PSYC 361: Mental Health Disorders

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

Other multicultural characteristics that should be considered

• Emotional expression 

• Shame

• Power distance 

• Collectivism 

• Spirituality and religion

Behaviors need to be taken in context:

definitions of mental health need to reflect appropriate age-related and socio-cultural criteria 

Biological forces

• Genetic predispositions (more likely to develop those mental disorders because people in your family do) 

• Loss of important vitamins (vitamin B)

Psychological forces

Internal perceptual, cognitive, emotional, and personality factors that affect development

Sociocultural forces

Interpersonal, societal, cultural, and ethnic factors that affect development

Life-cycle forces

Differences in how the same biological, psychological, and societal forces may change depending on the timing in life

Assessment

• a formal process of measuring, understanding, and predicting behavior 

  • Includes gathering medical, psychological, and sociocultural information

  • Reliability and validity are important

Multidimensional Assessment

• Assess a diverse range of information related 

  • Physical health 

  • Cognitive functioning 

  • Psychological functioning 

  • Daily living skills (ADLs and iADLs)

  • Social and environmental resources 

• Often, through a team of professionals

Assessment Methods: Clinical interview

• Most widely used

• Includes direct and non-verbal information

Assessment Methods: Self-report

• Used extensively in research, policy

• Issues with validity from older adults

Assessment Methods: Report by others

Important in cases of dementia

Assessment Methods: Psychophysiological assessments

Assess brain and body function/responses

Assessment Methods: Direct observation

• May be systematic or naturalistic 

• Used to characterize unusual behaviors

Assessment Methods: Performance-based Assessments

Neuropsychological tests

Considerations in older adults

• Session in length

• Sensory deficits 

• Cognitive and health issues 

• Reliability and validity of measures in/for older adults

Mental Status Exams

A short screening test that assesses mental competence, usually used as a brief indicator of dementia or other serious cognitive impairment

Factors Influencing Assessment: Difficulties establishing a baseline level

• Eg, Education, IQ

• Previous exposure, possibility of learning

Factors Influencing Assessment: Environmental conditions

• Sensory deficits (eg. noisy emergency department)

• Motor issues 

• Anxiety

Bias: can be positive vs negative

• Negative bias

  • Racial, ethnic biases 

  • Ageism (dementia vs depression)

• Positive bias 

  • Ex. women not likely to abuse alcohol 

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)

• Dosage may be different for older than younger adults 

• Interaction with other medications 

• Older adults have complex medication regimens 

  • On average: 6-7 meds per day!

Testing and Safety of Medications in Aging

• Clinical trials do not regularly include older adults until 1990s!

  • And only more recently have they been required to represent people of different sexes, races, and ethnicities 

  • → we do not know if medications are as effective in these other groups as originally tested group (younger, more white, higher SES, more male)

• Metabolism changes in aging → changes in effective dose of medication

  • But also closer to doses that can lead to side effects, death

Developmental Changes in How Medications Work

• Absorption 

• Distribution

• Metabolism

• Excretion

Absorption

• the time needed for medications to enter the bloodstream 

  • May increase for some drugs

Distribution

• spread of drug throughout the body; depends on the cardiovascular system 

  • With age, more drugs remain free, available to bind to targets

  • Can lead to toxic buildup

Metabolism

• the process of getting rid of medications in the bloodstream; depends on the liver

  • Generally slower metabolism of medications in older adults

  • → drugs stay in the system longer and can lead to toxicity

Excretion

• the process of eliminating medications, often through kidney/urine

  • Lower kidney function with age → medications are often not excreted as quickly

  • → again this can lead to toxicity

Medication Side Effects

• Older adults have the highest rate of adverse side effects 

• Polypharmacy

• Many older adults go to multiple doctors

Polypharmacy

•  the use of multiple medications

  • Can be dangerous

  • Side effects can mimic dementia

  • Important to consider both prescribed and over-the-counter medications

  • Risks increase as the number of medications increase

Older adults have the highest rate of adverse side effects

• Partly due to metabolism changes on previous slide

• Partly due to interactions between drugs

Many older adults go to multiple doctors

Important to have accurate knowledge/sharing of medications

Most older adults are depressed

false

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

• This age-related decline may vary across cultures

• The mean age of diagnosis in the US is in the early 30s

True

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 reduction of physical movement (ovservable 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 decrease or increase in appetite nearly every day

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

  • Diminished ability to think or concentrate, or indecisiveness, 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

General symptoms and characteristics of people with depression

• 1. Symptoms must last at least 2 weeks 

• 2. Other causes must be ruled out

• 3. The symptoms must affect a person’s daily living

Risk factors for depression in older populations include

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

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

Gender and Depressive Symptoms

• Women tend to be diagnosed with depression more than men

• Major depression is associated with higher mortality in both genders

Characteristics of Depression Differ by Age

• Older adults often show

  • 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

Characteristics of Depression Differ by Gender:

• 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 irritable 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 in Aging

• Beck Depression Inventory (BDI)

• Geriatirc depression Scale (GDS)

• 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 for older women

Geriatirc depression Scale (GDS)

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

Biological Causes of Depression in Later Life

• Neurobiological factors

  • Genetic predispositions

  • Imbalance in neurotransmitters:

Genetic predispositions:

account for 40-50% of risk for depression in adults 

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

Imbalance in neurotransmitters:

• 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, which regulates arousal and alertness 

    • Feeling of fatigue 

  • Lower levels of BDNF* are linked to more severe depression 

    • *brain derived neutrophic factor 

Psychosocial theories for depression in later life

• Loss of stress/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 responsible for them

Treatment of Depression

• All forms of depression benefit from some form of therapy 

  • The best is a combination of medication and therapy 

Medications to Treat Depression

•  boost levels of neurotransmitters 

  • Selective serotonin reuptake inhibitors (SSRI)

    • Ex. prozac, paxil, zoloft 

  • Serotonin and norepinephrine reuptake inhibitors (SNRI)

    • Ex. cymbalta, effexor 

  • Norepinephrine-dopamine reuptake inhibitors (NDRI)

    • Ex. wellbutrin, remeron 

Behavioral therapy

•  focuses on reward behavior in depression 

  • Increasing the number of “good things’ and decreasing the number of “bad things.” 

• Cognitive behavior therapy (CBT): psychotherapy aimed at correcting negative thinking and consciously changing behaviors as a way of changing feelings 

• Stress reduction approaches, such as meditation and yoga, can be effective at reducing depression symptoms 

Stimulation-based treatments

• Electroconvulsive therapy (ECT): a strong electrical current is passed through the entire brain, causing a seizure 

• Transcranial magnetic stimulation: transiently inhibits or facilitates cortical activity in a targeted location 

• Other treatments being researched: 

  • Vagal nerve stimulation 

  • Deep brain stimulation

Alcohol Use Disorder (AUD)

• drinking pattern that reuslts in significant and recurring consequences that reflect loss of control 

• The severity of AUD is defined as:

  • Mild: The presence of two to three symptoms

  • Moderate: The presence of four to five symptoms

  • Severe: The presence of six or more symptoms

• Older adults’ drug of choice is alcohol 

  • Opioids are most often abused by midde-aged adults

AUD: Prevalence

• M > F (2-6x)

• In US, widowers over age 75 have the highest rate

Early-onset drinkers have a more severe course

In middle age, problems begin to emerge, including disease of the liver and pancreas, cardiovascular disease, and possible memory problems (Korsakoff’s Syndrome)

Late onset drinkers often start drinking after a stressful event (ex. Pandemic, loss)

• More women, more affluent 

• Fewer physical consequences because of shorter exposure 

• Moderate drinkers may experience interactions wit medications 

• Alcohol remains in the bloodstream longer

AUD Treatments

• Treatment focuses on three goals:

  • Stabilization and reduction of consumption 

  • Treatment of coexisting problems 

  • Arrangement of appropriate social interventions 

• Options: support groups, behavioral interventions, and medications