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. |

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|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 |

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|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. |

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|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. |

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|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. |

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|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. |

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|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. |

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|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. |

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|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. |

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|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 |

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|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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