Section 7: Emotional and Mental Health Assessment and Interventions

Question 1

What are the 3 types of stress?

Answer 1

• Eustress (good)
• Neustress (neutral)
• Distress – acute or chronic

Question 2

What are ACEs? Why are they important?

Answer 2

Adverse Childhood Events - potentially traumatic events that occur in childhood – links to poor health & wellbeing outcomes

Question 3

What are the health effects of chronic stress?

Answer 3

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

Question 4

What are some ways an individual can manage the stress response?

Answer 4

breathing, movement, meditation, nature, self-expression, community, self-help books, massage, music, light therapy

Question 5

Describe potential non-modifiable and modifiable causes of depression/anxiety?

Answer 5

• 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

Question 6

Describe the relationship between diabetes and depression? Outline a possible mechanism?

Answer 6

Depression and type 2 diabetes have bidirectional association (insulin affects brain serotonin, noradrenaline, dopamine)

Question 7

How are coronary artery disease and mental health linked?

Answer 7

depression alters platelet, endothelial function, independent risk factor for cardiac events - doubles cardiac events OR 2.55, similarly with anxiety OR 2.47

Question 8

What proportion of primary care visits relate to stress and lifestyle?

Answer 8

80%

Question 9

What is an appropriate screening tool for Stress?

Answer 9

Perceived Stress Scale: 10-item questionnaire, scored out of 40 (27+ is high stress)

Question 10

How does occupation affect stress?

Answer 10

Occupational stress factors – increases heart disease and diabetes risk
Job stress promotes unhealthy responses – smoking, alcohol, physical inactivity

Question 11

What is an appropriate screening tool for Depression?

Answer 11

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.

Question 12

Outline the DSM diagnosis for MDD:

Answer 12

5+ symptoms for nearly every day within 2 week period, and if symptoms are a change from previous functioning

Question 13

What is an appropriate screening tool for Anxiety?

Answer 13

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

Question 14

What do DSM criteria require for a diagnosis of anxiety disorder?

Answer 14

symptoms of anxiety for more than half the days over a least 6 month period

Question 15

How can a patient self-manage their mental and emotional health?

Answer 15

CBT, time management, positive psychology, gratitude journal, spiritual needs, limit screen time

Question 16

Other than self-management techniques, what else should be recommended to a patient to help with their mental and emotional health?

Answer 16

• Social support: connect with others, preferably face-to-face, support groups
• Community, online and mental health providers as needed

Question 17

What is the role of the practitioner in improving patients’ mental and emotional health?

Answer 17

• 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

Question 18

What is mindfulness?

Answer 18

• 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

Question 19

Is there evidence that mindfulness helps with any symptoms?

Answer 19

2014 meta-analysis showed mindfulness meditation programs have moderate evidence of improved anxiety, depression, pain

Question 20

Describe any known neurological changes that occur with mindfulness?

Answer 20

• 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

Question 21

Describe how mindfulness relates to self-awareness?

Answer 21

• 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

Question 22

What are the known medical benefits of mindfulness?

Answer 22

Improves physical and psychological symptoms – reduces inflammation, response to chronic pain, anxiety, depression, addiction
Helps with relationships – empathy, loneliness

Question 23

What is CBT?

Answer 23

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

Question 24

What are the benefits of CBT?

Answer 24

• Improves resilience, problem solving, wellbeing
• Better prefrontal cortex function

Question 25

Describe the efficacy of CBT compared to other treatments?

Answer 25

• 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

Question 26

For mental health disorders, when are lifestyle medicine treatment plans appropriate?

Answer 26

• Appropriate for chronic management and prevention
• Patients should be medically stable, without acute risk
• Can and should be used alongside medication and psychotherapy

Question 27

Is there evidence that lifestyle medicine is effective to prevent or treat mental health disorders?

Answer 27

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

Question 28

Describe the treatment of a major depressive disorder in adults?

Answer 28

• 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

Question 29

What non-pharmacological approaches may also be used for MDD?

Answer 29

Nonpharmacological approaches (either in addition, or if other approaches not desired)
* Exercise
* St Johns Wort
* Bright light therapy
* Yoga

Question 30

Describe the treatment of GAD or panic disorder?

Answer 30

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

Question 31

Describe how nutrition can affect mental health?

Answer 31

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

Question 32

What are some specific nutrients associated with mood?

Answer 32

Omega-3 fatty acids, SAMe, St John’s Wort, Folate

Question 33

When should a patient be referred to a mental health professional?

Answer 33

• 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

Question 34

What are the 3 main skills of mindfulness in the clinical encounter?

Answer 34

• 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