Managing pre-existing mental health conditions - transcript

Welcome everyone my name is Leanne Humphreys and today I’m talking with my colleague Dr John Cooper.

John’s a psychiatrist who has extensive experience in the management of issues relating to post-traumatic mental health and has been involved here at Phoenix in the policy and service development, training and education and research domains.

Hi John how are you?

John: I’m well thank you Leanne.

Leanne: that’s good. Today we’re going to be talking about the management of pre-existing mental health disorders following the experience of disaster and trauma. And John we know that for a proportion of the population who experience disaster a percentage of those individuals will have pre-existing mental health conditions. So my first question is: do these pre-existing conditions confer a vulnerability to the development of trauma-related mental health disorders?

John: Yes Leanne, we know that prominent amongst the pre-trauma risk factors for developing post-traumatic mental health problems, is a history of previous mental health disorder.

In understanding the presenting problems a person might bring to us, as clinicians in the post-disaster setting, it’s really important to obtain a history of the nature of any pre-existing mental health problems and the status of those problems at the time of the trauma or disaster. And I guess what we’re talking about here is a potential – broad range of pre-existing mental health conditions from the more serious mental health illnesses.

I’m just going to backtrack a little bit there. The range of pre-existing mental health conditions extends from serious mental illnesses such as schizophrenia, major mood disorders and the more severe personality disorders, through to some of the high prevalence disorders like mild or moderate depression, anxiety disorders, and post-traumatic stress disorder. But we also include consideration of vulnerable personalities and developmental disorders.

So these pre-existing conditions at the time of may have been presenting with stable and well-controlled symptoms not particularly impacting on function or the disaster may have occurred at a time where the person had active and ongoing symptoms it’s therefore really important for the clinician to determine whether they are dealing with a relapsed or exacerbation of a pre-existing condition or whether we’re dealing with a new condition that has a that has arisen as a result of the disaster given our task as clinicians is to provide effective advice and treatment that will reduce symptoms of associated risk and also to improve functioning we’ll do that a lot better with more success if their interventions are well matched to the presenting problems we’re better able to do this when we’ve taken a thorough history and performed a mental state examination that can then inform an accurate formulation from that formulation our treatment plans will logically follow

Leanne: Okay so that that response starts to lean into the issue of how best to approach the situation and in particular what’s standing out for me is an emphasis on the importance of formulating in guiding treatment planning. So why is formulation so important?

John: Well for me I think the formulation is the pivot to what we actually do in clinical practice. It’s the link between our assessment, including reassessments, and then the therapy treatment or management we provide to our patients. The psychiatric formulation has been said to be the clinician’s compass guiding our treatments. And when I’m thinking about formulation I’m looking at a systematic way of answering three main questions. What happened? Why did it happen?  What can be done about it and how do we proceed? And I think case formulation brings together all information gathered during the assessment in order to develop a full picture of these presenting problems.

I think in terms of approaches to formulation there are different approaches. I like to keep it simple and I tend to think through the the the method of the four P’s. It’s a fairly basic but useful approach, that considers the presentation in terms of predisposing factors, precipitating factors, perpetuating factors, and possible protective factors, things that might be a strength, that we can tap into. Obviously there are more sophisticated approaches but I like to keep it fairly simple.

So the context of this discussion, the pre-existing mental health conditions that a person might have, are clearly a predisposing or a vulnerability factor and I think understanding that, is a key plank in our formulation. It helps us understand the presenting problems that that we might see in the post-disaster setting.

So obviously the disaster event and that sequelae will be the precipitating factor. It might be the actual event and the related trauma but we know in post-disaster situations there are other relevant factors such as grief, loss of housing, financial stress and so forth.

A relapse or an exacerbation of a pre-existing condition might also act to perpetuate mental health problems, and if we don’t think about them or if we miss them in our assessment, they’re less likely to receive appropriate targeted treatment, and the absence of that treatment could perpetuate ongoing problems. And so, I think it’s also important to obtain a history of mental health conditions that have responded well to treatment in the past, and they may be formulated as a protective factor. It could give us as clinicians a strong basis to be optimistic about recovery, that the patient has had a positive experience of treatment, that we can elicit from that history, information about their treatment response.

It also helps when we know that our patients are comfortable and familiar with treatment pathways. I think these factors can reduce the likelihood of there being delay in a person presenting and accessing treatment and I think that if we can reduce those delays we improve their prognosis.

Leanne: Absolutely. Okay thanks very much John.

So in summary basically we’re saying that pre-existing mental health conditions certainly do confer a vulnerability for the development of post-traumatic mental health conditions and that we should approach the situation with an awareness that highlights the importance of conducting thorough assessment being really clear about diagnosis and in particular focusing on formulation in particular as we’re considering treatment planning.

Thanks very much John.