Could it be a mental illness?

Could it be a mental illness? How to encourage someone to get help Allan Fielding M.D., F.R.C.P.(C)

Outline of the presentation • 1. What are the warning signs that someone might be developing a mental illness • 2. Approaching the person with your concerns and preparing the groundwork • 3. Accessing help (including legal interventions)

What is a mental illness • An illness produced through a complex interaction of biological, psychological and social factors, which shows up primarily through alterations in emotions, thinking, relationships and/or behavior

The spectrum of mental illness • Over 50 different types of mental illness have been identified • Clustered into broad groupings: • Schizophrenia Spectrum Disorders • Affective (Mood) Disorders • Anxiety Disorders • Personality Disorders • Substance Abuse Disorders

Getting help • 1 in 5 will experience a mental illness in their lifetime • Almost half of all people with a depression or anxiety disorder have never gone to see a health professional about this problem • Only 1/3 of those who need mental health services in Canada actually receive them

Getting help • High stigma: • only 50% of Canadians would disclose that a family member has a mental illness • 46% of Canadians think people use the term “mental illness” as an excuse for bad behavior • Mental illness second leading cause of disability and premature death • 4 of top 10 leading causes of disability worldwide

Part 1 What are the warning signs that someone might be developing a mental illness?

Warning signs • Mood related symptoms • Sad, euphoric, irritable, withdrawn • Physical / bodily symptoms • Sleep, energy, appetite, weight • Mental functioning • Concentration, memory, decisions • Ability to function in their usual roles • School, work, home, kids, leisure

Warning signs • Measures of severity and persistence: • Symptoms cause clinically significant distress or impairment in functioning • The symptoms have been present for several weeks • This represents a change in functioning from previous levels

Depression • Mood • Sad, depressed, tearful or empty • Express feelings of worthlessness, uselessness • Physical • Trouble falling asleep and early morning awakening • Loss of appetite with significant weight loss • Fatigue, loss of energy

Depression • Mental • Trouble with memory, concentration • Loss of creativity, problem solving • Roles • Drop off in leisure, pleasurable activities, sex drive, self-care • Difficulties with work or school

Depression in Teens • Irritability often the main symptom • Hostile, grumpy, easily lose temper, rage • Unexplained aches and pains • Problems at school and home • Extreme sensitivity to criticism • Stemming from feelings of worthlessness • Selective withdrawal

Depression in the elderly • Lack of self care • Fatigue • Abandoning pastimes • Social isolation / withdrawal • Loss of appetite • Sleep disturbances • Loss of self-worth • Increased use of alcohol • Fixation on death • Sad / empty • Worsening of pain

Mania • Mood • Euphoric, irritable or hostile, hard to interrupt, never stop • Easily excited to enthusiasm or anger • Physical • Decreased need for sleep without fatigue • Increase in activities • Restlessness

Mania • Mental • Distractible, difficulty finishing tasks • Racing thoughts, disjointed thinking • Rapid or pressured speech • Overspending, poor judgment, impulsive • Inappropriate humor, behavior • Roles • May initially be hyper-productive, followed by disorganization

Psychosis • Mood • Inappropriate laughter or other emotions • Loss of interest or pleasure, • Flattening of mood • Increasing isolation, withdrawn • Physical • Day-night reversal • Deterioration of personal hygiene

Psychosis • Mental • Suspicious, odd behavior, odd thinking or associations • Preoccupied with their inner world • Distractible, concentration & memory problems • Roles • Withdrawal from usual roles, isolation

Drug or alcohol abuse • Mood • Unexplained change in personality or attitude • Unstable mood, mood swings • Lack of motivation, fearful, anxious, paranoid • Physical • Smells on breath, body, clothing • Signs of intoxication • Change in appetite, sleep, self-care

Drug or alcohol abuse • Mental • Difficulty concentrating (episodic) • Secretive or suspicious behaviors • Roles • Drop in attendance and performance • Unexplained need for money • Change in friends, activities

Red flags • Distinctly psychotic behavior (bizarre, responding to inner world, voices, delusions) • Violence, towards self or others • Expressed suicidal thoughts or any kind of suicide note • Giving away treasured or special possessions • Potentially self-injurious behavior • Marked drop-off in performance in usual roles

Warning signs: conclusions • Each illness has its own set of early symptoms • Usually a significant change from usual • Red flags exist which signal an emergency • Often missed - we write them off as a phase, explain away, remain unaware, or don't want to see • Useful to have open discussion with other family members

Part 2 Approaching the person with your concerns and preparing the groundwork

Approaching the person • Do your homework first: assemble your thoughts and observations, even make notes. Try it out on yourself first - would you be convinced? • Talk with other people (family, friends, teachers, pastor etc.) to help validate your perceptions. Sometimes it is “hard to see the forest for the trees”

Approaching the person • Pick or set (without being overly melodramatic) a time to talk that will allow you to comfortably explore your concerns • Allow for the possibility that you might have to come back to the subject at a later time, and that your first talk might be relatively short • We have two ears and one mouth – allow more time for listening than talking

Approaching the person • Try to use "I" statements rather than "you" statements • Think of the “sandwich” method • Allow it to be face-saving ("I understand you might be going through rough times these days...") without writing it off as just a phase

Approaching the person • Think of what attitudes towards mental illness have already been expressed in your household and how this might shape your own attitude and the attitude of your loved one • Get as many people involved as necessary but don't gang up on the person. See if you have consensus in the family

Approaching the person • Consider using a trusted third party to do the approaching, either with you or instead of you. • Be prepared for defensiveness, but remember and remind what are the drivers behind this conversation: changes in behavior, love and concern for their wellbeing

Approaching the person • Be especially open about the red flags, and broach the subject of suicide. You will never suggest it to someone for the first time. • Keep trying to imagine what this must feel like from their point of view • If they try to reassure you, try to negotiate a watchful waiting period and a re-discussion in a few weeks

Approaching the person • Sometimes "Help me understand..." is better than "I understand". It shows you really want to hear their story • Shame and embarrassment can be important reasons people don't want to talk about what is going on or seek help. • Commit to trying to be non-judgmental and understanding, but especially that you put their wellbeing above all other priorities, and would make your best effort to understand. • "Try me”

Special circumstances:Sexual orientation • Realization of sexual orientation and “Coming-out” often can occur at very vulnerable times in person’s development • Psychological stage of identity development • Relationship to peers very important • Member of a group • Homophobic response

Approaching the person • It may take multiple attempts to be able to join with the person and be able to talk • If you can build a link and have some agreement that there is a problem, you can introduce the idea of getting help • Again, try to remember what this must feel like from the other person's perspective

Approaching the person • Verify if you have agreement ("Have you thought about this as well...") and if they have tried something • Ask if they have any ideas or preferences of how to proceed, in particular a trusted person (who you also trust) who might be a starting point. Try to agree on how urgent you feel this is, and therefore what would be a good time frame

Approaching the person • Offer to research some options. If declined, pin down a time frame for them to look and a time to re-discuss • Be prepared to answer their concerns and address their fears. • Many people fear treatment before they have even been diagnosed and a treatment presented to them • Be prepared to help them advocate for treatment that is acceptable to them, as long as it doesn't put them at risk

Approaching the person • Offer accompaniment or anything else that would facilitate them seeking help (eg transportation) • Be aware if anyone is "undoing" your efforts • “Everybody’s an expert” • Inappropriate extrapolation from their own experiences

Approaching the person • Self-rating scales • Check if the person might be open to using a self-rating scale or checklist (see Resources) • May be useful to help elicit symptoms • More emotionally neutral, may be better accepted

Approaching the person: conclusions • Success rate may range from very high to very low • You may not be the best person to approach them, so find the best person and have them do it • Be prepared with a "Plan B" • Be prepared to be patient, but have an idea of what line being crossed would trigger emergency action

Part 3 Accessing care

Accessing care • There are multiple ways someone can access care and all have their pros and cons. • You may be faced with a situation where the first choice of the person is not your first choice, but if the aim of the exercise is to at least get the person started on the road to getting help, you might have to accept a compromise • The point of entry you choose may also be based on the urgency of the situation

Accessing care – Trusted Person • Often times if someone starts with a person in whom they have confidence, that person will be able to build trust and present an objective outside opinion that could lead them to seek other more specific help • Pastor or priest • Counselor at school or university

Accessing care – Family doctor • A GP is another good place to start. A recent survey of GP's in Quebec showed: • 1/3 do a lot of work in psychiatry • 1/3 will handle “easy cases” • GP's are now essential for accessing much of the mental health system • Best if the GP is already known to the person and has the time to do a proper interview

Accessing care - CLSC • CLSC's have been given the mandate to set up Mental Health teams and serve as the entry point (Guichet d'acces). • They usually start with a psychosocial screening (Acceuil psychosociale) where they determine whether you might need social services, a psychologist, or a psychiatric consultation

Accessing care - CLSC • Based on this initial assessment, they can then refer you on to their Mental Health Team where there would be a more in-depth assessment • They may then ask for a psychiatric assessment, either at the CLSC or in a hospital-based MEL Clinic

Accessing care: Emergency Room (ER) • Psychiatric services in most emergency rooms are consultation services • They do not see the person right away • Must be evaluated by the ER doctor • ER doctors may also decide this is not an emergency and refer you to the more regular channels for evaluation

Accessing care: ER • Teaching Hospital • Good chance that you would be assessed by a Resident doctor, who would also have to discuss your case with their Attending Staff. • Rare that it will be the doctor who sees you in the ER who will do the follow-up, so you also have to be mentally prepared to repeat the story several times. • Often do not have your chart

Accessing care: support • Given that all of these means of accessing care can take some time, there is a special and particular role for support during this period: • Encouraging the person to persist • Helping problem-solve • Facilitating the process • Accompaniment (if acceptable) • Getting the story straight

Accessing care: being prepared • Make the best use of the interview time by being prepared with such details as: • Medical history • Lists of medications taken • Family history • A timeline of the important symptoms or developments • A sense of prior functioning • Contact information

Accessing care: interviewing • Be prepared as a family member that you may not be invited in to all of the interview, but if you come along it would be expected that someone should interview you • Confidentiality: the professionals may not be able to share much of their interview with you. While you may not be able to ask, you certainly can tell and this would be the time to express your concerns, particularly about the red flags

Court ordered psychiatric evaluation • When all else fails, you might be left with having to use legal means to get the person assessed • Typically this means taking out a court-ordered psychiatric assessment • Handbook: Practical Guide to Mental Health Rights which can be • Download from Ami Quebec website under “Publications”

Court ordered psychiatric evaluation • A document must be presented to a judge outlining the various facts that make you consider that the person needs a psychiatric evaluation • Suicidal or are in danger of becoming violent towards others. • You, or an interested party (friend, relative) or even a physician if they have knowledge of the person, must provide details of how the person is behaving in such a way as that they are presenting a grave and immediate danger

Court ordered psychiatric evaluation • Facts (he only sleeps two hours a night, he is hitting the walls with his fist, he speaks about throwing himself off the bridge) and not opinions (I think he is depressed) • Family organizations in your area might be able to provide you with some assistance in filling out the forms and getting them piloted through the legal system

Could it be a mental illness?