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									A Mental Health Overview:
   Facts, Myths and Challenges
       at End of Life

Ariel Mindel, MC, LPC
Mental Health America of Illinois
      Presentation Topics
 Introduction to Mental Health America
  of Illinois
 Mental health and Mental illnesses

  Prevalence, myths, treatment
 Mental Illness and the Dying Patient

  Special considerations
               About MHAI
•Mental Health America of Illinois (MHAI) *Formerly Mental
Health Association in Illinois

•Statewide, non-profit organization founded in 1909 –
Celebrated 100-Years of Service in 2009!

•Mission is to promote mental health, work for the prevention
of mental illnesses, advocate for fair care and treatment of
those suffering from mental and emotional problems.

•Engage in advocacy, education and information
                 MHAI Focus Areas
   Advocacy:
       Mental Health Summit, Mental Health Education and
        Rally Day
   Education
       Prevention and promotion, educational presentations,
        mental health screenings, Social and Emotional Learning,
        disaster mental health trainers, stigma reduction
   Information
       Information and Resource line, referrals to providers,
        legal advocates, etc.
     Viewing Mental Health

Mental                  Mental
health                  Illness
              Prevalence Rates
   In any given year, 25% of the American population
    will experience some form of mental illness
     This holds true for youth
     Main burden of illness concentrated on 6% of
   50% of people who have a diagnosis, have more
    than one
   66% of people will not seek treatment due to
   In developed countries - burden of mental illness and
    substance abuse is greater than cardiovascular
              Prevalence Rates
In any given year, the percentage of the population 18 years of
    age and older experience the following mental disorders:

   Mood Disorders (Major Depressive Disorder, Bipolar Disorder)
     9.5%
   Anxiety Disorders (Generalized Anxiety Disorder, Panic
    Disorder, Post-Traumatic Stress Disorder, Obsessive Compulsive
    Disorder and Phobias)
     18%
   Psychotic Disorders (Schizophrenia, Schizoaffective)
     1.1%
   Eating Disorders (Anorexia Nervosa, Bulimia Nervosa)
     3%
                  Myths and Facts
Myth #1: Psychiatric disorders are not true medical illnesses like heart
  disease and diabetes. People who have a mental illness are just
Reality #1: Brain disorders, like heart disease and diabetes, are
  legitimate medical illnesses. Research shows there are genetic and
  biological causes for psychiatric disorders, and they can be treated
Myth #2: People with a severe mental illness, such as schizophrenia, are
  usually dangerous and violent.
Reality #2: Statistics show that the incidence of violence in people who
  have a mental illness is not much higher than it is in the general
  population. Persons with mental and emotional disorders are more
  likely to be victims of crimes than perpetrators - they represent a
  vulnerable population.
                   Myths and Facts
Myth #3: Depression results from a personality weakness or character
  flaw, and people who are depressed could just snap out of it if they
  tried hard enough.
Reality #3: Depression has nothing to do with being lazy or weak. It
  results from changes in brain chemistry or brain function, and
  medication and/or psychotherapy often help people to recover.
Myth #4: Depression is a normal part of the aging process.
Reality #4: It is not normal for older adults to be depressed. Signs of
  depression in older people include a loss of interest in activities, sleep
  disturbances and lethargy. Depression in the elderly is often
  undiagnosed, and it is important for older adults and their family
  members to recognize the problem and seek professional help.
                 Myths and Facts
Myth #5: Depression and other illnesses, such as anxiety disorders,
  do not affect children or adolescents. Any problems they have
  are just a part of growing up.
Reality #5: Children and adolescents can develop severe mental
  illnesses. In the United States, one in ten children and adolescents
  has a mental disorder severe enough to cause impairment.
  However, only about 20 percent of these children receive
  needed treatment. Left untreated, these problems can get worse.
  Anyone talking about suicide should be taken very seriously.
    Suicide is the 3rd leading cause of death for youth ages 15-
      19 and the 2nd leading cause of death for individuals ages
    Categories of Mental Illnesses
   Mood Disorders:
       Major Depressive Disorder, Bipolar Disorder
   Anxiety Disorders:
       Generalized Anxiety Disorder, Panic Disorder, Post-Traumatic Stress
        Disorder, Obsessive-Compulsive Disorder, Phobias
   Psychotic Disorders:
       Schizophrenia, Schizoaffective Disorder
   Eating Disorders:
       Anorexia Nervosa, Bulimia Nervosa
   Impulse Control Disorders:
       ADHD, Conduct Disorder
   Substance Abuse Disorders
       Major Depressive Disorder
   Persistent sad, anxious or “empty” mood
   Sleeping too little or too much
   Reduced appetite and weight loss or increased appetite
    and weight gain
   Loss of interest or pleasure in activities once enjoyed
   Restlessness or irritability
   Persistent physical symptoms that don’t respond to treatment
    (such as headaches, stomachaches, chronic pain,
    constipation, etc.)
   Difficulty concentrating, remembering or making decisions
   Fatigue or loss of energy
   Feeling guilty, hopeless or worthless
   Thoughts of death or suicide
                   Bipolar Disorder
   Episode of Major Depression, AND
   Episode of Mania:
     Increased energy: decreased sleep, little fatigue, increase in
      activities, restlessness
     Rapid speech, incoherent speech
     Impaired judgment: lack of insight, inappropriate humor,
      impulsiveness, excessive spending, grandiose thinking,
     Changes in thought patterns: distractibility, creative thinking,
      flight of ideas, disorientation, racing thoughts
     Mood changes: irritability, excitability, hostility
     Psychosis: hallucinations, delusions, paranoia
       Generalized Anxiety Disorder
   Excessive, persistent worry about various areas of life -
    disproportionate to actual source of worry
   Interferes with daily functioning (anticipate disasters,
    worried about health, money, death, family/friend
    problems, work, etc.)
   Physical symptoms: fatigue, headaches, nausea,
    numbness, muscle tension, muscle aches, difficulty
    swallowing, difficulty breathing, difficulty concentrating,
    irritability, sweating, restlessness, difficulty sleeping
          Treatment Options
 Therapy - individual, group, family
 Medication - monitored by psychiatrist or
  primary care
 Research has found that a combination of both
  therapy and medication is the most effective
  form of treatment
 Some illnesses may include a lifetime of
  treatment and management for the patient to
  find recovery
Mental Illness and the Dying Patient
   People with severe and persistent mental
    illnesses (SPMI) have higher than average
    mortality rates
      Adults with SPMI: 2:1 risk of dying from
       natural causes at any age, and at higher risk
       of death from neoplasms, cardiovascular,
       respiratory and GI illnesses
      Also much higher risk of death due to
       accidents, suicide and homicide
              Mental Illness and the Dying Patient:
                         Decision-making Capacity
   Decision making capacity and advance care planning:
     Discussions about end-of-life often bypass people with SPMI -
      assumption of incapacity and fear of emotional reaction
     May seek out family or substitute decision-makers
           People with SPMI may be left out of decisions regarding their care, or
            decisions may be made for them that they would not have made
       In certain states, statute of limitations exist around authority to
        implement certain forms of treatment by a guardian
           i.e. administration of antipsychotics, ECTs, withholding of treatments that
            might save/prolong life, withdrawal of artificial nutrition/hydration
      Mental Illness and the Dying Patient:
                Decision-making Capacity
 Recent studies challenge beliefs about lack of capacity:
 Foti & colleagues (2003-2005): Developed advance care
  planning tools to explore decision-making capacity, preference
  for advance care planning and preferences for end-of-life care
    Individuals with SPMI provided hypothetical end-of-life
     scenarios, asked to select treatment choices imaginary
     individual and self
    Also asked about values, opinions and attitudes concerning
    Choices made my SPMI population were similar to racial and
     ethnic groups with disparate access to care, quality of care,
    Conclusion: Tailored educational interventions can improve
     understanding to level falling within range of informed
     decision making capacity - and could tolerate discussions
      Mental Illness and the Dying Patient:
                 Access to Care

 People with SPMI may experience/respond to
  symptoms differently or may delay seeking
  medical assessment
 History may be difficult to elicit, track

 Comorbid medical conditions often present

 People with SPMI may have less access to cure-
  oriented treatment, and palliative care may
  become treatment from time of detection to
      Mental Illness and the Dying Patient:
                 Access to Care

 Factors such as medical and social problems,
  substance abuse, homelessness, incarceration,
  emotional/behavioral may make people with
  SPMI unwelcome in healthcare
 Limited/distanced personal/family relationships

   Fewer advocates, supports
             Mental Illness and the Dying Patient:
                                 Provision of Care

   Due to their history and illness, people with SPMI may be poor
    historians, may not be tolerated being touched, certain procedures or
    certain restrictions
       Know the patient, consider their life experiences – stigma, institutional care, grief,
        trauma, etc.
   Understanding/acceptance of diagnosis may fluctuate, may have
    different goals/beliefs about appropriate care
      Is physical or chemical restraint appropriate?

   Use periods of symptom remission to complete advance directives,
    discuss plans of care, and carry out physical exams, treat pain, etc.
   Use active listening, provide interpersonal supports, advocate for the
           Mental Illness and the Dying Patient:

   As much as possible, maintain consistency among care providers, staff
    education, and supervision, to maintain a unified team approach and
    ensure clear communication
   Palliative care must be centered on the needs of the person with SPMI
    – a relationship based on respect, dignity, hope and non-abandonment
   Cross-training in palliative care and mental health is recommended – a
    strong need exists for service integration and a multidisciplinary team
   *Build relationships with local mental health providers and agencies to
    continually improve care and address the needs of your patients
           Mental Illness and the Dying Patient:
                     Newly Diagnosed Patients
   Mental illnesses can often be comorbid with other physical illnesses –
    heart disease, stroke, diabetes, cancer, and Parkinson’s, etc.
     A recent study found that 50% of patients with advanced or
      terminal cancer were suffering from anxiety, depression, or an
      adjustment disorder.
     Less than half of these individuals received help they needed

   Mental illness can compromise the quality of one’s life even more than
    the physical pain of the illness they are dying from
   Depression is NOT a normal part of aging
     Loss is inevitable, but depression should not be expected/accepted
             Mental Illness and the Dying Patient:
                         Newly Diagnosed Patients

   Some individuals develop mental illnesses later in life, presenting with
    symptoms of depression, post-traumatic stress disorder (complicated
    by dementias), anxiety, psychosis, etc.
   Healthcare workers need to familiarize themselves with various illnesses
    to become skilled at detecting symptoms early on
       These illnesses are progressive and can worsen over time without treatment,
        patients can find recovery from mental illnesses if treated early
   Choose appropriate treatment based on capabilities – Cognitive
    Behavioral Therapy may be appropriate/effective for the patient
    without cognitive deficits, vs. patients with dementia or cognitive
    deficits may be better treated through medication
             Mental Illness and the Dying Patient:
                Family Members with Mental Illnesses

   Areas of concern:
       Emotional stability of family member
       Coping ability
       Potential guardianship issues
       Access to continued care and treatment
       Additional supports to assist family member in grieving process

What other areas have you faced with family members with
                     mental illnesses?

Palliative Care for People with Severe Persistent Mental Illness: A Review of the
Woods, A., Willison, K., Kington, C., & Gavin, A. The Canadian Journal of
Psychiatry, Vol 53, No 11, November 2008, p. 725-736.
        Thank you!
      Ariel Mindel, MC, LPC
Program Director of Public Education
  Mental Health America of Illinois


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