MENTAL HEALTH PROGRAM

Isabelita M. Samaniego MD
 Session Objectives
1. To discuss the magnitude of mental
health problems .
2. To define terms : mental health,
mental ill health, mental disorder
3.To describe the four facets of mental
health problems.
4. To discuss the stages of mental
health development.
5. To describe the goals and objectives
of DOH regarding mental health.
 Situationer
International
Studies
1% of population –
have severe mental
& neurological
disorder
4-5% mild- moderate
neurological
problems –alcohol &
drug abuse
 Situationer
Local studies:
36/1000 adults, children & adolescence-
Pampanga
17 % adults & 16 % of children
-Sampaloc Manila – Depressive
reactions & adaptation reaction.
12 cases / 1000 population adult
schizoprenia-Bulacan
 Situationer
Local studies:Region 6 adult
Psychosis- 4.3%
Anxiety – 14.3%
Panic- 5.6%
Children & adolescent:
Enuresis- 9.3%
Speech & language disorder- 3.9%
Mental subnormality- 3.7%
Adaptation reaction – 2.4%
Neurotic disorder – 1.1 %
 Situationer
DOH Mental Health resources:
Total Bed Capacity – 5465
NCR- 4200 beds
CAR-40
Region 2- 200
Region 3- 500
Region 11- 200
Regions 1,4,10,12,Caraga, ARMM- none
27- DOH medical centers- mental health facilty
Cavite- is the only province with mental health
facility.
Need to train health manpower
 Magnitude of Mental
Disorders
10-15% of adult population
affected
20% of patients seeking primary
health care have one or more
mental disorders, though not
recognized
One in four families have at least
one member with a behavioral or
mental disorder at any point in
GLOBAL BURDEN OF DISEASE
The GBD study offers significant surprises:

The burdens of mental illnesses, such as

depression, alcohol dependence and
schizophrenia, have been seriously
underestimated by traditional approaches that
take account only of deaths and not disability.

While psychiatric conditions are responsible for

little more than one per cent of deaths, they
account for 12% of disease burden world wide
and for 24% in the Americas
 Mental Health
A state of well
being where a
person can realize
his or her own
abilities , to cope
with normal
stresses of life
and work
productively.
 Mental Ill Health
Disturbance in a
person’s thoughts ,
feelings and
behavior.
It affects and is
affected by a
person’s interaction
with others, one’s
environment and
even one’s own self
esteem.
 Mental Disorder
Medically
diagnosable
illness that results
in significant
impairment of
one’s cognitive,
affective or
relational abilities
and is equivalent
to mental illness.
 Four Facets of Mental
Health Problems
Defined Burden-
Burden currently
affecting persons
with mental
disorders and is
measured in terms of
prevalence and other
indicators such as
the quality of life
indicators and
disability adjusted
life years. ( DALY)
 Four Facets of Mental
Health Problems
Undefined Burden- Burden
related to the impact of mental
health problems to persons
other than the individual
directly affected.
Felt heavily by the families &
communities both human &
economic loss
Mental ill health affects the
person’s functioning , thinking
process, diminishes the persons
social role and productivity to
the community.
Tremendous burden on
emotional & socioeconomic
capabilities of relatives who
care for the patient .
 Four Facets of Mental
Health Problems
Hidden burden Refers
to the stigma & violations
of human rights.
A mark of shame ,
disgrace or disapproval
that results in a person
being shunned or
rejected by others.
Generally increases as
his behavior differs from
that of the norm.
 Four Facets of Mental
Health Problems
Future burden –
burden in the future
resulting from the
aging of the
population ,
increasing social
problems and unrest
inherited from the
existing problem.
 Bare Facts of Mental
Health
450 million of people worldwide are affected
by mental, neurological, or behavioral
problems at any time
About 873,000 people die by suicide every
year
People with these disorders are often
subjected to social isolation, poor quality of life
and increased mortality causing staggering
economic and social costs
1 in 4 patients visiting a health service has at
least 1 mental, neurological or behavioral
disorder, but most these disorders are neither
diagnosed nor treated.
Mental illnesses affect and are affected by
chronic conditions such as CA,CVD, DM &
HIV/AIDS. Untreated, they bring about
unhealthy behavior, non-compliance with
prescribed medical regimens, diminished
immune functioning and poor prognosis

Barriers to effective treatment of mental

illness include lack of recognition of the
seriousness of mental illness and lack of
understanding about the benefits of
services
 Why a mental health Reform?

To fight against the violation of

human rights of people with
mental disorders
For clinical reasons
For economic reasons
For scientific reasons
To respond to the expectations of
users and families
Mental Health in the Different Stages of
Life
18th week – fetus reacts to
various stimuli passing the
amniotic sac such as
sound,( music,noise)
substances ( drugs,
alcohol.
Infancy- the psychosocial &
cognitive development is
affected by the absence of
the care taker, mother.
First Crisis -Trust vs mistrust
Consistent mothering is
important
Mothers living in conditions
of stress and adversity
Mental Health in the Different Stages of
Life
Toddler stage – greatly
affected by motor and
intellectual development .
Child learns to master
locomotion and impulses.
Crisis- asserting
independence against
shame and doubt.
The need for control &
firmness on the part of the
caretaker
Negative exposure &
punishment may cause
shame & develop self doubt
on the child.
Mental Health in the Different Stages of
Life
Pre school age – the child
can express complex
emotions : love,
unhappiness, jealousy and
envy which are influenced
by hunger & tiredness .
Aware of their bodies,
genitalia & gender
differences .
Concept of what they want
& need- leads to choices
between desire, the need to
grow outside the homes &
what parents restrict
turning parental values into
self regulating mechanism
( obedience, guidance &
punishment)
Milestone- development of
Mental Health in the Different Stages of
Life
School age – Education
plays a big role in
facilitating the child’s well
being & healthy social &
emotional growth.
They should be taught skills
to improve their
psychosocial competence.
Problem solving, critical
thinking, communication,
interpersonal skills ,
empathy and coping with
emotions.
Children & adolescent –
develop a sound & positive
mental health.
Mental Health in the Different Stages of
Life
Adolescence-
psychosocial concerns :
acceleration of cognitive
development ,
consolidation of
personality formation
and development of
morals.
Adulthood:-
Very productive age
Mental health concern-
work related problems
Emphasis- aspects of
work process that
promote mental health.
Concerns of Daily Living
Psychological
consequences &
suffering brought
about by :
Migration
Urbanization
Industrialization
Economic policies
Political confusion
Poverty & abuses
Victims of disaster
Violence & armed conflict
OFW’s & children in difficult
circumstances are exposed
to depressive circumstances
Mental Health in the Different Stages of
Life
Elderly- Aging population
is a result of increased
life expectancy as a
result of improved
quality of life
Must be able to live their
life full of potential.
Healthy older person is a
resource for the family,
community and
economy.
 Depression Burden
4th leading cause of burden among all
diseases

2nd leading cause among 15-44 year

age group

Among women in 15-44 year age

group, the amount reaches 10.6%
 Epidemiology
Ranks fourth among the major cause of
disability worldwide.
17% of population will suffer from this
during their lifetime.
Recurrent, despite newer medications
rates increases / age of onset is
decreasing.
2020- it will the second major cause of
disability , economic burden will be 2nd
to CAD
 Epidemiology
Depressive illness is more common in
the presence of :
1. Physical illness, chronic, painful or
stigmatizing
2. Excessive and chronic alcohol use
3.Social stresses, loss events
4. Interpersonal difficulties- social
humiliation
5. Lack of social support, with no
confiding relationship.
 DSM IV CRITERIA :
MDE/MDD
Major Major
Depressive Depressive
Disorder: Episode:
Accompanied by Follows a
co morbid psychosocial
conditions stressor
Childbirth
 DSM IV criteria : for
MDD/MDE
Five of the ff symptoms during the
two week period first two criteria
impt;
1. Depressed mood- most of the day
2. Markedly diminished interest or pleasure in
all activities
3. Significant weight loss or weight gain=
markedly decrease or increased in appetite
4.Vague physical symptoms: dizziness,
headache,weakness , muscle pains,other
physical symptoms
 DSM IV criteria : for
MDD/MDE
4. Insomnia or hypersomnia nearly
everyday.
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7.Feeling of worthlessness or excessive
inappropriate guilt.
8. Diminished ability to think or
concentrate.
9.Recurrent thoughts of death, suicidal
ideation
 DSM IV criteria : for
MDD/MDE
The symptoms do not meet the criteria
for mixed episode:
The symptoms cause clinically
significant distress or impairment in
social , occupational or other important
areas of functioning.
The symptoms are not directly due to
substance ( meds) or medical condition.
The symptoms are not due to
bereavement
Symptoms persists for more than 2
Treatment of Depression
Pharmacotherapy - most effective
intervention.- both for treatment
and relapse
Psychotherapy – adjunct in
refractory cases
ECT
 Psychosocial Therapy
1. Cognitive behavioral therapy- aims to
address irrational belief and distorted attitudes
towards self , environment and future of
patients.
2. Behavior therapy- specific techniques
including self control therapy , social skills
training, activity scheduling and problem
solving.
3. Interpersonal therapy- focuses on losses,
role disputes and transitions, isolation, deficits
in social skills .
 Psychosocial Therapy
4. Psychodynamic psychotherapy- It
focuses on conflicts related to guilt,
shame, interpersonal relationship,
management of anxiety, and repressed
unacceptable impulses. Some
techniques focuses on developmental
psychological deficits between the child
and the emotional;caretakers resulting
in the problem of self esteem.
5. Marital and Family therapy-
 Schizophrenia Burden
3rd most disabling condition among
15-44 years age group

About 10% of persons with

schizophrenia die by suicide

Reduces life span by an average of

10 years
 Definition
A clinical syndrome characterized
by profound disruption in cognition
& emotion , affecting the most
fundamental attributes : Language,
thought , perception, affect &
sense of self.
 Epidemiology
Lifetime prevalence: 0.9-11 cases
per 1000 population
Sex: equally prevalent
Age: Men between 15-25 yrs
Female 25-35
 Epidemiology
Birth & fetal complications are
common
Perinatal complications
Increased risk is unknown:
A) Genes
B) Hypoxia
C) Lower social class
 Etiology
Dopamine excess
Serotonin hyperactivity
Norepinephrine & GABA
Major Neuroanatomical theories-
involving the limbic system,
cortex, basal ganglia –
thalamocortical neural circuit
Genetic hypothesis
 Genetic
Population Prevalence %

Non twin Siblings of 8

Schizophrenic patient
Child with one 12
schizophrenic pt
Dizygotic twin of 12
schizophrenic pt
Child of two 40
schizophrenic pts
Monozygotic twin of a 47
schizophrenic Pt
 DSM IV Criteria
A. Two or more of the following , each
presenting for a significant portion of
time during a one month period
• Delusion
• Hallucination
• Disorganized speech
• Grossly disorganized catatonic
behavior
• Negative symptoms
 DSM IV Criteria
B. Social/ occupational
dysfunction
C. Continuous signs of
disturbance persist for at least six
months.
One month of symptoms that
meet criterion A & may include
periods of prodromal or residual
symptoms.
 DSM IV Criteria
D. Schizoprenia disorder and
mood disorder with psychotic
features have been ruled out
because:
A) No major manic, depressive ,
mixed episodes
B) If mood episodes occurred
during the active phase
symptoms , the duration is brief.
 DSM IV Criteria
E. Disturbance is not due to a
substance or medical condition.
F. If there is a history of autism or
developmental pervasive
disorder, schizophrenia diagnosis
can be made if hallucination or
delusion is prominent within one
month.
 Treatment
Consultation
Hospitalization- propensity to
harm
Pharmacotherapy:
• Rapid neuroleptics
• Antipsychotics :
a) DOPA receptor antagonist
b) Serotonin – dopamine
 Treatment
Acute Dose Maintenanc
Mg/day e
Haloperidol 20-60 Dose
5-20
mg/day
Chlorpromazine 300-1000 50-400

Levomepromazi 300-1000 25-300

ne
 Burden of Alcohol Use
Disorders
All Ages and both sexes 1.3 %

All ages, males 2.1 %

15-44 year olds, both sexes 3.0 %

15-44 year olds, males 5.1 %

 The Violent Patient
Assess the patient for the cause of
the violence
Assist in controlling the acute
situation
Make a prediction of future
violence
 Questions
What was the reason for the admission at the
ER?
Is the patient actively violent or only verbally
threatening?
Does the patient have a weapon?
Does he have a previous history of similar
problem?
How did the patient arrived at the hospital?
What are his present medications?
Has the patient been using alcohol or drugs?
 Causes of Violent or
Combative Behavior
Psychiatric causes
Substance- induced causes
Neurologic causes
General Medical causes
The most effective management is
the identification & treatment of
the underlying cause.
 Major threat to life
Potential threat to life of the staff ,
other patients & to himself
His/ her life maybe jeopardized if
serious medical problem is left
untreated.
General Medical Causes
Hypoxia
Hypoglycemia
Hyponatremia/ Hypernatremia
Electrolyte disturbance
Vit B12 deficiency / folate
Hyper & Hypothryroidism
Systemic Infections
Hepatic encephalopathy
Renal diseases
SLE
 Neurologic Causes
Seizure disorders
Meningitis/ encephalitis
Intracranial bleed
Dementia
Tumors
Wernicke’s encephalopathy
Stroke
Multiple sclerosis
 Psychiatric Causes
Schizophrenia
Mania
Delusional disorders
Major depression ( If psychotic/ agitated)
Impulse control disorders
Post –traumatic stress disorders
Personality disorders
Mental retardation
Dissociative disorders
Substance Induced Causes
Alcohol
Benzodiazepines
Methamphetamine / cocaine
Anticholinergics
Steroids
Neuroleptics
Poisons
Evaluate the Mental Status
Posture ( tense/ restlessness)
Manner ( threatening / demanding)
Speech( loud, cursing, slurred)
Motor activity (gesturing, pacing, destroying
property)
Thought processes ( Logical, illogical,
disorganized)
Thought content( paranoid, delusional)
Perceptions ( Illusions, auditory, visual,
command, hallucinations)
 Selective History
Previous history of violent behavior
Patient under arrest?
Circumstances of the arrest?
Before approaching the patient
remove any object in your body
that can be used as a weapon
against you.
Women MD should not wear
dangling earrings.
Hospital IDs should not be worn in
the neck , break away chains
should be used
Approach the patient slowly,
relaxed with hands visible
Announce your intention in
advance before any action
Do not make quick or unexpected
movement
Always remain 3-6 ft away from
the patient
Stand sideways firmly on your feet
Do not turn your back on the
patient until you are 15-20 ft away
Asses the patient for the possibility
of possessing a weapon
In the ER the patient is usually
searched before evaluation.
Do not assume that this has been
done.
If you suspect that he has a
weapon ask him directly
If you are not satisfied with his
answer tell him to surrender it by
putting it on the floor or desk.
Security guard must disarm the
patient
Never ask the patient to hand you
the weapon.
No matter how agitated the patient
is, speak slowly, calmly & firmly.
Make sure that the environment
has the least stimuli as possible.
Give him enough space, the staff
including you should be positioned
nearest top the exit.
The best intervention is to actively
listen to his problems in a non
judgmental manner.
Ask patient to describe the trouble.
If he request for a reasonable
concern comply or support if not
stand firm to the rules.
If the patient is amenable to verbal
redirection, invite the patient to sit
down & discuss the problem.
Often the “ violent patient” is
fearful of his situation
He may feel abandoned , ridiculed
or misunderstood, his behavior
maybe his crude attempt to be
heard.
 Drug Regimen
Haloperidol – ( Haldol) 5 mg
Benzodiazipine –
Diphenhydramine ( Benadryl) – 25-
50 mg & Benztropine Mesylate
(Congentin) 1-2 mg { Avoid
extrapyramidal side effects.
IM or IV ,medication for moderate
to severely agitated patients.
Restrain if necessary but at a
limited period of time.
Do not place him in an isolation
room – disastrous
One on one staff observation is
advisable
Once safety is established further
assessment of the psychiatric &
medical condition must be done
Review vital signs & check for
symptoms of drug or alcohol
withdrawal
If the patient made verbalized
threats to anyone that must be
taken seriously.
Document all your concerns in the
chart
 Remember
It is your responsibility to help the
patient to restore his or her
composure in the least restrictive
yet safest manner possible.
Because it is impossible to assess
impulsivity & dangerousness with
certainty, take whatever measures
are necessary to ensure patient &
staff safety.
 Goal
Mental Health is
promoted and
health related
effects of stressful
lifestyle is
mitigated. The
prevalence of
mental health
disorder is
reduced.
Health Status Objectives
1. Reduce by 1 % the prevalence of
mental health problems, major
depressive disorders, schizophrenia,
alcohol & drug abuse. ( Baseline data
established in 2000).
2. Reduce by 5% the members of the
workforce who have experienced
adverse life experiences as
consequences of stress in the workplace
( Special target groups government
employees) Baseline 2000)
Risk Reduction Objectives
1. Increase the proportion of high risk
population ( victims of violence &
disasters, OFW’s, children in extremely
difficult circumstances &
adolescents)who seek help for personal
& emotional problems. ( Baseline 2000)
2. Increase the proportion of the
members of the workforce who avail of
stress management services ( Special
target grp gov’t. employees) baseline
2000
Risk Reduction Objectives
3. Increase the proportion of
children who avail of psychological
stimulation & assessment for
mental health. Baseline 2000
Services & Protection Objective
1. Establish & upgrade existing mental health
facilities. ( baseline 2000)
2. Upgrade existing competencies on mental
health professionals & health care providers .
Baseline 2000
3. Increase the percentage of health care
facilities, workplaces & communities that
provide mental health services.
4. Develop self help & family care program.
5. Increase the capability of health facilities for
psychosocial assessment & screening of
mental disorders. ( Baseline data 2000)
THE CARROT, THE EGG
AND THE
COFFEE BEAN
Put three pots of water over the
fire.
In the first pot, put some carrots.
In the second pot, put some eggs.
In the third pot, put some coffee beans
that have been grounded into coffee
powder.
The carrots went in hard.
They are now soft.

The eggs went in soft inside.

Now they are hard inside.
 The coffee
powder has
disappeared.

But the water has

the color and the
wonderful smell of
coffee.
Now think about life.

Life is not always easy.

Life is not always

comfortable.

Sometimes life is very

hard.
 Things don’t happen
like we wish.

People don’t treat us

like we hope.

We work very hard but get few results.

What happens when we face difficulties?
difficulties
The boiling water is like
the problems of life.
We can be like the carrots.

We go in We come out
tough and strong. soft and weak.
We get very tired.
We lose hope.
We give up.

There is no more
fighting spirit.

Don’t be like the carrots!

We can be like the eggs.

We start with a We end up very

soft and hard and
sensitive heart. unfeeling inside.
We hate others.
We don’t like
ourselves.
We become
hard-hearted.

There is no warm feeling,

only bitterness.
Don’t be like the eggs!
We can be like the coffee beans.

The water does

not change the
coffee powder.

The coffee
powder changes
the water!
The water has become different because
of the coffee powder.

See it.
Smell it.
Drink it.

The hotter the water, the better the taste.

We can be like the coffee beans.

We make something good from

the difficulties we face.

We learn new things.

We make the world around us better.
Stress gives us the chance to
become stronger…
stronger and better…
better
and tougher.
tougher
Be like the coffee bean!
 PRAYER
“LORD, give me the serenity
to accept the things I
cannot change, the courage
to accept the things I can,
and the wisdom to know
the difference. Amen.”