MENTAL HEALTH TRAINING

FOR PHC DOCTORS & NURSES

DMHP,
KANYAKUMARI
05.08.2021
An introduction to
psychiatry
 As per the American Psychiatric Association, it is a branch of medicine focused
on diagnosis, treatment and prevention of mental, emotional and behavioural
disorders.
 Deals with functions of mind
 Promotes general well being
 What is mind?

 Mind has no structure of its own.

 It’s only a functional unit of brain, which includes all our emotions, memory,
thought and intellect.
How does psychiatry differ from other
medical fields?
 No single aetiology for psychiatric illnesses
 No specific investigation
 The multi-factorial aetiology is usually defined by the Bio-Psycho-Socio-Cultural
factors.
 Bio - hereditary and genetic factors
 Psycho - temperament of an individual
 Sociocultural - interaction with family, friends and society
 Symptoms are not disease specific
 Patients with major mental illness are not aware of their disease
 consultation at the psychiatric units is difficult, the stigma attached to the
psychiatric diagnoses.
 Major mental illnesses, sometimes have legal implications, when crimes may have
been committed under the spell of illness.
 Patient himself is unaware of his mental illness
 Informants are required to make a diagnosis
 Usually come late for consultation
Major mental illness: Minor mental illness:
Schizophrenia Depression
Bipolar disorder
Acute psychosis Anxiety
Substance induced psychosis Phobia

Organic psychiatric disorders: On basis of life span:

Delirium Acute
Dementia Chronic
Seizure disorder
When to look for psychiatric illnesses?

 Behavioural abnormalities are noted

 Symptoms do not correlate with any medical or surgical illness
 Symptoms do not abate with regular treatment
 Overt psychological symptoms are present
 Comorbid substance use is present
Psychotic disorders
SCHIZOPHRENIA
 Causes impairment of thinking process
 Loss of touch with reality

 Psychotic disorders consists of

 Schizophrenia
 Acute psychosis
 Delusional disorder
Positive symptoms

 Delusions
 Hallucinations
 Disorganized speech
 Grossly disorganized behaviour
 Hallucinations:
 Perceptions occurring in clear consciousness without an external stimulus.
 It occurs in all 5 sensory modalities, namely auditory, visual, tactile, olfactory and
gustatory.
 Auditory hallucinations are common in psychotic disorders
 Disorganised speech:
 Inability of the person to communicate in a proper manner, like not answering
immediately or the answers given are not relevant to the questions posed
 Disorganised behaviour:
 Inability of the person to behave in socially appropriate ways, for example,
drinking water from toilets or wearing inappropriate dresses etc.
 Duration of illness – 1 month or more – Schizophrenia
 *Duration of illness – less than a month – Acute psychosis
 Delusion – 3 mon
 Treatment of psychosis:
 The DMHP psychiatrist should be consulted first before instituting treatment.
 Principles involved in the treatment of psychosis
 Primary treatment with Antipsychotics
 Adjuvant treatment with counselling strategies
Treated with

 First generation typical antipsychotics:

 Tab. Haloperidol
 Tab. Chlorpromazine

 Second generation atypical antipsychotics:

 Tab. Risperidone
 Tab. Olanzapine
 Tab. Quetiapine
Oculogyric crisis
 A single episode of psychosis: treatment needed for a minimum of about 2
years
 Multiple episodes of psychosis: treatment needed for about 5 years or lifelong
When to refer

 Symptoms not controlled even after 6 weeks of treatment

 Worsening of psychosis
 Development of side effects for the antipsychotic drugs
 Development of medical complications
 Presence of suicidal ideations or attempts
Depression
Criteria

 Core symptoms:
Low mood
Diminished interest in all activities
Fatigue
 Changes in weight
 Sleep disturbances
 Changes in motor activities
 Feelings of worthlessness
 Excessive guilt
 Diminished ability to concentrate
 Recurrent thoughts of death
Presentation in various age groups

 Children and adolescents:

 Irritability
 School refusal
 Social withdrawal

 Geriatric age group:

 Somatic symptoms
 Cognitive symptoms like forgetfulness
 Completed suicides are more common
Pharmacotherapy
When to refer

 When intense suicidal ideations are present

 History of suicidal attempts are present
 Poor response to treatment with antidepressants
 When side effects are not tolerated
 When psychotic symptoms appear
Alcohol use disorder
Standard drink
Complications

 Alcohol withdrawal
 Alcohol withdrawal delirium
 Alcohol induced psychotic disorder
Alcohol withdrawal
 Alcohol withdrawal delirium or delirium tremens:
 Severe cognitive impairment along with features of delirium and alcohol withdrawal.
 Alcohol induced neurocognitive disorder:
 Severe thiamine deficiency ensues with excess alcohol consumption, and it can cause
Wernicke-Korsakoff Syndrome. It has two components.
 Wernicke’s encephalopathy is an acute life-threatening condition, characterised
by ataxia and ocular palsy.
 A chronic debilitating condition known as Korsakoff’s psychosis, characterised
by profound amnesia, impaired learning and judgement with severe behavioural
abnormalities.
Treatment
 Detoxification
 Detoxification – the removal of toxic effects of alcohol with benzodiazepine.
 Alcohol reduces GABA and increases glutamate levels and cause withdrawal
symptoms.
 Benzodiazepines has a similar mode of action and reduces GABA and increases
glutamate levels gradually – smooth withdrawal
 Like the common adage in Tamil, one toxin is utilised to eliminate another toxin.
 Parenteral Thiamine is administered to counter the neuro-psychiatric side effects
of alcohol.
Rehabilitation and Relapse prevention

 Motivating the person for abstinence

 Guiding the person for readjusting to a life without alcohol – counselling
Non-pharmacological treatment
of relapse
 Help in identifying high risk situations for relapse
 Avoid boredom
 Avoid mixing with persons who use alcohol
 Avoid celebrations where hot drinks are served
 Family counselling
 Group therapy
 Disulfiram
 Concomitant use of alcohol, while on Disulfiram, precipitates severe nausea,
vomiting and blood pressure changes.
 This threat itself works as a deterrent for person from reusing alcoholic
drinks.
 Disulfiram is started, after abstinence from alcohol for about a week.
 Concomitant use of products like aftershave lotions, perfumes which contain
alcohol to be withheld for a period of maximum 6 to 12 hours after the intake
of disulfiram tablet.
When to refer ?

 Seizures
 Delirium tremens
 Comorbid physical ailments
 Comorbid psychiatric ailments
Somatic symptom and
related disorders
 Core features
 Have a distressing prominent somatic symptom
 The symptoms may or may not be traceable to a physical problem but can cause
excessive and disproportionate levels of distress.
 Symptom amplification:
 Abnormal thoughts and behaviours are present for somatic symptoms
 Associated with disproportionate and persistent thoughts about the seriousness of the complaints
 Taking up the sickness role
 The affected person can spend excessive time and energy on a health concern.
 Somatic symptom disorder

 The focus on somatic symptoms is the primary feature of the illness, most
commonly pain.
 The individual’s suffering is authentic, whether or not the symptoms are medically
explained.
 Referral for psychiatric consultation is flatly refused by these individuals, as they
are far more concerned on the somatic aspects.
 Illness anxiety disorder

 Preoccupation with having a serious undiagnosed medical illness.

 These patients have minimal somatic symptoms and are primarily concerned with
the idea that they are ill.
 Believe that minor complaints are, signs of a serious illness.
 They consult multiple physicians, which is known as doctor shopping and they
obtain repeated
 Negative diagnostic test results.
 Conversion disorder

 Previously known as hysteria.

 The presenting symptoms are altered voluntary motor or sensory functions.
 Clear incompatibility of the symptoms with another neurological medical disease
for the diagnosis to be confirmed.
 The psychic pain of the individual is converted into physical symptoms, such as
motor or sensory deficits and pseudo seizures.
 Treatment

 Primary treatment modalities:

 Counselling
 Stress reduction
 Avoiding unnecessary investigations

 Antidepressants and SSRI drugs if needed

District Mental Health
Program
 DMHP

 The District Mental Health Program (DMHP) was launched under NMHP in the
year 1996 (in IX Five Year Plan).
 Components:
 1. Early detection & treatment of mental illness in the community (OPD/ Indoor &
follow up).
 2. Training: imparting short term training to general physicians for diagnosis and
treatment of common mental illnesses with limited number of drugs under guidance of
specialist. The Health workers are being trained in identifying mentally ill persons.
 3. IEC: Public awareness generation.
 4. Monitoring: the purpose is for simple Record Keeping.
 Increase awareness & reduce stigma related to Mental Health problems.
 Life skills education & counselling in schools
 College counselling services
 Work place stress management
 Suicide prevention services
 IEC activities
 DMHP TEAM

 Psychiatrist
 Clinical Psychologist
 Psychiatric Social worker
 Psychiatry/Community Nurse
 Program Manager
 Multipurpose health worker
 Record Keeper.