What is Mental Health?

Mental health = our emotional, psychological and social well-being, it is all about how we think, feel and behave

Affects how we think, feel and act
Determines how we handle stress, relate to others and make choices
Mental health can affect daily life, relationships and even physical health

World Health Organization’s Definition:

mental health is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” not just the “absence of a mental disorder!”

Often very underfunded (both human and financial) in low and middle income countries
Countries should integrate mental health into primary care, provide mental health care in general hospitals, and improve community-based mental health services, rather than just providing care in large psychiatric hospitals

Medilexicon’s Medical Dictionary Definition: mental health is “emotional, behavioral, and social maturity or normality; the absence of a mental or behavioral disorder; a state of psychological well-being in which one has achieved a satisfactory integration of one’s instinctual drives acceptable to both oneself and one’s social milieu; an appropriate balance of love, work and leisure pursuits.”

Why is Mental Health Important?

Mental Health Affects Everyone:

We all have the potential for suffering from mental health problems, no matter how old we are, whether we are male or female, rich or poor, or what ethnic group we belong to
National Institute of Mental Health (USA): mental disorders are common in the USA and internationally
- Approximately 55.7 million Americans suffer from a mental disorder in a given year (26.2% of adults)
- Main burden of illness is concentrated in about 1/17 people (6%) who suffer from a severe mental illness
- Approximately half of all people who suffer from a mental disorder probably suffer from another mental disorder at the same time

The United States is said to have the highest incidence of people diagnosed with mental health problems in the developed world.

Positive Mental Health Allows One to:

Realize their full potential
Cope with stress
Work productively
Make meaningful contributions to their communities
Associated with increased learning, creativity and productivity
Increased pro-social behavior
Positive social relationships
Improved physical health and life expectancy

Warning Signs for Poor Mental Health:

Eating or sleeping too much or too little
Pulling away from people and usual activities
Having low or no energy
Feeling numb or like nothing matters
Having unexplained aches and pains
Feeling helpless or hopeless
Smoking, drinking, or using drugs more than usual
Feeling unusually confused, forgetful, on edge, angry, upset, worried or scared
Yelling or fighting with family and friends
Experiencing severe mood swings that cause problems in relationships
Having persistent thoughts and memories you can’t get out of your head
Hearing voices or believing things that are not true
Thinking of harming yourself or others
Inability to perform daily tasks like taking care of your kids or getting to work

Misunderstanding Mental Health:

Mental health is frequently misunderstood. It is often used as a substitute for mental health conditions such as depression, anxiety conditions, schizophrenia and others.

Mental Health is about wellness rather than illness.

It is important to remember that mental health is complex. “The fact that someone is not experiencing a mental health condition doesn’t necessarily mean their mental health is flourishing. Likewise, it’s possible to be diagnosed with a mental health condition while feeling well in many aspects of life. Ultimately, mental health is about being cognitively, emotionally and socially healthy – the way we think, feel and develop relationships – and not merely the absence of a mental health condition.” – Beyond Blue

World Health Organization’s 10 Facts on Mental Health:

Around 20% of the world’s children and adolescents have mental disorders or problems (half of mental disorders begin before the age of 14)
Mental and substance use disorders are the leading cause of disability worldwide (about 23% of all years lost because of disability is caused by mental and substance use disorders)
About 800,000 commit suicide every year; it is the leading cause of death in 15-29 year olds
War and disasters have a large impact on mental health and psychosocial well-being; rates of mental disorder tend to double after emergencies
Mental disorders are important risk factors for other diseases, as well as unintentional and intentional injury
Stigma and discrimination against patients and families prevent people from seeking mental health care; misunderstanding and stigma surrounding mental health illnesses are widespread. Despite the existence of effective treatments for mental disorders, there is still a belief that they are untreatable or that people with mental disorders are difficult, not intelligent or incapable of making decisions. Stigma can lead to abuse, rejection, isolation and exclusion of people from proper care. Within the health system, people are too often treated in institutions which resemble human warehouses rather than places of healing
Human rights violations of people with mental and psychosocial disability are routinely reported in most countries. These include physical restraint, seclusion and denial of basic needs and privacy. Few countries have legal framework that adequately protects the rights of people with mental disorders
Globally, there is huge inequity in the distribution of skilled human resources of mental health.
There are five key barriers to increasing mental health services availability: the absence of mental health from the public health agenda and the implications for funding, the current organization of mental health services, the lack of integration within primary care, inadequate human resources for mental health, and lack of public mental health leadership.
Financial resources to increase services are relatively modest. Governments, donors and groups representing mental health service users and their families need to work together to increase mental health services, especially in low and middle income countries.

Myths Surrounding Mental Health

Myth 1: Mental Health Problems Don’t Affect Me

1/5 American adults have experienced a mental health issue
1/10 young people have experienced a period of major depression
1/25 Americans have lived with a serious mental illness, such as schizophrenia, bipolar disorder or major depression

Myth 2: Children don’t experience mental health problems

children may experience mental health issues that are often clinically diagnosable and can be a product of the interaction of biological, psychological and social factors
½ of all mental health disorders show first signs before a person turns 14 and ¾ of mental health disorders begin before age 24
less than 20% of children and adolescents with diagnosable mental health problems receive the treatment they need

Myth 3: People with mental health problems are violent and unpredictable

just as likely to be violent as anyone else
3%-5% of all violent acts can be attributed to people with serious mental health illnesses
people with severe mental illnesses are 10 times more likely to be victims of violent crime than the general population
many people with mental health problems are highly active and productive members of our communities

Myth 4: People with mental health needs, even those who are managing their mental illness, cannot tolerate the stress of holding down a job

people with mental health problems can be just as productive as other employees

Myth 5: Personality weakness or character flaws cause mental health problems. People with mental health problems can snap out of it if they try hard enough

mental health problems have nothing to do with being lazy or weak
many people need help to get better
factors that contribute to mental health problems are:
- biological factors (genes, physical illness, injury or brain chemistry)
- life experiences (trauma or a history of abuse)
- family history of mental health issues
people with mental health problems can recover and many recover completely

Myth 6: Therapy and self-help are a waste of time. Why bother when you can just take a pill?

Treatment effectiveness varies on the individual
Some need therapy and medicine

Myth 7: Prevention doesn’t work. It is impossible to prevent mental health illnesses

Prevention of mental, emotional and behavioral disorders focuses on addressing known risk factors such as exposure to trauma that can affect the chances that children, youth and young adults will develop mental health issues

Depression

What Causes Depression?

We don’t know exactly what causes depression. However, a number of things are linked to its development. “Depression usually results from a combination of recent events and other longer-term or personal factors rather than one immediate issue or event.” – Beyond Blue

Life events: long-term unemployment, living in an abusive or uncaring relationship, long-term isolation or loneliness, prolonged work stress
- Are more likely to cause depression than recent life stresses
- Recent events (such as losing your job) or a combination of events can trigger depression if you’re already at risk because of previous bad experiences of personal factors
Personal Factors
- Family History: depression can run in families and some people will be at an increased genetic risk
- Personality: people who have a tendency to worry a lot, have low self-esteem, are perfectionists, are sensitive to personal criticism, or are self-critical and negative have a greater tendency to develop depression
- Serious Medical Illnesses: the stress and worry of coping with a serious illness can lead to depression
- Drug and Alcohol Use: both can lead to and result from depression

Signs and Symptoms

Behavioral Symptoms: not going out anymore, not getting things done at work or school, withdrawing from close family and friends, relying on alcohol and sedatives, not doing usual enjoyable activities, unable to concentrate
Feelings: overwhelmed, guilty, irritable, frustrated, lacking in confidence, unhappy, indecisive, disappointed, miserable, sad
Thoughts: “I’m a failure,” “It’s my fault,” “Nothing ever good happens to me,” “I’m worthless,” “Life’s not worth living,” “People would be better off without me.”
Physical Symptoms: tired all the time, sick and run down, headaches and muscle pains, churning out, sleep problems, loss or change of appetite, significant weight loss or weight gain

Types of Depression

Major depression (major depressive disorder, clinical depression, unipolar depression): involves low mood and loss of interest in pleasure and activities; symptoms interfere with all areas of a person’s life (work and relationships)
- Melancholia: term used to describe a severe form of depression where many physical symptoms of depression are present
- Psychotic Depression: occurs when people start to lose touch with reality and experience psychosis
- Antenatal and postnatal depression: Women are at an increased risk of depression during pregnancy and in the year following childbirth
- Bipolar disorder (manic depression): person experiences periods of depression and periods of mania, with periods of normal mood in between
- Mania: the opposite of depression and can vary in intensity

Cyclothymic disorder: milder form of bipolar disorder
- Experiences chronic fluctuating moods over at least two years, involving hypomania (mild to moderate level of mania) and periods of depressive symptoms, with very short periods (no more than two months) of normality between
- Shorter duration of symptoms

Dysthymic disorder: the symptoms of dysthymia are similar to those of major depression but are less severe

Seasonal affective disorder (SAD): a mood disorder that has a seasonal pattern

Psychological Treatments

Cognitive behavior therapy (CBT): a structured psychological treatment which recognizes that the way we think (cognition) and act (behavior) affects the way we feel

Interpersonal therapy (IPT): a structured psychological therapy that focuses on problems in personal relationships and the skills needed to deal with these
- Helps you recognize patterns in your relationships that make you vulnerable to depression à la identifying the patterns helps improve relationships

Behavior therapy: a major part of CBT
- However, CBT doesn’t attempt to change beliefs and attitudes
- Behavior therapy focuses on encouraging activities that are rewarding, pleasant or satisfying, aiming to reverse the patterns of avoidance, withdrawal and inactivity that make depression worse

Mindfulness-based cognitive therapy (MBCT): generally delivered in groups and involves a type of meditation called mindfulness mediation
- Can help to stop one’s mind from wandering off into thoughts about the future or the past, and avoid unpleasant thoughts and feelings
- Thought to be helpful in preventing depression from returning because it encourages you to notice feelings of sadness and negative thinking patterns early on, before they become fixed
- Allows you to be able to deal with warning signs earlier and more effectively

Depression and HIV:

People living with HIV may experience mental health issues. Chronic illnesses, such as HIV, are known to take a toll on people’s mind. The extra stress due to the stigma surrounding the disease, disclosure to loved ones, and medication can contribute to the development of some mental health changes, such as the development of depression; one of the known causes of depression is major changes or events in one’s daily life or side effects of certain medications. According to www.aidsinfonet.org, about 5-10% of the general population can experience depression. However, the rates of depression in people with HIV are as high as 60%. Additionally, women with HIV are twice as likely to be depressed as men who live with HIV. Thus, depression and HIV is a pressing issue that needs to be addressed.

“Depression can lead people to not stay engaged in their care, to miss appointments or doses of their medications. It can increase high-risk behaviors that transmit HIV infection to others. Overall, depression can make HIV progress faster. It also interferes with your ability to enjoy life. A study in 2012 showed that patients with depression, especially women, were more likely to stop receiving care and to not achieve undetectable viral load. Depression often gets overlooked. Also, many HIV specialists have not been adequately trained to recognize or treat depression. Depression can also be mistaken for signs of advancing HIV.” - http://www.aidsinfonet.org.

Anxiety

“Anxiety is more than just feeling stressed or worried. While stress and anxious feelings are a common response to a situation where we feel under pressure, they usually pass once the stressful situation has passed, or ‘stressor’ is removed

Anxiety is when the anxious feelings don’t go away – when they’re ongoing and happen without any particular reason or cause

Signs and Symptoms

Normal anxiety tends to be limited in time and connected with some stressful situation or event, such as a job interview
Physical: panic attacks, hot and cold flushes, racing heart, tightening of the chest, quick breathing, restlessness, or feeling tense, wound up and edgy
Psychological: excessive fear, worry, catastrophizing or obsessive thinking
Behavioral: avoidance of situations that make you feel anxious which can impact on study, work or social life

Generalized Anxiety Disorder:

For six months or more you have: felt worried about a number of events or activities, found it hard to stop worrying, or found that your anxiety made it difficult for you to do everyday activities
Other symptoms: feeling restless or on edge, feeling easily tired, having difficulty concentrating, feeling irritable, having muscle tension, or having trouble sleeping

Phobias: feeling nervous with a specific object or situation or avoiding situations due to fear

Social phobia: feeling nervous or embarrassed when meeting unfamiliar people, being observed, or performing in front of others

Obsessive Compulsive Disorder (OCD): the person has obsessions and compulsions; the person has constant stressful thoughts and a powerful urge to perform repetitive acts, such as hand washing

Post-Traumatic Stress Disorder (PTSD): occurs after a traumatic event, something horrible and frightening that a person sees or experiences

Often, a person thinks that his/her life or other people’s lives are in danger
Sufferer may feel afraid or feel that he/she has no control over what is happening

Schizophrenia

Schizophrenia: not yet determined whether schizophrenia is a single disorder or a group of related illnesses

Most sufferers experience onset of schizophrenia between 15 and 25
Sufferer has thoughts that appear fragmented; he/she finds it hard to process information
Can have negative symptoms (withdrawal, lack of motivation and a flat or inappropriate mood) or positive symptoms (delusions, thought disorders and hallucinations)

Poverty and Mental Health:

According to the article Advances in Psychiatric Treatment, “It is a well-recognized fact that poverty has important implications for both physical and mental health. Poverty is a multidimensional phenomenon, encompassing inability to satisfy basic needs, lack of control over resources, lack of education, and poor health. Poverty can be intrinsically alienating and distressing, and of particular concern are the direct and indirect efforts of poverty on the development and maintenance of emotional, behavioral and psychiatric problems.” Although money is not a guarantor of mental health, its absence does not also necessarily lead to mental illness. However, “it is generally conceded that poverty can be both a determinant and consequence of poor mental health” (Advances in Psychiatric Treatment).

Additionally, a New Haven Study in 1958 and the Midtown Manhattan Study both indicated that there was a direct relationship between the experience of poverty and a high rate of emotional disturbance. The studies found that there was also a differential in availability and use of treatment modes and facilities by different social classes. Thus, “epidemiological studies throughout the world have demonstrated an inverse relationship between mental illness and social class. Psychiatric disorders have been consistently shown to be more common in lower social classes” (Advances in Psychiatric Treatment). Employment status has proven to be a major factor in explaining the differences in prevalence rates of all psychiatric disorders in adults; unemployment significantly increases the odds ratio of psychiatric disorders compared with the reference group.

Link Between Mood Disorders and Poverty:

“Many studies have reported that low socio-economic status is associated with high prevalence of mood disorders. In addition, longitudinal research in Stirling County indicated that during the 1950s and 1960s the prevalence of depression was significantly and persistently higher in the low socio-economic status population than at other low socio-economic status levels. Incidence of depression after the study began was also higher among those who were initially in the low socio-economic status group, supporting the view that the concentration of people with depression at the lower end of the social hierarchy may result from disabling aspects of the illness. The social causation hypothesis suggests that the stress associated with low social position, such as exposure to social adversity, might contribute to the development of mood disorder, whereas the social selection hypothesis argues that genetically predisposed individuals drift down to – or fail to rise out of – such a position” (Advances in Psychiatric Treatment).

Poverty and Children

According to the article Advances in Psychiatric Treatment, there is a growing body of research relating to poverty and health that indicates a low income combined with disruptive demographic factors and poor external support generate the stress and life crises that put children at risk, and may precipitate psychiatric disorders in children. Children living in the poorest households of the United States are three times more likely to have mental disorders than their richer counterparts. Additionally, in the behavioral domain, “conduct disorder and attention-deficient hyperactivity disorder show links with family poverty, and this is most marked for children in families facing persistent economic stress; it is well recognized that conduct disorder is three to four times more common in children who live in socio-economically deprived families with low income, or who live in a poor neighborhood” (Advances in Psychiatric Treatment). However, persistent poverty should be distinguished from current poverty because persistent poverty significantly predicts internalizing symptoms such as childhood behavioral disorders. Persistent poverty is likely to impose stress on parents that inhibits family processes of informal social control. As a result, the risks of harsh parenting and reducing a parent’s emotional availability to meet their child’s needs increase significantly.

Suicide and Poverty

According to the article Advances in Psychiatric Treatment, when compared to the general population, individuals associated with social destabilization and poverty attempt suicide more often. The study, Gunnel et al 1995, examined the relations between suicide, parasuicide and socioeconomic deprivation. They found that there was a strong association between suicide and socioeconomic deprivation; suicide occurs more frequently in highly populated, deprived areas. Additionally, the mortality rates of overdoses involving cocaine and opiates are significantly associated with poverty status.

Poverty increases the risk of mental disorders and having a mental disorder increases the likelihood of descending into poverty. People living in poverty lack financial resources to maintain basic living standards, have fewer educational and employment opportunities, are exposed to adverse living environments and are less able to access good quality health care. Additionally, people who develop a mental disorder may not be able to work due to their illness. Others, due to the stigma surrounding mental health, may be systematically denied work opportunities or may lose their existing job. Lack of employment drives people deeper into poverty and people are unable to pay for the treatment that they need.

Stigma and Mental Health Quotes

“At the root of this dilemma is the way we view mental health in this country. Whether an illness affects your heart, your leg or your brain, it’s still an illness, and there should be no distinction.”

– Michelle Obama

“It is an odd paradox that a society, which can now speak openly and unabashedly about topics that were once unspeakable, still remains largely silent when it comes to a mental illness.”

– Glenn Close

“I think it’s really important to de-stigmatize mental illness in any form. I think there’s a lot of people that are carrying around guilt and shame and baggage for shit that doesn’t matter. Everybody is going through something, everybody has had something that they’ve had to overcome.”

– Mary Lambert

“No one would ever say that someone with a broken arm or a broken leg is less than a whole person, but people say that or imply that all the time about people with mental illness.”

– Elyn R Saks

“We need so much more openness, transparency and understanding that it’s OK to talk about depression as an illness. It’s not a weakness. It’s not a moral shortcoming. It’s not something people brought on themselves.”

– John F Greden, M.D.

“What mental health needs is more sunlight, more candor, more unashamed conversation about illnesses that affect not only individuals, but their families as well.”

– Glenn Close

“We take care of our dental health. We don’t take care of our mental health … I think the solution to making this world better is if we would just be healthy, mentally.”

– Howie Mandel

“A child’s mental health is just as important as their physical health and deserves the same quality of support. No one would feel embarrassed about seeking help for a child if they broke their arm – and we really should be equally ready to support a child coping with emotional difficulties.”

– Kate Middleton

“We know that mental illness is not something that happens to other people. It touches us all. Why then is mental illness met with so much misunderstanding and fear?”

– Tipper Gore

HIV and Anxiety

One in five Americans living with HIV experience severe anxiety on an almost daily basis

A fifth of HIV-positive adults in the United States regularly experience symptoms of anxiety, according to research published in AIDS. Individuals with symptoms of generalised anxiety disorder (GAD) had poor engagement with the HIV care continuum, and also had high rates of poverty, homelessness and drug use. There was also evidence of an elevated prevalence of risky sexual behaviour.

“We estimate that nearly 1 in 5 people with HIV in the United States experienced recent symptoms consistent with a diagnosis of GAD,” comment the researchers. “The significance of the excess burden of anxiety among PWH [people with HIV] is compounded by our finding that GAD symptoms are related to suboptimal HIV care and outcomes in this population, which few studies have examined.”

Anxiety disorders are the most common mental health illness in the United States and can cause significant physical, psychological and social problems. GAD is characterised by persistent and excessive worry that is difficult to control. As little is known about the prevalence and associations of GAD among adults with HIV in the United States, investigators analysed data from the Medical Monitoring Project. This survey carefully sampled 3654 adults who are representative of all people diagnosed with HIV in the United States

Individuals with GAD had higher HIV stigma scores (55%) compared to individuals without GAD (33%).

GAD was associated with poorer engagement in the HIV care continuum, including use of antiretroviral therapy (82% vs 87%), 100% adherence (51% v. 62%) and viral suppression (56% vs 64%).

Depressive symptoms were seven times more common in people with GAD (75% vs 11%), and individuals with GAD were three-times more likely to be in need of mental health services (23% vs 7%).

Improving access to substance use treatment and HIV/STD risk reduction services could be beneficial for persons experiencing anxiety symptoms,” suggest the authors. “Collaborate care models – in which medical, mental health, and case management staff partner to provide comprehensive care – have been found to me more effective in improving anxiety in patients.”

Today, HIV is classified as a long-term health condition which can be managed effectively with medication and regular check-ups. However, as we’ve seen in our Invisible No Longer and Uncharted Territory reports, despite significant medical advances in HIV treatment, people living with HIV experience significantly higher rates of psychological difficulties than the general population. This can have a major impact on the quality of life and compromise physical health outcomes.

Although the presence of mental health difficulties has been found to the same across all ages, those from the older generation who were diagnosed at a time when the condition was not as treatable as it is today have often come through many traumatic and emotionally challenging times, and can feel forgotten within the ever improving medical field of HIV.

There is an entire generation of people growing older with HIV, which comes with its own set of new challenges in public health, social care and wellbeing. Although the clinical impact of HIV has clearly changed with the introduction of effective treatment, mental health issues continue to be a key issue for people living with HIV. We see a wide range of lived experience from the people attending our peer groups.

While some people are managing well, others are dealing with long periods of loss, struggling to manage a number of health conditions, or feeling overwhelmed by repeated reassessments for their welfare benefits. We hope that this podcast can help shed light on some of the difficulties and mental health issues faced by the older generation living with HIV.

Healthcare

As of 2014, most individual and small group health insurance plans, including plans sold on the Marketplace are required to cover mental health and substance use disorder services. Medicaid Alternative Benefit Plans also must cover mental health and substance use disorder services. These plans must have coverage of essential health benefits, which include 10 categories of benefits as defined under the health care law. One of those categories is mental health and substance use disorder services. Another is rehabilitative and habilitative services.

In a study from 2014, The risk of HIV infection may also increase with severity of psychiatric illness. In a multisite study in the United States, the prevalence of HIV among persons with SMI rose from 3.9% in community mental health centers, to 5.1% in intensive outpatient case management programs, to 5.9% in psychiatric inpatient units.

We have the necessary assessment (screening) tools and efficacious treatments to treat mental health problems among people living with and at risk for HIV. However, we need to prioritize mental health treatment, especially mental health treatment integrated into HIV care, with appropriate resources to address the current screening and treatment gap.

Promising advances have been made integrating mental healthcare into HIV primary care (via task-shifting, stepped-care interventions, and other strategies).