Posted: June 5th, 2023

Legal, Ethical, and Modalities of Mental Health Care

This assessment requires students to write an essay based on the case study provided on the Interact2 (I2) site, extending on the guided case study written for the first assessment.
Students are to review the case study provided on the Subject Interact2 (I2) site.
For this essay you are required to build on the theory of mental health and mental illness you discussed in the guided case study. If you did not do well in the first assessment, or wish to change the theory you based your assessment on, please discuss with your lecturer first.
You will need to review current, academic articles no more than five (5) years old, as well as professional Codes and Standards, and discuss in relation to your materials and the case study provided:
1. Legal aspects of mental health delivery to the patient;
2. Ethical aspects of mental health delivery to the patient (including general ethical principles as well as specific ethical professional requirements);
3. Different modalities of provision of mental health care, focusing on development in regional and rural areas.
You should relate each section to the specific patient in the case study, as well as the theory you outlined in the first assessment.
This assessment item must be presented as a scholarly paper and include an introduction, conclusion, supporting peer-reviewed research evidence, and a reference list.
This assessment should be written in formal academic style and sources must be correctly referenced in-text and in the reference list in accordance with APA 7th Edition referencing style.
Peer-reviewed references must be current (within the last five (5) years).
Students may use headings to organise their work, and this is encouraged to ensure you have addressed all sections of the assessment.

NRS384 – Health Challenges 3: Mental Health Care
Case Study for Assessment 1 & 2

Disclaimer (please read before reviewing the case study):
The following case study has been developed to support completion of both assessment tasks in NRS384 in the 202330 session.
In this scenario, a patient is admitted to hospital for ongoing mental health issues, with a significant background history. The scenario focuses on both assessment of the current presentation, as well as legal and ethical issues of the current presentation and previous mental health care the patient has received.
This scenario includes elements that you may find confronting. You may have been involved in similar events in your personal, professional or study experiences. If you are distressed by the scenario, please contact the Subject Convenor to discuss and consider contacting the Charles Sturt Student Counselling service (free and confidential) – https://www.csu.edu.au/current-students/safety-wellbeing/your-wellbeing/student-counselling

Your Setting
A rural hospital in a mid-sized regional town. The hospital has an emergency department, a combined ICU/HDU/CCU, a general medical ward, a general surgical ward, a rehabilitation ward, a paediatric ward and a maternity unit. On the hospital campus is a small, voluntary mental health unit which also covers drug and alcohol. There is no secure mental health unit in your town.

Your Patient

Hannah identifies as an Indigenous woman in her 30s. She is currently single with no children and lives in a share house with two roommates. She is currently working on a casual basis in retail. She has no relatives in your town and few community ties. She moved here to get away from stress in her old environment, and because a friend suggested work was easy to obtain.

Current Presentation

Hannah is bought to your emergency room in a mid-sized rural hospital by ambulance with police accompanying for an overdose of diazepam and ingestion of alcohol after an argument with her roommate.

She was held for danger-to-self and placed in a safe environment, however there are no vitals monitoring equipment available in your ‘safe room’. Hannah has been triaged, and a baseline set of vitals have been attended and a general observation chart has been commenced. Baseline blood test have been attended. Hannah has a back pack with her, and is wearing jeans and a hoodie with pockets. She is sitting quietly in your lockable ‘safe room’, and is staring at the floor. She is speaking only in single syllable words and is not making eye contact. She has refused offered food and drink. She has denied she needs to be at the hospital and says she ‘just wants to go home’ when asked.

You note that she has recently moved to town and started outpatient counselling with a new therapist, and to start with she identified this period as a “turning point”. While working with this therapist on her trauma, Hannah reported that she “hit a rough spot” and reconsidered the use of medications. She attended a psychiatric Assessment and because she was becoming more open about her history of childhood trauma, she disclosed to the psychiatrist that she experienced sexual abuse as child. Her notes from the new therapist recorded that she had recently started 75 mg of Sertraline for depression and anxiety but that she did not feel it was helping her depression; however, her anxiety was improved.

Background

On previous admissions when speaking about her history, Hannah has described a long history of involvement in the mental health system including the diagnosis of several
mental disorders, the prescription of various psychiatric medications, and multiple psychiatric hospitalizations.

From her previous notes from other admissions, you can see that Hannah has stated, “I had a very traumatic childhood. There was a lot of chaos in my home, a lot of abuse.” She described her father as unstable and prone to bursts of anger. During phases of her life when her father was the primary caregiver, Hannah explained that the needs of the children were often not met creating an unpredictable and insecure environment. Hannah reported that her father had difficulty maintaining a job, often relocating the family during her early childhood years. When she was approximately 11 years old, her father stopped working altogether and her mother was employed at two or three jobs at a time to meet the family’s financial needs. During this time, Hannah and at least one of her siblings experienced incidents of physical and sexual abuse by their father. She has described being perpetually “frightened”, and she remembers feeling that the children’s basic needs were often ignored. To illustrate, Hannah recounted an event when she fell and broke a bone. Hannah explained that when she sought help for her injury, “My father just lost it. He was screaming at me and telling me how much money I was going to cost him, and I was just terrified.”

Hannah described the abuse she experienced as episodic. When discussing the impact of these experiences, she recalled that living with a perpetual sense of fear was devastating.
Hannah reports that her parents divorced a few years later. When Hannah was in 9th grade,
she was taken by her mother to see a general practitioner to address sleep difficulties and
stomach aches. The medical record states that she was prescribed combination treatment with Imipramine and Nortriptyline at this time. Hannah indicated that she took the medications for a few months but chose to stop taking them. It is unclear if she consulted a physician before she discontinued use. Counselling was not offered as an option. It was not until later, when she viewed her medical record that she realized she was given a diagnosis of depression by this provider.

According to Hannah, at some point before age 16 she began using marijuana and alcohol. She acknowledged smoking marijuana daily and described this behaviour as an attempt to “get away” and reported she would often drink herself into “oblivion”. During this time, Hannah saw a general practitioner. At this appointment, the physician noticed cut marks on Hannah’s arms. The medical record indicates she was treated again for depression, with the doctor prescribing Paroxetine. It was also suggested for the first-time that she seek counselling, however, Hannah chose not to initiate these services at that time. After three months of taking Paroxetine, Hannah reports that “she didn’t like it” and discontinued the medication. The medical record indicates that it was later determined by a clinician that neither the earlier medications nor the Paroxetine were effective.

Despite two attempts to address her emotional difficulties through antidepressants, by late
adolescence, Hannah’s clinical status was declining. At this point, Hannah started her first of
what would be a long phase of various mental health services. Initially, Hannah attended three sessions of outpatient psychotherapy that she did not find helpful. At age 16, at the
recommendation of her physician, Hannah participated in an intake interview with a mental
health provider in which the provider reported that Hannah described “feeling awful all the time” and stated “nothing is worthwhile”. At the time of the interview, Hannah recounted being unhappy since age 11 and felt that she had been worsening over the previous year. As noted in this record, Hannah reported both alcohol and marijuana use but denied any history of physical, emotional, or sexual abuse.

As reported in the medical record, at age 17 Hannah’s psychiatrist began a trial of Mirtazapine, but due to extreme tiredness and lethargy chose to move to a trial of Venlafaxine which was eventually increased to 375 mg per day. Although others perceived her as improving on the medication, Hannah still reported she was unable to enjoy life and continued to experience a depressed mood and low energy. Later that year, the care provider tapered her off Venlafaxine and transitioned her to Phenelzine. Hannah experienced a number of adverse effects resulting in a dosage increase to 60 mg per day.

Within a few months, the medical record indicates the medication was not working and Hannah continued to experience adverse effects that included postural hypotension, tiredness, worsening suicidal thoughts, and a general sense of feeling bad physically and emotionally. The care provider opted to taper and discontinue the Phenelzine.

Hannah was hospitalized for acute suicidality and Phenelzine was restarted. The medical record indicates she experienced marked sleep disturbance and extreme depression. Olanzapine was prescribed and caused increased anxiety and agitation, myoclonic jerking and frequent nightmares, so it was discontinued. Two months later, Phenelzine was tapered and discontinued.

After discharge, Hannah received support through telephone contact with her care provider and additional psychotherapy but continued to have unremitting suicidal ideation and extreme sleep disturbances. A brief trial of Temazepam did not help with sleep, so the provider prescribed Valproic acid.

Within two days of the introduction of Valproic acid, Hannah was again hospitalized by her doctor due to her suicidal ideation. Hannah describes the first of these early hospitalizations
as “frightening”. During her stay, the medical record indicates she was diagnosed with major
depressive disorder, recurrent, severe, and dysthymic disorder and was treated with Maprotiline at the suggestion of her psychiatrist and Buproprion at Hannah’s request. According to the discharge summary, these medications were well-tolerated, with a normalization of sleep, a fair appetite, and improved energy levels and general outlook on life for a period of time.

Now 20 years old, the medical record indicates Hannah was hospitalized for severe
suicidal ideation, depression, and having cut her wrist with intent to kill herself. Hannah
describes the time period prior to this hospitalization as stressful. She had recently relocated to a large urban city and was attending college. Additionally, she had received news that her sibling was disclosing more details of being sexually abused by their father. In the history and Assessment, the care provider noted concern that this may have reactivated memories of her own possible sexual abuse, but it was unclear at the time. Because Hannah had not yet disclosed her history of sexual abuse to a provider, the provider was unable to confirm this history but cited concerns. The provider did, however, mention that Hannah had disclosed a history of significant verbal and physical abuse.

According to the record from this hospitalization, Hannah was diagnosed with Axis I:
major depression, recurrent, with melancholia, dysthymic disorder, post-traumatic stress disorder, chronic, and anorexia and Axis II: borderline personality disorder. She was initially treated with 20 mg of Fluoxetine daily as was her dosage at time of hospitalization; however, it was increased to 80 mg per day. It was determined that there was minimal improvement in mood. After two weeks her medication was changed to 45 mg of Mirtazapine. Hannah did not feel this medication was helpful and it was decided to return her to Fluoxetine. Gabapentin was added to her regimen at a dosage of 300 mg twice daily, increasing to 2400mg daily by the time of discharge, along with 5mg of Diazepam for anxiety.

It should be noted that the medical record describes Hannah’s refusal to eat or drink and
states “we will compel” her to increase her fluid intake if she continues to be unwilling to do so. Hannah explained that her eating problems were induced by her need to establish control. Her prognosis was considered to be “moderate impairment” which indicates symptoms that produce impairment of normal functioning at home, work, or school. She was discharged to a partial hospitalization program for three weeks and was instructed to continue seeing her private therapist.

For Hannah, hearing that she should reconsider what she was capable of and the idea that finishing her degree was not possible caused great despair. Hannah’s medical records indicate that within two months, she returned to the ER having taken an overdose of medications (including Diazepam, Fluoxetine, and Gabapentin). She admitted to suicidal ideation although she denied the desire to die. The intake record notes recent use of alcohol and marijuana. She was transferred to inpatient services and was restarted on Fluoxetine, Gabapentin, and Diazepam. Diagnosis was listed as dysthymia, poly-substance abuse, bulimia, and borderline personality traits. Hannah was discharged in six days with a prognosis of moderate impairment and placed in a partial hospitalization program.

Approximately three weeks after transferring to the partial hospitalization program, the
record indicates that Hannah was returned to full inpatient services due to increased suicidal ideation, symptoms of anorexia, and abuse of alcohol and marijuana. Diagnosis at intake was major depression, recurrent, anorexia nervosa, and borderline personality disorder. At discharge, two weeks later, an additional diagnosis of PTSD was added. Clinical status at this time was considered “very severe impairment”. All medications were discontinued during hospitalization with the exception of Lorazepam 1 mg GID for anxiety. Again, Hannah was transferred to the partial hospitalization program and discharged after 3 weeks. During this span of treatment, Hannah received inpatient or partial hospitalization for a period of two months.

After this series of hospitalizations, Hannah decided to discontinue use of all medications.
She described experiencing severe adverse effects that included a general sense of physical
illness and vision disturbances, as well as motor skill impairment. While in the hospital, Hannah stated she was told that the medications would not cause these adverse effects. It was Hannah’s feeling that hospital staff dismissed her concerns about adverse effects because of her diagnosis of borderline personality disorder.

_____________________
Legal, Ethical, and Modalities of Mental Health Care: A Case Study Analysis

This essay aims to explore the legal and ethical aspects of mental health delivery and different modalities of mental health care in regional and rural areas. The analysis will be based on a case study of Hannah, an Indigenous woman in her 30s, who presents with complex mental health issues. This essay will build upon the theory of mental health and mental illness discussed in the previous assessment and incorporate current academic articles and professional codes and standards to provide a comprehensive understanding of the topic.

Legal Aspects of Mental Health Delivery to the Patient:
The legal aspects of mental health care involve ensuring the rights of individuals with mental health disorders are protected. In Hannah’s case, it is crucial to consider the laws and regulations surrounding involuntary admission, patient confidentiality, and duty of care. Mental health legislation varies across jurisdictions; therefore, it is essential to review the specific laws applicable to the rural hospital where Hannah is receiving care. The Mental Health Act of the relevant jurisdiction should be examined to understand the provisions related to involuntary admission, detention periods, and the rights of the patient.

Ethical Aspects of Mental Health Delivery to the Patient:
Ethical considerations in mental health care encompass general ethical principles and specific professional requirements. Respect for autonomy, beneficence, non-maleficence, and justice are fundamental ethical principles to guide mental health professionals in their practice. In Hannah’s case, the mental health team must respect her autonomy by involving her in treatment decisions to the extent possible. Confidentiality is another critical ethical concern, and the team must ensure that Hannah’s personal information is protected unless there are legitimate reasons for disclosure, such as ensuring her safety or the safety of others.

Different Modalities of Provision of Mental Health Care:
Providing mental health care in regional and rural areas presents unique challenges due to limited resources and geographical barriers. To address these challenges, various modalities of care have been developed. Telepsychiatry, mobile mental health units, and collaborative care models are some of the approaches used to improve access to mental health services in remote areas. The case study does not explicitly mention the availability of these modalities in Hannah’s region; thus, it is important to review recent literature to explore the advancements and effectiveness of different modalities in rural mental health care.

Linking Theory and Case Study:
The theory discussed in the previous assessment, which outlined the impact of childhood trauma and the diagnosis of mental disorders, provides a foundation for understanding Hannah’s complex mental health history. The theory can be expanded upon by incorporating recent academic articles that explore the relationship between childhood trauma, multiple diagnoses, and treatment outcomes. This will further support the understanding of Hannah’s specific needs and inform the decision-making process regarding her care.

Conclusion:
Mental health care delivery must adhere to legal and ethical principles to ensure the well-being and rights of patients like Hannah. Additionally, innovative modalities of care can help overcome the challenges faced in rural areas. By considering the legal and ethical aspects and exploring various modalities, mental health professionals can provide comprehensive and patient-centered care to individuals with complex mental health needs. The case study of Hannah highlights the importance of understanding the individual’s history and tailoring the care accordingly to achieve the best possible outcomes.

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