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participant manual English-Haiti Introduction to Agitation, , and Curriculum for Psychologists/Social Workers

Partners In Health (PIH) is an independent, non-profit organization founded over twenty years ago in Haiti with a mission to provide the very best medical care in places that had none, to accompany patients through their care and treatment, and to address the root causes of their illness. Today, PIH works in fourteen countries with a comprehensive approach to breaking the cycle of poverty and — through direct health-care delivery as well as community-based interventions in agriculture and nutrition, housing, clean water, and income generation.

PIH’s work begins with caring for and treating patients, but it extends far beyond to the transformation of communities, health systems, and global health policy. PIH has built and sustained this integrated approach in the midst of tragedies like the devastating earthquake in Haiti. Through collaboration with leading medical and academic institutions like Harvard Medical School and the Brigham & Women’s Hospital, PIH works to disseminate this model to others. Through advocacy efforts aimed at global health funders and policymakers, PIH seeks to raise the standard for what is possible in the delivery of health care in the poorest corners of the world.

PIH works in Haiti, Russia, Peru, Rwanda, Sierra Leone, Liberia Lesotho, Malawi, Kazakhstan, Mexico and the United States. For more information about PIH, please visit www.pih.org.

Many PIH and Zanmi Lasante staff members and external partners contributed to the development of this training. We would like to thank Giuseppe Raviola, MD, MPH; Rupinder Legha, MD ; Père Eddy Eustache, MA; Tatiana Therosme; Wilder Dubuisson; Shin Daimyo, MPH; Noor Beckwith; Lena Verdeli, PhD; Ketnie Aristide; Leigh Forbush, MPH; and Jenny Lee Utech.

This training draws on the following sources: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association; Eapen, V., Graham, P., & Srinath, S. (2012). Where There Is No Child Psychiatrist: A Care Manual. RCPsych Publications; Mental Illness Fellowship Victoria. (2013). Understanding psychosis; Raviola, Kahn, Jarvis. (2015). The Quality Program, Boston Children’s Hospital; Sherman, M. (2008). Support and Family Education: Mental Health Facts for Families, http://www.ouhsc.edu/safeprogram/; Starling, J., Feijo, I. (2012). and Other Psychotic Disorders of Early Onset. In IACAPAP Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; Targum, S. D., & Busner, J. (2007). The Clinical Global Impressions Scale: Applying a Research Tool in Clinical Practice. Psychiatry, 4(7), 28; Winters, N., Hanson, G., & Stoyanova, V. (2007). The Case Formulation in Child and Adolescent Psychiatry. Child and Adolescent Psychiatric Clinics of North America, 16(1), 111–132; World Health Organization. (2010). mhGAP Intervention Guide. Geneva: World Health Organization; World Health Organization. (2010). Mental Disorders Fact Sheet 396, http://www.who.int/mediacentre/factsheets/fs396/en/.

We would like to thank Grand Challenges Canada for their financial and technical support of this curriculum and of our broad mental health systems-building in Haiti.

© Text: Partners In Health, 2015 Photographs: Partners In Health Design: Katrina Noble and Partners In Health Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

This manual is dedicated to the thousands of health workers whose tireless efforts make our mission a reality and who are the backbone of our programs to save lives and improve livelihoods in poor communities. Every day, they work in health centers, hospitals and visit community members to offer services, education, and support, and they teach all of us that pragmatic solidarity is the most potent remedy for pandemic disease, poverty, and despair.

II Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Table of Contents

Introduction to Agitation, Delirium, and Psychosis

Introduction...... 1

Objectives...... 2

Epidemiology, the Treatment Gap and Stigma...... 4

Diagnosis of Severe Mental Disorders...... 8

The Psychosis System of Care and the Four Pillars of Emergency Management of Agitation, Delirium and Psychosis...... 17

Safety and Management of Agitated Patients ...... 22

Medical Evaluation and Management of Agitation, Delirium, and Psychosis...... 28

Biopsychosocial Clinical Formulation...... 30

Medication Management for Agitation, Delirium, and Psychosis...... 36

Psychotherapy and Family & Patient Education...... 40

Clinical Outcome Measures – CGI and WHODAS...... 44

Follow-Up and Documentation...... 51

Using mhGAP for Psychosis and ...... 52

Review ...... 54

Notes...... 59

Partners In Health | PARTICIPANT HANDBOOK III Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Annex

Psychosis Care Pathway...... 61

Psychiatric Information Sheet ...... 62

Agitation, Delirium and Psychosis Checklist...... 65

Agitated Patient Protocol ...... 66

Agitation, Delirium and Psychosis Form...... 67

Medication Card for Agitation, Delirium, and Psychosis...... 68

Medical Evaluation Protocol for Agitation, Delirium, and Psychosis...... 71

Suicidality Screening Instrument...... 73

Suicidality Treatment Guidelines...... 74

Safety Plan...... 76

Clinical Global Impressions Scale (CGI) ...... 77

WHODAS 2 – 12 Item Version...... 79

IV Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Introduction to Agitation, Delirium, and Psychosis

INTRODUCTION

Psychotic disorders refer to a category of severe mental illness that produces a loss of contact with reality, including distortions of perception, , and . The most common psychotic disorders are schizophrenia and bipolar disorder, which affect a combined 81 million people. However, these two conditions do not account for all psychotic disorders. Despite the immense burden of illness from psychotic disorders, about 80% of people living with a in low-income countries do not receive treatment.1 Stigma and discrimination against people living with severe mental illness often result in a lack of access to health care and social support. Human rights violations including being tied up, locked up, or left in inhumane facilities for years; are all common.

Before a psychotic disorder can be diagnosed, however, patients require comprehensive medical evaluation to ensure that medical problems are not the root cause of the symptoms. The term “agitated” is often misused to describe patients who appear psychotic and are, therefore, immediately referred to mental health. However, oftentimes these patients are actually suffering from delirium, a state of mental that can resemble a psychotic disorder but is actually caused by a potentially severe medical illness. Patients who are delirious are often injected with high doses of to quell their “agitation” and they frequently do not receive any medical evaluation or care. Unfortunately, this misdiagnosis and mismanagement can lead to death.

Fortunately, psychotic disorders are treatable and for some, completely curable. With the right training and system of coordinated care, people with psychosis can receive effective treatment and lead rich, productive lives. In this training, psychologists and social workers will learn how to manage agitated patients safely and effectively and will also learn how to properly diagnosis psychotic disorders caused by mental illness.

1. World Health Organization. (Oct 2014). Mental Disorders Fact Sheet 396. Retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/

Partners In Health | PARTICIPANT HANDBOOK 1 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

By the end of this training, psychologists and social workers will understand how to work hand-in-hand with community health workers, nurses and physicians to provide high-quality, humane medical and mental health care for agitated, delirious, and psychotic patients.

Objectives

By the end of this training, you will be able to:

a. Describe the epidemiology of psychotic disorders and the corresponding treatment gap. b. Describe the various ways that psychosis may be viewed by the community and by health providers. c. Describe the impact of stigma on patient care and outcomes. d. Identify key clinical information related to the diagnosis of various psychotic disorders. e. Develop a basic mental health differential diagnosis using the Differential Diagnosis Information Sheet. f. Describe the psychosis care pathway and its collaborative care approach. g. Outline the main roles of physicians, psychologists, social workers, nurses and community health workers in the system of care. h. Explain the four pillars of emergency management of agitation, delirium and psychosis. i. Describe how a psychologist/social worker should use the biopsychosocial model when managing a patient with agitation, delirium or psychosis. j. Describe the identification, triage, referral, and non-pharmacological management of an agitated patient through the use of the Agitated Patient Protocol and Agitation, Delirium and Psychosis Form. k. Explain how to screen for and manage suicidal patients consistent with their severity and risk level. l. Define medical delirium. m. Describe the importance of proper medical evaluation for an agitated, delirious or psychotic patient. n. Explain the process of carrying out a medical evaluation for an agitated, delirious or psychotic patient. o. Explain how to gather information for a complete mental health history. p. Describe how to create a biopsychosocial clinical formulation to guide a patient’s treatment. q. Explain the collaboration between the physician and the psychologist/social worker in managing medication for agitation, delirium and psychosis. r. Describe the physician’s use of the Medication Card for Agitation, Delirium and Psychosis.

2 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

s. Explain the core approaches for patients with severe mental illness. t. Describe how to educate patients and family members about the effects and management of psychosis and bipolar disorders. u. Explain the core psychotherapy approaches for patients with severe mental illness. v. Describe how to educate patients and family members about the effects and management of psychosis and bipolar disorders. w. Explain the process of follow-up for people living with psychotic disorders and severe mental illness. x. Describe the importance of documentation during patient follow-up. y. Describe how to use mhGAP for the management of psychosis and bipolar disorder. z. Describe how to use mhGAP for the management of self-harm/suicide.

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Epidemiology, the Treatment Gap, and Stigma

Severe Mental Illness Severe mental illnesses are illnesses of longer duration, longer treatment and have significant impact on the activities of daily living. They include psychosis and mood disorders.

What is psychosis? Psychosis is a . A syndrome is defined as the association of several clinically recognizable which may have multiple causes.

Psychosis results in dysfunction in several domains: • (disorganized thinking and , problems) • Perception (hallucinations) • Behavior (social withdrawal, ) • Emotion (decreased emotion)

There are some psychiatric disorders that mimic psychosis, which can include PTSD, acute , intellectual development disorder, and .

Schizophrenia Schizophrenia is characterized by profound disruptions in: • thinking, affecting language • perception • the sense of self

It often includes psychotic experiences, such as hearing voices, visual hallucinations or delusions. Patients with schizophrenia often first begin to show symptoms of psychosis when they are teenagers. Prior to developing schizophrenia, patients may show subtle non-specific signs such as , social withdrawal, and .

Schizophrenia affects more than 21 million people worldwide. The prevalence ranges from 1 – 7 per 1,000 people. People with schizophrenia have a 20% reduction in life expectancy.2

2. World Health Organization. (Oct 2014). Mental Disorders Fact Sheet 396. Retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/

4 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Bipolar Disorder Bipolar disorder is a that can include symptoms of depression, and/or psychosis. Manic episodes involve elevated or irritable mood swings, over-activity, , inflated self-esteem, and a decreased need for sleep. Some people with bipolar disorder experience mixed episodes that involve both symptoms of mania and depression at the same time or alternating frequently during the same day. Bipolar disorder usually starts during adolescence and early adulthood.

Bipolar disorder affects about 60 million people worldwide. It is the sixth leading cause of disability in the world. People with bipolar disorder have a reduced life expectancy of 9 – 20 years.3

3. World Health Organization. (Oct 2014). Mental Disorders Fact Sheet 396. Retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/

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Treatment Gap

81 million + People living with severe mental illness

12 –19 million People living with severe mental illness who receive treatment

Treatment Gap! 62– 69 million People living with severe mental illness who receive no treatment

Statistics taken from World Health Organization Mental Disorders Fact Sheet #396

Health systems have not yet adequately responded to the burden of mental disorders. As a consequence, there is a wide gap between the need for treatment and its provision all over the world. In low- and middle-income countries, between 76% and 85% of people with mental disorders receive no treatment for their disorder. In high-income countries, between 35% and 50% of people with mental disorders receive no treatment for their disorder.4

Stigma Stigma refers to negative or prejudicial thoughts about someone based on a particular characteristic or condition, in this case someone with a severe mental illness.

As clinicians, it is not acceptable to have stigmatizing thoughts or behaviors toward people with severe mental illnesses. It the clinicians’ responsibility to overcome these feelings to be able to treat patients with dignity and respect.

4. World Health Organization. (Oct 2014). Mental Disorders Fact Sheet 396. Retrieved from: http://www.who.int/mediacentre/factsheets/fs396/en/

6 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

The Zanmi Lasante psychosis system of care aims to diminish Haiti’s treatment gap by safely and effectively treating people living with severe mental illness in a community-based system of care. Psychologists and social workers have the opportunity to close the treatment gap and reduce the stigma related to psychosis by building on the coherent system of care already developed for depression and . Psychologists and social workers have the opportunity to help some of the most vulnerable and marginalized people living in communities — those living with mental illness.

stigma role play

Story A patient is brought by his family to the emergency room. He is very talkative and focuses mainly on vodou and religion. The emergency nurse fears that he is violent and does not wish to touch him because she thinks he may hit her. The nurse does not check vital signs or provide any medical care. Instead the nurse calls the psychologist/social worker on the phone and says “a mental health patient is here.” In the meantime, the patient is totally dehydrated, and has both a high and pulse that go undetected. His family reports he has never behaved this way before and only became “a crazy person” after a dog bit him. For more than two hours, the patient and his mother wait and no one comes to them for help.

Script Family Member (Participant 2): Brings in sick patient to the emergency room.

Patient (Participant 1): Arrives to emergency room in the arms of a family member. Begins to talk a lot about vodou and religion in the emergency room.

Nurse (Participant 3): Acts scared because he might be violent. Calls psychologist/social worker to say a mental health patient is here.

Patient (Participant 1): Has a fever and becomes dehydrated. Does not look well.

Family Member (Participant 2): Reports to nurse that patient has never behaved this way before and only became “a crazy person” after a dog bit him. Becomes frustrated that a lot of time has passed and no one has helped them.

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Diagnosis of Severe Mental Disorders

The Different Signs and Symptoms Associated with Psychosis The different signs and symptoms associated with psychosis are divided into two categories: positive and negative.

“Positive” symptom – something is present that shouldn’t be: • Hallucinations • Delusions • Disorganized speech • Disorganized or catatonic behavior

“Negative” symptom – disruption to normal emotion or behavior: • Flattening of affect • Social withdrawal • Loss of motivation • Cognitive impairments

Phases of Psychosis There are three distinct phases of psychosis that psychologists/social workers will see throughout their work with psychotic patients: the prodromal phase, the acute phase and the stable phase. 1. Prodromal phase – the time between the first disturbance of normal thinking, feeling or behavior and the onset of psychosis 2. Acute phase – the period when psychotic symptoms are present (delusions, hallucinations, ) 3. Stable phase – symptoms start to remit and recovery begins

Psychosis: Mimics There are some medical problems that seem like psychosis: • Delirium • Psychiatric Disorder due to a General Medical Condition • Substance-Induced Psychotic Disorder • Post-Partum Psychosis

Delirium is a disturbance in and awareness due to a medical illness. A medical delirium can appear like psychosis; however it is not a psychotic disorder!

8 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

There are some psychiatric disorders that seem like psychosis. • Transient Hallucinations • Acute Stress/PTSD • Obsessive-Compulsive Disorder • Disorder •

Severe Depression with Psychotic Features Patients who show at minimum six of the following symptoms of depression with psychosis over a period of two weeks: • depressed mood most of the day nearly every day • noticeably increased or decreased sex drive • loss of interest or pleasure in all, or almost all, activities most of the day nearly every day • significant weight loss or weight gain, OR decrease or increase in appetite nearly every day • OR nearly everyday • OR retardation nearly every day • fatigue OR loss of energy nearly every day • feelings of worthlessness OR excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) • diminished ability to think or concentrate, OR indecisiveness, nearly every day • recurrent thoughts of death, recurrent ideas about suicide without a specific plan, or a suicide attempt or specific plan for committing suicide • delusions or hallucinations • increased and intense daydreaming

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Bipolar Disorder Bipolar disorder is diagnosed when a patient has at least one manic episode.

At least one manic episode • A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). • During the period of mood disturbance, three (or more) of the following symptoms have persisted and have been present to a significant degree: –– Inflated self-esteem or grandiosity. –– Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). –– More talkative than usual or pressure to keep talking. –– Insomnia or hypersomnia nearly every day. –– Psychomotor agitation or retardation nearly every day –– Flight of ideas or subjective experience that thoughts are racing. –– Distractibility Increase in goal-directed activity or psychomotor agitation. –– Excessive involvement in pleasurable activities that have a high potential for painful consequences.

Bipolar disorder usually starts during adolescence and early adulthood. It is not common that bipolar disorder develops in children who have no family risk factors and it is rare that it develops in people over 60 years (except when associated with another disease). Some people with bipolar disorder experience mixed episodes that involve both symptoms of mania and depression at the same time or alternating frequently during the same day. Some people may have as many maniac as depressive episodes, while others may experience one type of episode (usually depression). If you are not sure which episodes the patient has had, document it as bipolar unipolar.

Hypomania is a less severe form of mania, with similar symptoms, but less severe. Hypomania has a less of a negative impact on the daily activities of the person. Around half of people initially diagnosed with bipolar disorder achieve syndromal recovery within six weeks, and nearly all achieve it within two years, with nearly half regaining their prior occupational and residential status in that period. However, nearly half of people go on to experience a new episode of mania or major depression within the next two years.

10 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Brief Psychotic Disorder Presence of 1 or more symptoms for duration of at least 1 day but less than 1 month: • Hallucinations • Delusions • Disordered thoughts and speech • Severely disorganized behavior

Schizophreniform Disorder Two or more symptoms, each present for a significant portion of time during a 1 – 6 month period: • Hallucinations • Delusions • Disordered thoughts and speech • Severely disorganized behavior • Negative symptoms

The main difference between , schizophreniform disorder and schizophrenia is the duration of the symptoms/episode. Schizophreniform can be diagnosed if symptoms are present for 1 – 6 months only.

Psychosis Not Otherwise Specified (NOS) A person shows significant distress or impairment in important areas of functioning due to psychotic symptoms BUT does not meet the full criteria for a schizophrenic or other-psychotic disorder diagnosis.

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Schizophrenia Schizophrenia is thought to be caused by physical changes in the brain, however it may begin after a stressful event.

Two or more of the following present for at least a month: • Hallucinations • Delusions • Disordered thoughts and speech • Severely disorganized behavior • Negative symptoms –– Deterioration in social, educational or work functioning –– Duration of illness of at least six months –– Not due to another mental illness such as a mood disorder, or a medical condition.

Schizophrenia may begin at any time but most commonly it begins in the mid- to late teens or early 20s. Prior to developing schizophrenia, patients may show subtle nonspecific signs such as depression, social withdrawal, and irritability. Patients can have periods of stability with or without treatment during which their symptoms are absent or minimal.

Among adults, hallucinations are viewed as synonymous with psychosis and as harbingers of serious . In children, however, hallucinations can be part of normal development or can be associated with non-psychotic psychopathology, psychosocial stressors, drug intoxication, or physical illness. The first clinical task in evaluating children and adolescents who report hallucinations is to sort out those that are associated with severe mental illness from those that derive from other causes.

Delusional Disorder Diagnostic criteria: • Non-bizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, deceived by spouse or lover, or having a disease) of at least 1 month’s duration. • Tactile and olfactory hallucinations may be present in if they are related to the delusional theme. • Apart from the impact of the (s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre. • If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. • The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

12 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Differential Diagnosis Case Studies *For all cases assume that a medical illness has already been ruled out by the physician. All the patients referred to you have been determined to have a mental illness.

case 1

A mother has brought her 12-year-old girl to the health facility. She says that her daughter is often unfocused, seemingly “far away.” The daughter sometimes wakes up in the middle of the night screaming. The girl refuses to enter any cars. Through questioning the mother, you find out that this has been happening for 7 weeks. The girl has had difficulty falling asleep, has been sleeping poorly, and reports that sometimes she sees “shadows of people” at night who are not there. The mother reveals that their son died in a car accident about two months ago, and that the daughter was in the car when it happened. After performing a mental status exam, taking a history and asking the patient a few questions about her friends and school, you see she has no evident problems with cognition or emotion. There is no history of mental illness in the family.

1. Is the girl, in your opinion, psychotic? Why or why not?

2. What diagnosis might you present to the girl? Why?

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case 2

A 22-year-old woman is brought in by her husband. He says that his wife has been acting strangely recently. He reports that she has refused to get out of bed for the past week and has been crying frequently. He was worried she was depressed. However, yesterday she got out of bed extremely happy and was so energized cleaning the house she didn’t sleep at night. You observe the wife chatting excitedly with other people in the waiting room. She says she feels wonderful and doesn’t know why her husband brought her here. The husband reports that over the past few days she has been spending the family’s money on nonessential items and that he is worried that this is putting the family at risk.

1. Is the woman, in your opinion, psychotic? Why or why not?

2. What diagnosis might you present to the woman? Why?

14 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

case 3

A 20-year-old man is brought in by his friend. The friend says that recently, the patient started saying that his neighbor is watching him all the time. The patient cannot stop talking about the neighbor’s spying. The patient describes that he even hears what the neighbor is saying about him in his mind. When you ask how long this has been happening for, the friend says almost three months.

1. Is the man, in your opinion, psychotic? Why or why not?

2. What diagnosis might you present to the man? Why?

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case 4

A 25 year-old man is brought in by a neighbor. This patient has disorganized behavior and has not bathed recently. He is mumbling words under his breath and is not able to speak in complete sentences. You try to have a conversation with the patient, but cannot easily communicate. You ask the neighbor how long he has been like this. The neighbor responds that he has been like this for a few years already, but this is the first time that he is seeing a psychologist/social worker. The neighbor says that the man cannot work because of his mental state and sometimes the man is aggressive and yells threats to no one in particular. What diagnosis might you present to the man?

1. Is the man, in your opinion, psychotic? Why or why not?

2. What diagnosis might you present to the man? Why?

16 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

The Psychosis System of Care and the Four Pillars of Emergency Management of Agitation, Delirium, and Psychosis

The Psychosis System of Care Psychologists’ and social workers’ main roles in the Zanmi Lasante system of care are: a. to ensure safety for the patient and others through correct agitation management b. to make a preliminary diagnosis of delirium/medical illness or mental illness in coordination with the physician c. to provide psychotherapy and psychoeducation to patient and families d. to coordinate care with the physician and CHW

Psychologists/social workers are just one important element in the collaborative care approach; to provide the quality care they need to work closely with other team members that include physicians, nurses and community health workers.

Four Pillars of the Emergency Management of Agitation, Delirium and Psychosis There are three types of patients that will come looking psychiatric, although not all of them will have a psychiatric illness: • Patient is agitated • Patient has a medical illness • Patient has a psychiatric illness

Any decision around mental health or a treatment plan should include these four elements, in this order:

1. Safety a. Determine the risk of suicide b. Understand the exposure to violence c. Determine the risk of violence

2. Medical Health a. You cannot diagnose a mental illness without eliminating all medical causes b. Take vital signs, perform a physical and neurological exam, lab tests (RPR, HIV, hemogram), in some cases consider a scan

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3. Mental Health a. Plan the assessment and ongoing treatment b. Psychotherapy, pharmacology c. Create a safety plan

4. Follow-up a. Next appointment at the clinic b. Which providers are involved in the patient’s care (CHW, psychologist/social worker, nurse, physician)?

Each pillar will be informed by the psychologist/social worker’s use of the biopsychosocial model.

Biopsychosocial Model Medical providers need to approach the treatment and management of psychotic disorders and severe mental illness from a biopsychosocial approach, because there are biological, psychological and social factors involved in the development of mental disorders.

Biological Psychological factors factors

Mental and behavioural disorders

Social factors

World Health Organization: World Mental Health Report, 2001: p. 20

A biopsychosocial approach to mental health treatment will: • Assist with understanding the condition • Assist with structuring assessment and guiding intervention • Inform multidisciplinary practices

18 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

BIO PSYCHO SOCIAL • Medical comorbidities • Temperament • Support from family and • Genetic factors, family history • Personality friends • (sensitivity, • • Education and employment medication interactions, • Defense mechanisms (response • Religious and spiritual beliefs side-effects) to stressful situations) • Socioeconomic stressors • Drug or use • Past trauma and losses • Exposure to stigmatization • Explanatory model, system of beliefs • Different coping strategies

Case 1

Case: Biopsychosocial Considerations A 37-year-old man patient is brought by his family to the emergency room. He is very talkative and shouts about vodou and religion as he runs around the emergency room.

The emergency nurses fear that he is violent and do not wish to touch him because he may be contagious. They do not check vital signs or provide any medical care. Instead they call the psychologist and say “a mental health patient is here.” In the meantime, the patient is totally dehydrated and has a high fever that goes undetected.

His family reports he has never behaved this way before and only became “a crazy person” after a dog bit him two weeks ago. Since then he has been unable to work and care for his wife and two children. Other family members have to stay with him, thereby losing daily wages.

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The Four Pillars of Emergency Management of Agitation, Delirium, and Psychosis 1. safety

Violence: • Is the patient agitated or violent currently? (Use the Agitated Patient Protocol) • What is the history of violence? When did it happen, how severe was it? • Is the patient being exposed to violence/abuse?

Suicide: • Is the patient suicidal currently? Actively or passively? • What is the history of suicide? Past attempts with medical severity, past suicidal ideation? When did it happen?

Management: • How is safety being managed? Is 1:1 present? • How is risk being decreased?

2. medical

Medical Evaluation of Psychosis: • Must do a physical and neurological exam, vital signs, weight, laboratory tests (hemogram, HIV and RPR for all patients; renal and hepatic panels if available; CD 4 count for all HIV patients). • Consider a CT scan if the patient has a clear neurological deficit.

Consider Delirium: • Disturbance of with reduced ability to focus, sustain or shift attention; change in cognition/development of perceptual disturbance not due to ; disturbance develops over a short period of time (hours to days) and fluctuates during the day; evidence from the history, physical exam or lab tests that the disturbance is caused by a medical problem. • Treatment is aimed at underlying medical problem and avoiding diazepam.

Consider Epilepsy (Post-Ictal Psychosis): • The family reports the development of psychosis/agitation after seizures. • Treatment is anti-epileptic.

Medication Management: • Use the medication card to dose and prescribe. • Provide fluids and do an EKG for all hospitalized/emergency room patients receiving haloperidol. • Check for medication side-effects; do AIMS. • Check vital signs and weight for all patients

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3. mental health

Diagnosis: • Work with a psychologist/social worker, use the Differential Diagnosis Information Sheet. • Reconsider the diagnosis at each visit.

Psychoeducation and Support: • Provide education to patients and families regarding psychosis and medication.

Medication Management: • Use Medication Card for Agitation, Delirium and Psychosis; consider diagnosis.

4. follow-up

Date of next appointment/visit: • Follow-up based on acuity; for hospitalized patients, daily or several times a day; for outpatients, can be every 1– 2 days or weekly for more acute patients and every 2 – 4 weeks for stable patients. • Involve community health workers in the care.

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Safety and Management of Agitated Patients Safety is the first pillar when dealing with an agitated, delirious or psychotic patient.

Agitation Is agitation a disease? Agitation is not a disease, there are many causes: • Delirium (medical): mental retardation, thyroid abnormalities, dementia, seizures, , anti-cholinergic intoxication and urinary tract , HIV , various states of intoxication and withdrawal • Psychiatric problems: psychosis, mania, trauma • Emotional/

Agitation Spectrum There is a spectrum of agitation and patients can fall anywhere on the spectrum.

Agitation (Mild) Aggression (Moderate) violence (Severe)

• wringing hands • verbal threats • destroying property • pacing/moving restlessly • yelling, cursing • making a fist, physically • frequent demands • does not respond to threatening (e.g. hitting, • loud, rapid speech verbal redirection kicking, biting) • low frustration tolerance • does not respond to • harming people increased staff presence

Forms to Manage Agitated Patients The Agitated Patient Protocol will assist clinicians in properly managing different levels of agitation.

The Agitation, Delirium, and Psychosis Form assists physicians in recording vital information related to determining if an agitated patient is delirious or psychotic.

22 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

When Managing an Agitated Patient: Safety and Talking First! Often psychologists/social workers and other health providers are unsure what to do when there is an agitated patient. By talking to the patient, the nurse can evaluate the risk of violence, begin the medical evaluation and calm the patient.

How to ensure safety: • Do not see the patient alone (ask for security). Remain calm. Remember that patients do not suddenly become violent; their behavior occurs along a spectrum. • Maintain a safe physical distance from the patient. Do not allow the exit to be blocked. Keep large furniture between you and patient. • Remove all objects that can be used to harm (needles, sharp objects, other small objects). Check whether the patient has a history of violence or . • Talking to the patient is safe and effective. Do not yell. Keep your voice calm, quiet and friendly. • Make eye contact to show that you care about the patient. Show sympathy and empathy (‘I understand that you are scared, but I am here to help. We will not hurt you’).

Intramuscular Medication and Physical Restraint When should providers give medication intra-muscularly?

From a human rights perspective, you always want the least restrictive approach and use the fewest interventions necessary. We only give medication intramuscularly to a severely agitated patient who is at risk of imminent self-harm or is harming those around him. We only administer medication intramuscularly when a severely agitated patient refuses oral medication or is unable to comprehend the request to take oral medication. We must remember that administering an intramuscular injection is invasive and can cause physical pain. It can also potentially lead to physical harm towards providers.

In what situations should clinicians use physical restraint?

The goal is to use the least restrictive means necessary. The rights of a person must take priority, in balance with the safety of those around them. Physical restraint can be considered if: • If calming measures have been tried AND • The patient has been offered an oral medication and refused AND • The patient reaches a state of severe agitation where there is a significant worry about harm to self and others AND • It is felt that all alternatives have been tried

Partners In Health | PARTICIPANT HANDBOOK 23 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Gathering Information and a Brief Assessment Physicians and nurses should try to obtain as much history about the patient as possible to better inform the management of the patient’s agitation. It is helpful to obtain this information from the patient, if possible, but also from family members or anyone who has accompanied the patient. • What happened? • How did this start? • Has this happened before? • Has the person suffered from a mental illness in the past? • Does the person drink a lot of alcohol? • Has the person been taking medicines lately? • Has the person had any recent physical illnesses?

Although it would be ideal to obtain information about the agitated patient (whether from the patient or someone else), it is not always possible, depending on the level of agitation.

role plays

role play 1: Agitated Patient A 55-year-old man is brought to the clinic by concerned neighbors. They report that he has been talking to himself, yelling at people for no reason, and making threatening comments. They refer to him as ‘crazy’ and report that he has no friends or family. In the clinic he is disorganized and confused.

role play 2: Agitated Patient A 24-year-old woman is brought to the emergency room by her boyfriend and brother. She is angry, yelling and screaming. Her brother has to physically hold her in order to prevent her from lunging at her boyfriend. The brother reports that the patient’s behavior changed several days ago following an argument with her boyfriend in which she accused him of cheating.

24 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Suicide Risk The identification and triage of patients who may have suicidal ideation is one of the most important aspects of the clinical history and evaluation. It is important that each agitated or psychotic-appearing patient with a concern of self-harm is screened for suicidality. Psychologists/ social workers have the responsibility within the system of care to evaluate and properly screen patients for suicidality. The physician, when managing an agitated patient will ask and then record on the Agitated Patient Form if that patient has a history of suicide attempts. If the patient does have a history of suicide attempts, the psychologist/social worker will immediately use the Suicidality Screening Instrument to determine the patient’s level of risk. If it is not immediately apparent if the patient has a history of suicide attempts, but there is a concern about the patient’s self-harm (whether past or present), the psychologist/social worker should also administer the Suicidality Screening Instrument.

Safety Plan All patients who are screened for suicidality, whether low risk or high risk, need a safety plan. A safety plan is a plan, collaboratively developed by the patient and psychologist/social worker, which assists patients to decrease their risk of suicide.

The plan’s six essential components: 1. Recognize warning signs of a suicidal crisis about to happen 2. Identify and employ internal coping strategies without needing to contact another person 3. Utilize contacts with people as a means of distraction from suicidal thoughts & urges 4. Contact friends or family members who can help resolve a crisis & with whom suicidality can be discussed 5. Contact mental health professionals or agencies 6. Reduce potential use of lethal means

The most important aspect of the safety plan is its accessibility and ease of use. A safety plan will not be helpful if there are obstacles in the plan that the patient cannot overcome. The psychologist/social worker’s role is to discuss feasibility of the plan’s steps with the patient so the patient is prepared.

Partners In Health | PARTICIPANT HANDBOOK 25 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Role Play 1

Psychologist/Social Worker: Hello Emmanuel.

Patient: Hello.

Psychologist/Social Worker: I’d like to ask you a few additional questions to be sure that you are safe. Part of my job here in the health facility is to help people feel safe, and to help all of the physicians and nurses to ensure the safety of people we see here. Please know that you can trust me, and that I would like to be helpful to you.

Patient: OK.

Psychologist/Social Worker: Sometimes, when things are particularly difficult, some people have thoughts of not wanting to live. Have you ever wished you were dead in the past two weeks?

Patient: No.

Psychologist/Social Worker: Have you ever wished you were dead in the past year?

Patient: Yes.

Interview continues because patient said yes.

Psychologist/Social Worker: Have you had any thoughts of killing yourself in the past two weeks?

Patient: No.

Psychologist/Social Worker: Have you had any thoughts of killing yourself in the past year?

Patient: Yes. Things were just so hard!

Interview continues because patient said yes.

Psychologist/Social Worker: Have you been thinking of ways to do this in the past two weeks?

Patient: No.

Psychologist/Social Worker: Have you been thinking of ways to do this in the past year?

Patient: No. I never decided to do anything.

Interview ends because patient said no to each column of a question

26 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Role Play 2

Psychologist/Social Worker: Hello Katrina.

Patient: Hello.

Psychologist/Social Worker: I’d like to ask you a few additional questions to be sure that you are safe. Part of my job here in the hospital/clinic is to help people feel safe, and to help all of the physicians and nurses to ensure the safety of people we see here. Please know that you can trust me, and that I would like to be helpful to you.

Patient: OK.

Psychologist/Social Worker: Have you ever wished you were dead in the past two weeks?

Patient: Yes.

Psychologist/Social Worker: Have you ever wished you were dead in the past year?

Patient: Yes.

Interview continues because patient said yes.

Psychologist/Social Worker: Have you had any thoughts of killing yourself in the past two weeks?

Patient: Yes. I don’t want to live anymore, but I know my family would feel so bad.

Psychologist/Social Worker: Have you had any thoughts of killing yourself in the past 12 months?

Patient: (Nods).

Interview continues because patient said yes.

Psychologist/Social Worker: Have you been thinking of ways to do this, now or in the past two weeks?

Patient: Yes, I think a lot about it.

Psychologist/Social Worker: Have you been thinking of ways to do this, in the past year?

Patient: Yes, I guess I’ve been thinking about it for a long time.

Interview continues because patient said yes.

Psychologist/Social Worker: Do you have any intention to act on these thoughts?

Patient: I’m not sure…

Psychologist/Social Worker: We are here to help you, you are not alone. I would like to work with you to develop a plan to support you given that things are so difficult currently.

Interview ends as clinician develops a plan to support the patient based on the rest of the history obtained.

Partners In Health | PARTICIPANT HANDBOOK 27 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Medical Evaluation and the Management of Agitation, Delirium, and Psychosis Once a clinician has calmed an agitated patient, the physician and psychologist/social worker need to determine if the patient is psychotic or has a medical delirium.

Definition of Agitation, Delirium and Psychosis Agitation is a symptom to describe behavior. It is not a disease. It is not a mental illness.

Delirium is a medical emergency. It is not a mental illness. It occurs when medical illness results in mental confusion. Delirious patients are confused and off-center and have an increased chance of death. It also has an additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception).The disturbance develops over a short period of time (usually hours to a few days) and tends to fluctuate in severity during the course of a day. Delirium is often misdiagnosed as psychosis or other psychiatric illnesses.

There are many causes for delirium including: • (HIV/AIDS, , ) • Metabolic disorders (electrolyte disorders, especially hypo/hyperglycemia related to diabetes) • Drug intoxication/Alcohol withdrawal • Medications (corticosteriods, cycloserine, phenobarbital, efavirenz, high doses of antihistamines, isoniazid) • /Vitamin deficiencies • Brain (dementia, , head injury with bleed) • Malignancy • Post-Ictal Psychosis –– Takes place between seizures –– Usually follows a ‘lucid’ interval that lasts from hours to days following a seizure –– Characterized by delusions, hallucinations, and aggressive behavior –– Primary treatment is anti-epileptic medication • Hypertension

28 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Psychosis is a syndrome. A syndrome is defined as the association of several clinically recognizable signs and symptoms which may have multiple causes. It can be a sign of medical illness or mental illness. It is not always a mental illness! It results in dysfunction in thinking, perception (hallucinations) and behavior (decreased social and professional activity).

Treatment is aimed at a complete medical evaluation and treatment first, then a complete mental health evaluation and treatment, if necessary.

Standard Medical Evaluation for Agitation, Delirium and Psychosis • History (epilepsy, delirium, substance abuse, medications) • Vital Signs • Physical Exam • Neurological Exam • Mental Status Exam • Laboratory Tests (at least CBC, RPR, VIH, CD4 if HIV+) • Additional Tests (CT Scan, EEG, lumbar puncture)

Partners In Health | PARTICIPANT HANDBOOK 29 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Biopsychosocial Clinical Formulation If after a medical evaluation, it has been concluded that a patient has a mental illness, the psychologist/social worker will complete the Initial Mental Health Evaluation Form. This includes recording a complete mental health history and creating a biopsychosocial clinical formulation for a patient.

Information to Obtain from Patient/Family Based on the Zanmi Lasante Initial Mental Health Evaluation Form, obtain: • Identification/demographic information • Chief complaint (CC), in patient’s own words • History of present illness (HPI) • Psychiatric (ROS) –– Use of screening tools to help identify possible disorders –– Plus systematic interview to be able to identify disorders/diagnoses • Past Psychiatric History (PPH), including hospitalizations • Past Medical History (PMH) –– Head injury –– Loss of consciousness • Active medical problems

Questions to Ask to Obtain History • How long has the problem been present (hours, weeks, days, months, years), has it ever happened before? • How has it affected your life? • Are you currently being treated for this? • Have you had any similar problems to the current one before? • Any recent illness? • Do you have any physical problems that are bothering you? • Do you have any allergies? • Are you aware of a family history of mental health problems, including your siblings, parents or grandparents? • Is there any family history of depression, anxiety, alcohol or drug abuse, schizophrenia, bipolar disorder or suicide? • How would you describe your childhood?

30 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

• Were there any behavioral problems for you as a child? • Did you have difficulty at home or at school, as a child or as a teenager? • What is your highest level of education? • How have you and your family been doing financially? • Do you and your family have enough to eat? • Do you have any problems sleeping at night? • Have you lost interest in your daily activities? • Have you been seeing or hearing things that other people cannot hear? • Have you been feeling sad or unhappy recently? • Have you been scared or frightened recently? • How much alcohol have you been drinking recently? • Have you been able to do the activities you want to, without feeling that your mood or your thinking does not allow you to?

Biopsychosocial Clinical Formulation A biopsychosocial clinical formulation is a working hypothesis which attempts to explain the biological, psychological and sociocultural factors which have combined to create and maintain the presenting clinical problem. It is a guide to treatment planning and helps communicate providers’ impressions to other providers, and to a patient and their family. A clinical formulation is not a summary of the clinical data. A formulation must contain a theory about the etiology of the patient’s problems, related developmental status and strengths.

Creating a biopsychosocial formulation: • The biological factors include things such as genetics, general medical conditions and drugs. • The psychological factors include a person’s coping strategies, personality and stressors including past trauma, loss and prolonged grieving. • The social factors include a person’s living situation, their support (both family and friends), finances, situation at work/school, etc. • It is important to take note of areas of significant strength, competency and mastery. Areas of strength can be used as initial areas of intervention in supporting a person.

Partners In Health | PARTICIPANT HANDBOOK 31 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Biopsychosocial Clinical Formulation Example

Peterson is a 21-year-old male living in Mirebalais who lives with his parents and presented to the hospital with a chief complaint of “hearing voices.” From a biological perspective there is a family history of a similar problem (his father), and he also experienced head trauma in a motorcycle accident several years ago. From a psychological perspective, Peterson has experienced significant shame about his illness, which has significantly affected his self-esteem. He and his family believe that these symptoms are related to a curse that was cast on the family. From a social perspective, they also are poor, Peterson’s father drinks alcohol excessively, and at times there is domestic violence. Peterson has strengths in that he has been a good student at school, he goes to church, and he participates in a musical group.

32 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers S trengths reas of significant A reas competency strength, and mastery S ocial family/living situation, specifically __. work, specifically __. financial/economic, specifically __. changes and recent transitions of note such as __. as such behaviors risk high sexual or behavioral high environmental risk such as domestic violence or being harmed at home, or threatened school, work or in the community • • • • • • From a social perspective, From of concern include ___. areas several social con - are T here siderations in assessing the presentation. current patient’s T hese include : Psychological a history of personal and family losses notable for ___. a history of interpersonal conflicts notable for ___. a history of internal conflict about __. a history of challenges __. regarding belief system with regards to mental health and illness • • • • • From a general psychological From perspective, XYZ describes his/ to be her closest relationships __. H e/she lives with __ and - of these relation the nature ships is __. several psychological are T here considerations in assessing the presentation. current patient’s T hese include: hese have affected the person T hese have affected in the following ways: __. - B iological a developmental history notable for ___. a history of substance abuse a family history of __ and to potential predisposition illness a history of head trauma, or infection seizures, notable on exam that might indicate potential psychiatric co-morbidities developmental disabilities or serious developmental findings a history of medication side- effects co-morbid medical illness, and difficulty coping with that illness • • • • • • • • here appear to be no significant T here cur biologic factors in the patient’s presentation. rent OR several biologic consid - are T here erations in assessing the patient’s T hese in - presentation. current clude: B iopsychosocial Clinical Formulation Table

Partners In Health | PARTICIPANT HANDBOOK 33 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Biopsychosocial Formulation Cases

case 1 A 22-year-old woman, Darline, is brought in by her husband to the health facility in Cange. He says that his wife has been acting strangely. He reports that she has refused to get out of bed for the past week and has been crying frequently. Darline is usually very active in church but hasn’t gone the past two weeks. He was worried she was depressed. However, yesterday she got out of bed extremely happy and was so energized cleaning the house she didn’t sleep at night. You observe Darline chatting excitedly with other people in the waiting room. She says she feels wonderful and doesn’t know why her husband brought her here. When you ask Darline if there is any family history of mental illness she declines to reply. She asks you angrily what you are trying to suggest. She says that nothing is wrong with her, although she does admit she was feeling sad last week. The husband mentions that he is worried and frustrated because she hasn’t been able to work as much the past two weeks because of her condition, and that it’s straining the family finances. When asked about her physical health, Darline states she has no health problems. Her husband reports that this is the first time that Darline has acted this way.

Biopsychosocial formulation:

34 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Biopsychosocial Formulation Cases (continued) case 2 A 20-year-old man, James, is brought in by his friend, Simon. Simon says that recently James started saying that his neighbor is watching him; James cannot stop talking about it. James thinks that the neighbor is a spy. James lives with his aunt and used to go to school. James was a good student, but he stopped going to school because he couldn’t concentrate. James reports that he hears what the neighbor is saying about him in his mind. The neighbor says “I’m watching you. I’m going to get you.” When you ask how long this has been happening for, James says almost three months. James is so scared that he can’t sleep at night. When you ask about his family history, James says he has never met his father, and he hasn’t seen his mother since she was hospitalized at Mars and Kline in 2011. Simon reports that James’ girlfriend broke up with James because she was scared of how James was acting. James has begun to use alcohol to relax because he is nervous all the time about his neighbor.

Biopsychosocial formulation:

Partners In Health | PARTICIPANT HANDBOOK 35 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Medication Management for Agitation, Delirium, and Psychosis Once a medical evaluation has been performed, a physician must decide if pharmacological treatment is necessary. Physicians are responsible for prescribing but they must work with psychologists to determine the likely diagnosis.

Prescribing Principles for Agitation, Delirium and Psychosis The primary tools that can be used to guide prescribing practices are: • Zanmi Lasante Formulary • Epilepsy Medication Card • Agitated Patient Protocol • Medication Card for Agitation, Delirium, and Psychosis

Haloperidol and are the primary medications for the management of agitation, delirium, and psychosis. Risperidone has fewer side-effects and should be tried before haloperidol, unless the patient is violent or aggressive and could benefit from the sedation of haloperidol. Begin with a low dose and increase gradually.

Carbamazepine should typically be prescribed before valproate as a long-term mood stabilizer.

Valproate is particularly for patients with long-standing aggression or violence, and should never be prescribed to a pregnant woman (and avoided for women of child-bearing age).

Diazepam is only used in agitated patients and those going through alcohol withdrawal.

Children, the elderly, pregnant and breast-feeding patients are special populations. Please consult with the mental health team before prescribing for them. For suicidal patients, give a small supply of the medication to a family member to prevent possible overdose.

36 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Psychoeducation about Medication It is incredibly important to speak to patients and their family members in language that they understand, depending on their education level and knowledge. Do not speak to patients and family members in jargon or complex medical language.

Make sure to explain to the patient/family: • What the medication is for • How to take the medication properly • Common side-effects • Toxic side-effects and when to seek immediate medical care • How long it takes for medication to work How long it takes for medication to work

TIP: To know if the patient/family actually understands the information you are providing about taking the medication, ask the patient/family member to repeat back to you how to take the medication.

Additional information about prescribing principles: • It is important to take the medication regularly and not miss a dose. • Do not double up on a dose if a dose is missed. • It is important to continue to take medication even if symptoms improve. • Symptoms may worsen if medication is discontinued. • If any problems of concern develop, contact a member of the treatment team (community health worker, psychologist/social worker or physician) by phone, or return to the hospital for evaluation.

AIMS (Abnormal Involuntary Movement Scale) The AIMS is a 12-item scale that the clinician administers and scores. The clinician observes the patient and asks questions about involuntary movements due to tardive dyskinesia. If one can catch tardive dyskinesia early, one can intervene. • Facial and oral movements • Extremity movements • Truncal movements • Patient awareness of movements

The AIMS should be used at the beginning of treatment, and then every six months. It can be done in less than 10 minutes. The clinician tracks the numerical score over time (every six months).

Partners In Health | PARTICIPANT HANDBOOK 37 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Medication Review Worksheet

Use the Medication Card for Agitation, Delirium, and Psychosis, and the Agitated Patient Protocol.

1. Which three medications on the medication card can Zamni Lasante physicians prescribe without consulting the Mental Health team?

2. Which two medications on the medication card should NOT be routinely prescribed by Zamni Lasante physicians for bipolar disorder or other forms of mental illness?

3a. A 63-year-old man arrives in the emergency room. He is violent and out of control, pushing people and running around. He has been brought in by his wife and son, who report he has never behaved this way before. What level of agitation does he have (mild, moderate or severe)?

38 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Medication Review Worksheet (continued)

3b. According to the Agitated Patient Protocol Form, which medication should the physician give the patient? Give the medication name, dose, and form.

4. You are working in the emergency room of a local clinic when a father brings his 19-year- old daughter in. She is totally rigid, unable to walk, unable to turn her head, and unable to open her mouth. Her father has to carry her. He reports that she was taken to a psychiatric facility after becoming violent following a break-up with her boyfriend. At the facility, she was given multiple injections. How would you work with the physician to treat this case?

Partners In Health | PARTICIPANT HANDBOOK 39 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Psychotherapy and Family & Patient Education There are a variety of approaches for treating mental illnesses, many of which can be useful for treating patients with severe mental illness, like psychosis or bipolar disorder. • Interpersonal Therapy (IPT) • Cognitive Behavioral Therapy (CBT) • Behavioral Activation (BA) • Breathing/muscle relaxation techniques, stress management • Group therapy • Family therapy • School-based mental health and psychosocial interventions

Supportive Therapy Appropriate for two kinds of patients: • Chronic illness, low level of functioning: bipolar disorder, schizophrenia, chronic major depressive disorder • Person in crisis

Interventions: Permit venting, acknowledge and validate, accept, give hope, educate, give permission to (temporarily) accept the sick role, normalize, help problem-solve, advise, reality test, role play, request family meeting.

Interpersonal Therapy Interpersonal therapy can be helpful for some patients with severe mental illness because their illnesses often cause problems in their social relationships. • Psychological treatment designed to help a person identify and address problems in their relationships with family, friends, partners and other people. • Works on improving symptoms through a focus on interpersonal functioning.

Family-Focused Therapy Family-focused therapy can be one of the most helpful types of therapy for patients with severe mental illness.

40 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Family dynamics are often stressed when a member of the family has a severe mental illness. Families may blame the patient for their symptoms, or be hostile towards the patient. Often, families feel helpless and hopeless to control the illness. Unfortunately, this stressful home environment can lead to the worsening of the patient’s symptoms, creating a cycle of stress in the home. Family-focused therapy emphasizes the importance of building family support through education, problem solving techniques and communication skills.

Family-Focused Therapy: • Create a shared understanding of severe mental illness (bipolar disorder, schizophrenia) in the family which will: –– Maintain a low-key atmosphere –– Support the patient taking medication and monitoring it –– Separate the patient from the illness • Communication skills training • Problem-solving skills training –– Identify the precipitating life events that provoke worse symptoms –– Conduct a relapse prevention drill –> how to identify, what to do

Psychoeducation All of the therapy approaches previously mentioned include educating the patient and their family. Because of the importance of psychoeducation, all Zamni Lasante health providers have a role in delivering psychoeducation. Psychologists and social workers will practice psychotherapy that includes psychoeducation components, while the other cadres of health workers will provide basic education around severe mental illness.

General Messages to Share with Patients and Families

• A patient’s symptoms can improve with treatment and they can even recover. • It is important to continue with work, social, and school activities as much as possible. • The patient has a right to be involved in making decisions about their treatment. • It is important to exercise, eat healthy, and maintain good personal hygiene. • Families should not tie up or lock up patients. Instead, bring them to the clinic/hospital or ask the CHW for help/support. • Information about medication: –– It is important to take the medication regularly and not miss a dose. –– Do not double up on a dose if a dose is missed. –– It is important to continue to take medication even if symptoms improve. –– Symptoms may worsen if medication is discontinued.

Partners In Health | PARTICIPANT HANDBOOK 41 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Psychosis-Specific Messages

• Psychosis is a medical condition that is treatable. • Psychosis is not contagious. • Patients with psychosis are often stigmatized and mistreated. • Many patients recover from psychosis with medication and therapy and return to their normal functioning. • The patient may hear voices or may firmly believe things that are untrue. • The patient often does not agree that he or she is ill and may sometimes be hostile. • If there is a return/worsening of symptoms the patient should come back for re-assessment. • The patient should be included in family and social activities. • Family members should avoid expressing criticism or towards the patient. • The patient may have difficulties recovering or functioning in high-stress working or living environments.

Bipolar-Specific Messages

• It is important for the patient to maintain a regular sleep cycle (e.g. going to bed at the same time every night, trying to sleep the same amount as before illness, avoiding sleeping much less than usual). Difficulty sleeping, if it is persistent, can be helped with medication. • Relapses can be prevented, by recognizing when a patient’s symptoms return, such as sleeping less, spending more money or feeling much more energetic than usual. The patient should come back for treatment when this occurs. • A patient in a manic state can lack insight into the illness and may even enjoy the euphoria and improved energy, so carers must be part of relapse prevention. • Alcohol and other psychoactive substances should be avoided.

42 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Case study 1

• Gerard is a 25-year-old man with bipolar disorder. He is a patient of yours that you have seen for the past year and the physician has prescribed him carbamazepine. • His mother, Amelie, has accompanied Gerard to the health center. • Amelie says that Gerard stopped taking his medication a week ago. She says he has been acting “crazy.” Gerard confirms that he stopped taking his medication, but says he did so to see if he was cured. • The psychologist/social worker counsels Gerard and his mother.

Case study 2

• Rose is a 21-year-old who has been accompanied to the health center by her older sister and a community health worker. Rose is clearly agitated, having visual hallucinations and speaking to someone who is not there. • The older sister tells the psychologist/social worker that for the past three days she has been like this. The older sister says that someone has put a spell on her. • The community health worker says that Rose has a fever and that Rose’s mother is also sick with a fever. • The psychologist/social worker counsels Rose’s sister and community health worker about Rose’s condition and the process of determining if this is a medical illness or psychiatric illness.

Case study 3

• Jean is a 19-year-old man who is disheveled and was brought to the clinic by his brother. • Jean’s brother explains that Jean has stopped going out with friends and refuses to leave his house. Jean hasn’t attended his university classes in a month. Jean’s brother sometimes sees Jean talking to himself. • Jean refuses to speak to the psychologist/social worker. The psychologist/social worker shares general mental health messages with Jean and his brother.

Case study 4

• Ronald is a 55-year-old man who is brought to the clinic by his wife and son. • Ronald’s wife, Esther, explains that Ronald went out last night and spent all their money. He was up all night, repeating that he was the King of Haiti. She said he has had many of these types of days since they first met 25 years ago. Ronald’s son is very angry that Ronald has spent all their money and demands that the psychologist fixes Ronald’s disturbed mind. • The psychologist/social worker counsels Esther and her son.

Partners In Health | PARTICIPANT HANDBOOK 43 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Clinical Outcome Measures — CGI and WHODAS Effective care is that which has been shown to improve functioning and quality of life. Effective care may be based on several different types and levels of evidence, and it reflects the best care a system can offer at any given point. To measure effective care, the Zamni Lasante system of care will use the Clinical Global Impressions Scale (known as “CGI”) and the World Health Organization Disability Assessment Schedule (known as “WHODAS”).

Clinical Global Impressions Scale (CGI) The Clinical Global Impressions Scale (CGI) is an easily adopted tool that measures the effect of treatment over time. It is a global assessment of current symptoms, behavior, and the impact of illness on functioning. Its goal is to allow the clinician to rate the severity of illness (CGI-S), change over time (CGI-I), and efficacy of medication.

It evaluates the following elements: • Current symptoms • Behavior • Impact of illness on functioning

It rates the following elements: • Severity of illness • Change over time • Efficacy of medication

CGI – Severity Psychologists/social workers determine the CGI Severity by assessing how ill the patient is at the time of interview relative to the psychologist’s/social worker’s past experience with patients who have the same diagnosis. The psychologist/social worker will judge the level of mental illness that the patient has experienced over the past 7 days.

44 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Case 1

A 38-year-old, well-groomed, female patient, who is a successful professional, reports a one-month unprecipitated depressive episode that seems to be worsening. She is currently experiencing early morning awakening, loss of pleasure in her usual activities, feelings of guilt, reduced appetite, tearfulness, and depressed mood. She has found herself weeping several times over the past week, but cannot identify a reason. She is continuing to work, but found herself fighting back tears at an important meeting and believes her work may be less sharp than it had been in the past. No one has noticed, but she is concerned that the depression is worsening and may result in a significant impact on work. She is worried that she may lose her “edge.” She denies suicidal ideation. She has no previous psychiatric history.

Case 2

A 34-year-old, male patient with a diagnosis of paranoid schizophrenia has been in treatment at Zanmi Lasante for the past several years, having started medication treatment more than ten years ago after a hospitalization at Mars and Kline. According to his community health worker and physician, he had been stable on his medication regimen for the past year, but recently stopped taking his medication and would not cite a reason. He attended his church twice this past week, but missed four other days which he usually would have attended. After receiving a call from a family member, the community health worker went to his home and drove him to the hospital for evaluation and possible hospitalization. The community health worker reports he has become increasingly threatening and difficult to manage at home, and has been seen responding to auditory hallucinations, including taking cover in attempts to hide from “enemies.” In the past week, he obeyed a command to “go after” a neighbor, but was physically circumvented from harming the neighbor by three community health workers, who physically restrained him. The community health worker reported that although the patient was passively cooperative about coming to the clinic, he did not speak with her at all during the trip. In the clinic office, he is guarded and suspicious. He mumbles under his breath, but refuses to elaborate as to what he has said or to whom it was directed. Twice he makes a fist and raises his arm threateningly in the direction of the physician, but then puts his hand back in his lap. He appears disheveled and is not groomed; he has not changed his clothing over the past week, which his community health worker reports is a new behavior for him.

Partners In Health | PARTICIPANT HANDBOOK 45 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

CGI – Improvement • At Initial Evaluation: If the patient has been in treatment previously, rate CGI-I based on the history and compared to the patient’s condition prior to treatment. Otherwise, select 0, “not assessed.” • Follow-Up Appointment: Rate CGI-I by comparing the current condition to the patient’s condition at the initiation of the current treatment plan. Assess how much the patient’s illness has changed relative to a baseline state at the beginning of the treatment plan based on the first evaluation. Rate total improvement whether or not in your judgment it is due to treatment.

Case 1

A patient who has been in treatment and receiving an SSRI for an for four months comes in for a medication check. The patient’s CGI-S at the visit at which SSRI medication was initiated (“baseline” visit) was 4 (moderate). At today’s visit, the patient reports that the anxiety symptoms have decreased considerably. The patient is now able to sleep 7 to 8 hours each night, with no initial insomnia. This represents a significant change from baseline, at which time the patient spent 2 to 3 hours each night trying to fall asleep, with a nightly total of 4 to 5 hours of fitful sleep. The patient reports having felt excessively anxious this week about running out of gas and about a burglar entering the house. The estimated time spent engaged in these anxious thoughts was less than one hour per day, compared to an estimated 3 to 4 hours per day at baseline. The patient drove over a bridge this week, which was described as somewhat difficult and fear-provoking, but manageable. At baseline, the subject was wholly avoidant of bridges, which caused him to drive 30 minutes out of his way each day to get to work.

Case 2

The anxious patient in the previous example (CGI-I Case 1) returns one month later. He reports that he is now afraid of leaving his house without accompaniment. This is a new development for him. He is anxious and worried all day long. He called work and told them he had the flu. In reality, he was afraid to leave his house. He has only left the house three times this week, including his visit to the clinic today, all accompanied by his wife. He felt panicky on all three occasions. Although he denies any or other symptoms suggesting impending , he reports worrying constantly about “passing out” in front of a moving car or bus. He is fearful that he will forget the name of a well-known friend or relative should they call him on the phone. He is sleeping only 1 to 2 hours a night. His wife reports that she has “never seen him so bad.” He cries in the interview and admits he has considered “ending it all” to make the pain go away.

46 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

CGI – Side-Effects The side-effects scale scores a patient’s level of side-effects from medication on a scale of 0 – 3. The closer the number is to zero, the better. Medication side-effects will be monitored by physicians using the Abnormal Involuntary Movements Scale (AIMS). The psychologist/social worker’s role is not to actively check or identify side-effects. Rather, the CGI Side-Effects scale is simply used to serve as an additional tracking tool, and to double-check what the physician has found in his AIMS evaluation.

World Health Organization Disability Assessment Schedule The WHODAS is another tool that psychologists/social workers will use to track patients’ progress over time. There are six domains of functioning in the WHODAS that will be discussed with the patient and then recorded.

Partners In Health | PARTICIPANT HANDBOOK 47 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

WHODAS role play

Psychologist/Social Worker: “I now want to ask you a few questions. The interview is about difficulties people have because of health conditions. By health condition I mean diseases or illnesses, or other health problems that may be short or long lasting; injuries; mental or emotional problems; and problems with alcohol or drugs. Do you understand what I mean by health condition?”

Patient: “Yes.”

Psychologist/Social Worker: “Remember to keep all of your health problems in mind as you answer the questions. When I ask you about difficulties in doing an activity think about: increased effort, discomfort or pain, slowness, changes in the way you do the activity. When answering, I’d like you to think back over the past 30 days.”

Patient: “OK.”

Psychologist/Social Worker: “I would also like you to answer these questions thinking about how much difficulty you have had, on average, over the past 30 days, while doing the activity as you usually do it. Use this scale when responding: none, mild, moderate, severe, extreme or cannot do.”

Patient: “OK.”

Psychologist/Social Worker: “In the past 30 days, how much difficulty did you have in: standing for long periods such as 30 minutes?”

Patient: “I am always standing.”

Psychologist/Social Worker:

1.

(What should you say to the patient to obtain an answer of none, mild, moderate, severe, extreme or cannot do?)

Patient: “I did not have any difficulty.”

2. How would you record this answer on the WHODAS scale? Which category would you circle?

a. None b. Mild c. Moderate d. Severe e. Extreme or cannot do

48 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

WHODAS role play (continued)

Psychologist/Social Worker: “In the past 30 days, how much difficulty did you have in: taking care of your household responsibilities?”

Patient: “What type of household responsibilities?”

Psychologist/Social Worker:

3.

(What should you say to the patient to clarify what you mean?)

Patient: “I had no difficulty.”

Psychologist/Social Worker: “In the past 30 days, how much difficulty did you have in: learning a new task, for example learning how to get to a new place?”

Patient: “I haven’t learned any new tasks.”

Psychologist/Social Worker:

4.

(What should you say to the patient to probe about whether this question is not applicable?)

Psychologist/Social Worker: “In the past 30 days, how much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?”

Patient: “I always go to church but I don’t like going to other community activities.”

Psychologist/Social Worker:

5.

(What should you say to the patient to obtain an answer of none, mild, moderate, severe, extreme or cannot do? Remind the patient these questions are based on his health status.)

Patient: “I can go to everything — it’s just that I don’t want to. I suppose my answer is none.”

Partners In Health | PARTICIPANT HANDBOOK 49 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

WHODAS role play (continued)

Psychologist/Social Worker: “In the past 30 days, how many days were these difficulties present?”

Patient: “Oh, I don’t know. I can’t say.”

Psychologist/Social Worker:

6.

(What should you say to the patient to obtain the number of days?)

Patient: “I guess I could estimate that four days a month these difficulties were present.”

50 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Follow-Up and Documentation The Psychosis Care Pathway only works with functional follow-up and documentation.

Patients should be seen for follow-up appointments every one-to-two weeks if their symptoms are acute or if medications are being started, adjusted or stopped. Patients with psychosis whose symptoms are stable can be seen once a month or once every three months.

Follow Up Chart

How to Determine a Patient’s Why is documentation important? Improvement in Symptoms • •

• •

• •

• •

• •

Partners In Health | PARTICIPANT HANDBOOK 51 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Using mhGAP for Psychosis and Bipolar Disorder The mhGAP Intervention Guide is a document developed by the World Health Organization that outlines the diagnosis and management of various mental health disorders. It is designed to serve as a guide for clinicians around the world. It is an important resource to help guide decision-making for non-specialist providers such as physicians. The effective training of non- specialists is how the global treatment gap will be narrowed.

The mhGAP chapters on psychosis and bipolar disorder can be used to guide assessment and management of all these different disorders. mhGAP organizes psychotic disorders separately from bipolar disorder because bipolar disorder is considered a mood disorder. However, both bipolar disorder and depression can have psychotic features.

Questions to Ask about Psychosis Sometimes it is not obvious what symptoms a patient may have. By asking these questions, the physician may be able to better determine if a patient has psychotic features. • “Have you ever heard voices, even when nobody is present? Do you currently hear voices? Are you bothered or harassed by these voices? What did the voices tell you? Can other people hear the voices too? Do you think that I can hear them?” • “Have you ever seen things that may not actually be present?” • “Have you ever felt that your mind or body was being secretly controlled or somehow controlled against your will?” • “Have you ever felt that others wanted to hurt you or really get you for some special reason, maybe because you had secret or special powers of some sort?”

Determining Chronic vs. Acute Psychosis By asking the patient or carer about the onset of the psychotic episode and any prior episodes, participants will be able to determine if the person has acute psychosis or chronic psychosis. This is important because it can have an impact on the duration of treatment with medication. For acute psychosis, the provider will want to stop the medication at some point to see if the patient can recover without the medication. Medication can have potentially significant side-effects, and we want to minimize the use of medication as much as possible.

The red box in the middle of page 18 in mhGAP emphasizes the importance of ruling out medical delirium before prescribing any medication to someone with acute psychosis — just as you learned about earlier during this training.

52 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Self-Harm and Suicide During your work with depressed patients, epileptic patients and psychotic patients, you might come across a patient that has self-injurious behavior or suicidal ideation. It is critical to assess safety and risk of suicide for all patients for whom there is a mental health concern. By asking someone if they are thinking about hurting or killing themselves, psychologists/social workers will not increase the risk of the patient doing so. Asking about thoughts of self-harm is an important responsibility of every provider: physician, nurse, community health worker, social worker and psychologist. For the physician assessing a patient for self-harm, mhGAP can assist the physician to take the appropriate next steps.

No matter the condition of the patient, it is important not to leave the patient alone. Self-harm and suicide can be attempted by anyone who might have mental health issues, including depression, epilepsy, psychosis and bipolar disorder.

Supplementary Resources mhGAP Intervention Guide http://www.who.int/mental_health/publications/mhGAP_intervention_guide/en/

Partners In Health | PARTICIPANT HANDBOOK 53 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Review: Case Studies

Case study 1

A 40-year-old woman is brought into the health facility by her two sons. She is barely able to walk and is clearly confused. She cannot follow simple commands. Her sons said she has been fatigued and feverish for the past few days. The patient is mildly agitated, clearly frustrated with her sons. You, the nurse and the physician are available to evaluate and manage the patient.

1. What would you do with the nurse to manage the patient’s agitation? What form would you use to guide you?

2. How would you support the physician in evaluating the agitated patient? What forms would you help the physician manage during the medical evaluation?

The physician has concluded that the patient likely needs further neurological testing to determine if the patient has a neurological problem. The patient also has a confirmed fever above 38 C. The two sons said that they are sad that she is now “crazy” and want to know how you can cure her.

3. What would you say to the two sons?

54 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Case Study 2

A 27-year-old man, Pierre, is brought into the health center by two community health workers. He is yelling that the community health workers are trying to kill him. He lunges at anyone who tries to get close to him, screaming that he will kill everyone.

1. Is this patient agitated. What level of agitation does the patient have?

2. What do you do to manage the behavior and environment? Who do you collaborate with?

3. What forms would you use to assist you to manage this agitated patient?

After a few minutes of speaking calmly with the patient you leave the room, and identify someone to keep an eye on the patient to ensure his safety and that of others (1:1). You have been able to calm the patient without giving any medications and the physician has done an initial medical evaluation. The patient denies wanting to hurt himself or others. His lab tests have come back normal and the physician says he is not suffering from medical delirium.

4. What would you do next? What forms would you be utilizing to guide your work?

Partners In Health | PARTICIPANT HANDBOOK 55 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Case Study 2 (continued)

You see the patient for an initial mental health evaluation and the patient reports that he has been hearing voices that tell him that everyone wants to kill him. He is disheveled and it is apparent he has not bathed in many days. You ask the community health workers about the patient, and they say that he is typically locked in the house by his family. However, the community health workers were able to convince the family to let him come to the health facility. The community health workers say the patient has been this way for a few years. You are unable to get further information from the patient as his speech is disorganized and tangential.

5. What diagnosis would you give the patient? Why? Where would you record the diagnosis?

6. What clinical formulation would you record on the Initial Mental Health Evaluation Form?

7. What type of psychotherapy would you consider beginning with the patient during the next visit? Why?

56 Partners In Health | PARTICIPANT HANDBOOK Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Case Study 2 (continued)

8. After diagnosis, how would you collaborate with the physician that day?

9. What would be the follow-up plan for this patient? What other providers would you include, and what would their role be?

Partners In Health | PARTICIPANT HANDBOOK 57 Introduction to Agitation, Delirium, and Psychosis Curriculum for Psychologists/Social Workers

Case Study 3

This past year you began seeing a young, 18-year-old woman with a recent episode of psychosis. She was prescribed risperidone. Today during her monthly follow-up visit, approximately 8 months since the initiation of medication, you notice that she appears restless, frequently wringing her hands and looking upset.

1. What forms will you use or complete during your follow-up visit?

During her appointment, when you ask her how things are going, she begins to cry and tells you that things are not going well. She recently broke up with her boyfriend and cannot find a job to support herself.

2. How would you counsel her? What are some key messages you would give her during this time of stress?

You are worried that this stress could trigger a relapse.

3. How would you collaborate with other providers to ensures she is adherent to her medication and has social support during this time of stress?

58 Partners In Health | PARTICIPANT HANDBOOK notes

Partners In Health | Participant Handbook | Annex 59 Annex

60 Partners In Health | pARTICIPANT HANDBOOK | Annex M anage agitated patient Evaluation, diagnosis, and treatment with care Coordinate physician and C H W Psychoeducation M EQ/checklist M anage agitated patient Evaluation, diagnosis, and treatment M edication management care Coordinated with psychologist/ S W Psychoeducation • • • • • • • • • •

COLLABORATE Physician S ocial Worker Psychologist or AND TREATMENT EVALUATION, DIAGNOSIS DIAGNOSIS EVALUATION, FOLLOW-UP REFER Nurse CHW y AND REFERRAL CASE IDENTIFICATION CASE IDENTIFICATION athwa M anage agitated patient I dentify and refer care Coordinate Psychoeducation dentify, triage, I dentify, and refer Psychoeducation Follow-up Community activities • • • • • • • • P S y cho s i C ar e

Partners In Health | Participant Handbook | Annex 61 Differential Diagnosis Information Sheet for Severe Mental Disorders

Condition Symptoms Diagnostic Hints General Management Medical Symptoms or Psychosis Caused by Medical Conditions Delirium New onset abnormal mental status • Abnormal physical • Seek medical source exam, vital signs or of illness laboratory studies • Follow Medical • Abnormal mental Evaluation Protocol status examination for Agitation, Delirium Psychotic Disorder Psychosis is the direct physiological consequence • Psychotic symptoms and Psychosis Due to a General of a medical condition • Evidence of a Medical Condition contributing medical illness Substance-Induced Prominent hallucinations or delusions • Evidence of recent Psychotic Disorder or withdrawal Post-Partum New onset psychosis in a female • Recent childbirth Psychosis following childbirth Mental Health Related Symptoms that are not Psychosis Transient Anomalous experiences, may occur in a person • Common in children • Ensure safety of hallucinations in a state of good mental and physical health, and youth patient: assess for even in the apparent absence of a trigger (stress, self-harm fatigue, intoxication, etc.) • Seek to understand Acute stress, Stress and traumatic experiences can result in • Significant trauma patient’s explanatory anxiety, and unusual sensory and perceptual experiences that history model, and to trauma-related can mimic psychosis assess internal level problems of distress Usually in response to stress, a person can • Identification of • Obtain develop blindness, , or other nervous stressor Biopsychosocial system (neurologic) symptoms that cannot be • Poor insight into history explained by medical evaluation emotional stressors • Identify potential Obsessive- Excessive thoughts (obsessions) that can lead • Specific area of focus stressors compulsive disorder to repetitive behaviors (compulsions), with a • Consult traditional potential component of disordered thinking healer if currently Autism spectrum A serious that impairs • Longstanding involved in disorders the ability to communicate and interact history of unstable management interpersonal relationships Personality Disorder A deeply ingrained and maladaptive pattern • Longstanding of behavior of a specified kind, typically history of unstable manifest by the time one reaches adolescence interpersonal and causing long-term difficulties in personal relationships relationships or in functioning in society • Poor insight

1

62 Partners In Health | pARTICIPANT HANDBOOK | Annex Differential Diagnosis Information Sheet For Severe Mental Disorders (Continued)

Condition Symptoms Diagnostic Hints General Management Episodic Psychosis or Mania Depression with A primary depression with psychotic symptoms. • Depressive symptoms • Ensure safety of psychotic features before psychotic patient: assess for (Mood Disorder, symptoms self-harm depressed) • Seek to understand Bipolar Disorder Marked by alternating periods of elation and • Period of mania, patient’s explanatory (Mood Disorder, depression; some develop mania without or hypomania with model, and to manic or depressed) depression, others can develop hypomania depression assess internal level with depression of distress Brief psychotic A sudden, short-term episode of psychotic • Person returns to • Obtain disorder (less than thinking and behavior which occurs with a functioning Biopsychosocial one month) stressful event; can be informed by social and history cultural factors • Identify potential Schizophreniform Symptoms of schizophrenia are present for a • Do not make stressors Disorder significant portion of the time within a 1-month diagnosis of • Consult traditional (Schizophrenia period, but signs of disruption are not present Schizophrenia if healer if currently symptoms for the full six months required for the diagnosis symptoms are less involved in 1-6 months) of schizophrenia than 6 months management Psychosis Not Psychotic symptoms about which there is • Examples include: • Consider co-morbid Otherwise Specified inadequate information to make a diagnosis psychosis of a mental health (NOS) few days or diagnoses. weeks duration, • Both depression post-partum and psychosis are psychosis, and treated with distinct situations in which medications diagnosis is unclear • medications (fluoxetine, amitryptiline) can cause mania in a person with Bipolar Disorder

2

Partners In Health | Participant Handbook | Annex 63 Differential Diagnosis Information Sheet For Severe Mental Disorders (Continued)

Condition Symptoms Diagnostic Hints General Management Continous Psychosis Schizophrenia DSM 5 criteria1 • Consider age at onset • Ensure safety of (greater than Two (or more) of the following, each present • Consider prodromal patient: assess for 6 months) for a significant portion of time during a period before onset self-harm 1-month period. At least one of these must be of initial symptoms • Seek to understand (1), (2), or (3): patient’s explanatory model, and to 1. Delusions assess internal level 2. Hallucinations of distress 3. Disorganized speech • Obtain 4. Grossly disorganized or catatonic behavior Biopsychosocial 5. Negative symptoms, i.e., affective history flattening, , or avolition • Identify potential stressors Note: Only one of the above symptoms is required if delusions are bizarre or hallucinations • Take conservative consist of a voice keeping up a running approach to commentary on the person’s behavior or medication thoughts or two or more voices are conversing • Consult traditional with each other healer if currently involved in Social/occupational dysfunction: For a management significant portion of the time since the onset • Consider co-morbid of the disturbance, one or more major areas mental health of functioning, such as work, interpersonal diagnoses relations, or self-care, are markedly below the level achieved before the onset.

Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms and may include periods of prodromal or residual symptoms.

Exclusions: • Schizoaffective and mood disorder exclusion • Substance/general medical condition exclusion • Pervasive developmental disorder- the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least a month Delusional Associated with one or more nonbizarre • Delusion is usually disorder (plausible, delusions of thinking such as expressing beliefs realistic circumscribed that can occur in real life, provided no other delusions) symptoms of schizophrenia are present

1 DSM-5 Diagnostic criteria for schizophrenia. American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fifth edition,Washington, DC, 2013, American Psychiatric Association. 3

64 Partners In Health | pARTICIPANT HANDBOOK | Annex - up F o ll ow UATION (ONC E CA LM ) A L UATION PHYSICIAN E NT E D PATI AGITAT INITIA L EV A lert either psychologist/social worker to determine Follow A gitated Patient Protocol medication if level of agitation and to prescribe necessary Continue medical evaluation: physical/neuro exam, vital signs, lab tests to monitor antipsychotic U se M edication Card (consider EK G , fluids) side effects Document in A gitated Patient Form R eview I nitial M ental H ealth Evaluation Form with psychologist/ S W to diagnose delirium/medical illness or mental disorder Do complete medical evaluation: vital signs, exam, lab tests. U se M edical physical/neuro for A gitation, Delirium Evaluation Protocol and Psychosis or delirium, I f patient has a psychotic disorder to dose use M edication Card Do baseline AIMS exam Document everything in I nitial M ental H ealth Evaluation Form medication to last until next appt Provide Do psychoeducation about medication Plan follow-up with psychologist/ S W R eview the M ental H ealth Follow- U p Form with psychologist/ S W to see if patient is improving exam Do physical/neuro Check weight/vitals each visit; lab tests and AIMS every 6 months to check for side effects U se M edication Card and to adjust dose as needed medication to last until next appt Provide Discuss discontinuation of antipsychotic with M ental H ealth team in M ental H ealth Document properly Follow- U p Form Do psychoeducation about medication Plan follow-up with psychologist/ S W q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q dd/mm/yy - up Date ______F o ll ow NURSES UATION (ONC E CA LM ) A L UATION E NT E D PATI AGITAT alk to patient; support family A lert either psychologist/social worker A ccompany patient to room emergency R efer to A gitated Patient Protocol M anage environment T Do vital signs ASA P oral and IM medications Prepare if needed A rrange 1:1 if needed M onitor antipsychotic side to physician report effects, Continue to follow patient closely (at least every 15 min check) A ssist doctor in medical evaluation (vital signs, lab tests, and care EK G , fluids) psychoeducation and Provide support to patient and family Document all work in nursing forms Determine whether patient may be psychotic A ccompany patient to see support psychologist/ S W; collaboration with physician I f psychosis is diagnosed, provide psychoeducation and support the ensure discharge, Before patient has a follow-up appt with psychologist/ S W Do vital signs, weight at each visit Check labs when necessary Document in M ental H ealth Follow- U p Form q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q INITIA L EV

- up F o ll ow UATION (ONC E CA LM ) A L UATION E NT E D PATI AGITAT 2 weeks; coordinate with C H W 2 weeks; coordinate INITIA L EV PSYCHOLOGIST/SOCIAL WORKER Do psychoeducation and support for medication psychosis A gitation, Delirium and Psychosis Checklist Complete C GI /W H OD AS , R egistry, ccompany patient to emergency room A ccompany patient to emergency support nurse and physician R efer to the A gitated Patient Protocol; patient and family Collect information from A rrange 1:1 if needed R emain at bedside until patient is stable family & nurse/physician give phone number to patient’s Follow patient 2x/day, medications given and U sing A gitation, Delirium and Psychosis Checklist, ensure by nurse/ M D provided medical care G ive patient/family psychoeducation and support of illness A ssess & manage socioeconomic burden to initial evaluation (once calm) Proceed Complete Psychosis Checklist with C H W/nurse Complete Z L D SI Document in I nitial M ental H ealth Evaluation Form A gitated physician’s S peak with patient and T WO family members & review Patient Form to complete initial mental health evaluation checked vitals, weight, and labs are Ensure A ccompany patient to see physician (sees all psychotic, suicidal, violent cases) H elp physician follow checklist diagnosis of delirium/medical illness or mental with M ake preliminary the physician with physicians, if patient has coordinate I f patient needs medical care, schedule follow-up within one week psychotic disorder, to medication and psychosis Do psychoeducation and support related Checklist Complete C GI /W H OD AS , R egistry, U se M ental H ealth Follow- p Form (check mental status exam, functioning, S ee whether patient is improving patient and family report) Check medication compliance, side effects checked vitals, weight, and labs are Ensure A ccompany patient to see physician; help physician follow gitation, Delirium and Psychosis Checklist Plan follow-up for 1– q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q - up CHW F o ll ow UATION (ONC E CA LM ) A L UATION E NT E D PATI AGITAT , Del iriu m and Psy cho s i C h e c kl t A gitation Do follow-up of patient in the community (check patient side effects, adherence, encourage patients to do follow-ups) G ive the R eferral Form and I nitial Form to psychologist/ S W Visit Do psychoeducation U se the Z L D SI Document with the M ental H ealth Follow- U p Form Decrease risk and reinforce safety risk and reinforce Decrease if risk for suicide or violence G ive the R eferral Form and I nitial Form to psychologist/ S W Visit I f suicidal/violent, accompany patient and family to the clinic immediately Do psychoeducation U se the Z L D SI nitial Visit Form Complete the I nitial Visit Decrease risk and reinforce safety risk and reinforce Decrease if risk for suicide or violence I f suicidal/violent, accompany patient and family to the clinic immediately ccompany patient to emergency A ccompany patient to emergency immediately room q q q q q q q q q q q q q q q q q q q q q q q q q q q q INITIA L EV P

Partners In Health | Participant Handbook | Annex 6565 alking to patient is safe and Do not see the patient alone (ask for security). R emain calm. R emember that patients do not suddenly become violent; their behavior occurs along a spectrum. M aintain safe physical distance patient. Do not allow from exit to be blocked. Keep large between you and furniture patient. R emove all objects that can be used to harm (needles, sharp objects, other small objects). Check whether patient has a history of violence or substance abuse. T Do not yell. Keep effective. your voice calm, quiet, and friendly. M ake eye contact to show about the patient. you care S how sympathy and empathy scared, (“ I understand you are to help. I will but I am here not hurt you.”) • • • • • S AF E T Y FIR T! mg IM

mg IM

mg IM +

–10 destroying property destroying physical aggression (e.g., physical aggression hitting, kicking, biting) self-injurious behavior (e.g., biting hand, head banging) O R diazepam 10 30 minutes; if patient Wait agitated, can re-dose remains with ½ the original dose H aldol 5 25 to monitor U se M edication Card side effects Debrief with staff Consult mental health team if etiology is psychiatric M edications q q q q q q q q q q q SEVE R E Agitation 1. M anage B ehavior/ E nvironment 2. Consider ORA L M edications 3. Consider INTRA M U S CU L AR q q q q q mg) mg +

mg O R

mg + diphenhydramine mg O R Diazepam 10

verbal threats verbal threats yelling/cursing does not respond to verbal does not respond redirection does not respond to increased to increased does not respond presence staff Offer PO medications first if Offer ( H aldol 5 50 f patient refuses PO, give IM I f patient refuses medications ( H aldol 5 diphenhydramine 25 Diazepam 10 mg) Wait 30 minutes; if patient Wait agitated, can give ½ the remains original dose edication Card to monitor U se M edication Card side effects q q q q q q q q q q q q E Agitation M OD E RAT 1. M anage B ehavior/ E nvironment 2. Consider ORA L M edications q q q q mg PO; 2 S afety: talk first, do not medicate first M edical Health: vital signs, physical exam, mental status, exam to assess for delirium, labs and studies M ental Health: take history Follow-Up: contact psychologist/social worker Remember: • • • • wringing/tapping of hands pacing, moving restlessly requests/demands frequent loud or rapid speech low frustration tolerance U se calm voice, simple language, soft voice, slow movements A sk “ H ow can I help?” and solve with patient; problem be empathic R emove potentially harmful area objects from A sk about hunger/thirst stimulation/arrange 1:1 Decrease verbal support and Offer understanding A llow the patient to show anger/frustration Calm staff I f agitation due to delirium, consider H aldol 1– not in elderly q q q q q q q q q q q q q q q q q q q M I L D Agitation 1. M anage B ehavior/ E nvironment q q q q q q q q q R E F to Medical Evaluation Protocols for Agitation, Delirium and Psychosis R E CORD on Agitation, Delirium and Psychosis Form • • S T E P 1: Determine level of agitation by observing patient behavior S T E P 2: M anage agitation IT: Assessment THROUGHOUT V I S IT: E NT PROTOCO L E D PATI AGITAT

66 Partners In Health | pARTICIPANT HANDBOOK | Annex Agitation, Delirium and Psychosis Form

Patient Name:______Sex:____ Phone:______Provider:______Date: dd/mm/yy

1. SAFETY (USE AGITATED PATIENT PROTOCOL)

Patient is: q Not Agitated (But appears psychotic) q Agitated (Mild) q Aggressive (Moderate) q Violent (Severe) History of Violence: q No q Yes: Describe violent behavior______When did it take place:______q Manage Behavior/Environment Completed Does patient need a 1:1? q No q Yes:______

2. MEDICAL HEALTH (USE MEDICAL EVALUATION PROTOCOL) Vital Signs: Temp:______Pulse:______BP:______RR:______O2:______Weight:______Physical Exam Neurological Exam HEENT: q Normal q Abnormal:______Cranial Nerves: q Normal q Abnormal:______Cardiac: q Normal q Abnormal:______Motor Strength: q Normal q Abnormal:______Pulmonary: q Normal q Abnormal:______Sensory: q Normal q Abnormal:______Abdominal: q Normal q Abnormal:______Reflexes: q Normal q Abnormal:______Skin/Extremities: q Normal q Abnormal:______Gait/Coordination: q Normal q Abnormal:______Mental Status Exam Laboratory Tests Ordered q Alert q Sleepy q Unable to Arouse q Hemogram q CD4 q Hepatic Panel Thought Process: q Normal q Confused:______q RPR q TB q Renal Panel Can Follow Simple Commands: q No q Yes q HIV q Urinalysis q Malaria Hallucinations: q No q Yes:______Family History of Mental Illness: q No q Yes : Person q No q Yes Medical History: q HIV/AIDS (CD4:_____) q TB Place q No q Yes q HTN q Head Injury (with loss of consciousness) Time/Date q No q Yes q Epilepsy q Dementia q Other:______Friend/Family Member q No q Yes Alcohol Use: q No q Yes: q Daily? Current medications (names and doses):______Drug Use: q No q Yes:______Delirium q Disturbance of consciousness with reduced ability to focus, sustain or shift attention. q A change in cognition or the development of a perceptual disturbance (hallucinations) that is not better accounted for by a preexisting, established or evolving dementia. q The disturbance develops over a short period of time (usually hours to days) and fluctuates during the day q There is evidence from the history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition. q No q Yes (Patient must meet all four criteria above to make diagnosis)

3. MENTAL HEALTH History of mental illness: q No q Yes:______Has the patient gone to M&K/Beudet/other psych facility? q No q Yes:______Is this the first episode of agitation? q No q Yes:______History of suicide attempt: q No q Yes:______Post-Ictal Psychosis: q No q Yes (episodes of agitation/psychosis only take place after epileptic seizure) Antipsychotic Medication (Use Agitated Patient Protocol; give dose and indicate whether PO/IM): q Risperidone:______q Haloperidol:______q Other: Diphenhydramine:______

4. FOLLOWUP q Psychologist contacted about patient Presumed Etiology of Agitation/Psychosis: q Medical Problem/Delirium: ______q Mental Health Problem:______Has Haloperidol been given?: q No q Yes q Fluids ordered/given q EKG ordered/done Notes: ______

Partners In Health | Participant Handbook | Annex 67 1 mg must mg total daily mg twice daily mg (for mental illness) For treatment of all mental For treatment illness (excluding epilepsy) Women of child-bearing Women age/pregnant women L iver disease Caution if child E A L PROAT • • • • V 1000 Doses above 1000 with the mental be reviewed health team. 250 – 500 4th choice: Mood stabilizer Do not prescribe without consulting mental health team Use for: M ania without psychosis (longstanding aggression or violence in males) 200 – 250 valproic *Patients receiving a zidovudine acid may require to maintain dosage reduction unchanged serum zidovudine concentrations mg must mg (for mental illness) mg total daily mg twice daily For treatment of all mental For treatment illness (excluding epilepsy) or breastfeeding Pregnant women Blood disorder Epilepsy: A bsence seizures Caution if child • • • • • CAR B A M AZ E PIN 800 Doses above 800 with the mental be reviewed health team. 200 3rd Choice: Mood stabilizer Do not prescribe without consulting mental health team Use for: M ania without psychosis 200 mg daily Patient is delirious Pregnant/breastfeeding women (18 or younger) Children Elderly (65 or older) • • • • M DIAZ E PA Use for: Alcohol withdrawal, acute agitation with or without anti-psychotic 10 mg Doses above 10 with the must be reviewed mental health team. gitated Patient Protocol S ee A gitated Patient Protocol use. for guidelines regarding gitated Patient Protocol S ee A gitated Patient Protocol use. for guidelines regarding 7 days) mg – mg 6 weeks to – mg at night mg 2.5 iolent Patients: – mg daily must be mg increments. Prior history of on antipsychotic medication (18 or younger) Children For psychosis due to dementia risk of death) (increased women Pregnant Bipolar/Psychosis M oderate sxs: 0.5 – 2.5 S evere sxs: 2.5 – 5 lways prescribe A lways prescribe diphenhydramine 25 – 50 daily with haloperidol Delirium: 0.5 (Consider low-dose of risperidone first) Aggressive/ V S ee Agitated Patient Protocol • • • • • • • • HA L OP E RIDO 2nd Choice: “Typical” 2nd Choice: “Typical” Antipsychotic/Mood stabilizer Use for: Aggressive or violent psychosis (with or without mania) at night due to effects Take 4 A ntipsychotics require safety are I f there full effect. reach concerns, physicians can increase quickly (every 3 doses more by 2.5 10 mg Doses above 10 with the mental health team. reviewed 7 days) – 1 mg 6 weeks to – mg increments. mg daily must be mg increments. Delirium: mg increments. Caution if child/adolescent For psychosis due to dementia risk of death) (increased 18 or younger Children women Pregnant Bipolar/Psychosis – 0.5 – Delirium – 0.25 – 0.5 mg • • • • • • RI S P E RIDON 1st Choice: “Atypical” Antipsychotic/Mood stabilizer Use for: Psychosis (with or without mania) at night due to sedative effects Take 4 A ntipsychotics require safety are I f there full effect. reach concerns, physicians can increase quickly (every 3 doses more 2 mg Doses above 2 the mental health team. with reviewed by 0.5 by 0.25 increase T TH DO NOT U SE IF M U S T CON L L H E A ME NTA T E A M S tarting Dose (Adult) “ S tep” of uptitration M aximum Dose , Del iriu m, and Psy cho s i C ard for A gitation M e dication

68 Partners In Health | pARTICIPANT HANDBOOK | Annex 2 mg folic s, CBC E A L PROAT V R educe by steps above every 2 – 4 weeks. f already on, Do not initiate. I f already taking 4 make sure acid QD. Weight gain, L F T Weight valproic HI V patients receiving a zidovudine acid may require to maintain dosage reductin unchanged serum zidovudine concentrations. mg QD s, CBC, S odium CAR B A M AZ E PIN R educe by steps above every 2 – 4 weeks. Do not prescribe (for mental Do not prescribe or illness) to pregnant patients without breastfeeding consulting the mental health team; give folic acid 4 pregnancy. through L F T Rash, liver failure, decreased white blood count (Carbamazepine can cause hyponatremia ) can cause serious birth defects in pregnancy) (Valproate double vision Fatigue, , nausea/vomiting, incoordination, efficacy of oral contraceptives; (Carbamazepine decreases causes ) Valproate Only used for the management of agitated/violent patients and alcohol withdrawal. I t should not be than continued for more several days. M onitor for signs of sedation M onitor for dependence dose (need for increased to achieve same effect) S edation Dependence (should not be given for long periods of time) • • • • • • M DIAZ E PA Contraindicated Risk of S eizure if diazepam withdrawn without taper use at higher after regular dose mg mg QD mg daily) 6 months. – Consult with the mental health team before tapering medication. S ome patients may need to continue haloperidol indefinitely. I f the patient has other significant consider decreasing side effects, the dose slowly (by 2.5 and monitoring increments) Can also consider closely. changing to risperidone. Baseline: AIMS , weight, fasting glucose, hemogram, hepatic panel (if available) Every visit: weight, vital signs Every 6 months: AIMS , fasting glucose, hepatic panel, hemogram S edation H eavy tongue S tiffness A rrhythmia (for patients receiving than 10 more • • • • • • • • • HA L OP E RIDO Do not prescribe to pregnant or to pregnant Do not prescribe patients without breastfeeding consulting with the mental health team; give folic acid 4 pregnancy. through mg 0.5 – mg QD increments) and monitoring closely. and monitoring closely. increments) Can also consider changing to haloperidol. Consult with the mental health team before tapering medication. S ome patients may need to continue risperidone indefinitely. I f the patient has other significant consider decreasing side effects, the dose slowly (by 0.25 For delirium, stop the medication after medical illness is treated. psychosis due to mental illness: if the patient is showing For chronic do not stop the in symptoms and has no major side effects, improvement medication. For acute psychosis due to mental illness: consider slowly tapering the for 3 medication after patient is symptom-free Baseline: AIMS , weight, fasting glucose, hemogram, hepatic panel (if available) Every visit: weight, vital signs Every 6 months: AIMS , fasting glucose, hepatic panel, hemogram S edation G ain Weight L actation A menorrhea (for boys) • • • • • • • • • • • • • RI S P E RIDON through pregnancy. through Do not prescribe to pregnant or to pregnant Do not prescribe patients without breastfeeding consulting with the mental health team; give folic acid 4 Dystonia (especially of pharynx, eyes, neck—temporary but potentially fatal), Diabetes, Cardiac Dyskinesia (permanent), Akathisia (restlessness), Tardive arrhythmia leading to torsades des pointes erious S Common Toxicities * I f rash, stop medication to and return hospital M onitoring Tapering/ Discontinuing is a life- I f there side threatening/toxic stop immediately. effect, B reastfeeding M edication Card for Agitation, Delirium, and Psychosis (continued)

Partners In Health | Participant Handbook | Annex 69 3

Discontinue offending medication. Discontinue offending M edical evaluation and support (consider I V fluids) H ospitalize Consider dopamine agonists or outcome. to improve dantrolene Ne uro le ptic Ma l ignant S y ndro me (N MS ) 1. 2. 3. 4. Confusion, delirium, stiffness (like a Confusion, delirium, stiffness lead pipe), sweating, hyperpyrexia, drooling, autonomic instability, elevated WBC, CPK, death EMERGENCY mg/d) 1000 – 1600 IU /d) – ardi ve Dysk in es ia T + Vitamin E (1200 + Vitamin nvoluntary orofacial movements (may I nvoluntary orofacial be permanent) or lower dose Discontinue neuroleptic C (500 Consider Vitamin 20 mg TI D – s ia Ak athi rrhythmia, bronchospasm, S tevens- A rrhythmia, bronchospasm, Johnson syndrome Fatigue, dizziness, nausea, depression, Fatigue, dizziness, nausea, depression, insomnia Psychomotor restlessness 10 Propranolol the dose of Can also decrease medication 75 mg IM or – ES P ( E x trap y ra m ida l sym to ms) A cut e Dys tonia A naphylaxis, , arrhythmia Drowsiness, dizziness, headache, dry Drowsiness, constipation, mouth, tachycardia, vision blurred M uscle rigidity (potentially including: neck, tongue, back) eye muscles, throat, EMERGENCY Diphenhydramine 50 PO daily S everal liters of I V or PO fluids daily erious S Common M anifestation Treatment Toxicities Sid e Eff ct s me nt for A ntip sy chotic M e dication T r e at

70 Partners In Health | pARTICIPANT HANDBOOK | Annex 1

y Confusion A lertness Orientation H istory of mental illness Current medications Current A lcohol/substance abuse M edical H istory – – – – – – – – – – – – – – Vital signs, physical exam Vital Exam N eurological M ental S tatus Exam Brief H istory Disturbance of consciousness; reduced ability to focus, sustain or shift attention. A change in cognition or the development disturbance (hallucinations) of a perceptual established that is not due to a preexisting, or evolving dementia. T he disturbance develops over a short period of time (usually hours to days) and fluctuates during the day physical the history, is evidence from T here examination or laboratory findings that the disturbance is caused by direct physiological consequences of a general medical condition. • • • • 1. 2. 3. 4. B ox 1: S tandard M edical E valuation for Agitation/Delirium/Psychosis B ox 2: Delirium TH E N Refer to Agitated Patient Protocol guide agitation management depending on symptoms and severity U se calm voice G ive verbal support stimuli Decrease A sk, “ H ow can I help?” A lert staff Keep yourself safe U se W H O mh GA P (p.74) for S elf- arm/ uicide A ssessment if necessary • • • • • • • • S T E P 1b: Determine L evel of Agitation and M anage Continue evaluation and treatment of underlying Continue evaluation and treatment medical condition. Consider low-dose antipsychotic for delirium (see medication card) Consult mental health team/psychologist • • • YES YES NO NO ( S ee B ox 2) , Del iriu m and Psy cho s i u mm ar P rotoco ls for A gitation a l uation S afety: talk first, do not medicate first M edical Health: take vital signs, physical exam, mental status exam to assess for delirium M ental Health: take history Follow-Up: contact psychologist • • • • A bnormal mental status exam or meets criteria for delirium S ee Page 2 for continuation of M edical Assessment S T E P 2: Perform M edical Assessment ( S ee B ox 1, R E F to and CORD information on Agitated Patient Form, including): Violent, aggressive Violent, threatening Yelling, M anic, delusional (has untrue, fixed beliefs) H allucinating A cutely paranoid of hands, pacing, tapping hand Wringing R apid speech, raising voice low frustration tolerance requests, Frequent • • • • • • • • S T E P 1a: Is Person Agitated? Patient is considered agitated if they are any of the following: M e dica l E v l S etti ng protoco l i n a Cl ic /H ospita

Partners In Health | Participant Handbook | Annex 71 2 Within a few hours: withdrawal Within nausea, vomiting, sweating, , anxiety Within a few days: hallucinations, Within disorientation, fever, seizures, hypertension 28 hours prior to symptoms) – – – – – ertiary M alaria abnormalities (sodium, calcium) Electrolyte M alnutrition, thiamine deficiency disease T hyroid A lcohol withdrawal H ypoxia T Encephilitis A lzheimers) Dementia ( HI V, Parkinsons Brain tumors or other mass lesions ( T B, lymphoma, toxoplasmosis) H istory of heavy alcohol use (last drink 24 alcohol withdrawal: S evere Corticosteriods Cycloserine I soniazid, Efavirenz Corticosteroids Phenobarbital medication H igh doses of anti-cholinergic • • • • • • • • • • • • • • • • • • • B ox 4: Common S ystemic Conditions that can Cause/Contribute to Psychosis B ox 3: Neurological Conditions that Cause or Contribute to Psychosis B ox 5: Alcohol Withdrawal B ox 6: M edications that can Cause/Contribute to Psychosis NO ( S ee B ox 6) YES YES Perform M ental Health Assessment and Consult M ental Health Team Consider a primary psychotic disorder Determine whether history of psychosis and medication use coincide. Consider discontinuing medication. On medication causing psychosis? I V/ IM mg ( S ee B ox 3) , EE G or L P reat accordingly reat 10 with withdrawal alcohol reat diazepam, repeat after 15 mins as needed diazepam, repeat in 6 hours. then repeat until response, rate to avoid overdose M onitor respiratory Further neurological testing Further neurological Consider C T Consult with specialist M alaria smear and consider empiric for malaria treatment and consider empiric R x L umbar puncture antibiotic medication with appropriate as above L P, Consider empiric R x with appropriate antibiotic medication panel, liver Consider additional tests: renal panel, chest x-ray T T reat for neurosyphilis with penicillin for neurosyphilis reat • • • • • • • • • • • Consider CT before L P if asymmetric pupils or abnormal extra-ocular movement or gait. Consider treatment for toxoplamosis or crytococcus. T YES YES YES YES YES YES TH E N TH E N 200 ( S ee B ox 4) 38 C ( S ee B ox 5) NO NO NO NO NO NO Continuation of M edical Assessment exam A bnormal neurologic R ecent onset and > temperature HI V+ with CD4 count < Positive R P A bnl glucose, electrolytes, or other evidence of medical illness R isk factors for drug or alcohol withdrawal or intoxication? M edical E valuation Protocols for Agitation, Delirium and Psychosis S ummary (continued)

72 Partners In Health | pARTICIPANT HANDBOOK | Annex ZANMI LASANTE — MENTAL HEALTH SUICIDALITY SCREENING INSTRUMENT

LEVEL REACHED IN THE PAST TWO WEEKS? IN THE PAST YEAR?

1. Passive No Yes No Yes Ask: Do you have any thoughts of ending your life, Description: even if they are not clear in your mind? Possible Response: I think about it from time to time, but I’ve never acted upon it...I would make my family feel too bad...God would not forgive me

2. Non-Specific Active No Yes No Yes Ask: Do you want to die? Do you often think or talk Description: about death? Possible Response: desire/wish to be dead…prefer to be dead…think frequently/talk about death…God would rather have me

3. Methods but no Intent to Act No Yes No Yes Ask: If you would do it, how would you do it? Description: Possible Response: bleach, pesticide, herbicide, battery acid, hang themselves, medication overdose, stop taking medication, a knife, a gun

4. Intent to Act No Yes No Yes Ask: Do you intend to act on these thoughts? Description: Possible Response: I will kill myself but I do not know when… I do not think I can do so now…but it’s too much for me, I cannot yet

5. Planification No Yes No Yes Ask: Have you started planning the details about how you Description: will kill yourself? Danger Signs: there is a sudden change in attitude, withdraws from everything; not interested in anything; say: “when I am not here anymore”; seeks to implement the plan, write a note (on paper).

6. Attempted No Yes No Yes Ask: Have you tried to do something that could hasten Description: the end of your life? Have you stopped preserving your life, like not eating and not taking medication? Danger Signs: Realized did not want to die after the attempt failed, but it often gets worse again after a few days; might have some injuries or marks.

Low: Current = 0 Past = 0 Total “yes” in past Total “yes” in past year two weeks Medium: Current = 1–2 yes OR Past = 1 or more yes

High: Current = 3 or more yes OR Past = 3 or more yes

Partners In Health | Participant Handbook | Annex 73 ZANMI LASANTE — MENTAL HEALTH SUICIDALITY TREATMENT GUIDELINES

Provider: Location: Date: / / Last Name: ______First Name: Nickname: File #:

For ALL Patients

Act 1. _ Ensure that the environment will be private, safe and non-threatening.

2. _Begin the process of ensuring that the patient will be able to access necessary medication.

3. _Always work with the patient to develop a Safety Plan.

Say 4. _Use the patient’s name often, give hope, insist that there are other options, and declare your intent to help.

5. _Start IPT and collect IP inventory.

6. _Provide psychoeducation about depression, suicidality, psychopharmacology, therapy and ZL resources.

7. _Identify specific current supports and potentially welcome supports (e.g. neighbors, clergy). (Write this on the copy of your Safety Plan, on the back side).

Contact 8. _Always contact at least one person close to the patient to support and monitor them.

9. Contact as many of the current and potential supports as a patient will permit

• _You should utilize the clergy early and heavily for supporting, home visiting, and monitoring patients

• When involving anyone, ensure that you preserve confidentiality if possible and define these: 1. Depression, suicidality

2. The needs of such patients

3. How others can help

4. How others can hurt

Team 10. Consult and involve colleagues to help. Social Worker Psychologist Community Health Worker Doctor

Follow 11. If the patient has a higher risk level, continue to the guidelines below. Up

1

74 Partners In Health | pARTICIPANT HANDBOOK | Annex ZANMI LASANTE — MENTAL HEALTH SUICIDALITY TREATMENT GUIDELINES

For patients with MEDIUM risk, include these additional aspects in your care. Act 1. _ Maintain a high index of suspicion for understatement and concealed ideation. Be sure of your assessment.

Say 2. _ Ascertain what caused the ideation to increase in seriousness and specificity and/or what caused it to occur.

3. _ Seek agreement or at least acceptance that individuals in that patient’s milieu may need to be notified explicitly.

Contact 4. _ Close family should be informed quickly and explicitly of the patient’s suicidality.

Team 5. _ At least one social worker and psychologist should cooperate closely on all cases with greater than low risk.

Follow 6. _ If the patient is medium risk, schedule follow-up within 7 days. Date Time Up If the patient is high risk, continue to the guidelines below.

For patients with HIGH risk, include these additional aspects in your care. Act 1. _ Ensure safety and calm. Remove potential weapons. Obtain help and apply physical/chemical restraint if necessary.

2. Seek to admit patient to the emergency room or another service with beds for at least 24 hours.

3. Determine who will be available to watch the patient and when so that they are not left unattended.

Name Time Name Time

Name Time Name Time

Name Time Name Time

Say 4. Despite the potential necessity of negating the patient’s autonomy, do as much as possible to preserve dignity.

Contact 5. Any and all accessible individuals from the patient’s milieu (you are justified in breaching confidentiality here).

6. Any and all potentially influential individuals (neighborhood elder, clergy, Freemason).

Team 7. MD: Make sure no attempt has been made occultly, and rule out remediable organic processes (especially pain).

8. Any available clinical staff can be called upon to help in monitoring - if necessary, other patients can be as well.

Follow 9. Keep the patient admitted and under continuous monitoring (e.g. 4x/hr). Up 10. Frequently re-assess risk level.

11. If the patient leaves or can’t be kept, follow through with continued intensive psychosocial activation.

2

Partners In Health | Participant Handbook | Annex 75 ZANMI LASANTE — MENTAL HEALTH SAFETY PLAN STEP 1 Warning signs that a crisis is developing (such as thoughts, images, moods, situations, behavior): 1. 2.

3. 4.

5. 6.

STEP 2 Internal coping strategies – activities that I can do without others to distract myself from my problems, such as relaxation techniques: 1. 2.

3. 4.

5. 6.

STEP 3 People and social environments that offer distractions and support: Name Telephone

Name Telephone

Name Telephone

Where Where

Step 4 People and social environments that offer distractions and support: Name Telephone ______

Name Telephone ______

Name Telephone ______

STEP 5 Professionals and agencies I can contact during a crisis: Community Health Worker Telephone ______

Ajan Sante Telephone ______Social Worker Telephone ______Psychologist Telephone ______Doctor Telephone ______Spiritual Healer Telephone ______Emergency Room/Hospital Telephone ______

STEP 6 making the environment safe:

I, , will follow the steps when I’m in a crisis, and one thing more important to me than anything else that will help me live is…

76 Partners In Health | pARTICIPANT HANDBOOK | Annex Clinical Global Impressions ScalE

Date:

Name: Psychologist / SW:

Patient ID: Age:

Male/ Female (circle one) Phone #1:

Town: Phone #2:

District: Session#:

Date recieved patient info:

I. Severity of Illness Considering your total clinical experience with this particular population, how mentally ill has the patient been over the past 7 days? Tip: Compare relative to your past experience with patients who have the same diagnosis considering your total clinical experience with this population.

0 = Not assessed 1 = Normal, not at all ill. Symptoms of disorder have not been present in the past seven days. 2 = Borderline mentally ill. subtle or suspected symptoms within the past seven days. No definable impact on behavior or function. 3 = Mildly ill. Clearly established symptoms causing minimal, if any, distress or difficulty in social or occupational function. 4 = Moderately ill. Overt symptoms causing noticeable, but modest, functional impairment or distress. There is evidence of functional interference in multiple settings. Some symptoms may warrant medication. 5 = Markedly ill. intrusive symptoms that distinctly impair social or occupational function or cause intrusive levels of distress. Functional interference due to symptoms is obvious to others. 6 = Severely ill. Disruptive pathology; behavior and function are frequently influenced by symptoms. Dysfunction may require assistance from others. 7 = Among the most extremely ill patients. Pathology drastically interferes in many life functions. Patient may need to be hospitalized.

Rating (Number 0–7)

1

Partners In Health | Participant Handbook | Annex 77 Clinical Global Impressions Scale Continued...

II. Improvement Compared to the patient’s baseline condition before treatment, how much has the patient changed? Tips: For initial evaluation: if the patient has been in treatment previously, rate CGI Improvement based on the history and compared to the patient’s condition prior to treatment. Otherwise, leave blank. Progress Notes: Rate improvement by comparing the current condition to the patient’s condition at the initiation of the current treatment plan. Assess how much the patient’s illness has changed relative to a baseline state at the beginning of the treatment plan based on the first evaluation. Rate total improvement whether or not in your judgment it is due to treatment.

0 = Not assessed 1 = Very much improved. nearly all better; good level of functioning; minimal symptoms; represents a very substantial change. 2 = Much improved. notably better with significant reduction of symptoms; increase in the level of functioning but some symptoms remain. 3 = Minimally improved. Slightly better with little or no clinically meaningful reduction of symptoms. May represent very little change in basic clinical status, level of care, or functional capacity. 4 = No change. symptoms remain essentially unchanged. 5 = Minimally worse. slightly worse but may not be clinically meaningful; may represent very little change in basic clinical status or functional capacity. 6 = Much worse. Clinically significant increase in symptoms and diminished functioning. 7 = Very much worse. severe exacerbation of symptoms and loss of functioning.

Rating (Number 0–7)

III. Side Effects Select the terms that best describe the degree of side effects of medication treatment. 0 = None 1 = Do not significantly interfere with patient’s functioning. 2 = Significantly interfere with patient’s functioning. 3 = Outweighs therapeutic effects with patient’s functioning.

Rating (Number 0–3)

2

78 Partners In Health | pARTICIPANT HANDBOOK | Annex WHODAS-03(23Nov09).book Page 4 Tuesday, November 24, 2009 1:30 PM

WHODAS 2.0 12 WORLD HEALTH ORGANIZATION Interview DISABILITY ASSESSMENT SCHEDULE 2.0

Section 3 Preamble Say to respondent: The interview is about difficulties people have because of health conditions.

Hand flashcard #1 to respondent By health condition I mean diseases or illnesses, or other health problems that may be short or long lasting; injuries; mental or emotional problems; and problems with alcohol or drugs.

Remember to keep all of your health problems in mind as you answer the questions. When I ask you about difficulties in doing an activity think about...

Point to flashcard #1 • Increased effort • Discomfort or pain • Slowness • Changes in the way you do the activity. When answering, I’d like you to think back over the past 30 days. I would also like you to answer these questions thinking about how much difficulty you have had, on average, over the past 30 days, while doing the activity as you usually do it.

Hand flashcard #2 to respondent Use this scale when responding.

Read scale aloud: None, mild, moderate, severe, extreme or cannot do.

Ensure that the respondent can easily see flashcards #1 and #2 throughout the interview Please continue to next page...

Page 4 of 5 (12-item, interviewer-administered)

Partners In Health | Participant Handbook | Annex 79 WHODAS-03(23Nov09).book Page 5 Tuesday, November 24, 2009 1:30 PM

WHODAS 2.0 12 WORLD HEALTH ORGANIZATION Interview DISABILITY ASSESSMENT SCHEDULE 2.0

Section 4 Core questions Show flashcard #2

In the past 30 days, how much difficulty did you None Mild Moderate Severe Extreme or have in: cannot do

S1 Standing for long periods such as 30 12 3 4 5 minutes?

S2 Taking care of your household 12 3 4 5 responsibilities?

S3 Learning a new task, for example, 12 3 4 5 learning how to get to a new place?

S4 How much of a problem did you have 12 3 4 5 joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?

S5 How much have you been emotionally 12 3 4 5 affected by your health problems?

In the past 30 days, how much difficulty did you None Mild Moderate Severe Extreme or have in: cannot do

S6 Concentrating on doing something for 12 3 4 5 ten minutes?

S7 Walking a long distance such as a 12 3 4 5 kilometre [or equivalent]?

S8 Washing your whole body? 12 3 4 5

S9 Getting dressed? 1 2 3 4 5

S10 Dealing with people you do not know? 12 3 4 5

S11 Maintaining a friendship? 12 3 4 5

S12 Your day-to-day work/school? 12 3 4 5

H1 Overall, in the past 30 days, how many days were these difficulties present? Record number of days ____

H2 In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of Record number of days ____ any health condition?

H3 In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce Record number of days ____ your usual activities or work because of any health condition?

This concludes our interview. Thank you for participating.

Page 5 of 5 (12-item, interviewer-administered)

80 Partners In Health | pARTICIPANT HANDBOOK | Annex WHODAS-03(23Nov09).book Page 6 Tuesday, November 24, 2009 1:30 PM

WHODAS 2.0 Flashcard 1 WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0

Health conditions: • Diseases, illnesses or other health problems • Injuries • Mental or emotional problems • Problems with alcohol • Problems with drugs

Having difficulty with an activity means:

• Increased effort • Discomfort or pain • Slowness • Changes in the way you do the activity

Think about the past 30 days only.

Partners In Health | Participant Handbook | Annex 81 5 or do cannot Extreme Flashcard 2 4 Severe 3 Moderate 2 Mild 2.0

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82 Partners In Health | pARTICIPANT HANDBOOK | Annex

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