Instructions:
|Policy Title: |Mental Health Problems |
|Program Area: |Women’s Health (Maternity, Family Planning, OB CASE MANAGER) |
|Policy Identifier: | |Effective Date: |5/01 (FP), 5/02 and 1/9/08 (MH) |
|(optional) | | | |
|Approval Date: | |Revision Date(s): |5/02 (FP) 5/21/09 (MH), 9/23/10, 6/6/2018 |
|Approved by: |Kim Smith RN, BSN, MSHCA, Health Director |
|Approved by: |Patti Nance RN, MSN, Director of Nursing |
|Purpose: |
|The staff will evaluate the mental health status of patients in order to make appropriate referrals to ensure a healthy pregnancy, postpartum, |
|and reproductive years for mother and infant. |
|Definitions: |
|Columbus County Health Department (CCHD) Women’s Health patients will be screened for possible mental health issues that need addressing. |
| |
|Epidemiology |
|Etiology- Depression can be a normal reaction to everyday life. If it is appropriate to the life event and not severe, treatment may not be |
|necessary. Current theories focus on different factors, but the cause of depression is believed to be multi-factorial. |
|Psychological models include psychosocial stresses and developmental problems (personality defects, childhood events). Sense of loss, failure to |
|live up to one's ego ideal, and a sense of hopelessness and helplessness are all important concepts in the etiology of depression. Often, loss or|
|perceived loss precedes the onset of depression. Loss may involve a person, expectation, or job. Common ideals are to be loved, to be good and |
|kind, to be recognized for achievements, and to attain goals. With disappointments and failures comes the feeling of not living up to one's ego |
|ideals. Guilt felt because of failure can lead to anger and self-hatred with feelings of hopelessness and helplessness. These feelings are |
|related to one's negative self- concept, negative interpretation of one's experiences, and negative view of the future. |
|Biological models include genetic and biochemical factors. Depression appears to have some familial pattern or predisposition; however, the exact|
|familial role is not known. The biochemical model postulates a decrease in available biogenic amines at the postsynaptic membrane. Many studies |
|have used this model with inconsistent results. |
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|Risk Factors- Risk factors include, but not limited to, a family history of depression, poor self-concept or self- esteem, female gender, chronic|
|non-mood disorders, substance abuse, loss or death, or a stressful life event. Suicidal risk factors include, but not limited to, previous |
|attempted suicide, depression, dysfunctional family, battering, alcoholism, and chronic illness. |
|Incidence- The American Psychiatric Association reveals “Depression affects an estimated one in 15 adults (6.7%) in any given year. And one in |
|six people (16.6%) will experience depression at some time in their life. Depression can strike at any time, but on average, first appears during|
|the late teens to mid-20s. Women are more likely than men to experience depression. Some studies show that one-third of women will experience a |
|major depressive episode in their lifetime.” |
|Responsibilities: |
|Certified Nurse Midwifes (CNM)/Practitioners, Nurses, OB CASE MANAGER |
|Procedures: |
|Interviewing nurse will illicit and document history including mental health status risk factors and psychosocial screening in the electronic |
|medical record. Referral will be made to appropriate mental health agency as needed with medical physician consult. |
|Maternity Forms: |
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| Spanish Version |
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|Family Planning Forms: |
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|Subjective Data |
|Women frequently report somatic symptoms rather than depression, and several |
|conditions are typically revealed in history taking, including chronic illness and substance abuse. |
|Symptoms that the depressed woman frequently reports include headaches, constipation, sleep disturbances, loss of energy, change in appetite with|
|weight loss or gain, decreased libido, and chronic pain. These symptoms are somatic complaints, and a woman will more often present with them |
|than complaints of depression. Unidentifiable somatic complaints |
| |
| |
|frequently indicate depression and fatigue, but often women with these symptoms are labeled hypochondriacs. When asked about her feelings, a |
|woman may admit to sadness; decreased mood; feelings of guilt, worthlessness, or hopelessness; loss of interest in daily events; or withdrawal |
|from work and recreation. She may complain of difficulty concentrating and thinking or an inability to make decisions. |
| |
|History Incorporates the following areas: |
|Medical |
|Family history |
|Gynecological/Obstetric |
|Social Psychological |
|Medical history is taken with the realization that any illness may cause depression, but chronic illness is the most likely cause. Questions |
|regarding hospitalizations and injuries may provide important clues, especially if injuries are related to events such as violence or numerous |
|accidents. Substance abuse should be included in the history, as it is often related to depression |
|In addition, include prescription and over-the-counter medications that are being taken, because some are associated with symptoms of depression.|
|Stimulants can cause depression during withdrawal; certain antihypertensive agents, oral contraceptives, and corticosteroids may also cause |
|depression. |
|Family medical history includes questions about the family's history of depression, mental illness, suicide, and substance abuse |
|Gynecological obstetric history includes the date of the previous menstrual period and cycle length to determine the possibility of premenstrual |
|syndrome (PMS); PMS is associated with depression. |
|Social history includes marital status, home or work problems, job changes, economic status, and support systems. |
|Psychological history includes information about previous psychiatric illness, suicide attempts, and cognitive abilities (memory and thought |
|process). Always ask about suicidal ideation, what means would be used, if a plan has been established, and when the plan is to be carried out. |
| |
|Objective Data |
|A physical examination is done, as are several diagnostic tests, including those ruling out substance abuse. |
|Physical examination- Begins with the evaluation of the patient's general appearance. The patient may be over or under weight, be unkempt, have |
|poor affect, or move sluggishly. |
| |
|Skin, nails, and hair. Hair may be dirty and uncombed, and nails brittle and dry. Scars |
|may be visible on the wrist or other parts of the body. |
|Eyes. The eyes may appear dull with fixed gaze, poor eye contact, |
|circles under the eyes, from lack of sleep, and pale conjunctiva |
|and mucosa. |
|Mouth. Oral hygiene may be poor. |
|Neck Thyroid may be palpable or with nodules. |
|Nervous system. Examination may yield similar findings to those of substance |
|abuse, i e. abnormal cranial nerve findings:: peripheral |
|neuropathy cerebral degeneration, optic neuropathy, and |
|the presence of tremors. |
|Diagnostic tests are varied. Hematocrit and hemoglobin tests rule out anemia. The thyroid panel rules out thyroid disease. |
| |
|Nursing Implications |
|The health care provider must give full attention to the patient in the privacy of an office. If the patient does not feel comfortable, she will |
|probably not be honest about her problem, A nurse practitioner may provide care for a mildly depressed woman usually in collaboration with a |
|physician, but referral should be made to a psychiatric specialist for a seriously depressed woman. Always refer a patient if suicidal ideation |
|is expressed. If suicidal planning is expressed the CNM/Practitioner or nurse should call the Crisis Hotline so that the patient may be evaluated|
|immediately. |
|Differential Medical Diagnosis |
|Chronic illness, hypothyroidism, depressive side effects from medication, premenstrual syndrome, substance abuse. |
| |
|Plan |
|Psychosocial Intervention |
|The type of intervention depends on the type of depression. Individuals with major depression may benefit from antidepressant medication, |
|education, supportive counseling, psychotherapy, and family therapy. Individuals with dysthymia are often given antidepressant medication for |
|symptom relief, but are not as responsive as patients with major depression. The patient with dysthymia should also receive psychotherapy or |
|supportive counseling. The patient with reactive depression usually requires no antidepressant medication, but responds well to education, |
|supportive counseling, and family therapy. When precipitated by an illness, depression often resolves as the illness improves. |
| |
|Patient education should include information about depression and the relationship of it’s symptoms to medical illness, stressors, and |
|situational crisis. It should be stressed that depression is a medical illness, not a character defect or weakness. |
|Treatments can be effective, and there are many treatment options. An effective treatment can be found for nearly every patient. Recovery is the |
|rule, not the exception. The goal is complete symptom remission. Recurrence is a risk. Therefore, the patient should be encouraged to return with|
|any recurrent signs and symptoms |
|Teaching stress reduction, coping styles, and assertiveness may be beneficial. Help the patient identify and express her feelings of anger, |
|hostility, sadness, and anxiety. |
|Supportive counseling focuses on encouraging the patient to develop a social network and increase activity. Participation in support groups may |
|be beneficial for the patient and family. When appropriate, always involve persons who are important in the patient's life |
|Family counseling may be beneficial because episodes of depression have been associated with family dysfunction. |
|Psychotherapy's goal is to correct specific aspects of depression, including thoughts, behavior, and affect. Its purpose is not to change the |
|patient's personality. |
|. |
|Referral Options: |
|Family Alternatives: (910) 641-0052 or 640-1598 |
|Families First: (910) 642-5996 |
|Refer to the Columbus County List of Mental Health Providers or if preferred refer to a provider in another county. (See state Mental Health |
|Provider List on line: |
|Mental Health Crisis: |
|When a patient shows up or calls with a mental health crisis, the provider may access the 24 hour 7 days a week Access line for the following |
|counties. |
|Bladen, Columbus, Robeson, Scotland |
|1-800-670-6871 |
| |
|New Hanover, Pender, Brunswick |
|1-866-875-1757 |
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|There ARE crisis mental health services in Columbus County, including the following: |
|Mobile Crisis Team: Someone will come to your practice to talk with your patient, or to their home, to assess their immediate needs. If needed, |
|they will initiate an involuntary commitment order (IVC). This can prevent a long ER visit. |
|Facility-Based Crisis Units: Patients can go or be directed to such facilities for acute psychiatric treatment over several days, if necessary |
|(i.e. The Harbor by New Hanover Hospital in Wilmington.) This can prevent a lengthy hospital stay! |
|Walk-in-Clinics: Patients can be screened, triaged, and given an outpatient appointment within 24 hours if needed. |
|Trillium’s Access to Care Line at 1-877-685-2415 Mental Health For more information call 1.866.998.2597 or email Columbus@ |
|Laws and Rules: |
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|Reference(s): |
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|American Psychiatric Association |
|Trillium Mental Health |
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