Understanding Mental Health: Signs, Symptoms & Treatments for Well-being

1. Don’t call me crazy A Discussion on Mental Health Awareness – T.J. Tyndall PharmD

2. The author has no financial or other professional conflicts of interest to disclose

3. objectives • Define the term mental health • Describe the signs and symptoms of a major depressive episode and generalized anxiety disorder • Discuss general treatment options for mental illness • Discuss investigational treatment options to reduce the risk of suicide and treat acute suicidal ideation • Define “mental health stigma” • Describe ways to combat “mental health stigma”

4. Mental health • The World Health Organization(WHO) defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.

5. Early warning signs • Eating or sleeping too much or too little • Pulling away from people and usual activities • Having low or no energy • Feeling numb or like nothing matters • Having unexplained aches and pains • Feeling helpless or hopeless • Thinking of harming yourself or others • Inability to perform daily tasks like taking care of your kids or getting to work or school • Smoking, drinking, or using drugs more than usual • Feeling unusually confused, forgetful, on edge, angry, upset, worried, or scared • Yelling or fighting with family and friends • Experiencing severe mood swings that cause problems in relationships • Having persistent thoughts and memories you can’t get out of your head • Hearing voices or believing things that are not true

6. Major depressive episode • Five or more of the following symptoms have been present during the same 2 week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure • Depressed mood • Markedly diminished interest or pleasure • Changes in weight • Changes in sleep • Psychomotor agitation or retardation • Fatigue • Feelings of worthlessness or excessive or inappropriate guilt • Diminished ability to think or concentrate • Recurrent thoughts of death

7. Generalized anxiety disorder • Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) and finding it difficult to control the worry • The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): • Restlessness, feeling keyed up or on edge • Being easily fatigued • Difficulty concentrating • Irritability • Muscle tension • Sleep disturbance

8. Question #1 • The World Health Organization(WHO) defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is ________________________. • A. able to complete a train of thought. • B. able to write a term paper. • C. able to make a contribution to his or her community. • D. able to guide others in their mental health needs.

9. Question #1 • The World Health Organization(WHO) defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is ________________________. • A. able to complete a train of thought. • B. able to write a term paper. • C. able to make a contribution to his or her community. • D. able to guide others in their mental health needs.

10. General treatment options for mental illness • Psychotherapy • Medication • Group therapy/psychoeducation • Brain stimulation therapies • Complementary and Alternative medicine • Experimental Treatments

11. psychotherapy • Cognitive behavioral • Recognize and change patterns of negative thoughts and behaviors that potentiate depression • Desensitization in anxiety disorders • Interpersonal • Focuses on the individual’s interpersonal life in four problem areas: grief over loss, interpersonal disputes, role transitions, and interpersonal skill deficits • Psychodynamic/Psychoanalytic • Resolve internal psychological conflicts

12. medications • Prior to selection of medication a mental status examination along with a medical history is obtained as well as some laboratory tests should be obtained • Presence of depressive signs, including alterations in affect, cognition, psychomotor activity, ruminative thought processes, speech and suicidal thoughts are included in the mental status examination • Trial and error • Frustrating for patients and clinicians • Anecdotal evidence • Family history use

13. Group therapy/psychoeducation • Provides a supportive network • Commonly used for bereavement, in patients with a substance use disorder, or in patients experiencing a chronic or life-threatening condition • Combination of mentioned psychotherapies may be used in the setting of group therapy including psychoeducation

14. Transcranial magnetic stimulation • Noninvasive and no sedation involved • Painless magnetic pulse to stimulate nerve cells in hopes that it will activate the regions of the brain that have decreased activity in patients with depression • Generally done daily, five times per week for 4 to 6 weeks • Time to improvement is mixed but generally 2 weeks • Mild headache and pain at site of stimulation are the most common side effects

15. Electroconvulsive therapy • Done under general anesthesia • Small electric current triggers a brief seizure • Generally given 2 to 3 times weekly for 3 to 4 weeks • Relatively rapid response – symptomatic improvement within the first week and complete remission within 3 to 4 weeks • Headache, upset stomach, muscle aches, and memory loss are among the most common side effects

16. Complementary and alternative medicine • Meditation • Exercise • Alternative medications • Methylfolate (form that crosses the BBB) in combination with an SSRI may be effective for treatment refractory depression • Omega-3 fatty acids – large meta-analysis found a trend towards augmentation of antidepressants with omega-3 fatty acids may benefit patients with treatment refractory depression • St. John’s Wort– similar chemical properties to some SSRIs – well documented substantial drug interactions • S-adenosyl methionine – metabolite of folate

17. Question #2 • TRUE OR FALSE: • Electroconvulsive therapy is performed while a patient is under general anesthesia.

18. Question #2 • TRUE OR FALSE: • Electroconvulsive therapy is performed while a patient is under general anesthesia. • TRUE

19. The elephant in the room

20. Suicide • According to the Centers for Disease Control and Prevention (CDC) in 2016 suicide was the tenth leading cause of death overall in the United States claiming nearly 45,000 lives. • Twice as many suicides as homicides • Rates of suicide have risen by 28% since 1999 • 9.8 million adults aged 18 or older reported having serious thoughts about trying to kill themselves • Are we grossly underestimating the impact of suicide?

21. Lithium • A meta-analysis of four trials comparing lithium with placebo indicate that maintenance treatment with lithium can prevent suicide in patients with unipolar major depression or bipolar depression • A prior meta-analysis found similar benefit of lithium in preventing suicide in patients with mood disorders when compared with amitriptyline, carbamazepine, lamotrigine, or placebo. • Although the mechanism by which lithium prevents suicide remains unknown, it is known to prevent recurrence of mood episodes and may also reduce aggression or impulsivity

22. Ketamine • NMDA receptor antagonist – antidepressant and dissociative effects • Transiently alleviate treatment refractory unipolar major depression • Given intravenously at subanesthetic doses • Several randomized trials found similar data that reflects a rapid response in over half of the patients but the effect dissipates by day 10 to 14 • An analysis of 8 randomized trials found that greater improvement with ketamine began within one day of treatment, and resolution of suicidal ideation by day 7 occurred in more patients who received ketamine than controls (either saline or midazolam)

23. Ketamine • Obvious concerns for abuse potential • Recent study from Stanford University aimed to determine the role of the opioid system in ketamine’s antidepressant and dissociative effects • Administered naltrexone prior to treatment with ketamine • Small study but impactful enough for the American Journal of Psychology to note in the accompanying editorial urging caution in use of ketamine due to the risk for potentiating the opioid epidemic

24. buprenorphine • Mixed agonist-antagonist agent, exerts analgesic effects by binding to CNS receptors • Partial agonist at mu and antagonistic at kappa • When compared with placebo in patients with severe suicidal ideation, improvement of ideation was greater in the treatment group and was independent of treatment with antidepressants

25. Question #3 • The CDC reported that suicide was the ______ leading cause of death in the United States in 2016 claiming nearly 45,000 lives. • A. third • B. fourth • C. seventh • D. tenth

26. Question #3 • The CDC reported that suicide was the ______ leading cause of death in the United States in 2016 claiming nearly 45,000 lives. • A. third • B. fourth • C. seventh • D. tenth

27. What is mental health stigma? • Social stigma • Prejudicial attitude and discriminatory behaviors directed towards those individuals with a label of mental illness • Self • Perceived and internalized discrimination by the person suffering from mental illness

28. Ways to combat mental health stigma • Educate • Be conscious of language • Encourage equality between physical and mental illness • Show compassion for those with mental illness • Promote empowerment over shame • Be honest about your own journey with mental illness • Be an advocate for those who can’t

29. resources • Some companies and many universities will provide a certain number of counseling sessions to employees/students free of charge. • A therapist or psychiatrist may be seen either face to face or online • National Suicide Prevention Lifeline • 1-800-273-TALK or live online chat • SAMHSA Treatment Referral Helpline • 1-877-SAMHSA7

30. references • The National Institute of Mental Health – www.nimh.nih.gov • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. • Lyness MD. Unipolar depression in adults: Assessment and diagnosis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on October 2, 2018) • Baldwin MA, DM FRCPsych. Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on October 2, 2018) • Centers for Disease Control - www.cdc.gov • National Alliance on Mental Illness - www.nami.org • Thase MD Connolly MD. Unipolar depression in adults: Management of highly resistant (refractory) depression. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on October 8, 2018) • Nolan R. Williams, Boris D. Heifets, Christine Blasey, Keith Sudheimer, JaspreetPannu, Heather Pankow, Jessica Hawkins, Justin Birnbaum, David M. Lyons, Carolyn I. Rodriguez, Alan F. Schatzberg. Attenuation of Antidepressant Effects of Ketamine by Opioid Receptor Antagonism. American Journal of Psychiatry, 2018; appi.ajp.2018.1