First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care

The content of this chapter was revised in October 2011

Mental health is a broad topic addressed in several First Nations and Inuit Health publications. This chapter contains the clinical assessment and management of mental health concerns. The values and the philosophy integral to mental health care, including community programs and cultural consideration for First Nations and Inuit communities, are not addressed in this chapter. However, the approach to mental health care can be found in regional community health manuals, the National Orientation Manual and other First Nations lead organizations and associations.

Introduction

Mental Health

"A state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community."Footnote 1 It is a balance between the mental, emotional, physical and spiritual healthFootnote 2 of an individual and positive community functioning.

There is some agreement in the literature that mental health is evident in the following personal characteristics:Footnote 3

Self-awareness and accurate self-perception

Self-actualization (realizing one's full potential)

Autonomy (independence in thought and action)

Accurate perception of reality

Commitment

Possession of "mastery" skills (social and occupational ability to deal with the environment and adversity/stress)

Openness and flexibility

Long and satisfying interpersonal relationships

Able to express and cope with emotions

Self-esteem

The disparity between Aboriginal mental health and that of the rest of Canadians is of concern.Footnote 4,Footnote 5,Footnote 6

Mental Illness

"A serious disturbance in thoughts, feelings and perceptions that is severe enough to affect day-to-day functioning."Footnote 7 A person with a mental illness may display some or all of the following behavioural characteristics:

Social maladjustment

Impaired reasoning or intellectual functioning

Disorders of thinking, memory or orientation

Delusions or disorders of perception

Exaggerated, inappropriate or otherwise impaired emotional responses

Impaired judgment or impulse control

Unrealistic self-appraisal

In addition to the effects on the individual client, mental illness often affects the family.

Unlike the diagnosis of most physical disorders, diagnosis of a mental illness does not usually mean a specific cause can be identified.

Mental Wellness

"A lifelong journey to achieve wellness and balance of body, mind and spirit. Mental wellness includes self-esteem, personal dignity, cultural identity and connectedness in the presence of a harmonious physical, emotional, mental and spiritual wellness. Mental wellness must be defined in terms of the values and beliefs of Inuit and First Nations people."Footnote 8

Mental Illness Risk and Protective Factors Footnote 9, Footnote 10

Many social, environmental and economic factors can impact an individual's mental health. An increased likelihood of, more severe, and/or longer length of mental illness are associated with the following risk factors:

Social isolation (for example, lonely, caring for one with a chronic illness)

Lack of education, transportation, housing

Peer rejection (for example, social difficulties, communication problems, emotionally immature)

Poor social support (for example, family discord or disorganization)

Substance abuse or excessive use (personal, parental or perinatal)

Displacement

Racial injustice and discrimination

Social disadvantage

Exposure to violence, trauma and/or aggression

Socially or legally unacceptable behaviour (for example, abuse of any form, neglect, domestic violence towards mother, criminal behaviour)

Stress related to employment or life events (for example, personal loss, early pregnancy)

Unemployment and/or poor work skills and habits

Family history of mental illness

Medical illness (for example, chronic pain or insomnia) and/or chronic disease

The following are protective factors for mental illness (for example, factors that decrease the risk of adverse outcomes if mental illness occurs, factors that counteract mental illness risk factors, factors that decrease the risk of developing mental illness) if they predate it:

Ability to deal with stress and face adversity

Adaptable

Autonomous

Positive parent-child relationships

Good parenting, attachment and bonding

Social involvement

Social and emotional growth

Social and conflict resolution skills

Life skills, including problem-solving skills

Self-esteem

Social support of family and friends

Good school performance

Literate

Physical exercise

Cognitive stimulation early in life

Feeling secure

Feeling that have mastery and control

For the Aboriginal population in particular: knowing how to live on the land, being connected to culture and traditional activities, being involved in the community and aware of the history of Aboriginal peoples in Canada are protective factors.Footnote 11

Mental Health Assessment: Clinical Assessment and Management Footnote 12, Footnote 13

The purpose of mental health assessment is to provide specific information about a client's behaviour, thoughts and feelings and the relation of these factors to the client's background, experiences and present circumstances. It provides the database for describing, diagnosing and eventually treating concerns. The information may be gathered from direct interviews with the client or from material provided by relatives, friends, or referring agencies. The assessment should provide enough data to rule out a psychiatric emergency such as suicidality, homicidality, psychosis, drug intoxication or withdrawal.

Good communication skills are essential to provide mental health care. This includes ensuring that the privacy and confidentiality of a client is respected during client care while maintaining personal safety during all client encounters. For more information on communication, see "Communication" in the chapter, "Introduction to the Clinical Practice Guidelines."

One communication technique, the BATHE Model, helps develop a positive relationship with clients while also quickly screening for some mental health concerns. It can be used to elicit the chief concern and/or start an interview. It involves:Footnote 14

B ackground (for example, ask about what is happening in the client's life currently and/or any recent changes that have occurred to determine the context for the visit)

ackground (for example, ask about what is happening in the client's life currently and/or any recent changes that have occurred to determine the context for the visit) A ffect (for example, ask about their emotional response [feelings, mood] to the situation)

ffect (for example, ask about their emotional response [feelings, mood] to the situation) T rouble (for example, ask about what concerns or worries the client the most about the situation)

rouble (for example, ask about what concerns or worries the client the most about the situation) H andling (for example, ask about the resources and coping mechanisms the client is using to handle the situation)

andling (for example, ask about the resources and coping mechanisms the client is using to handle the situation) Empathy (for example, let the client know that their response is reasonable given the situation)

History

Client Profile

General description of the client:

Age, date of birth

Sex

Ethnic origin

Relationship status

Number and age of siblings or children

Spouse or parents

Living arrangements

Employment status and occupation

Education

If a client has difficulty stating this information, perform a more detailed cognitive screening (for example, Mini Mental Status Exam).

History of Presenting Problem

The following characteristics of each sign or symptom below, if present, should be elicited and explored:

Onset

Frequency

Progression

Potential precipitating factors (for example, stress, substance use)

Chief concern:

Use an open-ended question to find out what the client considers the chief concern and allow them time to disclose their perception of the problem.

Relationships (for example, not feeling safe, abuse)

Usual level of functioning (for example, energy, speed of thoughts, activities participating in)

Behaviour (for example, energy level, speech)

Sleep

Perceptions (for example, heard or saw people or things when alone or nothing is there; feels persecuted by others)

Cognitive abilities (concentration, memory); if a client describes difficulty with memory, perform a more detailed cognitive screening (for example, Mini Mental Status Exam)

Interest and pleasure in doing things

Increase in feelings of:

Depression, hopelessness

Mania (euphoria or irritability)

Anxiety (on edge or has fears that knows are not rational but is unable to suppress them)

Nervous or being overwhelmed (worried about many things)

Suspiciousness

Confusion

Somatic changes:

Gastrointestinal (for example, abdominal pain)

Insomnia, hypersomnia

Lethargy, fatigue

Weight loss or gain, loss of appetite (anorexia)

Palpitations

Nausea, vomiting

Neurologic (for example, headaches, seizures, dizziness)

Agitation, restlessness

Decreased sexual energy or libido

Concerns with no known physical cause

Integrative patterns and client's perception of their relationship to:

Others

Self

Things and ideas

Present situation

Reality

Relevant History

Personal

Recent major illness or diagnosis of chronic disease

Anxiety or panic attacks (for example, sudden fear causing palpitations making client feel they may die)

Hurt physically or emotionally in past year

Review of systems related to presenting concern

Stays in hospital and illnesses

Past and current medical, mental illness, and neurologic history

Prescription, over-the-counter and herbal medications (including compliance, duration, side effects)

Education

Religion

Occupational background

Ability to complete activities of daily living (for example, personal hygiene, getting dressed) and instrumental activities of daily living (for example, managing money, using telephone)

Role function at work, school, and home

Social adjustment and support

Sexual history

Social activity, including interests, hobbies, recreation

Substance use (for example, alcohol; smoking; caffeine; recreational, prescription, or over-the-counter drugs) and abuse

Significant life events (for example, divorce, abuse, death)

Suicidal, homicidal or violent behaviour (lethality, treatment needed, dates)

Legal involvement (for example, charges, violence)

Maternal substance use, pregnancy or delivery problems

Development as a child through to adolescence

Familial

Birth order

Perceived place within family

Relationship with parents

Relationships with siblings

Integrity of family unit

Mental health of biological family members: Psychiatric diagnosis, symptoms, duration, treatment(s), response Attempted or completed suicide Substance abuse Legal concerns



Clinical Examination

Much of the clinical examination is based on observation throughout the history taking, but sometimes questions will need to be asked in order to complete the mental status examination.

Mental Status Examination

Appearance

Physical condition and general health (for example, age, skin, hair and nail condition)

Dress (for example, clean, appropriate for season and presenting concern)

Grooming (for example, unkept)

Eye contact and facial expression; ensure cultural differences are respected

Posture (for example, rigid, slouched)

Relatedness to interviewer (for example, cooperative, guarded, hostile, accessible)

Behaviour

Motor activity (for example, psychomotor agitation/retardation, involuntary movements)

General level

Gait

Gestures and mannerisms (for example, repetitive tapping, hand wringing)

Awareness of environment

Impulse control (for example, aggressive, hostile)

Speech

Pitch, tone, volume, clarity (for example, monotonous)

Rate, rhythm, articulation, spontaneity (for example, stutter, pressured, mute)

Mood and Affect

Appropriateness

Intensity

Overall impression of affect (for example, depressed, anxious, angry, apprehensive, apathetic) and its appropriateness for the presenting concern

Emotionality (dominant emotion, range of emotions, lability)

Client's stated mood

Thought ProcessesFootnote 15 (how client comes to a conclusion)

Quality of logic and coherence

Appropriate (for example, logical)

Tangential (for example, digress from initial topic)

Concrete or abstract

Flight of ideas (stereotypic)

"Word salad" (incoherent medley of words)

Clang associations (words that rhyme or sound alike inserted in conversation without making sense)

Echolalia (sentences said to the client are repeated back by the client)

Neologisms (words created by client)

Confabulation (fabrication of events or facts due to memory impairment; not lying; observed in alcohol-induced dementia)

Idiosyncratic or unusual word usage

Cognitive ability: concept formation, level of intelligence, articulation (precision, vocabulary level)

General characteristics: speed of thought, spontaneity, flexibility or rigidity, distractibility, continuity, alertness, blocking (interruptions in train of thought)

Thought Content

Central themes

Self-concept

Insight and awareness

Judgment

Delusions

Obsessions

Fears and phobias

Somatic concerns (for example, hypochondriac, morbid thoughts)

Overvalued ideas

Rituals or compulsions

Religiosity

Suicidal or homicidal ideation; perform a risk assessment: intent/suicidal ideation (for example, when the thoughts occur, feeling so upset wishes he/she was dead, talking or writing about suicide/homicide) plan (if a plan exists, how, when and where of plan, how realistic it is, likelihood of someone rescuing them, any action taken [for example, stealing gun cabinet keys]) means to carry out plan (method availability at home and lethality [reality and client's perception] of the intended method) what would cause or prevent him/her from carrying out plan behaviour(s) that have been exhibited (for example, warning signs, impulsive or high-risk behaviours) see also "Suicidal Behaviour"



Perception

Hallucinations (any modality)

Illusions

Depersonalization (feel detached from body or vice versa)

Derealization (things do not seem real)

Sense of grandiosity or worthlessness

Nihilism (the order of things has disappeared)

Cognition

Level of consciousness

Attention and concentration

Knowledge of time, person, place, month, and year

Remote and recent memory

Memory retention (for immediate, recent and remote events)

Ability to distinguish between internal and external stimuli

Knowledge (for example, who is the prime minister)

Abstraction (for example, what does a saying such as "Be kind to your shadow" mean, or how are two different objects similar)

Insight and Judgment

Awareness and understanding into condition and need for assistance

Ability to understand what is likely when acting a certain way

Physical Examination

In order to rule out physiological conditions that may present as a mental health concern, a thorough head to toe physical examination, including weight and height, should be completed after the client's psychological symptoms started.

Assessment and Interpretation

Identify strengths and problems.

Make provisional diagnosis.

Determine need for emergency actions:

Overt homicidal or violent impulses

Potential suicide

Inability to function independently and no caregiver available

Acute psychotic symptoms

Delirium

Potential Goals of Treatment

Whenever possible, treatment goals should be identified and driven by clients as they are the ones who need to determine and prioritize what is most important for them to work toward, how they will do it, and in what time frame. These goals may be directly or indirectly related to their medical diagnosis. Agreement between the care provider and the client helps to facilitate progress toward them.

Relieve or decrease symptoms (for example, reduce anxiety)

Change attitude

Change behaviour (for example, cessation of compulsive hand-washing, habit change, self-control)

Develop insight (for example, an understanding of one's motivation, the reasons for emotional response, or the causes of disordered behaviour)

Improve interpersonal relationships (for example, getting along with one's family, overcoming social anxiety or shyness, controlling anger)

Improve personal functioning (for example, increase ability to accept responsibility, be productive)

Improve social functioning (for example, improve ability to function socially within the community)

Personal growth and well-being (for example, increase ability to adapt and cope in the future, increase physical activity)

Prevent secondary effects on the family (for example, no baby born with fetal alcohol spectrum disorder, family caregiver not burdened, child not neglected)

Nonpharmacologic Interventions

General interventions to support mental health care are described in the following documents:

Consultation and Referral

Consultation with another mental health provider (for example, physician, nurse practitioner, clinical nurse specialist, psychiatrist, psychologist, counsellor, social worker, mental health/wellness worker) is most often required in mental health care. This helps to ensure the client is linked to the best nonpharmacologic, pharmacologic, and specialist resources. Clients with, suspected to have, or at risk for serious mental or emotional impairments, psychoses, bipolar disorder, suicide and substance abuse require referral to an appropriate specialist as they will likely require long-term treatment. This consultation should take place early and regularly thereafter so that the client has a team of care providers to help them and so that further referral can take place if warranted.

Links with mental health and chronic disease (if the concern may be related to difficulties coping with a chronic disease) resources in the community should be made with the client's permission. Community resources may include community mental health/wellness worker, Native Aboriginal Youth Suicide Prevention Strategy worker, Native Aboriginal Drug and Alcohol Program worker, Brighter Futures/Building Healthy Communities worker, Indian Residential Schools Resolution Health Support or Cultural Support worker, community health representative, family visitor from the Maternal Child Health program, community wellness worker, diabetes worker, Home and Community Care worker, other clients and/or families who have experienced the particular mental health concern and are willing to serve as resources to those affected.

Hospitalization and Client Evacuation

The decision whether to treat the client on an outpatient basis or admit and/or evacuate the client to a hospital (voluntarily or involuntarily) depends on several factors. This decision must be made in consultation with a physician and/or psychiatrist. The following should be considered:

Is this the first known episode? How certain is the diagnosis? Is there a need for close observation and monitoring (for example, symptoms of psychosis and their acuity, degree of functional impairment, acute moderate to severe mania)?

How competent are the local medical and nonmedical (for example, community supports, friends, family) resources to deal with this mental health concern and with this client in particular? How available is psychiatric consultation, if it is required?

How dangerous (for example, suicidal, homicidal), frightened or unpredictable is the client now or has he or she been in the past? How compliant is the client with directions and medication?

What other medical needs does the client have (for example, comorbid conditions)?

Is the client in need of shelter? To what extent is the family disrupted by the client? Would it be dangerous or disruptive to return the client to the family or friends (for example, can they provide adequate supervision, and a safe environment for the client)?

What is the nature of the hospital program?

What are the wishes of the client? Is the client capable of consent? Does the client meet the criteria for an involuntary admission?

Whether the client enters hospital voluntarily or involuntarily, it is very important that the family be kept informed (if the client is capable and consents) of his or her progress and that they maintain close contact with the client as much as possible.

Involuntary Admission

Legal requirements, including consulting and referring to a psychiatrist, must be met before a person can undergo psychiatric assessment and/or be hospitalized against his or her will. These requirements vary from one jurisdiction to another, so you must refer to and follow the appropriate mental health legislation for your province or territory (for example, Form 1 admission). In most cases there must be evidence of risk of physical harm to the client or others before an unwilling person can be admitted. The assessment and recommendation for admission of one or more physicians is required in all jurisdictions.

Evaluation of Treatment

During follow-up care, caregivers need to determine whether the treatment has met the goals and expectations of both the client and caregiver. This helps determine whether the goals and treatment plan need to be revised.

Common Mental Health, Psychiatric and Related Problems

A group of mental health conditions that have specific combinations of physical, emotional, and behavioural symptoms, including excessive anxiety, fear, panic, worry, avoidance, and compulsive rituals, in response to a perceived threat. An anxiety disorder can be distinguished from normal anxiety or worries by having symptoms that persist, are of a greater intensity than expected, and impair daily functioning (for example, occupational, social).

Early signs of an anxiety disorder include persistent behavioural inhibition (for example, shyness and avoidance of novelty). This along with risk factors listed below are linked to anxiety disorder development.

Specific types of anxiety disorders include:

Generalized anxiety disorder -- difficult to control excess worry most days about many different normal things (for example, health, finances) or activities (for example, work) that usually causes physical symptoms (for example, headache, nausea, sleeplessness); not tolerant of uncertainty; told worries too much

Obsessive compulsive disorder -- repetitive, unwanted, intrusive thoughts or images that cause anxiety (obsessions); repetitive, unwanted behaviours (for example, cleaning) or mental acts (for example, counting) done to decrease anxiety from the obsessions (compulsions)

Panic disorder (with and without agoraphobia) -- sudden, unexpected, recurrent attacks (for example, palpitations, chest pain, dizziness, sweating, trembling, shortness of breath, fear of losing control, nausea) without an obvious trigger; may actively avoid places where the attacks may take place; cannot tolerate physical symptoms

Post-traumatic stress disorder Footnote 19 personal exposure (witnessed, experienced, or confronted) to a traumatic event (for example, actual or threatened death or serious injury or threat to physical integrity of others) and response was intense fear, helplessness or horror and the person persistently relives the traumatic situation and the person persistently avoids stimuli related to the trauma and the person has blunted responses and increased arousal that lasts for more than 1 month

Social anxiety disorder -- excessive fear or anxiety about social situations (for example, public speaking, interacting with others) and intolerant of others discussing them as a person

Specific phobias -- excessive, irrational fear or anxiety about an object (for example, snakes) or situation (for example, flying) so that it is usually avoided

The Diagnostic and Statistical Manual of Mental Disorders IV Text Revision (DSM IV TR) provides more specific criteria for the diagnosis of each anxiety disorder. The criteria for each disorder can be found on-line.

Risk Factors

Family history of mental illness (in particular, anxiety)

Personal history of childhood anxiety, including marked shyness

Stressful or traumatic event (for example, abuse)

Female

Comorbid psychiatric disorder (in particular depression)

History

Excessive stress, anxiety or worry lately? If so:

Symptoms experienced (see list below), onset, triggers (environment, situation, stimulus), duration, severity

Associated avoidance behaviour

Dysfunction (interference with ability to function at work/school, home, family life, socially)

Life events (for example, major life changes, stressors) or trauma that may correlate temporally with onset

Techniques and strategies to alleviate anxiety (including chemical substances used or abused)

Rule in or out the specific type of anxiety disorder by asking clients whether their symptoms fit the definitions above

Symptoms can be in one or more of three clusters: emotional, physiologic, and cognitive.

Emotional

Sense of doom

Apprehension

Fearfulness

Worry (about others, future)

Panic

Helplessness

Emotional blunting

Irritable

Physiologic

General: insomnia (often difficulty falling asleep) fatigue, weight loss

Central nervous system (CNS): tremor, muscle aches/tension, headaches, dizziness, light-headedness, parasthesias, memory loss, restlessness

Autonomic: sweating, dry mouth, increased heart rate, flushing, chills, trembling/shaking

Gastrointestinal: nausea, diarrhea, anorexia, choking

Cardiorespiratory: shortness of breath, hyperventilation, chest pain, palpitations

Recurrent unwanted behaviours (for example, repetitive hand-washing, compulsive double-checking)

Cognitive

Poor concentration

Poor memory

Recurrent intrusive thoughts or images

Recurrent mental acts

Other History

Review of systems

Review use of caffeine, any other stimulants, alcohol, any recreational drug

Review current medications, any over-the-counter (OTC) or herbal drugs

Review for symptoms consistent with underlying medical illnesses (for example, thyroid disease, asthma, congestive heart failure)

Review for symptoms consistent with another psychiatric illness (for example, depression, bipolar, substance abuse)

Obtain a history from as many sources as possible (for example, partner, teacher, co-workers), as symptoms often differ between those interviewed, and symptoms may be more prevalent in some situations than others

Physical Examination

A full physical exam should be completed as well, including:

Cardiorespiratory exam

Thyroid exam

Other exams as indicated by history and/or symptoms

Differential Diagnosis

Anxiety disorders: generalized anxiety disorder, panic disorder with or without agoraphobia, social anxiety disorder, specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder

Other psychiatric disorders: depression, somatization, hypochondrias, personality disorders, victim of abuse (physical, sexual, or emotional), psychosis, dementia, adjustment disorder

Medical disorder: endocrine (for example, hyperthyroidism, hypoglycemia, Cushing's disease), cardiorespiratory (for example, congestive heart failure [CHF], cardiac arrhythmia, mitral valve prolapse, angina, chronic obstructive pulmonary disease [COPD], asthma, pulmonary embolism), neurologic (for example, vestibular dysfunction, migraine, neoplasm, early dementia)

Substance use or withdrawal: especially caffeine, nicotine, alcohol, cannabis, cocaine, amphetamines

Secondary to medication use: for example, first 2 weeks of selective serotonin reuptake inhibitors

Complications

Inability to perform activities of daily living

Social phobias

Substance abuse

Depression

Suicide (particularly in panic disorder)

Diagnostic Tests

Complete blood count

Electrocardiography (ECG)

Thyroid-stimulating hormone (TSH)

Other tests may be required to rule out other conditions that may mimic an anxiety disorder

Management

Depending on the type of anxiety disorder, definitive treatment may involve psychotherapy, desensitization therapy and/or medications.

Goals of Treatment

Decrease or stop anxiety symptoms

Decrease or stop related disability

Prevent recurrence

Treat comorbidities

Appropriate Consultation

Consult physician:

If there are any safety concerns

If comorbid medical or psychological problem is suspected, since management will need to be tailored for the diagnosis

If symptoms are so intense as to interfere with normal function, in which case a short course of a benzodiazepine (minor tranquilizer) may be indicated

Nonpharmacologic Interventions

Whatever treatments available, clients must be willing and motivated to try the treatment(s) they choose.

Cognitive behavioural therapy, done by a trained therapist or specialist, can be very effective in treating anxiety disorders. It can include education, skills training (for example, problem-solving, social skills, monitoring emotions), exposure therapy, cognitive restructuring, and relapse prevention. Psychotherapy is often not available, but video conferencing may be available in your community to provide this intervention. The therapy helps clients recognize when they are anxious and encourages them to practice problem-solving strategies. Referral to a therapist or specialist should be done in consultation with a physician.

Pharmacologic Interventions

Consult a physician regarding medication use in acute/severe situations. Short-term use of lorazepam (Ativan) is a common approach, but it does not resolve the cause of the anxiety.

lorazepam (Ativan), 0.5-1 mg PO bid to tid prn

Benzodiazepines, SSRIs, SNRIs, anticonvulsants, and occasionally atypical antipsychotics may each have a role, depending on the type of anxiety.

Monitoring and Follow-Up

Follow up weekly until the client sees a physician; otherwise follow up every 3 months

Support and education about the illness process for the client as well as for the family are critical

If medication is started, follow up at 1 week, then every 2 weeks for 6 weeks, then monthly to assess degree of anxiety (use visual analogue 1-10 scale), suicidal ideation, weight, tolerance of medication, adherence, and adverse effects of medication; if no improvement within 12 weeks, consult with a physician

Referral

Medevac urgently if there is profound disturbance, if there are safety issues or if the client needs more definitive treatment urgently. The decision whether to treat the client on an outpatient basis or admit and/or evacuate the client to a hospital (voluntarily or involuntarily) depends on several factors. This decision must be made in consultation with a physician and/or psychiatrist. For further considerations, see Hospitalization and Client Evacuation and Involuntary Admission.

Arrange follow-up with a physician at next available visit for all but very severe cases.

A range of disorders with a measurable deficit in cognition in at least one area (for example, memory, aphasia, apraxia, agnosia, executive function) from previous levels of function. It includes mild cognitive impairment and dementia.

Mild cognitive impairment (MCI): at least area of cognitive deficit, but no impairment in activities of daily living. Clients do not have dementia, but are likely at an increased risk for dementia.

There are many different kinds of MCI. Amnestic MCI has memory impairment for age and education (objective and subjective complaint). These individuals are more likely to progress to Alzheimer disease and/or vascular dementia. Non-amnestic MCI has impairment in one area of cognitive functioning other than memory.

Dementia: syndrome of progressive impairment of memory and at least one other area of cognitive function (for example, aphasia, apraxia, agnosia, executive function) compared to previous levels of function. It is sufficient to interfere with normal activities (for example, work, relationships) and independence. It may be due to an underlying reversible or irreversible process, but other diagnoses (for example, delirium, psychiatric concern, brain or systemic disease) are not better explanations.

Types of Dementia

Alzheimer disease (60-80% of cases) progresses gradually with memory loss about recent events. Other cognitive deficits may be present, but language and visuospatial abilities are usually affected early. Executive function problems, apraxia, and behaviour changes occur later in the disease.

Vascular dementia (10-20% of cases) has early executive dysfunction, but little memory impairment early on. Symptoms start abruptly and usually have a stepwise decline. Physical examination may demonstrate prior stroke(s).

Mixed dementia is a combination of Alzheimer disease and vascular dementia.

Frontotemporal dementia usually presents at a younger age (less than 75) with early behaviour and personality changes, and nonfluent aphasia.

Dementia with Lewy bodies progresses gradually with fluctuating cognitive function, persistent visual hallucinations, and parkinsonian motor activity.

Parkinson's disease dementia is a common feature of Parkinson's disease (PD); presents after the development of other neurologic manifestations of PD while Lewy Body dementia develops before motor manifestations of parkinsonism.

Alcohol-related dementia, including Korsakoff's syndrome.

Normal pressure hydrocephalus with the triad of dementia, urinary incontinence and gait disturbance.

Causes

Senile plaques and neurofibrillary tangles (Alzheimer disease)

Cerebrovascular accident

Parkinson's disease

Central nervous system causes such as tertiary syphilis or subdural hematoma)

Nutritional deficiency (for example, Vitamin B12 and thiamine deficiency)

Chronic alcoholism as a cause of Korsakoff's dementia or nonspecific cognitive dysfunction

Risk Factors

Older age

Family history of dementia

MCI (for dementia)

History of head trauma with a loss of consciousness

Lower educational level

Lifestyle factors (for example, poor social networks, nonphysical activity, low mental activity)

History of depression

Alzheimer disease risk factors include female sex and family history

Vascular dementia risk factors include cerebrovascular disease, dyslipidemia, diabetes, and chronic kidney disease

History

Elicit the history from the client, but it is just as important to elicit corroborating information from a caregiver, friend, or the family (informant).

Client may present complaining of memory problems (recent and remote)

Client is often troubled about their symptoms (in the case of MCI)

More often, a caregiver or family member accompanies the client, having noticed the client's difficulties with tasks that previously were not a problem (cognitive or behavioural changes, for example, self-care, home care, shopping, finances)

Discuss a variety of current events, premorbid and current financial abilities to develop a sense of the impairment

Client reports difficulty with any one or more of: Learning and remembering new things Doing complex tasks (for example, driving, balancing a cheque book) Reasoning (for example, not able to deal with unexpected events) Spatial ability and orientation (for example, gets lost) Language (for example, unable to find words) Behaviour May present with concerns of inappropriate or bizarre behaviour, because of delusions and hallucinations May present with mood and behavioural symptoms, including depression, anxiety, irritability, aggression, apathy, agitation, wandering, falls, sleep deficits, sexually inappropriate behaviour, and delusions (MCI clients with these symptoms are more at risk of progressing to dementia). Take a careful history of events prior to the mood or behaviour occurring; also ensure the caregiver is asked about all these behaviours as they may not mention them Determine onset of symptoms and temporal course Record symptoms noted, objective behaviours observed Elicit degree of disturbance and dysfunction in activities of daily living and instrumental activities of daily living (ask about specifics, such as shopping, driving, self-care, handling of money, work performance or hobbies, as applicable; also inquire about ability to learn a new task). Document the findings to determine if there has been any progression at follow-up visits



Distinguishing Delirium from Depression

The chronic cognitive dysfunction associated with dementia and MCI should be differentiated from the acute and fluctuating level of consciousness associated with delirium. Although dementia puts patients at higher risk for delirium, that is, the two are often associated, delirium may also result from a number of other underlying medical conditions. Delirium is, by definition, a reversible deficit of attention. It is recognized on history by fluctuating agitation or psychomotor slowing over a period of hours to days. Tools such as the "digit span" (recalling a series of digits, starting with 2, and increasing the length of the series, until unable to recall a series on two attempts) can be helpful in testing attention in patients in whom delirium is suspected. Delirious patients should not undergo further cognitive testing until their acute condition has resolved.

Symptoms Associated with Underlying Medical Disorders

In order to help rule out an underlying medical condition, ask about the following:

Medical History

Past medical history, including thorough psychiatric history

Prescription, OTC or otherwise acquired drug or remedy, looking for drugs that impair cognition (for example, analgesics, anticholinergics, psychotropic drugs, sedative-hypnotics, steroids)

Substance use and/or abuse

Clinical Assessment

Orientation

Assess for mood, hopelessness, apathy, vegetative symptoms of depression

Inquire about suicidal ideation

Assess for psychotic symptoms (for example, thought disorder, delusions, hallucinations)

Assess for psychosocial stressors (for example, losses, abuse or neglect)

Observe speech (word-finding difficulty), affect, mannerisms, grooming, psychomotor skills

Mental Status Examination

A widely used tool is Folstein's Mini Mental Status Examination. A score of less than 24 out of 30 would require further assessment of the cognitive status

If the Mini Mental Status Examination is normal and dementia is suspected, further screening can be done by administering the Montreal Cognitive Assessment

Look for correlation between history and mental status examination; education level, intelligence, depression, delirium, age, culture, motor and visual impairments, and language can all affect the results of the above tests; additionally, mild dementias will not likely be identified with these tests

Assessing judgment, by asking the person to interpret hypothetical situations (for example, waking to find the house on fire) is also helpful

Physical Examination

The physical exam is directed by the differential diagnosis, as generated by the history. A full physical exam should be completed and must include the following:

Vital signs

Hearing and vision assessments (including extraocular movements, fundi)

Cardiovascular and pulmonary exam (for example, carotid bruits, evidence of atherosclerotic disease)

Full neurologic exam, looking for signs of parkinsonism (cogwheel rigidity, shuffling gait, fixed facial expression, resting "pill-rolling" tremor, soft voice) and stroke (motor or gait deficits, sensory deficits, cranial nerve deficits, aphasia/difficulty speaking

Differential Diagnosis

Delirium (acute and fluctuating, caused by infections, electrolyte disturbances, surgery, endocrine disturbances, cardiac ischemia, medications and constipation)

Psychiatric disease (for example, bipolar disorder and depression)

Substance use and abuse

Metabolic disturbance (for example, B 12 deficiency [extremely rare], hypothyroidism)

deficiency [extremely rare], hypothyroidism) Neurologic disease (for example, brain tumour, Parkinson's disease, cerebrovascular disease)

Other psychiatric disorders: psychotic, amnestic or dissociative

Delirium, dementia and depression can be difficult to distinguish from each other. Depression in the elderly is often confused with dementia because of the accompanying apathy and associated cognitive difficulties.

Diagnostic Tests

Unless an underlying cause is obvious, blood should be drawn for the following tests to rule out potentially reversible conditions:

Complete blood count

Electrolytes

Albumin

Calcium

TSH

Fasting blood glucose

Vitamin B 12

Creatinine

Serum folic acid or red blood cell folate

Consider urinalysis, urine for culture and sensitivity

Consider serum alcohol level, urine toxicology screen

Other investigations will be driven by the history and presentation.

Management,,

Management is ultimately driven by the diagnosis. Ensure medical conditions (for example, delirium) are diagnosed and treated. All clients should be screened and treated (by a physician) for vascular risk factors (for example, hypertension, diabetes).34

Goals of Treatment

Identify and correct reversible causes

Ensure safety of the client

Treat cognitive, behavioural and psychological symptoms

Optimize functioning and quality of life

Decrease caregiver burden

Appropriate Consultation

Consult a physician if client is in acute distress, if there are unexplained new neurologic symptoms or focal deficits, upon the initial suspicion that client has dementia, if there is acute onset of cognitive impairment, if there are rapidly progressing symptoms (neurologic or cognitive), or if there are risk factors for serious intracranial pathology (for example, anticoagulant medication, history of trauma, previous cancer).

Nonpharmacologic Interventions

Educate client and caregivers about safety measures and what to do should there be acute behaviour changes. Determine whether the client can safely remain at home. Encourage measures to ensure safety, and aid the client in optimal functioning and independence

Educate caregivers about environmental interventions for behavioural disturbances (for example, redirection, distraction, providing structure, avoiding confrontation, reminiscing, avoiding stimulants and preceding events for the behaviour) after ruling out physical or environmental causes

The Registered Nurses Association of Ontario's best practice guideline titled Caregiving Strategies for Older Adults with Delirium, Dementia and Depression, provides a valuable resource for education

Educate and mobilize community resources such as home care, friendly visitors, and/or long-term care placement, as required

If client is incapable, discuss treatment decisions with substitute decision-makers and/or Power of Attorney; if client is capable, encourage them to appoint a Power of Attorney and develop a will

Educate and support caregivers and family about managing their own stress (for example, refer to a support group or respite care, if available)

Educate clients and caregivers about dementia, its stages and how to focus on the client's abilities

If agitation or behavioural issues are the concern, manage according to guidelines under "Violent or Acutely Agitated Psychiatric Clients."

Other resources for clients and caregivers include:

Pharmacologic Interventions

If at all possible, do not medicate. In particular, avoid sedation and antipsychotics (for example, haloperidol), as it may cause falls, worsen symptoms of impairment, and/or cause severe deterioration/death in those with dementia.

Refer to a physician for pharmacologic treatment options:

Dementia (for example, cholinesterase inhibitor and/or memantine)

Symptomatic treatment for disturbing behaviours (such as hallucinations and depression) that cannot be controlled by nonpharmacologic measures

Treatment of vascular and dementia risk factors

Monitoring and Follow-Up

Follow up regularly (for example, monthly or more often as necessary), preferably on a home visit, to enable you to assess client functioning, behaviour, and cognition in his or her own environment. Regularly monitor response to treatment and manage any new symptoms.

Arrange for all clients with non-urgent symptoms of MCI or dementia to see a physician at the next available visit. Further diagnostic testing and/or referral may be warranted.

After a diagnosis of MCI or for those with persistent cognitive concerns, ensure reassessment (cognitive and functional) by a physician in 1 year.

Medevac may be necessary for clients with potential underlying organic pathology or if the risk-safety assessment requires that the client be admitted to hospital. The decision whether to treat the client on an outpatient basis or admit and/or evacuate the client to a hospital (voluntarily or involuntarily) depends on several factors. This decision must be made in consultation with a physician and/or psychiatrist. For further considerations, see "Hospitalization and Client Evacuation" and "Involuntary Admission."

Refer clients and caregivers to occupational therapy, if available, for assistance with using aids to daily living and to help develop coping behaviours.

Family Violence35,36,37,38,39,40,41,42,43,44,45,46,47,48,49

"Abuse of power to harm or control a person who was or is a family member."50 It includes actual or threatened physical (for example, hitting, stalking), verbal (for example, threatening, coercing, harassing), emotional, financial, and spiritual abuse, social isolation, sexual assault, and neglect. It affects the physical and mental health of the victims. Often violence is toward a female from a male family member, but anyone can be victimized (including children who witness abuse). Partners, whether married (or not), and/or living together (or not), are still considered family members.

Types of Violence

Physical Abuse

An act that results in, or can result in, physical injury. Such acts include inflicting blows that cause bruising, striking with a hand or instrument, kicking, biting, burning, beating, throwing, rough handling, assaulting, using physical restraints, confining, shaking, and threatening to cause harm. Bruising is the most common form of physical injury reported due to spousal violence.52

Emotional or Psychosocial Abuse

Repeated verbal or nonverbal attacks or omissions that affect, or could affect dignity, self-esteem, confidence, and self-worth. Such acts or omissions may include rejecting, criticizing, isolating, confining, intimidating, blaming, terrorizing, ignoring, corrupting, excessive pressuring, or verbally abusing or assaulting (for example, threats, humiliation, ridicule, insults) are categories of emotional/psychosocial abuse when the behaviours are repeated. This form of abuse can include spiritual abuse. Examples of emotional/psychosocial abuse include locking someone in a closet, preventing an older adult from attending church, threatening to leave the relationship, controlling what another person does and who they see, damaging the other person's belongings, or yelling at another person. Put-downs and name-calling are the most common form of emotional abuse reported due to spousal violence.53

Neglect

A non-deliberate failure to provide for basic physical, emotional, developmental, psychological, medical, and educational needs that results in, or may result in, harm to a person who cannot fully look after themself. This can include noncompliance with health care recommendations, withholding medical care, inadequate personal care, inadequate supervision, inadequate protection from environmental hazards, abandonment, withholding love or affection, lack of nurturing, and inadequate hygiene.

Financial Abuse

Acts involving an individual's money or property when that person does not know about it and/or does not consent to it. It includes withholding all finances, fraud, theft of money or belongings, misuse of funds, withholding means for daily living (including food, medications, and shelter and preventing one from working), and a misuse of power of attorney.

Other

Information about sexual abuse is presented in the "Sexual Assault" section of the adult clinical guidelines.

Information about child maltreatment and child sexual abuse is presented in chapter 5, "Child Maltreatment" of the pediatric guidelines.

Risk Factors

Pregnancy or postpartum (often begins or increases

> 80 years old

Frail older adult

Female (increased in those < 35 years old, single, divorced, separated, smokers, low socioeconomic status, substance abuse by themselves or partner)

History of childhood physical and sexual abuse

Males < 35 years old and in common-law relationship54

Situations in which to Suspect Family Violence

Maintain a high index of suspicion. Individuals are often reluctant to report abuse.

The following presentations raise suspicion of abuse:55

There is a delay in seeking medical attention for an injury physical findings are not consistent with the history (for example, client makes excuses for abuser's behaviour, client may become aggressive and angry if confronted) presents with chronic somatic concerns (for example, abdominal pain, chest pain, headache, insomnia, fatigue, and backache) client reports anxiety attacks or depression client reports stiff neck or shoulder muscles (due to violent shaking), which mimic the symptoms of whiplash client reports marital problems, especially if reference is made to fighting, arguing, jealousy, impulsiveness or drinking repeated suicidal gestures or attempts

Noncompliance with appointments or therapeutic interventions or unresponsiveness to treatment

Frequent visits to the health care facility, often for specific concerns

Unusual client actions during history or physical examination (for example, secretive, sad, withdrawn, fearful, evasive, hostile, flat affect, uncontrollable crying)

Increasing use of drugs or alcohol to cope

Injuries on central part of body (chest, abdomen and genitalia), head and neck (possibly related to attempted strangulation), forearms (related to self defense), bruises of different stages

Client's partner answers questions for client, is overly concerned about client's health, refuses to leave examination room, suggests that he/she is the victim, exaggerates or lies to make self look good or as the victim

Client-perceived Barriers to Reporting or Disclosing Abuse

Fear perpetrator will be arrested

Hope/belief that things will change

Fear of what the perpetrator might do if they find out about disclosure (for example, more abuse, abandon or institutionalize an older adult)

Blame self for circumstances

Feel like a failure, embarrassed or ashamed if admits abuse (stigmatization)

Victim has no proof of abuse

Fear of rejection by care provider (for example, nurse)

Belief that there is no alternative and/or no one can help

Ill or frail health (dependence on perpetrator)

Communication difficulties

Children are involved

Isolation

History57

The evidence is unclear whether routinely screening all clients for domestic violence is effective to prevent abuse.58 However, the Registered Nurses Association of Ontario Best Practice Guideline on woman abuse59 and most victims of abuse support routine verbal screening. It significantly improves detection rates of exposure to violence and can allow the nurse to assist individuals that are potentially or actually being abused.

Consider verbally screening for family violence as part of a medical or psychological assessment when:

Findings in the history and/or physical examination may indicate family violence (for example, bruising, traumatic injury, appointments cancelled on short notice, improbable injury)

A female is pregnant

Presentation is after regular clinic hours

Females have chronic abdominal or chest pain, headaches, and/or sexually transmitted infections

Older adults dependent on a caregiver or presenting with injuries

Initial clinic visit for new clients

Well-child visit (ask for safety of all family members)

Annual preventative care visits for females > 12 years of age

Interview and examine the client by herself or himself (unless accompanied by children under 3 only). The client will not feel free to talk or feel safe if the abuser is nearby. Allow the client to talk at their own pace and to openly state his/her feelings. Ask why they feel that way. Ask non-leading, non-judgmental and open-ended questions. Do not pressure. This may be the only chance the client has to disclose. Members of the family, boarding home staff or other caregivers should be interviewed separately.

Assure confidentiality, but educate about the limits of confidentiality in the presence of suspected abuse and that the encounter will be documented in his/her medical file.

Some screening tools have been developed for domestic violence, but none of the tools have well-established sensitivities and specificities.60

While taking the history, look for and document:

Inconsistencies or discrepancies in the history (for example, no history on mechanism of injury, partial history, history changes, difference between older adult and caregiver)

History incompatible with the presenting problem/injury

New or old injury with inadequate, evolving, or no explanation

Delays in seeking medical attention after an injury

Past record of repeated or unusual injuries

Element of neglect or inappropriate supervision (for older adults)

Unrealistic caregiver expectations of older adult

Client avoiding questions

Client reporting self-inflicted injury

Indicators of family violence as detailed below

A complete family violence history includes the following information:

Name(s), telephone number(s) and address(es) of the person(s) responsible, including the name(s), address(es), relationship to the victim, known facts (for example, intravenous drug use, physical description, substance use or abuse) of the alleged offender(s)

Dates, times and location of incidents

Exact mechanism and circumstance of injury and/or the experience

Physical injury to victim, including pain and bruising

Names of witnesses, including children, who saw injury occur and/or was with the client at the time

Location of other people (including children) when it happened

Health status until the injury happened

What was done immediately after the injury; was medical care sought

History of abuse by the same or another perpetrator

How often abuse has happened

Prior trauma or medical procedures in affected area

History of abuse or child protection agency involvement with children

Past medical history, including medications and immunizations

Family history of conditions that account for easy bruising or bone fragility (for example, von Willebrand disease) or that are relevant to abuse

Current living situation, who lives there, family composition and function, significant personal relationships, primary caregiver (if applicable)

Observations of emotional abuse, neglect, or financial abuse

Changes in eating, sleeping, or behavioural patterns

Anger, fear, concern, rage, suicidal ideation or attempts, depression, anxiety

Substance abuse

Feelings of safety in the relationship with family member(s)

How client feels about experience/situation

If friends or family are aware that the client has been hurt; if she/he would tell them; if they would provide support to the client

If the client has a safe place to go and what they might need in an emergency

Assess for immediate health needs (for example, laceration, sexual assault)

For older adults, whether the abuse or neglect reflects inadequate preparation or unrealistic expectations on the part of the caregivers

For older adults, the attitude of the caregivers toward caregiving, control of the client's activities, extent of outside contacts, and the physical and emotional well-being of their charge

Physical Examination

Objectively report what is observed to the client (for example, start statement with "I"), so client can offer additional information if they choose to; document it objectively as well

Complete a full physical examination, including vital signs, height and weight; in particular, focus on integumentary, head, ears, eyes, nose, throat and abdominal examination; look for indicators of family violence as detailed below

Note all injuries (including those on genitalia) on body map diagrams and with colour photographs if possible (for example, welts, burn marks)

Note signs of neglect (for example, BMI, cleanliness of clothing, hydration of mucous membranes)

Note signs of old, untreated injuries

Note the client's behaviour, emotional responses and attitudes toward the caregivers

Note ability to care for self (for example, activities of daily living and instrumental activities of daily living) and to protect self from danger by making and implementing decisions that consider the circumstances

Assess mental competence and refer to territorial or provincial mental health legislation to determine possible courses of action (for example, power of attorney or by legal appointment of a legal guardian) if not competent

Mental status examination for older adults; if cognitive impairment exists, the person may not provide a reliable history, so other information sources should be sought (for example, family, clergy, neighbours)

Indicators of Family Violence61

Physical Abuse

Bruises, welts, skin tears, and other lesions for which adequate explanation is lacking and/or in unusual or recognizable patterns and/or areas not usually injured; note that the colour of bruises does not accurately reflect age or onset of injury

Sores, ulcerations, and other similar lesions that do not heal

Serious bleeding injuries, especially to the head and face; in the case of sexual assault, there may be vaginal or anal tearing that requires stitching

Internal injuries, concussion, perforated eardrums, damaged spleen or kidney, abdominal injuries, punctured lungs, severe bruising, eye injuries and strangulation marks on the neck

Burns from cigarettes, hot appliances, scalding liquids, or acid

Broken or cracked jaw, arm, pelvis, rib, collar bone or leg (or dislocations); in older adult, spiral fracture of long bones, or fractures at sites other than wrist, hip, or vertebrae

Injuries in various stages of healing

Dental injuries (for example, fractured teeth)

Significant delay in getting treatment

Scalp wounds or hair loss

Afraid of caregivers

Sudden change in behaviour

Reports of unwanted physical contact (including things being thrown and/or being restrained against wishes)

Force fed or denied food and drink

Spit or urinated on

Threatened to be killed or injured

Pressured into alcohol or drug use

Frequently misses work, school, or social events with no explanation

Dresses in clothing that will hide bruises or scars (for example, sunglasses, long sleeves in summer)

Emotional or Psychosocial Abuse

Denial of any problems in relation to caregivers and/or overprotectiveness of caregivers

Emotional and/or social withdrawal and passivity or lethargy; resignation to current life situation; major personality changes

Fear and anxiety (for example, related to abandonment, authorities, or trying to please partner)

Unusual ease in settling into a medical setting (relief from abusive situation)

Absence of expectations of being comforted or receiving affection

Low self-esteem

Acts nervous around or fearful of caregiver and/or avoids eye contact

Emotional disturbances (for example, suicidal ideation, depression, upset or agitated)

Confusion

Forced to do illegal activities

States partner has a bad temper, is jealous or possessive

Forced to drop charges

Reports of frequent needs to account for time, activities and who talked to (for example, calls partner often)

Social isolation

Partner not allowing or forcing to use contraception

Forced to have abortion

No support from partner during pregnancy or birth

Partner insistence to accompany client into clinic room

Uses religion to justify abuse or situation

Not able to attend church

Destruction of client's property

Unusual behaviours (for example, sucking, biting, rocking)

Neglect

Malnutrition and dehydration when mental alertness enables expression of needs but immobility prevents independently meeting those needs

Oversedation or withholding of prescribed drugs

Failure to keep or make medical appointments for needed care (because no one will take the person to the appointment) resulting in untreated medical problems

Missing dentures, glasses or hearing aids

Poor hygiene

Injuries due to lack of supervision (for example, pressure sores)

Unsafe living conditions (for example, no heat, soiled bedding)

Alcohol or medication abuse

Unsupervised wandering

Self-neglect (for an older adult)

Abandoning a person that is in your care

Financial Abuse

Abuser takes/withholds money and/or forges name

Limited access to money or credit cards

Unpaid bills when previously able to pay them

Unexplained missing money or property (for example, unusual bank withdrawals)

Transfer of property when person does not have the capacity to consent

Living without affordable necessities for living

Sudden changes to a will or bank account

Inaccurate knowledge about financial situation

Differential Diagnosis

There are many potential differential diagnoses, including:

Accidental injury (for example, fall, motor vehicle collision, bicycle accident, animal bite)

Dermatologic condition (for example, contact dermatitis)

Infection or sepsis

Hematologic disorders

Depression

Anxiety disorder

Self-neglect

Complications

Economic dependence on abuser (due to abuser's control)

Social isolation

Psychological consequences (for example, anxiety, depression, low self-esteem, somatization, substance abuse, post-traumatic stress disorder, personality disorder, suicidal ideation)

Repeated injuries (for example, trauma, lacerations, fractures, falls)

Sexual health concerns (for example, sexually transmitted infections, unwanted pregnancy, infertility)

Poor health (for example, difficulty walking, completing daily activities, memory loss, untreated medical conditions, poor nutrition, pressure ulcers)

Death (suicide, murder, HIV, childbirth related)

Pregnancy complications and poor outcomes, including cesarean section, hospitalization due to premature labor, low birth weight baby

Increased risk of child abuse

Self-neglect (in older adults)

Short and long term effects (emotional, social, cognitive) on children who witness violence

Loss of independence and required support

Management

Appropriate Consultation

Consult a physician or nurse practitioner if the injuries require it (for example, need a medevac) and/or if referral to services is required.

Nonpharmacologic Interventions62

If the client does not disclose abuse:

Respect their decision

State your observations and why you are concerned for their health and safety, if you suspect abuse

Educate about prevalence and negative effects of abuse

Discuss services available for those experiencing family violence, if you suspect abuse

Document the client's responses and your interventions

If the client discloses abuse:

Do not minimize problems (for example, tell client he/she is experiencing abuse, you are concerned for his/her safety (and children if applicable), that violence is not his/her fault); ask how you, the care provider, can help them Avoid "putting down" the abuser

Do not discuss possible mechanisms of injury with the client. State simply that the injuries are a result of trauma. A suggestion can negatively influence the outcome or process of investigation

If verbal abuse occurs in clinic, state that the behaviour is not acceptable

Discuss and encourage use of client's personal supports and resources that can be used to help deal with the situation (for example, sympathetic friends and family)

Do not reassure the client that "everything will be fine;" educate the client about the nature and usual course of family violence and that it is a crime

Help client to be objective (for example, how likely do you think that is) and to focus on present (for example, what could you do differently)

Verbalize client priorities (for example, family more important than self) and that it is hard to make a change (for example, due to fear, economic dependence, no other place to go, belief that the abuse will stop and/or that the abuse is their fault)

Encourage use of "I" messages with abuser (for example, "I feel angry when...") Assess client safety and potential for escalating behaviours (for example, afraid to go home, current and future safety requirements, increased frequency or severity of violence, threatened that will kill client or children, previous choking, availability of weapons, perpetrator knows victim plans to leave); a home visit may be required, particularly for older adults. Educate that situation may be life-threatening if weapons are available or threats have been made. Assist the person in leaving the home or the relationship if that is desired, but do not pressure the person to do so. Try to reduce anxiety and provide necessary information so that rational, informed decisions regarding life and safety can be made

Assess danger to children in the household and whether they have witnessed violence. If concerned about child safety and/or if reporting is mandatory by law, see "Reporting Family Violence." Educate about the negative effects of children witnessing abuse (for example, bedwetting, low self-esteem, dropping out of school, conflict with the law). Also encourage the client to contact their local child welfare agency

Treat unmet medical needs (for example, depression, diabetes, reversible dementia, hypertension)

If a child is involved, listen to the child's feelings and discuss what they mean

Help client develop a safety plan. It should include what to do in an emergency, where to go (for example, shelters, transition homes or the home of a sympathetic relative or friend), how to get there, and resources and documents needed for the client and children involved

Educate about available resources (for example, police, family, shelter, job training, community support groups, financial support, justice/advocacy services) and counselling options; be cautious in giving written materials about these as it may cause more violence for the client. Support the client's decision by referring them to and/or calling the resources agreed upon, after discussing the advantages and disadvantages of all options for their current situation

Consult community social services to determine what form of assistance would be available and pertain to the client and/or the care providers

Provide the client with a crisis line and/or family violence services number and/or web sites The Centre for Suicide Prevention maintains a list of crisis lines for all the provinces and territories One service in British Columbia specifically for domestic violence is VictimLink BC (1-800-563-0808) Seniors Canada provides a list of resources on elder abuse by province (including telephone numbers)



Resources on family violence:

Documenting Family Violence63,64,65

Include the following information in a clear, legible, objective documentation:

If negative abuse screening, document "no disclosure to abuse screening"

Name and relationship of abuser

Detailed description of the history and physical findings (both those that require medical attention and those that do not), including your observations

Details of any explanations provided for abuse (be specific about what happened and where, time, date, and who witnessed it); document exact statements in quotations

History of previous injuries or accidents (first incident of abuse, worst and most recent)

Procedures performed (for example, funduscopic exam) and medical treatment provided

Measurements, drawings and/or colour photos where appropriate

Colour, size, shape, induration, texture, location, and level of discomfort or pain (pain scales to be used) related to lesions and bruises

Behaviour of partner or other people accompanying client

Safety check completed or not for both client and children

Diagnosis (for example, domestic violence)

Information given and referrals made with consent

Final disposition

Do not use the words "denies" or "claims" as they are judgmental. Instead use "reports," "chooses," "declines," or "client states." Do not document conclusions or general statements.

Monitoring and Follow-Up

Provide continual, ongoing medical and emotional support. For older adults, use frequent home visits to assess their safety.

Referral

Offer to refer to an agency or individual who can discuss options with the victim. A counsellor or social worker can assist the client to increase self-esteem and provide continued support. Refer to other resources if the client is interested. Refer to a physician if the medical condition of the client warrants it.

Reporting Family Violence

Family violence may be classified as child abuse if a pregnant woman is affected and/or a child witnesses a parent being abused. For information on reporting family violence when a child or fetus is involved, refer to chapter 5 of the pediatric guidelines titled "Child Maltreatment", under the "Management of Child Maltreatment" section.

Prevention

Monthly home visits from the prenatal period through infancy (until child's second birthday) for disadvantaged families, targeting first time mothers having one or more of the following: age less than 19 years, single parent status, and low socioeconomic status

Have brochures available for those who suspect someone they know is being abused and advise what they can do to help. One such brochure is available from the British Columbia government

An Aboriginal resource for community strategies to prevent family violence is called the " Healing Journey"

Domestic Violence

An individual in or formerly in an intimate relationship or marriage aims to dominate and control the other individual. The repeated behaviours create fear and intimidate so that there is increasing isolation from others. The behaviours may be physical violence, psychological attacks, and/or financial abuse.

Aboriginal individuals are almost twice as likely as other Canadians to report being a victim of spousal violence, and females are more at risk of serious violence (for example, gun involvement, choking) than males. The majority of those who experience spousal violence also are victims of emotional and/or financial abuse.67 Aboriginal women are 8 times more likely to be killed by their partner than other Canadians. Lastly, many reports show that over half and up to 90% of Aboriginal women in some communities experience domestic violence.68 The numbers for men are slightly lower.69

Risk Factors

In addition to those listed as risk factors under "Family Violence" above, risk factors include:

Age under 35 for both male and female

Blended families

Gay, lesbian or bisexual

Aboriginal

Elder Abuse,

Behaviour of someone with an ongoing relationship of power or trust to and a duty toward (for example, caregiver in retirement home or client's home, friend, spouse, child) an older adult (in Canada > 65 years, but some consider First Nations > 55 years old) that causes actual or potential harm (for example, physical abuse, emotional/psychosocial abuse, neglect, and/or financial abuse) to the older adult.

Older adult females are more likely to be abused by family members than males. Older adult females are most often abused by a spouse or an adult child, whereas older adult males are most often abused by an adult child. However, abuse by an acquaintance or stranger is also common in this group, yet is not accounted for in the definition of elder abuse.73 The most frequent type of abuse is financial and emotional/psychosocial, followed by physical.74

Aboriginal elders experience higher levels of abuse than other Canadian older adults.75

Risk Factors

In addition to those listed as risk factors under "Family Violence" above, risk factors include:

Inability to care for self (dependent on another person)

Dementia

Depression

History of hip fracture or stroke

History of abuse between family members

Socially isolated

External family stressors (for example, illness, death in family)

Caregiver has problems (for example, mental illness, substance abuse, financial dependence on older adult, history of violence)

Management

In addition to the items discussed under "Management" for family violence, the following considerations for elder abuse should be made:

The older adult, if judged competent, is entitled to make decisions that affect his or her life (for example, medical treatment, housing)

Older adults may require referral to more community resources than are listed above under "Nonpharmacologic Interventions." These include a home nursing program, Meals on Wheels, and home help aids to enable the elderly person to remain in his or her residence and community

Engage social services and other members of the extended family to reduce the stress on the caregiver's family

Provide counselling to the abused elderly person and the caregiver individually

If the caregiver is willing, consider referring them for treatment (for example, for depression, substance abuse)

Consider if the situation requires an institutional placement

Gang Involvement

Information about gang involvement is presented in chapter 19 "Adolescent Health" of the pediatric clinical guidelines.

Mood Disorders

A disturbance of mood, usually recurrent, in which a "high" (mania) or a "low" (depression) is experienced with a greater intensity and for a longer period than usual.76 The symptoms must cause significant distress and/or impair social, occupational or other functioning and must not be due to other physical or mental health disorders.

Types

Bipolar disorder

Depression: major depressive disorder, dysthymic disorder, seasonal affective disorder, and postpartum depression

Resources for Client Education

Conditions with Depressed Mood

Unhappiness, fearfulness and hopelessness can also appear in the following conditions:

Substance-related mood disorder

Mood disorder related to medical condition (including chronic diseases)

Adjustment disorder with depressed mood (including pathological grieving)

Normal Bereavement

Bereavement is a reaction to losing a close relationship. Often the following are present:

Feeling numb, in shock, intensely sad, anxious for the future and empty; having visual and auditory hallucinations of the deceased; chest tightness

Signs and symptoms of a full depressive syndrome may be present (for example, sadness, sleep and appetite changes, agitation)

Guilt, if present, is chiefly about things done or not done by the survivor

The survivor may wish that he or she had died with the deceased

Anger is a common reaction, because life goes on for others

The survivor regards the depressed mood as normal

The reaction may be delayed but rarely occurs later than the first 2 or 3 months after the death; periods of sadness may occur occasionally related to important events

The bereaved person often becomes suddenly aware of his or her own mortality, which heightens any sense of insecurity

The duration of "normal" bereavement varies considerably among different cultural and subcultural groups; abnormally long, intense, or debilitating bereavement is viewed as such by others of the same group

Morbid preoccupation with worthlessness, prolonged and marked functional impairment, and marked psychomotor retardation suggest major depression rather than bereavement

Members of the family can be expected to go through the grieving process at different rates, and will have certain reactions to that fact. They may be upset by each other or may attempt to protect each other from the unhappy feeling. Some members may feel guilt with regard to loving or enjoying other people or having fun while other members of the family are still grieving

Management of normal bereavement:

Call the bereaved to offer condolences and offer an appointment to "check in"

Describe for the bereaved the frequently observed or expected stages of bereavement: anger, despair, guilt, depression, and acceptance. Encourage maintenance of usual activity, sleep, exercise and nutrition routines

Allow time to grieve and do not force acceptance of the death, which may take 1 or 2 years to be fully achieved. Encourage and permit the person to talk about the death and express feelings related to it

Forewarn of the "anniversary phenomenon," in which the loss is re-experienced 1 year later. This is a normal experience and can be used to deal with unresolved grief in a constructive way

The belief systems of the person with respect to life after death should not be challenged, nor should the person be persuaded toward any particular belief. The person should simply be supported in his or her beliefs if they provide comfort and support

Monitor for prolonged grief (grief lasting more than 6 months with feelings of emptiness, bitterness and mistrust) and symptoms of major depression

Adjustment Disorder,

Identifiable psychosocial stressor (for example, marital, financial, diagnosis of a chronic disease or medical condition) occurred within 3 months of onset of disorder and is not normal grieving

Maladaptive reaction consists of impairment of social or occupational functioning or symptoms in excess of the normal and expected reaction to the stressor and does not meet the criteria of another disorder

Disturbance eventually remits after the stressor ceases (usually within 6 months)

Does not meet criteria for major depressive disorder

Management

Supportive counselling, including:

Explanation of the abnormal response to the individual, stressing its transient nature (it will resolve once the stressor is removed or the client adapts)

Mobilization of natural supports (family, friends)

Encouragement of a realistic sense of competency

Mobilization of the individual's personal resources and strengths

Mood Disorders: Bipolar Disorder80 81 82 83

Bipolar I disorder is defined as one or more manic or mixed episodes. Almost all clients also experience depression, but it is not required for the diagnosis. Bipolar I is equally prevalent in men and women.

Bipolar II disorder is defined as one or more major depressive episodes and at least one hypomanic episode. It is more likely to begin at a younger age, is more common in women and those with a strong family history, and has a higher risk of suicide.

Bipolar spectrum disorder includes other related mood disorders, but most are not recognized by the Diagnostic and Statistical Manual IV.

As with all mood disorders, the symptoms must cause significant distress and/or impair social, occupational or other functioning.

The Diagnostic and Statistical Manual IV describes manic episodes as lasting at least 1 week (less if the person requires hospitalization) and include a distinct period of a persistently elevated, expansive or irritable mood and at least 3 (4 if it is irritable mood) of the following during that time. They can be remembered with the mnemonic DIGFAST:84

D istractibility (in speech or activity)

istractibility (in speech or activity) I ndiscretion -- excessive involvement in pleasurable activities with high likelihood of painful consequences (for example, shopping sprees, sexual indiscretions)

ndiscretion -- excessive involvement in pleasurable activities with high likelihood of painful consequences (for example, shopping sprees, sexual indiscretions) G randiosity or inflated self-esteem (may be delusional)

randiosity or inflated self-esteem (may be delusional) F light of ideas or subjective experience of racing thoughts

light of ideas or subjective experience of racing thoughts A ctivity (goal-directed) increase or psychomotor agitation

ctivity (goal-directed) increase or psychomotor agitation S leep -- decreased need for it

leep -- decreased need for it Talkativeness increased or pressure of speech

Mania may include psychotic features, but only if they occur during mood episodes, that are either mood congruent (for example, consistent with typical mania themes) or mood incongruent (for example, persecutory delusions).

Hypomania is defined the same as a manic episode, but the symptoms are only present for at least 4 days and it is does not significantly impair functioning.

Mixed episodes are defined as the co-occurrence of a manic episode and a major depressive episode nearly every day for at least 1 week.

Rapid cycling is defined as 4 or more mood episodes in a year with full or partial remission for at least 2 months between episodes with similar symptoms or a switch from depression to mania or vice versa. This occurs in approximately 20% of those with bipolar disorder and is slightly more common in women.

Cyclothymia is defined as the alternation of hypomanic symptoms with mild depressive symptoms, often over at least 2 years; however, the symptoms do not meet the definition of manic, mixed, or major depressive episodes. Rarely are there periods without symptoms and the symptoms do not last more than 2 months at a time.

Between 1% and 2.4% of the general population has bipolar disorder, which generally starts between the ages of 14 and 24. If the disorder starts before age 19 then the individual is more likely to have significant disruptions in quality of life. Over 50% or 60% of those diagnosed with bipolar disorder have a first episode during childhood or adolescence.

The course of bipolar disorder is variable with relapses and remissions. Depressive symptoms occur more often than manic symptoms throughout the disorder.85

Individuals with bipolar disorder often have comorbid conditions. Up to half of those with bipolar disorder also experience substance abuse, suicidal behavior, and/or anxiety disorders.

Information specific to bipolar disorder in adolescents is presented in the "Adolescent Health" chapter of the pediatric clinical guidelines.

Risk Factors

Depression with a rapid onset, psychomotor retardation and psychotic features

Family history of affective disorders (particularly bipolar disorder)

History of psychomotor agitation or antidepressant-induced mania or hypomania

Cyclothymia

History

The manic client is usually coerced into attending a health care facility by family or police officers and is often hostile, agitated, and perhaps belligerent. The client will attempt to tone down their feelings and grandiosity in order to appear normal and will rationalize or deny symptomatic behaviour. The history presented by family or others should be given considerable weight in making a diagnosis and deciding about treatment and management.

If a client suspected of having or known to have bipolar disorder is agitated, rapidly assess for the following prior to management:86

Risk of impulsive or dangerous behaviours toward others

Suicide risk

Insight into current situation

Ability to comply with treatment

Assess a client for bipolar disorder if they present with:

A history of or symptoms of depression, hypomania or mania

Vague or nonspecific somatic concerns that are otherwise unexplained

Reverse vegetative symptoms (for example, hypersomnia, hyperphagia)

Obtain the history from both the client and family or friends, if possible, as some clients believe that their hypomanic states are normal and not a concern (particularly if they are in a depression). Ask open-ended, non-leading, and general questions about mood and symptoms of depression and mania. Then ask about specific symptoms of depression and mania (for example, whether they have experienced the symptoms, and their duration in current and previous episodes).

Assess for:

Mood lability

Symptoms of mania and depression, including history of symptoms, duration and severity, and whether they meet diagnostic criteria for mania and/or major depressive disorder

Degree of impairment in social and work relationships

Sleep disturbances

Psychotic symptoms (for example, delusions, hallucinations) and when they occur

Impulsive or dangerous behaviours

Prior episodes of mania, hypomania and/or depression

Family history of mood disorders

Suicide risk

Substance use or abuse

Medications (particularly antidepressants if rapid cycling)

Medical and psychiatric history

Physical Findings

Assess for the following physical and psychosocial findings. If the client is acutely agitated defer assessment until they are able to cooperate:

General appearance (dress and grooming)

Vital signs and weight

Attitude and interaction (cooperative, guarded, or avoidant)

Activity level (for example, calm, active, restless, psychomotor activity, abnormal movements)

Speech

Thought process (for example, coherent, disorganized, flight of ideas) and content (for example, delusions, obsessions, perceptual disorders, phobias)

Perception, cognition, insight, and judgment

Impulse control (for example, aggressive, hostile) and risk of harm to others

Suicidal ideation

Insight into condition

Mood or affect

Client interaction with family members or friends, if possible (for example, warm, nurturing, conflicting, rejecting, affectionate)

Rule out potential medical causes by doing a full assessment of the following:

Differential Diagnosis

Medical conditions (for example, multiple sclerosis, stroke, hyperthyroidism)

Substance abuse

Medications (for example, steroids, stimulants, levodopa, antidepressants)

Psychiatric disorders (for example, schizophrenia)

Major depression

Personality disorders (for example, borderline, narcissistic, histrionic, antisocial)

Anxiety disorders

Complications

Cognitive impairment

Disability (for example, unable to work); particularly for those with bipolar II

Suicide

Increased health care utilization

Death

Diagnostic Tests

A diagnosis of bipolar disorder requires initial and ongoing diagnostic tests. Consult a physician or nurse practitioner to establish the need for the following, unless the client will be starting lithium:87

CBC, fasting serum glucose, fasting lipid profile, electrolytes, liver function tests, creatinine, BUN, calcium, serum bilirubin, PT, PTT, urinalysis, urine toxicology screen for substance use, TSH, pregnancy test (if female), prolactin, EKG (if > 40 years or if indicated).

Management

Goals of Treatment

Control acute symptoms

Prevent recurrence of mood episode

Treat comorbid conditions

Assist clients to accept their diagnosis, develop confidence, and become effective at self-management

Appropriate Consultation

If possible, consult a physician before giving any medication. Consult a physician if the client is experiencing or has previously experienced manic or hypomanic symptoms, even in the absence of current or previous depression.

Nonpharmacologic Interventions

If in acute manic phase, treatment is usually difficult, trying, and stressful for everyone involved. Manic clients seldom have insight into the mood disturbance and feel great. They resent the need for treatment as it may bring them down from the "high" and hospitalization will place external controls on their movements.

The basis of management is sensitivity and firmness. Be sensitive to the fact that the client is frightened and will do almost anything to defend against attacks, whether real or imagined, on his or her self-esteem. Avoid reacting to the client's defensive assaults, recognize the source of the client's anger, be concerned, and respond calmly. Such a response will reassure the client that there is no need to fear counterattack by the professional. Firmness indicates to the client that external controls will be used if the client is unable to exercise restraint or is overwhelmed by impulses. The client may respond by testing the professional's determination.

In the initial stages of management, it is often necessary to employ the services of other staff or police officers, who would be capable of subduing and restraining the client. Do not hesitate to call for reinforcements if required (see "Violent or Acutely Agitated Psychiatric Clients").

Comorbid conditions must be treated as well as the bipolar disorder. During acute mania, the client should discontinue caffeine, alcohol, and any other substances used.

Comorbid conditions must be treated as well as the bipolar disorder. During acute mania, the client should discontinue caffeine, alcohol, and any other substances used.

If diagnosis is not clear, ask the client to keep a mood diary or calendar where they rate their mood from 1 (most depressed) to 10 (most high) every day over a period of time. This can help identify manic or hypomanic episodes.88

If stabilized, discuss and educate clients and family members about:

Bipolar disorder, its nature, scope, treatment options, and need for long-term management (for example, the importance of medication adherence since if they are not medicated they have a 70% chance in 1 year and 95% chance in 5 years of having another incident 89 )

) Potential early signs and symptoms of a relapse and an action plan to follow when this happens (for example, contact clinic immediately)

Disease management techniques related to lifestyle (for example, exercise routine, avoiding substance use, good nutrition, sleep and stress regulation)

The potential for drug-related side effects (for example, weight gain; nausea; diarrhea; renal, cardiovascular, endocrine, neurologic, dermatologic, and/or hematologic), cognitive impairment, and/or sedation and how to manage them

Lithium treatment requires clients to be consistent in their salt, caffeine, and fluid intake and losses

Discuss beliefs and attitudes about the illness, how it has affected their life and their beliefs about long-term effects of medication use

An educational booklet titled " What is Bipolar Disorder?" available from the Mood Disorders Society of Canada

Pharmacologic Interventions

Medication is essential to control the disordered behaviour, to alleviate stress, and to treat the underlying disorder. Initial adjunctive treatment is to manage acute agitation:

lorazepam (Ativan), 1-2 mg SL/PO/IM

Consultation with a physician is required for all of the following medications:

In severe cases, neuroleptic tranquilizers may be necessary for short-term use until in hospital:

haloperidol (Haldol), 0.5-5 mg PO bid to tid prn OR 2-5 mg IM q4-8h prn

An antiparkinsonian agent may have to be added to counteract extrapyramidal side effects caused by the haloperidol.

Occasionally, high doses of medication fail to settle a highly agitated manic client. The client is in danger of physical collapse and/or may pose a danger to staff or other clients.

Discontinue any antidepressant therapy.

Treatment in acute mania should start or optimize therapy with lithium, anticonvulsants and/or atypical antipsychotic medications.

Long-term maintenance therapy depends on the type of bipolar disorder. This can help to prevent or dampen future manic attacks.

Before lithium therapy is started, the following baseline diagnostic tests should be done: CBC, electrolytes, renal, liver and thyroid function, electrocardiography (ECG).

Often bipolar disorder, particularly early in the disease (for example, in adolescents), is chronic and refractory to treatment. But it will often respond to the medications listed above.90

Monitoring and Follow-Up

Follow up weekly until the client is stable for at least 2 months, then monthly to assess medication adherence and efficacy

Follow-up with regular, widely spaced appointments allows for continued education

Repeat CBC and liver function tests 4 weeks after starting treatment and then every 3-6 months

If taking lithium or divalproex, monitor trough serum levels 12 hours after the last dose (especially if the client is not adherent to their medications): 5 days after any dosage change (or starting) for lithium 3 to 5 days after any dosage change for divalproex

Two consecutive trough serum levels should be in the therapeutic range when a person is in the acute phase of treatment. Medication regimens need to be continued for at least 2 weeks at appropriate levels before assessing whether medication changes are needed, in consultation with a physician

Repeat BUN, creatinine, TSH at 3 and 6 months after starting lithium, then repeat every 6 months 91

After the acute phase (stable for at least 2 months), monitor serum trough levels every 3-6 months, unless needed otherwise (maintenance phase), along with a complete blood count, electrolyte levels, liver function and ECG

Since those with bipolar disorder are at increased risk for certain comorbid conditions (and this risk can be increased further with some drugs), routinely monitor in collaboration with a physician, for overweight/obesity, diabetes, metabolic syndrome, and dyslipidemia.92 Additionally, monitor for hematologic, hepatic, cardiovascular, and neurologic (for example, extrapyramidal symptoms) dysfunction. Assess females for polycystic ovarian syndrome

Referral

Medevac most manic clients, after consultation with a physician, to a hospital for observation and treatment. Clients who are not sent to hospital should be referred to a physician regardless of severity of symptoms

The decision whether to treat the client on an outpatient basis or admit and/or evacuate the client to a hospital (voluntarily or involuntarily) depends on several factors. This decision must be made in consultation with a physician and/or psychiatrist. For further considerations, see "Hospitalization and Client Evacuation" and "Involuntary Admission"

Outpatient treatment runs risks arising from the client's impaired judgment and erratic, unpredictable moods and behaviour

Psychotherapy, pharmacotherapy, and psychoeducation have important roles in the management of bipolar disorder. If resources are available, referral should be made by a physician

Mood Disorders: Depression93,94,95,96,97,98

The Diagnostic and Statistical Manual of Mental Disorders IV Text Revision (DSM-IV-TR) provides the following criteria for diagnosis of a major depressive episode:99

Five (or more) symptoms present for the same 2-week period, representing a change from previous functioning and at least one of the symptoms is depressed mood (for example, sad or irritable) or loss of interest or pleasure in usual activities for most of the day nearly every day.

All of the symptoms are listed in the mnemonic SADIFACES:

S for Sleep (for example, insomnia, hypersomnia, early morning wakening)

A for Appetite (for example, increased or decreased) or weight loss (more than 5% or not meeting expected gains in children) or weight gain

D for Depressed mood (can be irritable in children and adolescents, such as aggression or antisocial behaviour); often worse in morning

I for loss of Interest (for example, apathy, boredom, change in grades, social withdrawal)

F for Fatigue

A for psychomotor Agitation or retardation (change in energy level)

C for decreased Concentration or indecisiveness

E for low self-Esteem or excessive guilt (feeling worthless, hopeless)

S for Suicidal/infanticidal/homicidal ideation or recurrent thoughts of death (including recent dangerous behaviours)

Symptoms must cause significant distress or impairment in social, occupational (for example, school) or home functioning. Symptoms are not due to another medical condition (for example, hypothyroidism), delusions, hallucinations, bipolar disorder, substances (for example, drug abuse), or bereavement.

A major depressive episode can be categorized as mild, moderate, or severe. Mild depression is characterized by 5-6 symptoms, mild symptom severity, and mild functional impairment or normal functioning but with substantial and unusual effort. Moderate depression is between mild and severe depression. Severe depression is characterized by most symptoms, severe symptom severity, and an observable disability. Symptoms of depression may vary by cultural background.

Major depressive disorder occurs when the client experiences one or more major depressive episodes. Major depressive disorder can have melancholic features (for example, mood that does not improve even temporarily, early morning awakening, severe weight loss) and/or psychotic features (for example, mood congruent delusions or hallucinations). Major depressive disorder affects 11% of Canadians at some point in their life,100 yet over 30% of First Nations adults (27.2% of youth) have experienced major depression.101,102

Seasonal affective disorder is a major depressive episode with regular onset and remission of symptoms within a particular season. It usually occurs in the fall and/or winter.

Postpartum depression is a major depressive episode occurring within 4 weeks postpartum where symptoms can last up to 1 year after delivery. It occurs in at least 10% of mothers and is not the postpartum blues that may occur within 4 days postpartum.103

Subsyndromal/minor depression occurs when the client has fewer symptoms (for example 2-4) or a shorter duration of symptoms than required for a major depressive episode. The client may have functional impairment similar to a major depressive episode.

Dysthymic disorder occurs when depressed mood is present for most of the day on the majority of days for at least 2 years. Symptom-free periods may occur, but do not last longer than 2 months.104 In addition, 2 or more of the following are present during this time: change in appetite, insomnia or hypersomnia, fatigue or low energy, low self-esteem, difficulty concentrating, and/or hopelessness. Symptoms are not as severe as those during a major depressive episode and there are no psychotic features. A major depressive episode may not occur during the first 2 years of dysthymia, yet half of those experience one at some time during their life.97 Significant functional impairment occurs due to the length of symptoms. It may be superimposed upon or secondary to chronic mental disorder, personality disorder or organic mental disorder. It occurs in approximately 4% of Canadians during their life.105 Aboriginal individuals living off reserve are 1.5 times more likely to have depression than those in the general population.106

Females are twice as likely to be diagnosed with depression as males, starting in adolescence.107 However, depression can occur at any age.

For specific information about depression in children and adolescents, see "Depression" in the pediatric guidelines.

Causes

Genetics

Risk Factors,

History of depression (any kind)

Family history of depression

Mental illness (for example, anxiety or conduct disorders)

Substance abuse

Trauma

Psychosocial adversity (for example, family dysfunction)

Frequent use of the medical system

Chronic conditions (for example, diabetes, pain, cardiovascular disease)

Hormonal changes (for example, postpartum)

Presenting with pain, unexplained physical symptoms, fatigue, insomnia

History,

Assess for risk factors as listed above. If any risk factors are present, systematically screen (for example, at 6-week postpartum visit or 2-month well baby visit) and then assess for a depressive disorder.

Screening

The easiest way to screen for depression is to ask:

In the past month, have you had little interest or pleasure in doing things you usually do?

In the past month, have you been feeling down, depressed or hopeless?

If there is a "yes" answer to either one, a more detailed assessment is warranted.

Assessment

Standardized diagnostic ai