Physical and Mental Health Across Lifespan

World Mental Health Day 2005 Examines Close Link Between Mental and Physical Health Across The Life Span

The 13th World Mental Health Day (WMHD) will be celebrated today in many countries and this year examines the close relationship between mental and physical health across all life stages. A healthy mind effects physical well-being at any age. However, mental health is often still considered second to and independent from physical health. The lack of appreciation for the importance of mental health is reflected in insufficient resources provided to address mental health issues.

Dr Jose Miguel Caldas de Almeida, MD, Chief of the Unit of Mental Health and Specialized Projects, Pan American Health Organization (PAHO) said that health is a complete state of well-being and there is no health without mental health.

"The burden of mental disorders is significant in medical, social, and economic terms and is much underestimated. Many age groups are neglected. These problems are global, affecting rich and poor countries alike," Dr Caldas said.

The 2005 campaign developed by the World Federation for Mental Health (WFMH) aims to increase public education and awareness about mental health issues across the lifespan and focuses on the following topics:

-- A Healthy Start to Life (focusing on mental health issues of children up to 12 years of age)

-- Growing Up Well: Paying Attention to Health During the Teen and Tween Years (including substance abuse, teenage moods, eating disorders)

-- Physical and Mental Health in Adulthood (including different needs in men and women, effects of living longer)

-- Role of Primary Care in Mental Health

-- Special Projects such as attention deficit hyperactivity disorder, depression and bipolar disorder

According to the World Health Organization, at least one in ten people worldwide have suffered from clinically significant mental health problems during the past 12 months.1-3 In addition, many children, adults and elderly suffer in silence and may not be aware of their mental problems and how they impact and worsen every aspect of their life. It is estimated that more than 30 to 50 percent of people with psychiatric disorders remain undetected and untreated, even in rich countries.4

"Although effective treatments exist for many mental disorders, not enough resources are being made available to put these treatments into practice," Dr Caldas de Almeida said. "Significantly more effort is needed by all countries, rich and poor, to change policy, practice and service delivery systems to ensure mental health needs and concerns of people at all age groups receive the level of priority necessary. In many countries, mental health care constitutes less than 1% of the overall health budget."

The WFMH will mark the 13th World Mental Health Day with a symposium chaired by Dr Mirta Roses Periago, MD, Director of PAHO and Professor John Copeland, the WFMH President-elect. The keynote lecture will be presented by Dr Benedetto Saraceno, MD, Director of the Department of Mental Health and Substance Abuse of the World Health Organization, Geneva, Switzerland and prominent supporter of the WFMH. The symposium program includes presentations by Dr Maryland Pao, MD, National Institute of Mental Health, and Dr Thomas Wise, MD, INOVA Health Systems addressing aspects of mental health during childhood and adolescence, and adulthood and ageing, respectively.

The symposium will be held on 11 October 4:00 to 5:30 EDT at the headquarters of PAHO in Washington, and will be followed by a reception. Earlier during the day WFMH will also be holding a briefing of medical communications directors and health media, and a lunch meeting involving CEOs from mental health organizations.

Activities to mark WMHD 2005 are also taking place in many countries across the world. The launch of the play When Time Collapses featuring the ordeals of an undiagnosed schizophrenia sufferer will take place in London, Great Britain.

References:
1. Kessler RC et al. Arch Gen Psychiatry.2005;62:617-627.
2. Regier DA et al. JAMA. 1990;264:2511-2518.
3. WHO. JAMA. 2004;291:2581-90
4. wfmh.org/wmhday/WMHD2004EnglishSection2.pdf (Oct 2005)

Brain Activity and Social Phobia

Studying brain activity could aid diagnosis of social phobia

People suffering generalised social phobia experience increased brain activity when confronted with threatening faces or frightening social situations, new research shows.

The finding could help identify how severe a person's generalised social phobia is and measure the effectiveness of pharmacological and psychological treatments for the condition.

Up to one million Australians suffer from social phobia at any one time, making it the most common anxiety disorder, and the third most common psychiatric disorder after depression and alcohol dependence.

People with generalised social phobia experience heightened anxiety during potential or perceived threatening social situations. They generally avoid eye contact and fear any interpersonal situation.

The research, to be published in the journal Biological Psychiatry, was conducted by an international team of researchers, including Associate Professor Pradeep Nathan from Monash University's Centre for Brain and Behaviour and the Department of Physiology.

The researchers found that the area of the brain called the amygdala becomes increasingly hyperactive when patients look at threatening, angry, disgusted or fearful faces. Further, they found that the increased response in the amygdala correlated with the patients' level of social phobia symptoms.

The amygdala is in the limbic part of the brain, which controls emotions and sends messages to the parts of the brain controlling breathing and heart rate.

Using functional magnetic resonance imaging, the researchers compared brain activity when people with generalized social phobia looked at threatening faces compared to happy or neutral faces.

Dr Nathan said the study showed that functional magnetic resonance imaging could be used to monitor activity in the amygdala and therefore predict the level of clinical symptoms in generalised social phobia patients.

"Our findings suggest that amygdala activation to interpersonal threat can be specifically linked to the severity of social anxiety symptoms of individual patients with generalised social phobia," he said. Thus, it may serve not only as a useful functional marker of disease severity, but also as a marker of the effectiveness of pharmacological and psychological treatments."

The study was done by Dr Nathan in conjunction with lead author Dr Luan Phan and Dr Daniel Fitzgerald from the University of Chicago and Dr Manuel Tancer from Wayne State University.

Dr Nathan
Research Australia
www.researchaustralia.com.au

New Guidelines For OCD Treatment

New guidelines set to improve identification, diagnosis and treatment of obsessive-compulsive disorder in children and adults, UK


The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Mental Health have today (23 November) launched a clinical guideline on the identification, treatment and management of obsessive-compulsive disorder and body dysmorphic disorder in children and adults.

Obsessive-compulsive disorder (OCD) is characterised by the presence of obsessions (unwanted intrusive thoughts, images or urges, which repeatedly enter the person's mind) and/or compulsions (unwanted, unnecessary behaviours such as repeated washing or cleaning, checking electrical appliances or locks, etc). It can occur in people of all ages, and commonly starts in childhood or adolescence.

Body dysmorphic disorder (BDD) is characterised by a distressing preoccupation with an imagined defect in one's appearance or, in the case of a slight physical anomaly, the person's concern is markedly excessive. The most common preoccupations concern the skin, hair, nose, eyes, eyelids, mouth, lips, jaw, and chin.

The guideline recommends that:

• Cognitive behavioural therapy (CBT) including exposure and response prevention (ERP) should be offered as first line therapy for children, young people and adults with mild to moderate OCD

• Drug treatments (selective serotonin re-uptake inhibitors (SSRIs)) should be offered as an alternative to CBT (including ERP) for patients with more severe OCD or who decline, or do not respond to, psychological treatments

• Adults with BDD should be offered the choice of either a course of an SSRI or CBT (including ERP) that addresses key features of BDD.

Andrew Dillon, Chief Executive of NICE and Executive Lead for this guideline says:
“OCD is very common. Some studies suggest it is the fourth most common mental disorder after depression, alcohol and substance abuse, and social phobia with a lifetime prevalence of about 1-2%. The condition often goes unrecognised and untreated and we hope the guideline will help raise awareness of this distressing condition which in most cases can be effectively treated.”

Dr Tim Kendall, Joint Director of the National Collaborating Centre for Mental Health
who developed the guideline on behalf of NICE says: “This is the seventh mental health guideline where we have recommended psychological treatments as key treatments for a mental health condition, and the fourth where we have recommended them as the first line treatment. We know that there are currently not enough people to deliver psychological therapies. Now is the time to increase our capacity and provide real help for those people that need it.”

Professor Mark Freeston, Chair Guideline Development Group and Professor of Clinical Psychology, University of Newcastle upon Tyne says: “The World Health Organisation rank OCD in the top 10 of the most disabling illnesses by lost income and decreased quality of life. Despite this we know many people with OCD don't come forward for treatment for many years, often because of the stigma attached to the condition. Because people may not spontaneously talk about their difficulties, health professionals need to be better at asking the right questions and offering the right treatments. Accurate and early diagnosis, as well as effective treatment, can make a real difference.”

Dr Isobel Heyman, Consultant Child and Adolescent Psychiatrist, Maudsley and Great Ormond Street Hospitals, London says “About 1% of children and young people suffer from OCD. If OCD is left undetected and untreated it can cause marked psychological distress, and also disrupt social, educational and emotional development, leading to significant disability. This guideline should help raise awareness amongst the parents and carers of young people of the signs to look out for to ensure young people with OCD receive access to the treatments they need.”

Ms Gillian Knight, representative of people with OCD on the Guideline Development Group says: ”OCD hijacks peoples lives and has a serious impact on quality of life. Yet effective treatments do exist which can transform lives and bring people back into society. Raising awareness of OCD and de-stigmatising the condition is vital if people are to be persuaded to seek help. The NICE guideline gives new found hope to the many thousands of people with OCD who no longer need to suffer in silence.”

Piers Watson, Chairman of OCD Action says “I am delighted that these guidelines recognise the need for informed diagnosis and targeted treatment for OCD and BDD. They also make it clear that OCD and BDD can be addressed with great success. These guidelines, however, are only a first step in making appropriate treatment available to all sufferers. How quickly can the yawning gap be bridged, that presently exists between the many sufferers and the few available healthcare practitioners specifically trained to treat these illnesses? This is now the challenge.”

Ashley Fulwood, Chief Executive of OCD-UK says “OCD-UK are delighted that the new NICE guidelines for OCD have been released and hope they will lead to more consistent treatment for this often disabling condition. We are also pleased that the guidelines recommend psychological treatments such as Cognitive Behaviour Therapy (CBT) as the first line of treatment for OCD. The NICE guidelines are undoubtedly a step in the right direction and we hope they will also lead to accurate and earlier diagnosis of OCD, which on average is only diagnosed some 7 to 12 years after its onset.”

About NICE

1. On 1 April 2005 the National Institute for Clinical Excellence took on the functions of the Health Development Agency to form the National Institute for Health and Clinical Excellence (NICE). NICE is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

2. NICE produces guidance in three areas of health:

• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector

• health technologies - guidance on the use of new and existing medicines, treatments and procedures within the NHS

• clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

Exercise For Severe Depression

Exercise Helps Relieve Severe Depression - or So It Seems

28 Nov 2005

How useful is exercise for people with severe depression, anxiety, or chronic mental illness? According to the December issue of the Harvard Mental Health Letter, hundreds of studies show that it can help-but there are qualifications.

The Harvard Mental Health Letter reports that possible explanations for the mood-enhancing effect of exercise include:

- enhanced body image
- social support from exercise groups
- distraction from everyday worries
- heightened self-confidence from meeting a goal
- altered circulation of the neurotransmitters serotonin, norepinephrine, and the endorphins.

Exercise may also serve as a form of predictable stress that supplies a kind of “vaccination” against the uncontrolled stress that leads to depression and anxiety.

It's also possible that exercise's effect on mental health is an illusion, says the Harvard Mental Health Letter. According to some surveys and observational studies, it could be that depression and anxiety prevent people from exercising, rather than the other way around. Or some feature of personality or upbringing might cause both depression and sedentary habits.

Even controlled trials on the subject often have problems, such as insufficient follow-up, the difficulty of correcting for the effect of expectations, and the fact that people who volunteer for exercise studies are not necessarily typical.

These doubts may not matter, because exercise has many health benefits and does little harm. But low motivation is a problem. People are often told to find an activity they enjoy, but depressed people don't enjoy anything much. So it's necessary to begin slowly and remember that exercise does not have to be strenuous to be helpful. Walking, gardening, or household work will do.

Depressed People Skipping Meds?

Patients with depression skip medications and have elevated levels of norepinephrine

 

30 Nov 2005

Recent studies conducted at the San Francisco VA Medical Center suggest two possible mechanisms for the widely recognized link between depression and adverse outcomes in patients with coronary heart disease: lack of adherence to medication regimens and increased levels of norepinephrine, a stress hormone.

"Patients with depression are more likely to suffer heart attacks and heart failure, and more likely to die of heart disease, and no one knows why," notes Mary Whooley, MD, a staff physician at SFVAMC and the principal investigator of both studies. "These results give us two intriguing clues: one behavioral, one biological."

One study looked at the association between depression and self-reported medication adherence in 940 patients with stable coronary heart disease, 204 of whom were diagnosed as depressed. Fourteen percent of the depressed patients reported not taking their medications as prescribed over a 30-day period, compared with 5 percent of the non-depressed patients.

The study appears in the November 28 issue of Archives of Internal Medicine.

Another study examined 24-hour urinary norepinephrine levels in 598 coronary disease patients, 106 of whom had depressive symptoms. A total of 9.4 percent of the depressed participants had a urinary norepinephrine value above the normal range, compared with 3.3 percent of the non-depressed participants. In addition, the more depressive symptoms a participant had, the higher the participant's norepinephrine levels.

This paper appears in the November 2005 issue of the American Journal of Psychiatry.

Neither study indicates a mechanism for adverse coronary outcomes "because we were only looking at cross-sectional data," stresses Whooley, who is also an associate professor of medicine at the University of California, San Francisco.

However, she says, both papers suggest further avenues of research.

The medication-adherence study raises the possibility that because they're depressed, patients simply aren't doing what they're supposed to do to take care of themselves, and this in turn implies a potential treatment, according to Whooley. "If you get rid of the depression, you might get rid of the non-adherence."

The norepinephrine study, on the other hand, suggests that depression could make heart disease patients "more vulnerable to the ill effects of elevated stress hormones," she speculates. While there was no association between norepinephrine levels and baseline severity of heart disease in the current study, "that doesn't necessarily mean that patients with elevated norepinephrine won't have worse outcomes over time," she cautions.

The next thing to do, says Whooley, is "figure out which of these factors - behavioral or biological - accounts for increased risk of heart disease, or whether it's some combination of the two. And that's what we're working on now."

Whooley and her co-authors are conducting studies that will investigate whether medication non-adherence or elevated norepinephrine actually predict increased risk of heart disease over time.

Participants in both of the current studies are enrolled in the Heart and Soul Study, an ongoing, multi-center, prospective cohort study of psychosocial factors and health outcomes in patients with coronary heart disease that is in its fifth year. The study is sponsored by the Department of Veterans Affairs Epidemiology Program, the Robert Wood Johnson Foundation, and the American Federation for Aging Research.

"The overall goal of the Heart and Soul Study is to try to understand why depression predicts adverse cardiovascular outcomes," explains Whooley, who is the study's principal investigator. "Eventually, we hope to help these patients with the treatment they deserve, and by doing so, decrease the overall burden of death from cardiac disease."

Co-authors of the medication study include Anil Gehi, MD, and Donald Haas, MD, of the Mount Sinai School of Medicine, New York, and Sharon Pipkin, MPH, of the San Francisco Department of Public Health.

The medication study was funded by grants from the U.S. Department of Veterans Affairs and the Robert Wood Johnson Foundation, plus grants from the American Federation for Aging Research and the Nancy Kirwan Heart Research Fund that were administered by the Northern California Institute for Research and Education.

Co-authors of the norepinephrine study include Christian Otte, MD, of the University Hospital Hamburg-Eppendorf in Germany; Thomas C. Neylan, MD, of SFVAMC and UCSF; Sharon S. Pipkin, MPH, of SFVAMC, and Warren S. Browner, MD, MPH, of California Pacific Medical Center, San Francisco.

The norepinephrine study was funded by grants from the U.S. Department of Veterans Affairs and the Robert Wood Johnson Foundation, and a grant from the Ischemia Research and Education Foundation that was administered by NCIRE.

UCSF is a leading university that consistently defines health care worldwide by conducting advanced biomedical research, educating graduate students in the life sciences, and providing complex patient care.

Panic Disorder Easily Treated on Internet

Panic disorder - internet based treatment may be just as effective as face-to-face

23 Nov 2005

Internet-based treatments for sufferers of panic disorder may be just as effective as face-to-face methods, a study by Monash University researchers has found.

Panic attacks can involve a sudden rush of fear or intense anxiety and physical symptoms such as racing heartbeat, shortness of breath, light-headedness or nausea. When these attacks happen unexpectedly, the person has what is known as panic disorder.

The study compared the effectiveness of three types of treatment - internet-based cognitive behaviour therapy sessions, face-to-face sessions, and the use of medication (Selective Serotonin Reuptake Inhibitor) monitored by a psychiatrist.

Preliminary results, based on more than two years of research, showed that internet therapy was comparable with face-to-face treatment in reducing disturbing thoughts and improving stress and anxiety.

When undertaking internet-based therapy, sufferers of panic disorder have an initial face-to-face consultation with a psychologist and are then in regular email contact with the therapist.

Project Co-ordinator, Dr Litza Kiropoulos, said the results supported a new method of treatment for sufferers of panic disorder that was convenient and flexible to people throughout Australia.

"If the online method is as effective as face-to-face sessions, as our research suggests, this is likely to improve treatment accessibility for so many people, particularly in rural areas where people may not be able to access face-to-face treatment easily," she said.

"It could also be particularly useful to people suffering agoraphobia, who may feel unable to leave the house."

"We're not saying there will be no need for face-to-face therapy, this is just another method of therapy that people can access."

The study is being conducted by Dr Kiropoulos, Dr Britt Klein, Mr David Austin, Dr Ciaran Pier, Professor Leon Piterman and Ms Joanna Mitchell, all from Monash University's Department of General Practice.