Mental Health in the Primary Care Setting

February 9, 2013 Lynette Melby, MS, FNP-BC

Horizon Proprietary

Me
CNA RN BSN MS Board Certified as Primary Care Provider Specialize in Behavioral Health Telehealth provider for Horizon Healthcare Research / Sub-investigator Locum Tenens as Primary Care Provider

Therapy Assistant..Walter

Medical & Behavioral Health Family

What is mental health?

Mental health is how we think, feel and act as we cope with life. Determines how we handle stress How we relate to others How we make choices

Like physical health, it is important at every stage of life.

Self-Stigma?
Too many people believe that admitting mental distress makes them weak Self-stigma can prevent someone from getting help Reluctant to talk about how they feel Can cost lives

You may have to help others recognize when they might need help from a professional

Mental Health Statistics

According to the National Institute of Mental Health
Mental health disorders affect tens of millions of people each year in the U.S. Only a fraction of those with a disorder receive treatment (36%) In a given year approximately one quarter of adults are diagnosable for one or more disorders Average age of onset is 14 years old

Horizon Proprietary

Medical Conditions
Very important to look at the whole picture Medical conditions can have the same symptoms of depression
Hypothyroid Anemia Hormone levels for women
Think menopause

Hormone levels for men

Low testosterone

Medical conditions can cause anxietyphysically

Hyperthyroid

Treatment: Behavioral Health Puzzle Pieces

Psychotherapy Medication Genetics Community Support Environment
Family School Work

Depression
Common but serious illness Most need treatment to get better Different forms of depression
Major depressive disorder, or major depression Dysthymic disorder, or dysthymia Minor depression Psychotic depression Postpartum depression Seasonal affective disorder (SAD)

Questions to Ask
Are you tired and irritable all the time? Have you lost interest in work, family, hobbies? Having trouble sleeping? Feeling angry or aggressive? Sad? Worthless? Been feeling like this for weeks or months?

Suicide
11th most common cause of death in the U.S. Highest risk of suicide: white men Women and teens have more attempts If someone talks about suicide you should take it seriously National Suicide Prevention Hotline available 24/7 1-800-273-TALK (8255) Treating mental illnesses and substance abuse can reduce the risk of suicide

Self-Harming Behaviors
Self-harming behaviors do not stem from a desire to die, but may be life threatening
Cutting Burning Hitting Head banging Hair pulling Erasing skin

May self-harm to regulate emotions, to punish themselves, or to express pain

How Stress Affects Your Health

Chronic stress lowers immunity
More frequent and severe viral infections Vaccines such as flu shot are less effective

Digestive, excretory, and reproductive systems stop working normally Can lead to headaches, sleeplessness, depressed mood, anger and irritability Over time may lead to heart disease, high blood pressure, diabetes, depression, anxiety disorder, and other illnesses

Stress
Brains response to any demand Everyone feels stress and not all stress is bad Many things can trigger this response, including change The effects of stress build up over time

Anxiety
Normal reaction to stress that can be beneficial in some situations Anxiety can become excessive May have difficulty controlling it May negatively affect day-to-day living Many forms of anxiety disorders Collectively among the most common mental disorders experienced by Americans

Anxiety Disorders
Anxiety, NOS Generalized Anxiety Disorder Panic Disorder Obsessive Compulsive Disorder Post-Traumatic Stress Disorder Social Phobia Agoraphobia

Prevalence of Anxiety Disorders

OCD
People feel the need to check things repeatedly or Have certain thoughts or perform routines and rituals over and over Thoughts and rituals cause distress and get in the way of life Frequent upsetting thoughts are called obsessions To try to control the thoughts, will feel an overwhelming urge to repeat certain rituals or behaviors called compulsions Cant control these obsessions and compulsions

Post-Traumatic Stress Disorder (PTSD)

Anxiety disorder that some people get after seeing or living through a dangerous or traumatic event When in danger, its natural to feel afraid Fear triggers many split-second changes in the body This flight-or fight response is a healthy reaction Meant to protect a person from harm In PTSD this reaction is changed or damaged With PTSD feel stressed or frightened even when no longer in danger

Insomnia
Sleep disorder in which there is an inability to fall asleep or to stay asleep as long as desired Insomnia is both a sign and a symptom that can accompany several sleep, medical, and psychiatric disorders Insomnia is typically followed by functional impairment while awake Can occur at any age, but particularly common in the elderly

Bipolar Disorder
Formerly called manic-depressive illness Brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks Symptoms are severe Different from normal ups and downs that everyone has Often develops in late teens or early adult years At least half of all cases start before age 25

Bipolar Disorder Symptoms

Experience unusually emotional states that occur in distinct periods called mood episodes Overly joyful or overexcited state is called a manic episode Extremely sad or hopeless state is called a depressive episode Mixed state includes both mania and depression May be explosive and irritable during a mood episode

Bipolar Disorder Management

Not easy to spot when it starts Symptoms may seem like separate problems and not recognized as part of a larger problem Some people suffer for years before they are properly diagnosed and treated Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a persons life

Schizophrenia
Chronic, severe, and disabling mental disorder characterized by deficits in thought processes, perceptions, and emotional responsiveness Positive symptoms may include
Delusions Thought disorders Hallucinations

Paranoia

Schizophrenia
Negative symptoms
Those symptoms found among people who do not have the disorder but that are missing or lacking among individuals with schizophrenia
Avolition (a lack of desire or motivation to accomplish goals) Lack of desire to form social relationships

Positive symptoms
Psychotic behaviors not seen in healthy people Often lose touch with reality Sometimes severe and sometimes hardly noticeable

Hallucinations in Schizophrenia
Things a person sees, hears, smells, or feels that no one else can hear, smell, or feel Voices are the most common type of hallucination in schizophrenia Voices may talk to the person about his or her behavior, order the person to do things, or warn the person of danger Sometimes the voices talk to each other May see people or objects that are not there Feel things like invisible fingers touching their bodies when no one is near

Delusions in Schizophrenia
False beliefs that are not part of the persons culture and do not change Person believes delusions even after other people prove that the beliefs are not true or logical Can have delusions that seem bizarre, such as believing that neighbors can control their behavior with magnetic waves May believe that people on television are directing special messages to them Sometimes believe they are someone else, such as a famous historical figure

ADHD / Attention-Deficit Hyperactivity Disorder

One of the most common childhood disorders Can continue through adolescence and into adulthood Symptoms can include
Difficulty staying focused and paying attention Difficulty controlling behavior Hyperactivity (over-activity)

Types of ADHD
Combined Type Primarily Hyperactive Primarily Inattentive
Formerly known as ADD

ADHD / Children & Adolescents

ADHD / Adult

Adult ADHD
Adults with ADHD may have difficulty Following directions Remembering information Concentrating Organizing tasks Completing work within time limits Adults with ADHD may have Had a history of poorer educational performance and were underachievers Had more school disciplinary actions

ADHD: Common Behaviors & Problems

Chronic lateness and forgetfulness Employment problems Low self-esteem Impulsiveness Substance abuse or addiction Mood swings Relationship problems

Personality Disorders
An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it These patterns tend to be fixed and constant across situations Typically perceived to be appropriate by the individual even though they may markedly affect their day-to-day life in negative ways

Types of Personality Disorders

Antisocial personality disorder Avoidant personality disorder Borderline personality disorder

Borderline Personality Disorder

Serious mental illness marked by unstable moods, behavior, and relationships Characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior May experience intense bouts of anger, depression, and anxiety that may last for only a few hours or a day Problems with regulating emotions and thoughts Impulsive and reckless behavior High rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides

Borderline Personality Disorder

As many as 80% of people with Borderline Personality Disorder have suicidal behaviors About 4% to 9% commit suicide

Eating Disorders
Eating disorders are marked by extremes A person experiences severe disturbances in their eating behavior, such as
Extreme reduction of food intake Extreme overeating Feelings of extreme distress or concern about body shape or weight

Types of eating disorders

Anorexia Nervosa Binge Eating Disorder Bulimia Nervosa

Alcohol Abuse
Recognizing a drinking problem is not always easy Abusers sometimes just thought of as partiers Unhealthy drinking patterns can include
Drinking every day Drinking too much at a time

Can lead to strained relationships, missed work, trouble keeping a job, and difficulty finishing what you start Legal problems

Prescription Drug Abuse

In 2010 approx. 7 million persons were users of psychotherapeutic drugs taken non-medically
Pain relievers 5.1 million Tranquilizers 2.2 million Stimulants 1.1 million Sedatives 0.4 million

Among adolescents, prescription and over-thecounter medications account for most of the commonly abused illicit drugs by high school seniors
(National Institute on Drug Abuse)

Dementia
Dementia: Umbrella term describing a variety of diseases A loss of brain function that occurs when nerve cells in the brain die or no longer function normally Affects memory, thinking, language, judgment and behavior Alzheimers disease is one form of dementia that gets gradually worse over time 60 80% of dementias are Alzheimers disease Most types of dementia are nonreversible As dementia worsens symptoms interfere with the ability to take care of yourself Need complete physical exam including neurological exam

Alzheimers Disease
1 in 8 older Americans has Alzheimers disease Impairs an individuals ability to carry out such basic bodily functions as walking and swallowing Ultimately fatal 6th leading cause of death in the U.S. Over 15 million Americans provide unpaid care for a person with Alzheimers or other dementias No cure Goal of treatment is to slow progression
(2012 Alzheimers Disease Facts and Figures, Alzheimers Association)

Autism
Part of a group of disorders called autism spectrum disorders (ASD) Also sometimes referred to as pervasive developmental disorders Characterized by
Deficits in social interaction Deficits in verbal and nonverbal communication Engagement in repetitive behaviors or interests

1 in every 110 eight-year old children were diagnosable for an ASD (2006)

Special Populations: Veterans

Challenges for both the veteran and his/her family Readjustment to civilian life Everything has changed Anxiety Job Housing PTSD Substance abuse

Special Populations: Farmers

Prone to chronic stress And Depression Weather Little time off Financial stressors Governmental regulations Generational tension

Farmers put the farm first and themselves last

Women
Stress of being Super Woman Children Relationships Hormones.too much?.too little? Empty nest Menopause

Guilt.Guilt.Guilt

What helps?
Support from family & friends Spiritual resources Find time to take care of yourself and relax Healthy lifestyle & diet Regular exercise Treatment

What to do in your clinic?

Depends upon resources in your community Depends upon seriousness of mental health issue Refer to therapy Refer to provider for medication If you are worried NOW
Is there family involved? Take to ER Call local police