MENTAL HEALTH AWARENESS
How much do we know and accept for real?
Awareness and seeking of treatment for physical illnesses like diabetes, blood pressure, arthritis, asthma, etc. is high in the population. However, the same unfortunately cannot be said about mental health awareness and illnesses (like depression, anxiety, other stress-related or mood disorders, psychosis, and substance abuse). Such conditions are not only an ignored health aspect but also associated with myths and stigmas.
1 in 4 people in the world will be affected by mental or neurological disorders at some point in their lives. Around 450 million people currently suffer from such conditions, making mental disorders a leading cause of ill-health and disability worldwide. In India, 10-14% suffer from mental health problems, with more than 50 million people suffering from depression and anxiety disorders.
The myths and stigmas
Health surveys have revealed that 50-60% of people have inadequate mental health awareness, and have fixed, adverse opinions of people diagnosed with mental health disorders. People have reservations about mixing with them in society and working with them. Most people don’t accept that mental health conditions are real problems like physical illnesses and dismiss them off as mere attitudinal or behavioral problems of ‘difficult’ people.
Often, mental health problems and disorders get clubbed as a single entity in a person’s mind, but there are many defined types of mental illnesses, treated differently, and specifically. Sensitivity and understanding of mental illnesses can help in prevention as well as early diagnosis and treatment, which can greatly enhance productivity, individual performance, and the happiness of a family.
It is also important to understand that many people go through periods of low or affected mental health, depression, anxiety and stress. However, they may not have a mental health disorder, even though they may require or seek medical help, and benefit from treatment. Mental health disorders are those that fit defined criteria of symptoms and abnormalities in emotions and behavior, that have been present over a certain period of time, and significantly impact personal, social and occupational functioning.
TYPES OF MENTAL HEALTH DISORDERS
There are several categories of mental health disorders that broadly fit into the following groups –
PSYCHOSIS – SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS
These are disorders in which insight and perception of reality are lost. It is characterized by delusions, hallucinations, and disorganized speech and behavior.
MENTAL HEALTH DISORDERS OF MOOD, STRESS, AND ANXIETY
In these disorders, insight and perception of reality are maintained. These include:
Mood disorders mainly include depression and bipolar disorder.
Stress and trauma-induced disorders include post-traumatic stress disorder (PTSD), acute stress disorder, and adjustment disorder.
Anxiety-related conditions include generalized anxiety disorders (GAD), social and specific phobias, and panic. Other mental health disorders like obsessive-compulsive disorder (OCD), eating disorders (anorexia, bulimia, binge-eating, etc.) and somatic symptom disorders, though classified separately, are also elaborated under anxiety-related disorders as their causal basis is linked to anxiety.
These fall in between the realm of psychosis and mental health disorders of mood, stress and anxiety (earlier called neurosis).
These are placed in 3 clusters. A prior understanding of temperament and personality types and traits also helps analyze many mental health conditions, and customize psychotherapy.
This is a unique category that deals with disorders of sleep, dreams, and the subconscious mind.
SUBSTANCE ABUSE
Substance abuse (uncontrollable intake of intoxicating substances: alcohol, tobacco, and other narcotic or recreational drugs) is a recognized category of mental disorders, more common in men, with an alarming 25% population prevalence. Substance abuse is also associated with mental illnesses like psychosis, mood and anxiety disorders. It is important to rule out or diagnose and manage substance abuse while diagnosing and treating any mental health disorder.
MANIFESTATIONS AND SIGNS
Mental illnesses can manifest in multiple ways like aggression, violence, recklessness, inappropriate behavior, change in sleep and eating patterns, anxiety, depression or moodiness, decreased focus and work productivity, social withdrawal, and relationship problems.
Just as someone can have many physical disorders together like diabetes, high BP, or high cholesterol, the same can happen with mental disorders. So sometimes anxiety-depression can co-exist or the patient may present manic and depressive states together in bipolar disorder. Some may become substance abusers because of depression, may present a mood disorder with psychotic symptoms (schizoaffective disorder), or become obsessive-compulsive due to an underlying anxiety disorder. The COVID pandemic has also adversely impacted mental health due to the suffering induced by the disease itself (post-COVID stress disorder, similar to PTSD), and the loss of normal socio-cultural and economic aspects of life.
WHAT CAUSES MENTAL HEALTH DISORDERS?
There are many factors that play a role, and usually, a combination and interaction of these factors lead to mental health conditions:
Biological factors: genetic predisposition and family history
Development, functioning and interaction of certain parts of the brain: The amygdala and anterior cingulate gyrus (parts of the limbic system that regulates and processes emotion, and controls behavior), hippocampus (controls learning and memory), and the prefrontal and frontal cortex (controls thoughts, cognition, planning, motivation and actions).
Neurotransmitters (neurochemicals or neurohormones): These are chemicals that can have excitatory or calming effects, and regulate mood, as well as pleasure and motivation. These include serotonin and noradrenaline (decreased in depression), GABA (decreased in anxiety), glutamate (increased in anxiety), and dopamine (increased in schizophrenia). Medicines given in various mental health conditions act by modifying levels of these neurochemicals.
Hormones: Cortisol increase has been implicated in stress and anxiety disorders. Other hormones that can affect moods include thyroid hormones and estrogen in women.
Personality and temperament predisposition: Certain personality types like neuroticism and introversion, are associated with a greater risk of mental health conditions. A person’s temperament developed in childhood can also affect perceptions, interpretations, outlook and response to situations, people and events.
Social and Environmental factors: Adverse and unpleasant experiences, exposure to stressors, and traumatic events play a very important role. Many mental health conditions can be traced to such underlying causes, especially in childhood. Social and cultural practices prevalent in a region can also play a role. The degree of support and protection from family, as well as key people part of one’s life, coupled with one’s own learning, education and positive reinforcement can determine resilience and coping ability during stress and adversity.
Lifestyle factors: Reducing stress of daily living and having support systems play a crucial role, especially in the case of women. Other important factors are the amount and quality of sleep and the effects of circadian rhythm. The gut-brain connection is also seen to have a role, and a person’s diet especially if high on processed items, sugar, caffeine, and trans/saturated fat can lower mental health, as opposed to a positive impact with natural items like fresh fruits, vegetables, pulses, and curd. Adequate physical activity and exercise, breathing and mindfulness techniques, relaxing and engaging hobbies, family bonding, and social interaction, are all beneficial factors for better mental health.
Substance abuse: There is a vicious cycle-like relationship between mental health conditions and substance abuse (alcohol, narcotics, recreational drugs, sedatives or stimulant drugs) as each can be both the cause and effect of the other. Substance abuse is now classified as a separate category of mental health disorders.
Physical health: This too is a cause-and-effect factor, as often underlying chronic physical conditions may lead to mental health disorders like depression and anxiety, while many chronic conditions are linked to and exaggerated by mental health disorders. A medical examination and diagnosis of underlying or associated physical conditions is therefore as important.
HOLISTIC HEALTH SOLUTIONS
It is important to have a medical consultation when having symptoms of mental health disorders. The treating physician, psychologist, or psychiatrist will take a complete history, conduct a general medical examination, and advise blood tests and neuro-imaging tests where needed.
In managing mental health disorders, understanding, support, and cooperation of household members and family is of paramount importance for good and long-term treatment outcomes. Treatment approaches are a combination of the following:
- Lifestyle therapy
- Counseling and Psychotherapy
- Support groups, Helplines, and Organizations
- Medicines and Supplements
- Medical Interventions, or Hospital Care
LIFESTYLE THERAPY
This focuses on 5 important aspects.
Diet
Diet and the functioning of the gut have a direct link to mental health and the functioning of neurotransmitters (gut-brain connection). The diet has to be nutritious and eaten at a relaxed pace and at regular times.
The following points should be kept in mind:
- Increase vegetables, fruits, nuts, yogurt (curd), pulses, eggs, fish/chicken, and whole grains
- Decrease foods high in sugar and saturated/trans-fat, refined flour, deep-fried, packaged-preserved foods, and red meats
- Alcohol should be restricted to not more than once or twice a week with 1 or 2 glasses
- Stimulant beverages with caffeine should be kept at 1-2 cups a day.
- Water intake should be around 8-10 glasses or 1.5 L a day.
- Other fluids like buttermilk, coconut water, and green tea (chamomile tea at bedtime) also provide beneficial effects.
Physical activity and Exercise
Adequate physical activity or leading a physically active life can help release endorphins (chemicals that reduce stress and pain), improve mood and sleep, and decrease anxiety.
A regular form of physical exercise should be adopted like brisk walking, cycling, swimming, yoga, aerobics, or dance-exercise forms. This should be done for at least 30-45 minutes a day for 5 days a week. Taking up a sport can also be very helpful. However, physical activity and exercise should be in accordance with one’s age, physique and capacity, and should not be too exhausting or straining to the body. If taking up a new physical exercise or sport, it is best to start under the guidance of a trainer or coach.
In addition, stretching and breathing exercises or techniques practiced for 5-10 minutes a day can also have beneficial effects. It can help reduce anxiety and stress and also improve work capacity and lung function. Breathing techniques can also help at the onset of a panic attack.
Sleep
Sleep has to be adequate in quantity (6-8 hours every night), of good quality (without frequent awakenings or disturbance), and of a set pattern (regularizing sleeping and awakening time). Sound sleep can go a long way in boosting mental and physical health, and decreasing stress, anxiety, and low moods.
Stress relief and Relaxation
Managing stress is a cornerstone for both mental and physical health. It is important to allot time in the day, free of gadgets like mobile phones and laptops, spent with family, friends, or loved ones, and do things that are relaxing and enjoyable. Examples include playing a game, hobbies like music, painting, craft, dance, gardening, and reading. Taking regular vacations and spending time with nature is emotionally and physically rejuvenating.
Mindfulness is the human ability to be fully present in and aware of the moment. It is focusing on where one is and what one is doing in that moment, and not on what is around or what will happen. Taking some time out for mindful meditation for a set time daily is also very beneficial. Meditation can be practiced in various ways like focusing on breathing, imagery, and positive emotions, or by body scanning and tension release technique.
Personal Care
Taking care of one’s health, hygiene and comfort can make one feel good about oneself, and elevate self-esteem and mood. Regular bath, brushing well and rinsing the mouth after meals, dressing in comfortable nice clothes, making one’s hair neatly, applying moisturizer to the skin, using pleasing fragrances and oils like lavender (aromatherapy), etc. can enhance positivity.
Associated physical illnesses with underlying mental illness which when not addressed, gives the patient incomplete relief from his physical symptoms. This is often seen with chronic pains and digestive complaints. On the other hand, the presence of an untreated chronic physical problem can also cause mental health conditions like anxiety and depression.
COUNSELING AND PSYCHOTHERAPY
Various techniques of psychotherapy have evolved over a period of time. Many of them work well on their own, and also enhance the response to medicines. These techniques and therapies require time and patience, commitment, and cooperation of the individual and the family. It may sometimes seem like a challenging, uphill and long journey therefore disappointments and drop-outs do occur. Such treatments are usually given by qualified and experienced psychologists and sometimes even by psychiatrists.
Counseling and talk therapies in the form of structured sessions over a period of time are the most common and basic psychotherapies. These are usually short-term therapies over a few weeks to months, for understanding and targeting particular symptoms or current situations affecting the person, and offering suggestions and advice on how to deal with these. It involves listening, conversations and discussions, followed by guidance.
Psychotherapy refers usually to a longer treatment that focuses on gaining insight into the person’s chronic physical and emotional problems, one’s thought process and responses, and how these are influenced by past events. It consists of cognitive and behavioral therapies (CBT). While cognitive therapy focuses on change in thought processes and beliefs (cognitive restructuring), behavioral therapy focuses on change in behavior and responses to the external environment. Maintaining work books, writing down and recording symptoms, triggers and responses, and also learning by role-plays are part of such therapies. Cognitive processing therapy (CPT) is a type of CBT for reducing symptoms of PTSD by learning how to change disturbing beliefs and create a new understanding and concept of the traumatic event. Behavioral activation therapy (BAT) refers to goal directed environmental engagement activities for positive reinforcement.
Family therapy helps to increase understanding, coping and support, and can help in better response to treatment as well as lower relapses. These are especially useful in depression, anxiety, PTSD, and eating disorders. Interpersonal therapy (IPT) helps one to understand and change maladaptive interactions. Group therapy sessions are also practiced by psychologists for people with similar mental health disorders.
Exposure therapies use the technique of exposing the patient to the stimulus in a controlled way. This helps in phobias. Prolonged exposure techniques are used for PTSD, sometimes along with participant modelling where the therapist models the interaction with the phobic stimulus to help increase the confidence and decrease fear of the patient. Imaginary exposure techniques, or exposure by virtual reality, are also helpful techniques. Interoceptive exposure is a technique of exposure to internal sensations felt during panic or agoraphobia. Exposure and response prevention (ERP) combines exposure of the obsessive stimulus along with not allowing the patient to respond with compulsive actions or reactions, and is useful in OCD. A structured panic control treatment (PCT) is done in stages of counselling, awareness, and education with breathing and mindfulness training, followed by logical analysis by the patient of automatic thoughts, and then finally followed by exposure. Rarely flooding techniques by full exposure to the stimulus, maybe used but have to be done so very cautiously.
In professions like the military, combat, police, etc., psychological debriefing group sessions (also called critical incident stress debriefing- CISD) are done after exposure to traumatic events. As part of training in these professions, graded exposure of possible traumatic events is given (stress inoculation) to prevent severe mental impact or development of PTSD later.
Emotion regulation therapy (ERT) integrates components of cognition and behavior, acceptance, logical discussions, mindfulness, and experiences, to help manage emotions. It helps identify, describe and differentiate emotions, increase acceptance and adaptive ability, decrease emotional avoidance, and utilize emotions for effective decisions, motivation, and managing relationships. It is useful in anxiety and depression disorders. Dialectical behavioral therapy (DBT) combines CBT-ERT with mindfulness, positive interpersonal skills, and distress tolerance. It is useful in depression, complex PTSD, and personality disorders. Acceptance and commitment therapy (ACT) encourages embracing one’s thoughts, emotions and feelings, not suffering or feeling guilty about them. It then involves committing to facing problems head-on rather than avoiding them. It is often paired with mindfulness and helps in anxiety, depression, OCD, and substance abuse. Emotional freedom technique is an alternate medicine treatment combining acupressure and counseling to relieve physical pain and emotional distress to balance energy systems.
There are also ‘mind coach’ centers and organizations of psychologists/psychiatrists who have developed their own treatment techniques and psychotherapy.
SUPPORT GROUPS, HELPLINES, AND ORGANIZATIONS
There are various support groups, especially for depression, PTSD, and substance abuse. These are especially helpful for sharing experiences, motivation, collective commitment, as well as improving insight and understanding. Helplines are there for the same and are especially useful in suicide prevention.
Many NGOs and social organizations also run rehabilitation centers and residential non-hospitalized treatment centers for various conditions of mental health as well as substance abuse.
It is important to explore and connect with such support avenues in one’s area.
MEDICINES AND SUPPLEMENTS
There are many classes of medicines that are effective and have been used in treating mental health disorders.
Antidepressants
These are the most prescribed class of medicines for mental health conditions. These act by regulating the levels of the neurotransmitters serotonin and/or noradrenaline, which are implicated in depression, and other mental health disorders like anxiety-related disorders and PTSD. Various classes of antidepressants are available:
Selective serotonin reuptake inhibitors (SSRIs – fluoxetine, paroxetine, escitalopram, sertraline).
Serotonin and noradrenaline reuptake inhibitors (SNRIs – duloxetine, venlafaxine, desvenlafaxine).
Atypical antidepressants (trazadone, mirtazapine, vortioxetine, vilazodone, bupropion).
SSRIs and SNRIs act by inhibiting the reuptake of serotonin or/and noradrenaline thereby increasing their action. They may have side effects like dry mouth, weight gain, sleep disturbance, headache, nausea, indigestion or diarrhea/constipation, tremors/nervousness, abnormal thoughts, and decreased sexual drive or performance. It takes at least 4 weeks to perceive significant effects of these medicines on improving mood and emotional stability. There may also be a relapse of the condition or withdrawal symptoms on discontinuation. Therefore, proper medical monitoring is necessary.
Atypical antidepressants may inhibit serotonin/noradrenaline reuptake plus have other actions like modulating serotonin receptors. Bupropion is one of the few antidepressants not frequently associated with sexual side effects, sleepiness, or weight gain, but carries a risk of seizure. It inhibits dopamine and noradrenaline reuptake and is sometimes added to SSRIs.
Tricyclic antidepressants (TCAs – amitriptyline, nortriptyline, clomipramine, doxepin) are antidepressants used selectively and in cases non-responsive to SSRI/SNRIs. They have similar often more severe side effects compared to SSRI/SNRI plus the risk of heart rhythm abnormalities, seizures, glaucoma/blurred vision, hypertension (high BP), and urinary retention.
Monoamine oxidase inhibitors (MAOIs – selegiline, phenelzine) are the older antidepressants, very rarely prescribed now due to side effects similar to TCAs but also high interactions with many food items and drugs.
Mood Stabilizers
These are drugs used to treat bipolar disease, and to reduce agitation, emotional instability, and impulsiveness in depression, anxiety, stress disorders as well as schizophrenia and personality disorders. This group includes lithium, and some anti-epilepsy medicines (divalproex, lamotrigine, carbamazepine)
Some side effects include dizziness, nausea, tremors, slurring, increased thirst and urinations, palpitations, weight/appetite changes, sleep disturbance, indigestion/diarrhea, and headache. These drugs should be taken strictly under medical monitoring.
Antianxiety Medicines
Benzodiazepines (alprazolam, clonazepam, diazepam, lorazepam) are the most commonly used antianxiety medicines that also help to fall asleep by their mind calming and muscle relaxant action. They work by increasing the action of the neurotransmitter GABA. They are used for various anxiety disorders and phobias. They also act fast and are useful in panic. Daytime drowsiness, confusion, dizziness, and headache are some side effects. As they can be habit-forming and require increasing doses with time, they are used for short-term management, till other drugs start to take effect, then withdrawn gradually to prevent withdrawal symptoms.
Gabapentenoid drugs like pregabalin act by decreasing nerve excitability, inhibiting calcium channels, and reducing release of neurotransmitters so are also used in anxiety.
Buspirone is an antianxiety drug that takes effect over 3-4 weeks, but has the advantage of not being habit forming, and is also useful to manage the psychic symptoms of anxiety.
D-cycloserine is a drug sometimes used in anxiety, especially phobia along with exposure therapies.
Supportive medicines like those to reduce palpitation and tremor (beta-blockers –propranolol) may be prescribed especially for performance anxiety and social phobia.
Antipsychotic Medicines
These are drugs that act as inhibitors of dopamine D2 receptors and are used to treat schizophrenia, psychosis, and psychotic symptoms in mood, stress and anxiety-related mental health disorders. The first-generation antipsychotics (typical or neuroleptics – chlorpromazine, thioridazine, haloperidol, fluphenazine) are mainly used in schizophrenia
Second-generation or atypical antipsychotics (clozapine, olanzapine, risperidone, aripiprazole) are used in schizophrenia as well as depression, bipolar disorder, PTSD, or anxiety when psychotic symptoms like emotional blunting, obsession, delusions, and disorganized behavior/speech are seen. Side effects of atypical antipsychotics include drowsiness, weight gain, and sometimes developing diabetes that is a concern. Overall antipsychotics can increase negative symptoms like tiredness and low mood. Clozapine can cause a rare side effect of a drastic fall in white blood cells (agranulocytosis).
Nutritional Supplements
There is some evidence to show that certain supplements may help as adjunctive or add-on therapy to improve mental health. These include vitamin D, C, B group vitamins like folic acid and B12, and minerals like iron, zinc, and magnesium. However, more research and conclusive evidence is needed.
Omega 3 fatty acid and amino acid supplements are also sometimes prescribed for general health and mental health. Melatonin is useful as a supplement to improve sleep and circadian rhythm.
The gut-brain axis (GBA) consists of bidirectional communication between the central and the gut nervous system, linking emotional and cognitive centers of the brain with gut functioning and signaling by bacteria (gut microbiota). Probiotic supplements can help improve gut microbiota thereby stabilizing the gut-brain axis and interplay of neurotransmitters.
OTHER THERAPIES
There are interventional therapies that are used for mental health disorders, especially in severe or non-responsive cases. Some of them may require hospitalization and longer periods of observation, while many of these may be done as daycare procedures.
Biofeedback is a mind-body technique that involves using visual or auditory feedback to train a person to recognize and control the physical signs and symptoms of stress and anxiety, like increased heart rate, breathing, body temperature, and muscle tension, through electronic guidance and monitoring.
Hypnotherapy is used to identify and resolve root causes of phobias and release suppressed memories in PTSD and dissociative disorders.
Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic fields to stimulate nerve cells of specific areas in the brain. It is used in severe and refractory depression.
Light therapy (by exposure to artificial light) is used to treat seasonal affective disorder (SAD – depression that occurs around fall/winter annually).
Electroconvulsive therapy (ECT) involves a brief electrical stimulation of the brain while the patient is under anesthesia. It is used in patients with severe major depression or bipolar disorder that has not responded to other treatments.
Institutionalization or hospitalization for long periods in a mental health facility may be needed in some cases that are resistant to most treatments.
Learn, understand, accept, then help ones in need……
Most people with mental health illnesses have normal intelligence and are as capable, competent, and talented as any other person. There should be no undue fear, reservation, or hesitation in mixing, interacting, and working with anyone undergoing or in need of treatment for any mental illness.
In fact, with mental health awareness of the types and presentations of mental illnesses, one can help oneself or a known one to seek help for diagnosis and treatment. This can greatly help in regaining health as well as productivity and normalcy in life, just as would happen after treating a physical illness.
Also read:
Depression and Anxiety – Causes, Signs and Holistic Treatment
Not getting enough sleep can be detrimental to health: Tackling Insomnia
For any query, additional information or to discuss any case, write to info@drvarsha.com, and be assured of a response soon.
References:
NMHS report: Mental Health 2015
TLLLF 2018 NATIONAL SURVEY REPORT: Mental Health Perception
National Institute of Mental Health (NIMH)
Diet and Mental Health: Mental Health Foundation
19 Comments
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It was really interesting when you mentioned that counseling can be used to target particular symptoms of depression. As far as I know, anxiety is a condition that often comes with depression. I would imagine that counseling would be able to help people manage their anxiety.
Thanks for the information.
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Thanks for helping me understand that mental illnesses could have various manifestations such as aggression, inappropriate behaviors, and eating and sleeping patterns. With that in mind, I should take my sister to a mental health care center to get her checked. It’s because she has been having eating patterns that can affect her physical health ever since the break up she had from her partner of four years.
Thanks for pointing out that lack of adequate sleep can affect mental health. My husband and I have been feeling down since last month because we cannot go on a vacation due to work problems. We are hoping to find mental health experts on Monday who can help us move forward through this tough time.
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I’m glad that you talked about a survey that said 50-60% of people have deficient mental health attention and have fixed, adverse opinions of people diagnosed with mental illnesses.
I liked it the most when you shared that behavioral therapy focuses on change in behavior and responses to the external environment. This made me realize how taking care of your mental health is important. I think it’s best to turn to behavioral health consulting to ensure that proper treatment is being done.
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