2. 1 Control and Prevention of Mental Ill Health

3. 2 Objectives You 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

4. 3 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

5. 4 Mental Health/Illness Continuum Mental Health Mental Illness Mental 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”.

6. 5 Mental Disorders Are Disabling 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.

7. 6 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.

8. 7 Concepts of Health Health as the absence of disease Health as a positive state Health as a fluctuant experience Health as independence for living Health as adaptation

9. 8 Personal Well-Being An inner world, “the psyche” Our body Other individuals or groups The material environment and life conditions The culture in which we live Our existence in an immense universe, “spiritual health”

10. 9 Ill Health Objective diagnosis of disease via bio-medical model Subjective social construction – negotiation over meaning of symptoms holistic v. reductionist views Pathogenic v. salutogenic views

11. 10 Positive Mental Health Ability to cope Stress management Self-concept and identity Self-esteem Self-development Autonomy/Locus of control Willingness to change/adapt Social support networks

12. 11 Often sad, sometimes mad, occasionally bad The medical model is insufficient Diagnosis is largely clinical and experiential

13. 12 More of an art than a science Treatment is pragmatic Prevention is about the politics of health “populations, people pressures, poverty”

14. 13 Mental Health is a worldwide problem

15. 14 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

16. 15 We are all vulnerable

17. 16 A Holistic Approach BODY MINDSPIRIT Arrow of Time CULTURE

18. 17 Intelligence IQ IQ = 100 I.Q. = the Mental Age x 100 the Chronological age

19. 18 Personality Each human being is unique We all have different personalities My personality reflects genetic inheritance and Environment

20. 19 Behavior SUPER-EGO EGO ID The Parent The Adult The Child

21. 20 The Subconscious Mind The Conscious The Subconscious

22. 21 A Classification Affective Disorders Anxiety,depression,mania,obsessional disorders Schizophrenia Simple,Hebephrenic,Catatonic,paranoid Organic states Delirium,dementia Personality Disorder Abnormal personality,Psychopathy Substance abuse problems Drugs, alcohol Learning disorders Subnormality

23. 22 The Classification of Mental Illness: The Neuroses Depression, 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

24. 23 Clinical Diagnosis

25. 24 The Classification of Mental Illness Drug Problems Addictive drugs, (Heroin, Cocaine, Amphetamines,) alcohol and drug related illness-psychosis, delirium and dementia Personality Disorders A 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

26. 25 Aetiology Inheritance-Genetics/Intra- uterine environment Schizophrenia, Huntington’s Infections- HIV,Syphilis,CJD Drug Abuse Alcohol,Heroin etc Trauma/head injuryBiochemistry/metabolic Porphyria, Diabetes Vascular-CVA Neurological diseases MS,Brain tumour Upbringing Mothering,education, parenting Nutrition/PCM

27. 26 Treatment and Care Hospital Care Community Care

28. 27 Preventive Networks Mosques, Family, Home, Friends, Work

29. 28 The Mental Health Act Compulsory Psychiatric Treatment Criminal responsibility Power of attorney

30. 29 Mental Handicap/learning disability The mind of a young child in the body of an adult

31. 30 Depression

32. 31 What Is Depression? A Continuum Normal Mood Lowering Abnormal Mood Lowering Abnormal mood lowering and loss of function

33. 32 What Is Depression? Depressive disorder Pervasive (Prevalent) Persistent Wide range of symptoms

34. 33 What Is Depression? Range of symptoms Negative views Worthlessness Incapacity Guilt Sleep disturbance Diurnal mood variation Loss of energy Impaired concentration

35. 34 What Is Depression? Impaired work ability Poor social functioning Psychomotor retardation Pessimism Better off dead Thoughts of suicide Suicide / action Fear / belief of bodily illness

36. 35 Vulnerabilities (Risk Factors) Losses Stressful life events Lack of social support Physical illness Familial factors Genetic factors

37. 36 What Is Depression? Various Criteria. Defeat Depression Campaign Depressed mood or loss of pleasure for at least 2 weeks. Plus 4 or more of: Worthlessness or guilt Impaired concentration Loss of energy and fatigue Thoughts of suicide Loss or increase of appetite or weight Insomnia or hypersomnia Retardation or agitation

38. 37 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

39. 38 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:

40. 39 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?

41. 40 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.

42. 41 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.

43. 42 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.

44. 43 Numbers At 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.

45. 44 Why Missed? 50% are missed. 10% subsequently recognised. Of the 40% who remain unrecognised: Half remit spontaneously. Half remain depressed 6 months later.

46. 45 Missed: Patient Factors Present somatic symptoms. Physical problems. Stigma. Beliefs about GP role and time to listen. Longstanding depression. Less overt / typical. Less insight.

47. 46 Missed: Doctor Factors More 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.

48. 47 Assessment Severity Duration Social network Views of self, world and future Suicidal thoughts Past history Factors affecting symptoms Biological features

49. 48 Assessment Skills Directive not closed questions Picking up on verbal clues “clarification” Picking up on non-verbal clues and using them Empathy Summarising

50. 49 Treatment Contract Key skills Re-frame symptoms as depression Link to life events Negotiate anti-depressants if necessary Problem list and priorities Set realistic time scale Agree regular review

51. 50 Explanations Depressive illness is clinically different from the blues and involves chemical changes in the brain. Depressive illness has characteristic symptoms and explain them.

52. 51 Explanations Depression benefits from both drug and non-drug approaches. “Pills for symptoms.” “Talking for problems.”

53. 52 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.

54. 53 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.

55. 54 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.

56. 55 Control of Mental Ill Health Is it Possible? How? Difficulties?

57. 56 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.