Mental Health Evaluation of Sandy Veale - Essay Example

? Case Study: Mental Health Introduction Scientific studies have shown that psychosocial variables play a major role in the ability to predict whether medical treatment will be effective or not (Bruns & Disorbio, 2009). Medical care practitioners have a valuable role to play in dealing with the challenges presented by biopsychosocial assessments of candidates requiring treatment, most especially surgical procedures. In this paper, we are going to examine the case of Mr. Sandy Veale. Mr. Veale aged 95 years, was brought to the mental health clinic by his case manager from a residential aged care facility called Placid Palms. Mr. Veale is well thought of at the aged care facility and is popular there. He is a widower with two sons who both live in Adelaide and with whom he is estranged with as they accuse him of being violent to them and their mother when they were growing up. They have irregular contact with their father. Mr. Veale has a history of mental health illness, having been diagnosed with psychotic depression three years ago and been admitted twice to the psychiatric unit. Mr Veale has been brought to the clinic because of a number of concerns. Mr. Veale thinks that there is a man fishing in his stomach and so feels unable to eat and complains of constipation; he also believes that his room at the aged care facility is constantly being searched and that the cleaners there are in charge of medications and dispense him the wrong tablets. Recently the cook gave him a lavender spray for his room but he believes this is a poison spray. He also believes that a mate of his is being abused in the room next to his. Assessment According to Gatchel, Peng, Peters, Fuchs, & Turk (2007) a collaborative biopsychosocial model is superior to traditional biomedical model of patient care and may be used to diagnose and predict medical treatment outcomes. A biopsychosocial assessment is a significant document that is used to determine what medical interventions should be applied to a patient. All pertinent information contained in the document should be addressed thoroughly. All sections should be covered and addressed in full in order to be beneficial. The biopsychosocial assessment is as shown below. Demographic data Name: Sandy Veale Age: 95 years old Gender: Male Address: Placid Palms residential aged care facility Chief complaints a) He thinks that there is a man fishing in his stomach and so feels unable to eat. b) Constipation. c) Believes that his room at the aged care facility is constantly being searched. d) Believes that the cleaners at the facility are in charge of medications and dispense him the wrong tablets. e) Given lavender spray for his room but believes this is a poison spray. f) Believes that a mate of his is being abused in the room next to his. Mental health history The client is Argentinian but grew up in Poland where at some point became a prisoner of war. There is considerable empirical evidence that suggest a strong relationship between traumatic life experiences and psychotic symptoms (Bebbington et al., 2004; Janssen et al., 2004; Morrison & Ross, 2005; Fowler & Holmes, 2005). Urlic, Strkalj-Ivezic & John (2009) conducted a study among ex-prisoners of war and established that such traumatic war experiences tend to result in severe psychic stress on the victims which may involve feelings of guilt and shame, especially if no psychiatric help is sought. In Mr Veale’s case, he did not seek psychiatric help after the experience but migrated to Australia and settled in Lismore to start a family. He has a history of aggressive behaviour, as his two sons claim he was violent towards them and their mother when they were growing up. Mr Veale was diagnosed with psychotic depression in 2010, two years after his wife’s death. This illness led to his admission to the psychiatric unit on two occasions. He was put on a small dose of Rispiridone, and Prothiadin at night. Family history Mr Veale was born in Argentina in 1918 but his family moved to Poland shortly thereafter, where he grew up and later got enlisted for military service. He later settled in Lismore, Australia and married Phoebe, with whom he got two sons. The two remained married until Phoebe’s death five years ago. His two sons live in Adelaide. Currently, Mr Veale and his sons are not close as his sons harbour resentment towards him for the violence they allege he showed them and their mother. As such, they keep in irregular contact with him since he moved to the residential aged care facility. Risk assessment Some of the risk factors considered important include adverse environmental influences, such as bereavement. Mr. Veale lost his wife 5 years ago, and only two years later was diagnosed with psychotic depression and the loss may have been a significant contributor to that. The lack of a support system, shown by the clear family discord between him and his sons is also a risk factor. Another risk factor is the fact that Mr Veale is placed in a residential care facility which may contribute to the development of severe depressive disorder. However, Mr Veale appears calm and alert. His appearance is clean and well maintained. He poses no risk to himself or others, and does not harbour suicidal thoughts or extreme feelings of worthlessness or shame. Mental status and general appearance Mr Veale appears able to take care of himself well enough. He is well-dressed in a neat suit and tie and very meticulous in appearance. His posture is erect and does not need any assistive devices to function normally. His manner is relaxed and cooperative. He is alert and seems aware and in control of his behaviour. His disposition is congruent with his optimistic mood. He has no problem expressing himself and is very sociable. At the facility Mr Veale is popular with the others, including the staff who give him stuff. He is educated and enjoys reading the dailies and is very informed on current affairs. Mental Health Problem Mr Veale was diagnosed with psychotic depression three years prior. Psychotic depression is used to describe unipolar major depressive disorder, characterized by delusions or hallucinations or both. The 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) classification distinguishes between psychotic and non-psychotic features when determining how severe an episode is, which ranges from mild and moderate to severe for episodes without psychotic features and severe with psychotic features. The DSM-IV therefore, does not recognize psychotic depression as being mild or moderate in nature but only in the severe state. DSM-IV considers the classic signs of psychotic depression to include:- a) Delusions or hallucinations in the context of a depressive episode. b) No diurnal variation in mood. c) Guilt d) Psychomotor disturbance e) Cognitive impairment f) Paranoia g) Hopelessness h) Hypochondriasis i) Anxiety j) Early and middle insomnia k) Constipation The psychotic features of Psychotic depression may be consistent with the patient’s moods or not and delusions are more prevalent than hallucinations (Black Dog Institute, 2005). The delusions of the psychotically depressed are typically guilty, paranoid and somantic (Schatzberg & Rothschild, 1992). Psychotic depression, for the most part, has a high risk of relapse and recurrence. It is mostly episodic, lasting for a given period of time and that’s it. Because Mr Veale has had a previous psychotic depression episode, the symptoms he displays indicate that the problem has recurred. Depression appears to be caused by various factors from biological to social. Mr Veale has a few strengths that enable him to cope with the problem and reduce his vulnerability to it worsening. For one, Mr. Veale has an easy going temperament. This acts as a protective factor that helps him deal with the problem in a calm and polite manner as opposed to becoming agitated, which would draw him into deeper depression. Secondly, Mr Veale has an effective set of coping skills, for instance, effective social skills that enable him to get along with a lot of people at the facility. Mr. Veale is popular and well thought of, which means he somewhat has a social support system, and this is a protective factor against his sinking into further depression. Third, Mr Veale enjoys reading the newspaper and staying abreast of current affairs. This practice is beneficial to him as it lowers the chances of his losing all of his cognitive capabilities anytime soon. Treatment The goal of any treatment for psychotic depression is remission which translates into better functioning and reduced likelihood of relapse (Kennedy & Foy, 2005). Remission is illustrated in a case where a patient’s psychosis is resolved and their depression much improved to a level of mild intensity of either one or two symptoms. If remission is not possible, patients may look to achieving response to treatment, which is the defined as the patient’s safety being stable and registers significant improvement in the number, severity and rate of psychotic and depression symptoms. According to the American Psychiatric Association, the treatment of psychotic depression is best handled by two options, i.e.:- a) Electroconvulsive therapy (ECT). b) Combining antipsychotic and antidepressant medication. ECT ECT has been found to be a very effective treatment option. However, not many patients are comfortable with this treatment method and also, not all patients will respond to ECT. ECT treatment involves using short-acting anaesthesia, muscle relaxants and oxygen with the aim to induce a modified type of seizure that is intended to positively influence the levels of neurotransmitters which would lead to improved moods or reduced psychotic symptoms (Coppolow & Mitchel, 2001). Rothschild (2009) establishes that combined treatment of antipsychotic and antidepressant medication is usually selected as initial treatment as it is easier to administer, readily available and more receptive to patients compared to ECT. Medication Studies reveal that a combination therapy of antidepressant and an antipsychotic was more effective that just using either option. Antidepressant medication help to relieve the depression, encourage normal sleeping patterns, induce appetite and reduce anxiety. Antidepressants work by altering the activity of neurotransmitter pathways. Antidepressants are categorised as follows (Beyond Blue, 2008):- a) Selective serotonin uptake inhibitors (SSRIs), for example, sertraline, paroxetine. b) Serotonin or noradrenalin reuptake inhibitors (SNRIs), for example, venlafaxine c) Atypical antidepressants for example, nefazadone and/or mirtazepine d) Tricyclic antidepressants (TCAs) for example, amitriptyline, doxepin e) Monoamine oxidase inhibitors for example, phenelzine, tranylcypromine. Early studies showed that medication was effective when a combination of tricyclics antidepressants (TCAs) and atypical antipsychotics were used. Recent studies show that a combination of SSRIs in combination with atypical antipsychotics is particularly effective in treating psychotic depression. Meyers et al (2009) report of a case in which a combination of Sertraline and Olanzapine was effective for treating severe psychotic depression in a suicidal patient, and this combination is mostly considered in typical psychotic depression treatment. In the same study, 3% of participants withdrew as a result of negative side effects from the medication, which are:- a) Weight gain of at least 2.7 kg b) Sedation c) Orthostasis d) One or more falls e) Significant increases in serum cholesterol, triglyceride, and glucose concentrations from baseline to study termination (Meyers et al, 2009). Other Treatments In such instances when the patient is resistant to medication, and is reluctant to receive ECT, they should be put on lithium augmentation. Birkenhager et al (2009) describe patients with unipolar psychotic depression who initially were unresponsive to the combined medication treatment method but responded positively to lithium augmentation (Mental Health Information New Zealand, 2002). Lithium is given after a month or two following unsuccessful treatment with a combination of antidepressant and antipsychotic, at a dose that is adequate to achieve a 12-hour serum trough level of 0.5 to 1.0 mEq/L. from 2 weeks to a month is enough to determine if the lithium augmentation has been effective. Another treatment option for this is psychotherapy. This is meant to foster acceptance among patients to reduce stress and teach them how to manage their symptoms by without considering them as true or false. Gaudiano, Miller & Herbert (2007) illustrate that this is a type of commitment therapy that works by encouraging patients to set identified goals and working towards them in an effort to increase the acceptance of unavoidable stress. It is often accompanied by treatment in order to be effective. Nursing Care Plan There are a lot of ways to care for a person who has psychotic symptoms and is elderly, which do not involve medication at all (Elder, Evans & Nizette, 2005). These ways may involve relationship building, providing support and information and facilitating change in thinking patterns and abilities (Diehl & Goldberg, 2004). In Mr Veale’s case, the nursing care plan will be as follows:- Objective: Mr Veale will engage in reality-based interactions Intervention: Spend time with the client and re-orient him with time, place and people he has delusions about so as to experience the reality of the situations as is. Objective: Mr Veale will eat small meals at regular times Intervention: Find out what Mr Veale enjoys to eat, and make them available for meals and snacks. Objective: Mr Veale will show compliance with and knowledge of medication. Intervention: Involve client as much as possible in planning his own treatment. Allow and encourage the client to verbalize his feelings and teach him problem-solving techniques. Objective: Mr Veale will demonstrate decreased hallucinations Intervention: Provide a consistent and structured environment and encourage the client to set goals. Spend time with client. Objective: Mr Veale will identify ways of dealing with stress and emotional anxiety. Intervention: encourage client to pursue personal interests, hobbies and leisure activities as much as possible. Conclusion Mr Veale was brought to the mental health clinic by his case manager. He had a history of psychotic depression and had two admissions to the psychiatric unit and put on medication of antidepressant and antipsychotic medication. At the time he was prescribed small dose of Rispiridone, and Prothiadin at night. His main symptoms were delusions, constipation, paranoia and anxiety. He was put on a combination therapy of antipsychotic medication and antidepressant medication. Initially, he received dosage of sertraline 25 mg/day and olanzapine 2.5 mg/day. The dose was then increased by the same amount every three to five days to a minimum target dose of sertraline 150 mg/day and olanzapine 15 mg/day, and a maximum target dose of sertraline 200 mg/day and olanzapine 20 mg/day. The nursing care provided included spending time with the client, providing a consistent and structured environment, involving client as much as possible in planning his own treatment and encouraging him to pursue personal interests so as to teach effective coping skills. 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