Mental State Of Patient John: Recognizing Deterioration And Biopsychosocial Essay.

Recognising signs of deterioration

John is a 47-year-old male who was admitted to the medical ward several days ago following an ‘injury’ on his rural property and issues with ongoing chronic back pain. John was also diagnosed (two (2) weeks ago) by his local general practitioner (GP) with depression, and commenced on antidepressant medication. John is being cared for in a single room, but during shift handover, there are concerns the ‘injury’ is a possible self-harm episode, although attempts to discuss this with John have been unsuccessful so far. John was initially cheerful and chatty when first admitted, however in the last 24 hours it has been documented that John has become withdrawn, he has stated ‘he feels miserable and is in pain’, but he smiles when nursing staff enter the room. He has voiced his frustration at being in hospital and says he does not think he is ‘depressed’. This morning John refused to take his medications and his daily self-care is lacking.

To begin to build the therapeutic relationship with John, the nurse (following handover) sat down with John to discuss his past, present, and future health needs and goals from the biological (physical), psychological (mental health) and social domains.

During the conversation, the nurse discussed John’s ongoing history of a ‘bad back’. John did not report this to the GP who diagnosed his depression, since John did not see it as important but rather ‘just a part of getting old’. John also told the nurse that he has had no previous history of mental illness and was not sure what had triggered his depression, however, he went on to say he was recently retrenched from his job as a horticulturalist. This

occurred soon after John’s boss told him that business had slowed down. John wondered if he was retrenched as a result of his bad back, which had been effecting him more and more with each passing year. With this history in mind, the nurse then explored John’s current situation and found the back pain that John experienced often kept him awake at night. John says he doesn’t sleep, so wakes feeling tired and unmotivated. He states he doesn’t feel like socialising because he feels exhausted.

In gathering additional background information, John tells the nurse “he thinks his dad may have had some sort of mental illness”. John also reports that the antidepressant medication was doing nothing other than putting on weight, so John thought it might be better if he just stopped taking it. However, his wife and adult children, who are supportive, have told him not to and this is the only reason he continues to take it.

The nurse then asked John to think about his future. At first John was unable to see any hope - either for re-employment (because working outdoors was his only skill), or for being able to keep his own farm due to how he was feeling and his ongoing back issues. John did agree (after some discussion) that he was interested in finding out if there was anything that could be done for his back. When the nurse asked John how he sustained his injury (a deep cut on his upper thigh), John was evasive, became upset, and refused to answer any more questions.

Later that afternoon John was seen packing his overnight bag, he had changed out of his hospital gown and when approached by the nurse he said “there is no point, there is nothing wrong with me and I am not depressed, I told everyone that so I am going home”.

• What are the immediate identifiers of possible signs of deterioration in John’s mental state?
• Identify how baseline information can be obtained and communicated about John’s current mental state.
• What aspects of the comprehensive mental health assessment are the most important in this case? Explain your rationale for your choice.
• In the scenario, what could be contributing to John’s feeling of depression? Discuss in reference to the biopsychosocial model of assessment.
• Address why this approach is deemed ‘best practice’ in mental health care.
• How can the nurse ensure accurate risk assessment and management strategies are implemented for John, while maintaining positive relationships with him and his family?
• Identify and provide rationale as to whether John would be deemed low, moderate or high risk based on predisposing, perpetuating and precipitating factors.
• Discuss how the nurse might manage these risks.
• Describe a potential duty of care (legal/law) versus individual rights conflict as an ethical dilemma that may arise concerning John’s mental state.

Mental state can be broadly defined as the intellectual capacity, general mental health, and emotional state of a person, depending on the clinical observations, and by conducting a thorough interviewing. Mental state most commonly comprises of the behaviour, mood, memory, judgment, problem solving skills, and contact with the reality (Caplan, 2013). Thus, any deterioration from this mental state refers to all forms of changes or alterations that occur in the mental state of the person, thus indicating the need of a closer monitoring or conduction of frequent clinical reviews (Lamond, Joseph & Proverbs, 2015). Some mental states have often been attributed to the beliefs, desires, perceptions, and memories of an individual. While others are often accredited to sub-personal faculties such as, the visual system and language capabilities. Both the types of mental states and processes that are related to the states are intentional. Hence, intentionality is in accordance to the facts that are represented by a mental state. Other paradigms of a mental state are related to hate, love, pain, pleasure, and different attitudes towards propositions that encompass belief, hope, and fear. The essay will elaborate on the mental state of a patient John and will further discuss the biopsychosocial care model, in relation to the case study.

Recognising signs of deterioration- The immediate identifier of the deteriorated mental state in John can be linked to his injury on the rural property that appears to be an instance of self-inflicting harm. The fact that he was active and cheerful upon being admitted to the mental ward is in clear contrast with his sudden apathy and withdrawal. Other identifiers can be related to the feelings of miserableness and pain as reported by him. Refusal to adhere to medications prescribed by the doctors and portrayal of a frustration also demonstrate a sudden worsening of mental health. Recognizing the immediate identifiers is a crucial aspect of providing care to a patient who is mentally distressed. This can be attributed to the fact that maintenance of good mental health is considered utmost essential for living a healthy and long life. While poor mental outcomes can impede a person from leading a successful and purposeful life, good mental state can enhance the emotional abilities. Self-harm, commonly referred to as self-injury has often been defined as the intentional injury to parts of the body that is done without any suicidal ideations. Owing to the fact the desire to inflict self-harm upon an individual has often been considered a major symptom of borderline personality disorder, a mental illness, this should be considered as an important adjunct to deteriorating mental state (Mehlum et al., 2014). Apathy or lack of enthusiasm and interest, in combination with social isolation have been strongly connected with mental illnesses. Withdrawal is a core symptom of schizophrenia and is usually exhibited by people in response to dejection, disappointment, and stress (Strauss et al., 2013).

Baseline assessment

Baseline assessment refers to a structured assessment that is conducted upon a patient by a nursing professional in order to retrieve complete and exhaustive information of the patient’s physical and mental health status. Baseline examination are generally conducted for assessing the physical state of a patient and form the initial point of patient-physician contact (Lindsay & Desforges, 2013). The first assessment should focus on measuring the attention span of the patient. An inattentive patient is usually not able to provide complete cooperation and will therefor hinder all forms of testing. Other baseline assessments would encompass measuring the memory, orientation to place, time and person, judgment, reasoning and verbal abilities (Dennis & O’Toole, 2014). The baseline mental examination will also be conducted by utilizing the Montreal Cognitive Assessment (MOCA) that covers a range of cognitive functions (Memória et al., 2013). Upon obtaining the results of the different evaluation techniques, the results will be analysed so as to ascertain the current mental state of the patient.

This will be followed by conduction of a comprehensive Mental State Examination (MSE). Hence, this would provide an opportunity to observe and describe the psychological functioning of the patient in a structured way to determine certain domains related to patient mental state. Some of the major components of the MSE that will be evaluated are namely, attitude, thought process, thought content, mood and affect, and perception (Ekkekakis, 2013). Attitude is an essential component since it refers to the cooperation or rapport displayed by a client during the interviewing. Affect will help in assessing the dynamic and external manifestations of the internal emotional state of John. His mood assessment will also describe the predominant internal state at a particular time frame. Abnormal or disordered thoughts would help in the diagnosis of formal thought disorder and would also determine if John experiences a flight of ideas (House, 2014). Assessment of the thought content would encompass the majority of the comprehensive MSE and would facilitate gaining a sound understanding of depressed cognition, suicidal ideation, overvalued ideas, phobias, obsession, and preoccupation (Barnard & Teasdale, 2014).

The biopsychosocial model of care- The biopsychosocial model refers to a concept that helps in the development of a sound understanding on the health and illness of individuals, besides taking into account different factors that pertain to sociology, psychology, and biology (Pilgrim, 2015). Depression is usually different from the different mood vacillations that are experienced by people in their lives and is not concomitant with emotional responses occurring in regular basis. An analysis of the case study suggests that the ‘bad back’ that John has been suffering from created an impact on his personal and professional life. The fact that John had been terminated from his job of a horticulturist created a severe impact on his mood and subsequent mental state. Although his boss suggested the slowdown of the business as the primary reason for the latter’s termination from job, John considered his back pain as the major contributing factor. Upon further analysis it was also found that the back pain was responsible for insomnia, which in turn made John feel fatigued and demotivated to work. Additionally, the pain was also found responsible for restricting his social interaction with members of the community or envisioning other job prospects. The contributing factor can be discussed in terms of the biopsychosocial model in that back pain, isolation from community, and joblessness stand for the biological, psychological, and social facets, respectively (Sarafino & Smith, 2014).

Comprehensive Mental State Examination

An individual suffering from any physical ailment shows an increased likelihood of suffering from depression. Back pain is a common illness that primarily affects the lumbar region and makes it difficult for the person to support the entire weight of the upper body part (Hoy et al., 2014). The consequent symptoms of insomnia experienced by John was another biological factor. The major psychological factor was social withdrawal and demotivation, since older people most commonly portray presence of a range of isolating dynamics that increase with an elevation in their frailty, and results in a possible decline in their status of health and wellbeing (Girard et al., 2014). Economic struggles have been found to add to the isolative behaviour among the elderly. Demotivation is used to refer to the lack of enthusiasm and interest in work (Yapko, 2014). Thus, John did not have any strong reason to accomplish his goals, which contributed to the development of persistent low mood. The major social factor was his unemployment. Long-term joblessness has also been related to twice the risk of developing mental disorders particularly anxiety and depression, when compared to the employed individuals (McGee & Thompson, 2015). This also contributes to an increase in their mortality rates. Considering the fact that loss of job would lead to lower family income, thus subsequently resulting in poor housing, limited social support and lack of food security, the patient John became depressed.

The biopsychosocial model has been adopted for gaining a sound understanding of the underlying factors that might have contributed to the condition since the model is grounded on a dualistic and fractional process that facilitates the conduction of a comprehensive assessment of the patient being analysed. Introduced by the psychiatrist George Libman Engel in 1997, the fundamental property of the model is that it considers all illnesses and health as major products of interchange between psychosocial, physical, and social factors (Smith et al., 2013). Hence, it is considered as the best practice due to its deviation from the biomedical model that only placed an emphasis on the biological variables. Additionally, the biopsychosocial model is also regarded as a best practice since it is an inclusive model and helps in exploring all the three fields, thereby creating provisions for complete mental assessment of the patient (Baranyi et al., 2013). It also takes into account the fact that the psychopathology of all patients were unique from one another.

The biopsychosocial model of care

Identifying and managing risks- Patient suffering from mental illness are disadvantaged in that they are subjected to unpleasant symptoms related to their mental condition and are at an increased likelihood of inflicting self-harm. Hence, conducting an assessment of the risks that are associated with a particular mental health problem forms a crucial component of mental healthcare, in relation to best practice. The nurse-in-charge can ensure that adequate risk assessment strategies have been adopted for treating the depression that John is currently suffering from by gathering adequate information from reliable sources regarding his medical and family history (Paniagua & Yamada, 2013). An important step would be the inclusion of the patient as well as his family members in the plan, in order to enhance safety and optimal health outcomes. Family members can greatly contribute to the care that is provided to a particular patient by providing their support and guidance (Meis et al., 2013).

Hence, the nurse should develop a rapport with John and his family, with the aim of establishing an effective therapeutic relationship. Demonstrating empathy and establishing a rapport are the two major strategies that should be implemented in the scenario, with the aim of ensuring accurate risk assessment. Adorning the role of a successful leader and motivating other nursing professionals will also facilitate checking the implementation of management strategies. Listening will also form a critical component of effective communication, while interacting with the patient (Videbeck & Videbeck, 2013). Hence, effective interpersonal skills will prove central to the ability of the nurse in the clinical setting.

While predisposing factors put an individual at risks of developing a disorder, precipitating factors trigger the development of onset of the problem that the person is currently suffering from. Additionally, perpetuating factors are those that are capable of maintain the problem, following its establishment (Lievesley, Rimes & Chalder, 2014). An analysis of the case study suggests that old age, sudden joblessness, and social isolation were the predisposing, precipitating and perpetuating factors, respectively. This mood disorder primarily creates an impact on the way by which a person feels, thinks, and behaves, thus creating a surfeit of physical and emotional problems. John can be considered on at a high risk since he reports most symptoms of depression that comprise of feelings of tearfulness, sadness, irritability, frustration, sleep disturbance, agitation, suicidal ideations, unexplained back pain, and feelings of worthlessness (Martin et al., 2013). Considering the fact that depression often remains untreated and undiagnosed in the elderly population, there is a need to provide immediate treatment to John.

Risk management- Management of the diagnosed mental disorder would encompass different aspects of lifestyle changes, counselling strategies, psychoanalysis and administration of antidepressants. Owing to the fact that John considered his antidepressants to be futile in their effectiveness, he must be encouraged by adopting the process of motivational interviewing to adhere to lifestyle modifications such as moderate physical exercise, smoking cessation and regular sleep to reduce the severity of his presenting complaints (Gallo et al., 2016). The nurse should engage in regular personal interaction with John to help him overcome his troubles in a desired way. Thus, the talk therapy might prove beneficial in increasing the functioning and enhancing the wellbeing of the person (Gensichen et al., 2013). The nurse can also engage the patient in psychoanalysis that elaborates on resolution of mental conflicts (Axelrod, Naso & Rosenberg, 2018). The dosage of antidepressants (SSRI) should also evaluated and increased (if required).

Ethical dilemmas might arise in relation to caring for the patient with depression associated to the need for ensuring patient safety, and restoration of a sound mental state (Weimand et al., 2013). The Mental Health Act encompasses the core principles of assessing and treating the patient in a least intrusive manner, while supporting them to participate in decision making and protecting their autonomy and dignity (Victoria State Government, 2014). Patient autonomy is one of the basic principles of caregiving since the right for making decisions related to medical care is bestowed upon the patients, without the influence of the care providers (Hess et al., 2015). Thus, although the law allows the nurse to educate the patient on the potential benefits of the treatment, it does not allow the staff to forcefully exert any plan of care on the patient. However, John’s decision to leave the hospital and return home might result in the ethical dilemma since he has been found at an increased depression risk and might have also had inflicted harm upon himself. Thus, the conflicting situation might make the healthcare providers coax John to stay at the hospital and continue his treatment. 

Conclusion

The term mental health deterioration is often used interchangeably with ‘risks’ and ‘change’. In other words the need for recognizing and providing an appropriate response to the clinical deterioration of any patient has been identified as a national priority by the Australian healthcare system, with the aim of bringing about an improvement in the safety of the people. Baseline examination of the mental state is also imperative in this scenario for obtaining a detailed record of the current mental faculties and their functioning. The MSE would form an essential part of the clinical assessment and would help to unravel the psychological disturbances that are faced by John. An analysis suggests that the back pain and its subsequent impacts on unemployment and poor health were responsible for the onset of depressive feelings in John. To conclude, it can be deduced that John is at a high risk on the spectrum of the diagnosed mental illness (depression). Hence, efforts must be taken to implement a proper risk assessment and plan of action for reducing his depressive symptoms and enhancing his health and wellbeing.

References

Axelrod, S. D., Naso, R. C., & Rosenberg, L. M. (2018). Introduction. In Progress in Psychoanalysis (pp. 23-36). Routledge.

Baranyi, A., Meinitzer, A., Stepan, A., Putz-Bankuti, C., Breitenecker, R. J., Stauber, R., ... & Rothenhäusler, H. B. (2013). A biopsychosocial model of interferon-alpha-induced depression in patients with chronic hepatitis C infection. Psychotherapy and psychosomatics, 82(5), 332-340.

Barnard, P., & Teasdale, J. (2014). Affect, cognition and change: Re-modelling depressive thought. Psychology Press.

Buckner, J. D., Heimberg, R. G., Ecker, A. H., & Vinci, C. (2013). A biopsychosocial model of social anxiety and substance use. Depression and anxiety, 30(3), 276-284.

Caplan, G. (2013). An approach to community mental health. Routledge.

Dennis, T. A., & O’Toole, L. J. (2014). Mental health on the go: Effects of a gamified attention-bias modification mobile application in trait-anxious adults. Clinical Psychological Science, 2(5), 576-590.

Ekkekakis, P. (2013). The measurement of affect, mood, and emotion: A guide for health-behavioral research. Cambridge University Press.

Gallo, J. J., Hwang, S., Joo, J. H., Bogner, H. R., Morales, K. H., Bruce, M. L., & Reynolds, C. F. (2016). Multimorbidity, depression, and mortality in primary care: randomized clinical trial of an evidence-based depression care management program on mortality risk. Journal of general internal medicine, 31(4), 380-386.

Gensichen, J., Petersen, J. J., Von Korff, M., Heider, D., Baron, S., König, J., ... & König, H. H. (2013). Cost-effectiveness of depression case management in small practices. The British Journal of Psychiatry, 202(6), 441-446.

Girard, J. M., Cohn, J. F., Mahoor, M. H., Mavadati, S. M., Hammal, Z., & Rosenwald, D. P. (2014). Nonverbal social withdrawal in depression: Evidence from manual and automatic analyses. Image and vision computing, 32(10), 641-647.

Hess, E. P., Grudzen, C. R., Thomson, R., Raja, A. S., & Carpenter, C. R. (2015). Shared decision?making in the emergency department: respecting patient autonomy when seconds count. Academic Emergency Medicine, 22(7), 856-864.

House, R. M. (2014). The mental status examination. Retrieved from https://www.brown.edu/Courses/BI_278/Other/Clerkship/Didactics/Readings/THE%20MENTAL%20STATUS%20EXAMINATION.pdf

Hoy, D., March, L., Brooks, P., Blyth, F., Woolf, A., Bain, C., ... & Murray, C. (2014). The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Annals of the rheumatic diseases, 73(6), 968-974.

Lamond, J. E., Joseph, R. D., & Proverbs, D. G. (2015). An exploration of factors affecting the long term psychological impact and deterioration of mental health in flooded households. Environmental research, 140, 325-334.

Lievesley, K., Rimes, K. A., & Chalder, T. (2014). A review of the predisposing, precipitating and perpetuating factors in Chronic Fatigue Syndrome in children and adolescents. Clinical psychology review, 34(3), 233-248.

Lindsay, G., & Desforges, M. (2013). Baseline assessment: Practice, problems and possibilities. David Fulton Publishers.

Martin, L. A., Neighbors, H. W., & Griffith, D. M. (2013). The experience of symptoms of depression in men vs women: analysis of the National Comorbidity Survey Replication. JAMA psychiatry, 70(10), 1100-1106.

McGee, R. E., & Thompson, N. J. (2015). Peer reviewed: unemployment and depression among emerging adults in 12 states, behavioral risk factor surveillance system, 2010. Preventing chronic disease, 12.

Mehlum, L., Tørmoen, A. J., Ramberg, M., Haga, E., Diep, L. M., Laberg, S., ... & Grøholt, B. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 53(10), 1082-1091.

Meis, L. A., Griffin, J. M., Greer, N., Jensen, A. C., MacDonald, R., Carlyle, M., ... & Wilt, T. J. (2013). Couple and family involvement in adult mental health treatment: A systematic review. Clinical Psychology Review, 33(2), 275-286.

Memória, C. M., Yassuda, M. S., Nakano, E. Y., & Forlenza, O. V. (2013). Brief screening for mild cognitive impairment: validation of the Brazilian version of the Montreal cognitive assessment. International Journal of Geriatric Psychiatry, 28(1), 34-40.

Paniagua, F. A., & Yamada, A. M. (Eds.). (2013). Handbook of multicultural mental health: Assessment and treatment of diverse populations. Academic Press.

Pilgrim, D. (2015). The biopsychosocial model in health research: its strengths and limitations for critical realists. Journal of Critical Realism, 14(2), 164-180.

Sarafino, E. P., & Smith, T. W. (2014). Health psychology: Biopsychosocial interactions. John Wiley & Sons.

Smith, R. C., Fortin, A. H., Dwamena, F., & Frankel, R. M. (2013). An evidence-based patient-centered method makes the biopsychosocial model scientific. Patient education and counseling, 91(3), 265-270.

Strauss, G. P., Horan, W. P., Kirkpatrick, B., Fischer, B. A., Keller, W. R., Miski, P., ... & Carpenter Jr, W. T. (2013). Deconstructing negative symptoms of schizophrenia: avolition–apathy and diminished expression clusters predict clinical presentation and functional outcome. Journal of psychiatric research, 47(6), 783-790.

Victoria State Government. (2014). Mental Health Act 2014. Retrieved from https://www2.health.vic.gov.au/mental-health/practice-and-service-quality/mental-health-act-2014.

Videbeck, S., & Videbeck, S. (2013). Psychiatric-mental health nursing. Lippincott Williams & Wilkins.

Weimand, B. M., Sällström, C., Hall-Lord, M. L., & Hedelin, B. (2013). Nurses’ dilemmas concerning support of relatives in mental health care. Nursing Ethics, 20(3), 285-299.

Yapko, M. D. (2014). When living hurts: Directives for treating depression. Routledge.