5.

A Patient’s Journey Through Mental Health Services

 Have an awareness of the impact that early childhood trauma can have on one’s
mental health.
 Gain an understanding of how mental health services are configured and the
roles of the different members of the MDT (doctor, community psychiatric nurse,
psychologist, etc.).
 Gain an understanding of what it is like to be assessed under the Mental Health
Act 1983 and to be admitted to a psychiatric ward.
 Understand the importance of “hope” and “recovery” in a patient’s journey.
 Understand, from a patient’s perspective, how to communicate effectively with
patients with mental health issues

 Was lecture on pt’s personal journey – watch on 2x

6. Alcohol and Illicit Substance misuse

 Be competent in taking a history from a patient with suspected alcohol or substance
misuse.
 Have an understanding of the links between alcohol misuse and mental disorder.
 Have an understanding of the links between illicit substance misuse (including novel
psychoactive substances) and mental disorder.
 Have an understanding of the management of opiate dependence.
 Have an understanding of the management of acute alcohol withdrawal and
alcohol dependence.

Dependence =
3 or more of: (ICD 10 diagnosis)
- C- strong desire/ compulsion to take the substance
- C- impaired control of substance taking behaviour in terms of onset, termination or
levels of use
- P- Physiological withdrawal state when use is reduced/ stopped
- S- Preoccupation with use, to exclusion of other pleasures or interests (salience/
primacy – obtaining and using the substance takes over, other interests and pursuits
are neglected)
- T- Tolerance to effects of substance leading to increased use
- H- Persistence despite clear harm

Tolerance = increased doses of psychoactive substance are required to achieve effects

originally produced by lower doses; contributes to escalation of use

Narrowing of repertoire = loss in variation in the use of the substance (e.g get same
substance, go to same dealer)

Intoxication = overloading body with substance

- disturbances in: level of consciousness, cognition, perception, affect, behaviour
- disturbance directly related to effect of substance
- resolves with time
Withdrawal state = clear evidence of recent cessation or reduction of use
- Signs and symptoms compatible with known features of withdrawal
- These don’t attribute to other disorder
- In some, will be aborted by reinstating the substance
- Pinpoint pupils (intoxication), dilated = coming off opioid

Harmful use = pattern of psychoactive substance use that is causing damage to health
- Clear evidence of harm – physical/psychological
- Pattern of use has persisted for at least one month or repeatedly over a 12 mo
period
- Only classified when person knows the risks but still continues

Abstinence = period during which no substance is used

Detoxification – benzodiazepine for alcohol withdrawal

Reinstatement = occurs after period of abstinence, when patient re-starts the substance
and rapidly increases use to previous levels
Stages of change: Prochaska and DiClemente
1. Pre contemplation
a. Person feels there is no problem, though others recognise it
2. Contemplation
a. Person weighs up pros and cons and consider if change necessary
3. Decision
a. Person decide to act (or not)
4. Action
a. Choose strategy for change and pursues it
5. Maintenance
a. Gains are maintained and consolidated
6. Relapse
a. Returns to prev pattern, buy relapse may help learning

Substance abuse = due to ability to cause pleasure

- E.g Morphine (gives a peak high)

History taking: substance misuse

- Age at starting
- Types and quantities
- Frequency
- Route of administration
- Overdose
- Abstinence and relapse triggers (history of)
- Symptoms when drug unavailable (withdrawal symptoms)
- Medical complications when in withdrawal
- Psychiatric history
- Uncover relationship of substance of abuse to presenting complaint
- Diagnose the specific syndrome
 a. Acute intoxification
b. Harmful use
c. Dependence syndrome
d. Withdrawal state
e. Psychotic disorder
f. Amnesic syndrome
- Explore consequences of patient’s addiction:
a. Physical health
b. Psychological well being
c. Social and family relationship
d. Economic and employment status
e. Determine level of patient motivation to change
f. Offer appropriate intervention
- Dual diagnosis
a. Mental illness and comorbid substance
misuse problem
b. Diagnosis of mental illness becomes
challenging in face of substance misuse
c. Primary psychiatric illness may
precipitate substance misuse
d. Substance misuse may worsen course of
psychiatric illness
- 22-44% of psychiatric inpatients have
problematic drug/ alcohol use (highest rate in
urban city areas)
- Intoxication &/ dependence may lead to
psychological symptoms and social difficulties
- Substance misuse &/ withdrawal may cause
psychiatric symptoms or illness and may trigger
illness in those who are predisposed Intermediary factors; eg. Familial

Alcohol:
- Safe levels:
a. Men and women: 2-3 units/ day
b. 14 units/ week
- Harmful levels:
a. Women > 6 units/ day; ≥35 units/week
b. Men > 8 units/day; ≥50 units/ week

Alcohol dependence:
- Aetiology:
a. M>F
b. Genetic - 25-50% of predisposition may be inherited
c. Occupation – publicans, doctors, journalists, salesmen, actors, entertainers,
seamen
d. Social – childhood difficulties/ problems, parental separation, low education
- Clinical presentation:
 a. Intoxication
i. Relaxation and euphoria followed by disinhibition, various emotional
states (irritable, weepy, morose), impulsive, irresponsible behaviour
ii. Slurred speech, ataxia, sedation, confusion, flushed face, nystagmus,
conjunctival injection (bright red)
b. Withdrawal (often opposite of intoxication)
i. Headache
ii. Nausea
iii. Retching
iv. Vomiting
v. Sweating
vi. Insomnia
vii. Anxiety
viii. Agitation tachycardia
ix. Hypotension
x. Delirium tremens
xi. Seizures

Physical complications of alcohol:

- Liver
a. Hepatitis
b. Cirrhosis in 10-20% of dependent persons
- GI
a. Pancreatitis
b. Oesophageal varices
c. Gastritis
d. Peptic ulceration
- Neurological
a. Peripheral neuropathy
b. Seizures
c. Dementia
- Cancer: bowel, breast, oesophageal, liver
- CVS: hypertension and cardiomyopathy
- Head injuries/ accident
- Foetal alcohol syndrome
a. Infants born to those who drink during pregnancy

Psychological complications:
- Depression and anxiety
- Self harm and suicide risk
- Amnesia/ blackouts (due to intoxication)
- Cognitive impairment:
a. Alcoholic dementia
b. Kosakoffs psychosis
c. Alcoholic hallucinations
d. Morbid jealousy (othello’s syndrome)
Social:
- Poor work performance
- Unemployment
- Domestic violence
- Family breakdown
- Legal issues: drink driving, assault, theft
- Childhood neglect, abuse

Management:
- Motivation to change needs assessment
- Detoxification: benzodiazepines (GABA receptor cover; make brain think already on
alcohol), Vitamins (thiamine); patients with alcohol are severely BE1 deficient ->
could lead to Wernicke’s Korsakoff syndrome (degenerative brain disorder =
damage to brain thalamus and hypothalamus)
- Relapse prevention
a. Psychological support (AA – alcohol anonymous; 12 steps )
b. Medical
i. Acamprosate – reduce craving
ii. Disulfiram- induce flushing if alcohol taken (aversion therapy: get
averted into alcohol – makes them feel very sick and not want to go
on it) (only work when well motivated; risky and overload with
formaldehyde)
Unit of alcohol = (total vol (ml) by its ABV percentage)/ 1000

Alcohol related emergencies:

- Delirium Tremens (severe form of alcohol withdrawal – sudden and severe mental/
nervous system changes )
a. Onset in 48hrs after abstinence
b. Confusion, hallucination, illusions, agitations, sweating, tachy, tremor,
seizures
c. Treat: reduce benzodiazepine regime and parenteral B vitamins and
complexs (pabrinex) to avoid Wernicke Korsakoff syndrome

- Wernicke’s encephalopathy
a. TRIAD: confusion, ataxia, ophthalmoplegia
b. Acute thiamine (vitamin B1) deficiency
c. Treat: parenteral B vitamins via IM or IV
d. If untreated -> korsakoff’s psychosis (IRREVERSIBLE anterograde amnesia
with confabulation)

Benzodiazepines
- diazepam (long acting), Lorazepam, Temazepam
Short acting: give quicker high and quicker down – more addictive
- Can be addictive
- Prescribed/ bought
- Usually oral, can be injection
 - Produces sedation, euphoria, disinhibition, lability of mood, anterograde amnesia,
unsteady gait, slurred speech, nystagmus, reduced consciousness, respiratory
depression
- Withdrawal can cause delirium tremens – like presentation with psychotic symptoms
and seizures
- Treatment – convert to diazepam equivalent dose and withdraw gradually over 8+
weeks

Cocaine:
- Stimulant
a. Alert, confident, strong, disinhibited
b. Short acting – need to repeat dose
c. “come down” – fatigue, depression/ dysphoria, paranoid ideation,
depersonalisation
- Two forms:
a. Powder (hydrochloride)
i. Sniff/snort/ inject
b. Crack (alkaloid)
i. Heated and inhaled through pipe
ii. Quick acting with fast high
iii. Inject if added to acid (vit C) – often with heroin (speedball) (heroin
gives calm (downer), cocaine gives stimulant)
c. Management:
i. No replacement therapy available
ii. Acute psychotic episodes may require antipsychotic and
benzodiazepines (short term) for symptom control
iii. Self help and support group
iv. Cocaine anonymous

Cannabis (second most used) (weed/ marijuana)

- Cannabis sativa
- Dried vegetative state or resin – eat/ smoke
- Active substance tetrahydrocannabinol – 75% of available cannabis is “skunk”
(genetically engineered to have more THC)
- Produces high – but can exaggerate prev mood state, paranoia, distortion of time,
mild hallucinogen
- Conjunctival injection, dry mouth, tachy, resp symptoms
- Associated with schizophrenia

Heroin:
- Opiate derivative, highly addictive
- “Brown, smack, gear”
- Injected
a. If combined with crack cocaine is speedballing
- Smoked
a. Heat on tinfoil and inhale smoke
b. “chasing the dragon”
 c. Also snort (less common)
- Give strong sense/ rush of relaxation/ wellbeing
- Withdrawal symptoms
a. Vomit, diarrhoea, cramp, sweat, dysphoria
- Risk of overdose

Physical effects:
- Pin point pupils
- “track marks” – injection sites
- Constipation
- Poor nutrition
- Poor dental state (reduced salivary flow)
- Resp depressant
- Blood borne virus (injecting patients): Hep B, C, HIV

Management:
- Harm reduction
a. Needle exchange, reduce
b. Encourage smoke rather than inject
c. Raise awareness
- Narcotics anonymous
- naloxone (opioid reversal)
- opioid substitution treatment:
a. methadone
i. full agonist, prolong QT interval (monitor ECG 6 monthly)
ii. cheap, large evidence base
b. Buprenorphine (Subutex)
i. Partial agonist, less sedative, less risk of OD
c. Others
i. Dihydrocodeine (short term stop gap only)
d. Patient choice – maintenance and detox

Amphetamines:
- Stimulant
- “speed”, “whizz”
- Snorted, injected, eaten/ put on gum
- CVS strain
- Enlarged pupils
- Talkative, agitated, full of energy, irritable
- Psychosis (schizophreniform)

Ectasy:
- MDMA
a. 3,4 methylenedioxymethamphetamine
- Tablet/ powder
- Causes increased energy, hyperaesthesia, increased feeling of wellbeing and love
- Can cause panic, dysphoria and depression
 - Associated w raised temp, dehydration, tachy, DIC (disseminated intravascular
coagulation)
- >200 deaths since 1990 in UK

Khat:
- Plant grown in east Africa
- Taken fresh, recently illegal
- Consumed in Africa/ arab communities
- Stimulant like effect
- Precipitate psychosis
- Used to make miaow miaow

Ketamine:
- Anaesthetic agent
- Powder/ tablet
- Produces hallucinations, reduced pain sensation, drowsiness, sedation, resp
depression
- Prolonged use – ketamine bladder; haematuria, scarring and severe pain – severe
cases need bladder removal

LSD:
- Taken as tab on tiny square of paper
- Hyperaesthesias, hallucinations, other altered perceptions and experiences (“trip”)
- Trip can be pleasant or unpleasant and frightening
- Flashbacks can occur days/ months later
- Can precipitate mental health probs in people with predisposition

Novel psychoactive substances:

- Previously known as legal highs; clockwork orange, bliss, mary jane
- Powder/pill/ smoking mix/ liquid capsule/ tabs
- None legal to produce, supply, import in may 2016

Main effects:
1. Stimulants:
a. Mephedrone, naphyrone - Act like amphetamines, cocaine, ecstasy
i. Feel energized, physically active, fast-thinking, chatty, euphoric
2. Downers/ sedative:
a. GBH/ GBL; benzodiazepines
i. Feel euphoric, relaxed, sleepy
3. Synthetic cannabinoids
a. Spices (more potent than natural cannabis; class B drug; smoked) , black
mamba – cannabis
b. Relaxation, altered consciousness, disinhibition, feeling energised and
euphoria
4. Hallucinogens/ psychedelics
a. LSD, magic mushroom, ketamine
Drug classification:
- Defined by gov, change time to time
- Class
a. Class A – crack cocaine, LSD, heroin, magic mushroom, methadone
i. Possession – 7 years and unlimited fine
ii. Possssion with intent to supply – life and unlimited fine
b. Class B – amphetamine, codeine, ket, cannabis
i. Possession – 5 years and unlimited fine
ii. “” 14 yrs and unlimited fine
c. Class C – anabolic steroids, benzo, GHB/GBL, Khat
i. Possession – 2 yrs and unlimited fine
ii. “” – 14 yrs and unlimited fine
- Diff classes carry diff penalties; usually reflect potential level of harm