Pathological and Psychological Aspects of Complex Care

This essay will examine the pathological and psychological processes and critical debate in relation to the complex care. Subsequently, the author aims at scrutinising whilst also illustrating the nursing interventions, implemented for the patient and how these interventions met the individual’s biopsychosocial needs. This assignment is based on a real-life patient that the author met in practice placement henceforth, a pseudonym Sara has been utilised for confidentiality purposes (Nursing Midwifery Council NMC 2018). Complex care is associated with a combination of multiple chronic illnesses, mental health issues, medication-related problems, and social vulnerability (Jeffs et al. 2013). Sarah is a 28-year-old woman currently under the care of a community mental health team. Sarah has a diagnosis of bipolar affective disorder, has a history of substance misuse and is 6 weeks pregnant. Sarah became mentally unstable and started using substances after 6 months of being clean and using replacement drugs. This was due to her ex-partner being released from prison after he was convicted for physically and emotionally abusing Sarah. On release from prison, they rekindled their relationship which resulted in pregnancy.

Sarah presented with bipolar affective disorder, a recurrent chronic disorder which is characterised by extreme mood disturbances polarity (Anderson et al.2012). According to Grande (2016), an individual affected would experience periods of extreme mood elevation and higher activity levels as well as severely decreased energy levels and lowering of mood, disabling them in carrying day to day normal activities. Sarah fits in the F31.1 of the International Classification of Disease of Mental Health Disorder (IDC-10). She is currently within the manic episode of bipolar affective disorder, which is manifesting as elevated mood, irritability and overactivity without any psychotic symptoms these symptoms align with F31.1 criterion of the ICD-10. The ICD-1 0 is a diagnostic manual which contains codes for diseases, disorders, injuries and other related health conditions (WHO 2016). Many professionals find that, the ICD-10 difficult to interpret and to implement in practice, because it is often based on selecting from a list in which some items are presented and others absent. Moreover, two people can have the same diagnosis with few, or no symptoms in common. Sarah’s interventions should not just be based solely on her diagnosis. The role of the nurse involved in Sarah’s care is to identify the underlying cause of her deterioration and prevent any further deterioration. This can be done by conducting a formulation. Lucy Stone (2018) stated that, formulation helps summarising the meanings and it allows both the professional and patient understand and communicate about them. Once those meaning are explored and identified, a clear person-centred plan can be put into place. Nevertheless, formulation was not done as Sarah did not engage due to being unwell. Prior to identifying that, Sarah’s mental health was deteriorating me and Sarah’s care coordinator (CC), who was a mental health nurse, paid Sarah a visit in her house whereupon encounter the CC carried out a clinical mental state examination. A mental state examination is a clinical way of observing a patient taking into consideration a clear accurate picture of the patient’s emotions, thoughts, behaviour, affect and appearance. A clear observation of the above can help one identify the patient’s deteriorating mental health and the risk they pose to self or others (Soltan and Girguis 2017). Sarah was deviating from being extremely happy then quickly changeable to being irritable, she appeared like she had not slept for a while and bags of shopping were all over the floor indicating that she had been shopping a lot. She informed us she was not compliant with her daily sodium valproate due to being pregnant. From this snapshot observation, it was clear that, Sarah had deteriorated and was presenting with symptoms of mania. In order to find out the severity of the mania my mentor utilised the Young Mania Rating Scale (YMRS).

YMRS is an interview-based assessment tool that covers the 11 core symptoms of the manic phase. YMRS is based on the patient’s subjective opinion of his or her clinical condition over the previous 48 hours and the clinician observations during the assessment (Measure 2011). Studies have shown that, YMRS has demonstrated excellent psychometric properties, including high interrater reliability for total scores. Nevertheless, research argues that, the YMRS does not account for all manic symptoms, including distractibility, increases in goal‐directed activity, or excessive involvement in pleasurable activities with a high potential for painful consequences (Miller et al. 2009). Therefore, in order to make the care more effective and assessment more accurate, the CC should have also used the Mood Disorder Questionnaire which is newer, slightly handier in the clinical area and focuses on symptoms of mania and hypomania (Siwek 2009). Drawing to the evaluation of both the assessments, I think Sarah was not in the right state for lengthy assessments. Therefore, it was only fair that, the CC trusts her clinical decision based on the results from the mental state examination, which was more effective as the CC that has known Sarah for a long time. The results from the YMRS indicated that, Sarah was acutely manic (AstraZeneca 2012). These results were shared in a multidisciplinary meeting resulting in several outcomes. The team believed that Sarah did not pose any immediate risk to self and other, therefore instead of hospital admission, the CC decided to make a referral to the Intensive Home Treatment Team (IHTT) for close monitoring. This might have been ideal to prevent hospital admission, however, due to Sarah’s vulnerability; she could have been cared for better wellbeing in a hospital setting as a short-term solution because it could have helped preserve her safety as well as her unborn child. This is also due to the fact that, the professionals would also have to look at her treatment options. Involuntary and compulsory hospital treatment can help prevent further deterioration of mental health, could help Sarah regain control over her life and provides safety (Commission on Acute Adult Psychiatric Care 2015; Chambers 2017; Pandarakalam 2015). NICE (2020) guidelines suggest that, it is important for the individuals, who are manic to have access to quiet, calm environments and reduced stimulation, which are available in mental health hospitals. In the hospital, Sarah would have 24 hours support and the professionals would be able to monitor her sleep, dietary and fluid intake as well as her compliance with prescribed medication and drug misuse especially now that she is pregnant (Gilburt et al., 2008). Moreover, she would have been safe from her ex-partner and this would alleviate some stress.

On exploring literature, it is evident that, there is a shortage of psychiatric beds, which has led to over-occupancy of acute wards, increased rates of admission and intense pressure on beds (Commission on Acute Adult Psychiatric Care 2015). Consequently, due to the lack of beds, it may be difficult to find a bed in her local mental health hospital which would then mean Sarah having to travel long distances for a bed (Quirk & Lelliott, 2001). The NICE Guidelines (2018) state that if an individual is experiencing a manic episode and is already taking valproate or another mood stabiliser as a prophylactic treatment, the dose of Valproate should be increased up to the maximum dose if necessary. Sarah’s bipolar is controlled with a daily compliance of Sodium Valproate, which is a mood stabiliser and an anticonvulsant. This is a licensed drug utilised to help alleviate symptoms of bipolar mania and hypomania and to prevent a recurrence. Sodium Valproate works by inhibiting the breakdown of a neurotransmitter named gamma-Aminobutyric acid (neurotransmitter) so it leaves enough of it in the brain to help prevent over-activity (Ghodke-Puranik et al., 2013). It inhibits what is called the repetitive firing of neurons to slow the number of messages back to the normal level (Haley 2016). NICE guidelines, however, fail to mention how to manage mania in pregnant women. Although Sodium Valproate is a very effective mood stabiliser, evidence-based research indicates that Sodium Valproate can severely harm the developing infant when taken throughout pregnancy (Macfarlane and Greenhalgh 2018). It increases the risk of serious developmental disorders and congenital malformations such as spina bifida, mental impairments and what is increasingly termed autistic spectrum disorder. Sodium Valproate is also linked to high rates of miscarriage (Haley 2016; Wieck 2018). Sarah’s care was complex, because she was pregnant and in a manic phase. It became very difficult for the CC to manage Sarah’s mental health needs whilst minimising the risks to the developing foetus. Due to the severity and high risks, the MDT worked collaboratively to review Sarah’s treatment plan and look at the best alternatives to help manage Sarah’s manic episode and preserve her and the unborn baby’s safety. After careful consideration, Sodium Valproate was stopped immediately, and Sarah was prescribed Aripiprazole, which is a second-generation antipsychotic (SGA). According to Abou-Setta (2012), SGA is more efficient than first-generation antipsychotics as they improve overall symptoms and cognition. Individuals on SGA also experience less extrapyramidal such as tremor and pressured speech.

Deciding whether to prescribe antipsychotics to treat mental health illness in a pregnant woman requires careful consideration, as it may be associated with premature birth, low birth weight and neonatal withdrawal effects (Bonen et al. 2012) Studies illustrate that women exposed to antipsychotics during pregnancy have higher risks of gestational diabetes (NICE 2015). Nevertheless, most of the evidence comes from the use of first-generation antipsychotics like Haloperidol and not SGA (Khalifeh et al. 2015; Baldwin 2018). In addition to Sara’s diagnosis of bipolar affective disorder, Sarah’s care was further complicated by her substance misuse. As Sarah relapsed, she began to use heroin, which is a class A drug (Legislation gov 2020). This was detected by a urine drug screen done by Sarah’s CC. Post and Kalivas (2013) stated that, experience of early life adversity and stressors is a risk factor for humans subsequently adopting drug self-administration and addiction (Sparhawl and Ghaemi 2011). According to the NICE guidelines (2018) individuals who suffer from bipolar affective disorder often suffer from concurrent substance misuse. Research emphasises that continuous usage of heroin leads to a strong internal drive to use frequently. Individuals using this drug may have impaired abilities to control usage and overtime the drug becomes a priority over everything (WHO 2019). Opioid leads to overstimulation of dopamine neurotransmitter, overstimulation of this area of the brain leads to further inbuilt of urges to continue using the drug and a strong sense of dependency. However, normal activation of the dopamine neurotransmitter facilitates in normal cognition functioning, motivation and emotions (Hulse et al. 2002). Comparing this research, it is safe to say Sarah’s dependency has become a complex brain disorder, which can be classified as a mental disorder (Leshner 1997; Yates & Malloch 2010; NIDA 2018)

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The complications of opioid dependences are as follows through heroin use like Sarah may share needles and therefore increase the risk of vertical transmission of bloodborne viruses and put the baby at risk of Human immunodeficiency virus (HIV), Syphilis, Hepatitis B and C. Babies may obtain these infections during pregnancy, at birth or through breastfeeding (Welch 2019). Vertical transmission of any of these infections has serious implications to the unborn child in the womb as it can lead to premature birth; acute infection or death before birth; birth defects, persistent infection and miscarriage. (Fajemirokun- Odudeyi et al. 2006). Poor access to healthcare during pregnancy is also a risk factor for a mother to child transmission of blood-borne infections which could have a significant impact on the child’s quality of life. (Chiva 2008). Sarah’s drug misuse and being pregnant further increased the complications of her care. Heroin use during pregnancy can increase the chance of premature birth, excessive crying, low birth weight, hypoglycaemia, intracranial haemorrhage, infant death and neonatal abstinence syndrome (NAS) (NIDA 2018 Wilks 2009; Bhuvaneswar et al. 2008). NAS occurs when heroin enters the placenta during pregnancy, causing the unborn child to become dependent. NAS can be life-threatening and in some cases fatal (Pat 2015; Medicine plus 2017; Fajemirokun- Odudeyi et al.2006). Sarah was prescribed methadone. According to Ferrari (2014), methadone is a synthetic opiate mainly used as a replacement drug for heroin. It works by blocking the reuptake of noradrenaline and serotonin in the periaqueductal grey matter (Frame et al. 2017). Although research indicates that, methadone reduces withdrawal symptoms and drug consumption; NICE (2015) argued that, individuals should also have access to psychotherapy to address the underlying issues of their drug addiction.

Although Sarah is on methadone, studies conducted by the National Institute on Drug Abuse (2018) indicated that, infants exposed to methadone during pregnancy may need to be treated for NAS as well. The CC was concerned about the safety of the unborn child and Sarah tried to minimise the risks by prescribing Buprenorphine. Similarly to Methadone, Buprenorphine is used to treat dependence to opioid. However, children who have been exposed to buprenorphine experience few side effects at birth. Consequently, it is safer for the infants, as they will require less morphine at birth (NIDA 2018).

Sarah’s CC was able to identify what triggered her manic episode. Sarah’s abusive ex-partner was the cause of her relapse and Sarah was using heroin as an unhealthy coping mechanism (Douglas 2019). Recent research informs that biopsychosocial stressors have an impact in determining deterioration of individual’s mental well-being (Keltner & Steele 2019). NICE (2016) stated that, Domestic abuse is any incident or pattern of incidents of controlling, threatening behaviour, violence or abuse between adults who are or have been an intimate partner or family member. The CC was concerned about Sarah’s safety and well-being (NMC 2018). Domestic abuse during pregnancy is of special concern due to the potential negative consequences to both the mother and foetus. (Van Parys et al 2017). The experience of violence and abuse during pregnancy has been linked to low birth weight, preterm labour and delivery, low maternal weight gain, kidney infection, antepartum haemorrhage, miscarriage and neonatal death (Huth-Blovks et al. 2002; Tailie and Brownridge 2010) Consequently, the police were alerted as Sarah’s ex-partner breached his release conditions and contacted her. Sarah’s CC referred Sarah to a Safehouse as a short-term solution. A safe house is a place of safety, where women who are experiencing domestic abuse can deal with practical and emotional issues free from fear (IWDA 2019). Such spaces are important for women’s recovery and empowerment after abuse. They are designed to promote freedom, autonomy and equality (Bowstead 2019; British Medical Association 2014). Women who have left an abusive relationship experience a higher than average level of anxiety, depression, panic attacks, post-traumatic stress disorder, substance misuse and chronic pain. Such disorders tend to persist long after the abuse ends. Victims of domestic abuse often feel hopeless and feel unworthy (Tatiana 2017). Therefore, CC could refer her to counselling to address the negative health consequences of the abuse. One general goal underlying many counselling interventions is to empower the client (McOrmond-Plummer et al. 2014). Empowerment counselling aims to establish an increased sense of control over their lives. It provides abused individuals with the means to ventilate their feelings in a non-judgemental environment and discuss strategies to improve their mental health and social support (McWhiter 1991; Sapkota 2019).On the other hand, it is important that the CC refers Sarah to counselling once she is ready as she has a history of non-engagement with services.

Communication between healthcare professionals is essential in order to deliver good quality medical care, especially when dealing with individuals with complex care problems and chronic conditions (Steihaug et al. 2016). Working within an MDT allows both the service user and the healthcare professional to identify the patient’s holistic needs, and to collaboratively establish a person-centred plan to meet those needs. (Mental health commission 2006; Royal College of Nursing 2016). The MDT involved in Sarah’s care did an excellent job at establishing the end goals and being involved in the treatment plan. The care could have been more effective, if Sarah was more involved in the decision-making process. Involving patients in their care is significant. NICE (2016) stated that, involving patients in their care improves patient safety, compliance with treatment, patient’s satisfaction and more effective use of resources If a lack of capacity is established, it is still important that the person is involved as far as possible in making decisions (Office of the Public Guardian 2009). The MDT applied the ethical principle of beneficence as they always had Sarah’s best interest in mind. Beneficence is the ethical theory of actions doing good and being in the correct interest of the patient (Doody & Noonan 2016). To conclude, the assignment highlights the importance of assessing and recognising an individual’s biopsychosocial needs as early as possible to plan and implement the best care. Due to Sarah’s complex circumstances, it was very difficult for the MDT to meet all her needs as they made a collective decision to prioritised Sarah’s safety and wellbeing as well as the unborn child’s wellbeing. Working alongside the CC in this complex case has taught me how important it is to work in a team when dealing with complex and challenging patients. The CC did the well by involving the MDT in Sarah’s care as getting professionals with different levels of expertise makes care more informed, effective and safe (Ndoro 2014). However, in my future career as a nurse, I would like to involve the patients in their care as this was not demonstrated very well by the CC.

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