Section 7: Emotional and Mental Health Assessment and Interventions Flashcards
What are the 3 types of stress?
- Eustress (good)
- Neustress (neutral)
- Distress – acute or chronic
What are ACEs? Why are they important?
Adverse Childhood Events - potentially traumatic events that occur in childhood – links to poor health & wellbeing outcomes
What are the health effects of chronic stress?
sympathetic nervous system dominates
Health effects of chronic stress: impaired immune function, inflammation, impaired wound healing, telomere shortening, increased appetite, metabolic effects, increased clotting, worsened mood, sleep, pain/fatigue
What are some ways an individual can manage the stress response?
breathing, movement, meditation, nature, self-expression, community, self-help books, massage, music, light therapy
Describe potential non-modifiable and modifiable causes of depression/anxiety?
- Non-modifiable factors – genetics, perinatal or environmental exposures, socioeconomic-political environment
- Modifiable factors – stress, nutrition, financial strain, sedentary lifestyle, comorbid conditions, addiction, social connectedness
- Dose-response relationship of risk of depression to number of risk factors
Describe the relationship between diabetes and depression? Outline a possible mechanism?
Depression and type 2 diabetes have bidirectional association (insulin affects brain serotonin, noradrenaline, dopamine)
How are coronary artery disease and mental health linked?
depression alters platelet, endothelial function, independent risk factor for cardiac events - doubles cardiac events OR 2.55, similarly with anxiety OR 2.47
What proportion of primary care visits relate to stress and lifestyle?
80%
What is an appropriate screening tool for Stress?
Perceived Stress Scale: 10-item questionnaire, scored out of 40 (27+ is high stress)
How does occupation affect stress?
Occupational stress factors – increases heart disease and diabetes risk
Job stress promotes unhealthy responses – smoking, alcohol, physical inactivity
What is an appropriate screening tool for Depression?
Simple screen is the Patient Health Questionnaire two question screening tool (PHQ-2)
* Over the past 2 weeks, have you felt down, depressed, or hopeless?
* Over the past 2 weeks, have you felt little interest or pleasure in doing things?
* Score 0 = not at all, 1 = several days, 2 = more than half of the days, 3= nearly every day
* Screen is positive with score of 3 or more (sensitivity 73%, specificity 85%)
Follow up with further assessment – eg PHQ-9, Hamilton depression scale or Beck Depression Inventory.
Outline the DSM diagnosis for MDD:
5+ symptoms for nearly every day within 2 week period, and if symptoms are a change from previous functioning
What is an appropriate screening tool for Anxiety?
Screen with General Anxiety Disorder 2-question screening tool (GAD-2)
* In the last 2 weeks, how often have you felt nervous, anxious or on edge?
* In the last 2 weeks how often have you not been able to stop or control worrying?
* Positive is score 3+ (same scoring system)
Following up with Hamilton Anxiety Rating Scale, GAD07 or Beck Anxiety Inventory.
Rule out anxiety before ascribing symptoms to stress
What do DSM criteria require for a diagnosis of anxiety disorder?
symptoms of anxiety for more than half the days over a least 6 month period
How can a patient self-manage their mental and emotional health?
CBT, time management, positive psychology, gratitude journal, spiritual needs, limit screen time
Other than self-management techniques, what else should be recommended to a patient to help with their mental and emotional health?
- Social support: connect with others, preferably face-to-face, support groups
- Community, online and mental health providers as needed
What is the role of the practitioner in improving patients’ mental and emotional health?
- First, medically stabilise the patient
- Focus treatments on self-management, cognitive restructuring and relapse prevention
- Create action plans around an emotional challenge and include social support
- Focus on adding positive experiences
- Create relapse prevention plan, eg for challenging times
What is mindfulness?
- Paying attention to what you are thinking and feeling - creates awareness of a space between a stimulus and response
- Being fully present in the moment
- Being aware of surroundings, withholding judgement
Is there evidence that mindfulness helps with any symptoms?
2014 meta-analysis showed mindfulness meditation programs have moderate evidence of improved anxiety, depression, pain
Describe any known neurological changes that occur with mindfulness?
- Adult humans can grow approximately 700 new neurons a day??
- Can increase thickness of prefrontal cortex, grey matter in hippocampus, reduce gray matter in the amygdala
- Promotes stronger connections between prefrontal cortex and amygdala –> problem-solving and modulating emotional responses
Describe how mindfulness relates to self-awareness?
- Extended self-reference links one’s experiences across time
- Momentary self-reference is awareness of oneself in the present
Mindfulness training: individuals can activate these distinctly, rather than them being habitually linked
What are the known medical benefits of mindfulness?
Improves physical and psychological symptoms – reduces inflammation, response to chronic pain, anxiety, depression, addiction
Helps with relationships – empathy, loneliness
What is CBT?
Evidenced, structured psychotherapy - gold standard
* Involves structured steps to change thoughts -> change emotions -> change behaviour
* Focusses on current life, not past
* Creates awareness of automatic thoughts
* Thoughts are evaluated as helpful or harmful, positive or negative. Not neutralised, nor bring up memories
What are the benefits of CBT?
- Improves resilience, problem solving, wellbeing
- Better prefrontal cortex function
Describe the efficacy of CBT compared to other treatments?
- Effective in depression, anxiety, personality disorders, substance use etc
- Is at effective to treat depression as medications
- Less relapse with CBT compared to meds
- CBT in combination with meds more effective than meds alone for major depression, panic disorder, and OCD
For mental health disorders, when are lifestyle medicine treatment plans appropriate?
- Appropriate for chronic management and prevention
- Patients should be medically stable, without acute risk
- Can and should be used alongside medication and psychotherapy
Is there evidence that lifestyle medicine is effective to prevent or treat mental health disorders?
Systematic review of evidence of lifestyle factors in onset/treatment of mental disorders:
* PA protective against developing bipolar, effective to treat ADHD, anxiety, major depression and psychotic disorders
* Not smoking protective against developing ADHD, depression bipolar, psychotic disorders
* Dietary pattern protective against developing depression, effective to treat
* Sleep protective against developing bipolar, anxiety, ADHD, effective to treat depression
Describe the treatment of a major depressive disorder in adults?
- Psychotherapy or meds or combination
- Pharmacotherapy is standard of care for moderate or severe MDD
- Assess and stabilise any suicidal/homicidal ideation
Lifestyle medicine interventions should address controllable lifestyle factors- nutrition, PA, sleep, risky substance use
For mental wellbeing/stress: Stress management, CBT, Meditation, Psychotherapy
What non-pharmacological approaches may also be used for MDD?
Nonpharmacological approaches (either in addition, or if other approaches not desired)
* Exercise
* St Johns Wort
* Bright light therapy
* Yoga
Describe the treatment of GAD or panic disorder?
First line treatments:
psychotherapy (CBT best evidence)
* pharmacotherapy (SSRIs)
* PA
Lifestyle medicine treatments in addition to initial therapy to address controllable factors – Nutrition, PA, sleep, risky substances
Mental wellbeing & Stress: stress management, patient-provider relationship, psychotherapy, meditation
Describe how nutrition can affect mental health?
Dietary patterns rather than nutrient deficiencies more likely to contribute
- High fruit/veges/whole grains, fish, olive oil, low-fat dairy and antioxidants, and low intake animal foods – decreased risk of depression
- MDD more likely in adults who eat fast food
- Fried foods, refined grains, sugary products -associated with increased rates major depression/anxiety
- Dietary patterns high in plant foods associated with better emotional well-being
Positive mood also promotes better eating patterns
What are some specific nutrients associated with mood?
Omega-3 fatty acids, SAMe, St John’s Wort, Folate
When should a patient be referred to a mental health professional?
- Active suicidal or homicidal ideation :/
- Prior suicide attempt, family history of suicide or another risk factors for suicide – talk of being a burden, isolation, wanting to die, looking for a means
- Clinical judgement
- Outside scope of own practice
- No improvement or relapse despite treatment
- Concurrent comorbid disorders – bipolar, OCD, personality disorder
- Unclear diagnosis
- Preference
- Indicated as part of treatment plan eg MDD, anxiety disorders
What are the 3 main skills of mindfulness in the clinical encounter?
- Presence – sustained attention, attention worsened by boredom, negative emotions eg feeling overwhelmed, psychiatric conditions or OSA, lifestyle factors, substance or medication use, multi-tasking
- Clarity
- Curiosity – less errors, conflict, bias. More innovation
