managing emotion for mental well-being · • the information presented in this talk is not...

W.L. Alan Fung, MD, ScD, FRCPC (Psychiatry)

Managing Emotion for Mental Well-Being

Scarborough Chinese Baptist Church

May 5, 2018

• The information presented in this talk is not intended or implied to be a substitute for professional medical advice, diagnosis or

treatment.

• All content, including text, graphics, images and information presented in this talk is for general information purposes only.

Medical Disclaimer

Objectives

1. What is mental well-being, and the lack of?

2. Some major mental disorders

3. Overall treatment approach

4. Mental health care providers in Ontario

5. Recovery

6. Further resources

Objectives

1. What is mental well-being, and the lack of?

2. Some major mental disorders

3. Overall treatment approach

4. Mental health care providers in Ontario

5. Recovery

6. Further resources

http://www.newbeginningswithgina.com/wp-content/uploads/2014/11/Square-logo-for-Mental-Wellbeing.jpg

https://www.helpguide.org/images/mental-health/keys-to-mental-health-400.jpg

http://crocuscoaching.co.uk/wp/wp-content/uploads/2013/03/wellbeing-diagram.png

http://www.bethelhk.org/Misn/8_dimensions_of_wellness.v4.jpg

https://karlynemile.files.wordpress.com/2015/10/emotions.png

https://sites.google.com/site/woburnguidance/_/rsrc/1509985288657/heath-and-wellness/mental-health/smh_blog_1_small.png

http://www.blogos.org/gotquestions/Christian-depression.php

http://www.pinsdaddy.com/christian-depression_ubFpPj0S8u5cneZqy3R8dDP0P46jnekZ1hwCkYXzt00/

https://www.amazon.com/Confessions-Depressed-Christian-Survived-Depression-ebook/dp/B00VGAB08Y

http://www.ctvnews.ca/health/stigma-surrounding-mental-illness-major-barrier-for-employment-

report-1.1485833

http://www.healthyplace.com/blogs/recoveringfrommentalillness/2012/10/mental-illness-stress-and-

relapse/mental-disorders/

http://www.nationalpost.com/related/topics/Managing+reality+mental+illness+office/1545972/story.html

Mental illness

• Affective

• Behavioural

• Cognitive

• Perceptual

abnormalities

Mental illness according to the Public Health Agency of Canada

• Characterized by alterations in thinking, mood or

behaviour (or a combination)

• Impaired functioning over an extended period of

time

• Symptoms vary from mild to severe depending on

– the type

– the individual

– the famliy

– Socio-economic environment

Objectives

1. What is mental well-being, and the lack of?

2. Some major mental disorders

3. Overall treatment approach

4. Mental health care providers in Ontario

5. Recovery

6. Further resources

Mental Disorders Classification Systems

• Diagnostic and Statistical Manual of Mental Disorders – Fifth edition (DSM-5)

• International Statistical Classification of Diseases and Related Health Problems, Tenth Edition (ICD-10)

DSM-5 – Major Diagnostic Categories

1) Neurodevelopmental disorders

2) Schizophrenia spectrum and other psychotic

disorders

3) Bipolar and related disorders

4) Depressive disorders

5) Anxiety disorders

6) Obsessive-compulsive and related disorders

7) Trauma- and stressor-related disorders

8) Dissociative disorders

9) Somatic symptom and related disorders

DSM-5 – Major Diagnostic Categories (2)

10) Feeding and eating disorders

11) Elimination disorders

12) Sleep–wake disorders

13) Sexual dysfunctions

14) Gender dysphoria

15) Disruptive, impulse-control, and conduct disorders

16) Substance-related and addictive disorders

17) Neurocognitive disorders

18) Personality disorders

19) Paraphilic disorders

Diagnosing Psychiatric Disorders

• Diagnostic Criteria:

- Constellation of symptoms

- Duration

- Functional impairment

Diagnosing Psychiatric Disorders (2)

• Diagnostic Hierarchy:

- Psychiatric disorder due to Generalized Medical Condition

- Psychiatric disorder due to substance abuse

- Psychotic disorder

- Mood disorder

- Anxiety disorder

Common Mental Disorders

• Anxiety Disorders

• Mood Disorders

– Depressive disorders

– Bipolar disorders

• Stress-related Disorders

• Substance-use Disorders

DSM-5 Anxiety Disorders- Separation Anxiety Disorder

- Selective Mutism

- Specific Phobia

- Social Anxiety disorder

- Panic disorder

- Panic Attack

- Agorophobia

- Generalized Anxiety disorder

- Substance/Medication-Induced Anxiety Disorder

- Anxiety disorder Due to another medical condition

Major Depressive Disorder

➢At least 1 Major Depressive Episode (MDE):

• Depressed mood and/or anhedonia for ≥ 2 weeks• ≥ 4 of:

- Sleep difficulties: too little or too much

- Appetite: too little or too much

- Energy: poor / fatigue

- Concentration and memory: poor

- Guilty/worthless feelings

- Psychomotor: retardation / agitation

- Suicidal ideations

Major Depressive Disorder

• Epidemiology

- Life time prevalence in adult is 17%

- Male: Female = 1:2

- Average age of onset: 25 - 30

- natural course of illness if not treated: 6-12 mo

Bipolar Disorder

- Prevalence M=F, 0.9%

- Age of onset: teens to early 20’s; can have late onset bipolar as well.

- Strong genetic predisposition

Bipolar Disorder

- Type I, at least 1 manic / mixed episode

- Type II, at least 1 MDE and 1 hypomanic episode without any manic/mixed episode

- Rapid cycling can occur in both types

Manic Episode

- Elevated or irritable mood for ≥ 1 week, with at least 3 of:

- Grandiosity

- Sleep - decreased need

- Pressured speech

- Flight of ideas

- Distractability

- Increased goal-directed activities

- Excessive involvement in pleasurable activities

Objectives

1. What is mental well-being, and the lack of?

2. Some major mental disorders

3. Overall treatment approach

4. Mental health care providers in Ontario

5. Recovery

6. Further resources

Psychiatric Management

• Biopsychosocial model

- Biological treatment

- Psychological treatment

- Social intervention

Bio-Psycho-Socio-Culturo-Spiritual Model

http://socialworkpodcast.blogspot.com/2007/02/bio-psychosocial-spiritual-bpss.html/

Bio Psycho Social Cultural Spiritual

Predisposing

Precipitating

Perpetuating

Protecting

Bio-Psycho-Socio-Culturo-Spiritual Formulation

http://ap.psychiatryonline.org/content/vol27/issue2/images/large/EB2026F1.jpeg

Biological management

• Medications

– Antidepressants e.g. SSRIs, SNRIs

– Anxiolytics

– Mood stablizers

– Antipsychotics

• Exercising

• Relaxation/meditation/mindfulness

Antidepressants

• Indications: unipolar depression, anxiety, anger

• Medications include:

- SSRIs: Sertraline, Citalopram, Escitalopram,

Paroxetine, Fluoxetine etc.

- SNRI: Venlafaxine, Duloxetine

- Bupropion, Mirtazapine

- Tricyclics

http://brainyinfo.com/antidepressants/ssri/

Depression Meds (1)

• SSRI - Escitalopram (Cipralex)

- Citalopram (Celexa)

- Sertraline (Zoloft)

- Paroxetine (Paxil)

- Fluoxetine (Prozac)

- Fluvoxamine (Luvox)

Depression Meds (2)

• SNRI

- Venalfaxine (Effexor)

- Duloxetine (Cymbalta)

Depression Meds (3)

• SSRIs and SNRIs:

- Main medications for mood issues

- Serotonin system

Depression Meds (4)

• Helpful additional meds:

- Bupropion (Wellbutrin) – boosting motivation/energy/level of interest

- Mirtazapine (Remeron) – helps with sleep, appetite

Depression Meds (5)

• Tricyclic antidepressants e.g.

- Amitriptyline (Elavil)

- Nortriptyline

- Desipramine (Norpramin)

- Imipramine

- Clomipramine (Anafranil)

Antidepressant Side-Effects

• CNS effect: anxiety, akathesia, dizziness, headache, sedation, insomnia, etc.

• Metabolic effect: wt gain / loss

• GI effect: GI disturbance. Can cause diarrhea or nausea.

• Sexual dysfunction: 50-60% pt experience decreased libido (SSRI).

• Pregnancy and breastfeeding safe?

Antipsychotics

• Indications: Schizophrenia and other psychotic disorders, bipolar disorder, antidepressant augmentation.

• Medications include:

- Typical antipsychotics, e.g. Haloperidol

- Atypical antipsychotics, e.g. Risperidone, Quetiapine, Olanzapine, Aripiprazole, Clozapine, etc.

Mood Stabilizers

• Indication: bipolar disorder (manic / depressive

phase, maintenance)

• Major meds include: Lithium, anticonvulsants,

antipsychotics.

• Anticonvulsants: Valproic acid, Carbamazapine,

Lamotrigen, Topiramate.

• Antipsychotics: Abilify, Risperidone, Seroquel,

Olanzapine, Clozapine, Haldol.

Anxiolytics/Hypnotics

• Indication: Anxiety (short-term), insomnia

(adjunctive)

• Medications include:

- Benzodiazepines

- Antidepressants: TCAs, Trazodone;

Psychotherapy

Psychotherapy

• Cognitive-behavioural therapy (CBT)

• Interpersonal Psychotherapy (IPT)

• Supportive Psychotherapy

• Psychodynamic Psychotherapy

• Group Therapy

• Couple/Family Therapy

https://www.mindovermood.com/

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Mindfulness

• Focusing on the PRESENT moment

• Mindfulness-Based Stress Reduction (MBSR)

• Mindfulness-Based Cognitive Therapy (MBCT)

• Acceptance and Commitment Therapy (ACT)

http://mbsrworkbook.com/

https://www.amazon.ca/Mindful-Way-Workbook-Depression-Emotional/dp/1462508146

• This art of attentive mindfulness taught by the ancient monastic fathers and mothers was centred on meditative exercises of awareness that sought to bring about a change to a mindful way of life.

• The practitioner was called to find ways of slowing down so as to become mindful of their breath, of their bodies, of their thoughts, of their actions and their surroundings, and especially of the sacred scriptures and the liturgy.

• Through those steps in mindfulness they sought to become aware of the Divine in-breathing that is present behind all of these phenomena as they arise.

• For the Christian Mindfulness Practitioner “breathing into love” is the beginning of the way of pure prayer, a prayer that transforms both our inner self and how we experience reality.

https://www.sanctuary.ie/breathing-into-love-christian-mindfulness/

Socio-cultural management

• Regular routine

• Functional activities – work, volunteering, social

interactions etc

• Housing

• Finance

• Family relationships

• Social work involvement

• Cultural sensitivity

• Participation in cultural groups

Spiritual management

• Encourage existing spiritual practice

• Be prepared about patient’s questions about religion/existential issues (e.g. ‘Why me?’)

• Collaboration with clergy members

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Physical Exercises

Extremely important!

Electroconvulsive therapy (ECT)

(for severe mood disorders)

Pearls for treatment

• Build strong therapeutic relationship – improving

treatment efficacy and compliance.

• Regular psychoeducation and inquires about side

effects to improve adherence.

• Individual / Group counseling - improving

relationships and coping skills.

• Exercise programs – improving lifestyle and

physical wellbeing, self-esteem.

Objectives

1. What is mental well-being, and the lack of?

2. Some major mental disorders

3. Overall treatment approach

4. Mental health care providers in Ontario

5. Recovery

6. Further resources

What is Psychiatry?

• The medical specialty devoted to the study and treatment of mental disorders

• First coined by German physician Johann Christian Reil in 1808

• psych-: mind (from Ancient Greek psykhē: soul;• -iatry: medical treatment (from Greek iāsthai: to

heal)

• The medical treatment of the mind

Psychiatric Training

• At least 3 years of university education (pre-med)

• 4 years of MD studies

• 5 years of specialist training in psychiatry (residency)

• Licentiate of Medical Council of Canada

• Specialist Certification (FRCPC)

• College of Physicians & Surgeons of Ontario

• 1 to 5 years of fellowship training

Psychologists

• PhDs instead of MDs

• Undergraduate education, followed by graduate

education - leading to a PhD (with thesis)

• Many fields

• Psychologists – PhD

• Psychological associates – Master’s + 4 yrs work exp• College of Psychologists of Ontario

• Cannot prescribe medications in Ontario

GP psychotherapists

• GP: a MD graduate, plus at least 1 year of internship;

• Family physician: MD graduate, plus family medicine

residency and certification (CCFP)

• Independent practice license with the College of

Physicians & Surgeons of Ontario

• Having psychotherapy as a major focus/part of his/her

medical practice

• May have additional training in psychotherapy

• May be members of Medical Psychotherapy

Association Canada (MDPAC)

Other mental health professions• Social Workers

– Ontario College of Social workers and Social Service Workers

– RSW (BSW or MSW)

• Nurses

– College of Nurses of Ontario

– RN and RPN

– Registered Practical Nurse vs. Registered Psychiatric Nurse (Western Canada)

• Occupational Therapists

– College of Occupational Therapists of Ontario

– OT Reg. (Ont)

Psychotherapists• “The practice of psychotherapy is the assessment and

treatment of cognitive, emotional or behavioural

disturbances by psychotherapeutic means, delivered

through a therapeutic relationship based primarily on

verbal or non-verbal communication.”- Psychotherapy Act (Ontario), 2007

• Controlled act that can be performed by:

- MDs, Psychologists, Nurses, OTs, SWs

- Registered Psychotherapists (RP) of the new

College of Registered Psychotherapists of Ontario

• American Association of Marriage and Family Therapy

(AAMFT)

Some other providers

• Mental health workers

• Case managers

• Crisis counsellors

• Addiction counsellors

• Psychosocial rehabilitation workers

• Housing support workers

• Personal support workers

• Volunteers

• Peer support workers

• Families

Clergy Members!

• ~40% of those with mental health concerns seek

assistance from clergy (Weaver, 1995)

• Clergy members: more likely than psychologists and

psychiatrists combined to have a person with mental

health dx come to them for assistance (Hohmann &

Larson, 1993)

• Young adults ranked clergy higher in interpersonal

skills than they did either psychologists or

psychiatrists (Schindler et al, 1987)

• Canadian Association for Spiritual Care (CASC)

(formerly Canadian Association for Pastoral Practice

and Education)

Collaborations between mental health & spiritual care professionals

• Greater trust in clergy members among those with

religious faiths (religious explanations of illness)

• Clergy members as first point of mental health care

contact (even in severe cases)

• Clergy members’ perspectives on mental health/illness can significantly affect detection, service

access, treatment adherence etc.

• Some clergy members are already providing

counselling

2014 Toronto Mental Health and Spiritual Care Symposium

May 8, 2014

Hart House, University of Toronto

Toronto, Ontario, Canada

Advancing Frontiers in Treating Mood Disorders

Mental Health and Faith Community Partnership

• Was created in 2014 to foster dialogue between psychiatrists and faith leaders.

• Facilitates collaboration among those who work within the different disciplines of faith and psychiatry and who share a common goal of promoting health, healing, and wholeness.

Mental Health and Faith Community Partnership (2)

• Provides a platform for psychiatrists and faith leaders to learn from each other.

• Faith leaders can increase their understanding of the best science and evidence-based treatment for psychiatric d/o.

• Psychiatrists & the mental health community can learn from faith leaders and increase their understanding of the role of spirituality in recovery & support faith leaders can provide.

Faith Leaders & Mental Health

• As religion & spirituality often play a vital role in healing, people experiencing mental health concerns often turn first to a faith leader.

• Faith community leaders are often gatekeepers or “first responders” when individuals and families face mental health or substance use problems.

• https://www.youtube.com/watch?v=FIGQLc28s50

Guidebook and Quick Reference for Faith Leaders

• The MH&FC Partnership has created:

- Mental Health: A Guide for Faith Leaders

- Quick Reference on Mental Health for

Faith Leaders, companion to Guides

Available for download from: www.psychiatry.org/faith

Objectives

1. What is mental well-being, and the lack of?

2. Some major mental disorders

3. Overall treatment approach

4. Mental health care providers in Ontario

5. Recovery

6. Further resources

Recovery

• The personal process that people with mental health conditions experience in gaining control, meaning and purpose in their lives.

• Involves different things for different people; e.g.

– complete absence of the symptoms of mental illness

– living a full life in the community while learning to live with

ongoing symptoms

• Goal for most treatment programs nowadays

• Excellent webpage from Canadian Mental Health Association: <http://ontario.cmha.ca/mental-health/mental-health-conditions/recovery>

Wellness Recovery Action Plan (WRAP)

• A peer-led, mental illness self-management program for managing illness and providing a plan when not well.

• Best practice used world-wide.

• Involves an educational and planning process that is grounded in mental health recovery concepts such as hope, education, empowerment, self-advocacy, and interpersonal support and connection.

• Within a group setting, individuals explore self-help tools and resources for keeping themselves well and for helping themselves feel better in difficult times.

• Generates an action plan to indicate how the person would like to be treated in times of crisis.

• Post-crisis plan for getting back on the road to recovery.

Objectives

1. What is mental well-being, and the lack of?

2. Some major mental disorders

3. Overall treatment approach

4. Mental health care providers in Ontario

5. Recovery

6. Further resources

Some resources for further information

• Canadian Mental Health Association

• Mood Disorders Association of Ontario

• Anxiety Disorders Association of Ontario

• Schizophrenia Society of Ontario

• Centre for Addiction and Mental Health

• Canadian Psychiatric Association

• American Psychiatric Association

• National Institute of Mental Health

• Living Water Counselling Centre

• Hong Fook Mental Health Association

Common aetiology of Insomnia

• Stress (‘adjustment insomnia’)• Mood, anxiety, psychiatric issues

• ‘Conditioning’ (psychophysiological insomnia)• Inadequate sleep hygiene

• Substance use

• Medical conditions e.g. pain, breathing, urological problems etc

• Medications

• ‘Misperception’ (paradoxical insomnia)

Key treatment strategies for insomnia

• Treat the underlying causes

• Sleep hygiene psychoeducation

• Cognitive-behavioural therapy for insomnia (CBT-I)

• Exercising

• Relaxation/mindfulness training

• Sleep medications as adjunct

Objectives

1. What is mental well-being, and the lack of?

2. Some major mental disorders

3. Overall treatment approach

4. Mental health care providers in Ontario

5. Recovery

6. Further resources

Thank you for your attention

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