In practice - People with mental health problems

Many people do experience problems (stress, debts, conflicts, worry, sleep problems), but by no means always seek help from the GGZ. Sometimes that has to do with unfamiliarity or shame. Mental health problems are still less socially accepted than physical complaints. And even less so with migrants if mental health problems and mental health care are unknown in their country of origin.

In practice - People with mental health problems
Many people do experience problems (stress, debts, conflicts, worry, sleep problems), but by no means always seek help from the GGZ. Sometimes that has to do with unfamiliarity or shame. Mental health problems are still less socially accepted than physical complaints. And even less so with migrants if mental health problems and mental health care are unknown in their country of origin.

In practice

 

Many people do experience problems (stress, debts, conflicts, worry, sleep problems), but by no means always seek help from the GGZ. Sometimes that has to do with unfamiliarity or shame. Mental health problems are still less socially accepted than physical complaints. And even less so with migrants if mental health problems and mental health care are unknown in their country of origin.

 

Even patients with serious disorders do not always think that they have a problem or that they are sick. The request for help sometimes comes from family or other people involved.

 

Organization of mental health care

GGZ is organized slightly differently than somatic care (see box). By the way, not everyone wants to be referred to a psychologist or a specialized mental healthcare institution.

 

GGZ

There are three levels of mental health care:

  1. GP care, partly performed by the POH ''The doctor treats people with simple mental health problems. He can consult a psychiatrist or psychologist or use e-health.''
  2. Basic generalist mental healthcare or basic mental healthcare ''Other primary care providers, such as psychiatric psychologists, treat people with more complex problems. This requires referral by the doctor.''
  3. Specialist mental healthcare, outpatient and clinical ''Care providers in specialized mental healthcare treat people with serious problems. A referral by the doctor is also required for this.''

 

Serious psychiatric disorders (EPA)

You are often aware of the serious psychiatric problems of your patient with EPA. The table below contains points for attention for the care of patients with EPA.

 

General points of attention in patients with EPA

Basic rules

 - Make contact

 - Match your communication to the person and what happens in the conversation

Health skills  - Take into account limited health skills (in recognizing, understanding, articulating, healthy behavior)
Load

 - Realize that a visit to the practice / pharmacy and staying in the waiting room can cause a lot of stress; that often demands so much from the patient that they can't get anything that day

 - Prevent the patient from having to wait long

Physical problems  - Stay alert to physical problems, which are common in this patient group
Network and direction

 - Know the network of care providers around this patient and know which care provider is in charge of care for physical health

 - Record data about network and coordinator in the patient file

 

People with EPA in the pharmacy

In the pharmacy you are alert for EPA (symptoms, prescribed medication, behavior) and signs of this in medication use, such as not receiving medication or getting it too late.

 

Specific points of attention in the pharmacy for people with EPA

Basic rules

 - Make contact

 - Match your communication to the person and what happens in the conversation

In the consultation room / treatment room / at the desk
Invitation  - Invite the patient to discuss medication use, now or next time
Understand

 - Check whether the patient understands the importance of consistent use of the medication

 - Ask about side effects

 - Ask if the patient has ever stopped by himself or would like to stop taking the medication; if so, ask for his considerations

Support  - Ask if the patient has or would like to have support with his medication use; if so, ask who could help him with this (family, residential counselor, ambulatory counselor) and what the pharmacy could mean therein
Medication overview

 - Pay extra attention to the medication overview

 - A good medication file is often missing when transferring between the second and first line; the patient often cannot indicate what his current medication is

Change?

 - Ask the patient if the medication is changed due to the preference policy (substitution) or the doctor has discussed this with him and what the change means for him

 - If the patient has doubts or is afraid that the medication will turn out differently, consult the pharmacist; the pharmacist can contact the prescribing doctor and get the doctor's explicit consent; this may reduce the patient's fear of change

 

Borderline personality disorder

People with BPD often have the feeling that they have none in their lives. This means that they often make an urgent or coercive appeal to care providers. It is important to recognize this behavior:

  • The patient often calls on emergency care (acute, compelling question; often contacting a GP).
  • The patient expresses his problem with many words and emotion (theatrical behavior).
  • The patient places the problem with the care provider, who must solve it according to the patient.
  • The patient threatens to harm himself if he does not get his way.

 

The table below contains points for attention for communication with borderline patients in general practice.

 

Points of attention in general practice for patients with borderline personality disorder

Basic rules

 - Make contact

 - Match your communication to the person and what happens in the conversation

On the phone / at the desk
Empathy

 - Show empathy and respect for the patient, even if you disagree with his behavior

 - Show understanding for the difficult situation that the patient is experiencing

Limits

 - Set limits on behavior; let us know if you do not accept certain behavior; also set limits on the time available to the patient

 - Set your limits in the I form ("I don't like it that you ...")

 - Indicate that you want to help the patient and what behavior you expect from him: "If you talk calmly, then ..."

 - Tips for dealing with claiming and aggressive behavior

Reliability

 - Be clear and keep agreements; do not make promises that you cannot keep; make sure you are reliable and credible

 - Apologize if something went wrong, for example if the patient was called back (too) late; with that you show understanding that that may have been annoying or difficult for the patient

Attention  - Do not go along with long stories, but ask about the here and now: "how are you now? what is the reason to call now? what is going on now? "
Risk behavior  - Ask explicitly about risk behavior ("have you taken any medicines?"); ask through and consult with the doctor; arrange, according to the agreements in your practice, a quick (telephone) consultation with the doctor
Offer  - Be clear about what you can and cannot offer: "It has been agreed with you that the doctor will not prescribe any additional medication. You can go to the doctor after the weekend "
Responsibility  - Let the patient remain responsible for his own behavior

 

Addicted patients in practice

Many addicted patients do not correspond to the image of addicts: junkies, emaciated, poorly cared for people living on the streets. Many addicts can more or less stand their ground in their social environment. They do not always see themselves as addicted, but for example as "social drinker" or "weekend user". It is good to be aware that addiction is common, even with people you do not suspect.

 

Aggression and violence

Patients who are under the influence can be anxious, irritated, excited or unrestrained. Withdrawal can cause the same symptoms. Users often have less control over their behavior. If they also misjudge the situation, it can lead to aggression and violence.

 

Aggression and violence occur in people who are under the influence of alcohol, cocaine and amphetamine, and in the withdrawal of alcohol, opiates, benzodiazepines and cannabis. Aggression and violence can also occur if the user needs a new dose of the medicine.

 

Addicted patients in general practice

Sometimes the doctor treats mild addiction problems. In the case of more serious problems, the GP refers and the patient is treated by GGZ / addiction care. Addicted patients often have somatic problems. The doctor offers their somatic care, even though the addiction care doctor will sometimes treat somatic complaints. It is important to analyze the problem well and not to attribute physical complaints too quickly to the addiction.

 

Usually the addiction care doctor is responsible for the drug treatment of the addiction. When benzodiazepines, for example for sleeping problems, are prescribed, the doctor and the addiction care doctor must make good agreements about this to prevent double prescriptions and negotiations. That is also why coordination and cooperation with addiction care is necessary.

 

Practitioners and general practitioners may also have to deal with family who want help for their addicted family member. They want substance use to stop, but that goal is often not achievable as long as the patient does not want it. In other situations the family asks for help because the situation is untenable for them. According to the Bopz Act (Special Admissions to Psychiatric Hospitals), forced admission is only possible in the event of immediate danger. As a result, family often feels left out in the cold.

 

Dealing with anger and aggression is discussed in another chapter.

 

Addicted patients in the pharmacy

As a pharmacist's assistant you see prescriptions for drugs used by patients with addiction. You also ask about the reason for use. That is not always easy. A patient may feel uncomfortable with this or become angry. Then explain that you ask because some drugs can be used for very different complaints and that it is important to know for which complaint the patient uses the drug.

 

In addition, there are of course also people with an addiction who are not being treated, or who are due to very different health problems. Sometimes their addiction problem is known or you can suspect based on medication, their health situation, external care and behavior. The table below contains points for attention for communication.

 

Points for attention for communication with addicted patients in the pharmacy

Basic rules

 - Make contact

 - Match your communication to the person and what happens in the conversation

At the counter
Respect

 - Show empathy and respect for the patient

 - Show understanding for possibly restless behavior, but set limits if the behavior hinders you in your work or is very disturbing for other patients

Health skills  - Take into account limited health skills (in recognizing, understanding, articulating, healthy behavior): adherence to therapy is difficult if life is very restless and the patient has other priorities
Manipulating, claiming and aggressive behavior

 - Stay friendly and respectful, but also clear about what you can and cannot do, what you can and cannot offer

 - Consult with the pharmacist if the conversation threatens to escalate; thereby you indicate that you take the patient's question seriously; the patient sometimes accepts a decision from the pharmacist more easily than from the assistant; sometimes the pharmacist can talk to the patient himself

 - Dealing with anger and aggression is discussed in the next chapter

 - When the pharmacist delivers less to addicted patients (nasal fentanyl, benzodiazepines), you can tell the patient that you can no longer give in from the pharmacist

 

Addicted patients in dental practice

The poor oral health of addicts is often the result of a combination of factors such as poor nutrition, insufficient oral hygiene, and less salivation due to medication use. Some problems are related to the substance used (see box).

 

Oral care problems with (serious) addicts

  • Lots of plaque and caries, often due to a combination of poor oral hygiene, use of a lot of sugar and less salivation. The need for sugar is high when using opioids (heroin).
  • Many gum problems.
  • Often neglected teeth, lack of elements.
  • Severe tooth wear due to bruxism (grinding teeth) and jaw clamp, especially when using alcohol, cocaine and amphetamine.
  • Problems of the jaw joint due to loss of elements and bruxism.
  • Shame about the teeth.
  • Erosion of the teeth due to alcohol, reflux and vomiting.
  • Mucosal abnormalities, inflammation of the corner of the mouth, Candida infection.
  • Broken teeth, due to caries and trauma (during epileptic seizures, fights).

 

Other health problems

Addicts often also have all sorts of other health problems, such as affective disorders, anxiety disorders, personality disorders (including borderline personality disorder), schizophrenia and PTSD. The dentist is not always aware of this. For example, you notice that the patient reacts suspiciously, is anxious, screams himself or herself, is absent or finds that there is nothing wrong.

 

(Ex) addicted patients are often very afraid of the dentist. People who are addicted to heroin or other opioids often have a heightened pain sensation. This means that a normal dosage for local anesthesia is often insufficiently effective. They are also very sensitive to stress situations and often afraid of anesthesia. The dentist will continue to sedate until sufficient pain relief has been achieved and the patient feels comfortable. Otherwise the tension and anxiety, and therefore the pain, will only increase. In the event of serious problems, treatment in a Special Dentistry Center is required.

 

Treatment plan

Pain relief and inflammation of the mouth are paramount in the treatment, in addition to limiting the damage to the teeth. Moreover, the ultimate goal is important: that patients can function again in society and can go to a "normal" dentist again. The treatment plan focuses on this. For example, the dentist will try to retain dental elements if they can be restored and do not perform extraction. Certainly those elements that catch the eye when laughing and talking. To achieve the ultimate goal, the dentist first works on the lateral parts of the teeth. The front is only the last one to come. If the dentist first improves the front, the patient is often satisfied and will not return for the rest. For the same reason, the dentist will usually only perform expensive follow-up treatments (crowns, bridges) when the patient is further in the treatment of his addiction and his life is in order.

 

From the start of treatment you pay a lot of attention to guiding the patient in improving his oral hygiene.

 

Points of attention for dealing with addicted patients are shown in the table below.

 

Points for attention when dealing with addicted patients

Basic rules

 - Make contact

 - Match your communication to the person and what happens in the conversation

General
Be aware of the use

 - Be alert for signs of addiction; if you recognize it, you (or the dentist) can ask if the patient uses resources and collect relevant data to tailor the treatment to the patient

 - Ask for fear of treatment, for pain, for anesthesia

Treatment relationship

 - Addicted patients do not always come (on time) for their appointment; make agreements about the consequences; find a balance

 - Addicts can sometimes behave impatiently, demandingly or aggressively; state the behavior and what it evokes in you; set your limits; say what behavior you expect to be able to continue

 - Dealing with anger and aggression is discussed in the next chapter

During the treatment
Motivate

 - Apply motivational techniques; emphasize that with a healthy mouth the patient no longer has pain and can smile again without having to hide his teeth

 - Pay extra attention to (guidance with) oral hygiene

Adjustment of local anesthesia

 - Explain to the patient that additional anesthesia may be needed; Have the patient indicate if he is still in pain so that the dentist can give more anesthesia

 - Use your communication skills to reduce anxiety

 

Migrants with mental health problems

When contacting migrants with mental health problems, make use of the points of attention in chapter ''Migrants''. Specific points for attention for mental health problems are listed in the table below.

 

Points to consider when dealing with migrants with mental health problems

Basic rules

 - Make contact

 - Match your communication to the person and what happens in the conversation

Interest

 - Show interest in the patient, his life and changes in his life or the life of his family through migration

 - Be careful not to explain the complaints or behavior from the culture too quickly: the patient is an individual and wants to be seen that way

Psychologically and physically

 - Do not enter into a dispute about whether complaints are psychological or physical

 - Use the words that the patient uses

Health skills

 - Take into account limited health skills (in recognizing, understanding, articulating, healthy behavior)

 - possibly refer to sites with specific information and support groups (www.pharos.nl; http://ziekofbezeten.marokko.nl/)