Saturday, November 23, 2013

Mental Health and Academic Performance in Children

mental health and academic performance in children
10yr window to treat mental health problems affecting academic performance

Mental health & academic performance

Mental health has a direct impact on academic performance in children. Neglected childhood psychiatric disorders like ADHD and Learning Disorders adversely affect the child’s academic performance and educational attainment. Poor educational outcomes affect the child’s health, employment, and status as an adult. This is especially so for psychiatric conditions that are seen at 7 years and persist beyond 16 years of age.

Mental health disorders in children have a greater impact on academic performance than chronic physical illness. The presence of a single mental condition results in morel board exams failures and backlogs. This association is more than for chronic illnesses of the neurological, lung, heart, or digestive systems. Physical impairments are not associated with exam failures. More than half the teenagers who fail to complete their secondary education have a diagnosable psychiatric disorder. Mental health problems in childhood impede academic performance as the student is unable to take advantage of learning opportunities at school and at home.

Poor academic performance may be a marker for mental health problems in childhood. We screened secondary school students performing poorly at academics for mental health disorders. 2/3 of these children had at least one mental health disability. ADHD and Depression were the most common mental health disorders in this population. One third of the children had more than one mental health disorder. Our study showed that screening children who had poor academic performance would help in the early identification of treatable psychiatric disorders. This in turn would improve academic performance and subsequent adult outcomes.

Mental health problems in children negatively impact physical health, employment and social status as they grow into adults. These adverse health, employment and social status outcomes are especially seen in those children with psychiatric disorders at age 7 that persist to age 16. There is a large window of opportunity between ages 7 to 16 during which psychiatric disorders can be addressed to prevent adverse outcomes in adulthood.

Mental health problems in childhood have a higher impact on academic performance than chronic physical conditions. Psychiatric disorders account for a large chunk of school failures in children. Poor academic performance in children may be a marker for the presence of undetected mental health problems. Treatment of childhood disorders like ADHD improves academic performance. There is a decade window between the ages of 7 and 16 years to prevent adverse impacts on physical health, employment and social status by treatment of mental health problems that are resulting in poor academic performance.

References
  1. Case, Anne, Angela Fertig, and Christina Paxson. "The lasting impact of childhood health and circumstance." Journal of Health Economics 24.2 (2005): 365-389. 
  2. Stoep VA, Weiss NS, Kuo ES, Cheney D, Cohen P. What Proportion of Failure to Complete Secondary School in the US Population Is Attributable to Adolescent Psychiatric Disorder? Journal of Behavioral Health Services & Research, 2003, 30(1), 119-124.
  3. Neville Misquitta, Sayyara Ansari. Prevalence of ADHD, Depression and Dysgraphia in School Children. 15th IACAPAP. New Delhi. 30-Oct-2002

Wednesday, September 18, 2013

What is normal? Dreams, the tiger and normality

what is normal?

What is normal? A 22-year-old man jumped into the tiger's enclosure at the local zoo on Saturday and was mauled on his back, stomach and thighs. The previous night he had dreamt that he was to free the big cat and that it wouldn't kill him. "See, it didn't kill me," he said. Doctors treating him said, "he has received injuries but he would be well soon ... he was not suicidal."


What is normal?

The concept of normality is at the core of mental health. Without a concept of what is normal one cannot identify the abnormal. In this post we explore the concept of normality from a mental health point of view.

Normality as Health

The WHO has defined health as a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity. Later they added spiritual well-being to the definition. So health is a positive state, not just the absence of disease. This concept looks at normality from a biological or medical point of view.

Suicide attempts are an important marker for mental health illness. However, the mere absence of this particular marker does not rule out mental illness. But the young man’s actions do indicate a lack of judgement - would jumping into the enclosure free the tiger? and after freeing the tiger what next? A display of impaired judgement is often the first visible sign of a mental health problem.

Normality as an Ideal

Normality is a blend of all the elements of the mental apparatus leading to optimal functioning that seeks perfection. However, Sigmund Freud wrote that "A normal ego is like normality in general, an ideal fiction. Every normal person, in fact, is only normal on the average. His ego approximates to that of the psychotic in some part or other and to a greater or lesser extent; and the degree of its remoteness from one end of the series and of its proximity to the other will furnish us with a provisional measure of what we have ...". This psychological interpretation of what is normal was the first to conceive of normality and abnormality as different ends of the same spectrum.

Abnormality

Normality is also defined by the persons internal experience or "personal world" - the way they think or feel. Karl Jaspers, psychiatrist and philosopher, viewed the goal of eliciting signs and symptoms from the patient as an attempt to reach an understanding of their personal experience without any prior assumptions or bias. According to Jaspers, the "personal world" is abnormal when it is based on a disease condition such as schizophrenia, when it alienates the person from others emotionally, or when it does not provide the person with a sense of “spiritual and material” security.

Normality as Average

Normal is also a statistic. The field of psychology contributed further to the concept of normality and mental health by introducing objectivity through measurement. Take intelligence, for example. A graph plotting the distribution of individual intelligence scores (IQ) in the population would follow a bell-shaped curve. The middle range of this curve is considered as normal, and the extremes as significantly low or high intellectual ability. This normal as an average is in the context of the total group. When is it normal to jump into the tiger enclosure?

Normality as Process

Normality is also conceived as being the result of an interacting system. This process-concept emphasises changes over time as against a cross-sectional definition of normality viewed at a particular point of time. The trajectory of development of an infant into an adult is one such process of normal change. When seen against this background an act such as crawling is normal in infancy but would need explanation in adulthood.

Social Normality

Normality is also assessed from a social viewpoint. Is the person normal to others in the same society? Is the person viewed as abnormal by the person's society but normal by others from outside the person's society? Is the person normal in the person's society but abnormal when viewed by persons outside the society? The answers to these questions are directly impact whether the person will be labelled as mentally ill and associated with the stigma of mental illness. The answers are also medically important as they will impact the decision to seek healthcare.
In a world where young people are exhorted to follow their dream one also needs to consider the dream.
References
  1. Coelho MT. [Conceptions of normality and mental health among prisoners in a correctional institution in the city of Salvador].Cien Saude Colet. 2009 Mar-Apr;14(2):567-75.[Article in Portuguese]
  2. Freud, Sigmund. (1937c). Die endliche und die unendliche Analyse. GW, 16; Analysis terminable and interminable. SE, 23: 209-253.
  3. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/clinical ...By Benjamin J. Sadock, Harold I. Kaplan, Virginia A. Sadock. 9th Edition. Lippincott Williams and Wilkins. Philadelphia. 2003
  4. Jaspers, Karl (1997). General Psychopathology - Volumes 1 & 2. translated by J. Hoenig and Marian W. Hamilton. Baltimore and London: Johns Hopkins University Press
  5. Sabshin, Melvin. Psychiatric perspectives on normality. Archives of General Psychiatry 17.3 (1967): 258.
  6. World Health Organization. WHO definition of Health, Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. In Grad, Frank P. (2002). "The Preamble of the Constitution of the World Health Organization". Bulletin of the World Health Organization 80 (12): 982.

Tuesday, February 21, 2012

Mental health checklists and screening tests for rampaging bus drivers

pune bus
Checklists and psychological screening questionnaires for mental illness are effective, easy to use and widely available. Pune was shocked into considering the need for mental health screening of its bus drivers after one of them wilfully killed eight people and injured 32 others. He hijacked a bus at the depot and mowed down victims in broad daylight. Amidst the protests, and outrage the Pune administration has decided that all its bus driver undergo psychological testing.

We have already looked at screening of police personnel for mental health problems, and also screening of teenagers for alcohol and drug abuse. Here we specifically examine the feasibility of regularly screening the 8600 PMPL staff and Pune bus drivers for mental health problems.

Mental illness in bus drivers

  • Mental health problems are higher for bus drivers who suffer from back pain, are dissatisfied with their jobs or undertake long-distance driving. This is more so for employees who have worked for >10 years. (Issever et al 2002)
  • Aggressive bus drivers have more anxiety, hostility, and anger. They display competitiveness when driving aggressively, and display anger at slow drivers and traffic obstructions (Galovski 2002). Aggressive drivers with Intermittent Explosive Disorder (IED) endorse more assaultiveness and resentment. They display more impatience, hostility and have an angry temperament.
  • Bus drivers have higher hospital admissions with diagnoses of mood reactions, paranoia and non-specific psychoses. (Ugesker 1989)

Ideal mental health screen

Easy to administer
it is to be conducted regularly without consuming excessive time
Culturally acceptable
anything stigmatising will be shunned
Sensitive
picks up potentially vulnerable persons
Specific
excludes those who do not have mental health problems
Easy to interpret
results should be available immediately
The aim of mental health screening is to identify individuals who require a more detailed examination. One counsellor will never be able to carry out any evaluation of 8600 staff.

Mental health checklists and screening instruments

There are already valid (test identifies persons mental illness) and reliable (results remain the same when administered by different testers and on re-testing) checklists for mental health screening. Two mental health screening instruments that satisfy many of the ideal criteria are the COOP/WONCA charts and the WHO-5 questionnaire. Both have high diagnostic accuracy for mental disorders. Specificity, sensitivity and positive predictive values range from 0.85 to 0.87 (Anything more than 0.7 is good).

COOP/WONCA

The COOP/WONCA measures six core aspects of functional status: physical fitness, feelings, daily activities, social activities, change in health and overall health through six charts. The charts have been successfully used in illiterate populations, and have guidelines for translation where required. The average time for completion is less than five minutes. One-time assessment with the COOP/WONCA Charts is a valid and feasible option for screening for mental disorders at the primary care level.

WHO-5

The WHO-Five Well-being Index (WHO-5) is a set of 5 questions that can be used when six charts are too much.

A mental health check is most acceptable as part of the regular or annual ‘health check’. Those who score above the cut-off are taken up for detailed assessment by a psychiatrist or other mental health professional. No additional man-power is required. The process will not cost in crores. Our roads will be safer.
We need to use available checklists and screening tests for early detection of mental illness in Pune’s bus drivers.
References
  1. Galovski T, Blanchard EB. Psychological characteristics of aggressive drivers with and without intermittent explosive disorder. Behav Res Ther. 2002 Oct;40(10):1157-68. 
  2. Issever H, Onen L, Sabuncu HH, Altunkaynak O. Personality characteristics, psychological symptoms and anxiety levels of drivers in charge of urban transportation in Istanbul. Occup Med (Lond). 2002 Sep;52(6):297-303. 
  3. Joao Mazzoncini de Azevedo-Marques, MD, PhD1 and Antonio Waldo Zuardi, MD, PhD. COOP/WONCA Charts as a Screen for Mental Disorders in Primary Care.  Annals of Family Medicine 9:359-365 (2011) doi: 10.1370/afm.1267
  4. C. van Weel, C. K├Ânig - Zahn, F.W.M.M. Touw - Otten, N.P. Van Duijn, B. Meyboom - de Jong. Measuring functional status with the COOP/WONCA charts: a manual. Northern Centre of Health Care Research 1990. ISBN 90 72156 33 1 
  5. WHO. WHO-Five Well-being Index (WHO-5) Accessed 17-Feb-2011 
  6. Ugeskr Laeger. Psychiatric admissions among city bus drivers. A prospective study. Ugeskr Laeger. 1989 Jan 30;151(5):302-5. 

Sunday, January 15, 2012

Recovery from mental illness

recovery from mental illness
Recovery to meaningful functioning after even severe mental illness is the present standard of care in mental health treatment. Recovery is made possible by medications that are now widely available at a reasonable cost. Planning and persistence with treatment need to be ensured to achieve a quality recovery.

Recovery from mental disorders is a process of change through which individuals
  1. improve their health and wellness
  2. live a self-directed life
  3. strive to reach their full potential
The road to recovery from mental illness has four components that together give meaning to life.
1. Health
Overcoming or managing the disease and living in a physically and emotionally healthy way.
Start with the basics - medication, meals, sleep and exercise. Establishing routines for these basic health tasks are essential for recovery of function. Medication is the corner stone on which recovery is nurtured. In the absence of medication frequent relapses and recurrences disrupt basic functions that protect the individual from the illness producing effects of daily stressors.
2. Home
A stable and safe place to live.
In daily practice we see persons with the most severe mental illnesses putting aside their disturbing thoughts, controlling their behaviours and getting back to school or work; while others with a milder illness are unable to leave their preoccupations and move ahead with life. Trusting relationships are quite often what they lack. Trust makes the home feel safe.
3. Purpose
Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society.
A person needs something to recover to. Amazing recovery can be sustained in a supportive job environment. Some bosses give this support naturally. It may be it is in their outlook; they see the illness as just one aspect of the persons identity. Vice versa, others with good symptom recovery without stigmata are unable to function in a hostile work place, and are unable to integrate with society  and lead meaningful lives.
4. Community
Relationships and social networks that provide support, friendship, love, and hope.
From volunteering at the community bookshop to joining a local football team; community interactions bring many otherwise isolated individuals into useful contact with others. These valued interactions are based on a personal identity which is not connected to their mental illness.
Recovery is a process towards achieving ones potential. The first small steps result in giant gains. Without them the individual is unable to reach any level of meaningful recovery. The first step for persons with serious mental illness is medication. Without medication, recovery from serious mental illness is long-drawn, stigmatising, and characterised by frequent relapses. Medication is the pillar around which recovery is fostered. A supportive home, work-place and community further augments this process. Recovery from severe mental illness is a process, it does not happen overnight, but for those who stay the course it brings the meaning back to life.

References
  1. SAMHSA’s Definition and Guiding Principles of Recovery – Answering the Call for Feedback
     Accessed 04-Jan-2012

Thursday, November 3, 2011

Diet and mental health

strawberries


Mental health and diet quality are closely linked. The food choices you made as a teenager affect the development of conduct and emotional problems that continue into adulthood. Lifestyle diseases such as heart disease, diabetes and obesity are attributed to changes in diet and exercise habits. Recently there is increasing evidence that diet and exercise also have a major influence on mental health. Dieting peaks after the festival season. This post will help you avoid the 'isms' and fads and point you in the direction indicated by current research.

A good quality diet predicts better mental health

Evaluating the quality of the complete diet provides a better and more consistent picture of nutrition status than focusing on individual nutrients like magnesium or food groups like various fatty acids (omega, polyunsaturated). A traditional diet of vegetables, fruit, meat, fish, and whole grains is associated with lower risk for depression and for anxiety disorders as compared to a "western" diet of processed or fried foods, refined grains, sugary products, and beer (Jacka 2010).

Switching to a high quality diet improves mental health

Switching to a healthy diet improves mental health. Unhealthy diets are associated with lower scores on mental health tests. The best part is that improvements in diet quality are mirrored by improvements in mental health (Jacka 2011). Also the reverse, when diet quality deteriorates psychological functioning is adversely affected.


What constitutes a high quality diet?

The quality of diet is assessed using food frequency questionnaires. Points are allotted for each type and frequency of food consumed. For example one point is allotted for each of at least two fruit servings per day, at least four vegetable servings per day; using reduced fat or skimmed milk, using soy milk, consuming at least 500mL of milk per day; using high fibre, wholemeal, rye or multigrain breads; having at least four slices of bread per day; using polyunsaturated or monounsaturated spreads or no fat spread; having one or two eggs per week, using cottage cheese, using low fat cheese. Out of a maximum possible score of 74, the average is about 33.0 (+9.0).You can get some idea of your diet quality score from this chart (Collins 2008).

Preventive psychiatry

Improving diet quality improves mental health outcomes. Especially for adolescents this is an important preventive intervention. Three quarters of all long term psychiatric illness manifest during adolescence and early adulthood (Kessler 2005) . These illness are among the most disabling. They occur with a high enough frequency to contribute a major portion of life years lost due to disability. Mental health illnesses cause long-term problems at work and at home. They usually persist over the lifetime and require medication and support at various stages. Adopting a high quality diet is an important primary preventive intervention for improved mental health - easy to implement and proven to be effective.

References
  1. Collins CE, Young AF, Hodge A (2008). Diet quality is associated with higher nutrient intake and self-rated health in mid-aged women. J Am Coll Nutr 27: 146–157.
  2. Jacka FN, Pasco JA, Mykletun A, Williams LJ, Hodge AM, O'Reilly SL, Nicholson GC, Kotowicz MA, Berk M. Association of Western and traditional diets with depression and anxiety in women. Am J Psychiatry. 2010 Mar;167(3):305-11. Epub 2010 Jan 4.
  3. Jacka FN, Kremer PJ, Berk M, de Silva-Sanigorski AM, Moodie M, Leslie ER, Pasco JA, Swinburn BA.A prospective study of diet quality and mental health in adolescents. PLoS One. 2011;6(9):e24805. Epub 2011 Sep 21.
  4. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, et al. (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62: 593–602.

Thursday, September 22, 2011

Stress in the festival season

festival time
Festivals as a source of stress? Festivals are meant to be a time of happiness, enjoyment and family togetherness. However for some it can be time of great stress and can adversely affect mental health. The extended festival season starts around Independence Day (15th Aug) and extends right up to New Year including Ganesh Chathurti, Dusshera, and Diwali. Vacations have a positive effect on well-being. However, these effects fade soon after resumption of work (de Bloom 2009). These four months of celebration are associated with psychological distress and mental health problems for many individuals and their families.

Festival distress

(Harion 2009)
Expectations take their toll on the family. Festivals are a prime time for couples to come in for counselling with relationship problems, problems with in-laws, siblings and their children. 'Don't we get to celebrate at least once in our own home?". They end up celebrating each in their own parental homes at Pune and Ahmedabad.

For those in the workforce it means negotiating and competing with everyone else for leave or being the only one left in the office. No one at home understands why you cannot get leave. No one understands why work-pressures and deadlines increase in the time leading up to the holiday. Financial stress also comes into the picture; cool electronics, gifts, partying and vacation trips cost.

For people with mental health problems festivals are another source of stress. Well intentioned, though ill informed relatives prevail on them to stop their medications 'they are addicting', 'why do you need to take them if you're allright?' Many are coaxed into stopping medications entirely.They relapse some time after they return to work, when the social supports are at a minimum and the beneficial effects of the vacation begin to wear off. That is also the time when they have to start paying out the EMIs. This time lag to relapse after stopping psychotropic medication is a prominent factor in non-adherence. 'But he was allright at home. It's the job that is causing stress; we are thinking of relocating'.

Fasting and sleep deprivation are associated in the run up to the festivities. In vulnerable people, especially those with mental health problems, these can play havoc with the body rhythm and with medication regimens leading to a relapse. Every religion excuses ill followers the rigours of these rituals, yet the very people who should be supporting moderation often goad their vulnerable members to comply. 'I thought he was just being lazy'.

Alcoholism is another problem that is likely to recur. It starts insidiously at the beginning of the festival season. By the time the season ends its time for another stint of 'deaddiction'. Binge drinking at parties is just another problem that requires to be addressed recurrently.

Violence and injuries in the home occur through the combination of excitement, stress, tiredness and alcohol. Pressures lead to conflict and then violence. Domestic abuse is about one-third more likely on the day of the festival than the daily average. Homicide rates are generally higher on all major holidays.

Loneliness and isolation are particular issues at festivals. The holiday season is the time of the year when our desire for social contact is most likely to outstrip what our circumstances will allow; it is into this gap that loneliness creeps (Lancet 2010). As festivals are associated with friends and family, it can be difficult for those on their own to avoid feeling lonely at this time. This is especially so for older people living alone who may have no one to spend the festive season with. The loneliness felt on the festival day is often the worst. Festivals can be a sad and nostalgic time, when the loss of a family member may become especially painful. It is often a difficult time for bereaved people. The rates of suicide are known to increase especially on New Years Day (Bridges 2004).

What to do?

Prior to the festival
  1. Communicate. Make your festival plans keeping your spouse in mind. If there were problems  last year don't expect them to disappear. ' I thought we agreed on that last year'. Putting off the discussion could ruin your festivities.
  2. Collaborate. Work together to find a solution that satisfies the needs of all parties. You may not get everything you want, but you get enough of what you want to feel satisfied. Colaboration requires respect for the needs of the other party, communication skills, patience, and creativity. Parties usually do better when they collaborate than when they compete.
  3. Watch the finances. Budget for the expenses and keep a track.
During the festival
  1. Limit your alcohol. Don't drink if you don't want to.
  2. Keep to your normal sleep-wake schedule as far as practicable. When it is disrupted return to your normal schedule at the earliest. Take some time out for exercise.
  3. Take some time off for just yourself and your family. A walk, movie or meal away from the others will contribute to a few more days of harmony.
  4. Your medication is sacrosanct. Don't negotiate on this.
Strategies for loneliness
(Masi 2010)
  1. Improve social skills: After relying on a partner to share experiences and thoughts a separation, breakup or bereavement requires relearning of skills needed to build new relationships and participate in community functions.
  2. Enhance social support: Find a listening ear – people who are lonely can find it helpful to speak to a counsellor or someone removed from their situation.
  3. Increase opportunities for social contact: Be a volunteer – many charities and organisations need help at festivals and you could spend a few hours working as a volunteer. The absence of close family need not be the end of companionship. 
  4. Address maladaptive social cognition: Loneliness can also be tackled by helping people to feel happier in their own company.
    • 'Everyone else is having a good time'. Keep busy – try to stop the festival taking over your life. Make time for enjoyable activities, such as reading, walks, joining a social club or going for a movie.
    • 'What's the point, I'm just not up to it'. Take some physical exercise – this reduces stress and enhances mood. Just getting off the sofa and getting outside should improve mood.
  5. Visit an older neighbour who lives alone if you have a little spare time on your hands over the holidays; it might be just what they need to make their holiday a happy one. 
References
  1. Bridges SF. Rates of homicide and suicide on major national holidays. Psychological Reports, 2004,94,723-724.
  2. de Bloom J, Kompier M, Geurts S, de Weerth C, Taris T, Sonnentag S. Do we recover from vacation? Meta-analysis of vacation effects on health and well-being. J Occup Health. 2009;51(1):13-25. Epub 2008 Dec 19.
  3. Hairon N. How christmas festivities and pressures can damage health and well-being. Nurs Times. 2008 Dec 16-2009 Jan 12;104(50-51):33-4.
  4. Masi CM, Chen HY, Hawkley LC, Cacioppo JT. A meta-analysis of interventions to reduce loneliness. Pers Soc Psychol Rev. 2011 Aug;15(3):219-66. Epub 2010 Aug 17.
  5. No authors listed. Tackling loneliness in the holidays.Lancet. 2010 Dec 18;376(9758):2042.