What does a Public Mental Health Service Look Like?

While developing a lecture to prepare nursing students for clinical experience in community mental health, I realised that some others may be interested to know what a public mental health service looks like. In the early 1990s I first gained mental health experience working across two aging purpose-built mental health facilities – Hillcrest Hospital and the beautiful Glenside Hospital (now being used by the South Australian Film Corporation). These facilities had started out as asylums where people were hidden away from the rest of the world behind Ha-Ha Walls and layers of misunderstanding and stigma: “the madhouse”, “the funny farm”, “the loony bin”, “the nuthouse” etc.

That’s not a very accurate (or kind) representation of a what a public mental health service looks like in Australia in 2015.

Parkside Lunatic Asylum then Glenside Hospital now SA Film Corp. Photo via http://www.weekendnotes.com/z-ward-glenside-hospital/

Let’s try to get our head around what a public mental health service actually looks like by deconstructing its elements. It’s not about grand old buildings any more; it’s about an array of services, most of which are community-based. I’ll deconstruct a mental health service I know a bit about, but to make it easy for myself I’m leaving out the “and Hinterland” part and some other details of the Cairns and Hinterland Mental Health Service. Hopefully this will give an overview of what components make-up a mental health service in a large regional city.

Red = primary intake points
Yellow = inpatient beds
Green = community (outpatient) teams

Primary Intake Points
ACT = Acute Care Team = assessment, crisis response and short-term intervention
ACT ED = as above, based in the Emergency Department of Cairns Hospital
CLPS = Consultation Liaison Psychiatry Service = mental health assessment, support and education in the general hospital setting (more about that here)

Inpatient Beds
Annex = Mental Health Unit (MHU) Annex (10 beds) = an offsite annex to the mainstream MHU for short-stay sub-acute admissions/transition to home
LDU = Low Dependency Unit of the MHU (approx 26 beds, I think, on site at Cairns Hospital) = average length of admission is about 12 days
SPA = Special Purpose Area of the MHU (4 beds on site at Cairns Hospital) = used for people with specific needs (eg: elderly, teenage, new parent)
PICU = Psychiatric Intensive Care Unit (8 beds on site at Cairns Hospital) = an area of containment for people experiencing severe symptoms and/or behavioural concerns; usually short-stay

Community (Outpatient) Teams
CCT = Continuing Care Teams (3 teams: North, Central & South) = multidisciplinary recovery-focused teams that provide medium to long-term support to people in their homes and/or in community-based clinics
MIRT = Mobile Intensive Rehabilitation Team = a multidisciplinary recovery-focused team that provides medium-term intensive support to people experiencing significant psychiatric distress and/or disability
CYMHS = Child & Youth Mental Health Service = multidisciplinary team that provides assessment, support and treatment of young people (up to age 18) experiencing significant psychiatric symptoms
Evolve = Evolve Therapeutic Services = specialist multidisciplinary team for children/young people on child protection orders in out-of-home care, with severe/complex mental health support needs
OPMHS = Older Persons Mental Health Service = multidisciplinary team catering for older persons experiencing first-presentation psychiatric disorder or psychological and behavioural symptoms associated with a cognitive disorder
ATODS = Alcohol Tobacco & Other Drugs Service = multifaceted multidisciplinary team that provides free, confidential counselling and psychology services to anyone seeking help with alcohol and other drugs
Forensic = Forensic Mental Health = multifaceted multidisciplinary team that provides mental health assessment, support and treatment of people experiencing significant psychiatric symptoms and within, or at risk of being within, the corrective services system

Five things I want to emphasise:

1. People receiving inpatient care make-up about 2% of the total amount of the people receiving mental health support at any given time. Public mental health services are community-based services; most people receiving support via a public mental health service have never been a hospital inpatient because of psychiatric problems and probably never will
2. Mental health care is not just about a public mental health services: local GPs, psychologists, social workers, occupational therapists, mental health nurses and others are working in a wide variety of private and non-government organisations to support people in their recovery.
3. It should be obvious by the intro and daggy look of my web page that I’m not representing the Cairns and Hinterland Mental Health Service here, but just to clarify: I’m not! If you’re feeling miffed or misled, please see points 10 and 13 on the meta4RN “About” page (here) or bypass me and go straight to the webpage for the Cairns and Hinterland Hospital and Health Service (here). Sorry for the confusion.
4. I know that there a bits I’ve left out. I acknowledged that in the intro.
5. This blog post is just a small excerpt of info that was included in a lecture for student nurses. If you’d like to see the lecture slides, here they are below:

That’s it. Thanks for visiting.

Paul McNamara, 18th January 2015.

 

Movies, Myths, Mistakes

The Cairns Post, 14th August 2003:

As if schizophrenia isn’t enough of a burden to those who have it, they also have to put up with the myths and misunderstandings that accompany it, and the discrimination that follows.

So, let’s try to get some of the facts about schizophrenia right.

Probably the most common myth is that schizophrenia means split personality. Comparisons to Jekyll and Hyde are commonplace, but utterly wrong.

In Latin schizophrenia means split mind. This refers to the split between perceiving the world in the way most of us do and perceiving it in other ways.

To illustrate, someone with schizophrenia may interpret everyday events as having significance beyond their intent.

In health, our jargon terms for these sorts of symptoms are delusional beliefs and/or ideas of reference.

In the film Angel Baby the main character sought special meaning from a game show. I have met plenty of people with schizophrenia and haven’t heard anything quite like that, but then I don’t have to make a living by entertaining people either.

I think what the movie-makers were doing was jazzing-up and stylising the experience of perceiving the everyday in another way.

Speaking of jazzing-up and stylising, A Beautiful Mind certainly did a good job with making paranoia look exciting (it’s not).

Perhaps because movies are visual, this film gave the impression the main character was experiencing his paranoia as a visual experience.

Some people with schizophrenia do have paranoid beliefs and delusions when they are unwell. Nobody I’ve met has described this visually, although quite a few have spoken about hearing things, usually voices,.

It seems these auditory hallucinations are an intrusive and exaggerated version of what all of us experience when we have those little conversations with ourselves throughout the day.

From what I’ve heard, most people’s idea of what a mental health ward looks and functions like comes straight out of One Flew Over The Cuckoo’s Nest.

Anyone who has been inside our local mental health unit at CBH will be able to tell you that it is a modern, light-filled place where there’s direct access to fresh air from just about every room.

In my opinion, the layout and design is the best of all the wards in the hospital.

Finally there’s the violence myth. Hollywood has created a perception that schizophrenia means danger.

I don’t associate violence with schizophrenia at all. I know that on occasions tragic things have happened, but this is rare.

I’ve met dozens of people with schizophrenia who would not  hurt a fly.

I guess if you’re making movies you’re not interested in a story about an ordinary-looking person doing everyday stuff in a pretty average way, other than taking medications to control uninvited symptoms.

Final Notes

Back in 2003 a journalist from The Cairns Post invited me to submit this article for the My Say column (a daily feature presenting the views of a cross-section of the community). The article’s reference to man’s inhumanity to man is in the context of current events at the time – it was published during the second week of the war in Iraq.

As I was identified as an employee of a local hospital, at the time of publication the content of the article had to be approved by the hospital’s media department. The media department approved the article without changes to content.

In 2003 I used some phrases that I find a bit jarring now. I was tempted to correct it in this 2014 version, but decided it was more authentic to leave the original unaltered.

Anyway, I stumbled across the very-low-resolution JPG version of the article today and thought it might be worth reprising. Stigmatising representations of schizophrenia still pop-up in Hollywood, – this is a tiny, inadequate bit of counter-balance.

As always, your feedback is welcome in the comments section below.

Paul McNamara, 26th October 2014

Short URL:  meta4RN.com/movies

Originally:
McNamara, Paul (2003). Movies, myths, mistakes. The Cairns Post, 14 Aug 2003, pg 13.

A Blog About A Blog About Suicide

I’m going to keep this short.

On the eve of the second anniversary of the meta4RN.com blog we (guest writer Stevie Jacobs and I) have finally released her powerful, gutsy post “These words have been in my head and they needed to come out (a blog post about suicide).” I thought by opening up meta4RN.com to occasional guest posts I would save myself some time and effort. Ha! Stevie’s post has had the longest, most difficult gestation of all of the posts on this blog.

Why? It’s not because of Stevie’s writing – she writes very well – It’s because of the content.

It’s because we don’t know how to talk about suicide.

 I remember as a 14  year old learning about suicidal ideation via the famous Hamlet soliloquy which starts: “To be, or not to be, that is the question…” Shakespeare didn’t seem to be as afraid as getting the tone/message wrong as Stevie Jacobs and I have been.

Luckily, we don’t have to navigate this tricky territory without a map. Mindframe – Australia’s national media initiative – have some very handy tips aimed (mostly) at media. They also have info for universities, the performing arts, police and courts. It would be silly to replicate all their information here – cut out the middle-man and visit the Mindframe website:
www.mindframe-media.info

The only thing I want to make sure is included here is that we, the health professionals, remain mindful of responsible use of language in social media, including blogs (and Facebook, Twitter, Instagram etc) . Melissa Sweet of croakey (the Crikey health blog) has used the term “citizen journalist” to refer to us non-journos who are active on social media. I have shied-away from that label because I have zero knowledge/pretensions of being a journalist. However, when it comes to talking about mental health and/or suicide, I reckon that those of using social media as health professionals should take some ownership of the “citizen journalist” tag.

Health professionals are used to being informed by evidence-based guidelines, right? That’s what the Mindframe guidelines are. They are guidelines for how language should be used by journalists. Those of us who are blogging/Tweeting/Facebooking/whatever can, if we choose to be safe and ethical, abide by the same code of good practice (here).

Let’s watch our language.

Let’s edit and re-edit.

Let’s reflect and think about our impact. Let’s do that slowly.

Let’s be safe. ethical and kind.

Let’s do no harm.

Let’s follow the Mindframe guidelines when we’re blogging about mental health and/or suicide.

End.

That’s it. Thanks for visiting.

If you haven’t done so already, visit Stevie Jacob’s guest post here: meta4RN.com/guest02 My favourite part is the middle part (the meat in the sandwich?) which is honest, powerful, raw and gutsy. I hope/think that the edits made have been in keeping with the Mindframe guidelines. If  not, that is my responsibility. Please let me know and I will fix it as soon as possible.

Paul McNamara, 23rd September 2014

Short URL: meta4RN.com/mindframe

Follow Friday and other Twitterisms

I’ve made no secret of my bold plan to try to indoctrinate enthuse nurses and midwives re professional use of social media, especially Twitter. This blog post is primarily for the benefit of Twitter newbies, especially health professionals dipping their toes into professional use of social media.

I’ll post a link to this page most Fridays too as an explanatory note about my OTT #FF use.

Experienced Twitter campaigners probably won’t be at all interested in this blog post (quick! jump away now! watch this funky short video instead!), but those unaccustomed to Twitterisms may find it helpful to have info and context readily available in the same stream where the #FF hashtag is being used.

What is #FF?

#FF = #FollowFriday = Follow Friday (did you think it was something rude? shame on you and your dirty mind!).

Use the #FF hashtag to recommend a Twitter account/person to others. Why bother? It’s a good way to show appreciation, to build the connectivity of your networks, and it’s part of the “Share. Enjoy. Be generous.” Twitter ethic I’ve mentioned previously.

I like to individualise my #FF recommendations by Tweeting one at a time with a brief introduction, which I often lift/adapt straight from the bio. This way my #FF recommendations will look something like this:

#FF @reeannekeena – community mental health nurse and cricket tragic living in far north queensland #FNQ

To my way of thinking, mass #FF tweets are much less compelling as a recommendation. The mass #FF tweets look something like this:

#FF @reeannekeena @impactednurse @CEOKimRyan @ACMHN @HPitt3 @karenyatesjcu @croakeyblog @AngieGittusRN @MerynFry

Does #FF work to promote more followers? As far as I can tell, only modestly. I’m pretty sure Harry only gained two new followers when I recommended him with a #FF. That’s better than nothing, but the ROI is limited.

All the links above are live – you could do worse than follow these people on Twitter, but I don’t know that many people will be inspired to just go ahead and do so because of a list of names. I reckon one Tweet per #FF with a brief introduction is much better.

However, does #FF actually work to promote more followers? As far as I can tell, only modestly. I’m pretty sure Harry Pitt (see screenshot) only gained two new followers when I recommended him with a #FF. That’s better than nothing, but it’s worthwhile being realistic, and knowing that the impact of the #FF hashtag is limited.

What is OTT?

OTT = Over The Top = my use of #FF.

On reflection, I think I’ve been OTT with the #FF thing. On Twitter, as in real life, too much chatter just becomes white noise: it gets heard, but doesn’t really get listened to. So, with the goal of not diluting the potential potency of recommendations, I will keep my use of #FF down to about half-a-dozen times per Friday from now on.

Less [Twitter stream clutter] is [probably] more [effective].

With all those #FF tweets, do you ever work on Fridays?

Yep: most Fridays I am at work, so resort to using scheduled Tweets to trickle-out my #FF recommendations throughout the day. My rationale is threefold:

1. A tweet every hour or two is less intrusive and irritating than a rush of five tweets in five minutes.
2. Twitter has connected me with other health professionals in every Australian state/territory, and in a heap of other countries all around the world. That means lots of different timezones. By spreading out the #FF tweets there is a better chance of broad introductions rather than narrow, place-specific recommendations.
3. I’m experimenting with social media, Twitter especially, to test its usefulness for healthcare communication. Part of the experiment is to build the profile of the meta4RN portfolio. For this I’m treating meta4RN a bit like a brand; #FF not only recommends others, but also keeps the meta4RN portfolio visible. At time of writing (July 2013), I’m planning to make #FF a meta4RN staple activity to promote and link healthcare professionals on Twitter.

Scheduling tweets is pretty easy using tools such as HootSuite and TweetDeck. The only real risk with scheduling tweets is when a major event happens, say a terrorist attack or natural disaster. Under those circumstances Twitter erupts with activity specific to that event, and scheduled tweets can seem incongruent/out-of-touch or, in a worse-case scenario, insensitive and stupid. I’ll try to keep an eye out for this but fully expect it to happen from time-to-time; hopefully because #FF tweets are pretty benign it won’t be too much of a problem*.

What is RT?

RT = ReTweet = a way to share information that somebody else has already shared. If you’re familiar with Facebook, a RT is like hitting a “Like” button on steroids. Most retweets are not preceded by RT now, because the Twitter “retweet” button has done away with ye olde RT. It still pops-up though, especially if people want to add a comment.

What is MT?

MT = ModifiedTweet = a way to share information that somebody else has already shared, but edit or tweak the message a little. By making it MT rather than RT, you’re making it clear that it’s not a direct quote of the original.

See the screenshots of my MT of @PANDA_NATIONAL for an example.

What is HT?

HT = Hat-Tip or Heard-Through = a way to acknowledge the source of your info without necessarily quoting them.

What about other abbreviations like LMAO, ROI, TYVM, PMSL?

LMGTFY

What is LMGTFY?

The easiest way for me to explain is to ask you to click here: LMGTFY

What is the #hashtag thing about?

This explanation is a cut and paste straight from Twitter support:

• People use the hashtag symbol # before a relevant keyword or phrase (no spaces) in their Tweet to categorize those Tweets and help them show more easily in Twitter Search.
• Clicking on a hashtagged word in any message shows you all other Tweets marked with that keyword.
• Hashtags can occur anywhere in the Tweet – at the beginning, middle, or end.
• Hashtagged words that become very popular are often Trending Topics.
• If you Tweet with a hashtag on a public account, anyone who does a search for that hashtag may find your Tweet
• Don’t #spam #with #hashtags. Don’t over-tag a single Tweet. (Best practices recommend using no more than 2 hashtags per Tweet.)
• Use hashtags only on Tweets relevant to the topic.

For Twitter newbies, don’t get too freaked by the hashtag thing. You can ignore hashtags and still enjoy Twitter. However, when you find your feet you’ll find them very useful – I’ve previously written about hashtags being used for health conferences, health promotion and education. There are plenty of other hashtag applications too.

What else?

Don’t be a silent egg. That is, add a profile pic, a bit of a bio and introduce yourself to Twitter. Getting started on Twitter is usually a slow learning curve anyway, but not sharing anything at all will make it excruciatingly dull.

That’s probably all you need to get started, other than a warning about Twitter spam. You have probably developed a good radar for email spam by now, but Twitter spam seems to be especially good at preying on the insecurities of Twitter newbies. So, if you get a message that looks a bit like this:

@meta4RN This person is saying horrible things about you dodgylink.com/8g6lyn

or

@meta4RN Have you seen this photo of you? LOL. dodgylink.com/8g6lyn

just delete/report the message.

Whatever you do, don’t click the links! There is a good chance your account will then start sending out spam if you do. That’s a really irritating way to learn about Twitter spam; prevention is best, but there is support available if you do stumble into a spam-pit: support.twitter.com

End

That’ll do for now.

If required, there’s a bit more info that may be useful for healthcare professionals new to Twitter via my previous blog post Social Media for Nurses: my ten step, slightly-ranty, version.

As always, your comments/feedback is welcome.

Paul McNamara, 21st July 2013

* Please consider this an apology in advance. I know for certain that an important/tragic event will happen on a Friday. Consequently, there is a pretty good chance that my #FF scheduled tweets will show up in the Twitter stream. This may seem incongruous and callously unaware at the time, but in reality it’s just a product of not being able to continuously monitor Twitter.

I hope no offence is taken; none is intended.

Perinatal Jargon Busting

Ever noticed how in the USA the term “postpartum depression” is used more often than here in Australia, where we mostly use the term “postnatal depression”? In the UK, from my online vantage-point anyway,  it seems more mixed – as if the two terms are interchangeable.

What’s the difference? Is it like, “You say potato, I say potato. You say tomato, I say tomato.”?

What about “perinatal mental health” – what’s that all about?

What’s the difference between “prenatal”, “antenatal” and “antinatal”?

What’s “puerperal” – something to do with caterpillars?

Words do matter. Many years ago I made the mistake of asking if the lady I was following-up had delivered. I was very firmly advised by my colleague, a Midwife, that, “Babies are born. Women give birth. Pizzas are delivered.” I was suitably chastened and, although not a midwife myself, I have tried to stay on top of most of the language midwives use.

So, with that spirit of adventure, let’s see if we can get our heads around some key words in today’s perinatal jargon-busting post.

Let’s get started with the basics:

“Natal” = relating to an infant being born

“Partum” = relating to a woman giving birth

“Peri” = around/about

“Perinatal” = around the time of birth, that is: both before and after the baby is born.

Austin M-P, Highet N and the Guidelines Expert Advisory Committee (2011) Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period. A guideline for primary care health professionals. Melbourne: beyondblue: the national depression initiative.

How long before and after is where it gets a bit tricky. The World Health Organisation define the perinatal period as from 22 completed weeks of pregnancy to 7 days after birth. The Australian Institute of Health and Welfare differ: they say the perinatal period starts after 20 completed weeks of gestation and ends 28 completed days after birth. The Australian Perinatal Mental Health Clinical Practice Guidelines, issued as part Australia’s National Perinatal Depression Initiative (NPDI), define the perinatal period as pregnancy and the first year after birth. Other organisations, such as the Queensland Centre for Perinatal and Infant Mental Health, define the perinatal period as including preconception, pregnancy, and up to three years after birth.

Generally (not always) in the mental health clinical context, we think of the perinatal period as being over three phases: 1. planning pregnancy; 2. pregnant; 3. new parent.

Just choose your definition of when the perinatal period should begin and end – from what we’ve seen above that’s what everyone else is doing.

Perry Natal is on facebook

“Perry Natal” is on facebook – judging by his profile pic, he seems like a pretty fun guy. As far as I can tell he has no relationship to the perinatal period.

I like to think that Perry Natal gets a lot of enjoyment out of confusing health professionals who work with pregnant women and new mums… “She’s not perinatal! I’m Perry Natal!” Why is that so hard for you to understand? A man can be Perry Natal without there being a perinatal woman!”

Fun times.

“Prenatal” refers to pregnancy. I don’t think it gets used all that much in Australia – not that I’ve noticed, anyway. Semantically, it makes sense to use prenatal, but the usual convention seems to be to use the word “antenatal”.

“Antenatal” gets used all the time to refer to pregnancy. “Ante” = before, so antenatal = before the infant is born.

“Anti Natal” is either a spelling mistake, or an indication that somebody really hates Natal – the capital and largest city of Rio Grande do Norte, a northeastern state in Brazil. It is hard to imagine anyone hating Natal – it looks very pleasant, is considered the safest capital city in Brazil, and is home to the largest cashew tree in the world! Everyone loves cashews, don’t they?

“Antepartum” is not a word I’ve heard used alone as replacement for “antenatal”, although I guess it could be. The word pops-up as a descriptor for a medical emergency that sometimes occurs after 20 weeks gestation: “antepartum haemorrhage” (aka APH). It’s probably used in other contexts too – please feel free to add anything important I’ve overlooked in the comments section below.

Labour and childbirth may attract the descriptors “Intranatal” if it relates to the baby, and ‘intrapartum” as it relates to the woman.

“Postnatal” is after the infant has been born. Literally speaking, everyone can participate in the postnatal period – baby, mum, dad, and whoever is there after the baby is born. Semantically this is why dads can experience postnatal depression.

As with the definition of perinatal, definitions of how long the postnatal period lasts vary a lot. Generally when we’re thinking about postnatal depression we think mostly about the first six or twelve months, but it wouldn’t be unusual to think of any depression that arrives before baby’s third birthday as postnatal depression.

“Postpartum” is after the woman has given birth.

If we get bogged-down in the semantics, I’m pretty sure only a woman who has given birth can experience postpartum depression. Why? Because only the woman is postpartum, the baby and man are postnatal.

That said, it’s also pretty safe to say that hardly anyone gets bogged-down in the semantics. In common usage “postpartum depression” is applied to both women and men, and as with “postnatal depression’ there are varied definitions of how long the postpartum period lasts when it is related to depression. I think obstetricians and midwives have a much more defined, discrete definition on how long the postpartum period is, and sometimes refer to it as the “fourth stage of labor”.

“Puerperal” or “the puerperium” relates to the time from immediately after birth of the placenta to six weeks, with an emphasis on the first two weeks.

In mental health the puerperium is especially noteworthy for two things:

[1] Something like 80%-90% of first-time mums will experience the baby blues in the puerperium. It’s a transient, self-resolving emotional lability that arrives within a few days of childbirth and goes away within hours or (if you’re a bit unlucky) a few days. More info here.

[2] Much, much rarer – something that affects one or two women per thousand births – is puerperal psychosis. “Psychosis” = losing touch with reality. To lose touch with reality at any time is pretty scary; to do so when there’s a brand-new baby on the scene even more so. This is nearly always a very frightening time for the woman and the people who love her; specialist mental health support will certainly be required. For more info, there are two great puerperal psychosis resources available via the Helen Mayo House website:

Information on Puerperal Psychosis (March 2010) by Dr Anne Sven Williams and Sue Ellershaw

Puerperal Psychosis: a Carer’s Survival Guide (2011) by Craig Allatt

Which brings me back to where the idea for this post started. Broadly, when people use any of the terms “postnatal psychosis”, “postpartum psychosis” and “puerperal psychosis”, they’re usually talking about the same thing. I would make the distinction that puerperal psychosis is specific to onset of symptoms in the first fortnight or so after birth. Similarly, “postnatal depression” and “postpartum depression” are used pretty-much as interchangeable terms, even though there are semantic differences… same with the abbreviations PND and PPD.

Maybe this picture clears it up:

If the illustrated summary is of any use, there is an easier-to-print PDF version here.

As always, your thoughts/comments/corrections are welcome in the section below.

Paul McNamara, 23rd April 2013