could it be a mental illness?

Could it be a mental illness?

How to encourage someone to get help

Allan Fielding M.D., F.R.C.P.(C)

Outline of the presentation

1. What are the warning signs that someone might be developing a mental illness

2. Approaching the person with your concerns and preparing the groundwork

3. Accessing help (including legal interventions)

What is a mental illness

An illness produced through a complex interaction of biological, psychological and social factors, which shows up primarily through alterations in emotions, thinking, relationships and/or behavior

The spectrum of mental illness

Over 50 different types of mental illness have been identified

Clustered into broad groupings:• Schizophrenia Spectrum Disorders• Affective (Mood) Disorders• Anxiety Disorders• Personality Disorders• Substance Abuse Disorders

Getting help

1 in 5 will experience a mental illness in their lifetime

Almost half of all people with a depression or anxiety disorder have never gone to see a health professional about this problem

Only 1/3 of those who need mental health services in Canada actually receive them

Getting help

High stigma: • only 50% of Canadians would disclose that a

family member has a mental illness• 46% of Canadians think people use the term

“mental illness” as an excuse for bad behavior

Mental illness second leading cause of disability and premature death

4 of top 10 leading causes of disability worldwide

Part 1

What are the warning signs that someone might be developing a mental illness?

Warning signs Mood related symptoms

• Sad, euphoric, irritable, withdrawn

Physical / bodily symptoms• Sleep, energy, appetite, weight

Mental functioning • Concentration, memory, decisions

Ability to function in their usual roles• School, work, home, kids, leisure

Warning signs

Measures of severity and persistence:– Symptoms cause clinically significant

distress or impairment in functioning– The symptoms have been present for

several weeks– This represents a change in functioning

from previous levels

Depression Mood

– Sad, depressed, tearful or empty– Express feelings of worthlessness,

uselessness Physical

– Trouble falling asleep and early morning awakening

– Loss of appetite with significant weight loss– Fatigue, loss of energy

Depression

Mental– Trouble with memory, concentration– Loss of creativity, problem solving

Roles– Drop off in leisure, pleasurable activities,

sex drive, self-care– Difficulties with work or school

Depression in Teens

Irritability often the main symptom– Hostile, grumpy, easily lose temper, rage

Unexplained aches and pains Problems at school and home Extreme sensitivity to criticism

• Stemming from feelings of worthlessness

Selective withdrawal

Depression in the elderly

Mania

Mood– Euphoric, irritable or hostile, hard to

interrupt, never stop– Easily excited to enthusiasm or anger

Physical – Decreased need for sleep without fatigue– Increase in activities– Restlessness

Mania Mental

– Distractible, difficulty finishing tasks– Racing thoughts, disjointed thinking– Rapid or pressured speech– Overspending, poor judgment, impulsive– Inappropriate humor, behavior

Roles– May initially be hyper-productive, followed

by disorganization

Psychosis

Mood– Inappropriate laughter or other emotions– Loss of interest or pleasure, – Flattening of mood– Increasing isolation, withdrawn

Physical– Day-night reversal– Deterioration of personal hygiene

Psychosis

Mental– Suspicious, odd behavior, odd thinking or

associations– Preoccupied with their inner world– Distractible, concentration & memory

problems Roles

– Withdrawal from usual roles, isolation

Drug or alcohol abuse Mood

– Unexplained change in personality or attitude– Unstable mood, mood swings– Lack of motivation, fearful, anxious, paranoid

Physical – Smells on breath, body, clothing– Signs of intoxication– Change in appetite, sleep, self-care

Drug or alcohol abuse

Mental– Difficulty concentrating (episodic)– Secretive or suspicious behaviors

Roles – Drop in attendance and performance– Unexplained need for money– Change in friends, activities

Red flags Distinctly psychotic

behavior (bizarre, responding to inner world, voices, delusions)

Violence, towards self or others Expressed suicidal thoughts or any kind of

suicide note Giving away treasured or special possessions Potentially self-injurious behavior Marked drop-off in performance in usual roles

Warning signs: conclusions

Each illness has its own set of early symptoms

Usually a significant change from usual Red flags exist which signal an emergency Often missed - we write them off as a phase,

explain away, remain unaware, or don't want to see

Useful to have open discussion with other family members

Part 2

Approaching the person with your concerns and preparing the groundwork

Approaching the person

Do your homework first: assemble your thoughts and observations, even make notes. Try it out on yourself first - would you be convinced?

Talk with other people (family, friends, teachers, pastor etc.) to help validate your perceptions. Sometimes it is “hard to see the forest for the trees”


Pick or set (without being overly melodramatic) a time to talk that will allow you to comfortably explore your concerns

Allow for the possibility that you might have to come back to the subject at a later time, and that your first talk might be relatively short

We have two ears and one mouth – allow more time for listening than talking


Try to use "I" statements rather than "you" statements

Think of the “sandwich” method Allow it to be face-saving ("I understand you

might be going through rough times these days...") without writing it off as just a phase


Think of what attitudes towards mental illness have already been expressed in your household and how this might shape your own attitude and the attitude of your loved one

Get as many people involved as necessary but don't gang up on the person. See if you have consensus in the family


Consider using a trusted third party to do the approaching, either with you or instead of you.

Be prepared for defensiveness, but remember and remind what are the drivers behind this conversation: changes in behavior, love and concern for their wellbeing


Be especially open about the red flags, and broach the subject of suicide. You will never suggest it to someone for the first time.

Keep trying to imagine what this must feel like from their point of view

If they try to reassure you, try to negotiate a watchful waiting period and a re-discussion in a few weeks

Approaching the person Sometimes "Help me understand..." is better than

"I understand". It shows you really want to hear their story

Shame and embarrassment can be important reasons people don't want to talk about what is going on or seek help.

• Commit to trying to be non-judgmental and understanding, but especially that you put their wellbeing above all other priorities, and would make your best effort to understand.

• "Try me”

Special circumstances:Sexual orientation Realization of sexual orientation and

“Coming-out” often can occur at very vulnerable times in person’s development– Psychological stage of identity

development– Relationship to peers very important– Member of a group

Homophobic response


It may take multiple attempts to be able to join with the person and be able to talk

If you can build a link and have some agreement that there is a problem, you can introduce the idea of getting help

Again, try to remember what this must feel like from the other person's perspective

Approaching the person Verify if you have agreement ("Have you

thought about this as well...") and if they have tried something

Ask if they have any ideas or preferences of how to proceed, in particular a trusted person (who you also trust) who might be a starting point. Try to agree on how urgent you feel this is, and therefore what would be a good time frame

Approaching the person Offer to research some options. If declined, pin

down a time frame for them to look and a time to re-discuss

Be prepared to answer their concerns and address their fears.

• Many people fear treatment before they have even been diagnosed and a treatment presented to them

• Be prepared to help them advocate for treatment that is acceptable to them, as long as it doesn't put them at risk


Offer accompaniment or anything else that would facilitate them seeking help (eg transportation)

Be aware if anyone is "undoing" your efforts• “Everybody’s an expert”• Inappropriate extrapolation from their own

experiences


Self-rating scales– Check if the person might be open to using

a self-rating scale or checklist (see Resources)

– May be useful to help elicit symptoms– More emotionally neutral, may be better

accepted

Approaching the person: conclusions Success rate may range from very high to

very low You may not be the best person to approach

them, so find the best person and have them do it

Be prepared with a "Plan B" Be prepared to be patient, but have an idea

of what line being crossed would trigger emergency action

Part 3

Accessing care

Accessing care

There are multiple ways someone can access care and all have their pros and cons.

You may be faced with a situation where the first choice of the person is not your first choice, but if the aim of the exercise is to at least get the person started on the road to getting help, you might have to accept a compromise

The point of entry you choose may also be based on the urgency of the situation

Accessing care – Trusted Person

Often times if someone starts with a person in whom they have confidence, that person will be able to build trust and present an objective outside opinion that could lead them to seek other more specific help

• Pastor or priest• Counselor at school or university

Accessing care – Family doctor

A GP is another good place to start. A recent survey of GP's in Quebec showed:

• 1/3 do a lot of work in psychiatry• 1/3 will handle “easy cases”

GP's are now essential for accessing much of the mental health system

Best if the GP is already known to the person and has the time to do a proper interview

Accessing care - CLSC

CLSC's have been given the mandate to set up Mental Health teams and serve as the entry point (Guichet d'acces).

They usually start with a psychosocial screening (Acceuil psychosociale) where they determine whether you might need social services, a psychologist, or a psychiatric consultation

Accessing care - CLSC

Based on this initial assessment, they can then refer you on to their Mental Health Team where there would be a more in-depth assessment

They may then ask for a psychiatric assessment, either at the CLSC or in a hospital-based MEL Clinic

Accessing care: Emergency Room (ER) Psychiatric services in most emergency

rooms are consultation services • They do not see the person right away• Must be evaluated by the ER doctor

ER doctors may also decide this is not an emergency and refer you to the more regular channels for evaluation

Accessing care: ER

Teaching Hospital• Good chance that you would be assessed by a

Resident doctor, who would also have to discuss your case with their Attending Staff.

Rare that it will be the doctor who sees you in the ER who will do the follow-up, so you also have to be mentally prepared to repeat the story several times.

Often do not have your chart

Accessing care: support

Given that all of these means of accessing care can take some time, there is a special and particular role for support during this period:

• Encouraging the person to persist• Helping problem-solve• Facilitating the process • Accompaniment (if acceptable)• Getting the story straight

Accessing care: being prepared

Make the best use of the interview time by being prepared with such details as:

• Medical history • Lists of medications taken• Family history• A timeline of the important symptoms or

developments• A sense of prior functioning• Contact information

Accessing care: interviewing

Be prepared as a family member that you may not be invited in to all of the interview, but if you come along it would be expected that someone should interview you

Confidentiality: the professionals may not be able to share much of their interview with you. While you may not be able to ask, you certainly can tell and this would be the time to express your concerns, particularly about the red flags

Court ordered psychiatric evaluation

When all else fails, you might be left with having to use legal means to get the person assessed

Typically this means taking out a court-ordered psychiatric assessment

Handbook: Practical Guide to Mental Health Rights which can be

• Download from Ami Quebec website under “Publications”

Court ordered psychiatric evaluation A document must be presented to a judge

outlining the various facts that make you consider that the person needs a psychiatric evaluation

Suicidal or are in danger of becoming violent towards others.

• You, or an interested party (friend, relative) or even a physician if they have knowledge of the person, must provide details of how the person is behaving in such a way as that they are presenting a grave and immediate danger

Court ordered psychiatric evaluation Facts (he only sleeps two hours a night, he is

hitting the walls with his fist, he speaks about throwing himself off the bridge) and not opinions (I think he is depressed)

Family organizations in your area might be able to provide you with some assistance in filling out the forms and getting them piloted through the legal system

Court ordered psychiatric evaluation Temporary Confinement Order (Garde

Provisoire) allows the police, if necessary, to bring the person to the ER for a psychiatric assessment and essentially orders the person to submit to the exam.

It does not obligate the hospital to admit the person - that has to be an outcome of the examination (a “stay-go” decision)

Court ordered psychiatric evaluation In extreme emergencies (the person is trying

to commit suicide in front of you) police can usually be requested to bring the person to the ER.

Under these circumstances, the person is not under any court order either to stay in hospital or to submit to an examination, so the hospital must institute these proceedings itself

Court ordered psychiatric evaluation Three possible outcomes:

– The person MUST stay– The person should stay but could go if they

refuse– The person would be best treated as an

outpatient– In rare circumstances, the person is not

mentally ill and needs to be directed elsewhere (eg dementia)

Accessing care: conclusions

We need to keep in mind the desired outcome of this process: getting help for your loved one

Different starting points depending on many variables:

• Trust, communication, urgency, connections, alliance, attitudes, support network


There are different warning signs and even red flags that should alert you that the person is beginning to suffer from a mental illness and would require help

When you have time (not a grave and immediate danger to themselves) you should try to work with them to build a link of trust, address their concerns, and facilitate access to an assessment.

Accessing care: conclusions Care may be accessed at a variety of levels

(pastor, school counselor, CLSC, GP, ER) In an emergency, with a willing person, the ER

will be the quickest but will still typically require a long wait and an assessment by the ER doctor before being seen in Psychiatry

In severe emergencies, legal tools exist to force the person to submit to an examination. Since these often break the trust the person had in you, they are often last resort


This is not an easy process. Accompaniment for yourself equally

important:• Perspective• Wise counsel• Information• Practical advice• Debriefing

Part 4

Care for the caregivers: taking care of yourself during this process

Care for the caregivers

This process can be very taxing and stressful for families– Conflicts over how to proceed– Judgment calls– Who is the “point person” and how are they

received– Worry over loved-one– Forced evaluation / difficult cooperation


Consider invoking some of the same support resources for yourselves (Pastor, GP, counseling)

Family support groups– Experience– Collective wisdom– Tips & suggestions, practical advice


Try not to make it all-consuming– Activities not focused on a mental illness– Time for fun, relaxation

Importance of a healthy lifestyle– Nutrition, sleep, exercise

Sustainable pace Get informed

Resource suggestions AMI Quebec

www.amiquebec.org Douglas Hospital

www.douglas.qc.ca Mike’s Story

www.mikesstory.com Centre for Addiction and Mental Health

www.camh.net (Recovery stories)

Quebec Ministry of Health

www.msss.gouv.qc.ca (Google “Mental Illness Recovery”)

Resource suggestions

Canadian Mental Health Association– www.cmha.ca (BC chapter has good

pamphlets) American Psychiatric Association

– www.psych.org Bring Change 2 Mind

– www.bringchange2mind.org

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