Often, when we are presented with a case it can be difficult to find a way forward. To aid clinical decisions, it is sometimes necessary to break down the decision making process into stages. The problem based learning task below does just that. Here I was given a case study and we methodically worked through the problem to get to a solution.
Identify, read and reflect upon the information supplied
Maud is uncomfortable with seeking support but her doctor has noticed symptoms of low mood or depression, and although MDS scores are mild, she may be under-reporting symptoms. She is worried about memory loss, and despite tests confirming no cognitive decline, she experiences negative cognitions pertaining to memory loss.
Her support network is changing; this combined with the fact that she is avoiding going out and that safety behaviours are preventing family visits, means she is also isolated. She is however, maintaining cognitive activities.
Identify terms you are familiar with and search out meanings
Identify what you already know to work toward resolving the problem
- Isolation in older adults is common and is linked to increased mental health difficulties (Age UK, 2011)
- Her extensive family are already engaging with the service and they are motivated to visit
- She has a network of friends who she used to socialise with
- People may under-report the severity of their difficulties for a variety of reasons (Papworth et al, 2013)
- In service Iâ€™ve found that many people believe that support for mental health is only appropriate for serious concerns
- Low mood can contribute to memory difficulties (Burt et al, 1995)
- Avoidance of anxiety producing situations is a common behavioural symptom of anxiety (Richards & Whyte, 2011)
- People with anxiety and low mood underestimate their ability to cope and the possibility that other people may support them
- A common symptom of low mood is increased irritability (DSM-5, 2013)
- Those suffering with low mood and anxiety often experience higher levels of negative automatic thoughts (Beck et al, 1979)
- Low-Intensity CBT-based interventions are recommended for mild to moderate low mood and anxiety (NICE, 2009 and NICE, 2011)
Identify what you need to know in order to work towards resolving the problems.
- The extent to which her family and friends can support her
- Physical symptoms
- Mobility, LTC, disabilities or physical restrictions
- Barriers to engagement
- Previous mental health history
- Where, with whom, and when the problem occurs
- Coping strategies
- Attitude to medication
- Current housing / financial situation / future plans
How and where you can access new information to lead towards the resolution of problems
- More extensive assessment with Maud
- Permission to speak to family about support available
- I could talk to the GP to understand more about her physical health / capabilities
- I could discuss the case in supervision to gain a different perspective
- Psycho-education around IAPT, anxiety and low mood in person or telephone dependant on client preference
- If Maud is comfortable, offer cCBT, group or GSH although due to isolation a group may be beneficial
- Cognitive Restructuring to develop realistic view of her situation
- Problem Solving to avoid missing family visits
- Behavioural Activation to encourage her to socialise more, although if related to anxiety, then Graded Exposure may be more appropriate.
- Age Concern befriending service and social support groups
- Support Time Recovery team in service to provide housing support if needed