Mental Health Disorders GN PDF

Mental Health Disorders Miss H Rogers GDC ILOs 1.1.3 Explain general and systemic disease and their relevance to oral health 1.1.11 Recognise psychological and sociological factors that contribute to poor oral health, the course of diseases and the success of treatment 1.2.1 Recognise the importanc...

Mental Health Disorders Miss H Rogers GDC ILOs 1.1.3 Explain general and systemic disease and their relevance to oral health 1.1.11 Recognise psychological and sociological factors that contribute to poor oral health, the course of diseases and the success of treatment 1.2.1 Recognise the importance of and carry out an appropriate systema>c intra- and extra-oral clinical examina>on 1.2.3 Recognise the signi@cance of changes in the pa>ent’s reported oral health status and take appropriate ac>on 1.2.4 Recognise abnormali>es of the oral cavity and the rest of the pa>ent and raise concerns where appropriate 1.2.6 Assess pa>ents’ levels of anxiety, experience and expecta>ons in respect of dental care 1.5.3 Plan the delivery of, and carry out, care in the best interests of the pa>ent 1.5.4 Iden>fy where pa>ents’ needs may diJer from the treatment plan and refer pa>ents for advice when and where appropriate 1.7.1 Treat all pa>ents with equality, respect and dignity 1.7.2 Explain the impact of medical and psychological condi>ons in the pa>ent 1.7.4 Manage pa>ent anxiety and pain through eJec>ve communica>on, reassurance and relevant behavioural techniques 1.7.7 Refer to other members of the dental team or other health professionals 1.7.8 Recognise the need for and make arrangements for appropriate follow-up care 1.7.9 Recognise local referral networks, local clinical guidelines and policies 1.10.1 Recognise the responsibili>es of the dental team as an access point to and from wider healthcare 1.10.2 Provide pa>ents with comprehensive and accurate preven>ve educa>on and instruc>on in a manner which encourages self-care and mo>va>on 1.10.3 Underpin all pa>ent care with a preven>ve approach that contributes to the pa>ent’s long-term oral health and general health 1.10.6 Describe the health risks of diet, drugs and substance misuse, and substances such as tobacco and alcohol on oral and general health and provide appropriate advice, referral and support 1.11.1 Assess and manage the health of periodontal and soT >ssues taking into account risk and lifestyle factors 3.2 Recognise the importance of non-verbal communica>on, including listening skills, and barriers to eJec>ve communica>on 4.1 Communicate eJec>vely with colleagues from dental and other healthcare professions in rela>on to the direct care of individual pa>ents, including oral health promo>on Aim Gain a brief overview of mental health disorders (MHD) and how they may inZuence the delivery of dental care Learning Outcomes By the end of this session you should be able to:  Recognise the prevalence of MHD in society and its rela>onship with other health condi>ons  Name and brieZy explain MHD that may present in a medical history  Recognise any oral @ndings associated with MDH  Explain how MHD may impact on the delivery of dental care, and it’s management Lecture Outline Part 1- Introduc>on to Mental Health Disorders Part 2- Types of Mental Health Disorders Part 3- Dental Implica>ons and Management Introduc:on to Mental Health Disorders Neurological disorders and learning disabilities Mental Health Disorders- what are they? ‘There are many diJerent mental disorders, with diJerent presenta>ons. They are generally characterized by a combina>on of abnormal thoughts, percep>ons, emo>ons, behaviour and rela>onships with others’. – World Health Organisa:on (2019) And what are their contribu:ng factors? ‘Determinants of mental health and mental disorders include not only individual aaributes such as the ability to manage one's thoughts, emo>ons, behaviours and interac>ons with others, but also social, cultural, economic, poli>cal and environmental factors such as na>onal policies, social protec>on, standards of living, working condi>ons, and community support. Stress, gene>cs, nutri>on, perinatal infec>ons and exposure to environmental hazards are also contribu>ng factors to mental disorders’. – World Health Organisa:on (2019)  Neurodevelopm Schizophrenia 20 different sub headings ental Disorders Spectrum and Other Disorders Other Psychotic Disorders Bipolar and Paraphilic Related Disorders Disorders Personality Depressive Disorders Disorders Neurocognitive Anxiety Disorders Disorders Substance Use and Addictive Classifications Obsessive- Compulsive Disorders of MHD and Related Disorders Disruptive, Trauma- and Impulse Control Stressor- and Conduct Related Disorders Disorders Gender Dissociative Dysphoria Disorders Somatic Sexual Symptom Dysfunctions Disorders Feeding and Sleep-Wake Eating Disorders Elimination Disorders Disorders MHD Globally Approximately 13% of the global popula>on (around 971 million people) suJer from some kind of mental health disorder10 Anxiety is the most common mental illness in the world, aJec>ng 284 million people11 An es>mated 264 million people are aJected by depression, with women being the most aJected3 MHD in the UK Mixed anxiety & depression is the most common mental disorder in Britain, with 7.8% of people mee>ng criteria for diagnosis1 1 in 4 people will experience a mental health problem of some kind each year in England Since the COVID-19 pandemic began, depression rates have doubled (Ohce of Na>onal Sta>s>cs)12 MHD and Chronic Illness Those who have a physical health problem are at an increased risk of developing mental health problems; the same is true for the opposite (mental health problems increase the risk of physical health problems)  More than 15 million people - 30% of the UK popula>on - live with one or more long-term condi>ons, more than 4 million of these people will also have a mental health problem.1  People with cancer, diabetes, asthma and high blood pressure are at greater risk of a range of mental health problems such as depression, anxiety and PTSD.1 Mental Health and Chronic Diseases CDC Fact Sheet 2  MHD are on a spectrum… They can present differently person to person, day to day, week to week Remembering this can change over short space of time or stay the same over long periods Care needs to be tailored to individual and how they are feeling at that specific time - think how much they can take on during that specific time - may want to increase recall Types of Mental Health Disorders Different physiological and physical presentations - tailored approached to each individual Anxiety9 It’s a natural human response we feel when worried, tense or afraid, especially when it is about things that are about to happen, or think could happen in the future It becomes a mental health problem if it impacts on a persons ability to live their life as fully as they want to, for example: Avoidance of Feelings of situations that Worries feeling anxiety are very may cause very distressing strong and last a feelings of or hard to control long time anxiety Regularly Fears or worries Hard to go about experiencing are out of daily life or do symptoms of proportion to the enjoyable things anxiety situation Management9 Self-help workbooks Online Cognitive Behaviour Therapy (CBT) Self- programmes eg apps directed Therapist or psychologist CBT Talking Applied Relaxation Therapy Therapies Fluoxetine, sertraline, citalopram - most common Anti-depressants (SSRIs) Pregabalin Anti seizure but licensed for anxiety and other pain conditions Beta-blockers More for treatment of physical anxiety symptoms - rapid heart beat, palpitations and tremors Medication Benzodiazepine tranquillisers More for severe anxiety or crisis period - not very nice side effects and more addictive - not for long term use  Anxiety/depression most common Need to make oral hygiene routine manageable for patient Depression 4-10% of people in England will experience depression in their life>me.1 Can be long las>ng or recurrent Can be characterised by: Loss of Feelings of Sadness interest or guilt or low pleasure self-worth Disturbed Poor sleep or Tiredness concentration appetite Individuals may also experience physical complaints with no apparent cause In some cases it may impact a person’s ability to func>on at Management 3 Medications not recommended for children and teenagers - more management of stress factors and having support Talking therapies CBT Mild/ Psychotherapy Moderate Medication not always first treatment for mild depression Medication SSRIs most common Anti-depressants Moderate/ Severe  Manic and depressive episodes OR manic episodes by themselves Bipolar Disorder3 AJects about 45 million people worldwide Typically consists of both manic and depressive episodes, separated by periods of normal mood. However, individuals may experience manic aaacks without the depressive episodes Manic episodes involve: Elevated or Rapid irritable Over-activity speech mood Decreased Inflated self- need for esteem sleep Management 3 Medication Depressive Psychological treatments eg CBT Episode Medication Manic Episode Less likely to be offered talking therapies at the manic episode time - when more stable will likely be offered long term Talking therapies Help to develop strategies to notice triggers before they happen Help to set goals to stay stable for longer period of time CBT Support and management of episodes Interpersonal therapy Long term Enhanced relapse prevention Post-Trauma:c Stress Disorder (PTSD)9 PTSD may develop aTer an individual experiences a trauma>c event Trauma>c events may involve an event where a person feared for their life, witnessing others being hurt, having a job where distressing things are repeatedly seen/heard or surviving a natural disaster Dentist - vulnerable experience, handing over control, in personal space, wearing of PPE May trigger an individual who suffers with PTSD - access to care may be difficult and Psychological symptoms can include: lead to avoidance of dental care Reliving Avoiding Panicking when Alertness or Difficult beliefs aspects of what feelings or reminded of the feeling on edge or feelings happened memories trauma Displaying Being upset Being jumpy or other symptoms easily or angry easily startled of anxiety Can present alongside physical symptoms: …which can present alongside physical symptoms: Stomach Headaches Dizziness Chest pains aches  Impact the tailored advice we give to patients Think of achievable goals to set to be more supportive to patient PTSD can have an impact on aspects of a person's everyday life such as: Remembering Looking after Coping with Keeping a job and making themselves change (Oral hygiene routine) decisions And can be associated with other mental health disorders: Dissociative Anxiety Depression disorder Suicidal Substance feelings misuse Management 3 CBT Eye movement desensitisation and Talking reprocessing (EMDR) Therapies Types of antidepressants Paroxetine SSRI Mirtazapine Amitriptyline Medication Phenelzine Schizophrenia A severe mental disorder, aJec>ng 20 million people worldwide Characterised by distor>ons in: Thinking Perception Emotions Sense of Language Behaviour self Psycho>c episodes can include hallucina>ons and delusions It can make it dihcult for those aJected to work and study normally Management 9 CBT Psychodynamic therapy Talking Family intervention Therapies Antipsychotics Medication Art Music Help individuals to express feelings if unable to talk and express them Arts Dance Recommended by NICE Therapies Drama Obsessive Compulsive Disorder (OCD)7 Classified as anxiety disorder AJects around 1-2% of the popula>on8 a common mental health condi>on where a person has obsessive thoughts and compulsive behaviours. There are three elements of OCD: Create a cycle - Rationale and makes no sense Obsessions Emotions Compulsions Unwanted intrusive thoughts/image Can be distressing - strong/ Result of emotions lead to compulsions - repetitive behaviours - repeated intense emotions - cannot and mental acts control Starts to prevent or reduce feelings or anxiety - temporary help to relieve but them obsession comes back - cycle continues There is no clear cause, but there are many factors that may play a role: Differences in Family history Life events Personality the brain High level of activity or low levels of serotonin Management 3 CBT Talking therapies Selective Dopamine serotonin reuptake blockers: inhibitors (SSRIs): Risperidone Fluoxetine Aripiprazole Medication Sertraline Olanzapine Citalopram Cover a lot of conditions Feeding and Ea:ng Disorders Ea>ng disorders aJect approximately 16 million people worldwide11 De@ned as: “…condi:ons that involve abnormal ea:ng or feeding behaviours that are not be\er accounted for by other health condi:ons and are not developmentally appropriate or culturally sanc:oned.”13 DIFFERENT TYPES = DiJerent types: Other specified Binge eating Anorexia Bulimia feeding or eating disorder disorder (OSFED) Avoidant/restrictive Rumination food intake disorder Pica Orthorexia disorder (ARFID) Anorexia Nervosa6 Some common signs of anorexia include: fear of fatness or pursuit of thinness, preoccupa>on with body weight a distorted percep>on of body shape or weight Long term aJects may include: Affect our prevention treatment and delivery of care Heart Osteoporosis Tooth erosion problems Damage to Weakened organs immune (kidneys/liver) system Bulimia/Bulimia Nervosa6 Involves cycles of bingeing and purging Long term aJects may include: Damage of Damage of Tooth erosion vocal chords the stomach and throat and intestines Increased risk Kidney of heart damage problems Management6 For bulima CBT/CBT-BN Cognitive analytic therapy (CAT) Interpersonal psychotherapy (IPT) Talking Focal psychodynamic therapy (FPT) Therapies Family interventions Evidence based self-help Support groups Self- directed  Effects everyone differently Au:sm There are around 700,000 people in the UK with a diagnosis of au>s>c spectrum disorder Medical name Characteris>cs may include: Finding it hard to Seeming blunt, understand what Anxious about rube or not Finding it hard to Taking things very others are thinking social situations interested in others describe feelings literally and feeling without meaning to Having the same Disliking being Noticing smells daily routine and Avoiding eye touched or close and sounds others feeling anxious if it contact contact may not changes May also experience other conditions such as = May also experience Attention deficit other condi>ons such as: Dyslexia and hyperactivity Anxiety Depression dyspraxia disorder (ADHD) Epilepsy Insomnia Management 4 No management of autism as such more treatment for other associated conditions Epilepsy ADHD Anxiety Treatment for Depression associated OCD conditions Dental Implica:ons and Management How do you know? Pa:ent Management Pa>ents should be assessed at each visit, therefore there is no ‘blanket’ management but should be tailored on an individual and appointment basis Build a rapport and trust: May notice eating disorder intra orally (erosion) - make safe environment for patient Consider the language we use Delivery of message Non-judgemental environment Empathy Support Avoid pre-conceived ideas/stereotyping May be the @rst person that no>ces or the @rst person the pa>ent has con@ded in – not our job to diagnose but to recognise and raise concern/refer as appropriate Considera:ons for au:s:c pa:ents Book appointments at the start or end of the day Consider making a double appointment OJer a visit before the appointment Suggest bringing someone else along with them Have a designated quiet space in the wai>ng area Ask how you can make things easier 4 Helpful Resources Dental Care and Au>sm- a guide for den>sts Den>stry and au>sm: parental experiences Going to the den>st – a guide for parents and families Making dental prac>ces more au>sm-friendly  Antidepressants have become very common Medical History Medica:on Side Edects Common medica>on side eJects that may require management: Dry Mouth Altered Taste Vomiting Xerostomia How do they compensate? Add Link to tooth erosion Common with antidepressants more sugar - increase risk in caries Help to manage Ac:vity: Have a look on the BNF for the medica>ons below. What side eJects can you iden>fy that may have an impact on the oral cavity or on the delivery of dental care? Medication Side Effect Common = Drowsiness Amitriptyline Abnormal pain or discomfort Uncommon = anxiety, abnormal appetite, dry mouth, confusion, delusions, vomitting Fluoxetine Common = Anxiety, abnormal appetite, dry mouth, weight changes, vomitting, sleep disorders, memory loss Major depression Uncommon = Abnormal behaviour, hallucination, suicidal behaviours Common = Agitation, drowsiness, dry mouth, hypersalivation, movement disorders, vomitting, tremors. Risperidone Acute and chronic psychosis Uncommon = Confusion, thrombosis. Carbamazepine Common = Drowsiness, dizziness, dry mouth, fatigue, headache, movement disorders, vision disorders, vomitting Tonic-clonic seizures Uncommon = Tremors, constipation/diarrhoea Uncommon = abdominal discomfort, delirium, dry mouth, hypotension, movement disorders, muscle Lithium Carbonate weakness, altered taste, vomitting, renal disorders, speech impairment. Bipolar Major depressive disorder Very rare = nephropathy Aggressive self harming behaviour Addi:onal considera:ons and their management Smoking, alcohol, Tooth wear Oral appearance Caries & perio substance misuse Reduced Side effects of Self neglect Avoidance motivation medications Nail Biting Bruxism Toothbrush Abrasion Barriers to accessing care Avoid seeking care and only present when in pain Low self esteem S>gma and discrimina>on Phobia May not be able to afford care - due to loss of job due to MHD Avoidance Socioeconomically disadvantage Isola>on Raising concerns If you have concerns regarding your pa>ent, or a pa>ent discloses informa>on to you and you are unsure how to respond, speak with a senior colleague or your safeguarding lead. Summary Don’t forget that MHD may not always present alone but alongside other chronic illnesses which may present their own challenges in pa>ent management MHD can present on a spectrum and their presenta>on can vary, not only person to person but for one person across >me Endeavour to create a non-judgemental safe environment Dental management should be tailored to the pa>ent, not the condi>on If you have a concern, @nd out who to speak to in your prac>ce Resources If there are addi>onal resources you think would help with any of the issues covered within this lecture, or wider MHD, then please post in this weeks forum on Moodle. Further Reading UCLH Trust training on mental health- looks at the causes, signs and symptoms of anxiety, depression and stress. haps://learning.uclh.nhs.uk/totara/program/required.php?id=1361&useri d=12485 Mental Illness and Oral Health haps://www.dentalhealth.org/mental-illness-and-oral-health Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014. haps://digital.nhs.uk/data-and-informa>on/publica>ons/sta>s>cal/adult- psychiatric-morbidity-survey/adult-psychiatric-morbidity-survey-survey-of- mental-health-and-wellbeing-england-2014 Caring for dental pa>ents with ea>ng disorders haps://www.nature.com/ar>cles/bdjteam20159.pdf?proof=t References 1. haps://www.mentalhealth.org.uk/ 2. haps://equallywell.co.uk/wp-content/uploads/2018/09/Mental-health-and-c hronic-disease.pdf 3. haps://www.who.int/news-room/fact-sheets/detail/mental-disorders 4. haps://www.nhs.uk/condi>ons/au>sm/ 5. haps://www.au>sm.org.uk/ 6. haps://www.beatea>ngdisorders.org.uk/ 7. haps://www.nhs.uk/mental-health/condi>ons/obsessive-compulsive-disord er-ocd/ 8. haps://ocdac>on.org.uk/ 9. haps://www.mind.org.uk/ 10. haps://www.theguardian.com/society/2019/jun/03/mental-illness-is-there-r eally-a-global-epidemic 11. haps://www.singlecare.com/blog/news/mental-health-sta>s>cs/ 12. haps://www.health.org.uk/news-and-comment/news/latest-data-highlights- a-growing-mental-health-crisis-in-the-uk 13. haps://bmcmedicine.biomedcentral.com/ar>cles/10.1186/s12916-019-1327 -4 14. haps://www.na>onalea>ngdisorders.org/dental-complica>ons-ea>ng-disord ers