Issues in Mental Health Assessment - Case Study Example

Mental disorders are generally defined by the Mental Health Act of 1983 as “mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind”. This definition was not improved much by the 2007 amendment of the Act. It did not particularly define the limits and parameters of mental illness, nor did it modify the provisions for compulsory treatment of patients diagnosed to be mentally ill under the Mental Health Act. This point of contention, among others, is one of the areas of concern in the assessment and care planning of the mentally ill patient. The assessment of the adverse side-effects of psychiatric drugs shall also be discussed in this paper. These issues are discussed in the hope of coming up with improved quality of life and improved treatment and interventions for mentally ill patients. The assessment of mental health patient is seen from the initial admission or consultation of the patient. From the initial visit, which includes recording the agreement of the patient to Mental Health Care Service, history-taking, mental state examination, assessing associated risks and any co-morbidities, and the formulation of the diagnosis, there are various issues and concerns that may manifest (Thomas, 2006). Assessment is vital to patient diagnosis and treatment. Good assessment makes for good medical practice because it is the jumping off point to further investigations on patient symptoms and manifestations. It is also the basis for suitable and prompt action and referral. These decisions in patient care would not be properly made if not for good assessment. Assessment of the mental health patient is vital in the course of their illness because “people with mental illnesses are likely to have their physical health needs poorly managed and are less likely to have their blood pressure, cholesterol, urine…checked” (Colbeck, 2008). The assessment of the mental health patient is not wholly focused on the initial examination of the patient. The assessment of the adverse effects of psychiatric medications is also crucial in caring for mentally ill patients. The CNS Forum (2004) discusses various tools of assessing the neuroleptic effects of psychiatric drugs being used by different clinicians and mental health caregivers. These tools are briefly described forthwith. First, is the Simpson-Angus Scale which is used to assess extrapyramidal side-effects (EPS). It is based on the observations made by the mental health professional. The second assessment tool is the UKU. It is an assessment scale performed by a specially trained mental health professional. This assessment is accomplished through an interview with the patient and from other relevant sources. The interviewer’s observations are given great weight in this assessment scale. The third tool is the Abnormal Involuntary Movement Scale which assesses the prevalence of dyskinesia in patients undergoing psychiatric treatment. The fourth is the Extrapyramidal Side-effects Rating Scale which is a physician-rated scale of patient’s extrapyramidal side-effects. The fifth assessment tool is the Liverpool University Neuroleptic Side-Effects Rating Scale (LUNSERS). It is presently the most highly recommended rating scale in assessing the adverse effects of psychiatric drugs. The distinctive feature of the LUNSERS is that it is a self-rating assessment. LUNSERS “provides accurate automatic self-scoring across 7 subscales and provides rich information to allow careful monitoring of the frequency and severity of side-effects across time” (Royal College of Psychiatry, 1995). The fact that it is based on the patient’s personal assessment of his symptoms makes this test very much patient-centred. “Patient-rated side-effects may provide important clinical information not detected by clinician-rated interviews” (Lindstrom, et.al., 2001). Ultimately, these patient-rated scales can yield results that may be used in the development of treatment programs for mentally ill patients. The patient admitted into the Critical Resolution Home Treatment and assessed under the LUNSERS will more likely report adverse drug effects that would not be revealed using other assessment tools. LUNSERS is favoured more than any other assessment tool because it allows for a more accurate account of what the patient is actually feeling and experiencing in the course of her treatment. Not only does LUNSERS “give a more sensitive measure of the progress of the disorder, but people with schizophrenia are treated as agents of their management” (Burns, 2007). Another distinct feature of the LUNSERS is that it has an inherent ‘red herring’ subscale. This “enables detection of patients that may be over-reporting symptomatology” (Lambert, 2003). This important feature helps lend accuracy and validity to this assessment tool. Some patients are wont to exaggerate their symptoms just to be able to get out of taking their psychiatric medicines; however, the LUNSERS makes possible the detection of this patient subterfuge. The LUNSERS also functions “as a cost-effective primary screening tool for side effects, particularly in non-hospitalized or community therapy settings where no medical examination is possible”(Lambert, 2003). LUNSERS gives a chance for patients to express their distress and frustrations about their medications. The neuroleptic side-effects often frustrate many mentally ill patients. Their inability to cope with these symptoms often leads them to skip or stop medication. Adverse drug effects accounts for “poor medication adherence, stigma, distress and impaired quality of life” (Hamer & Haddad, 2007). The stigma against mentally ill patients is often attributed to manifestations of adverse drug effects which many people mistake for the actual symptoms of mental illness. Involuntary jerking motions, tongue sticking out, drooling, agitation, flat affect, and restlessness are just some of the many extrapyramidal side-effects of psychiatric drugs that seem to the unenlightened public as manifestations of mental illness (Anderson & Freeman, 2004). These neuroleptic side-effects naturally distress mentally ill patients and add to their depression and frustration. The actual symptoms of their disease are often not accurately assessed “due to side-effects of treatment presenting other symptoms” (Oliver, 1983). Ultimately, the quality of life of patients is affected not just by the patient’s mental disorder, but also by his neuroleptic side-effects. The side-effects mask the symptoms of the actual mental illness of the patient. The patient himself cannot accurately narrate which among his symptoms still persist and need attention, and which symptoms are due to his psychiatric drugs. In the LUNSERS assessment tool, it is possible to distinguish the neuroleptic symptoms from the actual disease symptoms. Hence, this assessment tool is used more than any other assessment tool. The improvement of the quality of life of mentally ill patients is the ultimate goal of assessment tools. In the case of physician-centred assessment tools, the patient often “fails to spontaneously report common or clinically mild drug-related symptoms” (Foster, et.al., 2007). And yet, these mild symptoms still result to medication non-compliance or skipping of doses. Whether the symptom is perceived by the mental health professional as minor or major symptoms, they produce the same ultimate consequence--medication non-compliance. The best way to determine which side-effects are of most concern to the patient is to get accurate accounts from the patient himself. The “perception of patients on possible side-effects of treatment is best captured by the use of self-reported questionnaires” (Foster, et.al, 2007). Some have advocated the practice of a more clinician-centred approach in assessing the mental health patient. However, it is now firmly believed by many mental health professionals that “the final arbitrator or evaluator of the ‘quality’ of life is the person who lives that life, not some external expert” (Basu, et.al., 2004). It is with these beliefs that the LUNSERS approach is the most highly recommended assessment tool in determining neuroleptic symptoms in patients who are mentally ill. LUNSERS is also favoured more than any other assessment tool because in cases of “poor treatment outcomes, relapse, self-injurious behaviour…to poor medication compliance…the key factor in improving concordance is effectively monitoring and managing side-effects” (Royal College of Psychiatry, 1995). When patients experience lesser side-effects from their medicines, they are more likely to comply with their medication regimen. On the part of caregivers and managers, their accurate knowledge of patient’s neuroleptic side-effects enables them to assess their practice and their limitations in caring for mentally ill patients. Necessary adjustments in type, dosage, and time of intake of medications can be made in order to reduce or eliminate neuroleptic side-effects. This accurate assessment of side-effects through LUNSERS allows for the achievement of the long term goals of recovery with reduced possibility of relapse. LUNSERS helps “elicit potential strategies for managing each side-effect effectively…” (Morrison, et.al., 2000). The process of caring for the mentally ill patients relies on accurate depictions from each step of the care process. Accurate and reliable assessment leads to reliable diagnosis from which accurate and reliable interventions may be planned. Other issues stemming from the assessment and care planning of mental health patients are seen from the provisions of the Mental Health Act. The definition of mental disorder does not discriminate between mentally ill patients and patients who are physically ill and are manifesting neurological symptoms that come under the definition of the Mental Health Act. Some clinicians argue that many diseases manifest symptoms similar to mental disorders. Epilepsy often presents symptoms that lead many people-even mental health professionals, to conclude that the patient is suffering from a mental disorder. Some interest groups argue that presenting symptoms that may be classified as mental disorders under the Mental Health Act may lead to abuses in human rights. To be classified as mentally ill is to be compulsorily subjected to mental health institutions. Compulsory treatment under the Mental Health Act makes the patient subject to different forms of assessment, diagnosis, and treatment even without patient consent. The danger in this situation arises in instances when the patient is not actually mentally ill but is only manifesting neurologic symptoms akin to those seen in mental disorders. Since the diagnosis of the patient is wrong-the treatment is wrong. The patient will continue to manifest symptoms from his actual illness and unless a correct diagnosis on his condition is made, he will continue to be subjected to the wrong treatment. Another issue in the assessment and care of mental health patients is the issue of informed consent. Due to compulsory treatment, many of the patients are subjected to all sorts of interventions and medical procedures in the name of doing what is in the best interest of the patient. However, many clinicians have argued that in instances where families are there to give an informed consent, they are not adequately informed of the hidden risks of some interventions undertaken on the patient. In the past, electro-convulsive therapy was actively sought as a form of treatment for mentally ill patients. In many instances where ECT was used, patients and their families were not informed that ECT decreased life expectancy, caused brain damage, and increased the risk for suicide. The right to informed consent was violated in favour of a more drastic and aggressive treatment of patient symptoms. Another point of contention in the assessment and care planning of mental health patients is the fact that relapse is often attributed to patient’s medication non-compliance and/or the patient’s illness. Signs of relapse “could be due to overuse of toxic chemical restraints which involves some severe withdrawal symptoms” (Oliver, 1983). When these chemical restraints are actually out of the patient’s system, the manifestations of the mental illness come back full force, and are labelled as a relapse. However, the truth is that, the symptoms were never actually treated and addressed in the course of the patient’s treatment. They were just suppressed for the time being and later surfaced when the chemical restraints wore off. Hence, the practice of using chemical restraints on the mentally ill patient has been questioned by many mental health practitioners and interest groups. They argue that chemical restraints only serve to “appease the public, clinicians, carers, families…” (Oliver, 1983). They do not treat the patient, but they do make the patient docile and agreeable. They make him subject to various regimens and medical procedures that further violate his human rights. In the end, many clinicians usually do not “want to risk diminishing the rights of the majority to control the minority” (Oliver, 1983). And they adhere to the more expedient method of ‘treatment’-restraining the unmanageable mentally ill patient. Patient confidentiality has also been an ethical dilemma for many clinicians. Patient confidentiality is mandated by law in order to protect the patient and to keep intact the relationship of trust and confidence between the latter, his physician and his caregivers. Many physicians however have violated this mandate. Some physicians have also adapted the habit of not fully explaining to patients the limits of confidentiality and thereby allowing patients to reveal sensitive information. In instances when the patient means to harm his person and others, confidentiality may be breached. This fact is often not fully explained to patients. The “patient expects to have his or her privacy respected by the physician and should not be disappointed” (American Medical Association, 2007). However as the patient’s welfare is put at risk and his plans for suicide or inflicting other people harm are thwarted, the possibility of the patient establishing another relationship of trust with his caregiver is usually no longer available. Once this point is reached, attempts at ever-reaching the patient on any level becomes virtually impossible. If the patient plans to harm him or others again, the untrusting patient is unlikely ever to share this to his caregivers. They are now left to deal with a patient who is uncooperative and suspicious of their actions and interventions. In this instance, the hope of the patient ever recovering from his mental illness is now a dim possibility. The assessment and care planning or patients is crucial in establishing accurate diagnosis and treatment. Inaccurate assessments lead to inaccurate interventions. Precise assessments ultimately lead to improved quality of life for mentally ill patients. LUNSERS offers a welcome alternative to assessing neuroleptic symptoms. They offer reliable, valid, responsive, appropriate, and practical measures of psychiatric drugs and their adverse effects. As opposed to the more clinician-centred assessment tools, LUNSERS addresses various issues and shortcomings seen in other assessment tools. Mentally ill patients have been legally incapacitated to make rational decisions for themselves and for their lives. Their lives are in the hands of caregivers-psychiatrists, clinicians, and nurses. This fact has made them vulnerable to many abuses and human rights violations. In the hope of equalizing this disparity, accurate assessment tools play an important role. It is a way of saying, since the law deems them incapable of making the right decisions for themselves, then those who have taken upon themselves the role of caring for mentally ill patients should make sure that their illness is properly diagnosed, assessed and their symptoms properly treated. Only then can it be said that the best interest of the patient is actually taken into account. Works Cited Read More