Mental Health Program

MENTAL HEALTH PROGRAM Isabelita M. Samaniego MD

Session Objectives 1. To discuss the magnitude of mental health problems . 2. To define terms : mental health, mental ill health, mental disorder 3.To describe the four facets of mental health problems. 4. To discuss the stages of mental health development. 5. To describe the goals and objectives of DOH regarding mental health.

Situationer International Studies 1% of population – have severe mental & neurological disorder 4-5% mild- moderate neurological problems –alcohol & drug abuse

Situationer Local studies: 36/1000 adults, children & adolescencePampanga 17 % adults & 16 % of children -Sampaloc Manila – Depressive reactions & adaptation reaction. 12 cases / 1000 population adult schizoprenia-Bulacan

Situationer Local studies:Region 6 adult Psychosis- 4.3% Anxiety – 14.3% Panic- 5.6% Children & adolescent: Enuresis- 9.3% Speech & language disorder- 3.9% Mental subnormality- 3.7% Adaptation reaction – 2.4% Neurotic disorder – 1.1 %

Situationer DOH Mental Health resources: Total Bed Capacity – 5465 NCR- 4200 beds CAR-40 Region 2- 200 Region 3- 500 Region 11- 200 Regions 1,4,10,12,Caraga, ARMM- none 27- DOH medical centers- mental health facilty Cavite- is the only province with mental health facility. Need to train health manpower

Magnitude of Mental Disorders 10-15% of adult population affected 20% of patients seeking primary health care have one or more mental disorders, though not recognized One in four families have at least one member with a behavioral or mental disorder at any point in

GLOBAL BURDEN OF DISEASE

The GBD study offers significant surprises: The burdens of mental illnesses, such as depression, alcohol dependence and schizophrenia, have been seriously underestimated by traditional approaches that take account only of deaths and not disability. While psychiatric conditions are responsible for little more than one per cent of deaths, they account for 12% of disease burden world wide and for 24% in the Americas

Mental Health A state of well being where a person can realize his or her own abilities , to cope with normal stresses of life and work productively.

Mental Ill Health Disturbance in a person’s thoughts , feelings and behavior. It affects and is affected by a person’s interaction with others, one’s environment and even one’s own self esteem.

Mental Disorder Medically diagnosable illness that results in significant impairment of one’s cognitive, affective or relational abilities and is equivalent to mental illness.

Four Facets of Mental Health Problems Defined BurdenBurden currently affecting persons with mental disorders and is measured in terms of prevalence and other indicators such as the quality of life indicators and disability adjusted life years. ( DALY)

Four Facets of Mental Health Problems Undefined Burden- Burden related to the impact of mental health problems to persons other than the individual directly affected. Felt heavily by the families & communities both human & economic loss Mental ill health affects the person’s functioning , thinking process, diminishes the persons social role and productivity to the community. Tremendous burden on emotional & socioeconomic capabilities of relatives who care for the patient .

Four Facets of Mental Health Problems Hidden burden Refers to the stigma & violations of human rights. A mark of shame , disgrace or disapproval that results in a person being shunned or rejected by others. Generally increases as his behavior differs from that of the norm.

Four Facets of Mental Health Problems Future burden – burden in the future resulting from the aging of the population , increasing social problems and unrest inherited from the existing problem.

Bare Facts of Mental Health 450 million of people worldwide are affected by mental, neurological, or behavioral problems at any time About 873,000 people die by suicide every year People with these disorders are often subjected to social isolation, poor quality of life and increased mortality causing staggering economic and social costs 1 in 4 patients visiting a health service has at least 1 mental, neurological or behavioral disorder, but most these disorders are neither diagnosed nor treated.

Mental illnesses affect and are affected by chronic conditions such as CA,CVD, DM & HIV/AIDS. Untreated, they bring about unhealthy behavior, non-compliance with prescribed medical regimens, diminished immune functioning and poor prognosis Barriers to effective treatment of mental illness include lack of recognition of the seriousness of mental illness and lack of understanding about the benefits of services

Why a mental health Reform? To fight against the violation of human rights of people with mental disorders For clinical reasons For economic reasons For scientific reasons To respond to the expectations of users and families

Mental Health in the Different Stages of Life 18th week – fetus reacts to various stimuli passing the amniotic sac such as sound,( music,noise) substances ( drugs, alcohol. Infancy- the psychosocial & cognitive development is affected by the absence of the care taker, mother. First Crisis -Trust vs mistrust Consistent mothering is important Mothers living in conditions of stress and adversity

Mental Health in the Different Stages of Life Toddler stage – greatly affected by motor and intellectual development . Child learns to master locomotion and impulses. Crisis- asserting independence against shame and doubt. The need for control & firmness on the part of the caretaker Negative exposure & punishment may cause shame & develop self doubt on the child.

Mental Health in the Different Stages of Life Pre school age – the child can express complex emotions : love, unhappiness, jealousy and envy which are influenced by hunger & tiredness . Aware of their bodies, genitalia & gender differences . Concept of what they want & need- leads to choices between desire, the need to grow outside the homes & what parents restrict turning parental values into self regulating mechanism ( obedience, guidance & punishment) Milestone- development of

Mental Health in the Different Stages of Life School age – Education plays a big role in facilitating the child’s well being & healthy social & emotional growth. They should be taught skills to improve their psychosocial competence. Problem solving, critical thinking, communication, interpersonal skills , empathy and coping with emotions. Children & adolescent – develop a sound & positive mental health.

Mental Health in the Different Stages of Life Adolescencepsychosocial concerns : acceleration of cognitive development , consolidation of personality formation and development of morals. Adulthood:Very productive age Mental health concernwork related problems Emphasis- aspects of work process that promote mental health.

Concerns of Daily Living Psychological consequences & suffering brought about by : Migration Urbanization Industrialization Economic policies Political confusion Poverty & abuses Victims of disaster Violence & armed conflict OFW’s & children in difficult circumstances are exposed to depressive circumstances

Mental Health in the Different Stages of Life Elderly- Aging population is a result of increased life expectancy as a result of improved quality of life Must be able to live their life full of potential. Healthy older person is a resource for the family, community and economy.

Depression Burden 4th leading cause of burden among all diseases 2nd leading cause among 15-44 year age group Among women in 15-44 year age group, the amount reaches 10.6%

Epidemiology Ranks fourth among the major cause of disability worldwide. 17% of population will suffer from this during their lifetime. Recurrent, despite newer medications rates increases / age of onset is decreasing. 2020- it will the second major cause of disability , economic burden will be 2nd to CAD

Epidemiology

Depressive illness is more common in the presence of : 1. Physical illness, chronic, painful or stigmatizing 2. Excessive and chronic alcohol use 3.Social stresses, loss events 4. Interpersonal difficulties- social humiliation 5. Lack of social support, with no confiding relationship.

DSM IV CRITERIA : MDE/MDD Major Depressive Disorder: Accompanied by co morbid conditions

Major Depressive Episode: Follows a psychosocial stressor Childbirth

DSM IV criteria : for MDD/MDE Five of the ff symptoms during the two week period first two criteria impt; 1. Depressed mood- most of the day 2. Markedly diminished interest or pleasure in all activities 3. Significant weight loss or weight gain= markedly decrease or increased in appetite 4.Vague physical symptoms: dizziness, headache,weakness , muscle pains,other physical symptoms

DSM IV criteria : for MDD/MDE 4. Insomnia or hypersomnia nearly everyday. 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7.Feeling of worthlessness or excessive inappropriate guilt. 8. Diminished ability to think or concentrate. 9.Recurrent thoughts of death, suicidal ideation

DSM IV criteria : for MDD/MDE The symptoms do not meet the criteria for mixed episode: The symptoms cause clinically significant distress or impairment in social , occupational or other important areas of functioning. The symptoms are not directly due to substance ( meds) or medical condition. The symptoms are not due to bereavement Symptoms persists for more than 2

Treatment of Depression Pharmacotherapy - most effective intervention.- both for treatment and relapse Psychotherapy – adjunct in refractory cases ECT

Psychosocial Therapy 1. Cognitive behavioral therapy- aims to address irrational belief and distorted attitudes towards self , environment and future of patients. 2. Behavior therapy- specific techniques including self control therapy , social skills training, activity scheduling and problem solving. 3. Interpersonal therapy- focuses on losses, role disputes and transitions, isolation, deficits in social skills .

Psychosocial Therapy 4. Psychodynamic psychotherapy- It focuses on conflicts related to guilt, shame, interpersonal relationship, management of anxiety, and repressed unacceptable impulses. Some techniques focuses on developmental psychological deficits between the child and the emotional;caretakers resulting in the problem of self esteem. 5. Marital and Family therapy-

Schizophrenia Burden 3rd most disabling condition among 15-44 years age group About 10% of persons with schizophrenia die by suicide Reduces life span by an average of 10 years

Definition A clinical syndrome characterized by profound disruption in cognition & emotion , affecting the most fundamental attributes : Language, thought , perception, affect & sense of self.

Epidemiology Lifetime prevalence: 0.9-11 cases per 1000 population Sex: equally prevalent Age: Men between 15-25 yrs Female 25-35

Epidemiology Birth & fetal complications are common Perinatal complications Increased risk is unknown: A) Genes B) Hypoxia C) Lower social class

Etiology Dopamine excess Serotonin hyperactivity Norepinephrine & GABA Major Neuroanatomical theoriesinvolving the limbic system, cortex, basal ganglia – thalamocortical neural circuit Genetic hypothesis

Genetic Population Non twin Siblings of Schizophrenic patient Child with one schizophrenic pt Dizygotic twin of schizophrenic pt Child of two schizophrenic pts Monozygotic twin of a schizophrenic Pt

Prevalence % 8 12 12 40 47

DSM IV Criteria

• • • • •

A. Two or more of the following , each presenting for a significant portion of time during a one month period Delusion Hallucination Disorganized speech Grossly disorganized catatonic behavior Negative symptoms

DSM IV Criteria B. Social/ occupational dysfunction C. Continuous signs of disturbance persist for at least six months. One month of symptoms that meet criterion A & may include periods of prodromal or residual symptoms.

DSM IV Criteria D. Schizoprenia disorder and mood disorder with psychotic features have been ruled out because: A) No major manic, depressive , mixed episodes B) If mood episodes occurred during the active phase symptoms , the duration is brief.

DSM IV Criteria E. Disturbance is not due to a substance or medical condition. F. If there is a history of autism or developmental pervasive disorder, schizophrenia diagnosis can be made if hallucination or delusion is prominent within one month.

Treatment Consultation Hospitalization- propensity to harm Pharmacotherapy: • Rapid neuroleptics • Antipsychotics : a) DOPA receptor antagonist b) Serotonin – dopamine

Treatment Haloperidol

Acute Dose Mg/day 20-60

Maintenanc e Dose 5-20 mg/day

Chlorpromazine 300-1000

50-400

Levomepromazi 300-1000 ne

25-300

Burden of Alcohol Use Disorders All Ages and both sexes 1.3 % All ages, males 2.1 % 15-44 year olds, both sexes 3.0 % 15-44 year olds, males 5.1 %

The Violent Patient Assess the patient for the cause of the violence Assist in controlling the acute situation Make a prediction of future violence

Questions What was the reason for the admission at the ER? Is the patient actively violent or only verbally threatening? Does the patient have a weapon? Does he have a previous history of similar problem? How did the patient arrived at the hospital? What are his present medications? Has the patient been using alcohol or drugs?

Causes of Violent or Combative Behavior Psychiatric causes Substance- induced causes Neurologic causes General Medical causes The most effective management is the identification & treatment of the underlying cause.

Major threat to life Potential threat to life of the staff , other patients & to himself His/ her life maybe jeopardized if serious medical problem is left untreated.

General Medical Causes Hypoxia Hypoglycemia Hyponatremia/ Hypernatremia Electrolyte disturbance Vit B12 deficiency / folate Hyper & Hypothryroidism Systemic Infections Hepatic encephalopathy Renal diseases SLE

Neurologic Causes Seizure disorders Meningitis/ encephalitis Intracranial bleed Dementia Tumors Wernicke’s encephalopathy Stroke Multiple sclerosis

Psychiatric Causes Schizophrenia Mania Delusional disorders Major depression ( If psychotic/ agitated) Impulse control disorders Post –traumatic stress disorders Personality disorders Mental retardation Dissociative disorders

Substance Induced Causes Alcohol Benzodiazepines Methamphetamine / cocaine Anticholinergics Steroids Neuroleptics Poisons

Evaluate the Mental Status Posture ( tense/ restlessness) Manner ( threatening / demanding) Speech( loud, cursing, slurred) Motor activity (gesturing, pacing, destroying property) Thought processes ( Logical, illogical, disorganized) Thought content( paranoid, delusional) Perceptions ( Illusions, auditory, visual, command, hallucinations)

Selective History Previous history of violent behavior Patient under arrest? Circumstances of the arrest?

Before approaching the patient remove any object in your body that can be used as a weapon against you. Women MD should not wear dangling earrings. Hospital IDs should not be worn in the neck , break away chains should be used Approach the patient slowly, relaxed with hands visible

Announce your intention in advance before any action Do not make quick or unexpected movement Always remain 3-6 ft away from the patient Stand sideways firmly on your feet Do not turn your back on the patient until you are 15-20 ft away

Asses the patient for the possibility of possessing a weapon In the ER the patient is usually searched before evaluation. Do not assume that this has been done. If you suspect that he has a weapon ask him directly If you are not satisfied with his answer tell him to surrender it by putting it on the floor or desk.

Security guard must disarm the patient Never ask the patient to hand you the weapon. No matter how agitated the patient is, speak slowly, calmly & firmly. Make sure that the environment has the least stimuli as possible. Give him enough space, the staff including you should be positioned nearest top the exit.

The best intervention is to actively listen to his problems in a non judgmental manner. Ask patient to describe the trouble. If he request for a reasonable concern comply or support if not stand firm to the rules.

If the patient is amenable to verbal redirection, invite the patient to sit down & discuss the problem. Often the “ violent patient” is fearful of his situation He may feel abandoned , ridiculed or misunderstood, his behavior maybe his crude attempt to be heard.

Drug Regimen Haloperidol – ( Haldol) 5 mg Benzodiazipine – Diphenhydramine ( Benadryl) – 2550 mg & Benztropine Mesylate (Congentin) 1-2 mg { Avoid extrapyramidal side effects. IM or IV ,medication for moderate to severely agitated patients.

Restrain if necessary but at a limited period of time. Do not place him in an isolation room – disastrous One on one staff observation is advisable Once safety is established further assessment of the psychiatric & medical condition must be done

Review vital signs & check for symptoms of drug or alcohol withdrawal If the patient made verbalized threats to anyone that must be taken seriously. Document all your concerns in the chart

Remember It is your responsibility to help the patient to restore his or her composure in the least restrictive yet safest manner possible. Because it is impossible to assess impulsivity & dangerousness with certainty, take whatever measures are necessary to ensure patient & staff safety.

Goal Mental Health is promoted and health related effects of stressful lifestyle is mitigated. The prevalence of mental health disorder is reduced.

Health Status Objectives 1. Reduce by 1 % the prevalence of mental health problems, major depressive disorders, schizophrenia, alcohol & drug abuse. ( Baseline data established in 2000). 2. Reduce by 5% the members of the workforce who have experienced adverse life experiences as consequences of stress in the workplace ( Special target groups government employees) Baseline 2000)

Risk Reduction Objectives 1. Increase the proportion of high risk population ( victims of violence & disasters, OFW’s, children in extremely difficult circumstances & adolescents)who seek help for personal & emotional problems. ( Baseline 2000) 2. Increase the proportion of the members of the workforce who avail of stress management services ( Special target grp gov’t. employees) baseline 2000

Risk Reduction Objectives 3. Increase the proportion of children who avail of psychological stimulation & assessment for mental health. Baseline 2000

Services & Protection Objective 1. Establish & upgrade existing mental health facilities. ( baseline 2000) 2. Upgrade existing competencies on mental health professionals & health care providers . Baseline 2000 3. Increase the percentage of health care facilities, workplaces & communities that provide mental health services. 4. Develop self help & family care program. 5. Increase the capability of health facilities for psychosocial assessment & screening of mental disorders. ( Baseline data 2000)

THE CARROT, THE EGG AND THE COFFEE BEAN

Put three pots of water over the fire.

In the first pot, put some carrots.

In the second pot, put some eggs.

In the third pot, put some coffee beans that have been grounded into coffee powder.

The carrots went in hard. They are now soft.

The eggs went in soft inside. Now they are hard inside.

The coffee powder has disappeared. But the water has the color and the wonderful smell of coffee.

Now think about life. Life is not always easy. Life is not always comfortable. Sometimes life is very hard.

Things don’t happen like we wish. People don’t treat us like we hope.

We work very hard but get few results. What happens when we face difficulties? difficulties

The boiling water is like the problems of life.

We can be like the carrots.

We go in tough and strong.

We come out soft and weak.

We get very tired. We lose hope. We give up. There is no more fighting spirit. Don’t be like the carrots!

We can be like the eggs.

We start with a soft and sensitive heart.

We end up very hard and unfeeling inside.

We hate others. We don’t like ourselves. We become hard-hearted. There is no warm feeling, only bitterness. Don’t be like the eggs!

We can be like the coffee beans. The water does not change the coffee powder. The coffee powder changes the water!

The water has become different because of the coffee powder. See it. Smell it. Drink it. The hotter the water, the better the taste.

We can be like the coffee beans.

We make something good from the difficulties we face. We learn new things.

We make the world around us better.

Stress gives us the chance to become stronger… stronger and better… better and tougher. tougher

Be like the coffee bean!

PRAYER “LORD, give me the serenity to accept the things I cannot change, the courage to accept the things I can, and the wisdom to know the difference. Amen.”