clinicalassessment,mentalhealth,andmentaldisorders

Definitions of mental health need to reflect

appropriate age-related and socio-cultural criteria, and behaviors need to be interpreted in context

Western-defined characteristics of mentally healthy people

• Positive attitude toward self

• Accurate perception of reality

• Mastery of the environment

• Autonomy

• Personal balance

• Growth and self-actualization

Multicultural characteristics that should also be considered in determining mental health

• Emotional expression

• Shame

• Power distance

• Collectivism

• Spirituality and religion

A multidimensional life-span approach to psychopathology

Viewing adults’ behavior from a lifespan perspective

• Biological forces

• Psychological forces

• Sociocultural forces

• Life-cycle factors

Biological forces

Health problems increase with age and can provide clues about psychological difficulties

Psychological forces

• Normative changes can mimic mental disorders

• Nature of personal relationships

Sociocultural forces

• Social norms and cultural factors play a role in helping to define psychopathy

• Social norms and customs vary across cultures, so we must ask if the behaviors are appropriate for a particular person or culture

Life-cycle factors

How a person behaves is influenced by one’s past experiences

Assessment

A formal process of measuring, understanding, and predicting behavior

The 2 things important in assessment

Reliability and validity

Multidiminesional assessment

Often done by a team of professionals who assess

• Physical health

• Cognitive functioning

• Psychological functioning

• Daily living skills (ADLs an IADLs)

• Social an environmental resources

Assessment methods

• Clinical interview

• Psychophysiological assessments

• Direct observation

• Performance-based assessments

Clinical interview

• Direct information

• Nonverbal information

• Self-report

• Report by others

Psychophysiological assessments

Recording and quantifying variou physiological responses in controlled conditions using electromechanical equipment (ekectroencephalogram, MRI)

Direct observation

Watching and recording behavior in real-time without relying on self-report

• Sytematic: structured, uses a checklist or coding scheme, often in controlled settings

• Naturalistic: Unstructured, done in natural settings without inteference

Performance-based assessments

Assessments where individuals complete tasks to directly measure cognitive or behavioral functioning

• Neuropsychological tests: structured tasks designed to asess specific brain functions

Mini-mental status exams

Quick measures of mental competence used to screen for cognitive impairment

Include

• Orientation to time and pleace (date, address)

• Simple math (add up coins)

• Simple visual-manual skills (copy drawing)

• Simple verbal behavior (repeat sentences)

• Naming (name pictures of objects)

• Simple memory (remember 3 nouns)

• More complex memory (digit span)

• Working memory and understanding (follow instructions)

Neuropsychological

Boston naming test

Language test that requires an examinee to name 60 line drawings of objects that are increasingly difficult to identify

Factors that influence assessment

• Difficulties establishing a baseline level, hard to determine what’s normal due to differences

  • Education, IQ

  • Previous exposure, possibility of learning

  • Environment in which the test is administered, anxiety

• Negative and positive biases

  • Negative: stereotypes (e.g., race, age, gender) can skew interpretation

  • Positive: assumptions (e.g., women less likely to abuse alcohol) may overlook real issues.

Developmental issues in interventions

• Medical treatments (prescription drugs)

• Therapy for mental disorders

  • Different ages may present different problems, and techniques must be adapted to the unique needs of older adults

Medical treatments (prescription drugs)

• Older adults may need different dosages due to changes in metabolism

• Higher risk of drug interactions due to multiple medications

Therapy for mental disorders

Different ages may present different problems, and techniques must be adapted to the unique needs of older adults

Medication clinical trials

Inclusion of older adults and diverse participants was not required in clinical trials until the late 1990s

Medication cost

New drugs are frequently very expensive

Medication side effects

Some side effects may mimic cognitive symptoms

Medication safety

New drugs may be dangerous to older adults so a good strategy is to start low and go slow

New medications

• Explosion of new medications available

• People over 60 take nearly 50% of all prescription and over the counter medications

Developmental changes in how medications work

• Absorption

• Distribution

• Metabolism

• Excretion

Absorption

The time needed for medications to enter the bloodstream may increase

Distribution

Once in the bloodstream the drig distributed throughout the body and there can be increases in toxic buildup if distribution time changes

Metabolism

Slower metabolism of medications means drugs stay in the system longer and can lead to toxicity

Excretion

Medications are often not excreted as quickly, and again this can lead to toxicity

Medication side effects and interactions

• Polypharmacy

• Adherence to medication regimens

Polypharmacy

• The use of multiple medications in the same person

• Interactions

  • Potentially dangerous, may cause medical problems, and mimic other conditions

  • Adverse drug reactions increase as the number of medications taken increase

Adherence to medical regimes

• Difficulty with olderpatiends

• Many older patients go to more than one doctor so accurate knowledge of medications taken is important

Depression in older adults

Rates of depression decline from young adulthood to old age for healthy people

Age-related decline of depression may vary across cultures

• About 5% of older adults living in the community show signs of depression

• For those receiving home health care, the rate is 13%

• Certain groups are at a greater risk for depression:

  • People with diabetes, cancer, heart disease, Parkinson’s disease (rates up to 50%)

  • Nursing home residents and family care providers also experience elevated risks

Physical illness that may cause depression in older adults

• Coronary artery disease

  • Including bypass surgery

• Neurological disorders

  • Including stroke, AD, and thyroid problems

• Metabolic disturbances

  • Including diabetes and thyroid problems

• Cancer

  • Including undetected cerebral metastasis

• Other conditions

  • Including chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, deafness, sexual dysfunction

Mean age of depression in US

Early 30

Symptoms of depression

General symptoms and characteristics of people with depression persisting for some periods - most of the day, nearly every day

• Depressed mood or

• Loss of interest or pleasure

  • A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down)

  • Fatigue or loss of energy nearly every day

  • Significant weight loss when not dieting, or weight gain, or a decrease or increase in appetite nearly every day

  • Feelings of worthlessness or excessive or inappropriate guilt nearly every day

  • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Requirements for depression diagnosis

• Symptoms must last at least 2 weeks

• Other causes must be ruled out

• The symptopms must affect a person’s daily living

Risk factors for depression in older populations include

• Being female, unmarried, or widowed; experiencing stressful life events; lacking social social support

• Having a chronic illness, living in a nursing home, or being a caregiver

Gender and depression

• Women tend to be diagnosed with depression more than men

• Major depression is associated with higher mortality in both genders

Older adults depression symptoms

• Persistent sadness

• Feeling slowed down

• Excessive worries about finances and health problems

• Frequent tearfulness

• Feeling worthless or helpless

• Weight changes

• Pacing or fidgeting

• Difficulty sleeping

• Difficulty concentrating

• Somatic complaints (unexplained physical pain or gastrointestinal problems)

• Withdrawal from social activities

Women vs men depression symptoms

Men and women often express depression differently—women internalize with sadness, self-blame, and withdrawal, while men externalize through anger, blame, and avoidance

• Women feel anxious and scared; men feel guarded

• Women blame themselves for the depression; men blame others

• Women commonly feel sad, worthless, and apathetic when depressed; men tend to feel irratable and angry

• Women are more likely to avoid conflicts when depressed; men are more likely to create conflicts

• Women turn to food and friends to self-medicate; men turn to alcohol, TV, sex, or sports to self-medicate

• Women feel lethargic and nervous; men feel agitated and restless

• Women easily talk about their feelings of self-doubt and despair; men hide feelings of self-doubt and despair, considering it a sign of weakness

Assessment scales for depression

• Beck Depression Inventory (BDI)

• Geriatric Depression Scale (GDS)

• Center for Epidemiological Studies - Depression Scale

Diagnosis of depression should never be made on the basis of a test score alone

Beck Depression Inventory (BDI)

Commonly used with adults; has questions focused on feelings and physical symptoms; more accurate with older women

Geratric Depression Scale (GDS)

Physical symptoms have been removed; format is easier for older adults

Center for Epidemiological Studies - Depression Scale

Reliable 20-item scale measuring depressive symptoms over the past week, widely used across diverse populations with established cutoffs to identify risk for clinical depression

Causes of depression in older adults

• Neurobiological factors

• Low levels of serotonin

• Low levels of norepinephrine

• Lower levels of BDNF

• Psychosocial theories

Neurobiological factors

• Genetic predispositions account for 40-50% of risk for depression in adults

  • Higher rates in relatives of depressed people, especially early-onset depression

• Imbalance of neurotransmitters appears to be the most likely biological cause of severe depression in later life

Low levels of serotonin

May result from high levels of stress experienced over a long period

• Early morning insomnia

• Difficulty concentrating

• Feeling tired or listless

• Loss of interest in sex or social activities

Low levels of norepinephrine

Regulates arousal and alertness

• Feeling of fatigue

Lower levels of BDNF

are linked to more sever depression (brain deprived neurotrophic factor)

Neuromodulator systems involved in depression

• Norepinephrine

• Serotonin

Psychosocial theories of depression

• Common reasons for depression

• Loss/stressor/negative event

  • Bereavement (most common), a job, one’s health

• Internal belief system

  • Where people are experiencing events that they perceive as unpredictable and uncontrollable

  • Feel resposible for them

Treatments of depression

• Drug therapies

• Brain stimulation

• Behavior therapy

Drug therapies

• First line medications

• Older pharmaceuticals

First line medications

• Selective Serotonin Reuptake Inhibitors (SSRI)

• Serotoninc and Norepinephrine Reuptake Inhibitors (SNRI)

• Norepinephrine-Dopamine Reuptake Inhibitors (NDRI)

SSRI

• Selective Serotonin Reuptake Inhibitors

• Prozac, Paxil, Zoloft

SNRI

• Serotonin and Norepinephrine Reuptake Inhbitors

• Cymbalta, Effexor

NDRI

• Norepinephrine-Dopamine Reuptake Inhibitors

• Wellbutrin, Remeron

• Work by boosting levels of neurotransmitters

• Have lower side-effects

Older pharmaceuticals

• Heterocyclic Antidepressants (HCAs)

• Monoamine Oxidase (MAO) inhibitors

• Ketamine (nasal spray Spravato)

HCAs

• Heterocyclic Antidepressants (HCAs)

• Have a higher rate of side effects and interactions with other medications

MAO inhibitors

• Monoamine oxidise inhibitors

• Interfere with transmissions between neurons

• Can produce deadly side effecs when they interact with food that contains tyramine or dopamine

Ketamine

• Nasal spray Spravato

• Potential for abuse

Brain stimulation

Used for treating very severe forms of depression that do not respond to medication

• Electroconvulsive therapy (ECT)

• Others: repeated Transcranial Magnetic Stimulation (rTMS), Vagal Nerve Stimulation (VNS), Magnetic Seizure Therapy (MST)

Behavior therapy

• Behavioral therapy

• Cognitive therapy

• Yoga

Behavioral therapy

• Focuses on changing current behavior without focusing on the underlying causes

• Increasing the number of good things and decreasing the number of bad things

Cognitive therapy

Focuses on changing how people think

Depression is not

a normal part of adult life and is treatable

All forms of depression benefit

from some form of therapy (often a combination of medication and therapy)

Anxiety disorders

Cluster of 6 conditions

• Generalized anxiety disorder

• Panic disorder

• Phobia

• Agoraphobia

• Social anxiety disorder

• Separation anxiety disorder

Generalized anxiety disorder

• Interferes with daily living

• May include physical symptopms

Panic disorder

• Recurrent attacks

• Severe physical symptoms

• Mean age of onset 20-24

Phobia

Excessive fear of a specific object, situation or activity that is generally not harmful

Agoraphobia

Fear of being in situations where escape may be difficult, not available, or embarassing in the event of a panic system

Social anxiety disorder

Excessive fear of being embaraased, humiliated, rejected in social interactions

Separation anxiety disorder

Excessive fear of separation from those with whom they are attached

The percentage of adults in the US that report anxirty symptoms in any given year

30%

Women vs men and anxiety

Women are 60% more likely than men to experience anxiety

Anxiety disorders in older adults

• In older adults can be associated with healt, relocation stress, isolation, fear of losing control…

  • 17% older men an 21% older women

Anxiety in older adults may be appropriate to the situation or due to underlying health problems

Possible causes and context should be investigated first, as an appropriate response that may not warrant medical intervention

The trick is to distinguish between warranted anxiety and:

• Feeling of severe anxiety for no apparent reasons

• Obsessive-compulsive symptoms

• Phobias

• Physical changes that interfere with functioning

  • Dry mouth, diarrhea, insomnia, hyperventilation, chest pain (signs of panic)

Treatment of choice of anxiety of older adults, especially when anxiety occurs first in later life

Psychotherapy

• Relaxation training

• Subsituting rational for irrational thought

• Gradual exposure to images or sitatutions that generate anxiety

Post-Traumatic Stress Disorder (PTSD)

Condition that can evelop after experiencing or witnessing a traumatic event

PTSD diagnostic criteria

• Intrision (flashbacks, nighmares)

• Avoidance (avoiding memories or reminders)

• Negative mood/cognitions (guilt, detachment, distorted beliefs)

• Arousal/reactivity (irritability. hypervigilance, sleep issues)

• Symptoms must cause signifcant distress/impairmentand not be ue to substances or medical issues

• Specfiy whether

  • With dissociation

  • With delayed expression (criteria met after 6 months event)

In addition to the diagnostic criteria a person with PTSD should show the following dissociative symptoms

• Depersonalization

• Derealization

Depersonalization

Feeling like an outsier observer of oneself, sense of unreality

Derealization

Persistent of recurring symptoms of unreality

Multiphase treatment for PTSD

• Exposure therapy

• Cognitive restrucuring

Alcohol Use Disorder (AUD)

Drinking pattern that results in significant and recurring consequences that reflect loss of reliable control over alcohol use

Older adults’ drug of choice is

alchohol

Middle-aged adults’ drug of choice is

Opioids

AUD diagnostic criteria

• Meet 2/11 criteria over a 12-month period

• Signs of problematic alcohol use include: drinking more than intended, failed attempts to cut down, neglecting responsibilities, craving, tolerance, withdrawal, risky behavior, and continued use despite physical, mental, or social harm

Severity of AUD is defined as

• Mild: the presence of 2-3 symptoms

• Moderate: the presence of 4-5 symptoms

• Severe : the presence of 6+ symptoms

Prevalence of AUD men vs women

2-6x higher for men than women

The group that have the highest rate of AUD in the US

Widowers

The group that will have a more severe course of illness

• Early onset drinkers

• In middle age problems begin to emerge, including disease of liver and pancrease, cardiovascular disease, possible memory problems (korsakoff’s syndrome)

Late onset drinkers and AUD

• Often start drinking after a stressful event

• More women

• More affluent

• Fewer physical consequences because of shorter exposure

• Moderate drinkeres may experience interactions with medications

• Alcohol remains in the blood stream longer

Ethnic group with highest rate of AUD

American Indian