Section 7: Emotional and Mental Health Well Being Flashcards
Emotional Wellness
- 70% of primary care provider visits are related to stress and lifestyle
Studies:
- Occupation factors: long hours work increased heart disease risk
- Work stressors increased incidence of T2DM in women``
Stress Assessment Tool
Perceived Stress Scale Assessment
- Scale of 1-4. 1 (never), 4 (very often) for negatively phrased questions (1,2,3,6,9,10)
- Scoring is reverse for 4,5,7,8
- Upset because of something that happened unexpectedly
- Unable to control the important things in your life
- Felt nervous and stressed
- Felt confident about your ability to handle your personal problems
- Felt that things were going your way
- Could not cope with all the things that you had to do
- Able to control irritations in your life
- Felt that you were on top of things
- Angered because of things that happened that were outside of your control
- Felt difficulties were pilling up so high that you could not overcome them
Scoring:
0-13: Low Stress
14-26: Moderate Stress
27-40: High Stress
Screening for Depression
Should be in in primary care settings with adequate support system in general adult population and pregnant and postpartum women
Patient Health Questionnaire 2 Question Screening Tool (PHQ-2)
1. Over the past 2 weeks, have you felt down, depressed, or hopeless?
2. Over the past 2 weeks, have you felt little interest or pleasure in doing things?
Screen is positive is score is >3
Sensitivity is 72% and specificity is 85%
If positive requires further assessment with nine question PHQ-9, HAM-D (Hamilton depression scale), or BDI-II (Beck Depression Inventory)
0- not at all
1- several days
2- more than half the days
3 - nearly everyday
Diagnosis of Major Depressive Disorder (MDD)
Dx is made if px has 5 or more symptoms persisted nearly every day for 2 weeks period:
- At least one of the following must be present:
- Depressed mood most of the day
- Loss of interest or pleasure - Four or more of the following must be present:
- Significant weight loss or gain (unintentional), or change in appetite
- Insomnia, hypersonmina
- Psychomotor agitation, retardation, inc. irritability
- Fatigue or loss of energy
- Feeling of worthlessness or excessive guilt
- Trouble concentrating or indecisiveness
- Recurrent thoughts of death, recurrent suicidal ideation with or without a specific plan or suicide attempt
Screening for General Anxiety Disorder (GAD)
- Rule out anxiety before concluding symptoms are due to stress
- GAD-2:
1. In the last 2 weeks, how often have you felt nervous, anxious, or on edge?
2. In the last 2 weeks, how often have you not been able to stop or control worrying?
If positive (>3), follow up with HAM-A, GAD-7, DSM-5, or Beck Anxiety Inventory (BAI) diagnostic criteria.
Diagnostic criteria for anxiety
- if following symptoms present more than half the days over at least a 6 months period of time:
1. Excessive anxiety
2. Worry is difficult to control
3. At least 3 other symptoms: restlessness, easily fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
4. Significant impairment has occurred due to anxiety, worry, or physical symptoms
5. Symptoms above are not due to substance us
6. Symptoms are not from another disorder
PHQ-4
Brief Screening for depression and Anxiety
0-3
0: not at all, 1: several days, 2: more than half the days, 3: nearly everyday
a. Feeling nervous, anxious or on edge?
b. Not being able to stop or control worrying?
c. Over the past 2 weeks have you felt down, depressed, or hopeless?
d. Over the past 2 weeks, have you felt little interest or pleasure in doing things?
Scoring:
0-2: normal
3-5: mild
6-8: moderate
9-12: severe
Potential causes of clinical depression/anxiety disorders
Depression and Anxiety Assesment Test (DAAT), to help identify categories of causes:
1. Inherited genetic mutations
2. Developmental causes (i.e. adverse childhood)
3. LIfestyle causes (i.e no exercise)
4. Circadian rhythm causes (i.e. irregular sleep wake up times)
5. Addiction causes
6. Nutritional causes (i.e. noe enoug folate, tryptohpan, tyrosine, antioxidants, omega 3 deficit, or too much arachidonic acid
7. Toxic causes (ie. mercury, lead, arsenic)
8. Social stress causes (socially traumatic events)
9. Medical causes (i.e. cancer, autoimmune disease)
10. Frontal lobe causes (not taking part in activities that enhance frontal lobe functions such as melodious music, reading)
Mental illness and Chronic Disease
Diabetes
- Insulin mediated level of tryptophan and tyrosine resulting in brain serotonin, norepinephrine, and dopamine synthese
- Carbs stimulate formation of serotonin
Depression is associated with inc risk of cardiac disease, stroke, cancer, and diabetes. It’s a strong independent marker for mortality as smoking
Risk factors in DM px:
- Insulin therapy
- Duration of DM
- Unsatisfactory glycemic control (HbA1c >6.5
Coronary Artery Disease
- Depression, independent risk factor for cardiac events
- Px with depression suffer from:
1. Inc. abnormal platelet adherence
2. Endothelial dysfunction
3. Lowered heart rate variability
4. Worse adherence to lifestyle changes
Treatment of depression:
- Selective seratonin reauptake inhibitors (SSRI) is relatively safe
- Trucyclic Antidepressants (TCAs) NOT RECOMMENDED due to the risk of QT prolongation and orthostatic hypotension
Provider’s role in facilitating px emotional wellness
- Screen and diagnose significant stress or underlying mood disorders
- Develop non pharmacologic stress management plans
- Promote self management techniques for emotional well being
- Encourage px to use social support
- Refer the px to accessible community and online resources
- Refer the px to mental health providers if necessary
Indications for referral to a mental heatlh professional
- High psychiatric screening scores
- Meets DSM-5 criteria for depression and anxiety, care is beyond one’s scope of practice
- Active suicidal or homicidal ideation
- Hx of prior suicide attempt
- Comorbid mood disorders
- Unclear diagnosis
- Prefers to be seen by behavioral health provider
- Shows no improvement despite tx
- Experiences a relapse of symptoms
- If your judgements says there is a need for referral
Treatment in comorbid px
- Depression
- Exercise, mindfulnesss, bibliotherapy, light therapy, computerized intervention, sleep management, positive relationships, addressing lifestyle related precipitants of depression (i.e. lack of sleep)
- Cognitive behavioral therapy, behavioral therapy, interpersonal therapy, psychotherapy
- Pharmacotherapy: SSRI- first line of tx. Benefit is more prominent as disease severity increases.
- TCA only used if SSRI are not tolerated or hx that make TCA more faborable/
- MAO more side effects and food interactions. Only as 3rd or 4th line of tx.
- Physical exercise for depression is comparable to CBT
- Exercise more effective than no treatment. BUT it’s NOT more effective compared to psychological or pharmacological therapies.
- Can prevent depression in young adults if started in childhood.
Mental health and nutrition
Refined food - inc. risk of depression
Whole foods - dec. risk of depression
- Plant based diet (apparently) showed improvement in just 2 weeks for depression
- Avoid arachidonic acid which is present in meat, fish, eggs, and inc. magnesium, folate, long chan omega 3, EPA DHA, associated with less depression.
Mood and Nutrients
- Omeag-3 Fatty acids: may be helpful in bipolar disorder, PTSD etc.
- S-adenosyl methionine (SAMe) - efective antidepressant adjunct to a SSRI and clinically audmenting effects of pharmaceutical anti depressants
- N-acetyl methionine (NAC): potential benefit for bipolar depression, etc. NAC augments production of glutathione, and may have anti inflammatory effect.
- Zinc deficinecy linked to increase depressive symptoms
- Folate or vit. b9 can help production of serotonin and dopamine. Combined with meds, it’s been shown to improve efficacy and shorten response time.
- Vit. D, low levels in linked to inc. depressive symptoms
- Silexan, active ingradient in lavander oil. Reduces anxiety equivalent to lorazepam but with no sedative effects nor potential drug abuse. It can improve test anxiety and test scores.
- Saffron (in small studies) shows to reduce depression and premenstrual dysphoria
- Folic acid can help treat depression
Emotional Wellness Self Management
Patient responsibilities:
- Self management: connect with others, gratitude journal, spiritual needs, relax
- Cognitive restructuring: look at events from a different angle, focus on what is going well in life
Treatment activities:
1. Create action plan: specific plant to address which emotional challenge will be focused on.
- Create a relapse prevention plan
Positive Psychology
- Study of strength and virtues to enable individuals to thrive. Focus to produce happiness and fulfillment, not to specifically lessen misery.
Components:
- Developing positive emotions and affect
- Experience contentment with the past, happiness in the present, and hope for the future
- Focusing on individual virtues and strength (courage, compassion, integrity, curiosity, hope, perseverance, gratitude, self control, etc.)
Not a treatment, but can accompany tx of mental illness
Practical techniques of positive psychology:
1. Find and improving one’s strengths
2. Counting blessings
3. Establish short and long term goals
4. Savoring the pleasing things in life
5. Writing down what one wants to be remembered for
6. Looking for opportunities to extend kindness, then acting
7. Thinking about the happiest days in one’s life frequently
