Mental health & crisis management 7 april qui z

Introduction to this week’s topic

The language we use has a direct and profound impact on those around us. The negative impacts of stigma can be reduced by changing the language we use about substance use.

Two key principles include:

· Using neutral, medically accurate terminology when describing substance use

· Using “people-first” language, that focuses first on the individual or individuals, not the action (e.g. “people who use drugs”)

It is also important to make sure that the language we use to talk about substance use is respectful and compassionate.

· People who use drugs

· Instead of “addicts” use people who use drugs

· Instead of “junkies” use people with a substance use disorder

· Instead of “users” use people with lived/living experience

· Instead of “drug abusers” use people with lived/living experience

· Instead of “recreational drug user” use person who occasionally uses drugs

· People who have used drugs

· Instead of “former drug addict” use people who have used drugs

· Instead of referring to a person as being “clean” use people with lived/living experience or people in recovery

· Drug use

. substance/drug use

. substance use disorder/ opioid use disorder

. problematic [drug] use

. [drug] dependence

. Instead of “substance/drug abuse” or “substance/drug misuse” use:

This document was created in discussion with people with lived and living experience, through existing research and documentation from other organizations trying to address stigma. This is not an exhaustive list. Furthermore, as a result of the evolving discussion around the best language to use to accurately discuss substance use, this list will likely be revised.

Anxiety disorders

A common problem

Anxiety disorders are the most common mental health illnesses, affecting one in ten Canadians.

In the clinical setting, anxiety disorders often co-exist with other mental health problems such as depression, eating disorders and substance use disorders. This is particularly the case if anxiety disorders are left untreated.

However, when we work on managing the anxiety, the overall functioning, quality of life and well being of that person improves. Thus showing that anxiety can be a big part of the problem, but its treatment is also a big part of the solution.

It is very important to manage anxiety before it escalates further.

 Levels of anxiety

1.
Mild anxiety, which occurs in the normal experience of everyday living, allows an individual to perceive reality in sharp focus. A person experiencing a mild level of anxiety sees, hears, and grasps more information, and problem solving becomes more effective. Physical symptoms may include slight discomfort, restlessness, irritability, or mild tension-relieving behaviours (e.g., nail biting, foot or finger tapping, fidgeting, wringing of hands).

2. Moderate Anxiety, As anxiety increases, the perceptual field narrows, and some details are excluded from observation. The person experiencing 
moderate anxiety
 sees, hears, and grasps less information and may demonstrate 
selective inattention
, in which only certain things in the environment are seen or heard unless they are pointed out. While the person’s ability to think clearly is hampered, learning and problem solving can still take place, although not at an optimal level. Physical symptoms of moderate anxiety include tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic symptoms (gastric discomfort, headache, urinary urgency). Voice tremors and shaking may be noticed. Mild or moderate anxiety levels can be constructive because anxiety may signal that something in the person’s life needs attention or is dangerous.

3. Severe Anxiety, The perceptual field of a person experiencing 
severe anxiety
 is greatly reduced. A person with severe anxiety may focus on one particular detail or many scattered details and have difficulty noticing his or her environment, even when it is pointed out by another. Learning and problem solving are not possible at this level, and the person may be dazed and confused. Beh

Mood disorders and schizoaffective disorders

Overview1

 

Mood disorders affect about 10% of the population. Everyone experiences “highs” and “lows”, but people with mood disorders experience them with greater intensity and for longer periods of time.

 

Depression is the most common mood disorder; a person with depression feels “very low.” Symptoms may include: feelings of hopelessness, changes in eating patterns, disturbed sleep, constant tiredness, an inability to have fun, and thoughts of death or suicide.

 

People with bipolar disorder have periods of depression and periods of feeling unusually “high” or elated.

 

Some examples of mood disorders include2:

Major depressive disorder (MDD)

Prolonged and persistent periods of extreme sadness.

Bipolar disorder

Depression that includes alternating times of depression and mania.

Seasonal affective disorder (SAD)

A form of depression most often associated with fewer hours of daylight in the far northern and southern latitudes from late fall to early spring.

Cyclothymic disorder

A disorder that causes emotional ups and downs that are less extreme than bipolar disorder.

Premenstrual dysphoric disorder

Mood changes and irritability that occur during the premenstrual phase of a woman’s cycle and go away with the onset of menses.

Persistent depressive disorder (dysthymia)

A long-term (chronic) form of depression.

Disruptive mood dysregulation disorder

A disorder of chronic, severe and persistent irritability in children that often includes frequent temper outbursts that are inconsistent with the child’s developmental age.

Depression related to medical illness

A persistent depressed mood and a significant loss of pleasure in most or all activities that’s directly related to the physical effects of another medical condition.

Depression induced by substance use or medication

Depression symptoms that develop during or soon after substance use or withdrawal or after exposure to a medication.

Schizoaffective Disorder

verview3

The two types of schizoaffective disorder — both of which include some symptoms of schizophrenia — are:

· Bipolar type, which includes episodes of mania and sometimes major depression

· Depressive type, which includes only major depressive episodes

Schizoaffective disorder may run a unique course in each affected person, so it’s not as well-understood or well-defined as other mental health conditions.

Untreated schizoaffective disorder may lead to problems functioning at work, at school and in social situations. People with schizoaffective disorder may need assistance and support with daily funct

Perry: Maternal Child Nursing Care in Canada

Chapter 36:  The Infant and Family

Case Study 24:  Child Abuse

1.  Jamie is 6 months old and was brought to the emergency department by her mother. In your assessment of Jamie, you find multiple bruises in different stages of healing and decreased range of motion in the left leg.
   As the nurse in the emergency department, what should  you do?

   (a)  Call the division of family services.
   (b)  Maintain confidentiality of physical data until Jamie’s mother signs admission  papers.
   (c)  Obtain a thorough patient and family history.
   (d)  Obtain a serum sample for a CBC.

2.  Jamie is 6 months old and was brought to the emergency department by her mother. In your assessment of Jamie, you find multiple bruises in different stages of healing and decreased range of motion in the left leg.
  Jamie has been diagnosed with a fractured femur.  During your interview with Jamie’s mother on the nature of the fracture, which one  of the following statements made by Jamie’s mother would cause you to suspect  abuse?

  (a)  “Jamie  got her leg caught in the crib bars and it twisted.”
  (b)  “Jamie hurt herself while crawling.”
  (c)  “I can’t remember Jamie falling or hurting herself.”
  (d)  “Jamie fell out of her car seat because I didn’t have it secured properly.”

3.  Jamie is 6 months old and was brought to the emergency department by her mother. In your assessment of Jamie, you find multiple bruises in different stages of healing and decreased range of motion in the left leg.
  The criterion that is most important for causing  the nurse to suspect child abuse is which one of the following?

  (a)  Appropriate  parental concern for the degree of injury.
   (b)  Absence  of the parents for questioning about the child’s injury.
  (c)  Parental  concern about health problems other than the ones associated with the possible  abuse.
  (d)  Incompatibility between the history given and the observed injury.

Chapter 36: The Infant and Family

Case Study 25: Infant Growth and Development

 

1.  Elizabeth is a 6-month-old female delivered at 40 weeks of gestation weighing 3400 g. She now weighs 6800 g. You are discussing infant growth and development with Elizabeth’s mother.  Elizabeth’s mother is concerned that her baby is not gaining enough weight. You can assure her and provide anticipatory guidance. Which of the following statements should you make to Elizabeth’s mother?

   (a)  Elizabeth is gaining weight well. At 6 months an infant is expected to have doubled her birth weight. At 1 year the weight should triple.
   (b)  Elizabeth is gaining weight well. At 6 months an infant is expected to have tripled her birth weight. At 1 year the weight should quadruple.
   (c)  Elizabeth is gaining weight well. At 6 months an infant is expe

Anonymous self-help support groups

Addiction may be expressed in individuals regardless of their age, gender, sexual orientation, socioeconomic status, education, culture, or occupation. Addiction is the most prevalent of all mental conditions, the leading preventable cause of death and disease globally. For these reasons, it has been argued that addiction is the most important illness of our time (Els, 2007). Yet addiction is often neglected and undertreated in Canadian society. There are significant barriers (e.g., stigma and resources) for persons with addiction to overcome in order to access the treatment they need, and these systemic barriers may be as intractable as the disease of addiction itself. Individuals affected with addiction are often alienated and isolated from both their family and communities.

 

Spirituality (which is not to be confused with religion) has a close relationship with the field of addiction treatment; individuals who have recovered from addiction often mention spiritual experiences or motivation as a major contributory factor in their recovery. Spirituality can be defined as the relationship between an individual and the sacred (numinous), perhaps represented by a transcendent higher being (or higher power) or force (or mind of the universe). This relationship is personal to the individual and does not require affiliation with any organized religion; religion is not necessary for an individual to develop his or her spirituality or, for that matter, to recover from addiction. Spirituality is an integral dimension of the Twelve Step tradition of Alcoholics Anonymous (AA).

 

Twelve-step programs emphasize the conceptualization of addiction as an incurable, progressive disease that has spiritual, cognitive, and behavioural components. Alcoholics Anonymous (AA) was the first 12-step self-help group and started in the mid-1930s by William Wilson (“Bill W.”) and a physician. The AA movement has become a worldwide fellowship of people with problems (current or past) related to alcohol, which provides support, individually and at meetings, to others who seek help. The only criterion for entry into AA is the “desire to quit drinking.” Many treatment programs discuss concepts from AA, hold meetings at treatment facilities, and encourage patients to attend community meetings when appropriate. They also encourage continuing use of AA and other self-help groups as part of an ongoing plan for continued abstinence. Twelve-step methods firmly endorse the need for abstinence and are considered by followers as lifelong programs of recovery with success attained 1 day at a time. The importance of recognizing and relying on a “higher power,” or a power greater than the individual, is a central element of these programs.

 

Members of 12-step groups

ResouRces

n

n

n

n

Download this card and additional resources at http://wwww.sprc.org

Resource for implementing The Joint Commission 2007 Patient
Safety Goals on Suicide http://www.sprc.org/library/jcsafetygoals.pdf

sAFe-T drew upon the American Psychiatric Association
Practice Guidelines for the Assessment and Treatment of
Patients with Suicidal Behaviors http://www.psychiatryonline.com/
pracGuide/pracGuideTopic_14.aspx

Practice Parameter for the Assessment and Treatment of Children and
Adolescents with Suicidal Behavior. Journal of the American Academy
of Child and Adolescent Psychiatry, 2001, 40 (7 Supplement): 24s-51s

AcKNoWLeDGMeNTs

n Originally conceived by Douglas Jacobs, MD, and developed as
a collaboration between Screening for Mental Health, Inc. and
the Suicide Prevention Resource Center.

n This material is based upon work supported by the Substance
Abuse and Mental Health Services Administration (SAMHSA) under
Grant No. 1U79SM57392. Any opinions/findings/conclusions/
recommendations expressed in this material are those of the
author and do not necessarily reflect the views of SAMHSA.

National Suicide Prevention Lifeline

1-800-273-TALK (8255)

Suicide Prevention Resource Center

HHS Publication No. (SMA) 09-4432 • CMHS-NSP-0193
Printed 2009

SAFE-T
Suicide Assessment Five-step

Evaluation and Triage
1

IDeNTIFY RIsK FAcToRs

Note those that can be
modified to reduce risk

2
IDeNTIFY PRoTecTIVe FAcToRs

Note those that can be enhanced

3
coNDucT suIcIDe INQuIRY

Suicidal thoughts, plans,
behavior, and intent

4
DeTeRMINe RIsK LeVeL/INTeRVeNTIoN

Determine risk. Choose appropriate
intervention to address and reduce risk

5
DocuMeNT

Assessment of risk, rationale,
intervention, and follow-up

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
www.samhsa.gov

Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical
change; for inpatients, prior to increasing privileges and at discharge.

1. RISK FACTORS
3 suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior

3 current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality
disorders, conduct disorders (antisocial behavior, aggression, impulsivity)
Co-morbidity and recent onset of illness increase risk

3 Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations

3

3 Precipitants/stressors/Interpersonal: triggering events

Opioids and Clinical Opiate Withdrawal Score (COWS)

Box 18-2 Canada’s Fentanyl Public Health Crisis

Developed in 1959 for use as a general anesthetic, fentanyl is therapeutically used to provide physical and emotional relief from acute pain, principally for palliative care patients or those with long-term chronic pain who experience breakthrough pain when using other less potent opioids. It has rapid onset and short duration of action; thus it is primarily administered transdermally in a hospital setting to make its use more convenient for those who are severely ill, with each patch designed to slowly release the potent substance over 72 hours.

In 2017, illicit street use of the potent licit synthetic opioid fentanyl became a national public health crisis, with overdose deaths in Canada reaching new levels. A decade before, a less potent licit synthetic opioid oxycontin had likewise become a public health issue, which led to its use being prohibited but without the development of a concurrent treatment strategy for those who had become addicted. In fact, during this time the Harper government appealed all the way to the Supreme Court of Canada in an attempt to shutter the nation’s lone supervised injection site; after losing that appeal, the government introduced legislation creating additional barriers to opening any new facility anywhere in Canada.

Historically, whenever a psychoactive substance is prohibited, in its void an alternative arises (Csiernik, 2016). Unfortunately in this case the prohibition of oxycontin, which was accompanied by its manufacturer, Purdue Pharma, paying a $600 million fine for product misbranding, led to an increase in heroin use. However, heroin is both expensive and illicit, whereas fentanyl, a synthetic drug that is 3 times as potent as uncut heroin and 100 times as potent as morphine, is both far cheaper to manufacture and can be legally produced in nations such as China. Across Canada, the cheaper fentanyl was being mixed with heroin, and at times cocaine, so that less of the expensive drug needed to be used and thus drug dealers could increase their profit margins. Combining the two drugs in street-level labs, however, often creates “hot spots” where more fentanyl is incorporated into the mix and thus the risk of overdose is further increased. Along with fentanyl, another synthetic opioid, even more potent, carfentanil began to be used for this purpose, again increasing the likelihood of each injection leading to an overdose.

 

Canada is facing a national opioid crisis. The growing number of overdoses and deaths caused by opioids, including fentanyl, is a public health crisis. This is a complex health and social issue that needs a response that is comprehensive, collaborative, compassionate and evidence-based.

 

Since January 2016 there have been:

· 15,393 Apparent opioid-related deaths, or 11 pe

SAFE-T Protocol with C-SSRS (Columbia Risk and Protective Factors) – Recent

Step 1: Identify Risk Factors
C-SSRS Suicidal Ideation Severity Month

1) Wish to be dead
Have you wished you were dead or wished you could go to sleep and not wake up?

2) Current suicidal thoughts
Have you actually had any thoughts of killing yourself?

3) Suicidal thoughts w/ Method (w/no specific Plan or Intent or act)
Have you been thinking about how you might do this?

4) Suicidal Intent without Specific Plan
Have you had these thoughts and had some intention of acting on them?

5) Intent with Plan
Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?

C-SSRS Suicidal Behavior: “Have you ever done anything, started to do anything, or prepared to do anything to end your
life?”

Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t
swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or
actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.

If “YES” Was it within the past 3 months?

Lifetime

Past 3
Months

Activating Events:
□ Recent losses or other significant negative event(s) (legal,

financial, relationship, etc.)
□ Pending incarceration or homelessness
□ Current or pending isolation or feeling alone

Treatment History:
□ Previous psychiatric diagnosis and treatments
□ Hopeless or dissatisfied with treatment
□ Non-compliant with treatment
□ Not receiving treatment
□ Insomnia

Other:
□ ___________________
□ ___________________
□ ___________________

Clinical Status:
□ Hopelessness
□ Major depressive episode
□ Mixed affect episode (e.g. Bipolar)
□ Command Hallucinations to hurt self
□ Chronic physical pain or other acute medical problem (e.g. CNS

disorders)
□ Highly impulsive behavior
□ Substance abuse or dependence
□ Agitation or severe anxiety
□ Perceived burden on family or others
□ Homicidal Ideation
□ Aggressive behavior towards others
□ Refuses or feels unable to agree to safety plan
□ Sexual abuse (lifetime)
□ Family history of suicide

□ Access to lethal methods: Ask specifically about presence or absence of a firearm in the home or ease of accessing

Step 2: Identify Protective Factors (Protective factors may not counteract significant acute suicide risk factors)

Internal:
□ Fear of death or dying due to pain and suffering
□ Identifies reasons for living
□ ___________________
□ ___________________

External:
□ Belief that suicide is immo

AMERICAN PSYCHIATRIC ASSOCIATION | DIVISION OF DIVERSITY AND HEALTH EQUITY | © 2019

Treating Women Who Have Experienced
Intimate Partner Violence

Intimate partner violence (IPV) is one of the most common form of violence against women. It could be
physical, sexual, and emotional abuse and controlling behaviors by an intimate partner and occurs in all settings
and among all socioeconomic, cultural and religious groups. IPV may lead women to negative health
consequences, including mental health disorders. Therefore, it is important to implement IPV screening and
counselling safely and effectively throughout the health care delivery system. It can be achieved by educating
health care professionals in IPV screening and counseling techniques.

The following sections discuss screening, safety assessment, treatment options and best practices in treating
women who have experienced IPV.

Screening for IPV Survivors in Mental Health Settings
Women with mental health symptoms or disorders (depression, anxiety, post-traumatic stress disorders (PTSD),
self-harm/suicide attempts) should be screened for IPV in health care settings as part of best clinical practice.
Survivors should be evaluated for safety and homicide risk and undergo a general health screening. Other areas
to assess include history of substance abuse/misuse and social support.

In 2007, the Centers for Disease Control and Prevention released the screening tool Intimate Partner Violence
and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings: Version , that is
widely used by providers.

Safety Assessment

A vital role for health care providers is to assess the safety of a survivor and develop a plan to ensure immediate
safety of the survivor. Health care providers may connect survivors to a nurse, social worker, advocate,
community resource, or health care workers who are trained in violent prevention.

Suicide Assessment

Studies have found a link between the number of previous traumatic events and the risk of attempting suicide.
Mental health providers should conduct a suicide risk assessment in all interactions with IPV survivors. Mental
health care providers should:

o Conduct the assessment in a private, confidential space.

o Provide interpreters as needed.

o Discuss the reasons for assessment with your patients. It will reduce their fear, anxiety and the
risk of aggression.

AMERICAN PSYCHIATRIC ASSOCIATION | DIVISION OF DIVERSITY AND HEALTH EQUITY | © 2019

2

o Describe with as much detail as possible what is happening or going to happen which will
increase a sense of control and decrease fear and anxiety.

o De-brief with staff involved in the process.

o Work with the patient on

Chapter 39

The School-Age Child and Family

Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Promoting Optimal
Growth and Development

• “School age” generally defined as ages 6 to 12 years
• Physiologically begins with shedding of first deciduous teeth; ends at puberty with acquisition of final permanent teeth
• Gradual growth and development
• Progress with physical and emotional maturity

Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

*

Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Fig. 39-1. Middle childhood is the stage of development when deciduous teeth are shed.

Copyright © 2013 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

*

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