This programme has been organised

and funded by Janssen.

R4R: Mental Health Awareness Training: Spotlight on Schizophrenia[insert date]

[Insert location]

Item code: PHGB/MEDed/0918/0005

Date of preparation: October 2018

RCN Accredited until September 3rd

2019.

Accreditation applies only to the

educational content and not to any

product.

Disclaimer

• The Royal College of Nursing cannot confirm competence of any practitioner.

• Adverse events should be reported. Reporting forms and information can be found at

www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or

Apple App Store. Adverse events should also be reported to Janssen-Cilag Limited

on 01494 567447 or at dsafety@its.jnj.com.

Module 1: Mental Health Awareness: Spotlight on Schizophrenia

By the end of this module, you will:

• Have increased your awareness and understanding of mental health issues.

• Have explored your own and your colleagues’ experiences and attitudes relating to

mental health.

• Be able to discuss the extent to which patients attend primary care with mental health

issues.

• Be able to identify and challenge negative attitudes to schizophrenia.

• Understand the role of mental health clustering in treatment and care, with particular

reference to patients who may come under cluster 11.

Module aims

How many patients do you see with mental health issues in a typical day?

Likelihood of going to the GP for help with a mental health problem

53

52

52

51

55

55

27

31

30

31

29

27

6

6

7

4

6

7

6

6

5

7

5

6

4

3

3

4

3

4

3

3

2

3

3

2

2009

2010

2011

2012

2013

2014

Very likely

Quite likely

Neither

Quite unlikely

Very unlikely

Don't know

Adapted from Time to Change (2015) Attitudes to Mental Illness 2014 Research Report [Internet] Available from: https://www.time-to-

change.org.uk/sites/default/files/Attitudes_to_mental_illness_2014_report_final_0.pdf [Accessed May 2018].

• One in four adults experiences a mental health problem at some point in their life.1 Almost half of

all adults will experience at least one episode of depression during their lifetime.1

• Mental health problems account for 23% of the burden of illness in the UK and is the largest single

cause of disability.1

• 90% of people with mental health problems across their lifespan are managed in primary care.2

• Mental ill health costs approximately £105 billion each year to the economy in England alone,

roughly the cost of the entire NHS.3

• People with severe mental illness are at risk of dying on average 15-20 years earlier than the

general population.3 They are more likely to have poor physical health - this is due in part to higher

rates of health risk behaviours, such as smoking, alcohol and substance misuse.1

Mental ill health - the facts

1. Department of Health (2011) No Health Without Mental Health [Internet] Available from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf [Accessed May 2018].

2. Royal College of General Practitioners (2014) RCGP Curriculum Statement 3.10 Care of People with Mental Health Problems [Internet] Available from: http://www.rcgp.org.uk/gp-

training-and-exams/gp-curriculum-overview/~/media/Files/GP-training-and-exams/Curriculum-changes/RCGP-Curriculum-3-10-Mental-Health-Problems-track-change-2014.ashx

[Accessed May 2018].

3. NHS England (2016) The Five Year Forward View for Mental Health [Internet] Available from: https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-

FYFV-final.pdf [Accessed May 2018].

Which types of patients with mental health problems are most likely to attend their GP practice?

Prevalence of psychiatric disorders seen in a typical general practice

Adapted from Royal College of General Practitioners (2007) RCP Curriculum Statement 13: Care of People with Mental Health Problems [Internet] Available from:

http://www.rcgp.org.uk/-/media/Files/GP-training-and-exams/Curriculum-previous-versions-at-July-2012/curr_archive_13_Mental_Health_v1_0_feb07.ashx?la=en [Accessed May

2018].

92

47

28

19

412

7

42

81

0

10

20

30

40

50

60

70

80

90

100

Weekly prevalence per 1000 adults

aged 16-64 years

Diagnosis

• In the UK, the 1-week prevalence rate of clinical depression from the Office of National Statistics 2007 survey was 2.3%, and lifetime estimates of the proportion of the population that experience major depression are between 4% and 10%,1 with significantly higher prevalence in women.2

• The age of onset of mood disorders can range from 25-45 years old.3

For diagnosis, the DSM-IV and ICD-10 require at least one or two of these key symptoms, respectively:4

Depression

1. National Institute for Health and Care Excellence (2011) Common mental health problems: identification and pathways to care. NICE clinical guideline [CG123] [Internet] Available

from: http://www.nice.org.uk/guidance/cg123 [Accessed May 2018].

2. The Health & Social Care Information Centre (2009) Adult psychiatric morbidity in England, Results of a household survey. NHS Information Centre, Leeds.

3. Kessler R., et al. (2007) Age of onset of mental disorders: A review of recent literature. Current Opinion in Psychiatry. 20(40); 359–364.

4. National Institute for Health and Care Excellence (2009) Depression in adults: recognition and management. NICE clinical guideline [CG90] [Internet] Available from:

https://www.nice.org.uk/guidance/cg90 [Accessed May 2018].

• Symptoms should be present for at least 2 weeks and each symptom should be present at sufficient severity for most of every day.4

• ‘Sub-threshold depressive symptoms’ are when there is at least one key symptom, but with insufficient other symptoms and/or functional impairment to meet the criteria for full diagnosis.4

Loss of energy Low moodLoss of interest

and pleasure

• The PHQ-9 assessment is a 9 item, self report questionnaire version of the PRIME-MD diagnostic

instrument for common mental disorders, focusing on presence (or absence) of the symptoms of

depression.1

• The questionnaire was devised in 2001, it is shorter than other depression measures, but is

comparable with regards to sensitivity. It can also deliver a dual purpose of both establishing a

depressive disorder diagnosis as well as grading symptom severity.1

• The PHQ-9 assessment is available from:2

http://www.agencymeddirectors.wa.gov/files/AssessmentTools/14-PHQ-9%20overview.pdf

The Patient Health Questionnaire (PHQ-9) assessment tool

1. Kroenke K., et al. (2001) The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine. 16(9); 606-613.

2. Pfizer (1999) The Patient Health Questionnaire (PHQ-9) Overview [Internet] Available from: http://www.agencymeddirectors.wa.gov/files/AssessmentTools/14-PHQ-

9%20overview.pdf [Accessed May 2018].

Living with depression

NHS Choices (2009) Clinical Depression: Lawrence’s story [Internet] Available from: https://www.youtube.com/watch?v=BfZ7VKhwpeI [Accessed May 2018].

View this video here:

https://www.youtube.com/watch?v=BfZ7VKhwpeI

In 2013 there were 8.2 million cases of anxiety recorded in the UK alone, and the one-week

prevalence of generalised anxiety in England is 6.6%.1

Some key physical and psychological symptoms of anxiety include:2

Anxiety

1. Mental Health Foundation (2018) Mental Health Statistics: Anxiety [Internet] Available from: https://www.mentalhealth.org.uk/statistics/mental-health-statistics-anxiety [Accessed

May 2018].

2. Mind (2017) Anxiety and Panic Attacks, anxiety symptoms [Internet] Available from: http://www.mind.org.uk/information-support/types-of-mental-health-problems/anxiety-and-panic-

attacks/anxiety-symptoms/#.V9LN4fkrI1I [Accessed May 2018].

Feeling nervous, tense or on edge

Difficulty sleeping RuminationRestlessness and

concentration difficulties

Racing heartbeat and faster breathing

Dizziness Sweating Panic attacks

• The GAD-7 assessment was developed in 2006 as a seven-item, self-report questionnaire designed

to assess a patient’s health status over the previous 2 weeks, with a focus on the relative presence

(or absence) of symptoms related to Generalised Anxiety Disorder (GAD).1,2

• The scale uses a normative system of scoring (0 - Not at all, 1 - several days, 2 - more than half the

days, 3 - nearly every day) across seven items – with a final question to assess the impact the

patient’s anxiety over the past 2 weeks has had on their ability to function, in terms of their work,

home life or interpersonal interactions. This question does not factor into the overall scoring, and is

not utilised when implemented within the NICE guidelines.3

• The GAD-7 assessment is available from:1

http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf

Generalised Anxiety Disorder (GAD-7) assessment tool

1. Spitzer R. et al. (2006) A brief measure for assessing Generalized Anxiety Disorder: the GAD-7. Archive of Internal Medicine. 166; 1092- 1097.

2. Williams N. (2014) The GAD-7 questionnaire. Occupational Medicine. 64(3); 224.

3. National Institute for Health and Care Excellence (2011) Common mental health problems: identification and pathways to care. NICE clinical guideline [CG123] [Internet] Available

from: http://www.nice.org.uk/guidance/cg123 [Accessed May 2018].

Bipolar disorder is relatively common, and around 1 in every 100 adults will suffer from bipolar disorder at some point in their life.1 It usually starts during puberty, and initial symptoms rarely appear over the age of 40.1 Men and women are affected equally.1

There are a number of types of bipolar disorder, with differing symptom profiles:1

Bipolar disorder

1. Royal College of Psychiatrists (2015) Bipolar disorder: Problems and disorders [Internet] Available from: http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/bipolardisorder.aspx

[Accessed May 2018].

2. NHS Choices (2017) Cyclothymia [Internet] Available from: https://www.nhs.uk/conditions/cyclothymia/#symptoms-of-cyclothymia [Accessed May 2018].

Bipolar I disorder

• Mania and depression

Bipolar II disorder

• More than one episode of severe depression, with only mild manic episodes (hypomania)

Rapid cycling

• >4 episodes per year

Cyclothymia

• Characterised by periods of feeling low followed by periods of extreme happiness and excitement (hypomania), where the person doesn’t need much sleep and has a lot of energy. The periods of low mood include feeling sluggish and losing interest, but does not stop people going about their day-to-day life.2

• As most people who experience cyclothymia have mild symptoms, it often goes undiagnosed and untreated, but the mood swings can affect daily life, and cause problems with personal and work relationships.2

Mental health stigma

Adapted from Time to Change (2015) Attitudes to Mental Illness 2014 Research Report [Internet] Available from: https://www.time-to-

change.org.uk/sites/default/files/Attitudes_to_mental_illness_2014_report_final_0.pdf [Accessed May 2018].

0 5 10 15 20 25

It is frightening to think of people with mental problemsliving in residential neighbourhoods

People with mental illness should not be given anyresponsibility

As soon as a person shows signs of mentaldisturbance, he should be hospitalised

People with mental illness are a burden on society

% agreeing

2014

2003

1994

Fear and exclusion of people with mental illness, 1994 - 2014

• Parity of esteem is the principle by which mental health must be given equal priority to physical

health, however currently mental health accounts for around ¼ of the disease burden across the

NHS but receives only 13% of the funding.1

• Respect and understanding afforded to those with severe and chronic physical health issues is not

always replicated in attitudes towards people with severe, chronic mental health issues. Parity

means equal respect and hope when dealing with difficult prognoses.1

• Campaigns such as Time to Change have contributed to an increase in more positive

representations of mental health in the media.2

• Longer term commitments to parity of esteem have been made through the Five Year Forward View

for Mental Health.3

• However, many people living with mental health problems still experience discrimination which

can also have a negative impact on their mental health, therefore decreasing stigma should be

regarded as an important health issue.4

Mental health discrimination and parity of esteem

1. Millard C. & Wessely S. (2014) Parity of esteem between mental and physical health. British Medical Journal (Clinical research ed.). 349(10); 6821.

2. Thornicroft A. et al. (2013) Newspaper coverage of mental illness in England 2008-2011. The British Journal of Psychiatry. 202; ss.64-69.

3. NHS England (2016) The Five Year Forward View for Mental Health [Internet] Available from: https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-

FYFV-final.pdf [Accessed May 2018].

4. Hamilton S. et al. (2016) Qualitative analysis of mental health service users’ reported experiences of discrimination. Acta Psychiatrica Scandinavica.134; ss.14-22.

How do you view patients with schizophrenia?

Number of patient homicides by primary diagnosis and UK country (2003 – 2013)

Adapted from Healthcare Quality Improvement Partnership (2015) National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report. [Internet]

Available from: http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/NCISHReport2015bookmarked2.pdf [Accessed May 2018].

32

19

14

35

12 12

9

1314

22

9

16

11

33

18

13

16

7

30

6

0

5

10

15

20

25

30

35

40

England NorthernIreland

Scotland Wales

Schizophrenia and otherdelusional disorders

Personality disorders

Affective disorder

Alcohol dependence/misuse

Drug dependence/misuse

• The term 'psychosis' refers to the group of psychotic disorders that includes schizophrenia,

schizoaffective disorder, schizophreniform disorder and delusional disorder.1

• Although those who develop psychosis will each have their own unique combination of symptoms

and experiences, generally psychosis may be described as a psychiatric disorder in which a

person’s thoughts, perceptions, mood and behaviour are significantly altered.1

• Schizophrenia affects around 1 in 100 people over the course of their lifetime.2 Approximately 1 in

10 people diagnosed will also have a parent with the illness.2

• The first episode of psychosis usually occurs in late adolescence or early adulthood, but it is

frequently preceded by a prodromal phase or a so-called ‘at-risk’ mental state.3 The symptoms and

behaviour associated with schizophrenia can have a distressing impact on family and friends.4

Schizophrenia - definition and prevalence

1. National Institute of Health and Care Excellence (2014) Psychosis and schizophrenia in adults: prevention and management. NICE clinical guideline [CG178] [Internet] Available

from: https://www.nice.org.uk/guidance/cg178 [Accessed May 2018].

2. Royal College of Psychiatrists (2015) Problems and Disorders: Schizophrenia [Internet] Available from:

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/schizophrenia.aspx?theme=mobile%202015 [Accessed May 2018].

3. Owen M. et al. (2016) Schizophrenia. Lancet. 388; 86-97.

4. Department of Health (2011) No Health Without Mental Health [Internet] Available from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf [Accessed May 2018].

Living with schizophrenia

Time to Change (2014) Time to Change Champions video blog – Stephen’s story (short) [Internet] Available from: https://www.youtube.com/watch?v=rlmralPSP7U [Accessed May

2018].

View this video here:

https://www.youtube.com/watch?v=rlmralPSP7U

Elyn Saks, a professor of law at South California university, recipient of the

MacArthur ‘genius grant’ and living with schizophrenia (2009)

Living with schizophrenia

Adapted from Saks E.R. (2009) Scientific American: Diary of a high-functioning person with schizophrenia [Internet] Available from: http://www.scientificamerican.com/article/diary-

of-a-high-function/ [Accessed May 2018].

“I think there are a lot of myths about schizophrenia. What I most wish the

public knew is that, at bottom, we are really just like you: we want, in the

words of Sigmund Freud, “to love and to work”. There are myths out there

that we can’t do this, but they are just that: myths. Mental health

professionals should stop immediately telling patients to drastically lower

their expectations. With proper resources and proper care, people can live

up to their potential.”

• The cluster framework is designed as a planning framework, to ensure each patient is placed in the

most appropriate services and receives the best treatment, support and interventions to meet

their individual needs at any one time.1

• A cluster is a global description of a group of people with similar characteristics as identified from

a holistic assessment and then rated using the Mental Health Clustering Tool (MHCT).1

Clustering

1. NHS England (2017) Mental Health Clustering Booklet v5.0 2016/17 [Internet] Available from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499475/Annex_B4_Mental_health_clustering_booklet.pdf [Accessed May 2018].

More detailed information about clustering can be found at: http://www.mednet.co.uk/imhsec/

Clustering

Cluster Description

11. Ongoing recurrent

psychosis (low

symptoms)

This group has a history of psychotic symptoms that are currently controlled and causing minor problems if any at

all. They are currently experiencing a sustained period of recovery where they are capable of full or near

functioning. However, there may be impairment in self-esteem and efficacy and vulnerability to life.

12. Ongoing or

Recurrent Psychosis

(High Disability)

This group has a history of psychotic symptoms with a significant disability with major impact on role functioning.

They are likely to be vulnerable to abuse or exploitation.

13. Ongoing or

Recurrent Psychosis

(High Symptom and

Disability)

This group will have a history of psychotic symptoms which are not controlled. They will present with severe to

very severe psychotic symptoms and some anxiety or depression. They have a significant disability with major

impact on role functioning.

14. Psychotic Crisis They will be experiencing an acute psychotic episode with severe symptoms that cause severe disruption to role

functioning. They may present as vulnerable and a risk to others or themselves.

15. Severe Psychotic

Depression

This group will be suffering from an acute episode of moderate to severe depressive symptoms. Hallucinations

and delusions will be present. It is likely that this group will present a risk of non-accidental self-injury and have

disruption in many areas of their lives.

16. Psychosis & Affective

Disorder (High

Substance Misuse &

Engagement)

This group has enduring, moderate and severe psychotic or bipolar affective symptoms with unstable, chaotic

lifestyles and co-existing problem drinking or drug taking. They may present a risk to self and others and engage

poorly with services. Role functioning is often globally impaired.

1. NHS England (2017) Mental Health Clustering Booklet v5.0 2016/17 [Internet] Available from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499475/Annex_B4_Mental_health_clustering_booklet.pdf [Accessed May 2018].

Ongoing recurrent psychosis (low symptoms)

Cluster 11 description

This group has a history of psychotic symptoms that are currently

controlled and causing minor problems if any at all. They are

currently experiencing a sustained period of recovery where they are

capable of full or near functioning. However, there may be

impairment in self-esteem and efficacy and vulnerability to life.

1. NHS England (2017) Mental Health Clustering Booklet v5.0 2016/17 [Internet] Available from:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499475/Annex_B4_Mental_health_clustering_booklet.pdf [Accessed May 2018].

Returning to primary care

1. National Institute of Health and Care Excellence (2014) Psychosis and schizophrenia in adults: prevention and management. NICE clinical guideline [CG178] [Internet]

Available from: https://www.nice.org.uk/guidance/cg178 [Accessed May 2018].

Offer people with psychosis or

schizophrenia, whose symptoms

have responded effectively to

treatment and remain stable, the

option to return to primary care

for further management.1

If a service user wishes to do

this, record this in their notes

and coordinate transfer of

responsibilities through the care

programme approach (CPA).1

First referral to secondary care

If a person is distressed, has a decline in social functioning and has:1

• transient or attenuated psychotic symptoms or

• other experiences suggestive of possible psychosis or

• a first-degree relative with psychosis or schizophrenia

refer them for assessment without delay to a specialist mental health service or an early intervention in

psychosis service because they may be at increased risk of developing psychosis.

Referrals to secondary care

1. National Institute of Health and Care Excellence (2014) Psychosis and schizophrenia in adults: prevention and management. NICE clinical guideline [CG178] [Internet]

Available from: https://www.nice.org.uk/guidance/cg178 [Accessed May 2018].

Re-referral to secondary care

• When a person with an established diagnosis of schizophrenia presents with a suspected relapse,

primary healthcare professionals should refer to the crisis section of the care plan (for example, with

increased psychotic symptoms or a significant increase in the use of alcohol or other substances).1

• Consider referral to the key clinician or care coordinator identified in the crisis plan.1

When re-referring people with psychosis or schizophrenia to mental health services, take account of

service user and carer requests, especially for:1

• review of the side effects of existing treatments

• psychological treatments or other interventions.

Referrals to secondary care (continued)

1. National Institute of Health and Care Excellence (2014) Psychosis and schizophrenia in adults: prevention and management. NICE clinical guideline [CG178] [Internet]

Available from: https://www.nice.org.uk/guidance/cg178 [Accessed May 2018].

Any questions?

Question one

Which of the following statistics are false in relation to schizophrenia? (choose one answer)

a) 1 in 10 people diagnosed will have a parent with the illness.

b) 1 in 100 people have schizophrenia over a lifetime.

c) 4 per 1000 adults typically attend the GP every week.

d) Across 2003-2013, 60% of homicides in England were committed by people with a history of schizophrenia.

Question two

Which of the following are true in relation to bipolar disorder? (choose two answers)

a) Women are more likely to be affected.

b) It is characterised by periods of mania and depression.

c) It is very rare only occurring 1 in every 10000 adults.

d) People can continue with their relationships and jobs.

Multiple choice assessment

Question three

Which of these descriptions would be related to cluster 11? (choose two answers)

a) Experiencing auditory and visual hallucinations for the first time.

b) Experiencing hallucinations that are controlled and causing minor problems.

c) Finding it difficult to get a job due to low self-esteem or lack of experience.

d) A person has attended a number of visits visibly drunk to the degree that they are incoherent.

Question four

If you hear people expressing negative attitudes about mental health how would you challenge this? (choose all that

apply)

a) Explain that mental health does not get as much funding as physical health currently.

b) Explain that it is similar to having a broken arm and the brain just needs to be fixed.

c) Explain that people with mental health conditions are just like you and want to live their lives normally working

and loving.

d) Explain that the media focuses on mental health if someone has committed a violent crime, whereas

people with mental health problems are more likely to have violence perpetuated to them.

Multiple choice assessment

Question one

Which of the following statistics are false in relation to schizophrenia? (choose one answer)

a) 1 in 10 people diagnosed will have a parent with the illness.

b) 1 in 100 people have schizophrenia over a lifetime.

c) 4 per 1000 adults typically attend the GP every week.

d) Across 2003-2013, 60% of homicides in England were committed by people with a history of

schizophrenia.

Question two

Which of the following are true in relation to bipolar disorder? (choose two answers)

a) Women are more likely to be affected.

b) It is characterised by periods of mania and depression.

c) It is very rare only occurring 1 in every 10000 adults.

d) People can continue with their relationships and jobs.

Multiple choice assessment - answers

Question three

Which of these descriptions would be related to cluster 11? (choose two answers)

a) Experiencing auditory and visual hallucinations for the first time.

b) Experiencing hallucinations that are controlled and causing minor problems.

c) Finding it difficult to get a job due to low self-esteem or lack of experience.

d) A person has attended a number of visits visibly drunk to the degree that they are incoherent.

Question four

If you hear people expressing negative attitudes about mental health how would you challenge this? (choose all that

apply)

a) Explain that mental health does not get as much funding as physical health currently.

b) Explain that it is similar to having a broken arm and the brain just needs to be fixed.

c) Explain that people with mental health conditions are just like you and want to live their lives normally,

working and loving.

d) Explain that the media focuses on mental health if someone has committed a violent crime,

whereas people with mental health problems are more likely to have violence perpetuated

to them.

Multiple choice assessment - answers