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Mental illnesses & office administration

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Dr. George Boghozian, BSc, DC, MSc

Mental Illnesses for PTA

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Physical Therapy Assistant (PTA) Program Mental Health & Office Administration Instructor: Dr. George Boghozian, B.Sc., D.C.
Dr. George Boghozian, B.Sc., D.C. Education: 1980-1985: Iranian Medical College B.Sc. In Medical Laboratory Science 1998-2000: York University Kinesiology and Health Science 2000-2003: Cleveland Chiropractic College Doctor of Chiropractic (D.C.)
Dr. George Boghozian, B.Sc., D.C. Teaching Experience: 1985-1989: Bushehr Midwifery School Medical Laboratory Nutrition Clinical Genetics 2001-2003: Cleveland Chiropractic College Clinical Laboratory Diagnosis 2005-2006: Canadian Memorial Chiropractic College Systems Pathology
Mental Health & Office Administration Prepared by: Dr. George Boghozian
Mental Health Introduction Psychopathology Models Mental Health Promotion
Mental Health Introduction Mental health is a concept that refers to a human individual's emotional and psychological well-being. Merriam-Webster defines mental health as "A state of emotional and psychological well- being in which an individual is able to use his or her cognitive and emotional capabilities, function in society, and meet the ordinary demands of everyday life."
Mental Health Introduction According to the World Health Organization (WHO), there is no one "official" definition of mental health. Cultural differences, subjective assessments, and competing professional theories all affect how "mental health" is defined. In general, most experts agree that "mental health" and "mental illness" are not opposites. In other words, the absence of a recognized mental disorder is not necessarily an indicator of mental health.
Mental Health Introduction One way to think about mental health is by looking at how effectively and successfully a person functions. Feeling capable and competent; being able to handle normal levels of stress, maintain satisfying relationships, and lead an independent life; and being able to "bounce back," or recover from difficult situations, are all signs of mental health.
Mental Health Introduction Most experts consider mental health as a continuum. Thus, an individual's mental health may have many different possible values. Mental wellness is generally viewed as a positive attribute, such that a person can reach enhanced levels of mental health, even if they do not have any diagnosable mental illness. This definition of mental health highlights emotional well being, the capacity to live a full and creative life and the flexibility to deal with life's inevitable challenges.
Mental Health Introduction Many therapeutic systems and self-help books offer methods and philosophies espousing strategies and techniques vaunted as effective for further improving the mental wellness of otherwise healthy people. Positive psychology is increasingly prominent in mental health. According to the the World Health Organization: "Mental health has been defined variously by scholars from different cultures.
Mental Health Introduction Concepts of mental health include subjective well- being, perceived self-efficacy, autonomy, competence, inter-generational dependence, and self-actualization of one's intellectual and emotional potential, among others. From a cross-cultural perspective, it is nearly impossible to define mental health comprehensively. It is, however sometimes used as a broader definition, and professionals generally agree that mental health is broader than a lack of mental disorders."
Mental Health Introduction Mental health was first described as "mental hygiene" by Clifford Whittingham Beers in 1908, who founded the National Committee for Mental Hygiene in 1909 and actively campaigned for the rights of the mentally ill Dr. William Glasser, a psychiatrist, described 'Mental Hygiene' in his book Mental Health or Mental Illness (1961), following the dictionary definition of hygiene as the establishment and maintenance of health, i.e. mental health.
Mental Health Introduction Mental health, as defined here, is distinct from mental illness. Enhancement of mental health is not the primary goal of some mental health professionals more concerned with treating illnesses and restoring function. Psychiatry relies primarily upon the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) or ICD-10 to diagnose and treat mental illnesses and disorders. Mainstream mental health consumer community services are an adjunct to psychiatry, not an alternative.
Mental Health Psychopathology Models The scientific consensus on mental illness views disorders as neurobiological, but more than neurochemistry. Other brain functions identified as contributing to mental illness include circadian rhythms, cognitive processing, brain networks and more. Brain imaging studies demonstrate physical changes in neuroanatomy accompanying disorders such as schizophrenia, autism and bipolar disorder.
Mental Health Psychopathology Models As well, environmental, developmental and interpersonal factors have been studied, and research is ongoing. Best-evidence medicine as defined by the independent National Institute for Health and Clinical Excellence (NICE) treatment guidelines indicate that bipolar disorder, for example, requires a combination of medication, psychotherapy, self-help and social supports. Mental health agencies are increasingly involved and promote self-reliance and peer support.
Mental Health Psychopathology Models Some mental health advocates, such as the Critical Psychiatry Network, Scientology, and MindFreedom, do not accept mental illness as brain-based. They oppose the "chemical imbalance theory" and claim the DSM-IV involves oversimplified causes and treatments for mental illness. This strain of advocacy is not representative of most established mental health consumer organizations, such as the National Mental Health Association, Depression and Bipolar Support Alliance, Canadian Mental Health Association, Rethink, and others.
Mental Health Psychopathology Models It is, however, in line with 12 step peer support groups that utilize: "surrendering to a higher power" and self-shaming as treatment. Opposing viewpoints to biological psychiatry theories include those of anti-psychiatry advocates, some of whom are psychiatrists, who contend psychiatric patients do not necessarily have a mental illness, but in fact are individuals who do not ascribe to the conventional belief system, or consensus reality, shared by most other people in their culture or race.
Mental Health Psychopathology Models According to Dr. Glasser, a critic of psychiatry, the Public Health model is an established model delivering physical health to millions of people. He advocates to have this model expanded into a Public Mental Health Delivery model to put into practice by mental health professionals and institutions, by hiring mental health professionals (as defined by Glasser, not the established industry of mental health professionals such as psychiatric nurses and counsellors) to deliver services without diagnoses or first-line medication to people who need professional help.
Mental Health Psychopathology Models This model does not provide adequate treatment for consumers with severe, persistent, genetic mental illness who are unable to take care of themselves, even to direct a self-empowering treatment plan. Lack of insight is a key definition of psychosis and mania in which the person does not believe (s)he is ill and refuses or does not comply with treatment.
Mental Health Mental Health Promotion Mental health promotion works from the principle that everyone has mental health needs, not just people who have been diagnosed with a mental illness. Mental health promotion is essentially concerned with making changes to society that will promote people's mental well-being. Positive psychology is also concerned with mental health and enhancement rather than treating illness.
Mental Health Mental Health Promotion Mental health promotion is a term that covers a variety of strategies. These strategies can be seen to occur at three levels: Individual - encouragement of individual resources by promotion of interventions for self-esteem, coping, assertiveness in areas such as parenting, the workplace or personal relationships. Communities - increasing social inclusion, developing support structures that promote mental health in workplaces, schools and neighbourhoods. Government reduce socioeconomic barriers to mental health at governmental level by promoting equal access for all and support for vulnerable citizens.
Mental Illnesses Overview Mood Disorders Anxiety Disorders Psychoses Personality Disorders Eating Disorders Addiction Suicidal Behaviour
Mental Illnesses Overview Mental illnesses are characterized by alterations in thinking, mood or behaviour (or some combination thereof) associated with significant distress and impaired functioning. The symptoms of mental illness vary from mild to severe, depending on the type of mental illness, the individual, the family and the socio-economic environment.
Mental Illnesses Overview Mental illnesses indirectly affect all Canadians through illness in a family member, friend or colleague. Twenty percent of Canadians will personally experience a mental illness during their lifetime. Mental illnesses affect people of all ages, educational and income levels, and cultures. The onset of most mental illnesses occurs during adolescence and young adulthood. A complex interplay of genetic, biological, personality and environmental factors causes mental illnesses.
Mental Illnesses Overview Mental illnesses can be treated effectively. Mental illnesses are costly to the individual, the family, the health care system and the community. The economic cost of mental illnesses in Canada was estimated to be at least $7.331 billion in 1993. Eighty-six percent of hospitalizations for mental illness in Canada occur in general hospitals. In 1999, 3.8% of all admissions in general hospitals (1.5 million hospital days) were due to anxiety disorders, bipolar disorders, schizophrenia, major depression, personality disorders, eating disorders and suicidal behaviour. The stigma attached to mental illnesses presents a serious barrier not only to diagnosis and treatment but also to acceptance in the community.
Mental Illnesses Mood Disorders Mood disorders include major depression, bipolar disorder (combining episodes of both mania and depression) and dysthymia. Approximately 8% of adults will experience major depression at some time in their lives. Approximately 1% will experience bipolar disorder. The onset of mood disorders usually occurs during adolescence. Worldwide, major depression is the leading cause of years lived with disability.
Mental Illnesses Mood Disorders Mood disorders have a major economic impact through associated health care costs as well as lost work productivity. Most individuals with a mood disorder can be treated effectively in the community. Unfortunately, many individuals delay seeking treatment. Hospitalizations for mood disorders in general hospitals are approximately one and a half times higher among women than men.
Mental Illnesses Mood Disorders The wide disparity among age groups in hospitalization rates for depression in general hospitals has narrowed in recent years, because of a greater decrease in hospitalization rates in older age groups. Hospitalization rates for bipolar disorder in general hospitals are increasing among women and men between 15 and 24 years of age. Individuals with mood disorders are at high risk of suicide.
Mental Illnesses Mood Disorders Mood disorders may involve depression only (also referred to as "unipolar depression") or they may include manic episodes (as in bipolar disorder, which is classically known as "manic depressive illness"). Individuals with mood disorders suffer significant distress or impairment in social, occupational, educational or other important areas of functioning.
Mental Illnesses Mood Disorders Individuals with depression feel worthless, sad and empty to the extent that these feelings impair effective functioning. They may also lose interest in their usual activities, experience a change in appetite, suffer from disturbed sleep or have decreased energy. Individuals with mania are overly energetic and may do things that are out of character, such as spending very freely and acquiring debt, breaking the law or showing lack of judgement in sexual behaviour.
Mental Illnesses Mood Disorders These symptoms are severe and last for several weeks, interfering with relationships, social life, education and work. Some individuals may appear to function normally, but this requires markedly increased effort as time with the illness progresses. Both depressive and manic episodes can change the way an individual thinks and behaves, and how his/her body functions.
Mental Illnesses Mood Disorders Major depressive disorder is characterized by one or more major depressive episodes (at least 2 weeks of depressed mood or loss of interest in usual activities accompanied by at least four additional symptoms of depression). Bipolar disorder is characterized by at least one manic or mixed episode (mania and depression) with or without a history of major depression.
Mental Illnesses Mood Disorders Dysthymic disorder is essentially a chronically depressed mood that occurs for most of the day for more days than not over a period of at least two years, without long, symptomfree periods. Symptom-free periods last no longer than 2 months. Adults with the disorder complain of feeling sad or depressed, while children may feel irritable. The required minimum duration of symptoms for diagnosis in children is 1 year.
Mental Illnesses Mood Disorders Symptoms Depression Mania Feeling worthless, helpless or hopeless Loss of interest or pleasure (including hobbies or sexual desire) Change in appetite Sleep disturbances Decreased energy or fatigue (without significant physical exertion) Sense of worthlessness or guilt Poor concentration or difficulty making decisions Excessively high or elated mood Unreasonable optimism or poor judgement Hyperactivity or racing thoughts Decreased sleep Extremely short attention span Rapid shifts to rage or sadness Irritability
Mental Illnesses Mood Disorders How Common Are Mood Disorders? As a group, mood disorders are one of the most common mental illnesses in the general population. Canadian studies looking at lifetime incidence of major depression found that 7.9% to 8.6% of adults over 18 years of age and living in the community met the criteria for a diagnosis of major depression at some time in their lives. Other studies have reported that between 3% and 6% of adults will experience dysthymia during their lifetime, and that between 0.6% and 1% of adults will have a manic episode during their lifetime.
Mental Illnesses Mood Disorders Who Is Affected by Mood Disorders? Mood disorders affect individuals of all ages, but usually appear in adolescence or young adulthood. However, late diagnosis is common: the average age of diagnosis of major depressive disorder is in the early twenties to early thirties.1 Studies have consistently documented higher rates of depression among women than among men: the female-to-male ratio averages 2:1.3 Women are 2 to 3 times more likely than men to develop dysthymia.
Mental Illnesses Mood Disorders Sex differences in the symptoms associated with depression may contribute to the differences in the prevalence of depression between men and women. For example, men are more likely to be irritable, angry and discouraged when depressed, whereas women express the more "classical" symptoms of feelings of worthlessness and helplessness, and persistent sad moods. As a result, depression may not be as easily recognized in a man.
Mental Illnesses Mood Disorders In addition, women are more likely than men to seek help from health professionals. Biological or social risk or protective factors may also differ between men and women. For bipolar disorder, it is generally accepted that the ratio between men and women is approximately equal.
Mental Illnesses Mood Disorders Although most individuals with mood disorders are treated in the community, hospitalization is sometimes necessary. At the present time, hospitalization data provide the best available, though limited, description of individuals with mood disorders. The results must be viewed with caution, however, since this is only a subset of those with mood disorders: most individuals with mood disorders are treated in the community rather than in hospitals, and many do not receive treatment at all.
Mental Illnesses Mood Disorders How Do Mood Disorders Affect People? Because of their high prevalence, economic cost, risk of suicide and loss of quality of life, mood disorders present a serious public health concern in Canada. Depression and mania cause significant distress and impairment in social, occupational, educational or other important areas of functioning. Major depressive disorder is a recurrent illness with frequent episode relapses and recurrences.
Mental Illnesses Mood Disorders The more severe and longlasting the symptoms in the initial episode, due in some cases to a delay in receiving effective treatment, the less likely is a full recovery. Unipolar major depressive disorder is identified as the fourth-ranked cause of disability and premature death worldwide. Depression also has a major impact on the mental health of family members and caregivers, often with an increased presence of depression and anxiety symptoms.
Mental Illnesses Mood Disorders Causes of Mood Disorders: Mood disorders have no single cause, but several factors, such as a biochemical imbalance in the brain, psychological factors and socio-economic factors, tend to make some individuals prone to such disorders. Genetic Influence: Studies have established that individuals with depression and bipolar disorder often find a history of these disorders in immediate family members. Evidence suggests that many different genes may act together and in combination with other factors to cause a mood disorder.
Mental Illnesses Mood Disorders Although some studies have suggested a few interesting genes or genomic regions, the exact genetic factors that are involved in mood disorders remain unknown. Previous Episode of Depression: One episode of major depression is a strong predictor of future episodes. More than 50% of individuals who have an episode of major depression experience a recurrence.
Mental Illnesses Mood Disorders Stress Stress has traditionally been viewed as a major risk factor for depression. Recent research efforts have indicated, however, that stress may predispose individuals only for an initial episode and not for recurring episodes. Responses to stress differ greatly among individuals: some are more susceptible than others to depression following life events, when they are in difficult relationships, or because of socio-economic factors such as inadequate income or housing, prejudice and workplace stress.
Mental Illnesses Mood Disorders Physical Illness A strong association exists between various chronic medical conditions and an elevated prevalence of major depression. Several conditions, such as stroke and heart disease, Parkinson's disease, epilepsy, arthritis, cancer, AIDS and chronic obstructive pulmonary disease (COPD), may contribute to depression. Several factors associated with physical illness may contribute to the onset or worsening of depression. These include the psychological impact of disability, decline in quality of life, and the loss of valued social roles and relationships. Medication side effects may also be a contributing factor.
Mental Illnesses Mood Disorders Finally, it is possible that the physical disease itself may contribute directly to the onset of depression by affecting physiological mechanisms such as neurotransmitters, hormones and the immune system; for similar reasons, episodes of mania may occur following physical illness or use of medications. Indirect factors: Also influence the relationship between physical conditions and depression. Such factors include disability and quality of life of individuals with chronic disease and the tendency for some medications used for treating physical illnesses to cause depression. Treating chronic physical illness effectively requires vigilance for the early detection and treatment of depression.
Mental Illnesses Mood Disorders Treatment of Mood Disorders: Mood disorders are treatable. Many people with a mood disorder fail to seek treatment, however, and suffer needlessly. Of those who seek treatment, many remain undiagnosed or receive either incorrect medication or inadequate doses. The delay in seeking and receiving a diagnosis and treatment may be due to a number of factors, such as stigma, lack of knowledge, a lack of human resources and availability or accessibility of services.
Mental Illnesses Mood Disorders Current initiatives to relieve the burden of mood disorders include not only improved recognition and use of effective treatments, but also education for individuals and families and for the community. Primary care settings play a critical role in both recognizing and treating these illnesses. Innovative practice models have shown that effective interventions can decrease symptoms and increase work days. Effective early treatment of mood disorders can improve outcomes and decrease the risk of suicide.
Mental Illnesses Mood Disorders Antidepressant medications and education in combination with various forms of psychotherapy, such as cognitive-behavioural therapy, have demonstrated their effectiveness in treating depression. A recent publication from the Canadian Psychiatric Association outlines the clinical guidelines for the treatment of depressive disorders. Educating family and primary care providers is essential not only to ensure the recognition of early warning signs of depression, mania and suicide and to implement appropriate treatment, but also to ensure adherence to treatment in order to minimize future relapses.
Mental Illnesses Mood Disorders Sound support networks are crucial during both the acute phase of the illness and the post-illness adjustment to daily life. Major depression results in poor productivity and sick leave from the workplace. The workplace, therefore, is an important area for addressing mental health issues. Supporting the development of healthy work environments, educating employers and employees in the area of mental health issues, and providing supportive reintegration into the work environment for those experiencing mental illness would go a long way toward minimizing the effect of major depression on the workplace.
Mental Illnesses Mood Disorders Individuals with mood disorders may require hospitalization to adjust medication, to stabilize the disorder or to ensure protection against self- destructive behaviour. The higher hospitalization rates for depression among women than men support the clinical experience of higher rates of depression among women. Based on clinical research, rates of major depression among women are 2 times higher than among men. On the other hand, the hospitalization rates among women are only about 1.5 times higher than among men
Mental Illnesses Mood Disorders Suggesting that men may be hospitalized for major depression at higher rates than women. This requires further research for confirmation and explanation. Rates of bipolar disorder have been estimated to be equal among men and women. However, hospitalization rates for women with the disorder are much higher than men. Further research is required to assess if, in fact, rates of the disease are higher among women, or if women with the disorder are hospitalized at a higher rate than men, why this occurs.
Mental Illnesses Mood Disorders Hospitalization rates for both depression and bipolar disorder among women peak between the ages of 35-49 years. Research is required to assess the factors in women's lives that contribute to this phenomenon. Since 1987, hospitalization rates for depression among older Canadians have decreased much more than rates among younger age groups. Further research is required to determine the reasons for this trend.
Mental Illnesses Mood Disorders Has it been the result of better clinical treatment, and have outcomes for this age group also improved over this time period? Hospitalization rates for bipolar disorder among young women and men have increased since the early 1990s. Does this signify an increase in bipolar disorder in these age groups, earlier recognition of the disorder, or a change in treatment? Mood disorders, including major depression, bipolar disorder and dysthymia are common and contribute to major personal and family distress. They also have a significant impact on workplace and health care costs.
Mental Illnesses Mood Disorders Existing data provide a very limited profile of mood disorders in Canada. The available hospitalization data needs to be complemented with additional data to fully monitor these disorders in Canada. Priority data needs include: Incidence and prevalence of major depression, bipolar disorder and dysthymia by age, sex and other key variables (for example, socio- economic status, education, and ethnicity).
Mental Illnesses Mood Disorders Prevalence of depression in people with chronic physical illness. Impact of mood disorders on the quality of life of the individual and family. Access to and use of primary and specialist health care services. Treatment outcomes. Rates of suicide among individuals with mood disorders. Access to and use of public and private mental health services.
Mental Illnesses Mood Disorders Access and use of mental health services in other systems, such as schools, criminal justice programs and facilities, and employee assistance programs. Impact of mood disorders on the workplace and the economy. Stigma associated with mood disorders. Exposure to known or suspected risk and protective factors.
Mental Illnesses Schizophrenia What Is Schizophrenia? Schizophrenia is a brain disease and one of the most serious mental illnesses in Canada. Common symptoms are mixed-up thoughts, delusions (false or irrational beliefs), hallucinations (seeing or hearing things that do not exist) and bizarre behaviour. People suffering from schizophrenia have difficulty performing tasks that require abstract memory and sustained attention. All the signs and symptoms of schizophrenia vary greatly among individuals.
Mental Illnesses Schizophrenia There are no laboratory tests to diagnose schizophrenia. Diagnosis is based solely on clinical observation. For a diagnosis of schizophrenia to be made, symptoms must be present most of the time for a period of at least 1 month, with some signs of the disorder persisting for 6 months. These signs and symptoms are severe enough to cause marked social, educational or occupational dysfunction. The Canadian Psychiatric Association has developed guidelines for the assessment and diagnosis of schizophrenia. Symptoms: Delusions and/or hallucinations Lack of motivation Social withdrawal Thought disorders
Mental Illnesses Schizophrenia Who Is Affected by Schizophrenia? The onset of schizophrenia typically occurs between the late teens and mid-30s. Onset before adolescence is rare. Men and women are affected equally by schizophrenia, but men usually develop the illness earlier than women. If the illness develops after the age of 45, it tends to appear among women more than men, and they tend to display mood symptoms more prominently.
Mental Illnesses Schizophrenia Ideally, data from a population survey would provide information on the age/sex distribution of individuals with schizophrenia. Statistics Canada's Canadian Community Health Survey (CCHS) will provide data on the prevalence of self-reported schizophrenia in the future. This will likely underestimate the true prevalence, however, since the survey team will not reach those individuals with schizophrenia who are homeless, in hospital or in supervised residential settings.
Mental Illnesses Schizophrenia Although most individuals with schizophrenia are treated in the community, hospitalization is sometimes necessary to stabilize symptoms. In 1999, rates of hospitalization for schizophrenia in general hospitals varied with age. Rates among men increased dramatically in the 20-24 year age group and remained high before beginning to decrease among 40-44 year olds.
Mental Illnesses Schizophrenia The pattern among women showed a gradual increase in hospitalizations to a peak between 35 and 49 years, after which it showed a steady decline. Men had much higher rates than women until the age of 50, after which rates among women were slightly higher.
Mental Illnesses Schizophrenia How Does It Affect ? Schizophrenia has a profound effect on an individual's ability to function effectively in all aspects of life - self-care, family relationships, income, school, employment, housing, community and social life. The high rates of hospitalization among young and middle-aged men and women highlight the effect of schizophrenia on people who are in their most productive years - a time when most people are forming families, establishing careers, and generally "building equity" in their lives.
Mental Illnesses Schizophrenia Early in the disease process, people with schizophrenia may lose their ability to relax, concentrate or sleep and they may withdraw from friends. Performance at work or school often suffers. With effective early treatment to control symptoms, individuals can prevent further symptoms and optimize their chance of leading full, productive lives. The onset of schizophrenia in the early adulthood years usually leads to disruptions in an individual's education.
Mental Illnesses Schizophrenia Individuals with schizophrenia often find it difficult to maintain employment for a sustained period of time. Although some individuals have healthy relationships, the majority with schizophrenia (60% to 70%) do not marry, and most have limited social contacts. The chronic course of the disorder contributes to ongoing social problems. As a result, individuals with schizophrenia are greatly over-represented in prison and homeless populations.
Mental Illnesses Schizophrenia Up to 80% of individuals with schizophrenia will abuse substances during their lifetime. Substance abuse is associated with poor functional recovery, suicidal behaviour and violence. The responsibility for primary care of an individual with schizophrenia usually falls on the shoulders of the family. This has many implications. Not only are the family's normal activities disrupted, but family members must also cope with the unpredictability of the individual affected, the side effects of the medication, and the frustration and worry about the future of their loved one.
Mental Illnesses Schizophrenia In times of crisis, the decision whether to admit the individual to hospital involuntarily is one of the most difficult dilemmas that a family may face. The family often has to deal with the stigma attached to schizophrenia. The mortality associated with schizophrenia is one of the most distressing consequences of the disorder. Approximately 40% to 60% of individuals with schizophrenia attempt suicide, and they are between 15 to 25 times more likely than the general population to die from a suicide attempt. Approximately 10% will die from suicide.
Mental Illnesses Schizophrenia Economic Impact Schizophrenia places a substantial financial burden on individuals with the illness, the members of their family and the health care system. In 1996, the total direct cost of schizophrenia in Canada was estimated to be $2.35 billion, or 0.3% of the Canadian Gross Domestic Product. This includes health care costs, administrative costs of income assistance plans, and value of lost productivity, The indirect costs of schizophrenia are estimated to account for another $2 billion yearly. Globally, nearly 3% of the total burden of human disease is attributed to schizophrenia.
Mental Illnesses Schizophrenia Stigma Associated with Schizophrenia Public misunderstanding and fear contribute to the serious stigma associated with schizophrenia. Contrary to popular opinion, most individuals with the disorder are withdrawn and not violent. Nonetheless, the stigma of violence interferes with an individual's ability to acquire housing, employment and treatment, and also compounds difficulties in social relationships. These stereotypes also increase the burden on families and care givers.
Mental Illnesses Schizophrenia Causes of Schizophrenia Historically, a number of psychological hypotheses were advanced to account for schizophrenia. Today medical science recognizes schizophrenia as a disease of the brain. Although the exact cause is unknown, it is likely that a functional abnormality in neurotransmitters produces the symptoms of the illness. This abnormality may be either the consequence or the cause of structural brain abnormalities.
Mental Illnesses Schizophrenia A combination of genetic and environmental factors is considered to be responsible for the development of this functional abnormality. These factors appear to affect the development of the brain at critical stages during gestation and after birth. Genetic Influence Immediate family members of individuals with schizophrenia are 10 times more likely than the general population to develop schizophrenia Children of two parents with schizophrenia have a 40% chance of developing the disorder
Mental Illnesses Schizophrenia Environmental Factors Although the evidence to date is inconclusive, potential environmental contributions to the development of schizophrenia include prenatal or perinatal trauma, season and place of birth, and viral infections. While studies have established a link between severe social disadvantage and schizophrenia, the results suggest that social factors do not cause schizophrenia, but rather the reverse may be true: poor social circumstances are likely a result of the disorder.
Mental Illnesses Schizophrenia Treatment of Schizophrenia Unfortunately, given our state of knowledge, methods for preventing schizophrenia remain unknown. Minimizing the impact of this serious illness depends mainly on early diagnosis, appropriate treatment and support. Schizophrenia differs from other mental illnesses in the intensity of care that it requires.
Mental Illnesses Schizophrenia A comprehensive treatment program includes: Antipsychotic medication, which forms the cornerstone of treatment for schizophrenia Education of the individual about his / her illness and treatment Family education and support Support groups and social skills training Rehabilitation to improve the activities of daily living Vocational and recreational support Cognitive therapy Integrated addictions program
Mental Illnesses Schizophrenia The course of schizophrenia varies, but in most cases it involves recurrent episodes of symptoms. Although available pharmacological treatments can relieve many of the symptoms, most people with schizophrenia continue to suffer some symptoms throughout their lives. Appropriate treatment early in the course of the disease and adherence to continued and adequate treatment are essential to avoiding relapses and preventing hospitalization. During periods of remission, whether spontaneous or due to treatment, the individual may function well.
Mental Illnesses Schizophrenia Newer medications (and improved dosage guidelines for older medications) have substantially reduced the prevalence of severe neurological side effects that were once commonly associated with long-term pharmacological treatment of schizophrenia. Optimizing the functional status and wellbeing of individuals with schizophrenia requires a supportive family and wide range of services, including institutional, community, social, employment and housing services. Ideally, multidisciplinary community treatment teams provide these services.
Mental Illnesses Schizophrenia Social skills training strives to improve social functioning by working with individuals to resolve problems with employment, leisure, relationships and activities of daily life. Occasionally, however, timely admission to hospital to control symptoms may prevent the development of more severe problems. Canadian hospitalization data provide insight into the use of hospital services as one of the treatment modalities. In 1999, in the younger age groups with schizophrenia, the disorder was the most responsible for determining their length of stay in hospital In older age groups (65+ years), schizophrenia was more likely to be an associated condition.
Mental Illnesses Schizophrenia The high hospitalization rates for schizophrenia among young adults support the clinical finding that the onset of schizophrenia typically occurs in adolescence and early adulthood. Higher rates among young men than young women agree with the observation that although schizophrenia affects both men and women, men develop it at an earlier age. Assessing whether the illness affects men differently than women in such a way that they require more hospitalization needs further research.
Mental Illnesses Schizophrenia The increasing hospitalization rates for schizophrenia in general hospitals among young and middle-aged men may reflect, in part, the loss of psychiatric hospital beds that provided care for these men before deinstitutionalization. This care has now shifted to general hospitals. More research is needed to determine whether this also reflects shortcomings in the community treatment of the disease requiring hospitalization in order to control symptoms.
Mental Illnesses Schizophrenia The length of stay in hospital associated with schizophrenia has decreased since 1995. This may reflect either improved treatment or the effect of decreases in hospital funding, which put pressure on the institutions to discharge people earlier than in previous years. Discharging people too early could be contributing to the increase in hospitalization rates through the need for re-admissions. Further research is needed to understand both the reason for this trend and its impact on individuals.
Mental Illnesses Schizophrenia Future Surveillance Needs Schizophrenia is a very serious mental illness with major ramifications for individuals and families, causing not only a great deal of personal distress but also impairment of social and occupational functioning. Fortunately, schizophrenia can be treated effectively. Existing data provide a very limited profile of schizophrenia in Canada. The available hospitalization data need to be complemented with additional data to fully monitor this illness in Canada.
Mental Illnesses Schizophrenia Priority data needs include: Incidence and prevalence of schizophrenia by age, sex and other key variables (for example, socioeconomic status, education and ethnicity). Impact of schizophrenia on the quality of life of the individual and family. Access to and use of health care services and community- based programs. Treatment outcomes. Access to community supports, such as housing, employment and education. Impact of schizophrenia on the workplace and the economy. Stigma associated with schizophrenia. Exposure to known or suspected risk and protective factors.
Mental Illnesses Anxiety Disorders What Are Anxiety Disorders? Individuals with anxiety disorders experience excessive anxiety, fear or worry, causing them either to avoid situations that might precipitate the anxiety or to develop compulsive rituals that lessen the anxiety. Everyone feels anxious in response to specific events - but individuals with an anxiety disorder have excessive and unrealistic feelings that interfere with their lives in their relationships, school and work performance, social activities and recreation.
Mental Illnesses Anxiety Disorders Symptoms: Intense and prolonged feelings of fear and distress that occur out of proportion to the actual threat or danger Feelings of fear and distress that interfere with normal daily functioning
Mental Illnesses Anxiety Disorders Types of Anxiety Disorders Generalized Anxiety Disorder (GAD) Excessive anxiety and worry about a number of events or activities occurring for more days than not over a period of at least 6 months with associated symptoms (such as fatigue and poor concentration). Specific Phobia Marked and persistent fear of clearly discernible objects or situations (such as flying, heights and animals).
Mental Illnesses Anxiety Disorders Post Traumatic Stress Disorder Flashbacks, persistent frightening thoughts and memories, anger or irritability in response to a terrifying experience in which physical harm occurred or was threatened (such as rape, child abuse, war or natural disaster). Social Phobia, AKA Social Anxiety Disorder Exposure to social or performance situations almost invariably provokes an immediate anxiety response that may include palpitations, tremors, sweating, gastrointestinal discomfort, diarrhoea, muscle tension, blushing or confusion, and which may meet criteria for the panic attack in severe cases.
Mental Illnesses Anxiety Disorders Obsessive-Compulsive Disorder Obsessions : Persistent thoughts, ideas, impulses or images that are intrusive and inappropriate and that cause marked anxiety or distress. Individuals with obsessions usually attempt to ignore or suppress such thoughts or impulses or to counteract them by other thoughts or actions (compulsions). Compulsions : Repetitive behaviours (such as hand washing, ordering or checking) or mental acts (such as praying, counting or repeating words) that occur in response to an obsession or in a ritualistic way.
Mental Illnesses Anxiety Disorders Panic Disorder Presence of recurrent, unexpected panic attacks, followed by at least 1 month of persistent concern about having additional attacks, worry about the implication of the attack or its consequences, or a significant change in behaviour related to the attacks. There are three clusters of symptoms: reexperiencing, avoidance and numbing, and arousal. Panic disorders are sometimes associated with agoraphobia - anxiety about, or the avoidance of, places or situations from which escape might be difficult or embarrassing, or in which help may not be available in the event of a panic attack or panic-like symptoms.
Mental Illnesses Anxiety Disorders The essential feature of the panic attack is a discrete period of intense fear or discomfort that is accompanied by at least 4 of 13 physical symptoms, such as: Palpitations, increased heart rate or pounding heart Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Dizziness, unsteadiness, lightheadedness or fainting De-realization or de-personalization Fear of losing control or going crazy Fear of dying Paresthesias (numbness or tingling sensation) Chills or hot flashes
Mental Illnesses Anxiety Disorders How Common Are Anxiety Disorders? Combined anxiety disorders affect approximately 12% of Canadians: about 9% of men and 16% of women during a one-year period. As a group, anxiety disorders represent the most common of all mental illnesses.
Mental Illnesses Anxiety Disorders Who Is Affected by Anxiety Disorders? Women report and are diagnosed with some anxiety disorders more frequently than men. This may reflect the differences between men and women in their health-service-seeking behaviours, however, rather than true differences in prevalence. Ideally, data from a population survey would provide information on the age/sex distribution of individuals with anxiety disorders. Statistics Canada's Canadian Community Health Survey (CCHS) will provide these data in the future.
Mental Illnesses Anxiety Disorders At the present time, hospitalization data provide the best available description of individuals with anxiety disorders. These data have limitations, however, because most people with anxiety disorders are treated in the community rather than in hospitals, and many do not receive treatment at all. As a result, the data represents only a subset of all those with anxiety disorders, and the results must be interpreted with caution.
Mental Illnesses Anxiety Disorders In 1999, women were hospitalized for anxiety disorders at higher rates than men in every age category Young women aged between 15 and 19 years had much higher rates of hospitalization than the immediately adjacent age groups. Women and men over the age of 65 had the highest rates of hospitalization.
Mental Illnesses Anxiety Disorders How Does It Affect? Symptoms of anxiety disorders often develop during early adulthood. Although the majority of people have mild or no impairment, anxiety disorders can seriously restrict an individual's education, work, recreation and social activities because he / she avoids situations that precipitate the symptoms. Individuals severely affected by anxiety disorders are also more likely to have either another type of anxiety disorder, major depression or dysthymia, alcohol or substance abuse, or a personality disorder. This compounds the impact of the anxiety disorder and presents challenges for effective treatment.
Mental Illnesses Anxiety Disorders Economic Impact Because they are so common, anxiety disorders have a major economic impact. They contribute to lost productivity due to both time away from work and unemployment. Other associated costs include claims on disability insurance. Heavy use of the emergency department and primary care system in reaction to physical symptoms also contributes to significant health care costs.
Mental Illnesses Anxiety Disorders Stigma Associated with Anxiety Disorders Because anxiety disorders are the extension of what most people perceive as normal worry and concern, Those who experience them may fear that others would label their excessive worry and fear as simply a weakness. As a result, they may try to ignore the seriousness of their condition and deal with it themselves. They often avoid seeking help and suffer in silence.
Mental Illnesses Anxiety Disorders Causes of Anxiety Disorders The development of anxiety disorders appears to result from a complex interplay of genetic, biological, developmental and other factors such as socio-economic and workplace stress. A variety of theories have been proposed to explain how these factors contribute to the development of the disorder. The first is experiential: people may learn their fear from an initial experience, such as an embarrassing situation, physical or sexual abuse, or the witnessing of a violent act. Similar subsequent experiences serve to reinforce the fear.
Mental Illnesses Anxiety Disorders A second theory relates to cognition or thinking: In that people believe or predict that the result of a specific situation will be embarrassing or harmful. This may occur, for example, if parents are over-protective and continually warn against potential problems. A third theory focuses on a biological basis: Research suggests that the amygdala, a structure deep within the brain, serves as a communication hub that signals the presence of a threat and triggers a fear response or anxiety. It also stores emotional memories and may play a role in the development of anxiety disorders. The children of adults with anxiety disorders are at much greater risk of an anxiety disorder than is the general population, which may imply a genetic factor, an effect of parenting practices, or both.
Mental Illnesses Anxiety Disorders Treatment of Anxiety Disorders Early recognition and appropriate management are imperative in order to enhance the quality of life of individuals with anxiety disorders. Proper recognition and management also help to prevent common secondary disorders, such as depression and abuse of drugs and alcohol.
Mental Illnesses Anxiety Disorders The delay in seeking and receiving a diagnosis and treatment may be due to a number of factors, such as stigma, a lack of human resources, restrictive government funding systems and lack of knowledge. In addition, family physicians may not always recognize the pattern in an individual's symptoms that would lead them to a correct diagnosis. Too often, the symptoms are not taken seriously and an individual with an anxiety disorder is labelled as being emotionally unstable. Education of both the public and family physicians would help to solve this problem.
Mental Illnesses Anxiety Disorders A recent review of anxiety disorders suggests that effective treatments include: Drug therapy (with anti-depressants or anti- anxiety drugs) and cognitive-behavioural therapy, which helps people turn their anxious thoughts into more rational and less anxietyproducing ideas. Support groups for individuals and families can also help develop the tools for minimizing and coping with the symptoms.
Mental Illnesses Anxiety Disorders Anxiety disorders can be well managed in the primary care setting. Creating access to experts in cognitive-behaviour therapy through a shared-care model can help family physicians provide optimal care for the individuals they are treating. When individuals with anxiety disorders are hospitalized, another associated condition is usually responsible for determining their length of stay
Mental Illnesses Anxiety Disorders Overall, hospitalization rates for anxiety disorders decreased dramatically between 1987 and 1999, by 50% among women and 46% among men, with a combined reduction of 49% Since most anxiety disorders are treated outside of hospitals, hospitalization data provide a very limited picture of these disorders in Canada. The data do support the view that anxiety disorders are associated with other health problems and it is usually these, rather than anxiety disorders, that lead to hospitalization.
Mental Illnesses Anxiety Disorders The decrease in hospitalization rates for anxiety may be due to bed closures and a refocusing of hospital services to ambulatory services. Hospitalizations for anxiety disorders in general hospitals among seniors have shown a dramatic decrease (much greater than any other age group) since 1987. This trend reflects the pattern for the same age group for major depression. Further research is needed to determine the reason for this trend: Is the prevalence of the disorders decreasing? Have treatment methods changed? Have outcomes improved?
Mental Illnesses Anxiety Disorders The higher rates of hospitalization for anxiety disorders in general hospitals among women than men prompt several research questions: Are anxiety disorders really more common among women? Are women more likely to seek treatment than men? Are women treated differently than men, with greater use of hospitalization? Hospitalization rates for anxiety disorders have a pronounced peak among women between 15 and 19 years of age.
Mental Illnesses Anxiety Disorders This peak is also found in hospitalization rates for depression and personality disorders. This suggests that women in this age group are vulnerable to mental illnesses. The reasons for this phenomenon require further clarification through research.
Mental Illnesses Anxiety Disorders Future Surveillance Needs Anxiety disorders are common among Canadians, causing not only a great deal of personal distress but also impairment of social and occupational functioning. Anxiety disorders can be effectively treated with a combination of medication and cognitive behavioural therapy. Existing data provide a very limited profile of anxiety disorders in Canada. The available hospitalization data need to be complemented with additional data to fully monitor these disorders in Canada.
Mental Illnesses Anxiety Disorders Priority data needs include: Incidence and prevalence of each of the anxiety disorders by age, sex and other key variables (for example, socio-economic status, education and ethnicity). Impact of anxiety disorders on the quality of life of the individual and family. Access to and use of primary and specialist health care services. Impact of anxiety disorders on the workplace and the economy. Stigma associated with anxiety disorders. Access to and use of public and private mental health services. Access to and use of mental health services in other systems, such as schools, criminal justice programs and facilities, and employee assistance programs. Treatment outcomes. Exposure to known or suspected risk and protective factors.
Mental Illnesses Personality Disorders What Are Personality Disorders? Personality disorders cause enduring patterns of inner experience and behaviour that deviate from the expectations of society and lead to distress or impairment. Personality is seen today as a complex pattern of deeply imbedded psychological characteristics that are largely non-conscious and not easily altered, which express themselves automatically in almost every area of functioning. Personality characteristics or traits are expressed on a continuum of social functioning.
Mental Illnesses Personality Disorders Personality disorders reflect personality traits that are used inappropriately and become maladaptive. To some degree, this classification is arbitrary. Some deviations may be quite mild and interfere very little with the individual's home or work life; others may cause great disruption in both the family and society. Specific situations or events trigger the behaviours of a personality disorder. In general, individuals with personality disorders have difficulty getting along with others and may be irritable, demanding, hostile, fearful or manipulative.
Mental Illnesses Personality Disorders Symptoms: Difficulty getting along with other people. May be irritable, demanding, hostile, fearful or manipulative. Patterns of behaviour deviate markedly from society's expectations and remain consistent over time. Disorder affects thought, emotion, interpersonal relationships and impulse control. The pattern is inflexible and occurs across a broad range of situations. Pattern is stable or of long duration, beginning in childhood or adolescence.
Mental Illnesses Personality Disorders Personality disorders exist in many forms. Classification of personality disorders is arbitrary. Each person is unique, however, and can display mixtures of patterns.
Mental Illnesses Personality Disorders Type Patterns Borderline Instability in interpersonal relationships, selfimage and affects, and marked impulsivity. Antisocial Disregard for, and violation of, the rights of others. Histrionic Excessive emotionality and attention seeking. Narcissistic Grandiosity, need for admiration, and lack of empathy. Avoidant Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
Mental Illnesses Personality Disorders Type Patterns Dependent Submissive and clinging behaviour related to an excessive need to be taken care of. Schizoid Detachment from social relationships and a restricted range of emotional expression. Paranoid Distrust and suspiciousness in which others' motives are interpreted as malevolent. Obsessive Compulsive Disorder Preoccupation with orderliness, perfectionism and control. Schizotypal Acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour.
Mental Illnesses Personality Disorders How Common Are Personality Disorders? Canadian data on the prevalence of personality disorders are lacking. Epidemiological studies most often measure and report antisocial personality disorder. A 1991 Ontario survey estimated that the 1- year prevalence rate of antisocial personality disorder in the general population was 1.7%. According to the Edmonton study in the 1980s, 1.8% of the population had an antisocial personality disorder in the 6- month period before the survey, and 3.7% reported a personality disorder at some point in their lives. Estimates of the prevalence of other personality disorders range from 1% to 10% of the population.
Mental Illnesses Personality Disorders Who Develops a Personality Disorder? There is a sex difference in the personality disorder types. For example, antisocial personality disorder is more common among men, while borderline personality disorder is more common among women. The dependent and hysterical personality disorders are also more common among women. Labelling biases among health professionals may lead to some of the sex differences. Ideally, data from a population survey would provide information on the age/sex distribution of individuals with personality disorders. Statistics Canada's Canadian Community Health Survey (CCHS) will provide prevalence of self-reported obsessivecompulsive personality disorder in the future.
Mental Illnesses Personality Disorders At the present time, however, hospitalization data provide the best available description of individuals with personality disorders. These data have limitations, however, because most people with personality disorders, unless they show suicidal behaviour, are treated in the community rather than in hospitals. Many are never diagnosed or treated. Individuals with borderline personality disorder have higher rates of admission than individuals with other disorders because of their high rate of suicidal behaviour. These limitations must be kept in mind, then, when interpreting the data presented in this report.
Mental Illnesses Personality Disorders What Are the Effects of Personality Disorders? Although the onset of personality disorders usually occurs in adolescence or early adulthood, they can also become apparent in mid-adulthood. To some extent, the timing depends on the type of personality disorder and the situation or events surrounding the individual. For example, borderline personality disorder usually peaks in adolescence and early adulthood, and then becomes less prominent by mid-adulthood. On the other hand, narcissistic personality disorder may not be identified until middle age when the individual experiences the sense of loss of opportunity or faces personal limitations.
Mental Illnesses Personality Disorders Since personality disorders usually develop in adolescence or early adulthood, they occur at a time when most people develop adult relationship skills, obtain education, establish careers and generally "build equity" in their lives. The use of maladaptive behaviours during this life stage has implications that extend for a lifetime. A history of alcohol abuse, drug abuse, sexual dysfunction, generalized anxiety disorder, bipolar disorder, obsessive- compulsive disorder, depressive disorder, eating disorder, and suicidal thoughts or attempts often accompany personality disorders.’ Up to one half of prisoners have antisocial personality disorder because its associated behavioural characteristics (such as substance abuse and violence) lead to criminal behaviour.
Mental Illnesses Personality Disorders Other social consequences of personality disorders include: Spousal violence Child maltreatment Poor work performance Suicide Gambling Personality disorders have a major effect on the people who are close to the individual. The individual's fixed patterns make it difficult for them to adjust to various situations. As a result, other people adjust to them. This creates a major strain on all relationships among family and close friends and in the workplace.
Mental Illnesses Personality Disorders At the same time, when other people do not adjust, the individual with the personality disorder can become angry, frustrated, depressed or withdrawn. This establishes a vicious cycle of interaction, causing the individuals to persist in the maladaptive behaviour until their needs are met.
Mental Illnesses Personality Disorders Stigma Associated with Personality Disorders Since the behaviours shown in some personality disorders remain close to what is considered "normal", others often assume that the individuals can easily change their behaviour and solve the interpersonal problem. When the behaviour persists, however, it may be perceived as a lack of will or willingness to change. The fixed nature of the trait is not well understood by others.
Mental Illnesses Personality Disorders Causes of Personality Disorders Personality disorders likely result from the complex interplay of early life experience, genetic and environmental factors. In principle, genetic factors contribute to the biological basis of brain function and to basic personality structure. This structure then influences how individuals respond to and interact with life experiences and the social environment. Over time, each person develops distinctive patterns or ways of perceiving their world and of feeling, thinking, coping and behaving.
Mental Illnesses Personality Disorders Although little is known to date about possible biological correlates of personality disorder, individuals with personality disorders may have impaired regulation of the brain circuits that control emotion. This difficulty, combined with psychological and social factors such as abuse, neglect or separation, puts an individual at higher risk of developing a personality disorder. Strong attachments within the family or a supportive network of people outside the family, in the school and in the community help an individual develop a strong sense of self-esteem and strong coping abilities. Opportunities for personal growth and for developing unique abilities can enhance a person's self-image. This supportive environment may provide some protection against the development of a personality disorder.
Mental Illnesses Personality Disorders For biologically predisposed individuals, the major developmental challenges that are a normal part of adolescence and early adulthood: separation from family, self-identity, and independence may be the precipitating factors for the development of the personality disorder. This may explain why personality disorders usually begin in these years.
Mental Illnesses Personality Disorders Treatment of Personality Disorders Personality disorders are difficult to treat because of self-denial about the presence of the problem and the pessimism of health professionals based on a lack of success in previous efforts. Intensive individual and group psychotherapy, combined with anti-depressants and mood stabilizers, can be at least partially effective for some people. Difficulties arise from both the persistence of symptoms and the negative impact of these symptoms on the therapeutic relationship.
Mental Illnesses Personality Disorders Individuals with borderline personality disorder have more frequent hospitalizations, use outpatient psychotherapy more often, and make more visits to emergency rooms than individuals with other personality disorders. In 1999, in all age groups, personality disorders were more likely to be a contributing rather than the main factor determining length of stay in hospital. This reflects the fact that personality disorders are associated with other conditions, such as suicidal behaviour, that may need hospitalization.
Mental Illnesses Personality Disorders Most personality disorders are treated outside of the hospital. Thus, the hospitalization data provide a very limited picture of personality disorders in Canada. The higher rates of hospitalization for personality disorder in general hospitals among young women than men supports the clinical experience that women are more likely to have borderline personality disorder with its associated suicidal behaviour, leading to hospitalization.
Mental Illnesses Diagnostic and Statistical Manual of Mental Disorders The Diagnostic and Statistical Manual of Mental Disordersis is a reference work consulted by psychiatrists, psychologists, physicians in clinical practice, social workers, medical and nursing students, pastoral counselors, and other professionals in health care and social service fields. The book's title is often shortened to DSM, or an abbreviation that also indicates edition, such as DSM- IV-TR,which indicates fourth edition, text revision of the manual, published in 2000. The DSM-IV-TR provides a classification of mental disorders, criteria sets to guide the process of differential diagnosis, and numerical codes for each disorder to facilitate medical record keeping.
Mental Illnesses Diagnostic and Statistical Manual of Mental Disorders The stated purpose of the DSM is threefold: to provide "a helpful guide to clinical practice"; "to facilitate research and improve communication among clinicians and researchers"; and to serve as "an educational tool for teaching psychopathology." The third edition of DSM, or DSM-III, which was published in 1980, introduced a system of five axes or dimensions for assessing all aspects of a patient's mental and emotional health. The multi-axial system is designed to provide a more comprehensive picture of complex or concurrent mental disorders.
Mental Illnesses Diagnostic and Statistical Manual of Mental Disorders The five diagnostic axes specified by DSM-IV-TR are: Axis I: Clinical disorders, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders. Axis II: Personality disorders and mental retardation. This axis includes notations about problematic aspects of the patient's personality that fall short of the criteria for a personality disorder. Axis III: General medical conditions. These include diseases or disorders that may be related physiologically to the mental disorder; that are sufficiently severe to affect the patient's mood or functioning; or that influence the choice of medications for treating the mental disorder.
Mental Illnesses Diagnostic and Statistical Manual of Mental Disorders Axis IV: Psychosocial and environmental problems. These include conditions or situations that influence the diagnosis, treatment, or prognosis of the patient's mental disorder. DSM-IV-TR lists the following categories of problems: family problems; social environment problems; educational problems; occupational problems; housing problems; economic problems; problems with access to health care; problems with the legal system; and other problems (war, disasters, etc.). Axis V: Global assessment of functioning. Rating the patient's general level of functioning is intended to help the doctor draw up a treatment plan and evaluate treatment progress. The primary scale for Axis V is the Global Assessment of Functioning (GAF) Scale, which measures level of functioning on a scale of 1–100. DSM-IV- TR includes three specialized global scales in its appendices: the Social and Occupational Functioning Assessment Scale (SOFAS); the Defensive Functioning Scale; and the Global Assessment of Relational Functioning (GARF) Scale. The GARF is a measurement of the maturity and stability of the relationships within a family or between a couple.
Mental Illnesses Medications Antidepressants: Antidepressants are used to treat various types of depression. Several types of antidepressants, grouped by how they affect brain chemistry, are available. Antidepressants can help improve such depression symptoms as sadness, hopelessness, lack of energy, difficulty concentrating and lack of interest in activities. Antidepressants are often used to treat illnesses besides depression, including nonpsychiatric conditions.
Mental Illnesses Medications Precisely how antidepressants work to treat depression remains speculative. Scientists do know that antidepressants can influence brain activity through the effects they have on mood-related brain chemicals (neurotransmitters) and certain nerve cell receptors. Nerve cells release neurotransmitters to communicate with other nerve cells in the brain. Neurotransmitters transmit signals across a gap (synapse) between the nerve cells. Neurotransmitters associated with depression are serotonin, norepinephrine and possibly dopamine. Research suggests that people with depression have lower levels of one or more of these neurotransmitters.
Mental Illnesses Medications Here are the most common antidepressants to treat depression, with their generic or chemical names followed by available brand names in parentheses, and grouped by how they affect brain chemistry: Selective serotonin reuptake inhibitors (SSRIs) Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Tricyclic antidepressants (TCAs) Amitriptyline Amoxapine Desipramine (Norpramin)
Mental Illnesses Medications Doxepin (Sinequan) Imipramine (Tofranil) Nortriptyline (Pamelor) Protriptyline (Vivactil) Trimipramine (Surmontil) Monoamine oxidase inhibitors (MAOIs) Phenelzine (Nardil) Tranylcypromine (Parnate) Isocarboxazid (Marplan) Selegiline (Emsam)
Mental Illnesses Medications Mood-stabilizing medications: Mood stabilizers are most commonly used to treat bipolar disorder, which is characterized by alternating episodes of mania and depression. Mood stabilizers may also include anti-seizure medications. Mood-stabilizing medications include: Lithium (Eskalith, Lithobid) Divalproex (Depakote) and many others.
Mental Illnesses Medications Anti-anxiety medications: As their name suggests, they are used to treat anxiety disorders, such as generalized anxiety disorder and panic disorder. They may also be useful in helping relieve agitation,insomnia and muscle spasm. These medications are typically fast acting, helping relieve symptoms in as little as 30 minutes. A major drawback, however, is that they may cause dependency. Anti-anxiety medications include alprazolam (Xanax), lorazepam (Ativan) and many others.
Mental Illnesses Medications Antipsychotic medications: Antipsychotic medications, also called neuroleptics, are typically used to treat psychotic disorders, such as schizophrenia. A person who is psychotic is plagued by delusions and is unable to maintain a hold on reality. Antipsychotic medications may also be used to treat severe cases of depression accompanied by psychosis. Antipsychotic medications include clozapine (Clozaril), olanzapine (Zyprexa) and many others.
Mental Illnesses Substance Abuse People abuse substances such as drugs, alcohol, and tobacco for varied and complicated reasons, but it is clear that our society pays a significant cost. The toll for this abuse can be seen in our hospitals and emergency departments through direct damage to health by substance abuse and its link to physical trauma. Jails and prisons tally daily the strong connection between crime and drug dependence and abuse. Although use of some drugs such as cocaine has declined, use of other drugs such as heroin and "club drugs" has increased.
Mental Illnesses Substance Abuse Abused substances produce some form of intoxication that alters judgment, perception, attention, or physical control. Many substances can bring on withdrawal—an effect caused by cessation or reduction in the amount of the substance used. Withdrawal can range from mild anxiety to seizures and hallucinations. Nearly all these drugs also can produce a phenomenon known as tolerance where you must use a larger amount of the drug to produce the same level of intoxication. Drug overdose may also cause death.
Mental Illnesses Substance Abuse Tobacco: People cite many reasons for using tobacco, including pleasure, improved performance and vigilance, relief of depression, curbing hunger, and weight control. The primary addicting substance in cigarettes is nicotine. But cigarette smoke contains thousands of other chemicals that also damage health. Hazards include heart disease, lung cancer and emphysema, peptic ulcer disease, and stroke. Withdrawal symptoms of smoking include anxiety, hunger, sleep disturbances, and depression. Smoking is responsible for nearly a half million deaths each year. Tobacco use costs the nation an estimated $100 billion a year, mainly in direct and indirect health care costs.
Mental Illnesses Substance Abuse Alcohol: Although many people have a drink as a "pick me up," alcohol actually depresses the brain. Alcohol lessens your inhibitions, slurs speech, and decreases muscle control and coordination, and may lead to alcoholism. Withdrawal from alcohol can cause anxiety, irregular heartbeat, tremor, seizures, and hallucinations. In its severest form, withdrawal combined with malnutrition can lead to a life-threatening condition called delirium tremens (DTs). Alcohol is the most common cause of liver failure. The drug can cause heart enlargement and cancer of the esophagus, pancreas, and stomach. In addition to its direct health effects, officials associate alcohol abuse with nearly half of all fatal motor vehicle accidents.
Mental Illnesses Substance Abuse Drugs: Marijuana (also known as grass, pot, weed, herb): Marijuana, which comes from the plant Cannabis sativa, is the most commonly used illegal drug. The plant produces delta-9-tetrahydrocannabinol (THC), the active ingredient associated with intoxication. Marijuana resin, called hashish, contains an even higher concentration of THC. The drug is usually smoked, but it can also be eaten. Its smoke irritates your lungs more and contains more cancer-causing chemicals than tobacco smoke. Common effects of marijuana use include pleasure, relaxation, and impaired coordination and memory. Often, the first illegal drug people use, marijuana is associated with increased risk of progressing to more powerful and dangerous drugs such as cocaine and heroin. The risk for progressing to cocaine is 104 times higher if you have smoked marijuana at least once than if you never smoked marijuana.
Mental Illnesses Substance Abuse Cocaine (also known as crack, coke, snow, rock): Derived from the coca plant of South America, cocaine can be smoked, injected, snorted, or swallowed. The intensity and duration of the drug’s effects depend on how you take it. Desired effects include pleasure and increased alertness. Short-term effects also include paranoia, constriction of blood vessels leading to heart damage or stroke, irregular heartbeat, and death. Severe depression and reduced energy often accompany withdrawal. Both short- and long-term use of cocaine has been associated with damage to the heart, the brain, the lung, and the kidneys.
Mental Illnesses Substance Abuse Heroin (also known as smack, horse): Heroin use continues to increase. Officials see increased use mainly among people younger than 26 years, often women. In 1997, 87% of heroin users were younger than 26 years, compared to 61% in 1992. Effects of heroin intoxication include drowsiness, pleasure, and slowed breathing. Withdrawal can be intense and can include vomiting, abdominal cramps, diarrhea, confusion, aches, and sweating. Overdose may result in death from decreased breathing. Because heroin is usually injected, often with dirty needles, use of the drug can trigger other health complications including destruction of your heart valves, HIV/AIDS, infections, tetanus, and botulism.
Mental Illnesses Substance Abuse Methamphetamines (also known as meth, crank, ice, speed, crystal): Use of this drug also has increased, especially in the West. Methamphetamine is a powerful stimulant that increases alertness, decreases appetite, and gives a sensation of pleasure. The drug can be injected, snorted, smoked, or eaten. It shares many of the same toxic effects as cocaine—heart attacks, dangerously high blood pressure, and stroke. Withdrawal often causes depression, abdominal cramps, and increased appetite. Other long-term effects include paranoia, hallucinations, weight loss, destruction of teeth, and heart damage.
Mental Illnesses Substance Abuse Club drugs: The club scene and rave parties have popularized an assortment of other drugs. Many young people believe these drugs are harmless or even healthy. These are the more popular club drugs: Ecstasy (also called MDMA, Adam, STP): This is a stimulant and hallucinogen used to improve mood and to maintain energy, often for all-night dance parties. Long-term use may cause damage to the brain’s ability to regulate sleep, pain, memory, and emotions. LSD (also called acid, microdot) and mushrooms (also called shrooms, magic mushrooms, peyote, buttons): Popular in the 1960s, LSD has been revived in the club scene. LSD and hallucinogenic mushrooms can cause hallucinations, numbness, nausea, and increased heart rate. Long-term effects include unwanted "flashbacks" and psychosis (hallucinations, delusions, paranoia, and mood disturbances).
Mental Illnesses The PTA’s Role OTAs and PTAs help people who experience mental health problems to live fuller and more active lives. They can also prevent a problem or minimize its effects. Their role can be summarized as follows: Time Management: Clients can be taught to structure their time by using daily schedules, monthly calendars and flowcharts; they need to learn to use them and to get in the habit of referring to/updating them Planning and participating in a balance of self-care, work, leisure and rest activities promotes satisfaction and health; the occupational therapy practitioner helps the client prioritize and structure daily routines, as well as scheduling time and organizing tasks efficiently
Mental Illnesses The PTA’s Role Stress Management: The PTAs can help the client to change the stressful situation or to change the stress response to the situation Assertiveness training and anger management training increase skills in recognizing and dealing with feelings and needs They can provide instruction in the effects of stress and personal stress analysis and management Examples include: verbalization, biofeedback, humour, meditation, proper nutrition, sufficient sleep, guided imagery, aerobic activity
Mental Illnesses The PTA’s Role Working with cognitively impaired patients and substance abusers: Recognize cognitive impairments: Confusion (person responds to a simple question with an unrelated remark); disorientation (the person says it is 1983, but the current year is 2007); deficits in short term memory (client cannot remember where his wallet is); deficits in long term memory (client cannot remember his birthdate) Aim to improve: cognitive and perceptual skills, time management (especially leisure time), daily living skills, and acquisition of valued occupational and social roles
Mental Illnesses The PTA’s Role Help plan opportunities for new leisure activities and avoid people/situations associated with dependency Computer programs may be helpful in treating cognitive and perceptual deficits Clients need to learn new ways to cope with their feelings; expressive activities such as art, clay, drama may assist in recognizing and conveying emotions that client habitually blocked with defense mechanisms Stress management and relaxation techniques are important in addressing coping skills
Mental Illnesses The PTA’s Role Assertiveness training my provide patients with appropriate skills and strategies for social interactions Money management training: patients may need help with budgeting and redirection in steering spending away from substance abuse related activities Vocational retraining may be necessary if the patient was fired because of previous behaviours; job skill training and prevocational training may be necessary for lower functioning clients
Mental Illnesses The PTA’s Role Working with schizophrenia: Treatment is directed at problems that interfere with specific areas of functioning or with group interaction skill Social skills training is important, such as making eye contact, initiating conversation and responding to questions Behavioural coaching and cognitive-behavioural strategies can help a person identify and change problem behaviours ADL training is often necessary for clients with chronic schizophrenia; hygiene, dressing, and grooming often need to be focused on Homemaking, money management, community mobility skills, safety behaviours and emergency management skills are important for schizophrenic patients to succeed in the community
Mental Illnesses The PTA’s Role Assistance in the structuring of leisure skills is important; early onset and recurring episodes can have a detrimental effect on the development of personal interests Work and productivity are often negatively affected by this illness; may have difficulty maintaining long term employment; treatment focus on social skills and work skills improve marketability Remedial or compensatory approaches may be provided to improve cognitive functioning (e.g., use of notebook to record information)
Mental Illnesses The PTA’s Role Working with Anxiety Patients: Therapeutic use of self: encourage person to talk about what is upsetting them; answer questions, but avoid being drawn into long extended discussions about symptoms; reassure client that you are available, but keep a schedule Modifying the environment: provide a safe, calm environment that is not over stimulating; brief tour of treatment area and regular treatment schedule keep things predictable and calm Selecting treatment activities: gross motor activities can reduce uncomfortable physical symptoms; meditation can help relax; biofeedback can help increase self awareness and control of symptoms
Mental Illnesses The PTA’s Role Working with Depressed Patients: Therapeutic use of self: avoid being overprotective; be an effective listener and reflect comments back in a non-judgmental way; provide direction and help with the selection of short-term goals and activities; give clear directions and avoid giving too many choices Modifying the environment: environment should be safe and subdued; the more severe the depression, the less stimulation should be present; adapt schedule with client’s choices in mind Selecting treatment activities: start with simple, structured, short- term, familiar activities; the first activities used should be ones at which the person is guaranteed to succeed; initial activities should be ones that can be done alone, without the need to interact or share tools or materials with others; gross motor activities can help release tension
Mental Illnesses The PTA’s Role Working with Paranoid Patients: Therapeutic use of self: avoid approaching client suddenly, from behind, or in a manner that may be perceived as threatening; directions should be clear, consistent, and directive; make sure to stay in charge of the situation Modifying the environment: keep things stable and reliable as possible; social contact should never be forced Selecting treatment activities: activities must be ones the person can control; use structured activities involving controllable materials (such as leather work)
Mental Illnesses The PTA’s Role Issues in Therapeutic Relationships: Transference: occurs when one person (usually the client) unconsciously relates to the other person (usually the therapist) as if that person were someone else of importance in their life Counter-transference: occurs when the other person (usually the therapist) unconsciously falls into that role; the unconscious nature of this interaction makes it difficult to deal with this situation Dependence: clients come to depend on staff which they see as being more knowledgeable, skillful, and powerful than themselves Helplessness, anger, and depression: some clients are so severely disabled that no amount of rehab can improve their functioning; they may need excessive time and attention to maintain their few skills.
Mental Illnesses The PTA’s Role Unrealistic expectations of clients and their families that therapy will successfully return skills and improve functioning can lead to anger and frustration being directed at the occupational therapy practitioner with reciprocal behaviour being expressed Sexual feelings: clients and therapy practitioner can confuse closeness they experience (both physical and emotional) within a therapeutic relationship, with the intimacy of a sexual one Fear and revulsion: fear of contagion from clients with communicable diseases; fear of the unknown, or different and unfamiliar; revulsion of client’s previous behaviour or experiences can interfere with the therapeutic relationship
Mental Health & Office Administration Part II: Office Administration
Office Administration Telephone Techniques Record Keeping
Office Administration Telephone Techniques Answering the telephone is an important first contact with the physiotherapy office The voice tone, inflection and other non-verbal aspects of the person answering all have a profound impact on how the caller perceives the physiotherapy office The telephone has been an essential communication tool for business since the early 1900’s As is the case with most tools, skill is required to maximize its effectiveness Failure to use the business telephone in a proper manner may not only result in the ineffectiveness of the user, but may result in having a detrimental effect on the business.
Office Administration Telephone Techniques It has been said that the first thirty seconds of a telephone conversation sets the tone for the caller’s relationship with the physiotherapy office. The patient’s first contact with your physiotherapy office may be a telephone call and the first impression of the image and style of the practice begins to develop The practice image is perceived right from the start of this first call The answering content may be completely correct or even directly from a written script, but may project the wrong image due to the "non-verbal" aspects of the speaker’s voice
Office Administration Telephone Techniques These include unusual pauses in a normal speaking pattern, vocalized pauses (ah, uh, mmm) and changes in tone of the voice to mention a few These "non-verbal" aspects of the person’s voice answering the phone play a critical role in communicating the image of the practice When the first contact with a prospective patient is by telephone, special attention has to be paid to communication factors primarily because the caller cannot see the person at the other end of the telephone line. Without visual input, a caller relies entirely on the sound that emerges from the telephone to formulate an opinion about the person at the other end of the phone line
Office Administration Telephone Techniques As a caller, it is reasonable to expect the person who answers the telephone to be courteous, organized and helpful If those qualities are not part of the caller’s experience, then there is a distinct possibility that a negative opinion will be forged about both the business as well as the person answering the telephone The staff in each physiotherapy practice should establish and use an agreed upon telephone protocol and communication style which will reflect a positive image for the practice when the telephone is answered
Office Administration Telephone Techniques The protocol should include the following strategies: Be Prepared: A cardinal rule in maximizing effective telephone communication is, "be prepared to receive a call." Any person in the office who will be answering the telephone must be prepared with the necessary tools (notepads, charts and scheduling book) but even more, the person should be emotionally prepared to answer It is essential that the receptionist organize the items that may be needed during a call to avoid delays in the conversation and to avoid sending a message of disorganization in the office to the caller The appointment system (computerized or traditional appointment book) must be readily available near the site of the telephone receiver or headset
Office Administration Telephone Techniques Similarly, any office message system, whether it is computerized or consists of paper message pads, should be close at hand and ready to use if needed Message system information forms should be formatted to ensure that all critical information is obtained and recorded for future use Access to the patient’s computerized, or conventional dental record may also be helpful before initiating a call to a patient regarding an appointment, or his/her past care
Office Administration Telephone Techniques Who and When: The office manual is a good vehicle to document the elements of a telephone protocol This includes the identification of who should answer and when the telephone should be answered Control of the appointment schedule may be shared by more than one employee and a written telephone protocol will help to delineate the responsibilities of all who participate in the communication and appointment management process If the telephone is to be answered by selected employees, then the protocol should include this limitation Some protocols call for answering the telephone by the end of the first ring, while others call for answering by the fourth ring
Office Administration Telephone Techniques It’s in the Voice: It is a necessity that the person answering the telephone use "an alert, pleasant, well-modulated, cordial, cheerful voice…" Good basic telephone usage requires "…tact, courtesy and a genuine attempt to help the caller…" Upon answering, the telephone handset should be properly positioned so that the person can hear the caller in the receiver and so that the caller can, in turn, hear the PTA For traditional handsets, about one and one-half inches away from the mouth is recommended to maximize the clarity of the voice
Office Administration Telephone Techniques If a telephone headset is used, then the manufacturer’s recommendations should be followed for positioning the headset microphone The caller should not miss the first part of the greeting due to extraneous noise or improper telephone positioning The person receiving the call should try to avoid asking the caller to repeat their message just because they failed to position the handset properly
Office Administration Telephone Techniques Voice tone or vocal factors include pitch, tone, volume, rhythm, inflection, etc. are a critical part of the message conveyed on the phone If the voice is "raised," an emotion of frustration or anger may be communicated Increased volume with irregular inflection can project cheerfulness Voice pitch can communicate a lot about style and emotions Anger and excitement tend to cause a rise in the voice which may communicate frustration and anger Low pitched, monotonal speaking patterns may communicate indifference, laziness, or even incompetence
Office Administration Telephone Techniques The voice tone of a person answering the telephone becomes the personality of the office for the caller A positive, enthusiastic attitude must shine through when the phone is answered Positive language includes the use of such words as "can," "will," "shall," and "certainly." Energy and expression should be put into the voice It is important to interact with a pleasant and "smiling" voice More vocal expression is required when communicating over the telephone than when having a personal interaction in order to compensate for the loss of visual contact
Office Administration Telephone Techniques The person answering the telephone should use friendly, positive voice tones consistently to be an effective communicator It may actually be helpful to physically sit up and not slouch prior to answering the phone Facial expressions and gesturing, as if face to face, often are helpful aids in the infusion of desirable voice tones and non-verbal The voice should be made lively and the person must genuinely sound interested in helping the caller
Office Administration Telephone Techniques If the rhythm of the voice is unsteady or too fast, the greeting will be hard to follow or even lost entirely Therefore, the rhythm should be comfortably paced and steady The timing or pace may communicate important clues A long, drawn out pace may project indifference, while a short reply can indicate impatience Friendliness is conveyed through voice tone by inflection at the end of statements with a lilt in the voice The voice should have clarity so the caller will have no trouble understanding The deliberate clarity of the voice is necessary for this communication of a friendly greeting with an offer of help
Office Administration Record Keeping The CPO's Guidelines for the Use of Support Personnel (March 1996) require physiotherapists to ensure, on an ongoing basis, that any record keeping assigned to personnel working under their direction or supervision complies with College regulations and standards of practice Before allowing support personnel to record progress notes in client records, the physiotherapist should: provide support staff with training in appropriate record- keeping procedures, as well as a written copy of the College's standard of practice and regulation on record keeping and any facility policy governing documentation; determine whether staff who have received formal instruction in record keeping (e.g., during a recognized physiotherapist assistant program) require further training
Office Administration Record Keeping In no circumstances can a support person record a physiotherapy intervention that was performed by the supervising physiotherapist As a result, physiotherapists should never assign to support personnel the record keeping associated with an initial evaluation or subsequent reassessment, the development, evaluation and modification of the treatment plan, or discharge planning
Office Administration Record Keeping As per the College's standard of practice on record keeping, (Standards of Practice for Physiotherapists, April 1996, page 12) , the physiotherapist should indicate, in the client's clinical record, whether and to whom interventions have been assigned, as well as the frequency and time frame during which such services will be performed The physiotherapist must also clearly indicate in the client record when charting has been assigned to support personnel, the frequency with which charting will occur, and when he or she will reassess the client
Office Administration Record Keeping The College does not require supervising physiotherapists to co-sign entries recorded by support personnel However, members may adopt this practice as either a communication mechanism or an internal quality control check A physiotherapist may co-sign or initial entries to indicate to support staff that he or she has read the entry and understands the status of the client
Office Administration Record Keeping In such cases, the entry is an integral component of the communication system between the physiotherapist and his or her support personnel Physiotherapists may also co-sign entries made by support personnel as a means of determining whether record keeping is continuing to meet College and facility standards

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Mental illnesses & office administration

  • 1. Physical Therapy Assistant (PTA) Program Mental Health & Office Administration Instructor: Dr. George Boghozian, B.Sc., D.C.
  • 2. Dr. George Boghozian, B.Sc., D.C. Education: 1980-1985: Iranian Medical College B.Sc. In Medical Laboratory Science 1998-2000: York University Kinesiology and Health Science 2000-2003: Cleveland Chiropractic College Doctor of Chiropractic (D.C.)
  • 3. Dr. George Boghozian, B.Sc., D.C. Teaching Experience: 1985-1989: Bushehr Midwifery School Medical Laboratory Nutrition Clinical Genetics 2001-2003: Cleveland Chiropractic College Clinical Laboratory Diagnosis 2005-2006: Canadian Memorial Chiropractic College Systems Pathology
  • 6. Mental Health Introduction Mental health is a concept that refers to a human individual's emotional and psychological well-being. Merriam-Webster defines mental health as "A state of emotional and psychological well- being in which an individual is able to use his or her cognitive and emotional capabilities, function in society, and meet the ordinary demands of everyday life."
  • 7. Mental Health Introduction According to the World Health Organization (WHO), there is no one "official" definition of mental health. Cultural differences, subjective assessments, and competing professional theories all affect how "mental health" is defined. In general, most experts agree that "mental health" and "mental illness" are not opposites. In other words, the absence of a recognized mental disorder is not necessarily an indicator of mental health.
  • 8. Mental Health Introduction One way to think about mental health is by looking at how effectively and successfully a person functions. Feeling capable and competent; being able to handle normal levels of stress, maintain satisfying relationships, and lead an independent life; and being able to "bounce back," or recover from difficult situations, are all signs of mental health.
  • 9. Mental Health Introduction Most experts consider mental health as a continuum. Thus, an individual's mental health may have many different possible values. Mental wellness is generally viewed as a positive attribute, such that a person can reach enhanced levels of mental health, even if they do not have any diagnosable mental illness. This definition of mental health highlights emotional well being, the capacity to live a full and creative life and the flexibility to deal with life's inevitable challenges.
  • 10. Mental Health Introduction Many therapeutic systems and self-help books offer methods and philosophies espousing strategies and techniques vaunted as effective for further improving the mental wellness of otherwise healthy people. Positive psychology is increasingly prominent in mental health. According to the the World Health Organization: "Mental health has been defined variously by scholars from different cultures.
  • 11. Mental Health Introduction Concepts of mental health include subjective well- being, perceived self-efficacy, autonomy, competence, inter-generational dependence, and self-actualization of one's intellectual and emotional potential, among others. From a cross-cultural perspective, it is nearly impossible to define mental health comprehensively. It is, however sometimes used as a broader definition, and professionals generally agree that mental health is broader than a lack of mental disorders."
  • 12. Mental Health Introduction Mental health was first described as "mental hygiene" by Clifford Whittingham Beers in 1908, who founded the National Committee for Mental Hygiene in 1909 and actively campaigned for the rights of the mentally ill Dr. William Glasser, a psychiatrist, described 'Mental Hygiene' in his book Mental Health or Mental Illness (1961), following the dictionary definition of hygiene as the establishment and maintenance of health, i.e. mental health.
  • 13. Mental Health Introduction Mental health, as defined here, is distinct from mental illness. Enhancement of mental health is not the primary goal of some mental health professionals more concerned with treating illnesses and restoring function. Psychiatry relies primarily upon the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) or ICD-10 to diagnose and treat mental illnesses and disorders. Mainstream mental health consumer community services are an adjunct to psychiatry, not an alternative.
  • 14. Mental Health Psychopathology Models The scientific consensus on mental illness views disorders as neurobiological, but more than neurochemistry. Other brain functions identified as contributing to mental illness include circadian rhythms, cognitive processing, brain networks and more. Brain imaging studies demonstrate physical changes in neuroanatomy accompanying disorders such as schizophrenia, autism and bipolar disorder.
  • 15. Mental Health Psychopathology Models As well, environmental, developmental and interpersonal factors have been studied, and research is ongoing. Best-evidence medicine as defined by the independent National Institute for Health and Clinical Excellence (NICE) treatment guidelines indicate that bipolar disorder, for example, requires a combination of medication, psychotherapy, self-help and social supports. Mental health agencies are increasingly involved and promote self-reliance and peer support.
  • 16. Mental Health Psychopathology Models Some mental health advocates, such as the Critical Psychiatry Network, Scientology, and MindFreedom, do not accept mental illness as brain-based. They oppose the "chemical imbalance theory" and claim the DSM-IV involves oversimplified causes and treatments for mental illness. This strain of advocacy is not representative of most established mental health consumer organizations, such as the National Mental Health Association, Depression and Bipolar Support Alliance, Canadian Mental Health Association, Rethink, and others.
  • 17. Mental Health Psychopathology Models It is, however, in line with 12 step peer support groups that utilize: "surrendering to a higher power" and self-shaming as treatment. Opposing viewpoints to biological psychiatry theories include those of anti-psychiatry advocates, some of whom are psychiatrists, who contend psychiatric patients do not necessarily have a mental illness, but in fact are individuals who do not ascribe to the conventional belief system, or consensus reality, shared by most other people in their culture or race.
  • 18. Mental Health Psychopathology Models According to Dr. Glasser, a critic of psychiatry, the Public Health model is an established model delivering physical health to millions of people. He advocates to have this model expanded into a Public Mental Health Delivery model to put into practice by mental health professionals and institutions, by hiring mental health professionals (as defined by Glasser, not the established industry of mental health professionals such as psychiatric nurses and counsellors) to deliver services without diagnoses or first-line medication to people who need professional help.
  • 19. Mental Health Psychopathology Models This model does not provide adequate treatment for consumers with severe, persistent, genetic mental illness who are unable to take care of themselves, even to direct a self-empowering treatment plan. Lack of insight is a key definition of psychosis and mania in which the person does not believe (s)he is ill and refuses or does not comply with treatment.
  • 20. Mental Health Mental Health Promotion Mental health promotion works from the principle that everyone has mental health needs, not just people who have been diagnosed with a mental illness. Mental health promotion is essentially concerned with making changes to society that will promote people's mental well-being. Positive psychology is also concerned with mental health and enhancement rather than treating illness.
  • 21. Mental Health Mental Health Promotion Mental health promotion is a term that covers a variety of strategies. These strategies can be seen to occur at three levels: Individual - encouragement of individual resources by promotion of interventions for self-esteem, coping, assertiveness in areas such as parenting, the workplace or personal relationships. Communities - increasing social inclusion, developing support structures that promote mental health in workplaces, schools and neighbourhoods. Government reduce socioeconomic barriers to mental health at governmental level by promoting equal access for all and support for vulnerable citizens.
  • 22. Mental Illnesses Overview Mood Disorders Anxiety Disorders Psychoses Personality Disorders Eating Disorders Addiction Suicidal Behaviour
  • 23. Mental Illnesses Overview Mental illnesses are characterized by alterations in thinking, mood or behaviour (or some combination thereof) associated with significant distress and impaired functioning. The symptoms of mental illness vary from mild to severe, depending on the type of mental illness, the individual, the family and the socio-economic environment.
  • 24. Mental Illnesses Overview Mental illnesses indirectly affect all Canadians through illness in a family member, friend or colleague. Twenty percent of Canadians will personally experience a mental illness during their lifetime. Mental illnesses affect people of all ages, educational and income levels, and cultures. The onset of most mental illnesses occurs during adolescence and young adulthood. A complex interplay of genetic, biological, personality and environmental factors causes mental illnesses.
  • 25. Mental Illnesses Overview Mental illnesses can be treated effectively. Mental illnesses are costly to the individual, the family, the health care system and the community. The economic cost of mental illnesses in Canada was estimated to be at least $7.331 billion in 1993. Eighty-six percent of hospitalizations for mental illness in Canada occur in general hospitals. In 1999, 3.8% of all admissions in general hospitals (1.5 million hospital days) were due to anxiety disorders, bipolar disorders, schizophrenia, major depression, personality disorders, eating disorders and suicidal behaviour. The stigma attached to mental illnesses presents a serious barrier not only to diagnosis and treatment but also to acceptance in the community.
  • 26. Mental Illnesses Mood Disorders Mood disorders include major depression, bipolar disorder (combining episodes of both mania and depression) and dysthymia. Approximately 8% of adults will experience major depression at some time in their lives. Approximately 1% will experience bipolar disorder. The onset of mood disorders usually occurs during adolescence. Worldwide, major depression is the leading cause of years lived with disability.
  • 27. Mental Illnesses Mood Disorders Mood disorders have a major economic impact through associated health care costs as well as lost work productivity. Most individuals with a mood disorder can be treated effectively in the community. Unfortunately, many individuals delay seeking treatment. Hospitalizations for mood disorders in general hospitals are approximately one and a half times higher among women than men.
  • 28. Mental Illnesses Mood Disorders The wide disparity among age groups in hospitalization rates for depression in general hospitals has narrowed in recent years, because of a greater decrease in hospitalization rates in older age groups. Hospitalization rates for bipolar disorder in general hospitals are increasing among women and men between 15 and 24 years of age. Individuals with mood disorders are at high risk of suicide.
  • 29. Mental Illnesses Mood Disorders Mood disorders may involve depression only (also referred to as "unipolar depression") or they may include manic episodes (as in bipolar disorder, which is classically known as "manic depressive illness"). Individuals with mood disorders suffer significant distress or impairment in social, occupational, educational or other important areas of functioning.
  • 30. Mental Illnesses Mood Disorders Individuals with depression feel worthless, sad and empty to the extent that these feelings impair effective functioning. They may also lose interest in their usual activities, experience a change in appetite, suffer from disturbed sleep or have decreased energy. Individuals with mania are overly energetic and may do things that are out of character, such as spending very freely and acquiring debt, breaking the law or showing lack of judgement in sexual behaviour.
  • 31. Mental Illnesses Mood Disorders These symptoms are severe and last for several weeks, interfering with relationships, social life, education and work. Some individuals may appear to function normally, but this requires markedly increased effort as time with the illness progresses. Both depressive and manic episodes can change the way an individual thinks and behaves, and how his/her body functions.
  • 32. Mental Illnesses Mood Disorders Major depressive disorder is characterized by one or more major depressive episodes (at least 2 weeks of depressed mood or loss of interest in usual activities accompanied by at least four additional symptoms of depression). Bipolar disorder is characterized by at least one manic or mixed episode (mania and depression) with or without a history of major depression.
  • 33. Mental Illnesses Mood Disorders Dysthymic disorder is essentially a chronically depressed mood that occurs for most of the day for more days than not over a period of at least two years, without long, symptomfree periods. Symptom-free periods last no longer than 2 months. Adults with the disorder complain of feeling sad or depressed, while children may feel irritable. The required minimum duration of symptoms for diagnosis in children is 1 year.
  • 34. Mental Illnesses Mood Disorders Symptoms Depression Mania Feeling worthless, helpless or hopeless Loss of interest or pleasure (including hobbies or sexual desire) Change in appetite Sleep disturbances Decreased energy or fatigue (without significant physical exertion) Sense of worthlessness or guilt Poor concentration or difficulty making decisions Excessively high or elated mood Unreasonable optimism or poor judgement Hyperactivity or racing thoughts Decreased sleep Extremely short attention span Rapid shifts to rage or sadness Irritability
  • 35. Mental Illnesses Mood Disorders How Common Are Mood Disorders? As a group, mood disorders are one of the most common mental illnesses in the general population. Canadian studies looking at lifetime incidence of major depression found that 7.9% to 8.6% of adults over 18 years of age and living in the community met the criteria for a diagnosis of major depression at some time in their lives. Other studies have reported that between 3% and 6% of adults will experience dysthymia during their lifetime, and that between 0.6% and 1% of adults will have a manic episode during their lifetime.
  • 36. Mental Illnesses Mood Disorders Who Is Affected by Mood Disorders? Mood disorders affect individuals of all ages, but usually appear in adolescence or young adulthood. However, late diagnosis is common: the average age of diagnosis of major depressive disorder is in the early twenties to early thirties.1 Studies have consistently documented higher rates of depression among women than among men: the female-to-male ratio averages 2:1.3 Women are 2 to 3 times more likely than men to develop dysthymia.
  • 37. Mental Illnesses Mood Disorders Sex differences in the symptoms associated with depression may contribute to the differences in the prevalence of depression between men and women. For example, men are more likely to be irritable, angry and discouraged when depressed, whereas women express the more "classical" symptoms of feelings of worthlessness and helplessness, and persistent sad moods. As a result, depression may not be as easily recognized in a man.
  • 38. Mental Illnesses Mood Disorders In addition, women are more likely than men to seek help from health professionals. Biological or social risk or protective factors may also differ between men and women. For bipolar disorder, it is generally accepted that the ratio between men and women is approximately equal.
  • 39. Mental Illnesses Mood Disorders Although most individuals with mood disorders are treated in the community, hospitalization is sometimes necessary. At the present time, hospitalization data provide the best available, though limited, description of individuals with mood disorders. The results must be viewed with caution, however, since this is only a subset of those with mood disorders: most individuals with mood disorders are treated in the community rather than in hospitals, and many do not receive treatment at all.
  • 40. Mental Illnesses Mood Disorders How Do Mood Disorders Affect People? Because of their high prevalence, economic cost, risk of suicide and loss of quality of life, mood disorders present a serious public health concern in Canada. Depression and mania cause significant distress and impairment in social, occupational, educational or other important areas of functioning. Major depressive disorder is a recurrent illness with frequent episode relapses and recurrences.
  • 41. Mental Illnesses Mood Disorders The more severe and longlasting the symptoms in the initial episode, due in some cases to a delay in receiving effective treatment, the less likely is a full recovery. Unipolar major depressive disorder is identified as the fourth-ranked cause of disability and premature death worldwide. Depression also has a major impact on the mental health of family members and caregivers, often with an increased presence of depression and anxiety symptoms.
  • 42. Mental Illnesses Mood Disorders Causes of Mood Disorders: Mood disorders have no single cause, but several factors, such as a biochemical imbalance in the brain, psychological factors and socio-economic factors, tend to make some individuals prone to such disorders. Genetic Influence: Studies have established that individuals with depression and bipolar disorder often find a history of these disorders in immediate family members. Evidence suggests that many different genes may act together and in combination with other factors to cause a mood disorder.
  • 43. Mental Illnesses Mood Disorders Although some studies have suggested a few interesting genes or genomic regions, the exact genetic factors that are involved in mood disorders remain unknown. Previous Episode of Depression: One episode of major depression is a strong predictor of future episodes. More than 50% of individuals who have an episode of major depression experience a recurrence.
  • 44. Mental Illnesses Mood Disorders Stress Stress has traditionally been viewed as a major risk factor for depression. Recent research efforts have indicated, however, that stress may predispose individuals only for an initial episode and not for recurring episodes. Responses to stress differ greatly among individuals: some are more susceptible than others to depression following life events, when they are in difficult relationships, or because of socio-economic factors such as inadequate income or housing, prejudice and workplace stress.
  • 45. Mental Illnesses Mood Disorders Physical Illness A strong association exists between various chronic medical conditions and an elevated prevalence of major depression. Several conditions, such as stroke and heart disease, Parkinson's disease, epilepsy, arthritis, cancer, AIDS and chronic obstructive pulmonary disease (COPD), may contribute to depression. Several factors associated with physical illness may contribute to the onset or worsening of depression. These include the psychological impact of disability, decline in quality of life, and the loss of valued social roles and relationships. Medication side effects may also be a contributing factor.
  • 46. Mental Illnesses Mood Disorders Finally, it is possible that the physical disease itself may contribute directly to the onset of depression by affecting physiological mechanisms such as neurotransmitters, hormones and the immune system; for similar reasons, episodes of mania may occur following physical illness or use of medications. Indirect factors: Also influence the relationship between physical conditions and depression. Such factors include disability and quality of life of individuals with chronic disease and the tendency for some medications used for treating physical illnesses to cause depression. Treating chronic physical illness effectively requires vigilance for the early detection and treatment of depression.
  • 47. Mental Illnesses Mood Disorders Treatment of Mood Disorders: Mood disorders are treatable. Many people with a mood disorder fail to seek treatment, however, and suffer needlessly. Of those who seek treatment, many remain undiagnosed or receive either incorrect medication or inadequate doses. The delay in seeking and receiving a diagnosis and treatment may be due to a number of factors, such as stigma, lack of knowledge, a lack of human resources and availability or accessibility of services.
  • 48. Mental Illnesses Mood Disorders Current initiatives to relieve the burden of mood disorders include not only improved recognition and use of effective treatments, but also education for individuals and families and for the community. Primary care settings play a critical role in both recognizing and treating these illnesses. Innovative practice models have shown that effective interventions can decrease symptoms and increase work days. Effective early treatment of mood disorders can improve outcomes and decrease the risk of suicide.
  • 49. Mental Illnesses Mood Disorders Antidepressant medications and education in combination with various forms of psychotherapy, such as cognitive-behavioural therapy, have demonstrated their effectiveness in treating depression. A recent publication from the Canadian Psychiatric Association outlines the clinical guidelines for the treatment of depressive disorders. Educating family and primary care providers is essential not only to ensure the recognition of early warning signs of depression, mania and suicide and to implement appropriate treatment, but also to ensure adherence to treatment in order to minimize future relapses.
  • 50. Mental Illnesses Mood Disorders Sound support networks are crucial during both the acute phase of the illness and the post-illness adjustment to daily life. Major depression results in poor productivity and sick leave from the workplace. The workplace, therefore, is an important area for addressing mental health issues. Supporting the development of healthy work environments, educating employers and employees in the area of mental health issues, and providing supportive reintegration into the work environment for those experiencing mental illness would go a long way toward minimizing the effect of major depression on the workplace.
  • 51. Mental Illnesses Mood Disorders Individuals with mood disorders may require hospitalization to adjust medication, to stabilize the disorder or to ensure protection against self- destructive behaviour. The higher hospitalization rates for depression among women than men support the clinical experience of higher rates of depression among women. Based on clinical research, rates of major depression among women are 2 times higher than among men. On the other hand, the hospitalization rates among women are only about 1.5 times higher than among men
  • 52. Mental Illnesses Mood Disorders Suggesting that men may be hospitalized for major depression at higher rates than women. This requires further research for confirmation and explanation. Rates of bipolar disorder have been estimated to be equal among men and women. However, hospitalization rates for women with the disorder are much higher than men. Further research is required to assess if, in fact, rates of the disease are higher among women, or if women with the disorder are hospitalized at a higher rate than men, why this occurs.
  • 53. Mental Illnesses Mood Disorders Hospitalization rates for both depression and bipolar disorder among women peak between the ages of 35-49 years. Research is required to assess the factors in women's lives that contribute to this phenomenon. Since 1987, hospitalization rates for depression among older Canadians have decreased much more than rates among younger age groups. Further research is required to determine the reasons for this trend.
  • 54. Mental Illnesses Mood Disorders Has it been the result of better clinical treatment, and have outcomes for this age group also improved over this time period? Hospitalization rates for bipolar disorder among young women and men have increased since the early 1990s. Does this signify an increase in bipolar disorder in these age groups, earlier recognition of the disorder, or a change in treatment? Mood disorders, including major depression, bipolar disorder and dysthymia are common and contribute to major personal and family distress. They also have a significant impact on workplace and health care costs.
  • 55. Mental Illnesses Mood Disorders Existing data provide a very limited profile of mood disorders in Canada. The available hospitalization data needs to be complemented with additional data to fully monitor these disorders in Canada. Priority data needs include: Incidence and prevalence of major depression, bipolar disorder and dysthymia by age, sex and other key variables (for example, socio- economic status, education, and ethnicity).
  • 56. Mental Illnesses Mood Disorders Prevalence of depression in people with chronic physical illness. Impact of mood disorders on the quality of life of the individual and family. Access to and use of primary and specialist health care services. Treatment outcomes. Rates of suicide among individuals with mood disorders. Access to and use of public and private mental health services.
  • 57. Mental Illnesses Mood Disorders Access and use of mental health services in other systems, such as schools, criminal justice programs and facilities, and employee assistance programs. Impact of mood disorders on the workplace and the economy. Stigma associated with mood disorders. Exposure to known or suspected risk and protective factors.
  • 58. Mental Illnesses Schizophrenia What Is Schizophrenia? Schizophrenia is a brain disease and one of the most serious mental illnesses in Canada. Common symptoms are mixed-up thoughts, delusions (false or irrational beliefs), hallucinations (seeing or hearing things that do not exist) and bizarre behaviour. People suffering from schizophrenia have difficulty performing tasks that require abstract memory and sustained attention. All the signs and symptoms of schizophrenia vary greatly among individuals.
  • 59. Mental Illnesses Schizophrenia There are no laboratory tests to diagnose schizophrenia. Diagnosis is based solely on clinical observation. For a diagnosis of schizophrenia to be made, symptoms must be present most of the time for a period of at least 1 month, with some signs of the disorder persisting for 6 months. These signs and symptoms are severe enough to cause marked social, educational or occupational dysfunction. The Canadian Psychiatric Association has developed guidelines for the assessment and diagnosis of schizophrenia. Symptoms: Delusions and/or hallucinations Lack of motivation Social withdrawal Thought disorders
  • 60. Mental Illnesses Schizophrenia Who Is Affected by Schizophrenia? The onset of schizophrenia typically occurs between the late teens and mid-30s. Onset before adolescence is rare. Men and women are affected equally by schizophrenia, but men usually develop the illness earlier than women. If the illness develops after the age of 45, it tends to appear among women more than men, and they tend to display mood symptoms more prominently.
  • 61. Mental Illnesses Schizophrenia Ideally, data from a population survey would provide information on the age/sex distribution of individuals with schizophrenia. Statistics Canada's Canadian Community Health Survey (CCHS) will provide data on the prevalence of self-reported schizophrenia in the future. This will likely underestimate the true prevalence, however, since the survey team will not reach those individuals with schizophrenia who are homeless, in hospital or in supervised residential settings.
  • 62. Mental Illnesses Schizophrenia Although most individuals with schizophrenia are treated in the community, hospitalization is sometimes necessary to stabilize symptoms. In 1999, rates of hospitalization for schizophrenia in general hospitals varied with age. Rates among men increased dramatically in the 20-24 year age group and remained high before beginning to decrease among 40-44 year olds.
  • 63. Mental Illnesses Schizophrenia The pattern among women showed a gradual increase in hospitalizations to a peak between 35 and 49 years, after which it showed a steady decline. Men had much higher rates than women until the age of 50, after which rates among women were slightly higher.
  • 64. Mental Illnesses Schizophrenia How Does It Affect ? Schizophrenia has a profound effect on an individual's ability to function effectively in all aspects of life - self-care, family relationships, income, school, employment, housing, community and social life. The high rates of hospitalization among young and middle-aged men and women highlight the effect of schizophrenia on people who are in their most productive years - a time when most people are forming families, establishing careers, and generally "building equity" in their lives.
  • 65. Mental Illnesses Schizophrenia Early in the disease process, people with schizophrenia may lose their ability to relax, concentrate or sleep and they may withdraw from friends. Performance at work or school often suffers. With effective early treatment to control symptoms, individuals can prevent further symptoms and optimize their chance of leading full, productive lives. The onset of schizophrenia in the early adulthood years usually leads to disruptions in an individual's education.
  • 66. Mental Illnesses Schizophrenia Individuals with schizophrenia often find it difficult to maintain employment for a sustained period of time. Although some individuals have healthy relationships, the majority with schizophrenia (60% to 70%) do not marry, and most have limited social contacts. The chronic course of the disorder contributes to ongoing social problems. As a result, individuals with schizophrenia are greatly over-represented in prison and homeless populations.
  • 67. Mental Illnesses Schizophrenia Up to 80% of individuals with schizophrenia will abuse substances during their lifetime. Substance abuse is associated with poor functional recovery, suicidal behaviour and violence. The responsibility for primary care of an individual with schizophrenia usually falls on the shoulders of the family. This has many implications. Not only are the family's normal activities disrupted, but family members must also cope with the unpredictability of the individual affected, the side effects of the medication, and the frustration and worry about the future of their loved one.
  • 68. Mental Illnesses Schizophrenia In times of crisis, the decision whether to admit the individual to hospital involuntarily is one of the most difficult dilemmas that a family may face. The family often has to deal with the stigma attached to schizophrenia. The mortality associated with schizophrenia is one of the most distressing consequences of the disorder. Approximately 40% to 60% of individuals with schizophrenia attempt suicide, and they are between 15 to 25 times more likely than the general population to die from a suicide attempt. Approximately 10% will die from suicide.
  • 69. Mental Illnesses Schizophrenia Economic Impact Schizophrenia places a substantial financial burden on individuals with the illness, the members of their family and the health care system. In 1996, the total direct cost of schizophrenia in Canada was estimated to be $2.35 billion, or 0.3% of the Canadian Gross Domestic Product. This includes health care costs, administrative costs of income assistance plans, and value of lost productivity, The indirect costs of schizophrenia are estimated to account for another $2 billion yearly. Globally, nearly 3% of the total burden of human disease is attributed to schizophrenia.
  • 70. Mental Illnesses Schizophrenia Stigma Associated with Schizophrenia Public misunderstanding and fear contribute to the serious stigma associated with schizophrenia. Contrary to popular opinion, most individuals with the disorder are withdrawn and not violent. Nonetheless, the stigma of violence interferes with an individual's ability to acquire housing, employment and treatment, and also compounds difficulties in social relationships. These stereotypes also increase the burden on families and care givers.
  • 71. Mental Illnesses Schizophrenia Causes of Schizophrenia Historically, a number of psychological hypotheses were advanced to account for schizophrenia. Today medical science recognizes schizophrenia as a disease of the brain. Although the exact cause is unknown, it is likely that a functional abnormality in neurotransmitters produces the symptoms of the illness. This abnormality may be either the consequence or the cause of structural brain abnormalities.
  • 72. Mental Illnesses Schizophrenia A combination of genetic and environmental factors is considered to be responsible for the development of this functional abnormality. These factors appear to affect the development of the brain at critical stages during gestation and after birth. Genetic Influence Immediate family members of individuals with schizophrenia are 10 times more likely than the general population to develop schizophrenia Children of two parents with schizophrenia have a 40% chance of developing the disorder
  • 73. Mental Illnesses Schizophrenia Environmental Factors Although the evidence to date is inconclusive, potential environmental contributions to the development of schizophrenia include prenatal or perinatal trauma, season and place of birth, and viral infections. While studies have established a link between severe social disadvantage and schizophrenia, the results suggest that social factors do not cause schizophrenia, but rather the reverse may be true: poor social circumstances are likely a result of the disorder.
  • 74. Mental Illnesses Schizophrenia Treatment of Schizophrenia Unfortunately, given our state of knowledge, methods for preventing schizophrenia remain unknown. Minimizing the impact of this serious illness depends mainly on early diagnosis, appropriate treatment and support. Schizophrenia differs from other mental illnesses in the intensity of care that it requires.
  • 75. Mental Illnesses Schizophrenia A comprehensive treatment program includes: Antipsychotic medication, which forms the cornerstone of treatment for schizophrenia Education of the individual about his / her illness and treatment Family education and support Support groups and social skills training Rehabilitation to improve the activities of daily living Vocational and recreational support Cognitive therapy Integrated addictions program
  • 76. Mental Illnesses Schizophrenia The course of schizophrenia varies, but in most cases it involves recurrent episodes of symptoms. Although available pharmacological treatments can relieve many of the symptoms, most people with schizophrenia continue to suffer some symptoms throughout their lives. Appropriate treatment early in the course of the disease and adherence to continued and adequate treatment are essential to avoiding relapses and preventing hospitalization. During periods of remission, whether spontaneous or due to treatment, the individual may function well.
  • 77. Mental Illnesses Schizophrenia Newer medications (and improved dosage guidelines for older medications) have substantially reduced the prevalence of severe neurological side effects that were once commonly associated with long-term pharmacological treatment of schizophrenia. Optimizing the functional status and wellbeing of individuals with schizophrenia requires a supportive family and wide range of services, including institutional, community, social, employment and housing services. Ideally, multidisciplinary community treatment teams provide these services.
  • 78. Mental Illnesses Schizophrenia Social skills training strives to improve social functioning by working with individuals to resolve problems with employment, leisure, relationships and activities of daily life. Occasionally, however, timely admission to hospital to control symptoms may prevent the development of more severe problems. Canadian hospitalization data provide insight into the use of hospital services as one of the treatment modalities. In 1999, in the younger age groups with schizophrenia, the disorder was the most responsible for determining their length of stay in hospital In older age groups (65+ years), schizophrenia was more likely to be an associated condition.
  • 79. Mental Illnesses Schizophrenia The high hospitalization rates for schizophrenia among young adults support the clinical finding that the onset of schizophrenia typically occurs in adolescence and early adulthood. Higher rates among young men than young women agree with the observation that although schizophrenia affects both men and women, men develop it at an earlier age. Assessing whether the illness affects men differently than women in such a way that they require more hospitalization needs further research.
  • 80. Mental Illnesses Schizophrenia The increasing hospitalization rates for schizophrenia in general hospitals among young and middle-aged men may reflect, in part, the loss of psychiatric hospital beds that provided care for these men before deinstitutionalization. This care has now shifted to general hospitals. More research is needed to determine whether this also reflects shortcomings in the community treatment of the disease requiring hospitalization in order to control symptoms.
  • 81. Mental Illnesses Schizophrenia The length of stay in hospital associated with schizophrenia has decreased since 1995. This may reflect either improved treatment or the effect of decreases in hospital funding, which put pressure on the institutions to discharge people earlier than in previous years. Discharging people too early could be contributing to the increase in hospitalization rates through the need for re-admissions. Further research is needed to understand both the reason for this trend and its impact on individuals.
  • 82. Mental Illnesses Schizophrenia Future Surveillance Needs Schizophrenia is a very serious mental illness with major ramifications for individuals and families, causing not only a great deal of personal distress but also impairment of social and occupational functioning. Fortunately, schizophrenia can be treated effectively. Existing data provide a very limited profile of schizophrenia in Canada. The available hospitalization data need to be complemented with additional data to fully monitor this illness in Canada.
  • 83. Mental Illnesses Schizophrenia Priority data needs include: Incidence and prevalence of schizophrenia by age, sex and other key variables (for example, socioeconomic status, education and ethnicity). Impact of schizophrenia on the quality of life of the individual and family. Access to and use of health care services and community- based programs. Treatment outcomes. Access to community supports, such as housing, employment and education. Impact of schizophrenia on the workplace and the economy. Stigma associated with schizophrenia. Exposure to known or suspected risk and protective factors.
  • 84. Mental Illnesses Anxiety Disorders What Are Anxiety Disorders? Individuals with anxiety disorders experience excessive anxiety, fear or worry, causing them either to avoid situations that might precipitate the anxiety or to develop compulsive rituals that lessen the anxiety. Everyone feels anxious in response to specific events - but individuals with an anxiety disorder have excessive and unrealistic feelings that interfere with their lives in their relationships, school and work performance, social activities and recreation.
  • 85. Mental Illnesses Anxiety Disorders Symptoms: Intense and prolonged feelings of fear and distress that occur out of proportion to the actual threat or danger Feelings of fear and distress that interfere with normal daily functioning
  • 86. Mental Illnesses Anxiety Disorders Types of Anxiety Disorders Generalized Anxiety Disorder (GAD) Excessive anxiety and worry about a number of events or activities occurring for more days than not over a period of at least 6 months with associated symptoms (such as fatigue and poor concentration). Specific Phobia Marked and persistent fear of clearly discernible objects or situations (such as flying, heights and animals).
  • 87. Mental Illnesses Anxiety Disorders Post Traumatic Stress Disorder Flashbacks, persistent frightening thoughts and memories, anger or irritability in response to a terrifying experience in which physical harm occurred or was threatened (such as rape, child abuse, war or natural disaster). Social Phobia, AKA Social Anxiety Disorder Exposure to social or performance situations almost invariably provokes an immediate anxiety response that may include palpitations, tremors, sweating, gastrointestinal discomfort, diarrhoea, muscle tension, blushing or confusion, and which may meet criteria for the panic attack in severe cases.
  • 88. Mental Illnesses Anxiety Disorders Obsessive-Compulsive Disorder Obsessions : Persistent thoughts, ideas, impulses or images that are intrusive and inappropriate and that cause marked anxiety or distress. Individuals with obsessions usually attempt to ignore or suppress such thoughts or impulses or to counteract them by other thoughts or actions (compulsions). Compulsions : Repetitive behaviours (such as hand washing, ordering or checking) or mental acts (such as praying, counting or repeating words) that occur in response to an obsession or in a ritualistic way.
  • 89. Mental Illnesses Anxiety Disorders Panic Disorder Presence of recurrent, unexpected panic attacks, followed by at least 1 month of persistent concern about having additional attacks, worry about the implication of the attack or its consequences, or a significant change in behaviour related to the attacks. There are three clusters of symptoms: reexperiencing, avoidance and numbing, and arousal. Panic disorders are sometimes associated with agoraphobia - anxiety about, or the avoidance of, places or situations from which escape might be difficult or embarrassing, or in which help may not be available in the event of a panic attack or panic-like symptoms.
  • 90. Mental Illnesses Anxiety Disorders The essential feature of the panic attack is a discrete period of intense fear or discomfort that is accompanied by at least 4 of 13 physical symptoms, such as: Palpitations, increased heart rate or pounding heart Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Dizziness, unsteadiness, lightheadedness or fainting De-realization or de-personalization Fear of losing control or going crazy Fear of dying Paresthesias (numbness or tingling sensation) Chills or hot flashes
  • 91. Mental Illnesses Anxiety Disorders How Common Are Anxiety Disorders? Combined anxiety disorders affect approximately 12% of Canadians: about 9% of men and 16% of women during a one-year period. As a group, anxiety disorders represent the most common of all mental illnesses.
  • 92. Mental Illnesses Anxiety Disorders Who Is Affected by Anxiety Disorders? Women report and are diagnosed with some anxiety disorders more frequently than men. This may reflect the differences between men and women in their health-service-seeking behaviours, however, rather than true differences in prevalence. Ideally, data from a population survey would provide information on the age/sex distribution of individuals with anxiety disorders. Statistics Canada's Canadian Community Health Survey (CCHS) will provide these data in the future.
  • 93. Mental Illnesses Anxiety Disorders At the present time, hospitalization data provide the best available description of individuals with anxiety disorders. These data have limitations, however, because most people with anxiety disorders are treated in the community rather than in hospitals, and many do not receive treatment at all. As a result, the data represents only a subset of all those with anxiety disorders, and the results must be interpreted with caution.
  • 94. Mental Illnesses Anxiety Disorders In 1999, women were hospitalized for anxiety disorders at higher rates than men in every age category Young women aged between 15 and 19 years had much higher rates of hospitalization than the immediately adjacent age groups. Women and men over the age of 65 had the highest rates of hospitalization.
  • 95. Mental Illnesses Anxiety Disorders How Does It Affect? Symptoms of anxiety disorders often develop during early adulthood. Although the majority of people have mild or no impairment, anxiety disorders can seriously restrict an individual's education, work, recreation and social activities because he / she avoids situations that precipitate the symptoms. Individuals severely affected by anxiety disorders are also more likely to have either another type of anxiety disorder, major depression or dysthymia, alcohol or substance abuse, or a personality disorder. This compounds the impact of the anxiety disorder and presents challenges for effective treatment.
  • 96. Mental Illnesses Anxiety Disorders Economic Impact Because they are so common, anxiety disorders have a major economic impact. They contribute to lost productivity due to both time away from work and unemployment. Other associated costs include claims on disability insurance. Heavy use of the emergency department and primary care system in reaction to physical symptoms also contributes to significant health care costs.
  • 97. Mental Illnesses Anxiety Disorders Stigma Associated with Anxiety Disorders Because anxiety disorders are the extension of what most people perceive as normal worry and concern, Those who experience them may fear that others would label their excessive worry and fear as simply a weakness. As a result, they may try to ignore the seriousness of their condition and deal with it themselves. They often avoid seeking help and suffer in silence.
  • 98. Mental Illnesses Anxiety Disorders Causes of Anxiety Disorders The development of anxiety disorders appears to result from a complex interplay of genetic, biological, developmental and other factors such as socio-economic and workplace stress. A variety of theories have been proposed to explain how these factors contribute to the development of the disorder. The first is experiential: people may learn their fear from an initial experience, such as an embarrassing situation, physical or sexual abuse, or the witnessing of a violent act. Similar subsequent experiences serve to reinforce the fear.
  • 99. Mental Illnesses Anxiety Disorders A second theory relates to cognition or thinking: In that people believe or predict that the result of a specific situation will be embarrassing or harmful. This may occur, for example, if parents are over-protective and continually warn against potential problems. A third theory focuses on a biological basis: Research suggests that the amygdala, a structure deep within the brain, serves as a communication hub that signals the presence of a threat and triggers a fear response or anxiety. It also stores emotional memories and may play a role in the development of anxiety disorders. The children of adults with anxiety disorders are at much greater risk of an anxiety disorder than is the general population, which may imply a genetic factor, an effect of parenting practices, or both.
  • 100. Mental Illnesses Anxiety Disorders Treatment of Anxiety Disorders Early recognition and appropriate management are imperative in order to enhance the quality of life of individuals with anxiety disorders. Proper recognition and management also help to prevent common secondary disorders, such as depression and abuse of drugs and alcohol.
  • 101. Mental Illnesses Anxiety Disorders The delay in seeking and receiving a diagnosis and treatment may be due to a number of factors, such as stigma, a lack of human resources, restrictive government funding systems and lack of knowledge. In addition, family physicians may not always recognize the pattern in an individual's symptoms that would lead them to a correct diagnosis. Too often, the symptoms are not taken seriously and an individual with an anxiety disorder is labelled as being emotionally unstable. Education of both the public and family physicians would help to solve this problem.
  • 102. Mental Illnesses Anxiety Disorders A recent review of anxiety disorders suggests that effective treatments include: Drug therapy (with anti-depressants or anti- anxiety drugs) and cognitive-behavioural therapy, which helps people turn their anxious thoughts into more rational and less anxietyproducing ideas. Support groups for individuals and families can also help develop the tools for minimizing and coping with the symptoms.
  • 103. Mental Illnesses Anxiety Disorders Anxiety disorders can be well managed in the primary care setting. Creating access to experts in cognitive-behaviour therapy through a shared-care model can help family physicians provide optimal care for the individuals they are treating. When individuals with anxiety disorders are hospitalized, another associated condition is usually responsible for determining their length of stay
  • 104. Mental Illnesses Anxiety Disorders Overall, hospitalization rates for anxiety disorders decreased dramatically between 1987 and 1999, by 50% among women and 46% among men, with a combined reduction of 49% Since most anxiety disorders are treated outside of hospitals, hospitalization data provide a very limited picture of these disorders in Canada. The data do support the view that anxiety disorders are associated with other health problems and it is usually these, rather than anxiety disorders, that lead to hospitalization.
  • 105. Mental Illnesses Anxiety Disorders The decrease in hospitalization rates for anxiety may be due to bed closures and a refocusing of hospital services to ambulatory services. Hospitalizations for anxiety disorders in general hospitals among seniors have shown a dramatic decrease (much greater than any other age group) since 1987. This trend reflects the pattern for the same age group for major depression. Further research is needed to determine the reason for this trend: Is the prevalence of the disorders decreasing? Have treatment methods changed? Have outcomes improved?
  • 106. Mental Illnesses Anxiety Disorders The higher rates of hospitalization for anxiety disorders in general hospitals among women than men prompt several research questions: Are anxiety disorders really more common among women? Are women more likely to seek treatment than men? Are women treated differently than men, with greater use of hospitalization? Hospitalization rates for anxiety disorders have a pronounced peak among women between 15 and 19 years of age.
  • 107. Mental Illnesses Anxiety Disorders This peak is also found in hospitalization rates for depression and personality disorders. This suggests that women in this age group are vulnerable to mental illnesses. The reasons for this phenomenon require further clarification through research.
  • 108. Mental Illnesses Anxiety Disorders Future Surveillance Needs Anxiety disorders are common among Canadians, causing not only a great deal of personal distress but also impairment of social and occupational functioning. Anxiety disorders can be effectively treated with a combination of medication and cognitive behavioural therapy. Existing data provide a very limited profile of anxiety disorders in Canada. The available hospitalization data need to be complemented with additional data to fully monitor these disorders in Canada.
  • 109. Mental Illnesses Anxiety Disorders Priority data needs include: Incidence and prevalence of each of the anxiety disorders by age, sex and other key variables (for example, socio-economic status, education and ethnicity). Impact of anxiety disorders on the quality of life of the individual and family. Access to and use of primary and specialist health care services. Impact of anxiety disorders on the workplace and the economy. Stigma associated with anxiety disorders. Access to and use of public and private mental health services. Access to and use of mental health services in other systems, such as schools, criminal justice programs and facilities, and employee assistance programs. Treatment outcomes. Exposure to known or suspected risk and protective factors.
  • 110. Mental Illnesses Personality Disorders What Are Personality Disorders? Personality disorders cause enduring patterns of inner experience and behaviour that deviate from the expectations of society and lead to distress or impairment. Personality is seen today as a complex pattern of deeply imbedded psychological characteristics that are largely non-conscious and not easily altered, which express themselves automatically in almost every area of functioning. Personality characteristics or traits are expressed on a continuum of social functioning.
  • 111. Mental Illnesses Personality Disorders Personality disorders reflect personality traits that are used inappropriately and become maladaptive. To some degree, this classification is arbitrary. Some deviations may be quite mild and interfere very little with the individual's home or work life; others may cause great disruption in both the family and society. Specific situations or events trigger the behaviours of a personality disorder. In general, individuals with personality disorders have difficulty getting along with others and may be irritable, demanding, hostile, fearful or manipulative.
  • 112. Mental Illnesses Personality Disorders Symptoms: Difficulty getting along with other people. May be irritable, demanding, hostile, fearful or manipulative. Patterns of behaviour deviate markedly from society's expectations and remain consistent over time. Disorder affects thought, emotion, interpersonal relationships and impulse control. The pattern is inflexible and occurs across a broad range of situations. Pattern is stable or of long duration, beginning in childhood or adolescence.
  • 113. Mental Illnesses Personality Disorders Personality disorders exist in many forms. Classification of personality disorders is arbitrary. Each person is unique, however, and can display mixtures of patterns.
  • 114. Mental Illnesses Personality Disorders Type Patterns Borderline Instability in interpersonal relationships, selfimage and affects, and marked impulsivity. Antisocial Disregard for, and violation of, the rights of others. Histrionic Excessive emotionality and attention seeking. Narcissistic Grandiosity, need for admiration, and lack of empathy. Avoidant Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
  • 115. Mental Illnesses Personality Disorders Type Patterns Dependent Submissive and clinging behaviour related to an excessive need to be taken care of. Schizoid Detachment from social relationships and a restricted range of emotional expression. Paranoid Distrust and suspiciousness in which others' motives are interpreted as malevolent. Obsessive Compulsive Disorder Preoccupation with orderliness, perfectionism and control. Schizotypal Acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour.
  • 116. Mental Illnesses Personality Disorders How Common Are Personality Disorders? Canadian data on the prevalence of personality disorders are lacking. Epidemiological studies most often measure and report antisocial personality disorder. A 1991 Ontario survey estimated that the 1- year prevalence rate of antisocial personality disorder in the general population was 1.7%. According to the Edmonton study in the 1980s, 1.8% of the population had an antisocial personality disorder in the 6- month period before the survey, and 3.7% reported a personality disorder at some point in their lives. Estimates of the prevalence of other personality disorders range from 1% to 10% of the population.
  • 117. Mental Illnesses Personality Disorders Who Develops a Personality Disorder? There is a sex difference in the personality disorder types. For example, antisocial personality disorder is more common among men, while borderline personality disorder is more common among women. The dependent and hysterical personality disorders are also more common among women. Labelling biases among health professionals may lead to some of the sex differences. Ideally, data from a population survey would provide information on the age/sex distribution of individuals with personality disorders. Statistics Canada's Canadian Community Health Survey (CCHS) will provide prevalence of self-reported obsessivecompulsive personality disorder in the future.
  • 118. Mental Illnesses Personality Disorders At the present time, however, hospitalization data provide the best available description of individuals with personality disorders. These data have limitations, however, because most people with personality disorders, unless they show suicidal behaviour, are treated in the community rather than in hospitals. Many are never diagnosed or treated. Individuals with borderline personality disorder have higher rates of admission than individuals with other disorders because of their high rate of suicidal behaviour. These limitations must be kept in mind, then, when interpreting the data presented in this report.
  • 119. Mental Illnesses Personality Disorders What Are the Effects of Personality Disorders? Although the onset of personality disorders usually occurs in adolescence or early adulthood, they can also become apparent in mid-adulthood. To some extent, the timing depends on the type of personality disorder and the situation or events surrounding the individual. For example, borderline personality disorder usually peaks in adolescence and early adulthood, and then becomes less prominent by mid-adulthood. On the other hand, narcissistic personality disorder may not be identified until middle age when the individual experiences the sense of loss of opportunity or faces personal limitations.
  • 120. Mental Illnesses Personality Disorders Since personality disorders usually develop in adolescence or early adulthood, they occur at a time when most people develop adult relationship skills, obtain education, establish careers and generally "build equity" in their lives. The use of maladaptive behaviours during this life stage has implications that extend for a lifetime. A history of alcohol abuse, drug abuse, sexual dysfunction, generalized anxiety disorder, bipolar disorder, obsessive- compulsive disorder, depressive disorder, eating disorder, and suicidal thoughts or attempts often accompany personality disorders.’ Up to one half of prisoners have antisocial personality disorder because its associated behavioural characteristics (such as substance abuse and violence) lead to criminal behaviour.
  • 121. Mental Illnesses Personality Disorders Other social consequences of personality disorders include: Spousal violence Child maltreatment Poor work performance Suicide Gambling Personality disorders have a major effect on the people who are close to the individual. The individual's fixed patterns make it difficult for them to adjust to various situations. As a result, other people adjust to them. This creates a major strain on all relationships among family and close friends and in the workplace.
  • 122. Mental Illnesses Personality Disorders At the same time, when other people do not adjust, the individual with the personality disorder can become angry, frustrated, depressed or withdrawn. This establishes a vicious cycle of interaction, causing the individuals to persist in the maladaptive behaviour until their needs are met.
  • 123. Mental Illnesses Personality Disorders Stigma Associated with Personality Disorders Since the behaviours shown in some personality disorders remain close to what is considered "normal", others often assume that the individuals can easily change their behaviour and solve the interpersonal problem. When the behaviour persists, however, it may be perceived as a lack of will or willingness to change. The fixed nature of the trait is not well understood by others.
  • 124. Mental Illnesses Personality Disorders Causes of Personality Disorders Personality disorders likely result from the complex interplay of early life experience, genetic and environmental factors. In principle, genetic factors contribute to the biological basis of brain function and to basic personality structure. This structure then influences how individuals respond to and interact with life experiences and the social environment. Over time, each person develops distinctive patterns or ways of perceiving their world and of feeling, thinking, coping and behaving.
  • 125. Mental Illnesses Personality Disorders Although little is known to date about possible biological correlates of personality disorder, individuals with personality disorders may have impaired regulation of the brain circuits that control emotion. This difficulty, combined with psychological and social factors such as abuse, neglect or separation, puts an individual at higher risk of developing a personality disorder. Strong attachments within the family or a supportive network of people outside the family, in the school and in the community help an individual develop a strong sense of self-esteem and strong coping abilities. Opportunities for personal growth and for developing unique abilities can enhance a person's self-image. This supportive environment may provide some protection against the development of a personality disorder.
  • 126. Mental Illnesses Personality Disorders For biologically predisposed individuals, the major developmental challenges that are a normal part of adolescence and early adulthood: separation from family, self-identity, and independence may be the precipitating factors for the development of the personality disorder. This may explain why personality disorders usually begin in these years.
  • 127. Mental Illnesses Personality Disorders Treatment of Personality Disorders Personality disorders are difficult to treat because of self-denial about the presence of the problem and the pessimism of health professionals based on a lack of success in previous efforts. Intensive individual and group psychotherapy, combined with anti-depressants and mood stabilizers, can be at least partially effective for some people. Difficulties arise from both the persistence of symptoms and the negative impact of these symptoms on the therapeutic relationship.
  • 128. Mental Illnesses Personality Disorders Individuals with borderline personality disorder have more frequent hospitalizations, use outpatient psychotherapy more often, and make more visits to emergency rooms than individuals with other personality disorders. In 1999, in all age groups, personality disorders were more likely to be a contributing rather than the main factor determining length of stay in hospital. This reflects the fact that personality disorders are associated with other conditions, such as suicidal behaviour, that may need hospitalization.
  • 129. Mental Illnesses Personality Disorders Most personality disorders are treated outside of the hospital. Thus, the hospitalization data provide a very limited picture of personality disorders in Canada. The higher rates of hospitalization for personality disorder in general hospitals among young women than men supports the clinical experience that women are more likely to have borderline personality disorder with its associated suicidal behaviour, leading to hospitalization.
  • 130. Mental Illnesses Diagnostic and Statistical Manual of Mental Disorders The Diagnostic and Statistical Manual of Mental Disordersis is a reference work consulted by psychiatrists, psychologists, physicians in clinical practice, social workers, medical and nursing students, pastoral counselors, and other professionals in health care and social service fields. The book's title is often shortened to DSM, or an abbreviation that also indicates edition, such as DSM- IV-TR,which indicates fourth edition, text revision of the manual, published in 2000. The DSM-IV-TR provides a classification of mental disorders, criteria sets to guide the process of differential diagnosis, and numerical codes for each disorder to facilitate medical record keeping.
  • 131. Mental Illnesses Diagnostic and Statistical Manual of Mental Disorders The stated purpose of the DSM is threefold: to provide "a helpful guide to clinical practice"; "to facilitate research and improve communication among clinicians and researchers"; and to serve as "an educational tool for teaching psychopathology." The third edition of DSM, or DSM-III, which was published in 1980, introduced a system of five axes or dimensions for assessing all aspects of a patient's mental and emotional health. The multi-axial system is designed to provide a more comprehensive picture of complex or concurrent mental disorders.
  • 132. Mental Illnesses Diagnostic and Statistical Manual of Mental Disorders The five diagnostic axes specified by DSM-IV-TR are: Axis I: Clinical disorders, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders. Axis II: Personality disorders and mental retardation. This axis includes notations about problematic aspects of the patient's personality that fall short of the criteria for a personality disorder. Axis III: General medical conditions. These include diseases or disorders that may be related physiologically to the mental disorder; that are sufficiently severe to affect the patient's mood or functioning; or that influence the choice of medications for treating the mental disorder.
  • 133. Mental Illnesses Diagnostic and Statistical Manual of Mental Disorders Axis IV: Psychosocial and environmental problems. These include conditions or situations that influence the diagnosis, treatment, or prognosis of the patient's mental disorder. DSM-IV-TR lists the following categories of problems: family problems; social environment problems; educational problems; occupational problems; housing problems; economic problems; problems with access to health care; problems with the legal system; and other problems (war, disasters, etc.). Axis V: Global assessment of functioning. Rating the patient's general level of functioning is intended to help the doctor draw up a treatment plan and evaluate treatment progress. The primary scale for Axis V is the Global Assessment of Functioning (GAF) Scale, which measures level of functioning on a scale of 1–100. DSM-IV- TR includes three specialized global scales in its appendices: the Social and Occupational Functioning Assessment Scale (SOFAS); the Defensive Functioning Scale; and the Global Assessment of Relational Functioning (GARF) Scale. The GARF is a measurement of the maturity and stability of the relationships within a family or between a couple.
  • 134. Mental Illnesses Medications Antidepressants: Antidepressants are used to treat various types of depression. Several types of antidepressants, grouped by how they affect brain chemistry, are available. Antidepressants can help improve such depression symptoms as sadness, hopelessness, lack of energy, difficulty concentrating and lack of interest in activities. Antidepressants are often used to treat illnesses besides depression, including nonpsychiatric conditions.
  • 135. Mental Illnesses Medications Precisely how antidepressants work to treat depression remains speculative. Scientists do know that antidepressants can influence brain activity through the effects they have on mood-related brain chemicals (neurotransmitters) and certain nerve cell receptors. Nerve cells release neurotransmitters to communicate with other nerve cells in the brain. Neurotransmitters transmit signals across a gap (synapse) between the nerve cells. Neurotransmitters associated with depression are serotonin, norepinephrine and possibly dopamine. Research suggests that people with depression have lower levels of one or more of these neurotransmitters.
  • 136. Mental Illnesses Medications Here are the most common antidepressants to treat depression, with their generic or chemical names followed by available brand names in parentheses, and grouped by how they affect brain chemistry: Selective serotonin reuptake inhibitors (SSRIs) Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Tricyclic antidepressants (TCAs) Amitriptyline Amoxapine Desipramine (Norpramin)
  • 137. Mental Illnesses Medications Doxepin (Sinequan) Imipramine (Tofranil) Nortriptyline (Pamelor) Protriptyline (Vivactil) Trimipramine (Surmontil) Monoamine oxidase inhibitors (MAOIs) Phenelzine (Nardil) Tranylcypromine (Parnate) Isocarboxazid (Marplan) Selegiline (Emsam)
  • 138. Mental Illnesses Medications Mood-stabilizing medications: Mood stabilizers are most commonly used to treat bipolar disorder, which is characterized by alternating episodes of mania and depression. Mood stabilizers may also include anti-seizure medications. Mood-stabilizing medications include: Lithium (Eskalith, Lithobid) Divalproex (Depakote) and many others.
  • 139. Mental Illnesses Medications Anti-anxiety medications: As their name suggests, they are used to treat anxiety disorders, such as generalized anxiety disorder and panic disorder. They may also be useful in helping relieve agitation,insomnia and muscle spasm. These medications are typically fast acting, helping relieve symptoms in as little as 30 minutes. A major drawback, however, is that they may cause dependency. Anti-anxiety medications include alprazolam (Xanax), lorazepam (Ativan) and many others.
  • 140. Mental Illnesses Medications Antipsychotic medications: Antipsychotic medications, also called neuroleptics, are typically used to treat psychotic disorders, such as schizophrenia. A person who is psychotic is plagued by delusions and is unable to maintain a hold on reality. Antipsychotic medications may also be used to treat severe cases of depression accompanied by psychosis. Antipsychotic medications include clozapine (Clozaril), olanzapine (Zyprexa) and many others.
  • 141. Mental Illnesses Substance Abuse People abuse substances such as drugs, alcohol, and tobacco for varied and complicated reasons, but it is clear that our society pays a significant cost. The toll for this abuse can be seen in our hospitals and emergency departments through direct damage to health by substance abuse and its link to physical trauma. Jails and prisons tally daily the strong connection between crime and drug dependence and abuse. Although use of some drugs such as cocaine has declined, use of other drugs such as heroin and "club drugs" has increased.
  • 142. Mental Illnesses Substance Abuse Abused substances produce some form of intoxication that alters judgment, perception, attention, or physical control. Many substances can bring on withdrawal—an effect caused by cessation or reduction in the amount of the substance used. Withdrawal can range from mild anxiety to seizures and hallucinations. Nearly all these drugs also can produce a phenomenon known as tolerance where you must use a larger amount of the drug to produce the same level of intoxication. Drug overdose may also cause death.
  • 143. Mental Illnesses Substance Abuse Tobacco: People cite many reasons for using tobacco, including pleasure, improved performance and vigilance, relief of depression, curbing hunger, and weight control. The primary addicting substance in cigarettes is nicotine. But cigarette smoke contains thousands of other chemicals that also damage health. Hazards include heart disease, lung cancer and emphysema, peptic ulcer disease, and stroke. Withdrawal symptoms of smoking include anxiety, hunger, sleep disturbances, and depression. Smoking is responsible for nearly a half million deaths each year. Tobacco use costs the nation an estimated $100 billion a year, mainly in direct and indirect health care costs.
  • 144. Mental Illnesses Substance Abuse Alcohol: Although many people have a drink as a "pick me up," alcohol actually depresses the brain. Alcohol lessens your inhibitions, slurs speech, and decreases muscle control and coordination, and may lead to alcoholism. Withdrawal from alcohol can cause anxiety, irregular heartbeat, tremor, seizures, and hallucinations. In its severest form, withdrawal combined with malnutrition can lead to a life-threatening condition called delirium tremens (DTs). Alcohol is the most common cause of liver failure. The drug can cause heart enlargement and cancer of the esophagus, pancreas, and stomach. In addition to its direct health effects, officials associate alcohol abuse with nearly half of all fatal motor vehicle accidents.
  • 145. Mental Illnesses Substance Abuse Drugs: Marijuana (also known as grass, pot, weed, herb): Marijuana, which comes from the plant Cannabis sativa, is the most commonly used illegal drug. The plant produces delta-9-tetrahydrocannabinol (THC), the active ingredient associated with intoxication. Marijuana resin, called hashish, contains an even higher concentration of THC. The drug is usually smoked, but it can also be eaten. Its smoke irritates your lungs more and contains more cancer-causing chemicals than tobacco smoke. Common effects of marijuana use include pleasure, relaxation, and impaired coordination and memory. Often, the first illegal drug people use, marijuana is associated with increased risk of progressing to more powerful and dangerous drugs such as cocaine and heroin. The risk for progressing to cocaine is 104 times higher if you have smoked marijuana at least once than if you never smoked marijuana.
  • 146. Mental Illnesses Substance Abuse Cocaine (also known as crack, coke, snow, rock): Derived from the coca plant of South America, cocaine can be smoked, injected, snorted, or swallowed. The intensity and duration of the drug’s effects depend on how you take it. Desired effects include pleasure and increased alertness. Short-term effects also include paranoia, constriction of blood vessels leading to heart damage or stroke, irregular heartbeat, and death. Severe depression and reduced energy often accompany withdrawal. Both short- and long-term use of cocaine has been associated with damage to the heart, the brain, the lung, and the kidneys.
  • 147. Mental Illnesses Substance Abuse Heroin (also known as smack, horse): Heroin use continues to increase. Officials see increased use mainly among people younger than 26 years, often women. In 1997, 87% of heroin users were younger than 26 years, compared to 61% in 1992. Effects of heroin intoxication include drowsiness, pleasure, and slowed breathing. Withdrawal can be intense and can include vomiting, abdominal cramps, diarrhea, confusion, aches, and sweating. Overdose may result in death from decreased breathing. Because heroin is usually injected, often with dirty needles, use of the drug can trigger other health complications including destruction of your heart valves, HIV/AIDS, infections, tetanus, and botulism.
  • 148. Mental Illnesses Substance Abuse Methamphetamines (also known as meth, crank, ice, speed, crystal): Use of this drug also has increased, especially in the West. Methamphetamine is a powerful stimulant that increases alertness, decreases appetite, and gives a sensation of pleasure. The drug can be injected, snorted, smoked, or eaten. It shares many of the same toxic effects as cocaine—heart attacks, dangerously high blood pressure, and stroke. Withdrawal often causes depression, abdominal cramps, and increased appetite. Other long-term effects include paranoia, hallucinations, weight loss, destruction of teeth, and heart damage.
  • 149. Mental Illnesses Substance Abuse Club drugs: The club scene and rave parties have popularized an assortment of other drugs. Many young people believe these drugs are harmless or even healthy. These are the more popular club drugs: Ecstasy (also called MDMA, Adam, STP): This is a stimulant and hallucinogen used to improve mood and to maintain energy, often for all-night dance parties. Long-term use may cause damage to the brain’s ability to regulate sleep, pain, memory, and emotions. LSD (also called acid, microdot) and mushrooms (also called shrooms, magic mushrooms, peyote, buttons): Popular in the 1960s, LSD has been revived in the club scene. LSD and hallucinogenic mushrooms can cause hallucinations, numbness, nausea, and increased heart rate. Long-term effects include unwanted "flashbacks" and psychosis (hallucinations, delusions, paranoia, and mood disturbances).
  • 150. Mental Illnesses The PTA’s Role OTAs and PTAs help people who experience mental health problems to live fuller and more active lives. They can also prevent a problem or minimize its effects. Their role can be summarized as follows: Time Management: Clients can be taught to structure their time by using daily schedules, monthly calendars and flowcharts; they need to learn to use them and to get in the habit of referring to/updating them Planning and participating in a balance of self-care, work, leisure and rest activities promotes satisfaction and health; the occupational therapy practitioner helps the client prioritize and structure daily routines, as well as scheduling time and organizing tasks efficiently
  • 151. Mental Illnesses The PTA’s Role Stress Management: The PTAs can help the client to change the stressful situation or to change the stress response to the situation Assertiveness training and anger management training increase skills in recognizing and dealing with feelings and needs They can provide instruction in the effects of stress and personal stress analysis and management Examples include: verbalization, biofeedback, humour, meditation, proper nutrition, sufficient sleep, guided imagery, aerobic activity
  • 152. Mental Illnesses The PTA’s Role Working with cognitively impaired patients and substance abusers: Recognize cognitive impairments: Confusion (person responds to a simple question with an unrelated remark); disorientation (the person says it is 1983, but the current year is 2007); deficits in short term memory (client cannot remember where his wallet is); deficits in long term memory (client cannot remember his birthdate) Aim to improve: cognitive and perceptual skills, time management (especially leisure time), daily living skills, and acquisition of valued occupational and social roles
  • 153. Mental Illnesses The PTA’s Role Help plan opportunities for new leisure activities and avoid people/situations associated with dependency Computer programs may be helpful in treating cognitive and perceptual deficits Clients need to learn new ways to cope with their feelings; expressive activities such as art, clay, drama may assist in recognizing and conveying emotions that client habitually blocked with defense mechanisms Stress management and relaxation techniques are important in addressing coping skills
  • 154. Mental Illnesses The PTA’s Role Assertiveness training my provide patients with appropriate skills and strategies for social interactions Money management training: patients may need help with budgeting and redirection in steering spending away from substance abuse related activities Vocational retraining may be necessary if the patient was fired because of previous behaviours; job skill training and prevocational training may be necessary for lower functioning clients
  • 155. Mental Illnesses The PTA’s Role Working with schizophrenia: Treatment is directed at problems that interfere with specific areas of functioning or with group interaction skill Social skills training is important, such as making eye contact, initiating conversation and responding to questions Behavioural coaching and cognitive-behavioural strategies can help a person identify and change problem behaviours ADL training is often necessary for clients with chronic schizophrenia; hygiene, dressing, and grooming often need to be focused on Homemaking, money management, community mobility skills, safety behaviours and emergency management skills are important for schizophrenic patients to succeed in the community
  • 156. Mental Illnesses The PTA’s Role Assistance in the structuring of leisure skills is important; early onset and recurring episodes can have a detrimental effect on the development of personal interests Work and productivity are often negatively affected by this illness; may have difficulty maintaining long term employment; treatment focus on social skills and work skills improve marketability Remedial or compensatory approaches may be provided to improve cognitive functioning (e.g., use of notebook to record information)
  • 157. Mental Illnesses The PTA’s Role Working with Anxiety Patients: Therapeutic use of self: encourage person to talk about what is upsetting them; answer questions, but avoid being drawn into long extended discussions about symptoms; reassure client that you are available, but keep a schedule Modifying the environment: provide a safe, calm environment that is not over stimulating; brief tour of treatment area and regular treatment schedule keep things predictable and calm Selecting treatment activities: gross motor activities can reduce uncomfortable physical symptoms; meditation can help relax; biofeedback can help increase self awareness and control of symptoms
  • 158. Mental Illnesses The PTA’s Role Working with Depressed Patients: Therapeutic use of self: avoid being overprotective; be an effective listener and reflect comments back in a non-judgmental way; provide direction and help with the selection of short-term goals and activities; give clear directions and avoid giving too many choices Modifying the environment: environment should be safe and subdued; the more severe the depression, the less stimulation should be present; adapt schedule with client’s choices in mind Selecting treatment activities: start with simple, structured, short- term, familiar activities; the first activities used should be ones at which the person is guaranteed to succeed; initial activities should be ones that can be done alone, without the need to interact or share tools or materials with others; gross motor activities can help release tension
  • 159. Mental Illnesses The PTA’s Role Working with Paranoid Patients: Therapeutic use of self: avoid approaching client suddenly, from behind, or in a manner that may be perceived as threatening; directions should be clear, consistent, and directive; make sure to stay in charge of the situation Modifying the environment: keep things stable and reliable as possible; social contact should never be forced Selecting treatment activities: activities must be ones the person can control; use structured activities involving controllable materials (such as leather work)
  • 160. Mental Illnesses The PTA’s Role Issues in Therapeutic Relationships: Transference: occurs when one person (usually the client) unconsciously relates to the other person (usually the therapist) as if that person were someone else of importance in their life Counter-transference: occurs when the other person (usually the therapist) unconsciously falls into that role; the unconscious nature of this interaction makes it difficult to deal with this situation Dependence: clients come to depend on staff which they see as being more knowledgeable, skillful, and powerful than themselves Helplessness, anger, and depression: some clients are so severely disabled that no amount of rehab can improve their functioning; they may need excessive time and attention to maintain their few skills.
  • 161. Mental Illnesses The PTA’s Role Unrealistic expectations of clients and their families that therapy will successfully return skills and improve functioning can lead to anger and frustration being directed at the occupational therapy practitioner with reciprocal behaviour being expressed Sexual feelings: clients and therapy practitioner can confuse closeness they experience (both physical and emotional) within a therapeutic relationship, with the intimacy of a sexual one Fear and revulsion: fear of contagion from clients with communicable diseases; fear of the unknown, or different and unfamiliar; revulsion of client’s previous behaviour or experiences can interfere with the therapeutic relationship
  • 162. Mental Health & Office Administration Part II: Office Administration
  • 164. Office Administration Telephone Techniques Answering the telephone is an important first contact with the physiotherapy office The voice tone, inflection and other non-verbal aspects of the person answering all have a profound impact on how the caller perceives the physiotherapy office The telephone has been an essential communication tool for business since the early 1900’s As is the case with most tools, skill is required to maximize its effectiveness Failure to use the business telephone in a proper manner may not only result in the ineffectiveness of the user, but may result in having a detrimental effect on the business.
  • 165. Office Administration Telephone Techniques It has been said that the first thirty seconds of a telephone conversation sets the tone for the caller’s relationship with the physiotherapy office. The patient’s first contact with your physiotherapy office may be a telephone call and the first impression of the image and style of the practice begins to develop The practice image is perceived right from the start of this first call The answering content may be completely correct or even directly from a written script, but may project the wrong image due to the "non-verbal" aspects of the speaker’s voice
  • 166. Office Administration Telephone Techniques These include unusual pauses in a normal speaking pattern, vocalized pauses (ah, uh, mmm) and changes in tone of the voice to mention a few These "non-verbal" aspects of the person’s voice answering the phone play a critical role in communicating the image of the practice When the first contact with a prospective patient is by telephone, special attention has to be paid to communication factors primarily because the caller cannot see the person at the other end of the telephone line. Without visual input, a caller relies entirely on the sound that emerges from the telephone to formulate an opinion about the person at the other end of the phone line
  • 167. Office Administration Telephone Techniques As a caller, it is reasonable to expect the person who answers the telephone to be courteous, organized and helpful If those qualities are not part of the caller’s experience, then there is a distinct possibility that a negative opinion will be forged about both the business as well as the person answering the telephone The staff in each physiotherapy practice should establish and use an agreed upon telephone protocol and communication style which will reflect a positive image for the practice when the telephone is answered
  • 168. Office Administration Telephone Techniques The protocol should include the following strategies: Be Prepared: A cardinal rule in maximizing effective telephone communication is, "be prepared to receive a call." Any person in the office who will be answering the telephone must be prepared with the necessary tools (notepads, charts and scheduling book) but even more, the person should be emotionally prepared to answer It is essential that the receptionist organize the items that may be needed during a call to avoid delays in the conversation and to avoid sending a message of disorganization in the office to the caller The appointment system (computerized or traditional appointment book) must be readily available near the site of the telephone receiver or headset
  • 169. Office Administration Telephone Techniques Similarly, any office message system, whether it is computerized or consists of paper message pads, should be close at hand and ready to use if needed Message system information forms should be formatted to ensure that all critical information is obtained and recorded for future use Access to the patient’s computerized, or conventional dental record may also be helpful before initiating a call to a patient regarding an appointment, or his/her past care
  • 170. Office Administration Telephone Techniques Who and When: The office manual is a good vehicle to document the elements of a telephone protocol This includes the identification of who should answer and when the telephone should be answered Control of the appointment schedule may be shared by more than one employee and a written telephone protocol will help to delineate the responsibilities of all who participate in the communication and appointment management process If the telephone is to be answered by selected employees, then the protocol should include this limitation Some protocols call for answering the telephone by the end of the first ring, while others call for answering by the fourth ring
  • 171. Office Administration Telephone Techniques It’s in the Voice: It is a necessity that the person answering the telephone use "an alert, pleasant, well-modulated, cordial, cheerful voice…" Good basic telephone usage requires "…tact, courtesy and a genuine attempt to help the caller…" Upon answering, the telephone handset should be properly positioned so that the person can hear the caller in the receiver and so that the caller can, in turn, hear the PTA For traditional handsets, about one and one-half inches away from the mouth is recommended to maximize the clarity of the voice
  • 172. Office Administration Telephone Techniques If a telephone headset is used, then the manufacturer’s recommendations should be followed for positioning the headset microphone The caller should not miss the first part of the greeting due to extraneous noise or improper telephone positioning The person receiving the call should try to avoid asking the caller to repeat their message just because they failed to position the handset properly
  • 173. Office Administration Telephone Techniques Voice tone or vocal factors include pitch, tone, volume, rhythm, inflection, etc. are a critical part of the message conveyed on the phone If the voice is "raised," an emotion of frustration or anger may be communicated Increased volume with irregular inflection can project cheerfulness Voice pitch can communicate a lot about style and emotions Anger and excitement tend to cause a rise in the voice which may communicate frustration and anger Low pitched, monotonal speaking patterns may communicate indifference, laziness, or even incompetence
  • 174. Office Administration Telephone Techniques The voice tone of a person answering the telephone becomes the personality of the office for the caller A positive, enthusiastic attitude must shine through when the phone is answered Positive language includes the use of such words as "can," "will," "shall," and "certainly." Energy and expression should be put into the voice It is important to interact with a pleasant and "smiling" voice More vocal expression is required when communicating over the telephone than when having a personal interaction in order to compensate for the loss of visual contact
  • 175. Office Administration Telephone Techniques The person answering the telephone should use friendly, positive voice tones consistently to be an effective communicator It may actually be helpful to physically sit up and not slouch prior to answering the phone Facial expressions and gesturing, as if face to face, often are helpful aids in the infusion of desirable voice tones and non-verbal The voice should be made lively and the person must genuinely sound interested in helping the caller
  • 176. Office Administration Telephone Techniques If the rhythm of the voice is unsteady or too fast, the greeting will be hard to follow or even lost entirely Therefore, the rhythm should be comfortably paced and steady The timing or pace may communicate important clues A long, drawn out pace may project indifference, while a short reply can indicate impatience Friendliness is conveyed through voice tone by inflection at the end of statements with a lilt in the voice The voice should have clarity so the caller will have no trouble understanding The deliberate clarity of the voice is necessary for this communication of a friendly greeting with an offer of help
  • 177. Office Administration Record Keeping The CPO's Guidelines for the Use of Support Personnel (March 1996) require physiotherapists to ensure, on an ongoing basis, that any record keeping assigned to personnel working under their direction or supervision complies with College regulations and standards of practice Before allowing support personnel to record progress notes in client records, the physiotherapist should: provide support staff with training in appropriate record- keeping procedures, as well as a written copy of the College's standard of practice and regulation on record keeping and any facility policy governing documentation; determine whether staff who have received formal instruction in record keeping (e.g., during a recognized physiotherapist assistant program) require further training
  • 178. Office Administration Record Keeping In no circumstances can a support person record a physiotherapy intervention that was performed by the supervising physiotherapist As a result, physiotherapists should never assign to support personnel the record keeping associated with an initial evaluation or subsequent reassessment, the development, evaluation and modification of the treatment plan, or discharge planning
  • 179. Office Administration Record Keeping As per the College's standard of practice on record keeping, (Standards of Practice for Physiotherapists, April 1996, page 12) , the physiotherapist should indicate, in the client's clinical record, whether and to whom interventions have been assigned, as well as the frequency and time frame during which such services will be performed The physiotherapist must also clearly indicate in the client record when charting has been assigned to support personnel, the frequency with which charting will occur, and when he or she will reassess the client
  • 180. Office Administration Record Keeping The College does not require supervising physiotherapists to co-sign entries recorded by support personnel However, members may adopt this practice as either a communication mechanism or an internal quality control check A physiotherapist may co-sign or initial entries to indicate to support staff that he or she has read the entry and understands the status of the client
  • 181. Office Administration Record Keeping In such cases, the entry is an integral component of the communication system between the physiotherapist and his or her support personnel Physiotherapists may also co-sign entries made by support personnel as a means of determining whether record keeping is continuing to meet College and facility standards