risk are managed on 15 min and 1:1 or 1 min (i.e. a nurse is present with the patient at all times). Psychiatric care is heavily reliant on a MDT:The history of modern psychiatry began in the 1800s, and over the twentieth century biological theories around mental illness, psychological ideas, and psychopharmacology grew into the basis of what exists today. Psychiatric illnesses are classified in the ICD-10 (used in the UK, developed by the WHO) and the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (developed by the American Psychiatric Association). The classifications are periodically reviewed as new evidence emerges. The ICD-11 (currently being prepared for implementation) has classified gaming disorder, and reclassified gender incongruence from mental health to sexual health.
1. Be curious: ask questions to staff and patients alike.
2. Be respectful: when assessing patients, do not push your agenda.
3. Be safe: the wards can sometimes be chaotic and patients can quickly become agitated.
Most placements are general adult or older adult subspecialties with a mix of inpatient/outpatient experience, or attached to a psychiatry liaison team covering a general hospital. There may be options to access various subspecialties.
Observations (or ‘obs’) in psychiatry is different from a general hospital and refers to how often a member of the nursing team should check on a patient. Standard obs are hourly, and patients with risk are managed on 15 min and 1:1 or 1 min (i.e. a nurse is present with the patient at all times). Psychiatric care is heavily reliant on a MDT:
• Consultants and junior doctors.
• Community psychiatric nurses (CPNs): these nurses hold caseloads in the community, managing the patients with input from the psychiatrists and other members of the MDT. Social workers and occupational therapists also hold caseloads when working with the community teams.
• Registered mental health nurses (RMNs): all mental health nurses are RMNs, but the term is used commonly when requesting 1:1 obs on the general wards.
• Approved mental health practitioners (AMHPs, formally approved social worker): required to coordinate and facilitate Mental Health Act (MHA) assessments and to submit the paperwork.
• Occupational therapists (OTs): within a mental health unit, OTs run various groups for inpatients, may do 1:1 work around improving living skills, facilitate access to voluntary placements, and aid patients in accessing employment upon discharge.
• Psychologists: may provide individual cognitive behavioural therapy (CBT) on wards and in the community. In Child and Adolescent Mental Health Services (CAMHS), there may be psychologists providing family therapy, group therapy, or other forms of individual work. The wards may have art/music/drama therapists.
• Independent mental capacity advocates (IMCA): act as advocates for the patient, by liaising with the patient prior to a meeting (e.g. ward round) and relaying the patient's opinions and concerns.
The MHA came in to effect in 1983, and was amended in 2007, with the aim of enabling detention and treatment of those suffering with mental illness without their consent, due to risk to themselves or others. A MHA assessment is carried out by an AMHP and two section 12-approved doctors who all have to agree that a patient has a mental illness of sufficient degree and nature to warrant being placed under section of the MHA.
• Section 2: lasts for up to 28 days for assessment and treatment of a mental illness
• Section 3: lasts for up to 6 months, for assessment and treatment for a mental illness. After 3 months, the patient will be asked for consent to continue treatment. If this is refused and treatment is deemed necessary, a second opinion-appointed doctor will review.
• Section 5(2): used in both general hospital and mental health units, the admitting team (i.e. not necessarily the psychiatry team) can detain a patient for up to 72 hours if there are concerns that their mental state is deteriorating and the patient is a risk to self or others. Section 5(2) cannot be used in the ED. The use of section 5(2) will trigger a MHA assessment
• Section 12: approves a doctor on behalf of the Secretary of State as having special expertise in the diagnosis and treatment of 'mental disorders'.
• Section 136: lasts up to 72 hours; under this section the police can bring a patient into a place of safety for a MHA assessment if they are concerned about the mental state of a patient. The use of a section 136 will trigger review by an AMHP or doctor to assess whether there is evidence of mental illness
Legislation was produced in 2005 to enable clinicians to determine whether a patient is able to make an informed decision about their treatment. This applies to all specialties in medicine, not just psychiatry. It is commonly used for patients with:
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The MHA is, in part, used to treat mental health conditions with pharmacological interventions; however, inpatients often suffer with co-morbid physical health conditions, e.g. cardiovascular disease. These cannot be treated under the MHA, and instead the Mental Capacity Act should be used.
The clinician administering the proposed treatment plan should assess capacity.
The information provided must be in a language the person can understand (i.e. may require the use of an interpreter and the use of layman’s terms is important) and the communication does not have to be spoken (i.e. it can be written).
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1. The person is assumed to have capacity until it is established that they do not.
2. The person must be given appropriate help to make the decision.
3. A person is not treated as lacking capacity merely because the decision they make is considered unwise.
4. A decision made under this act for someone who lacks capacity must be in the person’s best interests.
5. Any decision made should be the least restrictive option.
There are plenty of learning opportunities on an inpatient ward. It is a chance to assess patients who are acutely unwell and review their progress during your rotation. It is important to follow safety procedures on the ward, which includes informing someone of your whereabouts at all times, and if appropriate, carrying a personal alarm or familiarizing yourself with the fixed alarms on the walls.
• Emotionally unstable borderline personality disorder.
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• side effect from Parkinson's medication
• CNS infection (e.g. syphilis, HIV)
• autoimmune conditions affecting the CNS system (e.g. SLE, MS).
Is the term describing a constellation of symptoms affecting a person's perception of their surrounding environment. The symptoms typically fall into two categories:
1. Hallucinations: a change in the perception by the senses (e.g. hearing voices of people who are not there which is the most common hallucination). It can affect all given senses.
2. Delusions: a disordered belief system that when examined are obviously untrue (e.g. believing that the FBI are spying on you through your chimney).
Disorders with psychosis as a feature you may see on the ward include:
• severe (psychotic) depression
• drug-induced psychosis (cannabis, ketamine, LSD, psilocybin, etc.).
This is characterized by a range of symptoms affecting a person's perceptions and thoughts. It is typically a long-term diagnosis, requiring antipsychotic medication to treat the symptoms and improve a patient's daily functioning. The symptoms of schizophrenia were documented by Kurt Schneider (known as Schneider’s first rank symptoms).
• Thought echo (hear own thoughts spoken aloud).
• Running commentary (of actions).
• Third-person auditory hallucinations (two or more voices conversing).
• Insertion (thoughts being placed in own mind).
• Withdrawal (thoughts being removed from own mind).
• Broadcasting (believing others know own thoughts).
• Feelings (belief that feelings are not own but have been imposed by an external force).
• Impulses (experiences impulses that are not own but believed to be imposed by an external force).
• Actions (experiences actions and will are controlled by external force).
• Somatic passivity (believing that an external agent is manipulating own body e.g. twisting intestines).
• Delusional perception (linking normal perceptions with bizarre meanings, e.g. hearing a car horn means the Queen has summoned you).
These listed symptoms would be considered positive symptoms of schizophrenia. Other positive symptoms of schizophrenia include:
• knight’s move thinking (thinking that is difficult to follow due to loosening of association of ideas)
• delusional mood/atmosphere (a sudden perceived change in the environment which may be linked to a specific meaning)
• word salad (confused, garbled speech that is difficult to follow).
Negative symptoms are more subtle and associated with a worse prognosis:
• slowness of thought, speech, and movement (psychomotor retardation).
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Be clear in your own mind the definitions of each of the listed symptoms. A top student will be able to differentiate each of the symptoms when taking a history so it is important to source a number of examples of each until you feel confident.
Ask the boss
The most common subtype of schizophrenia is paranoid schizophrenia. Ask your consultant about other subtypes such as hebephrenic and residual schizophrenia.
The management of all mental health conditions considers the:
• social aspects of the disease.
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The most common symptom in people with schizophrenia is lack of insight into their mental illness.
Immediate management of acute psychosis is with antipsychotics and benzodiazepines (to reduce agitation).
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Antipsychotics come in two classes—first and second generation. First-generation drugs have a more parkinsonian side effect profile (e.g. tremors, stiffness) and sedation. Second-generation drugs have a less pronounced parkinsonian side effect profile but can cause significant weight gain ( appetite) and sedation among others.
Tip: side effect profile can affect medication compliance.
Are the spectrum of disorders that encompass symptoms of:
• elated (manic and hypomanic)
• depressive (mild, moderate, and severe) moods.
The most commonly seen in an inpatient unit are manic episodes or severe depressive episodes.
Is a condition of both mania and depression. There are several differentiations:
• Bipolar 1 diagnosed after at least one manic episode lasting 1 week. A patient may only present with mania, but may have experienced preceding subclinical depressive episodes or develop subsequent depressive episodes.
• Bipolar 2 consisting of hypomania and moderate/severe depressive episodes.
• Cyclothymia with elated plus low moods that do not meet the threshold for bipolar affective disorder.
• Rapid cycling with four or more mood swings within a 12-month period.
Symptoms of mania/hypomania
• Persistently elevated mood, quick to become irritable.
• High energy levels/always on the go.
• Inflated self-esteem, grandiosity.
• Difficulty following thoughts—flight of ideas.
• ‘Risky’ behaviour: promiscuous behaviour, reckless spending, unawareness of personal safety (e.g. running across the road).
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For a diagnosis of mania, the symptoms have to be present for 7 days. For a diagnosis of hypomania, the symptoms should be present for 4 days and should not be severe enough to significantly impact daily functioning.
Hypomania may be seen in outpatient clinics but a manic episode is most often managed as an inpatient admission. Immediate management is with sedatives (benzodiazepines) and mood stabilizers (e.g. sodium valproate or lithium).
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Lithium toxicity can occur due to overdose, dehydration, or abnormal renal function. Symptoms include diarrhoea, vomiting, drowsiness, and muscle weakness.
Depressive episodes are classed as mild, moderate, and severe depending upon the number of symptoms present. The core triad of symptoms are:
• anhedonia (loss of enjoyment of activities previously enjoyed).
Ask the boss
Risk management in mania can be ethically complex such as:
• Should you remove a patient’s smartphone and tablet if you are aware they are spending online beyond their means?
• Should you prevent a patient having contact with another patient on the ward they are attracted to?
Beck’s triad (Fig. 29.1) forms the cognitive theory of depression consisting of the following negative thoughts:
There are additional biological and psychological features (See Table 29.1):
• Mild: at least one of the core symptoms and four in total.
• Moderate: two or more core symptoms and up to six in total.
• Severe: two or more core symptoms and seven or more in total or associated mood congruent psychotic symptoms.
Fig. 29.1 Beck’s triad. Reproduced from Wikimedia commons under the Creative Commons Attribution-Share Alike 3.0 Unported license
Table 29.1 Biological and psychological features of Beck’s triad
| Biological | Psychological |
| Poor sleep (especially early morning waking) | Low self-esteem/self-worth |
| Poor appetite | Poor concentration |
| Loss of libido | Feelings of guilt/blame/hopelessness |
| Psychomotor retardation | Suicidal ideation |
Diagnosis of depression (symptoms should be present for >4 weeks).
Immediate management is with antidepressants and levels of observation dependent upon levels of risk. Consider previous use of antidepressants and reasons behind non-compliance prior to commencement. CBT for depression should also be offered.
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Switching between antidepressants requires close monitoring due to thelong half-lives of the medication. Fluoxetine has the longest half-life (around 4–6 days).
Is the most common personality disorder seen on the acute psychiatric ward. Symptoms include extreme, intense, and volatile emotions, impulsivity, fear of abandonment, and feelings of emptiness. Patients are often admitted following an episode of deliberate self-harm or with suicidal ideation. A short admission or intensive work with the home treatment team can help to contain the risk during the crisis.
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The evidence suggests that long-term admission to acute inpatient units is not beneficial for this patient cohort.
Following deliberate self-harm or with ongoing suicidal ideation, a patient may be placed on 1:1 obs which are reviewed daily. Medication is not often used in acute crises except if the patient becomes a risk to themselves or others (e.g. extreme agitated behaviour). The patient may already be on medication in the community, which should be continued through admission as appropriate. The patient should be actively encouraged to engage in the therapeutic process and work with the MDT to resolve the crisis.
• Morning handover between staff is a good way to learn about new patients on the ward and decide with the staff who would be best for you to assess that day.
• Most wards will have a morning meeting with the patients, which can be useful to attend to observe the staff/patient dynamics and find out about OT-run groups that day.
• A ward round occurs once or twice a week.
• Other reviews such as CPA meetings with a care coordinator occur on an ad hoc basis
• Try shadowing the on-call doctor to experience ward emergencies, how to assess new admissions, walk-in patients, and patients brought in under section 136
Some inpatient sites will have a seclusion room. The seclusion room is a last resort to managing an escalating patient on the ward (e.g. if a patient becomes violent towards staff or other patients, and rapid tranquilization has failed to calm them down). Attend a seclusion review if possible. The team will re-assess risk and conclude whether the patient is settled enough to return to an open ward or may move to a psychiatric intensive care unit (PICU).
Is a single-sex locked ward with a higher staff-to-patient ratio to manage high-risk patients. The aim is to stabilize the patient on medication, reducing the risk in order to transfer them to an open ward. Patients from open wards can be escalated to a PICU. If a PICU bed is not available, patients can be managed on an open ward with two or more staff members providing continuous obs.
Is used as a treatment for severe treatment-resistant depression, a protracted manic episode, and catatonia. It involves placing the patient under sedation and providing a muscle relaxant, and then inducing seizure activity via electrodes placed on the temples. The procedure lasts a matter of minutes and is repeatedly weekly or twice weekly for a number of sessions (usually up to 12).
Trivia
ECT was developed in the 1930s and prior to electricity, seizures were induced by chemical agents such as metrazol and camphor.
Short-term amnesia, drowsiness, headache, confusion, loss of appetite, aching muscles, and risk of anaesthetic.
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Catatonia is defined as a state of neurogenic motor immobility and behavioural abnormality. It is rarely seen these days but can be a manifestation of schizophrenia, bipolar affective disorder, depression, and post-traumatic stress disorder. Symptoms include immobility (stupor), rigidity, posturing (waxy flexibility is the maintenance of a given position), echolalia, and echopraxia (mimicking speech and actions).
Outpatient clinics are a good place to assess patients diagnosed with anxiety disorders and review patients who are managing with schizophrenia in the community. It may also provide the opportunity for home visits.
Are more likely to be seen in clinic if the patient is on medication (typically SSRIs). Many are offered CBT through a GP or self-referral service known as IAPT (improved access to psychological therapies). When taking the history, it is important to elicit:
• whether the symptoms have worsened
• whether anything makes the symptoms improve
• whether there were any significant life changes prior to the symptoms
• how the symptoms affect daily functioning.
Is often experienced as a free-floating anxiety with constant chronic worrying about all aspects of daily life. Sufferers feel constantly on edge. To be diagnosed, the anxiety must be present for at least 6 months. They will catastrophize events (e.g. if their spouse has not arrived home from work, they will fixate on the cause being a fatal accident). GAD affects concentration and sleep. It may impact the ability to maintain employment and affect relationships with others.
Is defined as experiencing panic attacks without an apparent trigger. A panic attack is a physiological response to a stressful situation ( HR, sweating, breathlessness, chest pain). Often the symptoms of a panic attack will further cause anxiety, which can further perpetuate the symptom and can be a frightening experience. The person may avoid situations which trigger the panic attack (e.g. a crowds or tight spaces). Those who suffer with panic disorder can become extremely anxious about suffering another panic attack, as they fear the frightening experience.
The patient will experience obsessions and associated compulsions. Obsessions are intrusive thoughts or images, which are negative in nature (e.g. a belief that something deadly will happen, images of people dying, a fear of paedophilic thoughts). The patient may experience compulsions which, when carried out, can provide some immediate but not long-standing relief from the symptoms. The compulsions can start to affect daily living, intruding on time and ability to function in employment.
• A fear of contracting a deadly infectious disease (obsession) may result in compulsive hand-washing (compulsion).
• A belief that something bad will happen to love ones (obsession) may result in a switching the light switches on and off 33 times (compulsion).
Is the obsessional idea that the sufferer has an undiagnosed medical condition, often cancer or HIV, and will repeatedly request investigations to assess for the specific condition, only being temporarily satisfied with a negative result. Sufferers may also believe they have a serious illness with the experience of symptoms (e.g. experiencing a headache will precipitate the worry of a brain tumour). The anxiety experienced may cause physical symptoms which further perpetuate the idea that there is a serious medical issue.
Is the physical manifestation of psychological phenomenon where the patient experiences variable physical symptoms (GI, dermatological, cardiovascular such as chest pain, breathlessness, etc.) with no confirmed medical diagnosis. The symptoms must be present for at least 2 years. Often the sufferer will seek medical help or self-medicate to alleviate the symptoms. The difference between somatization disorder and hypochondriasis is that in somatization disorder, the sufferer does not fixate on a specific diagnosis.
Patients diagnosed with schizophrenia in the community attend outpatient appointments regularly to manage their medication and side effect profile. Those on depot medication will attend either fortnightly or monthly for their depot and will be reviewed by a CPN. They should also have annual blood tests and a physical health screen either by the CMHT or their GP.
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A person is diagnosed with treatment-resistant schizophrenia if they have tried two different antipsychotic medications at a therapeutic dose for 6 weeks or more and their symptoms are still uncontrolled. Clozapine is an antipsychotic medication that can be used in these cases.
There are subspecialties within psychiatry that you should experience.
The older adult wards treat older adults diagnosed with psychosis and mood disorders similar to those present in the general adult population. The older adult service also aids with diagnosis and management of dementia. See Table 29.2.
Table 29.2 Types of dementia
| Dementia | Pathological Characteristics | Symptoms |
| Alzheimer’s disease | Protein build-up in brain to form plaques and tangles | Short-term memory loss—forgetting appointments, forgetting location of day-to-day items (e.g. keys), forgetting recent events |
| Vascular dementia | Reduced blood supply to areas of brain through small strokes | Memory loss occurs later in comparison to Alzheimer’s Impairment of executive function |
| Frontotemporal dementia | Atrophy of frontal and temporal lobes over time | Significant behavioural/personality changes Progressive language difficulties Difficulties with comprehension |
| Dementia with Lewy bodies | Deposits of Lewy body protein in cortical areas | Impaired executive function Fluctuating alertness/attention over the course of the day Visual hallucinations Eventual motor coordination symptoms as in Parkinson’s |
| Parkinson’s dementia | Linked to deposits of Lewy bodies in brainstem | Differs from dementia with Lewy bodies as motor impairment occurs first Memory loss Loss of executive function Emotional volatility Visual hallucinations |
| Posterior cortical atrophy PCA (Honours) | Similar to Alzheimer’s affecting posterior region of the brain | Initially problems with recognizing faces/objects but persevered memory. There may be issues with literacy |
| Progressive supranuclear palsy (PSP) (Honours) | Linked to tau protein deposits. | Problems with balance/steadiness Frequent falls Supranuclear ophthalmoplegia |
There are several formal cognitive assessments to assess for dementia. The ward staff will have access to the assessment templates including the MMSE, Addenbrooke’s Cognitive Examination III (ACE-R), clock drawing test, and frontal lobe tests. Practise on each other for fluency and then assess patients.
Is based in general hospitals and consist of psychiatrists and psychiatric liaison nurses who will review inpatients on the general wards with regard to their mental health. These may be patients who have comorbid mental health issues but are being treated for their physical health or patients who have been admitted for a mental health issue (e.g. deliberate self-harm) but require medical input first. The psychiatric liaison nurses will review patients presenting to the ED with mental health problems.
(Sometimes known as the crisis team.) Is staffed by psychiatrists and psychiatric nurses, who deliver intensive care for weeks in the community. They provide a 24-hour community service, and will review patients once a day administering medication and monitoring their mental state. The inpatient teams may refer to the home treatment team to monitor a patient being discharged, or CMHT may refer a patient whose mental state deteriorates with the aim that intense community input will prevent admission.
The optimal outcome is to be able to sit in on an assessment with a family but this may not occur due to the age of the child or refusal of the family.
• attention deficit hyperactivity disorder (ADHD)
• autistic spectrum disorder (ASD)
• deliberate self-harm in the community (keeping the young person safe at home and school).
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ASD assessment considers the following areas:
• Reciprocal social interaction
• Repetitive/restrictive behaviour.
ADHD is a constellation of symptoms of inattention, hyperactivity, and impulsivity. The symptoms must be present for 6 months and onset before the age of 7 years.
Trivia
In the ICD-10, ADHD does not exist as a diagnosis, rather it is known as hyperkinetic disorder.
There may be opportunity to attend an inpatient or day patient service.
• Familiarize with diagnostic criteria for anorexia nervosa and bulimia.
• Psychotherapeutic interventions available (group therapy, cognitive analytical therapy).
A half-day/day placement in the learning disability inpatient or outpatient service is rare as often a trust will have one team covering a large area.
• Management of agitation/behavioural changes.
• Management of comorbid psychosis.
As well as addictions outpatient services, detoxing patients may also be seen on acute inpatient wards or with the psychiatry liaison team in general hospital.
• Familiarize with common medications used in detox such as chlordiazepoxide (Librium®), acamprosate, and methadone.
• Use of CIWA scale to monitor effects of alcohol withdrawal.
• Questionnaires to assess for harmful alcohol use (e.g. AUDIT questionnaire).
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• Intentional weight loss (BMI <17.5 kg/m2).
• Disturbed perception of body image.
• Physical signs: include dry yellow skin, fine blonde hairs (lanugo), bradycardia, hypotension, anaemia, and complications of recurrent vomiting (hypokalaemia, alkalosis, and poor dentition). Russel sign is calluses on the back of the hand from repeated and chronic self-induced vomiting.
• Binge eating sessions (>2000 kcal).
• Excessive compensatory behaviour (e.g. diuretics, laxatives, fasting or exercise).
A good history is the backbone of psychiatric diagnosis, with the bulk of clinical examination and investigations used to rule out organic causes. The history is comprehensive and relies on collateral history from family, previous discharge summaries, and from the patient’s GP.
Psychiatric assessment
How the patient presented to hospital (e.g. under section 136 or as a walk-in).
• What symptoms have caused the patient to present—explore each in depth considering length of symptom and current impact on patient’s life, e.g. are they able to continue working, have they stopped eating?
• Triggers that may have caused the admission, e.g. significant life event, non-compliance with medication.
• Previous admissions to hospital—informal or under section.
• Previous treatment options—oral medication, depot medication, ECT.
• Previous therapies—CBT, individual psychotherapy, group therapy.
• Any current/past medical conditions.
• Usually confirmed by the GP.
• Usually confirmed by the GP.
• Family history of mental health conditions.
• Usually gained through collateral history from family members.
• Developmental history (including pregnancy, reaching developmental milestones—may require input from family members or GP).
• Family circumstances during childhood.
• Current employment situation.
• Current relationship status.
• Current alcohol use (quantify units per week, binge-drinking).
• Any physical symptoms secondary to long-term alcohol misuse.
• History of substance use (quantify amount used per week).
• Previous history of attending rehabilitation facilities (e.g. inpatient, Alcoholics Anonymous).
• Any arrests or time served in prison—note the dates and history of allegations or convictions.
• Note specifically history of violence to others.
The history is concluded with a mental state examination, risk assessment, and summary/formulation. The mental state examination (MSE) provides a snapshot of how the patient is at the moment of assessment. This can help in the future to identify deterioration or assess improvement. Do not confuse the MSE with the MMSE (Mini-Mental State Examination)!
Mental state examination (mnemonic ASEPTIC)
• Appearance/behaviour: provide a snapshot of what the patient looked like at that moment. Comment on their ethnicity, general appearance (clothes, are they well-kempt?), and the quality of the interaction: was the rapport good, did they maintain good eye contact, were they agitated, pacing, violent, drowsy, etc.?
• Speech: describe the tone, rate, and volume of speech, e.g. angry tone, pressured speech (suggestive of a manic state) or slow (depression), loudly or quietly.
• Emotion/Mood and affect: consider both subjective mood and objective affect.
• Subjective—in patient’s own words, how would they describe their mood, what is their mood between 1 (the worse it has ever been) and 10 (the best it has ever been)?
• Objective—how do you perceive the patient’s mood: low, elated—and their affect—flattened or labile?
• Thoughts: comment on whether there is formal thought disorder. Consider the content of the thoughts (are they paranoid, grandiose, suicidal, delusions, obsessions?). Is there any thought possession (withdrawal, insertion or broadcasting)?
• Perceptions: is the patient experiencing any perceptual abnormality—comment on the nature of hallucinations (auditory, somatic, visual).
• Cognition: is the patient orientated to time, place, and person? Consider doing a MMSE or further cognitive testing if appropriate.
• Insight: assess the patient’s insight. Do they understand why they are in hospital? Do they believe they have a mental illness? How do they feel about taking medication? Assess their judgement and ability to problem-solve.
The risk assessment is dynamic and levels of risk change over time. The assessment provides a summary of historic and current concerns around risk.
Risk assessment
• Risk to self: has the patient had an episode of self-harm/suicide attempt in this admission? Has the patient harmed themselves or attempted suicide in the past? It is important to give details of the suicide attempts. Does the patient currently express suicidal ideation?
• Risk to others: has the patient been violent to staff/other patients/family members/strangers during this admission? Is there a past history of violence towards anyone? Has the patient ever been admitted to the PICU for violent behaviour? Do they have any criminal convictions following violence in hospital? Does the patient have any children or vulnerable adults in their care?
• Risk from others: is the patient particularly vulnerable? Has there been neglect from carers? Is the patient at risk of manipulation from others (e.g. financially)?
• Risk of neglect: has the patient been caring for themselves? Are they malnourished? Do they have any significant medical conditions that have been neglected?
• Risk of absconding: has the patient absconded during this admission? Does the patient have a history of absconding? Have they been admitted to PICU due to their persistent attempts at absconding?
The assessment is concluded with a summary or formulation of the presenting problem, ongoing stressors, and current risk.
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Consider the following for the current presentation:
• Predisposing factors: what predisposes the individual (e.g. genetic, environmental etc.)?
• Precipitating factors: what triggered the episode?
• Perpetuation factors: what ongoing issues contribute (e.g. homelessness, substance misuse)?
• Protective factors: what helps the individual/prevents worsening (e.g. supportive family, good relationship with CPN)?
• Be sure to use lots of open questions.
• Consider ‘why now’, as in why has the patient attended now or why have the symptoms precipitated now?
• Be sure to ask about compliance with medication.
• Ask about alcohol and substance use.
• Ask about any significant life events.
• Ask about how the patient feels about their diagnosis (insight) and what help they hope to gain from attending hospital/clinic.
See Tables 29.3–29.5 for common drugs and side effects.
Table 29.3 Antidepressants
| Class | Drug | Common side effects |
| SSRI (selective serotonin reuptake inhibitors) | Fluoxetine Sertraline Citalopram Paroxetine | GI symptoms, dizziness, insomnia, weight gain, tremor, sweating |
| SNRI (serotonin-norepinephrine reuptake inhibitors) | Venlafaxine Mirtazapine | Fatigue, weight gain, dry mouth, blurred vision |
| TCA (tricyclic antidepressants) | Amitriptyline Clomipramine | GI symptoms, sun sensitivity, difficulty passing urine, blurred vision |
Table 29.4 Antipsychotics
| Antipsychotic | Side effects |
| First generation | |
| Chlorpromazine | Severe sedative effects, moderate EPSEs |
| Haloperidol | Pronounced EPSEs, moderate sedative effects |
| Sulpiride | Moderate sedative, antimuscarinic and EPSEs |
| Second generation | |
| Olanzapine | Appetite and weight gain, drowsiness, GI symptoms |
| Quetiapine | Dry mouth, drowsiness, GI symptoms, appetite |
| Risperidone | Dizziness, EPSEs, restlessness |
| Amisulpride | Drowsiness, GI symptoms, weight gain, dry mouth |
| Aripiprazole | Dizziness, GI symptoms |
| Clozapine | Weight gain, GI symptoms, hypersalivation Neutropenia (incidence 2%) Agranulocytosis (incidence 0.8%) |
EPSE, extrapyramidal side effect.
Table 29.5 Mood stabilizers
| Drug | Common side effects |
| Lithium | GI symptoms, fine tremor, thirst, frequent urination, fatigue |
| Sodium valproate | GI symptoms, appetite, hair loss |
| Carbamazepine | GI symptoms, dry mouth, drowsiness, unsteadiness |
Sleep.