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CONCEPTS AND ISSUE
Basic life support for mental health crisis: You can be a hero
Catherine Poornaselvan
Nursing Faculty, MCC School of Nursing, NJ; Professor, Department of Global Health, Chamberlain University, IL, USA
Date of Submission 07-Oct-2019
Date of Decision 15-May-2020
Date of Acceptance 22-Jul-2020
Dr. Catherine Poornaselvan
Nursing Faculty, MCC School of Nursing, NJ
DOI: 10.4103/IJCN.IJCN_60_20
Mental illness is not limited to a certain gender, age, sex, religion or race. However, due to the lack of awareness, acceptance, and education, many people endure symptoms without help and treatment, which can lead to the illness becoming progressively worse. Basic life support for sudden cardiac arrest is a well-known first-aid measure. First aid for a mental health crisis, however, is not widely known or understood. ALGEE a pneumonic for approach, listen, give, encourage and encourage is used as an assessment instrument in mental health first aid (MHFA) training that was first initiated in Australia and is now being provided in many countries globally. The mnemonic is simple to learn, just like Circulation Airway and Breathing for cardiopulmonary resuscitation. Many studies done by MHFA organisations globally show that the information and knowledge ALGEE provides can help nurses, other professionals and interested members of the community to better interact with individuals who have mental health crisis. This article addresses the background, process and outcomes of MHFA.
Keywords: ALGEE, mental health crisis, mental health first aid
Poornaselvan C. Basic life support for mental health crisis: You can be a hero. Indian J Cont Nsg Edn 2020;21:12-6
Poornaselvan C. Basic life support for mental health crisis: You can be a hero. Indian J Cont Nsg Edn [serial online] 2020 [cited 2021 Jan 18];21:12-6. Available from: https://www.ijcne.org/text.asp?2020/21/1/12/295049
Mental health is increasingly becoming a vital indicator of population health now. Paradoxically, there is a lack of knowledge and stigma regarding mental illness among people and even among health professionals. Empirical evidence shows that mental health emergencies are increasing, and the need for mental health care exceeds that of the availability of beds or dedicated trained professionals. A systematic review of 174 surveys across 26 high-income countries and 37 low- and middle-income counties published in 2014 revealed that one in every five individuals (17.6%, 95% confidence interval: 16.3%–18.9%) suffered from mental illness in the previous 1 year of the survey. Mood and anxiety disorders were common among women, whereas alcohol and substance abuse were more common in men. The study findings from 85 lifetime survey studies also revealed a lifetime prevalence of some form of mental disorder as 29.2% (25.9%–32.6%).[1]
The United States (US) National Center for Health Statistics [2] reported that in 2017 there were about 46.6 million adults aged 18 years and older with acute mental illness (AMI) in the US. This number represented 18.9% of all US adults. The prevalence of AMI was higher among women (22.3%) than men (15.1%). Young adults aged 18–25 years had the highest prevalence of AMI (25.8%) compared to adults aged 26–49 years (22.2%) and aged 50 and older (13.8%). The prevalence of AMI among the US adults is depicted in [Figure 1].
Figure 1: Prevalence of any mental illness among US adults. Source NIMH (2018). Past year prevalence of Mental Illness among U.S. Adults (Chart) Retrieved From: https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_154785.
Mental illness and mental illness related to morbidity are becoming a national burden in India also. The national mental health survey done across 12 states in India in 2015–2016 reported the overall mental morbidity as 13.7% lifetime and 10.6% as point prevalence. Alcohol use disorders were more prevalent in men, and depressive illnesses were common in females, as was seen globally. Individuals from urban areas and cities were found to have a higher prevalence of all mental disorders than others. The risk of suicides was the highest among 40–49 years in this study and predominantly in females and from urban metros.[3]
These numbers indicate that there are many people suffering from mental illness or experiencing a mental health crisis during their lifetime. During a mental health crisis, an individual may exhibit erratic behaviour, become distressed and emotionally disturbed. They may consider harming themselves or others and be unable to function in a calm, rational way. These consequences could lead to suicide or other harmful behaviour that could endanger others.
Statistics indicate that higher suicide rates are a disturbing and stable trend globally. In the US, there has been a 35% increase in deaths related to suicide from 1999 to 2017 with a greater increase after 2006 among both males and females.[4] Although the deaths related to suicide in India has reduced over 15 years, especially in women, it is alarming to note that the suicide death rates in India is more than the global average [Figure 2][5] and suicide was the leading cause of death in individuals aged between 15 and 39 years in India in 2016.[6]
Figure 2: Suicide death rates in India compared to global rates
The rise in mental health issues across the globe indicates a need to upscale mental health services in all the countries. Although mental health and suicide prevention is given much emphasis in the Millennium Development Goals and later in the Sustainable Development Goal 3 by United Nations,[7] challenges still persist in providing mental health services to the population at large. Insufficient funding allocation for mental health services, lack of specially trained personnel to address the increasing demands of mental health issues, inequity in the distribution of the mental health resources in urban and rural areas and lack of leaders who can lobby for mental health promotion in public health arena have been identified as some barriers in improving mental health services as needed, especially in low- and middle-income countries [8] in one of the earlier studies. Family members of patients with mental illness found affordability, accessibility and stigma attached to mental illness as barriers to obtaining mental health services in another study.[9] Fewer mental health providers were available in the minority and integrated primary care service areas compared to the white primary care service areas in the US.[10]
The existing data, on both the prevalence of mental health illness and the availability of mental health services, therefore reveals that mental health throughout life span has become a concern for not only the health-care professionals but also families and the society. This has been apparent during the COVID-19 pandemic. Globally, people are facing additional stressors such as anxiety, unemployment, isolation, and some are dealing with family issues. Health-care and other essential workers are putting themselves at risk and are often working exceptionally long hours. All the above factors place people at risk for a mental health crisis. A mental health crisis can happen to anyone at any time and can have a great negative impact on the individuals experiencing the crisis and also on his/her family members, colleagues or peers. The vital aspects that need to be emphasised are the early identification and quick intervention, which will reduce mortality due to mental illness. Mental health first aid (MHFA) is the concept that has been introduced to address this need.
The concept of MHFA is that people should know how to provide basic first aid for those experiencing mental distress and showing signs of crisis and collapse. MHFA is defined as 'the help offered to a person developing a mental health problem, experiencing a worsening of an existing mental health problem or in a mental health crisis; the first aid is given until appropriate professional help is received or until the crisis resolves."[11] As in any first aid, the principle in mental health promotion is to identify warning signs early and take measures to prevent escalation of manifestations, thereby reducing morbidity and mortality. Therefore it is vital that MHFA is given utmost consideration and importance in health care. The importance of implementing MHFA is clearly articulated by the words of Arthur C. Evans, the current CEO of the American Psychological Association, 'If you're in a restaurant and someone has a heart attack, they'll probably be five or six people who can jump up and do cardio pulmonary resuscitation (CPR). If you are in a restaurant and someone starts to exhibit psychiatric symptoms, most people run the other way (2020, NIMH).'[12]
Approach to Mental Health first Aid
The concept of MHFA was first conceptualised and initiated in Australia in 2000 by Nurse Betty Kitchener, a nurse specialising in Health Education and Professor Anthony Jorm, an expert in mental health literacy and was developed as a training programme in 2001. The initiative was based on observations and evidence which showed that mental illness affected people from all strata of life and there was a need for greater awareness of its symptoms, even among health-care professionals.[13] MHFA Australia was founded as a non-profit organisation focussing mainly on training and research in MHFA. In the MHFA training, participants are trained in providing MHFA using courses that incorporate up-to-date evidence-based guidelines for mental health. The aim of MHFA is not about diagnosing or treating mental health issues but about offering support in the initial stages of mental health crisis until professional help arrives or can be sought or the crisis situation resolves. It is about being a supportive, non-judgemental friend for a person in need.
Mental Health first Aid Course
The MHFA course that was initiated in 2001 in Australia is now being provided in many countries worldwide. It is a standard 12 h course and aims to teach individuals on how to provide support to a person experiencing a mental crisis and how to get professional help. The course includes an overview of mental health problems, including the signs and symptoms and risk factors associated with some of the common mental health issues such as psychosis, anxiety, depression and substance abuse and other mental health crisis situations and assists in developing skill to identify the early manifestations of the signs and symptoms.[13] It also provides training on how to act as a first aider in a crisis situation using the first aid action plan. The cardinal action plan of MHFA is based on ALGEE, which is taught to all those who are interested in MHFA. The action plan comprises five steps forming the acronym ALGEE [Table 1].[14] The MHFA Australia mascot [Figure 3], ALGEE, the Koala, is named after the Action Plan acronym.[15]
Table 1: Action plan - ALGEE
Figure 3: Mental Health First Aid Mascot (NIMH (2018) [photo] Retrieved from: http://mhfastore.org/.)
The ALGEE action plan can be used in any setting and by anyone because it is easy to learn.
A-Assess-The first step in the intervention related to MHFA is to assess for risk of crisis and harm. Does the individual indicate wanting to harm themselves or others? This is the vital question that is asked. Choose a private place for talking to the person
L-Listen-The second step is to listen non-judgementally, putting aside one's own beliefs or moral codes. Listening without showing any strong emotions like disgust or anger is vital. If the person does not want to talk, they should not be forced. Be available to listen
G-Give reassurance-The third step is to give reassurance and information and letting the individual know that help and support are available. Demonstrate empathy by accepting their feelings and validating them as real. Be present and available even if they do not talk, to show that they are not alone. Let the person know that you want to help
E-Encourage-Step four is encouraging to get appropriate professional help, notifying the individual that it is okay to seek help from professionals. Discuss options and provide information. Let the person be in-charge of making decisions on what steps to take. Appreciate his or her effort in seeking professional help
E-Encourage-The final step is to encourage self-help and other support strategies and inform the individual of wellness activities that they could participate in. Encourage and assist her/him to find strengths to channel their energy positively. Provide information on self–help groups.
In all the efforts of first aid, the first responder should understand that they are only providing support and are not responsible for what the individual does or say.
Outcome Of Mental Health first Aid Training
ALGEE is a life-saving acronym. It saves life by providing mental health cardio pulmonary resuscitation
People need to look for signs of a mental health crisis to help. Early identification reduces the risk of the crisis escalating, and the risk to the person affected and others. Many countries like the USA have well-established MHFA centres which offer training through First Aid USA. The MHFA training was initiated in India in the year 2017 and the first training was provided in 2018.[16] Many health-care professionals, other professionals such as teachers, counsellors and any individual interested in MHFA are trained and certified.
The outcome of the MFHA training has been evaluated over a decade and has revealed the positive impact of the training. Students in professional groups have benefitted from the training. A study done in Australia in 2015, on 450 medical and nursing students, showed that both face-to-face and online courses in MHFA have been proven to be effective in helping the students improve their understanding of mental health issues.[17],[18] Findings from a randomised control study revealed a significant improvement in knowledge on mental health, confidence in helping, MHFA intentions and reduction in stigmatising attitudes in the group, which had the MFHA training compared to the control group among nursing students.[19] In the era where stigma and negative attitudes toward mental illness are still prevalent, MHFA training has helped in changing the attitude of professionals as well as the general public. Results from a systematic review revealed that MHFA increased participants' knowledge on mental health issues, their supportive behaviour towards those with mental health issues and reduced their negative attitude towards mental illness.[20] A meta-analysis of 18 trials supported the effectiveness of MHFA training on improving knowledge of mental illness and appropriate helping behaviour for those with mental health problems up to 6 months after training.[17] MHFA training was effective not only among professional groups but also among cross-cultural community members. Chinese community members living in Australia revealed a significant improvement in knowledge about mental disorders, beliefs about treatment and a reduction in stigmatising attitudes.[21] Arthur C. Evans discusses how the implementation of MHFA training as part of Philadelphia's Department of Behavioural Health and Intellectual Disability Services has made a difference. 'We got a really good response to this and it's been one of the most important things I've seen in terms of reducing stigma and changing perception' (2020, National Council on Behavioral Health).[22]
Unfortunately, mental health will continue to be a global issue. MHFA is the key to reduce the impact of mental health issues and illness. Any-one in the community who wishes to save the lives of people going through mental health crisis can be trained in MHFA. Health-care professionals, specifically nurses will most benefit from the training as they have more opportunities to identify crisis situations. MHFA and the information and knowledge provided through ALGEE will help nurses better interact with their patients who have a mental illness. MHFA is just a first response in a crisis situation. MHFA training does not intend to produce therapists or mental health specialists; therefore, the MHFA ers should not do more than provide the first aid that is taught as ALGEE.
This article was adapted from a poster session the author presented at the 2018 International Society for Psychiatric Nurses conference at Tempe, Arizona. The statistics have been updated, and additional content added.
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[Figure 1], [Figure 2], [Figure 3]
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