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Newsletter Volume 7, Issue 8 FEB 2017 Problem drinking in older adults Older adults suffering from multiple chronic health conditions and depression are nearly five times as likely to be problem drinkers as older adults with the same conditions and no depression, according to researchers at the University of Georgia. Their study is the first to document the connection between multiple chronic illnesses, depression and alcohol use in seniors. This information could help health care providers identify which older adults are most likely to experience problem drinking and lead to better preventative care for this segment of society. The study, conducted by researchers from the UGA School of Social Work, utilized data from the National Social Life, Health and Aging Project, a nationwide survey of older adults that is funded by the National Institutes of Health. Researchers looked at more than 1,600 individuals aged 57 to 85 who identified as active alcohol consumers. Among problem drinkers, or individuals who reported a high amount of negative consequences associ- ated with alcohol use, the researchers found that more than half—66 percent—reported having multiple chronic health conditions, or MCC, and 28 percent reported having symptoms of depression. The researchers also found that older adults who experienced MCC combined with depression were those who experienced the highest likelihood of problem drinking. “These findings suggest that effective training in screening and referral for mental health and alcohol use issues for health care providers of older adults may better serve the approximate 4 million older adults who currently experience problem drinking in the U.S.,” said Orion Mowbray, assistant professor at the UGA School of Social Work and lead author of the study. Previous efforts to prevent and manage disease in older adults have focused on a single disease at a time, said Mowbray. Few physicians consider the combination of multiple chronic conditions in connection with depression as a potential sign for increased alcohol misuse, although screening and follow-up counseling for behavioral problems is known to help. “There is sufficient evidence that even brief interventions delivered in medical-related settings can have a positive influence on reducing problem drinking among most older adults,” said Mowbray. “These interventions can include screening for signs of depression in individuals with long-term health problems, engaging the individual in a conversation about the risks of problem drinking, and providing a referral for alcoholrelated treatment.” The study was published in the October issue of the Journal of the American Geriatrics Society, and was presented at the Society for Social Work and Research’s annual conference in New Orleans. University of Georgia. “Problem Drinking in older adults.” Science Daily, 12 January 2017. www.sciencedaily.com/releases Inside this issue: CMHA Mental Health First 2 Aid Workshop Managing Powerful Emo2 tions Group Treatment-resistant schizo- 3 phrenia-distinct from treatment-responsive schizophrenia? Pets can help people man- 4 age long-term mental health conditions Postpartum depression seems distinct from other mood disorders 5 Schedule of Events 6 Psychiatrists’ experienc- 7 es of suicide assessment 385 Princess Street Kingston, ON K7L 1B9 613-544-2886 [email protected] Callers in crisis will be referred to the crisis line Kingston & Frontenac 613-544-4229 Lennox & Addington 613-354-7521 2 CMHA—Mental Health First Aid Basic CMHA Kingston is offering a Mental Health First Aid Training (Basic) course on February 23-24, 2017. Mental health first aid (MHFA) is the help provided to a person developing a mental health problem or in a mental health crisis. The first aid is given until appropriate professional treatment is received or until the crisis is resolved. Mental Health First Aid Basic is a 12-hour course focused on adults interacting with adults in all environments. The course discusses the following mental disorders: Substance related disorders Mood related disorders Anxiety and trauma related disorders Psychotic disorders Crisis first aid skills for the following situations are learned: substance overdose, suicidal behaviour, panic attack, acute stress reaction, and psychotic episode. To add your name to the list, please call CMHA Kingston at 613-549-7027 Course will be held at: Isabel Turner Library 935 Gardiners Road Kingston Cost: $200 +HST/person Managing Powerful Emotions A FREE 12-week skills training group Intended to help you better tolerate and regulate your emotions This group is designed to help you: Identify and label your emotions Understand the purpose of your emotions Recognize what activates and intensifies your emotions Understand the relationship between emotions and behaviour Participants are expected to attend all 12 sessions and to do the work assigned in order to achieve maximum effectiveness of the program. Groups are co-ed and will take place at SAC Kingston, 400 Elliot Ave., Unit 1 Childcare is available upon request For more information and to register, please contact Theresa Metcalfe at 613-545-0762 ext. 105 or email [email protected] 3 Treatment-resistant schizophrenia...distinct from treatment-responsive schizophrenia? Schizophrenia is a highly heterogeneous disorder, and around a third of patients are treatment-resistant. The only evidence-based treatment for these patients is clozapine, an atypical antipsychotic with relatively weak dopamine antagonism. It is plausible that varying degrees of response to antipsychotics reflect categorically distinct illness subtypes, which would have significant implications for research and clinical practice. If these subtypes could be distinguished at illness onset, this could represent a first step towards personalized medicine in psychiatry. A study conducted by the Psychosis Studies Department, King’s College, London sought to investigate whether current evidence supports conceptualizing treatment-resistant and treatment-responsive schizophrenia as categorically different subtypes. A systematic literature search was conducted, using PubMed, EMBASE, Psycinfo, CINAHL and OpenGrey databases, to identify all studies which compared treatment-resistant schizophrenia (defined as either a lack of response to two antipsychotic trials or clozapine prescription) to treatment-responsive schizophrenia (defined as know response to non-clozapine antipsychotics). Nineteen studies of moderate quality met inclusion criteria. The most robust findings indicate that treatment-resistant patients show glutamatergic abnormalities, a lack of dopaminergic abnormalities, and significant decreases in grey matter compared to treatment-responsive patients. Treatment-resistant patients were also reported to have higher familial loading; however, no individual geneassociation study reported their findings surviving correction for multiple comparisons. Tentative evidence supports conceptualizing treatment-resistant schizophrenia as a categorically different illness subtype to treatment-responsive schizophrenia. Research is limited, however, and confirmation will require replication and controlled studies with large sample sizes and prospective study designs. Source: BMC Psychiatry “Is treatment-resistant schizophrenia categorically distinct from treatment-responsive schizophrenia? A systematic review” Amy Gillespie, Ruta Samanaite, Jonathan Mill, Alice Egerton, James MacCabe, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London UK. 4 Pets can help people manage long-term mental health conditions Despite evidence that connecting people to relevant well-being resources brings therapeutic benefit, there is limited understanding, in the context of mental health recovery, of the potential value and contribution of pet ownership to personal support networks for self-management. A study from the University of Manchester aimed to explore the role of pets in the support and management activities in the personal networks of people with long-term mental health conditions. The consistent presence of pets was described as providing a tangible, immediate source of calm and therapeutic benefit for the pets’ owners. Researchers suggested that pets should be considered a primary source of support in managing longterm mental health conditions. Lead author of the study, Dr. Helen Brooks, of the University of Manchester, noted that people interviewed through the course of the study felt their pet played a range of positive roles, including helping them manage stigma associated with their mental illness and provided acceptance without judgement. Pets were also considered especially useful during times of crises, providing a form of validation through unconditional support, which was often not available from other family or social relationships. Despite often identified benefits of pet ownership, pets were not considered nor incorporated into wellness plans for any of the people in the study. Dr. Brooks stated: “These insights provide the mental health community with possible areas to target intervention and potential ways in which to better involve people in their own mental health service provision through open discussion of what works best for them.” Researchers interviewed 54 people, aged 18 and above, who were under the care of community-based mental health services, and had been diagnosed with severe mental illness. Participants were asked to rate the importance of members of their personal network (friends, family, healthcare professionals, pets, hobbies, places, activities and objects) by placing them in a diagram of three concentric circles. Anything placed within the centre circle was most important; the middle circle was secondary, and the outer circle was for less important things. Pets were found to play an important role in the social networks of the study participants, as 60 percent placed their pet within the central circle, and 20 percent placed their pet in the middle circle. Study participants noted that their pets helped by distracting them from symptoms and upsetting experiences, such as hearing voices or having suicidal thoughts. Participants in the study expressed the following feelings: “If I didn’t have pets I think I would be on my own...You know what I mean, so it’s...it’s nice to come home and, you know, listen to the birds singing…” (First circle, 2 pet birds) “You know, so in terms of mental health, when you just want to sink into a pit and just sort of retreat from the entire world, they force me, the cats, force me to sort of still be involved with the world.” (First circle, 2 pet cats) “Yes, you get comfort from them, because they lick you and all that, and they knead you with their claws and purr at you and all that, so yes, they’re lovely.” (First circle, 2 pet cats) “She sort of, does random stuff, like climbs on the bars and...stuff (laughs) and things which distract me, and it’s quite funny watching her, what she does, because she’s not like a normal hamster.” (Second circle, pet hamster) “They don’t look at the scars on your arms, or they don’t question things, and they don’t question where you’ve been.” (First circle, pet dog) The interviews supported existing evidence that some participants feel distanced from healthcare and uninvolved in decisions about services. A more creative approach to care planning, such as including discussions about pets, may be one way of helping to involve participants because of the value, meaning and engagement companion animals provide. The implications of the study propose that pets should be considered a main, rather than a marginal, source of support. Source: BMC Psychiatry, “Ontological security and connectivity provided by pets: a study in the self-management of the everyday lives of people diagnosed with a longterm mental health condition”, Helen Brooks, Kelly Rushton, Sandra Walker, Karina Lovell, Anne Rogers, University of Manchester, UK 5 Postpartum depression seems distinct from other mood disorders New research suggests that mental disorders that often occur in association with pregnancy affect a different part of the brain than traditional mood disorders. Neuropsychologists used functional MRIs to study brain activity during postpartum depression and anxiety and uncovered the distinct patterns. On the surface, postpartum depression (PPD) looks a lot like most other forms of depression. New mothers often withdraw from family and friends, lose their appetite, and feel sad and irritable much of the time. Many people and clinicians have not recognized the uniqueness of mood and emotional disorders that appear during pregnancy or shortly after giving birth. “Motherhood really can change the mother, which is something we often overlook. And we forget about examining the neurobiology of maternal mental health and maternal mental illness, particularly anxiety,” said behavioural neuroscientist Dr. Jodi Pawluski. Pawluski, of the University of Rennes in France, was co-author of the paper with Dr. Joseph Lonstein (Michigan State University) and Dr. Alison Fleming (University of Toronto). Overall, functional MRI studies show that neural activity in women diagnosed with PPD, compared to people with major depressive disorder who had not given birth, involves distinct patterns for new mothers with PPD. The amygdala is usually hyperactive in anxious and depressed people, but for women with PPD, the amygdala can be less activated. PPD is now referred to as “perinatal depression,” a subset of major depression, in the DSM-5, the text which sets industry standards for diagnosing mental conditions. Postpartum anxiety is not included at all in the DSM-5, even though one in seven new mothers are affected by it, said Pawluski. Postpartum anxiety is estimated to be just as prevalent as PPD, although it receives far less attention. Many of these mothers are not depressed, so their condition remains largely unaddressed. “When we talk about the neurobiology of postpartum depression and anxiety, our information from the studies done on humans is only comprised from about 20 papers,” Pawluski said. “If you think that 10-20 percent of women during pregnancy and the postpartum period will suffer from depression and/or anxiety, and then you realize there are only 20 publications looking at the neurobiology of these illnesses, it’s quite shocking.” Postpartum mood disorders not only affect mothers, but also their infants. New mothers experiencing anxiety or depression are more likely to report having trouble forming a bond with their baby, and are more likely to be irritated with their infants. Early interactions can have long-term impact on infants’ health. Children of depressed mothers have higher burden of illness, use health care services more often, and have more medical office and emergency room visits than do children of healthy women. The cost annually of not treating a mother with depression, in lost income and productivity alone, is estimated at $7,200. Although PPD and postpartum anxiety affect nearly one in ten women, they are still treated as extensions of major depression and generalized anxiety disorder. The experience of PPD can be further complicated by the fact that women are expected to enthusiastically enter new motherhood. Many women with postpartum mood disorders don’t feel that they can openly discuss feeling they experience, or issues they have. New parenthood is a lifechanger, although it is not always a happy time, and it is important that the everyone recognize that, and talk about it. Research needs to follow that will explain why pregnancy and childbirth can trigger mental illnesses in so many women. If the health of the mother is improved, the health of the entire family will be improved as well. Psychcentral.com/news 6 F e b ru a ry 2 0 1 7 Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 9 10 11 16 17 18 23 24 25 GA 5 6 7 AA ANX 8 Mood Disorders GA FSG 12 13 14 AA ANX 15 Mood Disorders GA SSRG 19 20 AA 21 CLOSED Mood Disorders 22 GA Family Day 26 27 AA 28 ANX Mood Disorders Schedule of Events ANX—Anxiety Support Group—Designed for adults 18+ as a safe place to discuss anything related to anxiety, and meet others who have gone through similar experiences. Focuses on open discussion about coping strategies, challenges, personal experiences and more. Self-help group, with a laid-back atmosphere and friendly faces. Contact CMHA for further information. 613-549-7027 or [email protected] FSG—Family Support Group—Meets the first and third Monday of the month (except for holidays) at Ongwanada Resource Centre, 191 Portsmouth Ave., Kingston. Drop-in format—no registration needed. 6:30—8:30 p.m. Contact FRC for further information 613-544-2886 or [email protected] Mood Disorders Peer Support—Meet every Tuesday at Ongwanada Resource Centre, 191 Portsmouth Ave., Kingston. Open group meets from 7-9 p.m.; Young Adult group meets from 5:30-7 p.m. Affiliated with Mood Disorders Association of Ontario. Drop-in format, free and confidential. Contact FRC for further information 613-544-2886 or [email protected] GA—Gamblers Anonymous—552 Princess St., Kingston. Enter the back door from the parking lot (ring bell). Call for details 613-544-1356 ext.4200. Wednesdays at 6:30 p.m. SSRG—Suicide Survivors Recovery Group—CMHA sponsored discussion group for persons reconciling the loss of a loved one by suicide, or helping another person to do so. Meets at 400 Elliot Ave., Unit 3, Kingston, every 2nd Tuesday of the month, from 7-8 p.m. Contact CMHA 613-549-7027 for more information. AA—Alcoholics Anonymous—552 Princess St., Kingston. Enter the back door from the parking lot (ring bell). Call for details 613-544-1356 ext. 4200. Sundays at 10:30 a.m. NAMI Family-to-Family Educational Program—Next session, Spring 2017. No cost to attend, but must be pre-registered. Open to all caregivers of adults with mental illness. Participants gain vital information, insight, and understanding of their loved one that many describe as life-changing. Contact FRC for information or to register. Family Resource Centre 613-544-2886 or [email protected] 7 Psychiatrists’ experiences of suicide assessment Clinical guidelines for suicide prevention often stress the identification of risk and protective factors as well as the evaluation of suicidal intent. However, we know very little about what psychiatrists actually do when they make these assessments. Semi-structured in-depth interviews were carried out with a purposeful selection of 15 psychiatrists by researchers at Gothenburg University in Sweden. To increase richness and variation in the interview data, a sample of psychiatrists were chosen based on age, gender, geographic location, and within-psychiatric specialization. Thirteen of the psychiatrists worked within adult general psychiatric services (two of these were also involved in emergency psychiatric services, two worked in addiction medicine, and one in forensic psychiatry). One further participant was a geriatric psychiatrist, and one worked in refugee services. The analysis revealed three main themes: understanding the patient in a precarious situation, understanding one’s own reactions, and understanding how the doctor-patient relationship impacted on risk assessment and management decisions. Emotional contact and credibility issues were common subthemes that arose then the respondents talked about trying to understand the patient. Respondents stressed that the global impression elicited a gut feeling, but this was not something that was taught in medical school. Rating scales were not considered helpful. Most of the respondents brought up the importance of emotional contact. It was difficult to get a grasp on the patient’s motives and intentions when emotional contact was lacking. Assessing risk in a patient with blunted emotions was like flying blind. Situations in which persons were mild or moderately depressed, with good formal contact but reduced emotional contact could be particularly difficult. One psychiatrist described blunted emotion as a sign of heightened risk. “{the patient said} “I don’t want to talk to you about this”…”blunted contact was a warning signal for me here.” Assessment was particularly challenging when substance use issues were involved. “(there was) no resonance in the person, one got no feeling of emotion behind the words…(no) eye contact...What does he feel? What does he think? What are his intentions?...the combination (of) lack of emotional contact and substance use, that’s what makes it really precarious.” Evaluation of emotional contact was something the psychiatrists learned over time. Although central to the assessment, it was not something that could be taught in a lecture hall. Several psychiatrists described situations in which they worked to find ways to improve emotional contact during the consultation. When such contact was achieved, the doctors felt more secure in their suicide assessments. Getting a grasp on the credibility of the patient’s narrative was often described as a central aspect of the assessment procedure. Many patients knew what the doctor needed to hear in order to grant ward leave or hospital discharge. Clinical impressions were stressed by respondents. Non-verbal cues were especially important. These clinical impressions translated to a gut feeling, which was essential to the assessment process. After years of experience, the process became semi-intuitive, and the gut feeling could help resolve credibility issues and facilitate management decisions. Concern was expressed that relying on the gut feeling might be unprofessional. One psychiatrist described a gap between the formal risk assessment approach taught in school and the more intuitive assessment ascertainment of risk. Attaining a real picture meant that the doctor needed to use implicit and emotional material to draw conclusions related to care and safety. The capability to do that was learned through clinical practice. Clinical guidelines call for structured evaluation of risk and protective factors. Some doctors related how they assessed risk factors in the back of their minds during the consultation, rather than actually ticking off a list or filling in values on a rating scale. Several respondents stated openly that they did not follow the clinical guidelines, concluding that they had no sense that rating scales enhanced their clinical assessment. The psychiatrists stressed the semi-intuitive nature of their assessments. Problems related to the use of risk factor assessments and rating scales were apparent. Assessment consultations could evoke physical and emotional symptoms of anxiety, and concerns about responsibility could lead to repressive management decisions. In situations of mutual trust, however, the assessment consultation could kick-start a therapeutic process. Source: BMC Psychiatry “Psychiatrists’ experiences of suicide assessment” Margda Waern, Niclas Kaiser, Ellinor Renberg, Section of Psychiatry and Neurochemistry, Gothenburg University, Sweden.