Physical health problems present the need for patient referral to a community caseload. However, community nurses may often find that their patient has an underlying mental health problem that either preceded their physical health complaint or was caused by it. As a community nurse, you may be the first to pick up on the problem. We cannot assume that the GP will be aware of any symptoms, so as nurses we have a duty to work with primary care and help find support for the patient, while also offering the immediate support required and any follow up, within the boundaries of the nurse's professional role. We cannot assume that patients will always open up and it may help using a gentle and open approach to engage a patient in conversation, as appropriate, about any worries or concerns, ability to cope, thoughts about the future and so on, all while taking care not to push for responses when the patient may feel uncomfortable.
Commonly diagnosed mental health problems
Mind (2023) states that one in four people will experience some sort of mental health problem every year in England, with one in six people experiencing common mental health concerns such as anxiety or depression in any given week. Fewer than one hundred people in any given week may experience panic disorder. Other common mental health concerns with similar rates of occurrence include generalised anxiety disorder, post-traumatic stress disorder, depression, phobias, and obsessive compulsive disorder (Mind, 2023). Such diagnoses change over time, with some people developing more complex mental health issues with a mixed range of symptoms including anxiety, depression, paranoia, obsessions and other symptoms associated with diagnoses such as borderline personality disorder, which occurs in two in one hundred people in their lifetime.
Antisocial personality disorder
Other complex diagnoses include antisocial personality disorder (ASPD), which occurs in three in one hundred people in their lifetime. However, such ‘personality disorder’ labels can be damaging and given the complexity of someone's mental health at any point and bearing in mind all potential triggers for symptoms, it is difficult and not necessarily helpful to simply label someone as having a personality disorder. The term itself has faced much backlash and professionals also dispute its use. However, without diagnosis of something such as a personality disorder, a patient would not receive long-term psychotherapy for their symptoms. In the UK, it is therefore often important to have a label if a patient is to receive any treatment that is appropriately prescribed for their condition/collection of symptoms. Patients are often encouraged to not go by their label but instead to focus on how to manage and resolve their symptoms. Some treatment is inappropriate due to an incorrect diagnosis, for example, in patients where their autism has been missed. Such patients have neurodiverse brains that cannot adapt to the treatment, often given for a personality disorder, and as such, some neurodiverse patients may experience iatrogenic harm from the treatment they are given for the diagnosis of ‘personality disorder’. This is why diagnosis can be extremely important—the wrong diagnosis does harm, yet no diagnosis can lead to no treatment and therefore, also does harm. It is therefore integral to get to know your patient and bring any concerns to the wider team in the primary care system, so that the appropriate psychiatrist can be allocated to assess the patient if there are concerns. Never be afraid to be an advocate for your patient and to speak up for them when you think they may have been misunderstood.
Bipolar disorder
Bipolar disorder occurs in two in one hundred people in their lifetime. This is a disorder that is psychiatric in nature as opposed to neurotic, such as the diagnoses aforementioned. The difference here relates to insight. Bipolar can cause either deep depressions or mania—a patient can experience only bouts of depression, or only mania, or a mixed range of states of either. The behaviour at times may appear similar to that of someone with borderline personality disorder. For example, with borderline personality disorder, identity and sense of self are often very changeable, thus leading the person to change their appearance often. A person with mania, however, may do so not because of an identity shift and a desire to fit in or to stand out, but through lack of insight and a complete change in character with loss of inhibitions. The loss of insight would be telling through the appearance of, for example, dressing in mismatched clothing in combination with a loud and unboundaried outward appearance, completely different to their usual behaviour, often with pressure of speech and a flight of ideas. Often, the two diagnoses are mistaken for the other. What is important here is that bipolar is a psychiatric condition that requires mood stabilisers and other drugs to ensure a good recovery, and therefore observing your patient is integral to getting them the timely support they need. If mistaken as someone with a personality disorder, they likely would receive no medication and may have to wait years for therapy for a condition they do not have. With psychiatric diagnoses involving loss of insight, the medication is an integral part of the treatment. Psychotic disorders such as schizophrenia also may present in patients at a lesser rate than bipolar. These patients may have long-term support with a psychiatric nurse in the community, a myriad of medications, and opportunities for rehabilitation.
Depression
Depression is common as a single diagnosis and is common in patients with bipolar, and is often severe but fleeting in someone with mood disturbances as seen in a personality disorder. The key is that across the spectrum of mental health issues, depressive thoughts are common. Suicide in our society is common. My colleague ended his life without leaving a note, and without any apparent prior history of mental health problems. It is evident he had suicidal thoughts that ended his life; yet, had no apparent history of mental illness, and nobody knew he was thinking of suicide. He was a very kind and peaceful natured man and dearly loved his young son.
Getting help
There are many people who may not go to the GP or psychiatrist and may have no diagnosis, and they may have protective factors such as a loving partner, children, a home and no hardship, yet they end their lives. It is a hugely difficult thing to understand and it is important to get people talking about, as sometimes, what is on the surface of a person is completely masking what is happening within. It is too common to believe depression must look like a slow, tearful, pale person with a downcast gaze. Some people have severe depressive thoughts, but appear happy. Mind (2023) notes that suicidal thoughts occur in one in five people across their lifetimes, one in fourteen people self-harm in their lifetime, and one in fifteen people in their lifetime attempt suicide. It is actually more common for women to have suicidal thoughts and make attempts to end their lives, yet men are three times more likely to take their own lives than women (Mind, 2023).
However, such figures are biased and lack generalisability to the rest of the population, as they are only based on a survey from 2014 that covered people ages 16 and over, lived in private housing, lived in England. Thus, the research excluded those who were in hospitals, prisons, sheletered housing, or those who were homeless or rough sleeping. These are all indicative of a heightened risk of mental health problems, but were not represented in the survey's findings.
Mind (2023) notes that only one in three people are receiving treatment for their mental health problem, and the most common treatment is medication, which on occasion may make the person worse. As a community nurse, it is important that you observe and note any changes that the patient might be going through, and act on any crisis, such as those resulting from adverse effects of new medications or medication changes. For example, suicidal thoughts can worsen while receiving selective serotonin reuptake inhibitors.
Suicide rates were going down prior to 2018 but have been increasing since, although this increase may be down to a change in the way a death is recorded—instead of an open or unexplained verdict, the ruling may force the verdict to be that of suicide.
There has been an extremely worrying trend of self-harm, which has increased by 62% between 2000 and 2014, and suicides in under 25-year-olds and in men have increased. The phenomenon of suicidal thoughts and self-harm is rising at a faster rate than the actual rate of mental health problems (Mind, 2023).
Greater risk of mental health problems is posed to marginalised communities such as those who identify as LGBTQIA+, black or black British people, young women aged 16-24, and people who experience problems with homelessness, substance misuse, and contact with the criminal justice system (Mind, 2023). Social inequality and disadvantage, discrimination and social exclusions, trauma, and differences in physical health can all worsen someone's mental health (Mind, 2023).
The King's Fund (2020) noted that primary care supports people with a range of mental health problems, where there may be a high need and a vast complexity to the person's problems. Yet, the charity acknowledges the mental health system does not benefit these people, as it is not built to best serve the range of problems people present with. The COVID-19 pandemic significantly disrupted all services for physical and mental health while also triggering higher rates of mental health problems among many people. The King's Fund (2020) indicated the success of improving access to psychological therapies (IAPT), but acknowledged that this service can only serve less complex cases and does not meet the needs for everyone. Many people fall through the gaps, being deemed too complex for IAPT, yet not complex enough for specialist mental health services, which is a huge injustice. Someone should not have to get worse in order to receive support. Services require a proactive approach rather than a reactive response. I worked as an expert advisor on NHS England's new Community Mental Health Framework, which the King's Fund (2020) noted is a significant step forward. However, greater clarity has been required to advise primary care on what mental health care should look like within their directorate. Thus, the charity indicated a direction of funding to the community for mental health practitioners to be based in general practices.
Integrated care systems across England have been implementing NHS England's Community Mental Health Framework, to offer a joined up and proactive approach to meet the needs of anyone with a mental health problem, and the results of the effectiveness of these changes are not yet published. The King's Fund (2020) notes that a joined-up policy-making approach at the national level is important, with close alignment between primary care policy and mental health policy. This will help better inform primary care on how to address mental health within its policies, funding and services.
Mental health and COVID-19
Mughal et al (2021) published a study on the effect of COVID-19, addressing the surge in mental health referrals in the wake of the pandemic, and the obvious link between such health issues and the consequences of such unnatural, restrictive measures placed upon society, which interfered greatly with peoples' everyday lives, their livelihoods, education and physical health. Mughal et al (2021) discussed the increases seen in cases of anxiety, depression, post-traumatic stress disorder and psychological distress since the pandemic.
The researchers found that living with young children, having pre-existing chronic or mental illness, being of a young age, female gender, and experiencing frequent exposure to pandemic news were all risk factors linked to COVID-19 related distress. Rates of suicidal thoughts were also seen to increase among people aged 18-29 during the pandemic, which enabled the researchers to highlight the particular toll of COVID-19 on young people. We already have the statistics relating to disadvantaged or marginalised groups and their risk, and we know about protective factors and general statistics about what factors elevate mental health risks, but this new research provides insight into the more specific risk factors in relation to the pandemic itself, which are slightly different to what we already know about environmental/situational risk factors.
The specific toll the pandemic took was unnatural and hard on many people who may not have otherwise been at much risk of emotional distress/mental health problems. The researchers found that repeated episodes of lockdown, periods of self-isolation following contact with infected people, social distancing, and the fear of contracting COVID-19 when outside the home led to a raised feeling of fear and anxiety in people of all ages. Mughal et al (2021) noted that self-isolation was found to be linked with symptoms of post-traumatic stress, anxiety, adjustment disorder, confusion, and anger.
Mental health support given by primary care is therefore something that should be a priority for patients, commissioners, researchers, and policy makers, Mughal et al (2021) commented.
Mughal et al (2021) noted that approximately 90% of mental health problems are managed entirely within the primary care sector, with GPs finding that 40% of their workload is taken up by mental health concerns among their patients. Through better management in primary care of people with mental health problems, access to treatment can be improved, stigma and financial pressures can be reduced from good response to timely treatment. Mughal et al (2021) also discussed the wellbeing of children and young people being further undermined by such disruption to their education, and social isolation from their friends. We may come across patients who have children with resulting mental health challenges, and therefore it is important to know how to understand and relate to the topic, while also being very aware of any safeguarding concerns that may accompany this type of problem in a young person in the patient's household.
In the community we also see an increase in those with long COVID—we may even have to visit the patient due to their physical symptoms and needs in relation to the condition, but it is important to understand that most patients experience a complex interaction of physical and emotional challenges. Mughal et al (2021) note that people with long-COVID often experience fear, uncertainty, and despair caused by persistent symptoms of their diagnosis, and place emphasis on mental health support as a key component of recovery.
In terms of what we are seeing in primary care, there are concerns to address, such as the urgent care needs of patients and the requirement for sustained mental health investment so that early diagnosis can be made of mental health conditions, with timely intervention and treatment, prevention, ongoing support, and access to specialist mental healthcare services (Mughal et al, 2021).
The researchers stated that a priority for primary care is to increase access to psychological therapies in combination with increased grassroots initiative support. The loss of in-person interaction between clinician and patient may also undermine the rapport that is so significant for effective mental healthcare, now that remote consultations have become the norm. This type of consultation may also reduce a clinician's ability to identify important cues, such as the possibility of substance misuse, domestic violence, self-harm, grief, low mood, signs of psychosis, or anxiety, particularly in young people, parents, and carers (Mughal et al, 2021). The time and resources of primary care staff are essential to the implementation of better care for all.
Conclusion
It is clear that mental health issues are common among much of our population, having been worsened in some groups by the pandemic. Primary care is the main place for management of mental health patients and a proactive stance should be taken to safeguard patients and their families, providing prompt and timely access to any support, as needed. The current services are not well-equipped or designed and some patients fall through the gaps. In the community, it is important we help those patients get the support they need. By having a general knowledge of mental health presentations, a community nurse may be able to pick up on cues and provide the support needed by the patient.