Mental Health Services in the Puttlam District

Common Mental Health DisordersDr. I.R.Medagama Consultant Psychiatrist,BH PanaduraHealthHealth is a state of complete physical, mental and social well being Mental health is an integral aspect of overall health and well-being

Good Mental HealthA state of well-being in which:The individual realizes his or her own abilities Can cope with the normal stressors of lifeCan work productively and fruitfully Is able to make a useful contribution to his or her community. Situation WorldwideApproximately 450 million people worldwide have a mental illness1 in 5 people have a mental illnessAbout 150 million people worldwide have depression One million people die due to suicide each year

Sri LankaAbout 10% of our population have a mental illness.About 2,000,000 have mental illnessesAbout 2% have major mental illnessesAbout 384,000 have major mental illnesses Mental illnessesMajor public health burden.Disability caused by Mental Illnesses is significantDepression and alcohol abuse are the mental disorders mostly associated with suicides.

Symptoms of mental illnessesPhysical/somatic sleep and appetite disturbances.Deterioration in functioningBehaviour- Symptoms such as aggressive behaviour, suicidal attempts.Feelings emotional symptoms such as fear, irritability and sadnessSymptoms of mental illnessesThoughts abnormal beliefs such as thinking someone is going to harm him/herPerceptual- Symptoms which are not real such as hearing voices, seeing things (hallucinations).Memory problems

Causes of mental illnessesStressful life events Bereavement relationship, family or marital problems, financial/ work related problems. Social isolation, poverty Domestic violence trauma/ war/displacement Natural disasters such as floods, tsunami.Genetic factors.Physical disordersSubstance abuse.

Mental illnessesDepressionGeneralized anxiety disorderPanic DisorderPhobiasObsessive compulsive disorderPost traumatic stress disorder

Mental illnessesSomatoform DisorderDissociate states/Conversion disorderMental illnessesSchizophreniaBipolar affective disorderDementia

DepressionDepression is a leading cause of disability across the world. According to the WHO, depression will rank second only to Heart Disease by 2020 in terms of global disabilityLie time risk of suicide is about 6%-15%1 in 10 people have Depression at some point in their livesCan present as mild, moderate or severe depression.Early detection and treatment important.

Depression - Essential featuresPersistent low moodLack of energyLack of interest and enjoyment

Depression Other featuresSleep and appetite problems Pessimistic and negative thoughtsSuicidal ideation and attemptsIdeas of guilt and unworthinesseduced self-esteem and confidenceReduced concentration. _ Symptoms of two weeks duration.

Case history 132 year old housewife, mother of 2 presented with a history of early morning awakening, reduced appetite, loss of weight and feeling low of two months duration. She admitted feeling lethargic and not enjoying things she enjoyed earlier. She was unable to cope with the daily activities. She cried often and expressed suicidal ideation. Her husband was taking alcohol regularly and verbally abused her and assaulted her frequently.

Case History 27 year old girl presented with a H/O Change of behaviour of two months.Father gone abroad three months back. Was very attached to the fatherStopped playing. Did not watch TV. Cried frequently. School work deteriorated.Later, did not come out of her room, did not eat, poor sleep, school refusal Case History 360 year old male, retired from work recently. Daughter left home 3/12 back.Lack of interest and energy, hopelessness and sadness, low mood, somatic complaints, daily functioning affected. Pessimistic and negative thoughts. Suicidal ideation and plansDepression in adolescentsIrritabilityAggressionIntolerance, being argumentativeDeterioration in school performance and level of functioningAnti-social behaviour and loss of controlAnxietyDifficulties with peers

Management of depressionDrug treatment SSRI, Tricyclics, SNRI( Venlafaxine)Moderate and severe disorders- drug treatment and psychological treatment can be combined.Psychological treatment : Cognitive behaviour therapy/ Interpersonal therapyECT : Severe disorders with high suicidal risk or very poor oral intake. Depressive stupor. Where response to other forms of treatment are poor Management of depression SSRICitalopram : 20-40mg/dayEscitalopram : 10-20mg/ dayFluoxetine : 20-60mg/dayFluvoxamine : 100-300mg/day(given b.d.)Paroxetine : 20-60mg daySertraline : 50-200mg/day

Management of depression Amitriptyline : 50-200mg/dayClomipramine : 50-250mg/dayImipramine : 50-200mg/dayDothiepin : 75-225mg/dayVenlafaxine : 75- 225mg/dayMirtazapine : 15-45mg/day AnxietyFeeling apprehensive, fearful and worried.Autonomic symptoms-palpitations, sweating, shortness of breath, chest pain, dizziness, tremors, headache.Poor sleep, irritability, reduced concentration.Muscle tension-tremors, restlessness, headachePanic attacks and phobic symptoms -Symptoms are persistent

Anxiety disordersPhobias Panic disordersGeneralized anxiety disorderObsessive compulsive disorder

Phobic anxiety disordersPersistent irrational fear with avoidance. Anxiety occurs only in specific situations orin the presence of specific objectsThe person is well at other times.Types of phobias: Simple phobia Social phobia Agoraphobia

Specific phobiasRestricted to highly specific situations such as fears occurring in the presence of certain animals, insects, heights, thunder, going in lifts, fear of closed spaces, sight of blood or injury

Start in childhood

Social phobiaStarts in adolescenceAnxiety related to criticism by others in social situations. Fear of being judged by others and of being embarrassed and humiliated.Avoidance of social situations

Case history 4A 22 year old university student presented symptoms of anxiety such as palpitations, sweating, dry mouth, and tremors whenever he had to talk in front of a crowd. He had severe difficulties in carrying out presentations which were required as a part of his academic work. This lead to him avoiding such situations. Even thinking about facing such situations made him severely anxious. He avoided facing oral examinations when he was compelled to go for such exams performed very poorly. Treatment of social phobiaResponds well to CBT and exposure therapyCBT is more effective than pharmacotherapy1st Line pharmacological treatment is SSRIs.Venlafaxine can be used as second-line treatmentTreatment should be continued for at least six months.AgoraphobiaCharacterized by fear of open spaces and the presence of crowdsAnxiety related to leaving home, going to shops, being in crowded places and public places and when travelling alone in trains, buses.Case history 5A 35 year old housewife presented with symptoms of anxiety in crowded places. She especially found it difficult when she went to the market. She started trembling and had features of anxiety and developed palpitations and fears that she might die. This led to avoiding such situations gradually. Ultimately she avoided leaving her home as far as possible.Panic DisorderRecurrent attacks of severe, unpredictable anxietySudden onset of palpitations, chest pain, choking sensation, dizziness are common.There is secondary fear of dying, losing control or going madCase history 6A 19 year old boy presented with episodes of palpitations, shortness of breath, and chest pain of one months duration. During these episodes, he felt fearful that he might develop a heart attack or he might die. The episodes lasted a few minutes. He was well in between episodes. There was no triggering factor related to the episodes.Management of panic disorderCBT and drug treatment effective.CBT is the treatment of choiceSSRIs, SNRIs, tricylics are effective. SSRIs considered 1st line of treatment.Starting doses of SSRI,SNRI and tricyclics are lower that the doses used for depression as they can initially exacerbate anxiety. The dose has to be adjusted according to the response.

Management of panic disorderTherapeutic effect could be delayed and may take up to 6 weeks. Treatment should be continued at least for 8 months. Antidepressants should be tailed off over several weeks.Little evidence to support the use of benzodiazepinesLittle evidence to support the use of pharmacological and psychological interventions in combination.Generalized anxiety disorderPersistent and excessive anxiety and worrying about everyday life situations.Chronic disorder associated with somatic complaints, high rates of comorbid depression and other anxiety disorders.Treatment of generalized anxiety disorderCognitive therapy is as effective a pharmacotherapy in GAD. Combined therapy effective SSRIs, SNRI, tricyclics are effective as pharmacological treatment. Buspirone is another drug which can be usedSSRIs are the first line of treatmentTreatment is with low initial doses. Dose has to be titrated gradually.If there is no improvement with 12 weeks of optimal treatment, switching to another drug from a different class is recommended. Treatment should be continued for 18 months. Obsessive Compulsive DisorderRecurrent intrusive thoughts (obsessions) or compulsive actsDistressing, arising from their own minds Realizes they are senseless, tries to resist.Obsessional thoughts are ideas, doubts, images, impulsesCommon themes contamination, doubts, sexual and blasphemous thoughtsRepeated acts/rituals (compulsions) are carried out to reduce anxiety- hand washing, bathing, counting, checking rituals.

Obsessive Compulsive DisorderInterference with daily activities.Can develop depressive episodes.

Case History 7A 18 year old girl presented with recurring intrusive thoughts of dirt and contamination. She engaged in repeated hand washing, bathing, and complicated cleaning rituals. She had repeated checking behaviours due to doubts. Daily functioning affected

Case History 8A 65 year old widow presented with a history of repeatedly occurring distressing bad thoughts related to her religion. To counter-act the sin which she felt she was doing, she repeated various gathas for long periods of time. This interfered with her daily functioning.

Case History 910 year old boy presented with excessive slowness when doing school work. He was very careful about how he wrote each letter and took a long time to write a sentence. When he made a mistake, he cut it off and started writing from the beginning. This affected his school performance significantly. He also, had rituals about how he kept his clothes prior to dressing and took a long time to arrange his school books.

Treatment of obsessive compulsive disorderCognitive behaviour therapy and SSRIs are the first line of treatmentCombining CBT with SSRI is more effective than monotherapyMain CBT interventions: exposure and response prevention

Treatment of obsessive compulsive disorderClomipramine is effective as SSRI. Can be used in patients not responding to SSRITricyclics other than clomipramine and benzodiazepines are not recommended for the treatment of OCDFluoxetine is started at a doseof 20mg/day and gradually increased up to a dose of 80mg/day according to the responseTreatment of obsessive compulsive disorderResponse may take 10-12 weeksTreatment should be taken for 1-2 years and tailed off over several months. If a patient has not responded adequately to a trial of 8-12 weeks of treatment which included 4-6 weeks at maximum tolerated dose, change of medication should be considered. CBT can be added if not already provided.Switching to another SSRI, or to clomipramine or velafaxine and augmenting with an atypical anti-psychotic can be done.

Reactions to stressIn response to life events: Adjustment reactionIn response to exceptionally severe stress: Acute stress reaction Post traumatic stress disorderPost traumatic stress disorderProlonged and abnormal response to exceptionally intense stressful circumstancesRe-experiencing the stressful event-Intrusive thoughts, imagery, flash backs, nightmaresHyper arousalAvoidance

Treatment of PTSDPsychological treatment: trauma focused psychological management. Consists of trauma based CBT and EMDRDrug treatment : SSRICase History 1010 year old boy who had been sexually abused presented with recurrent, intrusive thoughts regarding the event, flashbacks, nightmares and poor sleep. He had a fear of going out of the house. The features were of one months durationMedically unexplained symptoms (Somatoform disorders)Persisting physical symptomsNo evidence of organic aeitiologyConstantly preoccupied with thoughts related to the symptomsFrequent medical consultations and negative investigations.Precipitated by underlying psychosocial distress.Underlying depression has to be looked for.

Case history 11A 36 year old mother of two, was preoccupied with the thought that she was having a heart disease. She visited several physicians seeking treatment. However, all the investigations were normal. She was reluctant to accept that nothing was wrong with her and constantly talked of her complaints. Daily functioning was affected Case history 12A 8 year old girl presented with a history of recurring abdominal pain of four months duration. Investigations were normal She was found to be a victim of bullying in school.

Dissociative disordersIsolated neurological symptoms that cannot be explained in terms of known pathology related to a physical illness.Can present as seizures, paralysis, blindness, aphonia, sensory changes, amnesia, fugue, trance and possession statesAeitiology- Psychological distress due to an underlying psychosocial problem.

Case History 1315 year old boy presented with a history of hearing loss of one months duration. It started after he was put into a very strict religious school. All investigations were normal. Symptoms improved after he was removed from the school.Dissociative deafnessCase history 14A 16 year old girl presented with dysphonia. She had been returning home from school the previous day, when a man had tried to molest her. She escaped but was unable to speak afterwards. Diagnosis: Dissociative dysphonia

Dissociative amnesiaInability to recall important personal memories, usually stressful.Usually partial and selectiveAlone/with other disorders such as other dissociative disorders, ASR, PTSDMust be differentiated from amnesia due to medical causes esp.in the elderly.

Case History 1552 year old mother of one daughter presented with loss of memory of ten days duration. Physical examination was normal. Mental state examination revealed disorientation; other cognitive functions were normal. MRI was normal

Case History 15Her only daughter had got married ten days ago.Diagnosis: Dissociative amnesia

Trance and possession stateCharacterized by a temporary loss of sense of personal identity and full awareness of the surroundingsThe person behaves as if taken over by another personality/being for a brief periodThe persons focus of attention is narrowed to a few aspects of the environment.Causes such as psychotic disorders, organic disorders such as TLE ,Head Injury and substance abuse should be excluded.

Case History 16A 23 year old young man started getting possessed by a goddess for three months duration. During these episodes he appeared to be under external control.Prior to the onset of these episodes, there had been a land dispute with his neighbours. He was a quiet, timid person. He expressed feelings of utter helplessness due to his inability to help his family with this problem.

Case history 178 girls who were inmates of a childrens home developed sudden onset changes in behaviour which were indicative of possession states.Some girls developed pseudoseizures Initially, these episodes started in a girl who had a past history of such episodes.She and two others had been scared byan incident in the home.

Epidemic hysteriaOccur in closed groups of young womenOnset due to some threat to the group.Due to effects of shared anxiety and suggestionUsually the epidemic starts in some one who is very suggestible or the focus of attention.

Management-Acute dissociative/conversion disordersReassuranceSympathetic, positive attitude. Acceptable opportunity for rapid return to normality (e.g. physiotherapy etc.)Any personal issues should be addressed.

Management of persisting symptomsRemove any factors which are reinforcing the symptoms and encourage normal behaviour.Explain symptoms are not due to physical disease but due to inability to convert willed intention into action, provoked by psychological factors.Offer help through physiotherapy if necessary.

Management of persisting symptomsSupportive, sympathetic consistent approach by all staff.Self-help should be encouraged.Undue concessions should not be made to the disabilities.Medication not indicated (Unless secondary to a primary psychiatric disorder).Attention should be directed away from the symptoms and towards the problem that provoked the disorder.

Management of persisting symptomsAddress issues related to personal and social difficulties.Those who do not improve should be reviewed for undiscovered physical illness.All patients should be followed up to detect unrecognized organic disease which would have not been identified at the onset. Address issues related to personal and social difficulties.

TreatmentAbreaction- the patient is encouraged to reveal the underlying stressful events and express emotions.Hypnosis- A trance state is induced. The unconscious emotional conflicts are more accessible.

Anorexia NervosaBody weight less than 85% of the expected weightBMI < 17.5Weight loss induced by excessive dieting, self-induced vomitingBody image distortion- over valued ideas about being fat and out of shapeAmenorroea

Case History 18A 14 year old girl presented with -ankle oedema of one months duration -amenorrhoea of nine months duration -excessive loss of weight within a few months

Case History 10She had a history of severe dietingExercised excessively-mainly sweeping the gardenMorbid fear of being fat in spite of her emaciated appearance

SchizophreniaDelusions of control, thought insertion, thought withdrawal, thought broadcasting, delusional perception - also persecutory delusions, delusions of reference Hallucinations_ 3rd person AH, running commentary , thought echo, somatic hallucinations also 2nd person AHPoor self care, sleep problems, talking to self and smiling to selfAggressive behaviour

SchizophreniaSocial withdrawal, blunt mood, poverty of speech, lack of initiative and drive.Can present in different ways.Can have depressive symptoms. Risk of suicide is 10%.

Bipolar Affective DisorderDifferent phases of the illness.Depressive episodesManic Episodes- main features: over activity, increased energy disinhibited behaviour, over familiarity, irritability, grandiose delusions, auditory hallucinations, poor insight.

Dementia20% of our population will be over 65 years by the year 2020. A large proportion of them will face mental health issues, especially dementia.Usually in the elderly. Incidence increases with age.The prevalence in the over 65 age group is about 5%. It becomes as high as 20% in those over 80 years

DementiaMemory impairment _ usually early.Deterioration of personality, apathetic.Gradual progressionGlobal impairment of memory, intellect and personality and there is no impairment of consciousness 50-60% of cases of dementia are due to Alzheimers disease. Vascular dementia accounts for 20-25% of patients.

References1.The Maudsley Prescribing Guidelines in Psychiatry.11th Edition. Anxiety spectrum disorders. Chapter 4 pages 197-252National clinical guideline No:123 Common Mental Health Disorders. National Institute for Health and clinical excellence. May 20114.ICD 10 classification of mental and behavioural disorders WHO 19925. Gelder M, Harrison P and Cowen P. Shorter Oxford Textbook of Psychiatry (Fifth Edition)

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