Managing Emotion for Mental Well-Being

Transcription

1 Managing Emotion for Mental Well-Being W.L. Alan Fung, MD, ScD, FRCPC (Psychiatry) Scarborough Chinese Baptist Church May 5, 2018

2 Medical Disclaimer The information presented in this talk is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images and information presented in this talk is for general information purposes only.

3 Objectives 1. What is mental well-being, and the lack of? 2. Some major mental disorders 3. Overall treatment approach 4. Mental health care providers in Ontario 5. Recovery 6. Further resources

4 Objectives 1. What is mental well-being, and the lack of? 2. Some major mental disorders 3. Overall treatment approach 4. Mental health care providers in Ontario 5. Recovery 6. Further resources

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17 Mental illness Affective Behavioural Cognitive Perceptual abnormalities

18 Mental illness according to the Public Health Agency of Canada Characterized by alterations in thinking, mood or behaviour (or a combination) Impaired functioning over an extended period of time Symptoms vary from mild to severe depending on the type the individual the famliy Socio-economic environment

19 Objectives 1. What is mental well-being, and the lack of? 2. Some major mental disorders 3. Overall treatment approach 4. Mental health care providers in Ontario 5. Recovery 6. Further resources

20 Mental Disorders Classification Systems Diagnostic and Statistical Manual of Mental Disorders Fifth edition (DSM-5) International Statistical Classification of Diseases and Related Health Problems, Tenth Edition (ICD-10)

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24 DSM-5 Major Diagnostic Categories 1) Neurodevelopmental disorders 2) Schizophrenia spectrum and other psychotic disorders 3) Bipolar and related disorders 4) Depressive disorders 5) Anxiety disorders 6) Obsessive-compulsive and related disorders 7) Trauma- and stressor-related disorders 8) Dissociative disorders 9) Somatic symptom and related disorders

25 DSM-5 Major Diagnostic Categories (2) 10) Feeding and eating disorders 11) Elimination disorders 12) Sleep wake disorders 13) Sexual dysfunctions 14) Gender dysphoria 15) Disruptive, impulse-control, and conduct disorders 16) Substance-related and addictive disorders 17) Neurocognitive disorders 18) Personality disorders 19) Paraphilic disorders

26 Diagnosing Psychiatric Disorders Diagnostic Criteria: - Constellation of symptoms - Duration - Functional impairment

27 Diagnosing Psychiatric Disorders (2) Diagnostic Hierarchy: - Psychiatric disorder due to Generalized Medical Condition - Psychiatric disorder due to substance abuse - Psychotic disorder - Mood disorder - Anxiety disorder

28 Common Mental Disorders Anxiety Disorders Mood Disorders Depressive disorders Bipolar disorders Stress-related Disorders Substance-use Disorders

29 DSM-5 Anxiety Disorders - Separation Anxiety Disorder - Selective Mutism - Specific Phobia - Social Anxiety disorder - Panic disorder - Panic Attack - Agorophobia - Generalized Anxiety disorder - Substance/Medication-Induced Anxiety Disorder - Anxiety disorder Due to another medical condition

30 Major Depressive Disorder At least 1 Major Depressive Episode (MDE): Depressed mood and/or anhedonia for 2 weeks 4 of: - Sleep difficulties: too little or too much - Appetite: too little or too much - Energy: poor / fatigue - Concentration and memory: poor - Guilty/worthless feelings - Psychomotor: retardation / agitation - Suicidal ideations

31 Major Depressive Disorder Epidemiology - Life time prevalence in adult is 17% - Male: Female = 1:2 - Average age of onset: natural course of illness if not treated: 6-12 mo

32 Bipolar Disorder - Prevalence M=F, 0.9% - Age of onset: teens to early 20 s; can have late onset bipolar as well. - Strong genetic predisposition

33 Bipolar Disorder - Type I, at least 1 manic / mixed episode - Type II, at least 1 MDE and 1 hypomanic episode without any manic/mixed episode - Rapid cycling can occur in both types

34 Manic Episode - Elevated or irritable mood for 1 week, with at least 3 of: - Grandiosity - Sleep - decreased need - Pressured speech - Flight of ideas - Distractability - Increased goal-directed activities - Excessive involvement in pleasurable activities

35 Objectives 1. What is mental well-being, and the lack of? 2. Some major mental disorders 3. Overall treatment approach 4. Mental health care providers in Ontario 5. Recovery 6. Further resources

36 Psychiatric Management Biopsychosocial model - Biological treatment - Psychological treatment - Social intervention

37 Bio-Psycho-Socio-Culturo-Spiritual Model

38 Bio-Psycho-Socio-Culturo-Spiritual Formulation Predisposing Bio Psycho Social Cultural Spiritual Precipitating Perpetuating Protecting

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40 Biological management Medications Antidepressants e.g. SSRIs, SNRIs Anxiolytics Mood stablizers Antipsychotics Exercising Relaxation/meditation/mindfulness

41 Antidepressants Indications: unipolar depression, anxiety, anger Medications include: - SSRIs: Sertraline, Citalopram, Escitalopram, Paroxetine, Fluoxetine etc. - SNRI: Venlafaxine, Duloxetine - Bupropion, Mirtazapine - Tricyclics

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43 Depression Meds (1) SSRI - Escitalopram (Cipralex) - Citalopram (Celexa) - Sertraline (Zoloft) - Paroxetine (Paxil) - Fluoxetine (Prozac) - Fluvoxamine (Luvox)

44 Depression Meds (2) SNRI - Venalfaxine (Effexor) - Duloxetine (Cymbalta)

45 Depression Meds (3) SSRIs and SNRIs: - Main medications for mood issues - Serotonin system

46 Depression Meds (4) Helpful additional meds: - Bupropion (Wellbutrin) boosting motivation/energy/level of interest - Mirtazapine (Remeron) helps with sleep, appetite

47 Depression Meds (5) Tricyclic antidepressants e.g. - Amitriptyline (Elavil) - Nortriptyline - Desipramine (Norpramin) - Imipramine - Clomipramine (Anafranil)

48 Antidepressant Side-Effects CNS effect: anxiety, akathesia, dizziness, headache, sedation, insomnia, etc. Metabolic effect: wt gain / loss GI effect: GI disturbance. Can cause diarrhea or nausea. Sexual dysfunction: 50-60% pt experience decreased libido (SSRI). Pregnancy and breastfeeding safe?

49 Antipsychotics Indications: Schizophrenia and other psychotic disorders, bipolar disorder, antidepressant augmentation. Medications include: - Typical antipsychotics, e.g. Haloperidol - Atypical antipsychotics, e.g. Risperidone, Quetiapine, Olanzapine, Aripiprazole, Clozapine, etc.

50 Mood Stabilizers Indication: bipolar disorder (manic / depressive phase, maintenance) Major meds include: Lithium, anticonvulsants, antipsychotics. Anticonvulsants: Valproic acid, Carbamazapine, Lamotrigen, Topiramate. Antipsychotics: Abilify, Risperidone, Seroquel, Olanzapine, Clozapine, Haldol.

51 Anxiolytics/Hypnotics Indication: Anxiety (short-term), insomnia (adjunctive) Medications include: - Benzodiazepines - Antidepressants: TCAs, Trazodone;

52 Psychotherapy

53 Psychotherapy Cognitive-behavioural therapy (CBT) Interpersonal Psychotherapy (IPT) Supportive Psychotherapy Psychodynamic Psychotherapy Group Therapy Couple/Family Therapy

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57 Mindfulness Focusing on the PRESENT moment Mindfulness-Based Stress Reduction (MBSR) Mindfulness-Based Cognitive Therapy (MBCT) Acceptance and Commitment Therapy (ACT)

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62 This art of attentive mindfulness taught by the ancient monastic fathers and mothers was centred on meditative exercises of awareness that sought to bring about a change to a mindful way of life. The practitioner was called to find ways of slowing down so as to become mindful of their breath, of their bodies, of their thoughts, of their actions and their surroundings, and especially of the sacred scriptures and the liturgy. Through those steps in mindfulness they sought to become aware of the Divine in-breathing that is present behind all of these phenomena as they arise. For the Christian Mindfulness Practitioner breathing into love is the beginning of the way of pure prayer, a prayer that transforms both our inner self and how we experience reality.

63 Socio-cultural management Regular routine Functional activities work, volunteering, social interactions etc Housing Finance Family relationships Social work involvement Cultural sensitivity Participation in cultural groups

64 Spiritual management Encourage existing spiritual practice Be prepared about patient s questions about religion/existential issues (e.g. Why me? ) Collaboration with clergy members

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67 Physical Exercises Extremely important!

68 Electroconvulsive therapy (ECT) (for severe mood disorders)

69 Pearls for treatment Build strong therapeutic relationship improving treatment efficacy and compliance. Regular psychoeducation and inquires about side effects to improve adherence. Individual / Group counseling - improving relationships and coping skills. Exercise programs improving lifestyle and physical wellbeing, self-esteem.

70 Objectives 1. What is mental well-being, and the lack of? 2. Some major mental disorders 3. Overall treatment approach 4. Mental health care providers in Ontario 5. Recovery 6. Further resources

71 What is Psychiatry? The medical specialty devoted to the study and treatment of mental disorders First coined by German physician Johann Christian Reil in 1808 psych-: mind (from Ancient Greek psykhē: soul; -iatry: medical treatment (from Greek iāsthai: to heal) The medical treatment of the mind

72 Psychiatric Training At least 3 years of university education (premed) 4 years of MD studies 5 years of specialist training in psychiatry (residency) Licentiate of Medical Council of Canada Specialist Certification (FRCPC) College of Physicians & Surgeons of Ontario 1 to 5 years of fellowship training

73 Psychologists PhDs instead of MDs Undergraduate education, followed by graduate education - leading to a PhD (with thesis) Many fields Psychologists PhD Psychological associates Master s + 4 yrs work exp College of Psychologists of Ontario Cannot prescribe medications in Ontario

74 GP psychotherapists GP: a MD graduate, plus at least 1 year of internship; Family physician: MD graduate, plus family medicine residency and certification (CCFP) Independent practice license with the College of Physicians & Surgeons of Ontario Having psychotherapy as a major focus/part of his/her medical practice May have additional training in psychotherapy May be members of Medical Psychotherapy Association Canada (MDPAC)

75 Other mental health professions Social Workers Ontario College of Social workers and Social Service Workers RSW (BSW or MSW) Nurses College of Nurses of Ontario RN and RPN Registered Practical Nurse vs. Registered Psychiatric Nurse (Western Canada) Occupational Therapists College of Occupational Therapists of Ontario OT Reg. (Ont)

76 Psychotherapists The practice of psychotherapy is the assessment and treatment of cognitive, emotional or behavioural disturbances by psychotherapeutic means, delivered through a therapeutic relationship based primarily on verbal or non-verbal communication. - Psychotherapy Act (Ontario), 2007 Controlled act that can be performed by: - MDs, Psychologists, Nurses, OTs, SWs - Registered Psychotherapists (RP) of the new College of Registered Psychotherapists of Ontario American Association of Marriage and Family Therapy (AAMFT)

77 Some other providers Mental health workers Case managers Crisis counsellors Addiction counsellors Psychosocial rehabilitation workers Housing support workers Personal support workers Volunteers Peer support workers Families

78 Clergy Members! ~40% of those with mental health concerns seek assistance from clergy (Weaver, 1995) Clergy members: more likely than psychologists and psychiatrists combined to have a person with mental health dx come to them for assistance (Hohmann & Larson, 1993) Young adults ranked clergy higher in interpersonal skills than they did either psychologists or psychiatrists (Schindler et al, 1987) Canadian Association for Spiritual Care (CASC) (formerly Canadian Association for Pastoral Practice and Education)

79 Collaborations between mental health & spiritual care professionals Greater trust in clergy members among those with religious faiths (religious explanations of illness) Clergy members as first point of mental health care contact (even in severe cases) Clergy members perspectives on mental health/illness can significantly affect detection, service access, treatment adherence etc. Some clergy members are already providing counselling

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81 2014 Toronto Mental Health and Spiritual Care Symposium Advancing Frontiers in Treating Mood Disorders May 8, 2014 Hart House, University of Toronto Toronto, Ontario, Canada

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85 Mental Health and Faith Community Partnership Was created in 2014 to foster dialogue between psychiatrists and faith leaders. Facilitates collaboration among those who work within the different disciplines of faith and psychiatry and who share a common goal of promoting health, healing, and wholeness.

86 Mental Health and Faith Community Partnership (2) Provides a platform for psychiatrists and faith leaders to learn from each other. Faith leaders can increase their understanding of the best science and evidence-based treatment for psychiatric d/o. Psychiatrists & the mental health community can learn from faith leaders and increase their understanding of the role of spirituality in recovery & support faith leaders can provide.

87 Faith Leaders & Mental Health As religion & spirituality often play a vital role in healing, people experiencing mental health concerns often turn first to a faith leader. Faith community leaders are often gatekeepers or first responders when individuals and families face mental health or substance use problems.

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91 Guidebook and Quick Reference for Faith Leaders The MH&FC Partnership has created: - Mental Health: A Guide for Faith Leaders - Quick Reference on Mental Health for Faith Leaders, companion to Guides Available for download from:

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94 Objectives 1. What is mental well-being, and the lack of? 2. Some major mental disorders 3. Overall treatment approach 4. Mental health care providers in Ontario 5. Recovery 6. Further resources

95 Recovery The personal process that people with mental health conditions experience in gaining control, meaning and purpose in their lives. Involves different things for different people; e.g. complete absence of the symptoms of mental illness living a full life in the community while learning to live with ongoing symptoms Goal for most treatment programs nowadays Excellent webpage from Canadian Mental Health Association: <

96 Wellness Recovery Action Plan (WRAP) A peer-led, mental illness self-management program for managing illness and providing a plan when not well. Best practice used world-wide. Involves an educational and planning process that is grounded in mental health recovery concepts such as hope, education, empowerment, self-advocacy, and interpersonal support and connection. Within a group setting, individuals explore self-help tools and resources for keeping themselves well and for helping themselves feel better in difficult times. Generates an action plan to indicate how the person would like to be treated in times of crisis. Post-crisis plan for getting back on the road to recovery.

97 Objectives 1. What is mental well-being, and the lack of? 2. Some major mental disorders 3. Overall treatment approach 4. Mental health care providers in Ontario 5. Recovery 6. Further resources

98 Some resources for further information Canadian Mental Health Association Mood Disorders Association of Ontario Anxiety Disorders Association of Ontario Schizophrenia Society of Ontario Centre for Addiction and Mental Health Canadian Psychiatric Association American Psychiatric Association National Institute of Mental Health Living Water Counselling Centre Hong Fook Mental Health Association

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100 Common aetiology of Insomnia Stress ( adjustment insomnia ) Mood, anxiety, psychiatric issues Conditioning (psychophysiological insomnia) Inadequate sleep hygiene Substance use Medical conditions e.g. pain, breathing, urological problems etc Medications Misperception (paradoxical insomnia)

101 Key treatment strategies for insomnia Treat the underlying causes Sleep hygiene psychoeducation Cognitive-behavioural therapy for insomnia (CBT-I) Exercising Relaxation/mindfulness training Sleep medications as adjunct

102 Objectives 1. What is mental well-being, and the lack of? 2. Some major mental disorders 3. Overall treatment approach 4. Mental health care providers in Ontario 5. Recovery 6. Further resources

103 Thank you for your attention