An Approach to Mental Health, Wellbeing, and Addiction: Distinguishing Symptoms from Disorder

An Approach to Mental Health, Wellbeing, and Addiction: Distinguishing Symptoms from Disorder

Prof Philip Morris

November 2017

Aims

To distinguish symptoms from syndromes and to identify disorders from distress – with relation to dementia, depressive disorders, and alcohol and ICE addictions

To identify and manage suicide risk

To provide a general guide to promoting mental health wellbeing

At the end of the presentation participants will be able to answer the following four questions –

How is clinical depression distinguished from sad mood?

When are antidepressants appropriate for mood disorders?

How can suicidal thinking be uncovered in a non-threatening way?

What are the principles of enhancing mental health wellbeing?

Common Psychiatric Diagnoses

 Organic disorders: delirium, dementia, epilepsy, intoxication/withdrawal, systemic/neurological illness

 Psychotic disorders: schizophrenia type, delusional disorder, schizoaffective, bipolar mania, psychotic depression

 Mood disorders: bipolar mania, bipolar depression, major depression (melancholic and non-melancholic)

Non-psychotic conditions: dysthymia, generalized anxiety disorder, panic disorder, social anxiety, post traumatic stress disorder, obsessive compulsive disorder, agoraphobia, specific phobia

 Other conditions: adjustment disorder, substance abuse/dependence, personality disorder, eating disorders, ADHD, autism spectrum, dissociative/conversion/somatoform disorders, others

Dementia

Definition: memory impairment (including inability to learn new information or recall previously learnt information)

Plus one of: aphasia (language disturbance), apraxia (impaired motor capacity despite intact motor function), agnosia (failure to recognize objects despite intact sensory function), executive function disturbance (planning, organizing, sequencing, abstracting)

Common types: Alzheimer’s disease, vascular dementia, mixed dementia, frontotemporal dementia, Lewy body disease, Parkinson’s dementia

Differentiate from subjective memory complaints (no functional impairment)

Check for less common types (HIV disease, head trauma, Huntington’s disease, Creutzfeldt-Jacob disease)

Identify medical causes masquerading as dementia (thyroid disease, vitamin deficiencies, sleep aponea etc)

‘Pseudo-dementia’ (psychiatric illness presenting as dementia – usually depression)

Prescribed medications

Recreational drug use (eg. alcohol, cannabis, sedatives, opioids)

Anatomy of memory

Procedural memory, narrative/episodic memory (recent or remote), semantic memory including word meaning

Approach to history taking

Attention and concentration (including fluctuation), narrative memory (recent and remote), semantic memory including word meaning, executive functions, word finding problems, speech and language difficulties (comprehension, fluency, grammar/coherence), navigation problems, personality change, and mood

Behavioural and psychological symptoms of dementia (BPSD)

‘Challenging behaviours’: psychosis, depression, apathy, agitation, aggression, disinhibition (socially inappropriate, over-familiar, and sexualized)

Often leads to overuse of atypical antipsychotic medication (risperidone most common, but olanzapine and quetiapine as well)

But consider nootropic medications (especially cholinesterase inhibitors, possibly memantine), and SSRI antidepressants first

Only use antipsychotic mediations for psychosis and as last resort

Challenging behaviours change or extinguish over time and psychotropics need to be reviewed

Modifying environment and avoiding behavioural triggers and rewards is important (DBMAS)

Major depression (melancholic and non-melancholic)

Definition: two weeks or more of depressed mood or loss of interest

Plus five or more of: change in appetite and weight loss, insomnia, motor agitation or retardation, fatigue, worthlessness, poor concentration, indecisiveness, recurrent thoughts of death or suicide

Sad or depressed?

Approach to history taking

Explore sadness, persistence over days and weeks (dysthymia – depressed mood fluctuates over years or more), accompanied by loss of interest, tearfulness, loss of the ability to enjoy even happy situations (melancholic characteristic), insomnia, loss of self-esteem, confidence, motivation, and preoccupation with life is not worth living

Management

Provide support, reduce isolation, consider suicide risk, and review frequently

Psychological therapy the basis of treatment for all cases of depression – may be sufficient

Identify causes masquerading as depressed mood (medical conditions, prescribed medications, recreational drugs)

Some thoughts on prescribing antidepressant medications

Non-melancholic depression: SSRI antidepressant

Melancholic depression: SNRI antidepressant

Older patient with insomnia, weight loss and anxiety: mirtazapine

Patients with lethargy, fatigue and poor motivation: duloxetine, desvenlafaxine

Patients with concerns about weight gain: agomelatine (but no PBS subsidy), moclobemide, duloxetine

Patients with chronic pain: duloxetine, desvenlafaxine, amitriptyline

May need combination antidepressants: SSRI and mirtazapine

May need adjunctive atypical antipsychotic (usually at night): olanzapine, quetiapine

May need adjunctive mood stabilizer: lithium, valproate, carbamazepine, lamotrigine

May need adjunctive stimulant medication: dexamphetamine or methylphenidate or modafinil

May need adjunctive thyroxine

The combination of an SNRI and bupropion is equivalent to a tricyclic antidepressant – effective for melancholic depression (but seizure risk)

Antidepressants have low to moderate effect sizes (0.3), often need to switch antidepressants if no benefit or change in 2-4 weeks of use at recommended dose

Patients’ metabolism of antidepressants varies greatly and presence of other medications can alter metabolism – so be prepared to be flexible in dose

Early in treatment limit the amount of antidepressant to be dispensed to reduce suicide risk

Once started most patients will need to stay on antidepressant for one year

Substance dependence

Griffith Edwards (3/10/1928 – 13/9/2012)

British psychiatrist – the ‘father’ of the alcohol dependence syndrome (can be applied to all addictions)

British Medical Journal 1 May 1976

Elements of the dependence syndrome: narrowing of the drinking repertoire, salience of drink-seeking behaviour, increased tolerance to alcohol, repeated withdrawal symptoms (tremor, nausea, sweating, mood disturbance), relief or avoidance of withdrawal symptoms by further drinking, subjective awareness of compulsion to drink, and reinstatement after abstinence

Substance abuse

Essential feature: maladaptive pattern of repeated use leading within a 12 month period to one or more of: failure to fill major social roles in the home, or at school or work, use in hazardous situations, substance-related legal problems, continued use despite causing problems

Identifying and managing suicide risk

During the history and mental state sections of my consultations I gently explore the possibility of suicidal thinking

The first question goes something like “given the difficulties you have just mentioned, have you ever considered that if things go on this way that life would not be worth living?”

If the answer is positive I then go on to ask more specific questions about suicide intent, when, method, availability of methods, level of isolation and social support, triggers, risk factors (recreational drugs and alcohol, financial problems), guilt and shame, and severity of psychiatric illness

Prediction of suicide is problematic – no suicide prediction instruments have shown clinical utility – so the risk of suicide needs to be considered in all patients

I then develop a plan to reduce the risk of suicide (not possible to eliminate it)

The most important elements are to prevent isolation, reduce access to methods, provide frequent and regular planned follow up, engage family and social supports in the plan, and update the plan regularly

Perhaps the most important thing that can be done to prevent suicide is to connect the person at risk with individuals from caring networks of peers, family, and professionals. Personal contact with the person at risk by one or more of the individuals from the caring network reduces isolation and improves self-esteem – both likely to increase the threshold against self-harm.

Notably a 2007 Queensland Health (QH) report identified 140 unexpected deaths of patients treated by QH during the previous year, 86 of which occurred in mentally ill patients. Most of these deaths were by suicide within a week of assessment in a QH Emergency Department that did not result in admission, or within a week of discharge after psychiatric admission.

Other studies confirm that a high proportion of suicide deaths followed discharge from hospital. Relentless pressure to limit duration of hospital admission means some patients are discharged too soon, too unwell to return to home.

Limited intensive community follow-up of recently assessed but not admitted mentally ill patients and recently discharged patients leads to isolation from inadequate monitoring and care and increases the risk of suicide.

Mental health wellbeing

Very limited literature base

Resilience may act as a protective mechanism towards the development of mental health problems. Resilience refers to the ability to employ a collection of protective factors to return to or maintain positive mental health following disadvantage or adversity. Health promotion to enhance resilience.

One study highlights the potential of online mental health promotion and prevention interventions in promoting youth wellbeing and reducing mental health problems.

The review findings indicate that interventions promoting the mental health of young people can be implemented effectively in school and community settings with moderate to strong evidence of their impact on both positive and negative mental health outcomes.

Observational evidence suggested that volunteering may benefit mental health and survival although the causal mechanisms remain unclear.

Skills training interventions improved several aspects of emotional health in community-dwelling older adults, while the effects for other outcomes and interventions (exercise and social support) lacked clear evidence.

Attachment stability and quality in infancy

Improving parenting skills in low income first-time mothers – reduced child abuse and neglect

Physical exercise

Mediterranean diet

Omega 3 fish oil

Lithium in the water (Texas) – prevents suicide and violent crime!

Thank You!

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