In your daily practice, you would see patients presenting with different illness ranging from the common cold to mental health issues that are pressing. As it could be a crisis, the more prepared you are, the better the patient would be able to get the help in a timely manner.
What are the warning signs that indicate that a patient is experiencing a possible mental health crisis?
What you may face
Below are two scenarios that could happen in your daily practice.
Scenario 1
Patient A comes with his mother to your clinic for his monthly follow-up; you notice that there is something about him that feels off. He is unkempt, preoccupied and distracted. During the interview with him, you observe that his speech is pressured and tangential, and he starts to speak loudly. As you continue to speak to him, he becomes more agitated, begins to shout and starts pacing around the room. These are signs that he may be having a relapse and is getting aggressive.
Some signs that indicate that the patient is becoming aggressive include:
- Physical cues – Glaring at you, becoming restless, pacing around the room, adopting a rigid posture or displaying threatening gestures, standing very close to you or invading into your personal space
- Verbal cues – Hurling vulgarities, getting louder in his speech, being demanding with his requests
- Mood cues – Being irritable, angry, labile where the mood change is quick and spontaneous
- Thought cues – Being paranoid, suspicious, unable to focus on a task, is preoccupied, easily distracted
His mother shares that he is becoming more paranoid at home, closing the windows and drawing all the curtains in the house and not allowing anyone to leave the curtains undrawn as he feels that others would be able to read his mind if they did so. He refuses to shower as he feels that those who can read his mind will attempt to contaminate the water. His mum is unable to calm him down and he continues to shout and pace around the room.
You decide to try and de-escalate the situation so that he may calm down and minimise the possibility that he may get physical. If you feel that his mum may agitate him further, it would be advisable for her to leave the consultation room first.
You continue to engage him, pay attention to him, and identify his needs and feelings. Let him feel that he is being heard. You should be concise when communicating with him as he may not be able to pay attention to what you are saying. It would be all right to have periods of silence as it would allow him to take in what you have just told him. In the event he needs further treatment in the hospital, take the time to explain to him what is going to happen, for example, "Patient A, you are feeling really unsafe now, I will be calling the paramedics to bring you to the hospital for treatment as it is a safe place."
It is important to try and maintain a safe distance from him and know where the exit is, so that in the event he turns physical, you would be able to make your exit and call the police for assistance. If he calms down, you can discuss with his mum to bring him to the Emergency Services at the Institute of Mental Health (IMH) for review as he has shown signs of relapse. He may have to be admitted for treatment or his medication would need to be titrated. If his mum feels that she is not able to bring him to the IMH Emergency Services on her own, she can call the non-emergency ambulance to send him there.
Scenario 2
Patient B comes for her appointment. You observe that she keeps looking down and is rather quiet, unlike her usual self. She shares that she has problems sleeping for the past two weeks since her boyfriend's death. In addition to her insomnia, she has poor appetite and difficulties focusing on her job. She does not find any pleasure in the activities that she enjoyed doing previously and finds that life is hopeless. She has harboured thoughts of joining her boyfriend. She has searched the Internet on ways to end her life and has decided on a way to do so. She has tidied up her possessions and written suicide notes to her parents, siblings and friends so that they can read them after she passes on. You try to call her parents and siblings in view of her suicidal intent, but no one answers the calls.
She informs that she has no confidence in keeping herself safe when she goes home. You manage to contact her family and they rush to your clinic to attend to her. You explain the situation to them and they agree to bring her to the IMH Emergency Room immediately. However, in the event that you are unable to contact any next of kin and if she refuses to seek help at IMH Emergency Services, it is important that you call the police for assistance.
Patient B has displayed some of the warning signs of being suicidal – she has tidied up her possessions and written suicide notes, finds life meaningless and has searched for ways to end her life.
How to equip yourself
The Mental Health – GP Partnership Programme (MH-GPPP) is a collaboration between IMH and GPs to care for and manage patients with stable mental health conditions in the community. The GP partners who join the programme will be briefed by the MH-GPPP team and will undergo a clinical attachment to learn how to manage patients with mental health issues. In addition, the MH-GPPP team would pay visits to the GP clinics to update them on the community resources, as well as the resources that GPs and patients' next of kin can tap on in the event of a crisis or when the patient has a relapse and is unwilling to seek treatment.
During these visits, the team will update the GPs on the community resources that are available in the regions where they are practising. This is also an opportunity for our partners to seek advice on what they can do in managing complex cases or how to manage crises.
The resources that GPs can tap on to seek assistance when a patient is experiencing a mental health crisis are:
IMH Mental Health Helpline: 6389 2222
SOS: 1800 278 0022