EMOTIONAL AND MENTAL HEALTH - MODULE 3
Topics:
  • Emotional and Mental Health Assessment & Management
  • Lifestyle Medicine Management for Emotional and Mental Health
  • Psychological treatment
  • Components of Self-management
  • Indications for a referral to mental health professional
  • Benefits of Physician Empathy, Attunement, Resonance

lifestyle medicine management for emotional & mental health

Mental illness is a major contributor to the global burden of disease. According to a recent meta-analysis, 14.3% of all deaths worldwide, or approximately 8 million deaths each year, are attributable to mental disorders (1). Patients with mental and emotional problems are less likely to engage in healthy lifestyles as well.

Coronary Artery Disease (CAD) and Emotional Health
People with severe mental illness (SMI), including bipolar disorder (BPD) and major depressive disorder (MDD), have an average mortality rate that is 2 to 3 times higher than the general population, corresponding to a 10- to 25-year shortened life expectancy. As in the general population, CVD are the most common cause of death in people with SMI (2).

Depression is a risk factor for developing ischemic heart disease and for having a worse prognosis. It increases cardiac risk by 15-25% in patients with CAD (4); another study showed that it doubled cardiac events (5).
MDD and GAD predicted increased risk from cardiac death, MI, cardiac arrest and non-elective revascularization over a 2-year follow-up (6).

Treatment of depression in patients with CAD:
  1. Improves symptoms and quality of life. However, there are no clear findings that treatment of depression improves survival (7).
  2. SSRI treatment is relatively safe. Early treatment with SSRIs may help decrease cardiac events (8).
  3. Treatment with tricyclic antidepressants (TCAs) is unsafe à risk of QT prolongation and orthostatic hypotension (8)
  4. Optimal treatment: medication and psychotherapy (4)
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lifestyle modification

​A.    Exercise
  • Depression. Exercise can prevent or treat depression; its impact comparable to cognitive behavioral therapy (17).
  • Protective Effects. Can reduce the risk of various neurological diseases and protect the brain from the detrimental effects of aging (18).
  • Learning and Memory. Animal models have focused mainly on the effects of long-term exercise (i.e., weeks to months of increased exercise) on hippocampal function, with emphasis on exercise-induced adult hippocampal neurogenesis and hippocampal-dependent learning and memory (19).
  • Attention and Executive Functions. The most commonly reported area to undergo improvement with long-term exercise according to human studies is the prefrontal cortex, with enhancements observed in attention and other executive functions (20).
  • May improve cognitive function during aging (21).
  • Can improve symptoms in patients with cognitive decline and dementia (22).
  • Acute exercise has been shown to enhance affective, mood, and emotional states (23).

B.    Nutrition
  • Whole sources of grains and carbohydrates. Carbohydrates have been found to affect mood and behavior. They trigger release of insulin, which in turn triggers the entry of tryptophan, the precursor of serotonin, into the brain. Low serotonin levels are associated decreased mood (9).
  • Low GI foods. Low glycemic index (GI) foods such as some fruits and vegetables are more likely to provide a moderate but lasting effect on brain chemistry, mood, and energy level than the high GI foods - primarily sweets - that tend to provide immediate but temporary relief (9).
  • Variety of plant-protein sources.  Many of the neurotransmitters in the brain are made from amino acids (eg. dopamine is from the AA tyrosine, and serotonin from the AA tryptophan). Lack of these amino acids will result to inadequate synthesis, leading to low mood and aggression (9).
  • Omega-3-fatty acids. Found in foods such as flaxseed and walnuts. The brain is one of the organs with the highest level of lipids (fats). Fatty acids are constituents of membranes. It has been estimated that gray matter contains 50% fatty acids that are polyunsaturated in nature (about 33% belong to the omega-3 family), and hence are supplied through diet (9). Deficiency may cause disturbance in neural function, accelerate cerebral aging, and may contribute to depression.
  • Vitamin B12. Clinical trials have indicated that Vitamin B12 delays the onset of signs of dementia if given prior to the onset of the first symptoms. Enhances cerebral and cognitive functions in the elderly, promotes the functioning of the frontal lobe and the language function of people with cognitive disorders (10).
  • Folate. It has been observed that patients with depression have folate levels which are generally 25% lower than healthy controls (11). A controlled study showed that 500 mcg of folic acid enhanced the effectiveness of antidepressant medication (12). Various researchers have also noted that depressive symptoms are the most common neuropsychiatric manifestation of folate deficiency (13). It is not clear yet whether poor nutrition, as a symptom of depression, causes folate deficiency or primary folate deficiency produces depression and its symptoms.
  • Calcium. Excellent sources from plants are “greens and beans” (green leafy vegetables and legumes). A recent study has found that SSRIs inhibit absorption of calcium into the bones. This can be a greater problem  for those who are already aging, and it may predispose them to osteoporosis and increased risk of fractures (14).
  • Iron. Necessary for oxygen transport and energy production in the brain, and for the synthesis of neurotransmitters and myelin. Iron deficiency has been found in children with attention-deficit/hyperactivity disorder. Women of childbearing age experience more depression as well than during other times in their lives. This may be related to iron deficiency as well since deficiency can lead to fatigue and depression. Iron deficiency anemia is associated, for instance, with apathy, depression, and rapid fatigue when exercising (10). Some good plant sources of iron include lentils, beans, tofu, cashew nuts, chia seeds, and kale.
  • Zinc. At least five studies have shown that zinc levels are lower in those with clinical depression (15). Intervention research has also found oral zinc can influence the effectiveness of antidepressant therapy (16). Also, zinc protects the brain cells from free radical damage.

C.    Mindfulness, intentional distraction and relaxation therapy
  • Meditation can decrease the negative impacts of stress (24)
  • Researchers reviewed more than 200 studies of mindfulness among healthy people and found mindfulness-based therapy was especially effective for reducing stress, anxiety and depression (26).

D.    Bibliotherapy
"The use of books selected on the basis of content in a planned reading program designed to facilitate the recovery of patients suffering from mental illness or emotional disturbance. Ideally, the process occurs in three phases: personal identification of the reader with a particular character in the recommended work, resulting in psychological catharsis, which leads to rational insight concerning the relevance of the solution suggested in the text to the reader's own experience. Assistance of a trained psychotherapist is advised." --bibliotherapy in ODLIS, Online Dictionary for Library and Information Science.

E.     Light therapy
Light treatment is effective for SAD (Seasonal Affective Disorder: winter-type) and increasing data suggests that it has beneficial effects in non-seasonal depression as well. Bright light (>2500 lux) results in greater improvement than dim light; morning light of at least 3 to 4 days duration results in more responders than evening light in SAD. There are minimal side effects with the exception of the risk of inducing mania in bipolar patients. (25).

F.     Sleep management
  • Studies have shown that even partial sleep deprivation has a significant effect on mood. University of Pennsylvania researchers found that subjects who were limited to only 4.5 hours of sleep a night for one week reported feeling more stressed, angry, sad, and mentally exhausted. When the subjects resumed normal sleep, they reported a dramatic improvement in mood (27).
  • There is a perceived connection between emotions and sleep due to the dual role the amygdala plays in both (28).
  • Prolonged sleep deprivation has been connected to changes in the brain such as reduced receptor sensitivity and changes in functional communication between brain regions (28). 

G.    Positive relationships and social support
  • A meta-analysis was carried out in studies regarding the impact of social support on mental health that were performed from 1996 through 2015. 64 studies  were collected and analyzed.
  • Result: Positive social communication with family members and friends reduces anxiety and develops the feeling of security. People with more positive ethnical social relations and higher social support enjoy more efficient communication skills, which directs them away from depression and other mental problems (29).
  • Social support gives people the feeling of being loved, cared, respected, and belonging to a network of communication (30).
​

psychological treatment

​​ 1.Cognitive behavioral therapy (CBT)
  • A structured, short-term, present-oriented psychotherapy for depression, directed toward solving current problems and modifying dysfunctional thinking and behavior (31).
  • Effective in the treatment of MDD, GAD, panic disorder, social phobia, substance abuse, eating disorders, and couples problems.
2.Behavioral therapy
  • Also called behavior modification
  • Based on the theories of classical and operant conditioning
  • Premise: all behavior is learned
  • Abnormal behavior: result of faulty learning (i.e. conditioning)
  • Therefore the individual has to learn the correct or acceptable behavior. 
3.Interpersonal therapy (IPT)
  • A time-limited, focused, evidence-based approach to treat mood disorders
  • Main goal: to improve the quality of a client’s interpersonal relationships and social functioning to help reduce their distress
  • Provides strategies to resolve problems within four key areas:
    1.  Interpersonal deficits: including social isolation or involvement in unfulfilling relationships
    2.  Help patients manage unresolved grief: if the onset of distress is linked to the death of a loved one, either recent or past
    3. Help with difficult life transitions: like retirement, divorce, or moving to another city
    4.  Dealing with interpersonal disputes that emerge from conflicting expectations between partners, family members, close friends, or coworkers
4.Psychotherapy
  • A.k.a talk therapy
  • A general term for treating mental health problems by talking with a psychiatrist, psychologist or other mental health provider
  • Many types including CBT, IPT, psychodynamic therapy, psychoanalysis, and others.
5.Positive Psychology
  • Positive psychology is an umbrella term describing the scientific study of what makes life most worth living. It is concerned with optimal experience - what goes right in life, from birth to death. It assumes life is more than avoiding or undoing problems.
  • Regarded as a supplement to existing psychotherapies.
  • Correlates of happiness are social in nature (32):
    • Number of friends
    • Being married
    • Being extroverted
    • Being grateful
    • Being religious
    • Pursuing leisure activities
    • Employment (not income)
  • Study has shown that good relationships with other people is necessary for happiness. It is the most important contributor to a satisfied life (32).
  • Research findings have also begun to accumulate showing that religion has benefits in the psychological domain. Internalized religious beliefs may help a person cope with problems. Religiousness is robustly associated with longevity, happiness, and other indices of the life lived well (32).
  • Above extreme poverty, increased income has a surprisingly small relationship with life satisfaction (32).
  • People who are employed and engaged in what they do are happy, regardless of the status or compensation associated with their job. Happiness and engagement lead people to regard their work as a calling and to be more productive at whatever they do, take fewer sick days, and even postpone their retirement (32).
​

pharmacotherapy

A. Depression
  1. SSRIs/SNRIs are the first-line treatment
  2. TCAs are used only if SSRI/SNRIs are not tolerated
  3. MAOIs have increased side effects and more interactions with food and other medications
  4. Antidepressant treatment should be maintained for at least 6 months or the length of a previous episode, whichever is greater.
  5. Taper gradually over 1-2 weeks before discontinuation.

B. Anxiety
  1. Benzodiazepines are the drug of choice. Prescribed as prn or for a limited period (usually for 2-6 weeks then tapered for 1-2 weeks) because tolerance and dependence can occur.
  2. SSRIs may be effective especially for patients with comorbid depression. Major disadvantage: can transiently increase anxiety and cause agitated states.
  3. Buspirone is effective in 60-80% of patients. However, may take 2-3 weeks for effects to become evident.
  4. Venlafaxine is effective in treating the insomnia, poor concentration, restlessness, irritability, and excessive muscle tension associated with GAD.
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components of self-management

​Encourage non-pharmacologic management interventions including:
  1. Mindfulness exercises, meditation, relaxation, and time for contemplation
  2. Abdominal breathing
  3. Expressive and creative pursuits, such as playing a musical instrument, singing, or creating art
  4. Massage
  5. Bibliotherapy
  6. Self-help websites
  7. Volunteering for meaningful causes
  8. Spiritual and religious activities
  9. Regular time in nature
 
Encourage health coping skills:
  1. Learning cognitive behavioral skills
  2. Develop problem-solving skills
  3. Improve one’s sense of humor
  4. Learn time management techniques
  5. Learn assertiveness (as appropriate)

Encourage patient to tap social support:
  1. Use his/her social support teams to assist with behavior changes
    1. May be advantageous to make a list of her needs for a particular health behavior change and then write the name of the person who can help support/fill that need.
  2. Help patient identify gaps that are not addressed by her social network
    1. Work with patient how to fill-in those gaps

Refer patient to accessible community and online resources.
Refer patient to mental health providers as necessary.

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indications for referral to a mental health professional

  1. High score on psychiatric screening
  2. Meets DSM-5 criteria for MDD or GAD
  3. Has active suicidal or homicidal ideation. (A medical emergency! Needs immediate attention.)
  4. Has a history of prior suicide attempt. Assess patient’s present safety.
  5. Has an unclear diagnosis
  6. Prefers to be seen by a behavioral health provider
  7. Shows no improvement with initial treatment
  8. Experiences relapse of symptoms
  9. If the physician judges there is a need for referral.


Mental Health Professionals
1.Psychiatrist
  • A licensed medical doctor who has completed psychiatric training
  • They can diagnose mental health conditions, prescribe and monitor medications and provide therapy.
  • Most psychiatrists focus on prescribing the appropriate medications; a few also do psychotherapy.
  • Degree requirements: Doctor of Medicine (MD) plus completion of residency training in psychiatry.

2.Psychologist
  • Psychologists hold a doctoral degree in clinical psychology or another specialty such as counseling or education. 
  • They are trained to evaluate a person’s mental health using clinical interviews, psychological evaluations and testing.
  • They can make diagnoses and provide individual and group therapy. 
  • Degree requirements: Doctor of Philosophy (Ph.D.) in a field of psychology or Doctor of Psychology (Psy.D.).

3.Counselors, Clinicians, Therapists
  • These masters-level health care professionals are trained to evaluate a person’s mental health and use therapeutic techniques based on specific training programs.
  • They operate under a variety of job titles—including counselor, clinician, therapist or something else—based on the treatment setting.
  • Degree requirements: Master’s degree (M.S. or M.A.) in a mental health-related field such as psychology, counseling, psychology, marriage or family therapy, among others.

4.Psychiatric Nurse
  • Can provide assessment, diagnosis and therapy for mental health conditions or substance use disorders.
  • In some US states, they are also qualified to prescribe and monitor medications. 
  • Degree requirements: Master of Science (MS) or Doctor of Philosophy (Ph.D.) in nursing with specialized focus on psychiatry.
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5.Marriage and Family Therapist
  • Mental health professionals trained in psychotherapy and family systems, and licensed to diagnose and treat mental and emotional disorders within the context of marriage, couples and family systems.
  • Marriage and family therapists regularly practice short-term therapy: 12 sessions on average.
  • Degree requirements: Bachelor’s degree in a relevant area such as counseling, psychology, or social work; plus a Master's degree, Doctoral program, or Post-graduate clinical training programs in marriage and family therapy.

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benefits of physician emphathy, attunement, and resonance in clinical encounter

​An ongoing patient-provider relationship can be emotionally therapeutic for patients. Here are some tips for a supportive provider-patient relationship:
  1. Acknowledge and reflect patient’s views of self-care and quality of life
  2. Support patients’ autonomy
  3. Promote patients’ self-efficacy

TASKS
Reflective Journal
  • ​Emotional and Mental Health Assessment and Management
Practical Application
  • Find at least 2 individuals with emotional challenges. Discuss with them the learnings you have from your modules and let them fill out the assessment forms provided in this module. Create a written summary of your activity and include the personal reflection (verbatim) of your clients.
Deadline for completion: September 25, 2022
References:
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