Primary care nurses are at a unique advantage when it comes to early detection and diagnosis of mental health issues.
With one in four GP appointments mental health-related1 and an exponential increase in depression being diagnosed and treated in primary care, there has never been a more crucial time for community nurses to be skilled and confident in addressing common and less common mental health problems in everyday practice.
Primary and community care nurses can be seen as at the forefront of achieving the government’s outcome ambition set out in the outcome strategy No Health without Mental Health2The guidance sets out priorities for services, care and treatment, including the importance of early detection and diagnosis of mental health problems that so often cause a far-reaching impact on individuals, families and communities as well as society at large.
It is estimated that mental health problems cost the economy over £105 billion in England alone.3 Estimates suggest that 90 per cent of mental health problems are dealt with in primary care, not needing any referral to specialist services, so having a good set of strategies to help patients is very important to primary and community care nurses. Priorities for secondary care mental health teams generally involve those with serious and enduring, or long-term and complex mental illnesses, such as psychotic disorders (including schizophrenia and bipolar disorder) or with those who have a history of complicated depression, and who have had ongoing care, often involving periods as an in-patient in mental health units. So the role for primary care will be in both identifying patients needing help and potentially providing some ongoing support within agreed protocols with adequate skills and back- up where time permits.
Introduction and context
With practice and community nursing maintaining a key role in providing versatile adaptive skills to patients in primary and community care settings, it is inevitable that many patients will need, at the very least, signposting to specialist forms of help and treatment for mental health problems. The growing numbers of people experiencing ‘life problems’ leading to depression, anxiety, stress and other types of reactive and adjustment difficulties requiring help will mean core skills in mental health need to be up-to-date, tuned and effective. Six per cent of the population is treated each year for depression alone, and over the course of a lifetime 15% of us will suffer an episode.4 One in four of us will need help for a mental health problem at some point in our lives, and this ignores the growing number of people suffering from dementia in later life – all too common now that people are living longer thanks to improved treatment for long-term conditions. The Dementia Strategy5 published in 2009 tells us that one in five of the over 80s will have some level of cognitive impairment and one in twenty of the over 65s. This creates a challenging problem in communities in how to provide safe care packages for patients, with primary and community nurses often central to the care and monitoring being offered.
Amongst the younger adult age range, depression and anxiety are becoming ever more prevalent. Recent data shows increases of over 40% in the last four years in prescriptions for anti-depressants.6 This will inevitably mean mainstream practice and community nurses will face many patients who show signs and symptoms of depression and need treatment and possibly referral to specialist support and counselling such as cognitive behavioural therapy (CBT). Improving Access to Psychological Therapy (IAPT)investment has seen a large rise in primary care of counselling support to patients.7 This new programme is offering much-needed early intervention to people needing help.
The range of common mental health presentations is growing and the list below is by no means exhaustive but does give a selection of types of difficulties witnessed during the day-to-day work in local communities:
· Stress reaction and adjustment.
· Crisis in relationships.
· Lifestyle difficulties – such as alcohol misuse, smoking cessation and impact on health, domestic violence, etc.
· Personal impact issues e.g. unemployment, upset following bereavement.
· Deliberate self-harm.
· Suicidal ideation.
· Child and adolescent mental health problems.
· Family conflict.
· Sleep disorder.
· Phobia problems.
· Obsessional compulsive disorder.
Any or all of these difficulties can and do cause great distress, and can in many ways create a self-perpetuating cycle leading to worsening situations for people if early recognition and help is not provided.
Whilst a broad understanding of many mental health problems and psychiatric illness is addressed during basic training within the common foundation programme for nurses, it is also reasonable to suppose that few RGN and mainstream community nurses feel very confident and skilled in managing those with these kinds of problems. Textbooks, including those addressing diagnostic guidance and skills to help people in need, may often not provide enough ‘hands-on’ or ‘toolkit’-type direction required for a ‘jobbing’ community nurse. An awareness of the essential skills is important and can be broken down as follows:
1. Assessment skills.
2. Responding skills.
3. Exploring skills.
4. Management strategy option awareness- including referral guidelines and seeking back up and support when dealing with those with mental health problems.
Some nurses may feel they are sufficiently able, motivated and supported, and have the time to offer some ongoing therapeutic intervention which - with the consent and support of the primary care team - can offer a very valuable adjunct to enabling the recipient to deal with their issues and needs.
Underpinning this decision to take a role in ongoing care and treatment must include a programme of supervision and an agreed outcome- orientated aim to ensure any support is evidence-based and solution-focused. Solution-focused therapy, for example, may agree a particular target or problem to overcome where a finite number of sessions are agreed. In most cases, the local practice may use a formalised series of CBT or counselling sessions to assess and support action provided by a trained practitioner. It is worth knowing what local options are available for this type of support within each area.
Familiarising oneself with a good knowledge base at the same time as having an open mind to the source and cause of a patient’s problems should also be recommended. The view is that knowledge, skills and attitudes (such as those associated with the humanistic model of care pioneered by Carl Rogers,8founder of non-directive client-centred counselling) including being empathic, non-judgmental and having positive regard in offering good boundaries and help, will enable confident support to be offered.
Current training access
All too often it is reported that access to extended role training and specific skills-based workshops and learning events in mental health is limited, particularly where costs to organisations or individual are to be incurred. Talking to colleagues, including management and clinical team members, will assist in forming a plan to address needs in supporting care to patients.
Many nurses already have an identified special interest in a particular patient group, and this is often encouraged, provided it does not detract from the mainstream caseload work for the practice of community nurse.
Links with LTCs
The diagnosis of any form of illness, and particularly a long-term condition which many patients will regard as therefore life limiting, will invariably cause a good deal of anxiety and worry in those affected. The impact can be huge and it is not uncommon for patients and families to ‘catastrophise’ and negatively predict the future with their respective diagnosis, whether one of the commoner conditions like diabetes, COPD, or hypertension, or another less common long-term problem. Other common progressive or degenerative irreversible physical health problems will equally cause adjustment challenges, especially in the elderly where long-term conditions are most commonly seen. The link between mental health symptoms and physical health problems has been long acknowledged and suggests a level of awareness is necessary for all practitioners.9
Common mental health problems seen in primary and community care – what to do and how to help?
Using the Department of Health Map of Medicine tool,10linked to local management models and approaches, can make a real difference to the confidence of nurses in handling the less complex cases. Knowing how to seek help and avoid feeling isolated and over-burdened is also important. The emotional impact of dealing with patients’ sometimes tragic or difficult circumstances can take its toll on care staff on the front line of service provision. The key message will be to not work in isolation, putting your own mental health at risk, and to always share concerns and seek back-up when you feel you need it, including referring on with consent of the patient and GP.
It is worth developing some rehearsed responses when mental health distress is reported by patients, such as reassuring with (for example):
· ‘Mental health problems are very common and generally short
-lasting/time-limited with the right help and action.’
· ‘You are experiencing a normal reaction to abnormal and difficult circumstances.’
· ‘There are lots of options for help and treatment, not just medication where required.’
· ‘For some people medication can provide help to aid rest and recharge their batteries.’
· ‘Many people see mental health symptoms as a wake-up call/early warning system/message to yourself to change something in your life.’
· ‘Energy levels are often at the heart of a period of emotional distress - looking after yourself differently can be at the key to getting better.’
· ‘Being tough on yourself and neglecting your needs sometimes creates pressure and stress and can lead to nervous exhaustion.’
There are a number of tools and templates to aid the development of a practical assessment approach (see additional reading) however it can be claimed that when considering risk and need, some core questions can prove especially important. (See Box 1).
The policy context of the government is to rightly say there is ‘No Health without Mental Health,’ meaning we are all subject to the trials and tribulations of modern life with stresses and strains that will test our resilience and skills in coping. Whether we are fundamentally emotionally or psychologically strong, or otherwise, we will each be on some kind of mental health self-management spectrum,and this spectrum will fluctuate depending on our life circumstances and how we deal with change and adjustment demands.
There may be an argument to develop a means for practice and community nurses to share tools and techniques in being effective and efficient, not just in helping others but in preserving and protecting one’s own ‘fit for purpose’ status, in a climate where the NHS is again undergoing great restructuring, affecting us all.
Whilst mental health lead at Avon Health Authority in Bristol some years ago I was responsible for setting up a primary care nurse mental health special interest group, that amongst other things, developed guidelines for best practice in managing many mental health care issues. These included blood testing for mental health patients needing medication level monitoring, administration of depot medications for some patients and addressing the need for an anxiety and depression skill framework for practice nurses. This group thrived and used the principle of ‘show and tell’ that many of us may be familiar with from our children when getting positive support and feedback from friends at school. Perhaps a virtual network using the Nursing in Practicechat room available on the Nursing in Practice website might serve a similar purpose in offering a facility to ‘show and tell’ regarding mental health care. I have more recently presented at many of the Nursing in Practice national conference programme events and invariably have been approached afterwards and even emailed about issues from post-natal depression to deliberate self-harm, and from eating disorders to post-traumatic stress disorder, as well as many requests for signposting advice for dealing with individual patients. I would be interested in hearing from anyone who would like to set up a pan-community nurse network to develop this idea further – this could be the start of something not only great but crucial in terms of a manageable CPD domain and a useful resource for skill development and practice. Let me know. I would be very willing to offer ideas and assist in supporting local networking.
Conclusion and what next?
An action plan for further reflections can include the following:
o Take some time to reflect on where you are on the continuum of skills and competence.
o Respond to the idea of a virtual mental health ‘show and tell’ network via the author.
o Rehearse some key questions to use when assessing mental health need in patients who present and are a cause for concern – it can be argued that all patients should receive some level of routine screening during consultation as the stigma and embarrassment often leads to an unwillingness to disclose distress.
o Make sure you have a useful link to the local specialist mental health team, e.g. the Community Mental Health Team or local CPN – invite them to meet the practice staff and consider a treatment algorithm related to local referral criteria and particular configuration of services available to your locality or practice.
o Develop a local user network directory for potential advice for patients including Age Concern, Samaritans and any local third sector resources that offer support to people with mental health problems.
o Familiarise yourself with the local provision for CBT or primary care psychological support – there has been a lot of investment in providing time-limited support in primary care to people with mental health problems which can make a real difference to people’s lives.
o Retain an interest and add mental health skill acquisition to your personal development or CPD plan.
o Make sure you are equipped to look after yourself and team/colleagues, as well as have the basic toolkit to respond to the growing need for support amongst the wider population of people receiving healthcare in the community.
1. Department of Health. Healthy Lives, Healthy People: Our Strategy for Public Health in England. 2010. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_121941
2. Department of Health. No Health without Mental Health, cross government mental health outcomes strategy for all people. 2010. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123766
3. McCrone P, Danisisiri S, Patel A, et al. Paying the price: the cost of mental health care in England. 2008; London: Kings Fund.
4. Clinical Knowledge Summaries (CKS). Clinical Topics: Depression. Revised Feb 2011. Available at:www.cks.nhs.uk.depression
5. Department of Health. Living Well with Dementia: a National Strategy Implementation Plan. 2009. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_103137
6. National Prescribing Centre. Data Focused Commentary: Depression. 2010. Available at: www.npc.nhs.uk/therapeutics/cns/depression/data.php
7. National Information Centre (NHS). Initial guidelines on IAPT provision. 2007.
8. Rogers, C. Client-centered Therapy: Its Current Practice, Implications and Theory. 1951; London: Constable.
9. Coxon G. Assessing patients for depression. Nursing in Practice 2011;60:83-86.
10. Stein M, Epstein O. Map of Medicine. Available at: www.mapofmedicine.com/global/pdf/qrg/Managing_local_admin_info_MoM_QRG.pdf
No Health without Mental Health – a guide for General Practice www.centreformentalhealth.org.uk/pdfs/Web_Mental%20Health%20Strategic%20Partnership%20GPs.pdf
Beck Depression Inventory BDI- I and II:
Beck AT. Depression: Causes and Treatment. 2006; Philadelphia: University of Pennsylvania Press.
Beck Anxiety Inventory:
Brief Psychiatric Assessment Scale (BPRS):
Overall JE, Gorham DR. The brief psychiatric rating scale. Psychological Reports 1962;10:799-812.
George Coxon, RMN, is the specialist mental health advisory board member for Nursing in Practice, MHNA chair and regional lead for Wales, Director of CCH (care provider), the Independent Commissioning Advisor for Devon, and chair of the Devon Residential Care Quality Kit Mark.
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