefs despite evidence to the contrary. Formal thought disorder refers to problems in the organisation and interpretation of ideas, which can aﬀect communication and make it challenging for others to understand. Other symptoms that may occur during a psychotic episode include ﬂat or blunted aﬀect, social withdrawal, changes in sleeping and eating pa erns, and an absence of hygiene or personal grooming (Davidson et al., 2004) Checking for adherence to medications is important in patients with psychosis, as non-adherence has been estimated to occur in between 40% and 50% of cases in those living with schizophrenia. The non-adherence to g p medications contributes to relapse and increases the need for and number of hospital admissions (Tessier et al., 2017; Awad, 2004; Ba aglia, 2001), with symptom relapse being more severe compared with patients who maintain their medications as directed (Saba et al., 2007). Changes in routine and stresses such as job changes can precipitate non-compliance or trigger symptoms. Borderline personality disorder (BPD) refers to a pervasive instability in mood, relationships, behaviour and self-image with a primary diﬃculty in regulating and understanding emotions. Individuals with this disorder fear abandonment and often experience chronic feelings of isolation and emptiness. Impulsiveness is commonly seen in this condition and may contribute to destructive behaviours such as self-harm and addictions (Polk & Mitchell, 2009). As a personality disorder, BPD is not formally diagnosed until the patient is 18 years of age or older, when personality is considered to be a more stable and developed entity. These traits and symptoms may, however, occur in younger individuals. All patients with a diagnosed mental illness can have a relationship with health services in which they frequently access care on a crisis basis with li le ongoing support. This is especially the case for patients with BPD and for this reason most patients will have an established multidisciplinary plan that outlines the expected response for all of the clinicians involved in their care. There is also a perception that the changes in behaviour associated with BPD can be interpreted as patients using the ambulance response to seek a ention and that their presentation is not equivalent to those suﬀering a physical illness (see Box 52.3). BOX 52.3 Mental illness and ambulance misuse The question of misuse of ambulance services by patients with mental illness has been raised (Roberts & Henderson, 2009). Local and international literature, however, suggests that ambulances are not being misused by these patients (Fry & Brunero, 2004; Larkin et al., 2006). An Australian study by Fry and Brunero (2004) reported that 42% of patients with a mental illness who presented to ED were brought in by ambulance, while 39% were transported by police. They also noted that this group had higher triage codes on average than other a ending patients, suggesting a higher urgency for patients with mental illness. An international study by Larkin and colleagues (2006) supports these ﬁndings, with mental health patients deemed as higher urgency and more likely to result in admission than the general patient population, suggesting that ambulance services were not misused by this group. The transport of patients with a mental illness is indeed an appropriate use of ambulance resources and ambulance paramedics are well-placed to support the needs of patients, their families and the community during a mental health crisis. As our population grows older and a greater emphasis is placed on maintaining people in their own homes and providing care within the residential environment, paramedics are increasingly dealing with presentations involving dementia, delirium and older persons with complex care needs. The term delirium refers to a change in cognition and consciousness that develops over a short period of time. Possible symptoms include an altered conscious state, decreased a ention, a reversed sleep–wake cycle, disorientation, rambling or illogical speech, agitation and seeing things that do not exist (hallucinations). Delirium often has a clear cause which, if treated, can result in a reversal of symptoms (e.g. the classic urinary tract infection). The term dementia describes the symptoms of a large group of illnesses that cause a progressive decline in a person's cognition, memory and general functioning (Community Services and Health Industry Skills Council [CSHISC], 2009). There are many diﬀerent forms of dementia, each with its own cause. Alzheimer's disease is by far the most common cause of dementia, accounting for 50–70% of all cases (CSHISC, 2009). Dementia can occur at any age but is more common after the age of 65. Law and mental health Identifying the legal requirements for out-of-hospital treatment of mental health patients can be a challenging task. While mental health legislation exists in all states and territories within Australia and in New Zealand, the jurisdictions diﬀer in terms of the criteria for involuntary treatment, recognised practitioners and requirements. For this reason it is important to understand the agreed universal principles of mental health treatment. Universal requirements The fundamental aim of mental health legislation is to protect, promote and improve the lives and mental wellbeing of citizens. WHO (2005, p. 1) Key rights outlined by the WHO include quality in treatment delivery, non-discrimination, the rights to privacy and individual autonomy, freedom from inhumane and degrading treatment, the principle of the least-restrictive environment and the rights to information and participation in the treatment process (WHO, 2005). The World Medical Association (2006) states that compulsory treatment should be used only when medically necessary and for the shortest possible duration. Australia and New Zealand Mental health legislation diﬀers across jurisdictions, but each is informed by the universal requirements described above and the Convention on the Rights of Persons with Disabilities (CRPD). In Australia, there has been a move towards uniformity with the creation of the National Mental Health Reform Strategy (Department of Health, 2011). Voluntary versus involuntary Our aim is to provide care in the least-restrictive manner possible and therefore our goal should be to facilitate mental health care on a 'voluntary’ basis where the patient agrees to further assessment and treatment for their mental illness ('voluntary’ or 'informal’ patients) (Forrester & Griﬃths, 2001). However, other individuals who are experiencing mental ill health and are not able to safely be left at home and have diminished capacity to be able to make decisions may require 'involuntary’ treatment and transport by the ambulance service and the implementation of the relevant Mental Health Act. Such patients require admission for treatment of their mental illness to ensure their own safety or the safety of others but for whatever reason cannot or will not consent. Although speciﬁc guidelines for involuntary treatment diﬀer, some common criteria include that the person appears to have a mental illness and immediate treatment is required and the person presents a risk of harm to self or others and the person requires admission to a mental health facility for treatment (Forrester & Griﬃths, 2001). The decision to enact an involuntary treatment order is clearly a serious one, as it involves the revocation of a person's right to consent. For this reason a number of checks are included within mental health legislation to ensure a fair and just process. These include a request for admission from a friend, carer or authorised person; review from a psychiatrist following admission; limitations to detention periods; an appeals process; and, in most jurisdictions, a formal review board to monitor cases and ensure compliance with relevant legislation. Exclusions According to the United Nations (2002), there are a number of exclusions to involuntary treatment. Grounds for which someone cannot be held include: political, economic or social status; membership of a cultural, racial or religious group; family or professional conﬂict; non-conformity with moral, social, cultural or political values or religious beliefs prevailing in the person's community; or any other reason not directly related to mental health status. Confidentiality Maintaining patient conﬁdentiality is of paramount importance. However, the legal system recognises that there are times when the directive to keep a patient's information conﬁdential comes into direct conﬂict with the directive to maintain their safety. As an illustration, consider the case of an 88-year-old female who has a empted suicide following the death of her husband by taking a substantial overdose. Her daughter ﬁnds her in time and calls for an ambulance. During the assessment phase the patient conﬁdes that she intends to carry out her suicide plan once she is discharged home. She forbids the health professional from disclosing the information to her daughter or anyone else, fearing that her daughter will be distressed and that doctors may a empt to intervene in her plan. Although this information might ordinarily be considered conﬁdential, the risk the patient poses to herself is clear and immediate and therefore outweighs her rights to conﬁdentiality. In this case, the health professional is likely to be permi ed to disclose her plan to her doctors to ensure that she remains safe. Thus, rights to conﬁdentiality may be mitigated by risk. For more speciﬁc information regarding conﬁdentiality and consent in the case of mental illness and risk-speciﬁc behaviour, refer to the mental health legislation and/or health records legislation in your relevant jurisdiction. The Mental State Assessment The patient who presents with changes in behaviour poses a number of challenges with assessment and management in the out-of-hospital se ing. Mental health assessment and treatment in the out-of-hospital se ing is complex due to the broad nature of mental illness and the close association between mental health problems/mental illness and physical illness. For patients with changes in behaviour it is impossible to completely separate assessment from management: from the moment paramedics commence communicating with these patients they will be simultaneously assessing, managing and even treating. In almost every case, however, paramedic management will include communication as a tool for intervention and verbal de-escalation. The initial aim of assessment is to establish clinician and patient safety. This includes a scene assessment, observing the body language and interactions of those on the scene and, if circumstances allow, to obtain the patient's vital signs to systematically eliminate other physical (organic) causes for the changes in behaviour. Organic causes such as diabetes and other metabolic syndromes, hypoxia, hypotension, head injury, sepsis, intoxication, poisoning and cerebrovascular accident (CVA) can all present with changes in behaviour and should be considered and addressed if possible in the assessment and treatment of the patient. Diabetes, metabolic syndromes, cardiac issues and lowered life expectancy are all well documented co-occurring challenges for those living with mental illness. The physical eﬀects from social isolation and/or the breakdown of support networks and relationships (e.g. malnutrition, dehydration and substance use) and the high incidence of homelessness often associated with mental illness are important when assessing the patient in the out-ofhospital se ing. Assessment relies on careful history taking, skilful communication and the gathering of information from the person and others if the situation allows. Faced with a patient who may not be able to provide an accurate history or the changes in behaviour are too discrete and not obvious the challenge for paramedics is to safely identify the symptoms of concern, diﬀerentiate between the various causes of changes in behaviour, facilitate personcentred care and provide immediate support and treatment. To do this the paramedic needs to actively listen, observe and communicate with empathy. Techniques such as emotion recognition and acknowledgment, paraphrasing and summarising and open and non-threatening speech and body language are all vital in the development of the therapeutic relationship. Mental State Examination The Mental State Examination (MSE) or Mental State Assessment is a systematic assessment of a patient's mental health or state of mind at any given point in time (Victorian Government Department of Health, 2008). This formalised process of observation and questioning ensures that clinicians do not miss symptoms of concern. While the MSE provides a vital clinical picture and handover information it is important to note that it should never be the sole basis for a diagnosis. Diﬀerent versions of the MSE exist but cover the following domains: behaviour and appearance, aﬀect and mood, perception, thought ﬂow and thought content, conversation and speech, orientation and cognition, insight and judgment with particular interest in how the person is interacting with you and their environment (Table 52.2). Table 52.2 Mental State Examination categories and features It is important to note that the MSE is a standard assessment tool useful for patients with varying presentations, not just those presenting with a mental illness. While the MSE focuses exclusively on the patient's mental state, it is a part of an overall clinical assessment which include the person's physical observations, broader social and personal support networks, help-seeking behaviours, living environment (e.g. cleanliness, order, indication of ability to a end to daily living skills), sleeping pa erns and appetite and should be included as a part of the clinical handover. While paramedics do not engage in formal mental health diagnoses they do engage in the development of a clinical formulation to allow for a working diagnosis so that out-of-hospital treatment and service can be initiated. To make a clinical decision, even if it is to transport, paramedics must be able to perform a basic diﬀerential diagnostic process in order to identify the most appropriate treatment for the patient. You should therefore be able to identify whether the likely cause is a mental illness and, if so, what group of disorders is most likely (e.g. psychotic disorder versus anxiety disorder). The term 'diagnosis’ is used within this context as a working hypothesis with the understanding that it is in no way ﬁnal or deﬁnitive. Ask! What is bothering you the most today? What is your previous medical history? [To bystanders] Exactly what behaviour did you observe? Look for! Signs of an organic cause for abnormal behaviour An elevated temperature Abnormalities in pulse, blood pressure and respiratory rate Blood glucose level Sympathetic response giving pale, clammy skin and dilated pupils Signs of drug use CASE STUDY 1 Case 14934, 0954 hrs. Dispatch details: A 19-year-old female short of breath and in an altered conscious state in a stairway at her university. Initial presentation: The paramedics arrive to ﬁnd a frail, younglooking woman who is visibly distressed and hyperventilating. ASSESS The approach to this patient, a young female university student, should take into account her current vulnerability, social circumstance and age. Assuming no direct danger from the scene, the paramedics must ensure the patient feels safe for them to approach and take into account that this could be an assault or other trauma-related circumstance. Therefore, communication needs to be tailored accordingly. Approaching with relaxed body language, non-threatening position, tone of voice and empathy is vital to creating an eﬀective patient rapport and therapeutic relationship, which often creates a feeling of safety in the patient allowing more eﬀective history taking and sharing of their story. It is possible to maintain a relaxed posture while still keeping an eye on the safety of the situation. Patients with disturbed behaviour are rarely a threat to paramedic safety if they are handled with respect and sympathy. If preliminary observations of the scene and the patient suggest the presence of agitation or aggression that could threaten paramedic safety, modiﬁcations to the approach, assessment and treatment of the patient will need to be made to ensure everyone's safety (see Chapter 53). In this case, the observed behaviour is not threatening which allows paramedics to establish a set of baseline vital sign observations Gaining baseline observations (vital sign observations and initial observations of her behaviour, posture and interaction) will assist in diﬀerentiating between physical concerns which may be related to her current presentation, such as infection or injury, an acute stress response and/or mental illness such as anxiety or pos raumatic stress. Adequately se ing up rapport with the patient and gaining baseline observations aids paramedics in formulating a diagnosis and management pathway, but also meet the expectations of the patient and can quickly gain their conﬁdence and trust. This can be extremely useful when it comes time to ask more delicate details regarding the patient's social and mental health history, such as if there is a history of panic a acks or family history of anxiety or depression. It may also serve to distract the patient, resulting in a decline of her sympathetic nervous response. Vital signs Provided it is safe to do so and meets clinical assessment needs, obtaining the patient's vital signs and your initial observations of behaviour, scene and social context is a good starting point. While obtaining a full set of respiratory and perfusion observations, closely observe the patient's behaviour and start to include these factors in the assessment. Questions at this stage can focus on excluding physical causes such as a recent fall, illness or history of metabolic disorders such as thyroid disease or diabetes. Mental State Examination Table 52.3 provides an overview of the systematic way the Mental State Examination can describe and outline the patient's mental state from Case study 1. Table 52.3 Example Mental State Examination Risk assessment Initially the risk assessment aims to identify the risk the patient poses to the paramedic (harm to others) and to themselves (deliberate or accidental self-harm), which suggests paramedics need to be capable of performing a basic risk assessment to ensure their own safety and that of their patients. Although a basic risk assessment focuses on the physical risk of harm, other important considerations add to our understanding and clinical decisions regarding risk. The patient's level of engagement, presence of alcohol or drug use, personal and external resources, access to those resources, support networks and help-seeking behaviour, past medical history of mental illness, and individual capacity are also key areas to history taking and risk assessment. It may be argued that paramedics are not mental health professionals and as such should not have to perform a risk assessment. To counter this argument increasingly paramedics are being asked to make clinical decisions around referral pathways and whether the person needs hospital management (hospital avoidance); therefore, they are expected to be able to assess and make clinical judgments which includes when a ending those with mental illness. Recent data also shows that paramedics are a ending cases that are more primary mental healthcare focused and so they may not transport the patient to hospital and should be familiar with a basic risk assessment. In some circumstances the patient may well meet the criteria for involuntary admission on the grounds of their risk. If a risk assessment is not completed, this option will not be available and the patient may have a poorer outcome than if a good assessment had been done. Follow-up, transport and access to some form of deﬁnitive assessment and care is the best option to ensure patient safety and fulﬁl the paramedic's duty of care. Types of risk Harm to others In the out-of-hospital environment it is essential for paramedics to check for dangers prior to and when entering any scene. Being able to assess the potential for harm from the environment, patient or a third party is crucial to maintaining your own safety and the safety of others. Key to assessing risk is the ability to recognise changes in body language, speech and tone of voice and the interaction between yourself and the patient and others at the scene. Accidental self-harm Accidental self-harm refers to unintended harm that may come to a patient as a result of their mental state. Individuals with thought disturbance, perceptual disturbance(s) and/or active delusions may be considered to be at greater risk of accidental self-harm. Accidental self-harm can be assessed as a part of a formal MSE, most notably in the areas of judgment and insight. Deliberate self-harm Deliberate self-harm encompasses a spectrum of behaviour from minor self-inﬂicted injury to more serious suicide a empts. If adequate rapport has been established between patient and paramedic, acts of deliberate self-harm or intent will generally be disclosed in step 1 in the model below. In some instances, however, previous self-harm or intent may not be as overt. In these instances the paramedic may need to ask the patient directly. The four-stage model The diﬀerent forms of risk can be assessed using the following four-stage model (see Fig 52.2). To illustrate application of the model, a patient with suicidal intent is considered here (see also Case study 2 in this chapter). FIGURE 52.2 The four stages of risk assessment. Step 1: Plan. When considering this aspect of the risk assessment you are interested in whether the patient has plans to complete suicide. This is best identiﬁed by asking the question directly. If the patient does identify a desire to commit harm, you need to ask further information about their plan, as a more deﬁned plan may be suggestive of a higher degree of risk of actually going through with the intention. Here it is also important to understand the person's perception and if they view suicide as the only solution to their current situation, what supports they have and do they feel they can use those supports, and to consider and ask what has changed or precipitated these feelings. Depending on the answers to these, the risk of suicide may be higher and protective factors may be limited. Step 2: Means and lethality. Once the patient's plan has been identiﬁed, you need to establish whether the patient has access to the means required to carry out their plan and how likely those means are to be lethal. For example, a patient may have a clearly deﬁned plan to shoot themselves but may not own a gun or have access to any ﬁrearms, whereas a patient who has access to the means is likely to be at increased risk. This element of the assessment may also be important to ensure your own safety. Step 3: Timeframe. Establishing the intended timing of the a empt is also important. A clear and in many cases shorter timeframe may increase the risk or indicate how long you have to manage the situation. Some patients make plans to self-harm or commit suicide on the anniversary of a signiﬁcant event (e.g. the death of a partner). It is important to identify these patients and ensure the details are clearly documented and communicated at handover, because although the patient's immediate risk may be lower, their future risk may be increased and they may need additional support at that time. Step 4: History. The patient's history may reﬂect other risk factors that are important in determining your immediate treatment plan. Other factors may be important in determining a patient's risk of harm or suicide and research suggests that the risk factors in Box 52.4 should be considered. BOX 52.4 Risk factors for suicide History A history of past suicide a empts or having a loved one who has completed suicide may increase risk (Hirschfeld & Davidson, 1998). Age The ABS indicates that 30–34 year olds are statistically more likely to complete suicide (ABS, 2002). While the rate of suicide completion among adolescents aged 15–19 years is not as high as for other groups, suicide is the second highest cause of death in this age group after motor vehicle crashes (ABS, 2002). Gender Males are more likely to complete suicide, while females have a higher recorded rate of suicide a empts (Hirschfeld & Davidson, 1998). This diﬀerence is not necessarily due to the intent of the patient, but rather the means selected. Depression Depression has been linked to suicide. Paramedics should take note of patients who have been severely depressed and recently experienced an improvement in their mood. In some individuals this mood shift can be a ributed to feelings of relief as they have made a decision to end their life, thus in their mind addressing their concerns. Severely depressed individuals may lack the energy and planning required to action suicidal feelings, but an improvement in their symptoms provides room for them to consider the idea further (Cheng et al., 2000; Hirschfeld & Davidson, 1998). Alcohol/drug use Substance use lowers inhibitions and may therefore increase risk (Cheng et al., 2000; Hirschfeld & Davidson, 1998). Social support Social support may be viewed as a protective feature in the person's history, whereas a lack thereof may increase risk (Australian Government, 2012). Chronic illness Patients with a chronic illness are more likely to commit suicide (Hirschfeld & Davidson, 1998). Legal status Assessing the patient's legal status is important at this point, as it may determine speciﬁc treatment options. The paramedic should determine whether the patient is being treated involuntarily (under a form of community treatment order) for a mental illness or, if they are not, whether they require and are eligible for this form of treatment. This patient does not appear to be a risk to herself or others, she has no clear history of mental illness and does not appear to require inpatient treatment for a mental illness. As such, the paramedics need to (and should be able to) treat her as a voluntary patient. Initial assessment summary Problem Conscious state Position Heart rate Blood pressure Skin appearance Speech pa ern Respiratory rate Respiratory rhythm Chest auscultation Pulse oximetry Temperature Pain History Chest pain and short of breath GCS = 15 (despite reports of an altered conscious state) Si ing 112 bpm 110/80 mmHg Pink, warm, dry Speaks in short sentences 28 bpm Even cycles Clear air entry 99% on room air 37.1°C 4/10 She was climbing the stairs when she began to feel dizzy and faint. Her hands began to shake and she became increasingly nauseated. She felt that her heart was going to burst from her chest and was worried something was 'seriously wrong’ with her. She tried to ﬁnish climbing the stairs to remove herself from public view but she almost collapsed trying and so remained on the stairwell. She says that this is the ﬁrst time she has had these symptoms. She cannot identify any medical issues that might have contributed to her presentation. She has a past history of asthma. If we consider this case with regard to both the biomedical and the biopsychosocial models, even in the absence of a signiﬁcant underlying cause such as supraventricular tachycardia, the biomedical model can explain some of this patient's symptoms (e.g. tetany in the hands and palpitations), but it cannot explain why her emotional state ultimately produced these physical symptoms. In this case study social stressors (recent exams and limited social support) brought on biological changes (increased heart rate, increased respiration rate). Her psychological interpretation of the events (thoughts that she was seriously ill and that her symptoms were harmful) increased her anxiety, resulting in a progression of her physiological symptoms. This case illustrates the manner in which social, biological and psychological factors can interact, resulting in mental health concerns. DIFFERENTIAL DIAGNOSIS Mental illness Or Organic (e.g. cerebral hypoxia, hypotension, head injury, CVA, infection [especially encephalitis, meningitis], arrhythmias leading to hypotension) Metabolic (e.g. hypoglycaemia, hyperglycaemia, electrolyte imbalances, renal failure, liver failure) Intoxicants (e.g. alcohol, stimulants, hallucinogenics) Other cause (e.g. reactive anger/aggression, exposure to a traumatic scene) CONFIRM The essential part of the clinical reasoning process is to seek to conﬁrm your initial hypothesis by ﬁnding clinical signs that should occur with your provisional diagnosis. You should also seek to challenge your diagnosis by exploring ﬁndings that do not ﬁt your hypothesis: don't just ignore them because they don't ﬁt. What else could it be? Organic Assessment of the patient's perfusion status, including an electrocardiograph (ECG), should rule out hypotension as a cause of an altered conscious state. Accurate assessment of the ECG will exclude paroxysmal supraventricular tachycardia (see Chapter 23) as an underlying cause of her elevated heart rate. Chest auscultation which indicates equal and adequate air entry to the lungs will tend to exclude a respiratory cause such as hypoxia and asthma for her presentation and this should correlate with normal oxygen saturation (SpO2) readings. In this context the signs of hypocarbia (tetany) are consistent with the elevated respiratory rate. A neurological exam should rule out CVA and seizure. Metabolic A blood glucose reading (BGL) greater than 3.5–4 mmol and an enquiry as to a history of diabetes or other metabolic disorders should exclude this group of physical causes. Although infection can cause changes in behaviour, the infection needs to be severe and it is not likely to occur with normal vital signs and without a signiﬁcant fever. A normal tympanic temperature will exclude an infectious cause severe enough to lead to altered behaviour in a young person. Similarly, disorders causing electrolyte imbalances suﬃcient to cause abnormal behaviour may also create abnormal vital signs. In this case the pulse is elevated but the blood pressure, temperature and BGL are within normal limits. The ECG reveals no arrhythmia. Intoxicants By now the patient has seen the paramedics perform a number of tests that have produced objective (and within normal range) results and should be gaining a degree of trust in their assessment. This is an opportune time to enquire if they could be suﬀering from alcohol or drug eﬀects. But rather than ask these confronting (and accusational) questions directly, explore the more normal aspects of the patient's dietary intake ﬁrst. 'Have you had breakfast today?’ is an innocent question that opens the line of enquiry. 'Have you taken any medication today?’ followed by 'Are there any medications you have missed taking today?’ can add to the information gathered. At this point enquiries about alcohol can seem routine and far less judgmental. The patient denies any drug or alcohol use. Other cause After all of these factors have been ruled out, the paramedic can begin to enquire about events immediately prior to the onset of symptoms. Remember, eﬀective patient care uses the patient to assist. Ask the patient whether they can identify anything that may have triggered this change. If suﬃcient rapport has been built with the patient by this time and a thorough physical assessment has reassured the patient that the illness is not physical, you may be surprised by the honesty of their answer. The patient cannot oﬀer a trigger for the current episode. Given the above has excluded physical causes of this patient's presentation, it leaves a working diagnosis of anxiety with links to either panic a acks or panic disorder to generalised anxiety disorder. TREAT Despite the frequency and severity of cases of mental illness, these conditions do not ﬁt easily into the minds or practice of many paramedics. This may be because mental illness rarely requires the administration of medication by paramedics. Like most other conditions, however, there is a well-structured treatment plan that will suit most situations (see Fig 52.3). FIGURE 52.3 For paramedics, managing mental illness is challenging because it does not fit the normal clinical approach. Instead, these cases can be sequenced as communicate, advocate and transport. Emergency management Communicate Establishing good rapport is essential from the outset of treatment. Rapport is facilitated by the warmth of your approach, a empts to understand the patient's position and maintaining respect for the patient. The use of active listening, paraphrasing, emotion recognition and summarising are essential skills during communication. These skills are particularly important for patients displaying changes in behaviour who may have been laughed at, stared at or dismissed in the past. These experiences often make the patient more sensitive to perceived criticism, making appropriate communication a vital part of treatment and an intervention in itself. Out-of-hospital care is ﬁlled with signiﬁcant pressures, the most obvious being quick and eﬃcient treatment and transport of patients. As a paramedic you must balance these pressures with the need to engage patients for not only the patient's beneﬁt but for clinical management. A loss of engagement may result in treatment refusal or an escalation in emotional and physical distress, which result in poorer patient outcomes and are often more time-consuming. Patients will feel dismissed and disempowered and recognise and react to a rushed or disorganised assessment; remember you are there to provide a service and excellent clinical care. In this patient's case, the treating paramedic should keep their voice low, their tone reassuring and their manner calm. It may be helpful to coach the patient through some deep-breathing exercises, which will serve the dual purpose of distraction and symptom management. Advocate In some instances the paramedic may be required to advocate for a patient, ensuring that they receive the best possible treatment in the leastrestrictive manner. Individuals presenting with changes in behaviour often a ract an audience and you may be required to clear the scene to ensure that the patient's privacy and dignity are maintained. If the patient has close support networks present such as friends and family which are providing a sense of safety you will want to maximise their presence and support. Paramedics may also need to advocate to other professionals, such as the police, to ensure that the patient's needs are adequately met. In this case the paramedics may need to clear the scene to minimise distress caused by bystanders. Transport Transportation not only enables access to mental health care but also can be considered a point of care provision itself (Department of Health, 2011). While the transport protocols between police, mental health services and ambulance services may vary across jurisdictions, ambulance services are generally considered to hold primary responsibility for the transport of people with a mental illness. Paramedics have a vital role if the person is too ill to be transported by mental health clinical staﬀ alone (Department of Health, 2011), have other medical illness or other physical conditions which require management or require sedation or restraint. If they are agitated or have engaged in criminal activity, the police may be the most appropriate form of transport (Department of Health, 2010b; Health Department of Western Australia, 2012; Queensland Ambulance Service, 2012). Patients may favour an ambulance over a police vehicle as it could be viewed as less stigmatising and in many cases more appropriate, as paramedics have more training in mental health care compared with their police counterparts. As this patient has agreed to transport, is not an involuntary patient and is not aggressive, the primary transport choice is an ambulance. If other referral pathways are available such as follow-up with mental health teams, GP or through consultation with mental health triage, this patient may be able to be provided care by other means. Sedation The question of sedation to facilitate transport of patients with mental illness is often raised. In the vast majority of cases sedation is not necessary. With eﬀective communication most patients will feel listened to and engage with paramedics and agree to transport if required, although the length of time to gain their consent may vary. In some cases, however, paramedics will be faced with agitated patients (who may or may not have a mental illness) who require a diﬀerent approach. The sedation guidelines used in Australia and New Zealand were devised with this group in mind. Primary considerations for these patients include the availability and appropriateness of less-restrictive options such as verbal de-escalation: the need for early backup or support from other agencies (e.g. police or mental health teams), the provisions under local mental health legislation and the scope of practice of the clinician which vary across jurisdictions. Guidelines for safe sedation are described in local jurisdictional guidelines. EVALUATE The aim of the evaluation phase is to ensure that the selected intervention is appropriate. This may be assessed by considering the following. Is the intervention working? The treatment outcomes in the case of mental illness are as varied as the illnesses themselves. In some cases you will see a decrease in concerning symptoms, while in others there may be no apparent change in symptom severity. At the very least, you can assist the patient by building strong rapport and a collaborative and therapeutic relationship. Is the patient safe? Ensuring your safety and the patient's is of paramount importance. Safety should be considered from the outset, but you should also re-evaluate the scene and the patient's status throughout the intervention period. Has the patient consented to transport or appropriate follow-up? With appropriate communication and support most patients consent to transport or connection with further services. If the patient refuses transport but requires an urgent psychiatric assessment, you may need to reconsider your choice and communicate in a more direct but respectful manner. Highlight the need for transport and your concerns for the patient and consider oﬀering limited options; for example, 'I am quite worried about the possibility of your harming yourself and, as such, I cannot leave you at home. I have a duty of care to ensure that you are transported to hospital but you do have a choice regarding your transport. You can travel in the ambulance or I can call the (police/community mental health team, etc.) and ask them to transport you. Which would you prefer?’ If the patient continues to deteriorate, you may need to reconsider your initial diagnosis or communication strategies. Have you eﬀectively eliminated physical causes? Can you approach the patient in a diﬀerent manner or can your partner approach the patient? In this patient's case, the paramedics would expect to see a change in her sympathetic activation (e.g. decrease in heart rate, improved respiratory rate) as a result of their intervention. Specific treatment guidelines Table 52.1 earlier in this chapter provides an overview of common mental illnesses encountered in paramedic practice and their associated symptoms, medications and speciﬁc management strategies. Investigations Hospital staﬀ will again screen for and eliminate organic causes. Once this screening has been completed and a psychiatric cause is considered more likely, a psychiatric consultant will be called and a determination made regarding the next course of treatment. Hospital admission Modern psychiatric inpatient treatment is considered to be short-term and intensive intervention to minimise risk and manage symptoms. Care is provided 24 hours a day by a multidisciplinary team of professionals including psychiatrists, psychologists, mental health nurses, social workers and occupational therapists. Treatment is tailored to the needs of the individual, but is likely to include a medication review, short-term psychological treatment and family support. Inpatient wards also run comprehensive activity programs such as cooking, problem-solving groups and art therapy. Occasionally, treatment will be delayed in favour of observation if the patient's diagnosis or symptom proﬁle is unclear. Admission to a short-stay ward may be required for some intensive treatments, such as electroconvulsive therapy. Long-term treatment and impacts Patients are generally discharged to a community mental health service for follow-up. A case manager will be allocated and a longer-term treatment plan devised. The case manager links the patient's mental health supports together, ensuring continuity of care, to monitor the patient's mental state on an ongoing basis and to evaluate their progress over time (Victorian Government Department of Health, 2008). The course of a mental illness varies according to the individual, their diagnosis and the supports available. While some patients require only one hospital admission, others will have regular involvement with mental health and emergency services. With support and appropriate intervention, recovery from a mental illness is possible. CASE STUDY 2 Case 09755, 1423 hrs. Dispatch details: A 29-year-old male complaining of back pain. Initial presentation: The paramedics arrive at a farm that is relatively isolated. A dishevelled male walks slowly to the door to allow them to enter. ASSESS 1434 hrs Primary survey: The patient is conscious and talking. 1435 hrs Chief complaint: He has lower back pain. 1437 hrs Vital signs survey: Perfusion status: HR 68 bpm, BP 120/70 mmHg, skin pink and dry. Respiratory status: RR 16 bpm, good clear air entry bilaterally. Conscious state: GCS = 15. 1441 hrs Pertinent hx: The patient says he has had lower back pain for the past 3 months but it has become so bad that it is almost impossible to sleep. As a result he is constantly lethargic, which is a concern given the physically taxing nature of farm work. He is not maintaining and only engaging in limited eye contact and his voice is ﬂat and sounds detached. He appears drawn, tired and has obviously lost weight, based on his loose clothing. The paramedics are aware that ﬂooding 8 months ago had a signiﬁcant impact on local farmers, resulting in a loss of stock and, for many, signiﬁcant ﬁnancial strain. When asked if he has people to assist him with heavy lifting on the farm, the patient says that he had to let most of his farm hands go, though one remains. This placed a signiﬁcant burden on him and the stress led to conﬂict with his wife and a subsequent separation almost 4 months ago. 1444 hrs Secondary survey: There is no speciﬁc tenderness to his lower back and his range of movement does not appear particularly limited. PRACTICE TIP Psychomotor retardation or a slowing of cognitive processing may occur in individuals during a major depressive episode. In such individuals it is important to limit external stimuli during assessment, which may be taxing on concentration. It is also important to make questions clear and concise, and allow time for the individual to respond. Be patient. Although this patient presents with a clear physical complaint (back pain), strict adherence to this complaint during the assessment period without consideration of his ﬂat aﬀect, monotone speech and limited eye contact may limit the history taking solely to his pain and possible mechanisms of injury. Without prompting he may not disclose his stressors or his risk. It is also worth considering at this point that often chronic pain or disability result in or occur in conjunction with anxiety and depression. CONFIRM In many cases paramedics are presented with a collection of signs and symptoms that do not appear to describe a particular condition. A critical step in determining a treatment plan in this situation is to consider what other conditions could explain the patient's presentation. What else could it be? Chronic musculoskeletal back pain The lack of any tender areas in the patient's back and the relatively normal range of movement would seem to exclude chronic musculoskeletal back pain and a range of inﬂammatory arthritis and myositis conditions. Occult malignancy Weight loss could be a sign of occult malignancy or diabetes. Lack of any symptoms associated with malignancy makes this less likely but this is still a diagnosis that has to be considered in the background during his hospital investigation. Hyperglycaemia (diabetes) The weight loss could be caused by prolonged hyperglycaemia but li le else ﬁts this clinical picture. The normal blood sugar and lack of any history of urinary frequency and excessive thirst eﬀectively exclude diabetes. Hypothyroidism The early symptoms of hypothyroidism include fatigue, joint pain and depression but the disease is generally associated with weight gain, not loss. The patient does not report any increased sensitivity to cold or change to his hair and nails. This does not ﬁt the clinical picture but it should be investigated at hospital. DIFFERENTIAL DIAGNOSIS Clinical depression Or Chronic musculoskeletal back pain Occult malignancy Hyperglycaemia (diabetes) Hypothyroidism Intracranial tumour Undisclosed problem with alcohol/drugs of addiction Intracranial tumour Intracranial tumour can present with a mood disorder although it would be unusual to have no other focal signs or symptoms evident. This diagnosis cannot be excluded at this stage. Undisclosed problem with alcohol/drugs of addiction An undisclosed problem with alcohol or drugs of addiction could present with a depressed mood and weight loss, although it is likely that history or evidence of the problem would have occurred in the evaluation thus far. When asked direct (but not threatening) questions regarding his alcohol/drug use, the patient denies any issues. It should be noted that admission to drug and alcohol use or an addiction doesn't actually preclude depression and mood disorders as a diagnosis in the ﬁeld and should not change the management of this patient. In the absence of any physical factors and applying the patient's history and presentation to the MSE, clinical depression appears as a strong factor in his decision to request help for his back pain. Further assessment by health specialists will be needed to exclude other possibilities. TREAT With a provisional diagnosis of depression and considering this patient's se ing of isolation and ongoing stress it is essential that this patient is engaged with the wider health system and paramedics are perfectly placed to do this. Recognising the need for support and further assessment any discussion around mental health and depression should be done openly and honestly with the patient. A frank acknowledgment that his current circumstances are diﬃcult and challenging and having diﬃculty coping would not be unexpected opens the line of communication for him to talk and discuss what is occurring for him and how he feels about it. An inexperienced paramedic might use the 'need to investigate’ his back pain as a way to encourage the patient to agree to transport to hospital. However, during his hospital assessment it will quickly become obvious that the paramedics have lied and this may make him less likely to seek treatment in the future. Open, honest and empathetic exploration of his condition will not only align the patient and crew's expectations of what should occur, but will also provide more information for the paramedics to make an informed decision regarding treatment options. At this point a risk assessment should be conducted, and this can be done using the fourstage model presented earlier in the chapter. 1447 hrs: The paramedics complete a risk assessment for the patient as follows: Plan: The patient indicates that he has contemplated suicide. The paramedics ask for further information regarding his plan. He details the plan, noting that he has gone so far as to write a goodbye note to his family. Means: The patient admits that he has access to ﬁrearms, his chosen method, indicating a high degree of risk. Timeframe: He indicates that he will wait until after his daughter's birthday next week, as he does not want her to be sad on her birthday. History: He denies any past suicide a empts, but advises that his paternal grandfather commi ed suicide when he was 45. Based on the risk assessment, this patient is a very high risk of suicide. He is actively depressed, with a number of current social and personal stressors; he also has a clearly deﬁned plan, access to the means and a timeframe; as well as a family link to suicide. Broader considerations which also identify high risk are that he appears to have diminished resources (both internal and external) with reduced capacity to cope plus physical, social and family isolation. It is key to note, however, that he has a clear protective factor regarding his daughter and that relationship might be able to be used as a recognition of strength and life purpose (e.g. 'Tell me about your daughter. You said her birthday is next week and you want her to enjoy the day.’). This provides an opening to understand his current circumstances, the nature of his relationships and what support he sees as possible and existing. He clearly needs urgent assessment, care and safety within the mental health and hospital system. From an out-of-hospital perspective, the objectives of care are to provide: a safe space for the patient to feel listened to and not judged; therapeutic communication which acknowledges his emotions and also his strengths; and transport in a safe and supportive manner (see Box 52.5). As his risk of self-harm is quite high, it is essential that he is informed and understands that this information will be handed over at hospital so that he can receive the most appropriate support possible. BOX 52.5 General advice in cases of suicide risk Secure the environment and remove any unwanted distractions or stressors (this may include loved ones). Remove any accessible means of harm. Do not leave the person alone. Listen to the person's story and try to identify the factors that led to an increase in risk at that speciﬁc point in time. Many suicidal patients feel ambivalent about their desire to die or feel that they have no other option. Acknowledge the patient's feelings and identify protective factors (i.e. reasons they have not acted on their plans or reasons to live). Do not try to talk the patient out of their feelings as they will feel ignored and possibly more helpless. Be empathetic. While some clinicians may view suicide as pointless or selﬁsh, expressing these views is unprofessional and unlikely to be helpful to the patient. Encourage access to deﬁnitive treatment. If the patient is reluctant, explore legal options such as an involuntary status. The speciﬁcs of this option will vary depending on the local jurisdiction. If all a empts fail and the person acts on their plans, seek immediate support and debrieﬁng. Suicide can be very distressing and it is important that you take care of yourself. PRACTICE TIP Small quantities of IV midazolam repeated to eﬀect are safer than large quantities delivered intramuscularly. As he contacted the ambulance service, provided he is supported sensitively and with empathy, it is likely that he will agree to further support and mental health care which begins with his transport. The main aim is to facilitate this transport in the most digniﬁed and least-restrictive way while continuing to communicate with and assess him. If the paramedics have established a therapeutic rapport they will be wellplaced to deliver a comprehensive handover, including the patient in the process to ensure that they feel empowered and in line with personcentred care. As a last resort, if the patient is reluctant to be transported and unwilling to receive further care the paramedics may need to use their legal powers under mental health legislation to force transport. They may need to consider administering a chemical restraint to help reduce the level of distress and trauma for the patient, but this should only be used if absolutely necessary and all other means have been exhausted. If paramedics need to apply physical restraint to transport safely or obtain an intravenous line (IV), they must take extreme care not to compress his chest or diaphragm and continually monitor the patient for any changes in respiratory, cardiac or perfusion status. Mental illness should not preclude pain relief and managing this patient's pain with carefully titrated doses is strongly encouraged. EVALUATE Eﬀective out-of-hospital management of mental illness rarely requires the administration of medications and as such there is unlikely to be any signiﬁcant change in the patient's presentation during transport. Maintaining the patient's dignity is likely to lead to an uneventful journey to hospital. CASE STUDY 3 Case 09157, 1207 hrs. Dispatch details: A 25-year-old male with uncontrolled haemorrhage to his left arm. The caller states that the patient inﬂicted the wound intentionally. Initial presentation: When the paramedics arrive they ﬁnd the patient pacing around the room. His wound has been bandaged by his mother and is no longer bleeding. The patient presents as dishevelled, irritable and suspicious, and asks the paramedics to show their credentials before submi ing to a physical examination. ASSESS 1215 hrs Primary survey: The patient is conscious and talking. 1216 hrs Chief complaint: He reports that he lacerated his arm while searching for a tracking device that 'they’ had implanted under his skin. 1218 hrs Vital signs survey: The patient eventually sits at the request of the paramedics, although his legs move restlessly throughout the examination. Perfusion status: HR 90 bpm; unable to obtain BP due to the patient's agitation; skin pale and dry. Respiratory status: RR 24 bpm, no increase in respiratory eﬀort and no apparent respiratory disturbance evident on visual inspection while questioning the patient. Conscious state: GCS = 14, confused to time. 1220 hrs Pertinent hx: The patient denies a history of mental illness, although his mother reports that he was diagnosed with schizophrenia 5 years ago. She says that he has been well for the past 4 years, but became irritable and withdrawn after losing his job 5 weeks ago. She has noticed a decline in his sleep and appetite since then. 1223 hrs Further mental health questioning: While the patient is able to answer most questions, paramedics note long pauses in his responses and diminished concentration and focus. He engages only in limited eye contact and is unable to identify who ‘they’ are, except to say that ‘they’ watch him and always seem to know where he is. He also articulates concerns that his mother is trying to poison him and that his friends are talking about him. It is important for paramedics to understand the nature of the delusions and the hallucinations, whether there is any suggestion that voices or beliefs are commanding the patient to hurt themselves or others and the likelihood of the patient acting on those commands. The comment from the patient that he believes his mother is trying to poison him is signiﬁcant and should be considered in your risk assessment. 1228 hrs Secondary survey: There is no loss of sensation, movement and circulation to his left hand. Unless there is an indication of arterial bleeding, visualising any wound before transport is usually recommended as it may require a speciﬁc hospital for treatment, but in this case the crew leave the bandage in place to reduce distress and stimulus to the patient. This case is challenging in that the patient is presenting with both psychosis (clear evidence of delusions—ﬁxed false beliefs, increased psychomotor movement, changes in sleep and appetite pa erns) and a physical injury that requires treatment. His behaviour is likely to make the paramedics wary and may aﬀect their ability to communicate eﬀectively. His discussion provides insight into his thought processes, revealing a paranoid delusion and lack of insight into his previous medical history and his current state. The clinical picture is consistent with psychosis, although the precipitating cause could be primary schizophrenia alone, an exacerbation due to drug use or possibly a combination of both. CONFIRM In many cases paramedics are presented with a collection of signs and symptoms that do not appear to describe a particular condition. A critical step in determining a treatment plan in this situation is to consider what other conditions could explain the patient's presentation. What else could it be? Acute drug reaction A psychotic reaction to drugs, particularly stimulant drugs such as amphetamines, is not unusual and should be managed in a similar way to a primary psychotic state related to schizophrenia. Anecdotally, druginduced psychosis may be associated with more dramatic delusions resulting in more intense and violent responses from the patient. A psychotic reaction to prescribed medications (including steroids) will occasionally occur: this can be either a direct eﬀect of the drug or an interaction with an underlying psychotic condition. Unfortunately, excluding drug use without the use of toxicology relies on the history, which in this case may be unreliable. DIFFERENTIAL DIAGNOSIS Psychosis Or Acute drug reaction Encephalitis Focal epilepsy Hyponatraemia or other electrolyte imbalance Thyrotoxicosis Hypoglycaemia Encephalitis An acute psychotic state can be the ﬁrst presentation of encephalitis and no other signs of infection may be obvious in the early stages. Although this is very unusual it is not impossible and should be considered, particularly if there is no previous history or obvious precipitating cause of the psychosis. This cannot be eﬀectively excluded in the out-of-hospital se ing and even without an arm wound this factor would necessitate transport to hospital to determine. Focal epilepsy Focal epilepsy can give rise to acute episodes of changes in behaviour, but this is not usually psychotic and should have a deﬁnite onset and oﬀset associated with the epileptic activity. This is not consistent with this patient's presentation. Hyponatraemia or other electrolyte imbalance An electrolyte imbalance can precipitate disturbed behaviour that may be psychotic in nature. Hyponatraemia associated with excessive drinking of water or adrenal gland failure can present with delusional psychotic behaviour before progressing to cause seizures. An absence of suggestive history is helpful but a normal set of blood tests is necessary to exclude this hypothesis. It is worth considering in previously undiagnosed patients who are at risk of hyponatraemia (i.e. those a ending dance parties or raves where the combination of excessive activity and drug use increases the risk). The patient's history does not include these activities. Thyrotoxicosis Endocrine abnormalities such as thyrotoxicosis can produce a hyperactive state with some paranoid component, especially if the patient has an underlying mental illness. The absence of excessive tachycardia, tremors and signs of a hypermetabolic state would make this diagnosis unlikely but formal thyroid function tests would exclude it completely. Hypoglycaemia The presence of a normal blood sugar excludes hypoglycaemia as a possible cause of the abnormal behaviour. TREAT Further assessment and treatment in hospital is needed for this patient where the full range of possible alternative diagnoses can be excluded and he can be oﬀered antipsychotic medication and stabilisation in a controlled environment. He is considered a high risk of accidental self-harm (as noted by his laceration) and could be a risk of harm to others should his paranoid delusions escalate given his current state of agitation. PRACTICE TIP If using physical restraint: place no pressure on the patient's chest or abdomen; the patient should be face up to allow good observation of ventilation ensure that it is possible to rapidly roll the patient onto their side if they vomit. The patient is able to engage to some extent with paramedics so he may voluntarily agree to transport, in which case the treatment will be aimed at making the experience as stress-free as possible for him while gaining further insight into his current state of mind and possible precipitating causes. Unusually, his paranoia may preclude the paramedics from treating his wound with pain relief. Always oﬀer patients with physical injuries the option of receiving pain relief, but do not try to force the administration of medications. EVALUATE Should he not have enough insight or the capacity to make a decision regarding his own care, legal options may have to be pursued. This patient appears to be suﬀering from a mental illness, is considered a high risk of accidental self-harm due to his delusions (e.g. laceration to his arm) and thus cannot remain at home, and requires assessment and management in hospital. This would fulﬁl the legislative requirements for involuntary treatment and transport in most states. To achieve safe transport, chemical restraint may be considered and is the preferred option over physical restraint, the aim being to use the least-restrictive form of restraint that is compatible with both the patient's and the crew's safety. Eﬀective out-of-hospital management of mental illness rarely requires the administration of medications or restraints and as such there is unlikely to be any signiﬁcant change in the patient's presentation during transport. If physical or chemical restraint is used either temporarily or during transfer, several risks should be considered: 1. the risk of positional asphyxia, in which the victim is unable to breathe properly because of restrictions to chest movement caused by the restraint; and 2. the risk that a sedated patient becomes unconscious and vomits and the physical restraint prevents the paramedics from turning the patient quickly onto their side to clear the airway. While mechanically restraining the patient may be needed to ensure safety, it can prove fatal if the patient cannot be rolled quickly should they vomit. CASE STUDY 4 Case 10020, 0831 hrs. Dispatch details: A 25-year-old female in a gaming lounge with abnormal behaviour. Initial presentation: Casino staﬀ direct the paramedics to the patient in the gaming lounge where she has been for the past 40 hours and refuses to leave. They called the ambulance when they noticed that she was behaving unusually and had diﬃculty talking to her. The paramedics notice that she is extremely slim and dressed in bright, vibrant clothing. ASSESS In response to the paramedics’ greeting the patient reports that she is a university student studying for her ﬁnal exams. She goes on to discuss the last movies she has seen. When one of the paramedics ﬁrmly redirects her towards her behaviour she reports that in the last 4 weeks she has stopped eating as she has not been hungry. Her sleeping pa erns have also altered dramatically: she has had a maximum of 2 hours sleep per night in the last few days. She says that she has been far too busy to sleep as she has signiﬁcant study commitments and a professional tennis career to prepare for. Without appearing to draw breath, she acknowledges that she has never had formal tennis lessons or played regularly, but remains certain that she will be wildly successful. She is very ﬂirtatious with bystanders and the treating paramedic. 0847 hrs Vital signs survey: Perfusion status: HR 98 bpm, weak and irregular, BP 140/100 mmHg, skin ﬂushed and dry. Respiratory status: RR 18 bpm, good clear air entry, L = R, normal work of breathing, no complaint of dyspnoea. Conscious state: GCS = 15. The treating paramedic notes that the patient presents with grandiose and disorganised thought pa erns and pressured speech (a rapid, constant stream of speech which tends to be disorganised and diﬃcult to interrupt). She speaks in a loud voice with li le connection between ideas and it appears not in context to the situation. She admits to using amphetamines in the past 48 hours but denies any sustained or long-term use. Her symptoms are typical of a bipolar I manic episode. CONFIRM In many cases paramedics are presented with a collection of signs and symptoms that do not appear to describe a particular condition. A critical step in determining a treatment plan in this situation is to consider what other conditions could explain the patient's presentation. What else could it be? Amphetamine or stimulant use Hypomania describes a state of euphoria and disinhibition that is often associated with excessive conﬁdence and hypersexuality. It can be distinguished from mania by an absence of psychotic symptoms but the two should be considered as part of a continuum as opposed to separate conditions. The most likely alternative diagnosis for hypomania is amphetamine or other stimulant use. Diﬀerentiation will depend on whether there is a history of drug use, a history of bipolar cycles and a previous diagnosis. Without drug screening it can be very diﬃcult to diﬀerentiate between pure bipolar hypomania and drug-induced hypomanic behaviour—or, as in this case, a combination of both. The diagnosis is diﬃcult to determine in the ﬁeld but it could be relevant to immediate management. DIFFERENTIAL DIAGNOSIS Bipolar Or Amphetamine or stimulant use Other organic brain syndrome Other organic brain syndrome There are relatively few organic brain syndromes that mimic this degree of hypomanic behaviour. Possibly hyperstimulation associated with excessive amounts of circulating adrenaline or other catecholamines might present like this. Her pulse and blood pressure are not excessively elevated which suggests a systemic adrenaline-like syndrome is not likely. Serotonin syndrome is a potentially life-threatening condition caused by the interaction of serotonin re-uptake inhibitors with other drugs that results in the release of too much serotonin. It can produce a hyperactive state but it does not normally have the disordered ideas that are typical of a bipolar hypomanic phase. In addition, serotonin syndrome is always associated with physiological changes such as increases to temperature, heart rate and blood pressure. This does not ﬁt the clinical picture in this case. TREAT This patient's use of amphetamines will have exaggerated her hypomanic/manic state and allowed her to remain conscious for long periods of time without sleep. If someone who knows her well can be found they may be aware of a formal diagnosis of bipolar disorder or at least be aware of what medications she has been taking or is supposed to take. The patient has no insight into her behaviour and so will be challenging to interact with and convince that she needs help. A slow, steady approach will allow her more opportunity to process information. This interaction should be handled by one member of the crew, who should concentrate on slowing down in response to her hypomanic speech pa erns. The paramedics should consider discussing her physical symptoms (i.e. her lack of sleep, drug use and limited food intake) with her to see whether she will engage in treatment for these issues. Wherever possible, she should be encouraged to access treatment voluntarily. The treating paramedics’ risk assessment suggests that this patient is at risk of accidental self-harm and possible harm to others if left untreated. Given this assessment, the enacting of legislative powers needs to be considered. This patient meets the criteria for involuntary treatment for most jurisdictions. The paramedics have a duty of care to provide access to deﬁnitive mental health treatment. In this case since she has altered insight and capacity she cannot be left and requires transport to hospital or inpatient mental health care. Paramedics can provide her with as much choice as possible with the understanding that she will be transported to further care (e.g. comfort) without mechanical restraints. Police may need to intervene if the safety of the clinicians, public or person is at risk. Involving the police has advantages in terms of extra assistance and an authoritative presence but it can sometimes inﬂame the situation. The beneﬁts and risks of police involvement need to be considered before escalating to this level. The clinical decisions are further complicated by the patient's amphetamine use, which can mimic many of the symptoms of mania. When making a diﬀerential diagnosis, clinicians at the receiving hospital will construct a careful timeline to identify the presence of symptoms in relation to her substance use. They may also wish to monitor her for an extended period to determine whether her symptoms remain after the amphetamines have been metabolised and excreted from her system. A number of ambulance services support the administration of benzodiazepines such as midazolam to manage amphetamine overdose. This guideline was mostly developed for the small cohort of patients who present with painful bruxism, twitching, scratching and hypertension, but it can also be used as a last resort in aggressive patients. There are very strict guidelines regarding the use of sedatives to facilitate the transport of involuntary patients who are mentally ill. It is perceivable that the paramedics could misinterpret this patient's history and ﬁnd themselves administering a sedative against their local Mental Health Act. Consultation to support this decision would be recommended. EVALUATE Eﬀective out-of-hospital management of mental illness rarely requires the administration of medications and as such there is unlikely to be any signiﬁcant change in the patient's presentation during transport. Maintaining the patient's dignity and not engaging or challenging her delusions is likely to lead to an uneventful journey to hospital.

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