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Control and Prevention ofMental Ill Health

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ObjectivesYou will be capable to identify the

most common mental disorders in the society identifying risk factors.

You will be also capable to identify strategies that help in the prevention and creation of suitable society for those patients

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Why?

There is ignorance, superstition, stigma and fear around Mental Illness

Aetiology, pathogenesis diagnosis and treatment are imperfect.

There is a different paradigm and a less rigorous epidemiology

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Mental Health/Illness Continuum

Mental Health Mental IllnessMental Health Problems

Mental health and mental illness may be thought of as points on a continuum.

When we look at mental health and mental illness in this new light, we will see that this continuum applies to us all.

But first it’s important that we define what we mean by the terms “mental health”, “mental health problems” and “mental illness”.

Mental health and mental illness may be thought of as points on a continuum.

When we look at mental health and mental illness in this new light, we will see that this continuum applies to us all.

But first it’s important that we define what we mean by the terms “mental health”, “mental health problems” and “mental illness”.

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Mental Disorders Are Disabling% of Disease

Burden

All cardiovascular conditions 18.6

All mental illness 15.4

All malignant disease (cancer) 15.0

All respiratory conditions 4.8

All alcohol use 4.7

All infectious and parasitic disease 2.8

All drug use 1.5

Mental Illnesses account for 15.4% of the overall years of life lost to major illnesses in our country. The mental illness disease burden ranks second only to heart disease, and is greater than all forms of cancer added together.

The “Facts About Mental Illness” on the next page further emphasize the magnitude of mental illness in our society.

Mental Illnesses account for 15.4% of the overall years of life lost to major illnesses in our country. The mental illness disease burden ranks second only to heart disease, and is greater than all forms of cancer added together.

The “Facts About Mental Illness” on the next page further emphasize the magnitude of mental illness in our society.

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Facts About Mental Illness

Up to half of all visits to primary care physicians are due to conditions caused by or exacerbated by mental health problems. This again emphasizes the important connection between physical and mental health.

Approximately 15% of all adults who have a mental disorder in one year also have a co-occurring substance abuse disorder. As many as half of people with serious mental illnesses develop alcohol or drug abuse

problems at some point in their lives. As we will note later, this has great implications on how services are provided to people with co-occurring disorders.

One in five children has a diagnosable emotional disorder. We are learning that the many problems associated with emotional disturbances in

children are best addressed with a “systems” approach in which multiple service sectors work together in an organized, collaborative way.

The incidence of suicide among 15-24 year olds has tripled since 1960. This staggering statistic underscores the importance of positive, comprehensive

interventions with troubled youth. Nearly half of those with severe mental illnesses do not seek treatment.

This reluctance to seek treatment is often the result of some very real barriers that we will discuss in a few minutes. But first let’s look at a more positive note regarding mental health treatment.

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Concepts of Health

Health as the absence of diseaseHealth as a positive stateHealth as a fluctuant experienceHealth as independence for livingHealth as adaptation

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Personal Well-Being

An inner world, “the psyche”Our bodyOther individuals or groupsThe material environment and life

conditionsThe culture in which we liveOur existence in an immense universe,

“spiritual health”

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Ill HealthObjective diagnosis of disease via

bio-medical modelSubjective social construction –

negotiation over meaning of symptoms

holistic v. reductionist viewsPathogenic v. salutogenic views

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Positive Mental Health

Ability to copeStress managementSelf-concept and identitySelf-esteemSelf-developmentAutonomy/Locus of controlWillingness to change/adaptSocial support networks

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Often sad, sometimes mad, occasionally bad

The medical model is insufficient

Diagnosis is largely clinical and experiential

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More of an art than a science

Treatment is pragmaticPrevention is about the

politics of health“populations, people

pressures, poverty”

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Mental Health is a worldwide problem

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Mental illness is common 6 in 10 women and 4 in 10 men in Western Europe and North America will have a significant mental illness during their lifetime

Mental illness can affect any one of us

Mental illness occurs in all societies and cultures

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We are all vulnerable

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A Holistic ApproachBODY

MIND SPIRIT

Arrow of Time

CULTURE

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Intelligence

IQ

IQ = 100

I.Q. = the Mental Age x 100 the Chronological age

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Personality

Each human being is uniqueWe all have different

personalitiesMy personality reflects genetic

inheritance and Environment

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Behavior

SUPER-EGO

EGO

ID

The Parent

The Adult

The Child

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The Subconscious Mind

The Conscious

The Subconscious

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A ClassificationAffective Disorders Anxiety,depression,mania,obsessional

disorders

Schizophrenia Simple,Hebephrenic,Catatonic,paranoid

Organic states Delirium,dementia

Personality Disorder Abnormal personality,Psychopathy

Substance abuse problemsDrugs, alcohol

Learning disordersSubnormality

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The Classification of Mental Illness:

The NeurosesDepression, Anxiety, Mania, Obsessions and compulsions

(usually the patient retains insight and orientation; they experience deep distress and may commit suicide)

The Psychoses

Schizophrenia, puerperal psychosis(the patient is disorientated, deluded, and lacking in insight)

The Dementias

Progressive deterioration with loss of recent memory and deterioration of a normal personality,

They may be primary or more commonly secondary to another condition e.g. alcohol, stroke

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Clinical Diagnosis

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The Classification of Mental Illness

Drug Problems

Addictive drugs, (Heroin, Cocaine, Amphetamines,) alcohol and drug related illness-psychosis, delirium and dementia

Personality DisordersA personality and behavior that is damaging to the individual and/or to society and which is not tolerated by the dominant culture

Mental subnormality/learning disorders:Problems around intelligence and ability to learn on the basis of teaching and experience

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AetiologyInheritance-Genetics/Intra-uterine environment Schizophrenia, Huntington’s

Infections-HIV,Syphilis,CJD

Drug Abuse

Alcohol,Heroin etc

Trauma/head injury Biochemistry/metabolic

Porphyria, Diabetes

Vascular-CVA

Neurological diseases

MS,Brain tumour

Upbringing

Mothering,education,parenting

Nutrition/PCM

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Treatment and Care

Hospital Care

Community Care

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Preventive NetworksMosques, Family, Home, Friends, Work

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The Mental Health Act

Compulsory Psychiatric Treatment

Criminal responsibility

Power of attorney

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Mental Handicap/learning disability

The mind of a young child in the body of an adult

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Depression

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What Is Depression?A Continuum

Normal Mood Lowering

Abnormal Mood Lowering

Abnormal mood lowering and loss of function

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What Is Depression?

Depressive disorderPervasive (Prevalent)PersistentWide range of symptoms

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What Is Depression?Range of symptoms

Negative viewsWorthlessnessIncapacityGuiltSleep disturbanceDiurnal mood variationLoss of energyImpaired concentration

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What Is Depression?Impaired work abilityPoor social functioningPsychomotor retardationPessimismBetter off deadThoughts of suicideSuicide / actionFear / belief of bodily illness

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Vulnerabilities (Risk Factors)

LossesStressful life eventsLack of social

supportPhysical illnessFamilial factorsGenetic factors

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What Is Depression? Various Criteria.

Defeat Depression CampaignDepressed mood or loss of pleasure for at

least 2 weeks. Plus 4 or more of:Worthlessness or guiltImpaired concentrationLoss of energy and fatigueThoughts of suicideLoss or increase of appetite or weightInsomnia or hypersomniaRetardation or agitation

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What Is Depression? - Various Criteria.DSM – IV

• Duration > 2 weeks Depressed mood or Marked loss of interest or pleasure in normal activities

• Plus 4 of:

i. Significant change in weight

ii. Significant change in sleep pattern

iii. Agitation or retardation

iv. Fatigue or loss of energy

v. Guilt / worthlessness

vi. Can’t concentrate or make decisions

vii. Thoughts of death or suicide

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What Is Depression? - Various Criteria.

ICD – 10

Patient has low mood:

1) How bad is it and how long has it been going on?

2) Have you lost interest in things?

3) Are you more tired than usual?

If the answer is yes to these, then:

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ICD – 10 (Continued)

4) Have you lost confidence in yourself?

5) Do you feel guilty about things?

6) Concentration difficulties?

7) Sleeping problems?

8) Change in appetite or weight?

9) Do you feel that life is not worth living any more?

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ICD – 10 (Continued)

Mild. Two criteria from 1-3 and 2 others.Moderate. Two criteria from 1-3 and 3-4 others or a

yes to question 5.Severe. Most of the criteria in severe form

especially questions 5 & 9.

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Variants

Depressive episodes that do not meet the criteria for major depression.

Lifelong mild fluctuating depression (Dysthymia).

Mixed states of above two.Manic depression –

bipolar disorder.

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Numbers

10% of those diagnosed in primary care are referred to psychiatrists.

1 in 1000 are admitted to hospital.Lifetime incidence rates approach 33%.5% of consulters have major depression.5% have milder depression.A further 10% have some depressive

features.

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NumbersAt least one patient per surgery will have

depressive symptoms of some type.Commoner in younger people including

children than thought in the past.Men:women = 1:2.Common in the physically ill.50% recurrence rate.12% become chronically depressed.

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Why Missed?

50% are missed.10% subsequently

recognised.Of the 40% who remain

unrecognised:Half remit spontaneously.Half remain depressed 6

months later.

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Missed: Patient Factors

Present somatic symptoms.Physical problems.Stigma.Beliefs about GP role and time to

listen.Longstanding depression.Less overt / typical.Less insight.

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Missed: Doctor FactorsMore accurate doctors.

Make more eye contact.Show less signs of hurry.Are good listeners.Ask questions with social and psychological

content.Less accurate doctors.

Ask many closed questions.Ask questions derived from theory rather than

what the patient just said.

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AssessmentSeverityDurationSocial networkViews of self, world and futureSuicidal thoughtsPast historyFactors affecting symptomsBiological features

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Assessment SkillsDirective not closed questionsPicking up on verbal clues

“clarification”Picking up on non-verbal clues and

using themEmpathySummarising

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Treatment Contract

Key skillsRe-frame symptoms as depressionLink to life eventsNegotiate anti-depressants if necessaryProblem list and prioritiesSet realistic time scaleAgree regular review

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Explanations

Depressive illness is clinically different from the blues and involves chemical changes in the brain.

Depressive illness has characteristic symptoms and explain them.

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Explanations

Depression benefits from both drug and non-drug approaches.“Pills for symptoms.”“Talking for problems.”

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Explanations

Anti-depressants are not addictive or habit forming.

Anti-depressants take 2-3 weeks to begin to work and need to be taken for 4-6 months after the full benefit is obtained to prevent relapse.

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Explanations

Side effects occur and are expected – explain.

Drugs enable talking therapy to work better.

Regular review is important and needs to continue for at least 6 months.

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Explanations

Talking therapy can help solve problems that are soluble, cope with the insoluble and examine other problems that seem unrealistic to the patient or therapist.

Prevention of further trouble will be considered when the treatment is coming to an end.

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Control of Mental Ill Health

Is it Possible? How?Difficulties?

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Prevention of Mental Health Disorders

What level of Prevention? How?What are the Mental Health

Disorders could be prevented?Describe the role of the

Preventive Network.