As healthcare professionals, we will inevitably see many patients with mental health issues. These issues may be known to us, may emerge during the consultation or may remain hidden. Yet we have a duty to treat all of our patients with dignity and respect and to help them reach their full potential. An understanding of basic mental health is therefore essential for both our professional activity and for the successful care of our patients. Despite being more common than diabetes, there is still a stigma surrounding poor mental health. Misconceptions such as ‘It’s all in his head, he just needs to snap himself out of it’ abound and there is a poor general understanding of the causes, effects and treatment of mental health conditions. Campaigns such as the Mental Health Awareness Week (which ran last week) aim to redress the balance but, as eyecare professionals, we will inevitably see patients with mental health issues in our practice or may even ourselves be one of the one in four who suffer from a mental health problem during their lifetime.
Mental health is defined as our emotional, psychological and social well-being1 and is important because it allows us to reach our full potential and influences how we handle the challenges and stresses of everyday life. We all have a level of mental health in the same way that we all have a level of physical health, and recognising the signs of problems and understanding how to deal with them is just as important as recognizing physical symptoms and knowing the appropriate treatment.
MENTAL HEALTH CONCERNS
The most commonly cited problems are;
• Depression
• Anxiety
• Bipolar disorder
• Schizophrenia
We will look at each of these in turn.
KEY MENTAL HEALTH STATISTICS
•In 2009, one in six adults had a significant mental health problem at any given time.
•Depression affects one in five older people.
•4% of children age five to 16 are depressed or anxious.
•One in 10 children will experience a mental health problem at some point throughout their childhood.
•Women are more likely to be treated for mental health issues, however the suicide rate for men linked to mental health is three times higher than for women.
•90% of people who die from suicide in the UK are suffering from a mental health disorder.
•25% to 45% of visually impaired patients are depressed, whereas in the normal population less than 20% suffer from depression.
Depression
While sometimes feeling low is perfectly normal and common to us all, clinically significant depression describes a state of feeling down that has more impact on everyday life and can last for weeks or months and can be associated with a range of both physical and mental symptoms.2 Mental symptoms can include feelings of hopelessness and loss of interest in favourite activities while physical symptoms can range from being constantly tired and lethargic and disrupted sleep patterns to a loss of libido. Severe depression can lead to thoughts of suicide.
While there may be obvious triggers, such as a bereavement, continuing debt or job loss, other causes may be less easily identified such as illness, a family history of tendency to depressive states and alcohol or drug abuse.
COGNITIVE BEHAVIOURAL THERAPY
•Cognitive behavioural therapy (CBT) is a talking therapy designed to help a patient manage their problem.
•It has been found that depression can lead to cognitive distortion and bias in information processing causing patients to exaggerate the importance of minor problems and then over generalise and selectively dwell on events that confirm their negative view of themselves.17
•CBT does not remove a problem but provides a set of tools for a patient to deal with it. Unlike other therapies CBT sessions are focused on the patient’s current problems not historical ones.
•Practical solutions include, educating patients on how to react ‘differently’, monitoring their thoughts and feelings and challenging the negative thought patterns.
•CBT may also include behavioural elements such as setting targets and learning relaxation skills.
•CBT is usually a short term treatment with the therapy used initially to help people to cope with their emotions.
•A limited number of CBT sessions can often give the patient the tools and skills to cope with their emotional problems on a long-term and ongoing basis, reducing or eliminating the need for longer term therapy.18
Diagnosis
The National Institute for Health and Care Excellence (NICE) has produced a guideline (CG90)3 defining the identification and management of depression. The guideline recognises that symptoms may be distressing and debilitating, even if they fail to reach an established diagnostic threshold. This is because there are a range of social, physical and psychological factors that the diagnostic scales fail to capture.
NICE also recognises that depression is likely to be a recurrent problem and that the success of treatment should be judged on the relief of symptoms and states that this should be the key goal of intervention.
The guideline requires healthcare practitioners to be alert to signs of depression in individuals with a chronic health problem associated with functional impairment. This can be interpreted in an eye care setting as being applicable to those suffering from sight loss. Statistics produced by Margrain4 at Cardiff University show that 43% of partially sighted individuals do indeed suffer from depression and, more significantly, that 74.8% of those who do suffer depression have never received any treatment for it.
This should be a consideration when any management plan is being developed by a practitioner. (A more detailed review of the DEPVIT study findings will be published in a future issue of Optician).
NICE advocates the use of two questions:
• During the last month, have you often been bothered by feeling down, depressed or hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?
If the answer to either of these questions is ‘yes’ the practitioner should refer the person to an appropriate professional, usually the general practitioner (GP).
Treatment Strategies
Treatment strategies for depression vary depending on the severity of the condition. For mild depression treatment may simply be a case of ‘wait and see’. A strategy of watchful waiting, where a GP monitors the situation over a few weeks, may see spontaneous resolution. Exercise has also been shown to help. For more severe cases, ‘talking therapy’ is generally recommended. This may include counselling or cognitive behavioural therapy (CBT).5
More severe depression may require medication. First developed and introduced in the 1950s, a wide range of drugs are available. There are now five main types of anti-depressants:
• Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin and noradrenaline reuptake inhibitors (SNRIs)
• Noradrenaline and specific serotoninergic antidepressants (NASSAs)
• Tricyclic antidepressants
• Monoamine oxidase inhibitors (MAOIs)
MAOIs are rarely prescribed nowadays, and SSRIs and SNRIs are the most commonly prescribed antidepressants.6,7
SSRIs increase the serotonin levels in the brain by inhibiting the reuptake of the neurotransmitter by blocking the serotonin specific receptors on neurones. This results in more serotonin being available within the brain leading to a positive effect upon mood as more signals are able to be transmitted between the nerve cells. Regularly prescribed SSRIs include Prozac (fluoxetine). Cipramil (citalopram) and Seroxat (paroxetine).
SNRIs work in a similar way to SSRIs, as they too block the reuptake of serotonin. However, they also block the reabsorption of the neurotransmitter noradrenaline. Examples of SNRIs include Cymbalta (duloxetine) and Efexor (venlafaxine).
Side effects of SSRIs and SNRIs are well documented and include;
• feeling agitated, shaky or anxious
• nausea
• indigestion and stomach aches
• diarrhoea or constipation
• loss of appetite
• dizziness
• insomnia, or conversely, sleepiness
• headaches
• low sex drive
• erectile dysfunction
NSSAs act by blocking serotonin and noradrenaline receptors.
The side effects of NSSAs are similar to SSRIs and SNRIs but also include weight gain and drowsiness.
Tricyclic antidepressants increase serotonin and norepinephrine levels but also block the action of acetylcholine. Tricyclic drugs commonly prescribed include Amitriptyline (tryptizol) and Clomipramine (anafranil)
The side effects of tricyclic drugs include
• dry mouth
• slight blurring of vision
• constipation
• problems passing urine
• drowsiness
• dizziness
• weight gain
• excessive sweating (especially at night)
• palpitations or tachycardia
Anxiety
Anxiety disorders can affect up to 5% of the population and usually start from around the age of 20, but can develop later.
Anxiety is a disproportionate fear of any particular situation and, while it is a normal response to danger causing the fight or flight response, persistent fear can be a problem. Some people suffer from a generalised anxiety while others have severe sporadic bouts or panic attacks. Anxiety can also result in phobias, which are extreme anxiety states triggered by very specific situations or objects. Obsessive compulsive disorder and post-traumatic stress disorder are also considered to be forms of anxiety. Psychological symptoms include feelings of dread, while physical symptoms can include dry mouth, shortness of breath and dizziness.8,9
Treatment of anxiety may start with a self-help or small group course aimed at establishing and encouraging strategies for tackling the anxiety. If the patient fails to respond to this, CBT or applied relaxation techniques (such as yoga) may be tried.
If medication is prescribed, SSRIs or SNRIs are most likely, although pregabalin, an anticonvulsant used to treat epilepsy, has been found to help. The side effects of this can include drowsiness, dizziness, weight gain, blurred vision and dry mouth. Short term tranquilisers, such as diazepam, may also be used.
Bipolar Disorder
Bipolar disorder (formerly known as manic depression) is a condition in which people experience extreme highs and extreme lows in their mood. The mood swings may last for days or even weeks at a time. It affects about 1% of the population and usually develops in the late teens, with peak incidence between the ages
of 15 and 19.10 Although there are no obvious underlying causes, it is more common within families with a history of symptoms. The triggers for bipolar disorder are often stress-related, such as the breakdown of a relationship or a bereavement.
During the manic phase, people often feel very happy or excited, with declaration of lots of plans and ideas. They exhibit signs such as appetite loss or insomnia and may talk more quickly than normal. Irritability is also common, and the person can become very easily annoyed. In some cases, there may be psychotic episodes where people see or hear things that are not really there or convince themselves that things are true when they are not.
Mental health professionals describe this as the positive phase, in contrast to the depressive phase which is a negative experience. Unlike depression, bipolar disorder cannot be diagnosed by using questionnaires and, when suspected, requires a referral to mental health services.
Treatment
Bipolar disorder is most effectively controlled using a combination of treatments. This can include talking therapies and identification and management of the triggers. Medication may also be effective. The most commonly used medication is lithium carbonate, which is a mood stabiliser11 and is generally prescribed to treat the manic phase. Lithium can cause problems with thyroid function and is also contraindicated for non-steroidal anti-inflammatories (NSAIDs).
If a patient fails to respond to lithium treatment, an anticonvulsant such as carbamazepine (Tegrtaol) may be prescribed.
Although usually used to control epilepsy, anticonvulsants have been shown to be effective with some bipolar states. In a practice setting we need to be aware that carbamazepine has been shown to increase the risk of angle closure glaucoma.12
Antipsychotics, such as rispiredone, are considered to be long term mood stabilisers and may also be prescribed for bipolar tendency.
They have a risk of increased blood pressure as well as dry mouth and blurred vision.13
Schizophrenia
Schizophrenia is a long term condition characterised by hallucinations and delusions. This can cause confusion and changes in behaviour. It is a psychotic condition, meaning that people have difficulty distinguishing between their own thoughts and reality.14
Schizophrenia affects about one in 100 people, making it the most common of the serious psychiatric disorders. It usually manifests between the ages of 15 and 35 years and is diagnosed following an assessment by a psychiatrist. Schizophrenia is characterised by hallucinations and delusions, and in fact hallucinations are one of the diagnostic criteria for schizophrenia (DSM IV).15 Hallucinations seem real to the person experiencing them and, while they may affect any of the senses, the commonest are auditory in nature. MRI studies have suggested that problems with the mediating function of brain tissues surrounding the sensory processing areas is responsible for the hallucinations rather than lesions in the processing areas themselves. Delusions are a profound conviction and belief even though it is mistaken or based on false premises. While some delusions may be developed to explain the hallucinations, others may be idiopathic and without basis in any other material trigger or manifestation. In paranoid delusions, individuals will feel that they are being persecuted, often by friends or family. Other symptoms include thought disorder, where a person has trouble concentrating or keeping track of a conversation. This can lead to inappropriate behaviour and unpredictability.
Treatment
NICE has produced guidelines for treatment which advocate shared responsibility for care.16 Oral anti-psychotics, such as chlorpromazine, inhibit the effect of dopamine and may be given for acute episodes. They are normally taken for up to two years following an episode. Slow release versions have been developed which require a monthly injection. Side effects include shakiness, trembling and muscle spasms.
They may also cause dry mouth and blurred vision.
STEPS TOWARDS GOOD MENTAL HEALTH
The Mental Health Foundation recommend 10 steps to maintain good mental health. It is not just coincidental that many of these are also some of the steps to treating mental health problems.
1 Talk about your feelings – Talking about feelings can seem strange but bottling things up is not healthy, this might be as simple as telling other members of staff that you are feeling a bit rushed or overwhelmed by the number of patients you have to see.
2 Keep active – Regular exercise boosts selfesteem and makes you look and feel better.
3 Eat well
4 Drink sensibly – We often drink in social situations and moderate amounts of alcohol can help us to relax which both have beneficial effects however excess alcohol can alter neurotransmitter action which can in turn cause depression. See cpsych.ac.uk/healthadvice/problemsdisorders/alcoholdepression
5 Keep in touch with family and friends
6 Ask for help – Family and friends can often provide support but it may be that counselling would help. Counselling is available both through the NHS and privately and provides a non-judgemental, supportive space to talk about feelings.
7 Take a break – In a busy practice with patients waiting it can be difficult to take a break but even five minutes for a cup of tea can make a difference. At other times it might mean getting away for a holiday or doing something different for a day such as spending time outdoors instead of in the practice. It is important to realise the value of these breaks and prioritise them.
8 Do something you are good at – Enjoying something helps to beat stress and being good at it is good for your self-esteem. You also forget the worries of the day.
9 Accept who you are – We are all different and we need to recognise that we all have different skills and characters and accept who we are rather than strive to be who we are not.
10 Care for others – Caring for others builds relationships but sharing skills and doing something you are good at builds self-esteem and satisfaction.
CONCLUSION
Mental health issues obviously have the potential to impact on our professional role and it is important that we are aware of the issues, the conditions, symptoms and treatment to offer the best to our patients. It is an old adage that ‘you can’t care for someone else if you don’t care for yourself’ and, as eye care practitioners, we belong to a caring profession so it is only fitting that we know how to care for ourselves.
Andrew Millington is an optometrist with a private practice in Chepstow and teaches at Cardiff University where he has been instrumental in the development of the special clinic service aimed at children with learning and cognitive impairment. Laura Preece is a pre-registration optometrist.
REFERENCES
1 mentalhealth.gov/basics/what-is-mental-health/.
2 nhs.uk/Conditions/Depression/Pages/Introduction.aspx.
3 nice.org.uk/guidance/cg90.
4 Nollett, Claire L. et al. High Prevalence of Untreated Depression in Patients Accessing Low-Vision Services. Ophthalmology, Issue 2, s.l.: 2016, Vol. 123.
5 nhs.uk/Conditions/Depression/Pages/Treatment.aspx.
6 evidence.nhs.uk/formulary/bnf/current/4-central-nervoussystem/43-antidepressant-drugs.
7 nhs.uk/conditions/SSRIs-%28selective-serotonin-reuptakeinhibitors%29/Pages/Introduction.aspx.
8 mentalhealth.org.uk/a-to-z/a/anxiety.
9 nhs.uk/conditions/anxiety/Pages/Introduction.aspx.
10 nice.org.uk/guidance/cg185/chapter/Introduction.
11 cpsych.ac.uk/healthadvice/treatmentswellbeing/medicationsbipolardisorder.aspx?theme=mobile.
12 evidence.nhs.uk/formulary/bnf/current/4-central-nervoussystem/48-antiepileptic-drugs/481-control-of-the-epilepsies/
carbamazepine-and-related-antiepileptics/carbamazepine
13 evidence.nhs.uk/formulary/bnf/current/4-centralnervous-system/42-drugs-used-in-psychoses-and-relateddisorders/
421-antipsychotic-drugs/second-generationantipsychotic-drugs/risperidone
14 nhs.uk/Conditions/Schizophrenia/Pages/Symptoms.aspx.
15 Allen P et al. The hallucinating brain: A review of structural and functional neuroimaging studies of hallucinations. Neuroscience & Biobehavioral Reviews, 2008, pp 175 - 191.
16 nice.org.uk/guidance/cg178/chapter/1-Recommendations.
17 SJ, Enright. Cognitive behaviour therapy – clinical applications. BMJ 1997, Jun 21; 314(7097): 1811–1816
18 mentalhealth.org.uk/a-to-z/t/talking-therapies.