An Adult Mental Health Clinical Journey

Here’s how the clinical journey might look in an adult mental health service (thanks to Capital Coast Adult Mental Health service in New Zealand for helping us write this)…

Referral

Jeff is referred to AMHS by his GP as he has been feeling very low, having difficulty sleeping and thinking that there is no point to life, with some suicidal feelings and thoughts. The GP writes that he knows Jeff well, that in the past he has taken an overdose and knows he smokes cannabis from time to time – this has increased recently. Jeff is struggling to get in to work, feeling tired, having difficulty concentrating and he’s really worried that a report he filed had a major error in it that will have a devastating impact on his organisation. His mother has dementia and he spends a lot of time supporting his dad. He is worried about how the amount of time he is spending may impact on his relationship with his girlfriend Jane.

The service looks at referral letters daily. The difficulties described meet the eligibility for the service, although it is not clear whether Jeff’s problems could be managed in primary care or needed the adult mental health team or substance misuse service.

Clinicians call Jeff to find out a little more about the referral and to check the urgency. In discussion with Jeff they agree that he is not in crisis and so arrange for him to be seen in Choice.

(If the staff had been unable to reach Jeff they would have sent him and the referrer a letter asking him to call them. If he had been in crisis, he would have been seen the same day, but still in a Choice framework). Admin send information about the service, including a description of the aims of the Choice appointment. It tells him that if he wants to have some help from the adult mental health service after this then he will be able to book an appointment to see someone in the team who is best placed to help, who may not be the person they see in Choice. If Jeff was a particularly vulnerable person e.g. not able to read or had found it hard to engage previously, then he would be contacted by phone or the referrer asked to help him book in.

Choice

Clinical staff David, Emily, Dr. Bank and Pamela had each previously put several available dates they could do Choice appointments into the Choice diary.

When Jeff phoned in, admin offered two Choice appointments at different times and on different days. Jeff chose Wednesday at 4pm with Pamela as it just meant he had to leave work slightly early.

He turns up on Wednesday at 4pm and has his Choice appointment with Pamela. They talk about what the problems are, what he has tried (which is mainly cannabis, but once he took some cocaine and found it helped him work for a while) and what he would like to be different.

Pamela listens carefully and works hard to find out Jeff wants. She makes use of all the information available to her from the referrer and old notes (he once went to the substance misuse service about his cannabis use, but quickly dropped out). In her head she is actively considering risk issues (especially suicidality in Jeff’s case) and whether any diagnoses may be appropriate (including screening for his level of alcohol and substance use). She finds out enough to develop a shared initial understanding/formulation with Jeff. They agree that they need to clarify how much his cannabis use is affecting his mood. However, they acknowledge that this is not the whole story. Jeff’s parents’ infirmity and his relationship with girlfriend Jane are significant stresses in addition to a very busy job.

Together they decide that AMHS would be able to help him. Jeff wants to get on better with Jane- it’s an important relationship and he does not want to mess it up. He also wants to know if he has to stop using cannabis as it the one thing they share and enjoy together- and it makes him feel less anxious. He’s aware he found the cocaine great and is drawn to using it again.

Pamela describes what types of things could be offered and what the available evidence for each approach is. She also describes her experience of what helps others in similar situations. They talk about how drugs affect mood, couple relationship work and supports that may be available for his parents. Having decided on a Choice point together they discuss some things to try at home [Pre-Partnership work]. Jeff decides to reduce his cannabis use to only once at night and notice any impact on his mood. He also decides to talk to Jane about how he is feeling and let her know how important the relationship is to him.

They agree that involving Jane would be helpful and that the local substance misuse service may be able to offer some support around his cannabis use, and the local dementia cafe could be a place he could meet other people with a family member with dementia. His parents may be entitled to some additional support and Pamela gave him some leaflets and websites to look at, including guidance on the treatment of depression.

Core Partnership

Pamela knows that clinicians Emily and David have the extended core skills to help Jeff with the issues. She finds the Partnership diary and offers Jeff available dates with both. He decides he would prefer a female clinician and so books his first Core Partnership appointment with Emily, for 2 weeks time on a Wednesday at 4 pm.

David and Emily have previously each put available dates for new Core Partnership into the Partnership diary.

With Jeff’s consent, Pamela writes a summary of the Choice session and copies this to Jeff and his GP. She asks Jeff if it would be helpful for his manager or occupational health doctor at work to know he was depressed- but he prefers not. She refers Jeff to the substance misuse service. Pamela talks about the Choice work at the weekly meeting for Choice appointment review.

In 2 weeks Jeff and Jane meet with Emily. Emily finds out how Jeff has been doing since he met Pamela in Choice, including how it had gone reducing his cannabis use and talking with Jane. Were his goals the same? Are there things he did not talk about in Choice that are useful to talk about? She does not repeat the Choice appointment but actively makes use of all the information gathered previously.

Together they look at his mood and cannabis use diary, decide that, whilst contributing, his depression seems to be more related to over- whelming stressful events, with cannabis causing dips in mood but helping his anxiety. He has not managed to find out about the dementia cafe and Jane is encouraging him to talk with his boss at work about taking some time off.

They agree that the initial understanding of the issues remains the same as discussed with Pamela, but the additional impact of the one-off cocaine use complicates the picture as Jane uses this frequently as she feels it enhances her performance at work.

Specific Partnership Consult

Pamela asks Dr. Bank, one of the psychiatrists, to join to discuss with Jeff whether an antidepressant may be helpful whilst she works with Jeff and Jane in Core Partnership. Dr. Bank joins for some Specific Partnership assessment work. He builds on the information gathered by Pamela in Choice and by Emily in Core Partnership. Jeff does not have to repeat his story.

On going work

Emily and Dr. Bank talk about the work they are doing in the weekly peer group supervision. In Core Partnership Emily is liaising with Jeff’s work doctor, as he took Jane’s advice to allow him to be involved. She is supporting Jeff and Jane in understanding their relationship and they talk a lot about Jeff’s parents and Jane’s own cocaine use. After a few sessions of Core Partner- ship work, a review is held. Dr. Bank joins them, as does the substance misuse worker. It is clear now that Jeff’s mood is improving with this integrative help and he does not need an antidepressant. His depression is a reaction to life stress, drug use and exhaustion.

Specific Partnership Work

Things are going well but all think that Jeff may benefit from some individual work around managing his mood and anxiety. Now that Emily has got to know him she thinks that some CBT or Interpersonal therapy may help. She describes both to him. Jeff likes the CBT approach- he had tried some techniques when he kept his mood diary. Emily, who has core skills, works with him individually for some sessions on his own and continues to liaise with Jeff’s workplace.

Emily is the key worker and regularly updates the Care Plan following reviews with Jeff, Jane and the substance misuse worker. She ensures they have feedback from Jeff’s work to inform the review.

Outcome

After 8 sessions, things have improved. Jeff understands his relationship with Jane better and is no longer smoking cannabis. He realises the relationship is not as good as he hoped and was actually increasing his anxiety and moving him into drugs as a coping mechanism. He decided to end the relationship as Jane was not prepared to give up her cocaine.

Jeff feels more supported at work and not so alone in managing his parents now that a social worker has become involved.

Emily finishes her work with Jeff. He continues with the substance misuse worker for a little while longer. He is getting to work regularly after a few weeks sick leave, is no longer using cannabis and his mood has improved. He has started going to the gym. Following a final review all agree that the work is done and the case is closed. Jeff knows how to return if needed, which other services locally may be able to help and what sort of things he can do at home to keep on track.

Note

This clinical journey reflected one possible presentation in Adult Mental Health. Other conditions or problems that are more severe and enduring could have the same service structures but with different Core and Advanced skills and different numbers i.e. the treatment durations can be ac- counted for.