Sometimes, expectation and optimism does not match reality. That’s no reason to be pessimistic – just another opportunity to expand your viewpoint on previously held beliefs. This is how I have approached my third clinical placement, which is in a mental health facility in the suburbs of Melbourne. It is an area of nursing that holds great interest for me, hence my optimism. Halfway through this placement, the reality has been somewhat different to my expectation.
I have had to accept that, like with physical illness, not everyone recovers from mental illness. A myriad of factors may explain this – amotivated feelings about their condition (no desire to seek or engage in help), lack of participation in therapy, medication complications (this is its own set of issues, especially in relation to dependence), lack of access to programs or activities that can assist recovery, lack of a support network from family or friends, and medical personnel that are disengaged or victims of the health system, just to name a few.
What has surprised me at this early stage is the number of return patients. The overwhelming majority of patients are known to staff and are on their third, fourth, or even fifth admission. The facility does not accept high-risk patients, so I can only imagine how much worse this scenario is for facilities that do. Some patients only stay for a few weeks; others have been here close to three months. Some patients are being monitored for medication changes, while some patients are admitted for treatment that requires extended monitoring.
One of these treatment options is Transcranial Magnetic Stimulation, or TMS. I was fortunate enough to accompany a patient during one of their TMS sessions, which afforded me a fascinating insight. This patient is currently going through their third round of TMS treatment, and each round has consisted of 30 sessions. The session I attended was their 24th of this third round. The patient does not feel that the TMS is making a difference to their outlook or thought processes, but they do not want to try the alternative treatment (Electroconvulsive Therapy, or ECT, which induces seizures to alter brain activity) because of the sometimes severe side effects of memory loss.
In contrast, TMS reportedly has little to no side effects and is not invasive. It involves using magnetic fields to activate specific areas of the brain – generally the pre-frontal cortex, which is the area of the brain that among other things, is associated with how we see ourselves (self-consciousness) and self-related mental processes. As depression can alter these thoughts and behaviours, TMS has been shown to improve self-perception in depressed patients by progressively altering brain activity in this area with repeated treatments. No anaesthesia is required (in contrast to ECT) and a patient can resume their usual daily routine once treatment has completed for the day, and some patients can even have two treatments in one day (one session takes around 40 minutes, depending on the severity of the patient’s depressive state). TMS is not a first-line course of treatment – it is generally prescribed when a patient continues to show depressive symptoms after at least one anti-depressant medication has been attempted. Interestingly, it is not currently covered by Medicare in Australia as further research on its long-term effectiveness is still ongoing. This results in an access issue, as it requires private health insurance and an inpatient admission or self-funding.
But how effective is this treatment when numerous patients are seemingly coming back for repeated rounds of therapy? Or is it more of a case of these patients not fully understanding their triggers and therefore relapsing? It could also be medication compliance or potentially new triggers. There is no obvious or simple answer, as we are not obvious or simple beings. Our brain exerts more control over us than we may ever give it credit for (side note: I recommend Afflicted, a truly fascinating series currently on Netflix to see some real examples of this). In this case, this patient is having their third round of treatment, reports that they do not see any improvement, yet, this patient is quite engaging, warm and reactive to conversation. They have a supportive family network and cannot specify any possible triggers for their continued admissions other than the feeling of hopelessness and helplessness that engulfs them. Consequently, they continue their treatment in the hope that it may eventually have an effect.
This is another important factor to highlight: it will not necessarily make sense that someone is suffering a mental illness. I was involved in a new patient admission recently – this patient has suffered depression for nine years (from the age of 12), an eating disorder for six years and has attempted suicide twice this year. They have no history of trauma or abuse, no family history of mental illness, no obvious triggers or explanations for why they feel the way they do. There is evidence of alcohol abuse, but not drugs. They have a good social network and a job. Prescribed medications have not had an effect and something just isn’t right, so they want to give ECT a chance to help them. This patient is warm, engaging and not visually distressed. They were studying at university until it became too difficult to manage with their illness. I can only hope that we can help them and not have them become one of the “frequent flyers”.
Naturally, I wonder why patients are returning at the rate that they are. It is clear from speaking with the staff at this facility that the system is letting some patients down. Medications are prescribed and dispensed, mental states are constantly assessed, as are current risk statuses. What might be a confronting question is asked – have you had any suicidal ideation recently, and if so, how do you plan to go through with it? Self-harm is also assessed and is more common than I thought it would be – one patient explained that they self-harm just so they can feel something. Sadly, some patients self-harm so they can be admitted, otherwise they might be turned away for a lack of available beds. There are clear cases of dependence to medications and these are managed as much as possible, but some of the return rate of patients might just sit at the hands of the patients themselves.
Patients need to understand the role they play in their own recovery. As someone who has suffered mental illness, I experienced two critical aspects: I was going nowhere until I acknowledged my illness; the next important step was to seek help and want to work at feeling better about myself and my life, instead of feeling embarrassed and ashamed of my predicament as I initially did. This is by no means an easy or simple step – this is the most difficult thing to do. To acknowledge and accept you are struggling is tough; to seek help and open up to someone that you are struggling and need help is even tougher.
The logical thought would be that the patients in a mental health facility have accepted these two aspects about themselves. Why then are they mostly returning for repeated admissions? Are they returning to past negative behaviours or thoughts? Are they disengaged with their treatment plans (not attending therapy groups or possibly non-compliant with medication)? I believe there is no obvious or logical answer – our complex brain can lead to many variations to mood, behaviour, thought, cognition, desire, as well as many other factors. This is where the nurse must be the patient’s advocate – each patient will bring their unique set of idiosyncrasies and one care plan that has succeeded with one patient might not work with another, just as one type of medication may assist one patient but not another. It is the system that lets patients down when it is assumed one treatment option is a best-fit for all, or indeed, that all patients will fully recover from their illness. It might just mean taking that little bit of extra time to sit down and talk, to listen and to care. Rapport and trust between the patient and the nurse is vital, as is the patient’s want to recover, or at least manage their condition.
This should extend to your network of family and friends – you do not have to wait until you can see an obvious sign of a friend or loved one struggling. Take that little bit of extra time to have a genuine conversation and know that some people are doing it tough, no matter the façade they put up. Try not to judge those who have the courage to admit that they are struggling and instead find ways to understand their struggle and offer ways out of it. There is no telling when or if someone will suffer from a mental illness, but showing that person that they are not alone and that someone cares about them will make the world of difference to them – and you don’t have to be a nurse to do that.
Words Not Numbers 