In the course of your daily work, you will commonly find people who have the following problems:
People may be very troubled by these problems and need help. Without treatment these problems can interfere with a person’s work and relationships. Sometimes, but not always, these symptoms indicate the presence of mental disorder. In this session you will learn how to assess people who have these problems and detect any underlying mental health problems. A small proportion of people will need referral for further assessment, but many people can be helped with simple interventions. You will learn how to give advice on relaxation, ways of managing anxiety and panic, and sleep problems.
Another common experience that can affect a person’s mental health is exposure to violence or life-threatening accidents. Individuals can be exposed to violence by being the victims of it or because they have witnessed violent acts on others. Violence can occur at home, in the fields, in meeting places, in the bar and in other places. It affects children, women and men. Although violence is often assumed to be physical, it can also be psychological violence (violence that negatively affects the self-confidence and dignity of an individual). A person who experiences a life-threatening accident can also suffer from disabling mental health problems. The expectation, after completing this study session, is that you will understand the serious nature of violence, the common mental health consequences of violence and life-threatening accidents, and what you can do to support people who suffer from these kinds of mental health problems.
When you have studied this session, you should be able to:
16.1 Define and use correctly all of the key words printed in bold. (SAQ 16.1)
16.2 Describe what somatisation is, identify when it may be present and explain how you could help. (SAQ 16.3)
16.3 Explain how you would give advice to a person who is worrying too much. (SAQs 16.1 and 16.2)
16.4 Explain how you would help people with sleep problems. (SAQs 16.1 and 16.2)
16.5 Describe how you would detect mental health problems arising from violence or life-threatening accidents. (SAQ 16.4)
16.6 Explain how you would help women who are victims of intimate partner violence. (SAQ 16.4)
It is a common experience in primary healthcare that a person comes with a physical complaint but no medical cause can be found. The most common explanations for this situation are:
Studies from Ethiopia have shown that around one in five people attending a general medical out-patient clinic with a physical symptom actually have an undetected mental health problem. This is very similar to the situation in other countries. It is important to recognise when a person’s physical health complaint is being caused by an underlying mental health problem, otherwise there is a risk that they will repeatedly attend health services without getting relief. They may spend a lot of money on traditional treatments that don’t help, or may receive inappropriate treatment or investigations; for example, they may be given antimalarial medication for a headache that is actually caused by depression. Ultimately, they continue to suffer and be disabled because they don’t get the treatment they really need.
Some of the physical symptoms that can be caused by depression or anxiety are shown in Table 16.1.
Loss of appetite
Multiple aches and pains
Shortness of breath
In Ethiopia, there are some other physical complaints that seem to be more typical of somatisation than a medical illness or condition. These are listed in Box 16.1. In your area you may know of some additional physical symptoms that people use to express their mental or social distress. Make a note of them here.
Some indicators that physical symptoms might be related to a mental illness or somatisation are as follows:
Read Case Study 16.1 about Mrs Abeba carefully. List which features of her case are indicators of possible mental health problems and which features make it more likely that she has a physical health problem.
Mrs Abeba is a happily married woman with two healthy children. The family does not have any major financial concerns. One morning she noticed a pain in her lower back while she was picking up a bundle of wood. She tried to ignore the pain but it quickly became worse and would not go away. The pain was particularly bad in the mornings and became so severe that she would often cry. Antipain medication only helped for a short while before the effect wore off. She was seen by a hospital doctor three times within just two weeks, but he was not able to find anything significantly abnormal. There was a small cyst which the doctor removed in case it was the reason for the pain. However, the pain continued. The doctor thought the pain was due to a mental disorder and referred her to a mental healthworker.
Indications that Mrs Abeba’s back pain could have a physical cause are: that the pain is very severe, it is the only symptom Mrs Abeba has, there is no evidence of depression/anxiety and there are no obvious psychosocial stressors (i.e. stressful circumstances in her life). On the other hand, the doctor could not find any cause and the pain had become chronic, which could suggest a psychosocial cause.
This is a real case. Mrs Abeba went on to develop some other symptoms – including fluid coming out of her spine and loss of feeling in her leg – and was eventually diagnosed as having tuberculosis of the spine. This example shows the importance of keeping an open mind and being prepared to review the original diagnosis when new information becomes available.
Even if you think an unexplained physical complaint is due to mental illness, review if new symptoms develop – don’t miss a physical cause!
When somebody from your local community has physical complaints that don’t seem to have a medical cause, the first things you need to do are:
If any of these conditions are present then refer for treatment.
If the physical complaint doesn’t seem to be due to a medical cause, or to depression, anxiety or alcohol abuse, it might be due to somatisation. In this situation there are a few things that you can do to help:
All of us worry about things from time to time, especially if we have a lot of problems, but for some people the worry can become excessive. Anxiety disorders occur when a person worries without sufficient reason (Figure 16.2). Some examples of normal worry could be a student worrying on the night before an exam, a woman worrying about her child who is ill, or a man worrying about how he can provide for the family after the crops have failed. Some examples of abnormal worry (an anxiety disorder) could be a student who worries all the time, even when their exam results are good, a woman who worries constantly about her child even though the child is healthy and happy, and a man who worries about the harvest even when the crops are growing well.
Anxiety can be distressing and disabling, for example, preventing people doing things that they used to such as going out of the house and meeting up with other people. As well as causing a person to worry too much, anxiety can lead to physical symptoms (as you have already discovered in Table 16.1). Anxiety often goes hand-in-hand with depression. Also, people who are worrying too much may use alcohol and khat as a way of trying to cope with their symptoms. Although this might help them to feel better in the short term, alcohol and khat usually make anxiety worse in the longer term (see Study Session 14).
Here are some ways that you can help a person if they are suffering from an anxiety disorder (worrying too much):
If none of these approaches helps or the anxiety is severe, refer to the next level health centre for further assessment.
Next we would like you to complete Activity 16.1.
Think of something that you are worried about (or have been worried about in the past) and try to use the problem-solving approach on yourself. Once you feel confident, try it on a friend or family member.
Write about your experiences of trying this technique in your Study Diary and discuss them with your Tutor at the next Study Support Meeting.
This activity is also relevant to SAQ 16.2.
Sleep problems are common: in the USA 1 in 10 people have chronic insomnia. This is when a person has difficulty getting enough good quality sleep (Figure 16.3). Not everybody needs the same amount of sleep, but most adults seem to need between 7 and 9 hours of sleep in order to function properly. Children need more sleep and older people don’t need so much sleep.
From your general knowledge, can you think of five reasons why somebody might have problems sleeping?
Common causes of sleeping problems include: bad sleeping habits, undetected mental illness (depression, anxiety, psychosis), social problems (e.g. somebody has died, not enough food for the family), stimulants or other drugs (coffee, alcohol, khat, prescribed medications), a physical health problem (e.g. painful conditions, diabetes, breathing problems, epilepsy), late pregnancy, having a young child, something in the environment (uncomfortable sleeping place, cold, noisy).
Sleep problems can be very frustrating and distressing. People with sleep problems are more likely to be involved in road accidents because they are tired and don’t concentrate properly. Sleep problems can also lead to mental illness or make mental illnesses worse. People may try to treat their sleep problems through self-medication, either with sedative medication (usually diazepam) or alcohol. Sedative medication is medication that makes a person feel sleepy. Both alcohol and diazepam can lead to addiction and, instead of solving the sleep problem, can make it worse. Because of all these reasons, it is important to take sleep problems seriously. Simple advice can be very helpful.
If somebody tells you that they have a sleep problem, you need to do the following:
Go to bed and get up at regular times
Make sure you have regular exercise
Take time to talk with family and relax before trying to sleep
If you are worried about something, write it down/tell somebody about it and deal with it in the morning
Sleep during the day
Eat a heavy meal just before bed
Drink coffee in the afternoon or evening
Smoke a cigarette
Use alcohol to help you sleep
If a person experiences or witnesses very severe violence (e.g. due to physical or sexual assault, or fighting in a war) or a life-threatening accident (e.g. being thrown off a horse, a serious road traffic accident) then it is normal for them to become mentally distressed. In most cases, their distress will get better with support from family and friends, and with the passing of time.
For some people the effect of violence or major accidents on their long-term mental health will be very serious and they may develop one of the following mental illnesses:
In post-traumatic stress disorder (PTSD), the person remains very distressed because of the violence or accident they experienced. You can screen for PTSD by looking for the following symptoms:
The person with PTSD may not be able to work properly and they may develop problems in their relationships with other people. In Box 16.3 are some suggestions for how you can help when a person develops mental health problems as a result of life-threatening violence or accidents.
Violence against women, usually carried out by their husband or another family member (intimate partner violence, Figure 16.4), is sadly common in all cultures and societies around the world. Studies show that Ethiopia is no exception: nearly 3 out of 4 women experience violence at some point in their life. Of course, men can also be the victims of violence carried out by women, but this is much rarer and so we won’t focus on that problem here. Violence against women can be physical (e.g. beating), sexual (e.g. rape) and/or psychological (e.g. saying things that make the woman feel bad about herself). Violence tends to be worse when a woman is pregnant. Women who have just given birth may also be at increased risk because the tradition means that they should stay inside their home after giving birth and so they may not be able to escape from a bad situation.
Women who experience violence are at increased risk of developing mental illnesses. These women are more likely to develop depression or anxiety disorders, somatisation (see Section 16.1) and/or become so desperate that they consider ending their lives (suicide).
Read about the case of Mrs Alemtsehay, a postnatal woman living in a rural area (Case Study 16.2). This shows you the effect of violence on one woman’s mental health (this is a real case but the woman’s name has been changed). As you read about Mrs Alemtsehay’s experience, can you identify possible symptoms of mental illness?
‘First, we quarrelled and then he [her husband] started to beat me. I cried. I became angry about having a baby at that time. I was irritated. After that day, I couldn't sleep. All I did was cry. … At that time, had I been God or had I been the person who can do anything, I thought of killing her [her baby] and killing myself. … Since I didn't have the guts to kill the baby or kill myself, I just thought about it.’
Mrs Alemtsehay is showing possible symptoms of depression: sleep problems, crying, hopelessness and suicidal thoughts. It may not be abnormal for a woman to feel like this if she is being beaten by her husband, but it is important to check that she hasn’t also developed a depression. The thoughts of wanting to harm her child suggest that severe depression is present. If she does have depression, this might make her situation even worse. She may even try to end her life. If her depression is treated, she might be able to think more clearly and be more motivated to try to find ways to solve the problem.
As well as mental health effects, violence can lead to physical injury (see Study Session 7). If a pregnant woman is the victim of violence can lead to pain or bleeding and even cause her to lose her baby. If the baby survives, violence can cause the baby to be born early, have a lower birth weight or develop other health problems.
A woman who is the victim of violence may not know how to get help. Often women blame themselves even when it is not their fault. For example, they might say ‘I deserved to be beaten because I forgot to fetch the water’, or ‘He is my husband so it is his right to have sex with me even when I don’t want to have sex’. They may also be frightened that the violence will get worse if they tell an outsider (and this could be true). If they have also developed depression, this may be another obstacle that stops them looking for help.
See Box 16.4 for some ways in which you can help with the mental health effects of intimate partner violence.
In Study Session 16, you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
Which of the following statements is false? In each case explain why it is incorrect.
A Sleep hygiene means making sure that a person is clean before they go to sleep.
B Problem solving involves telling a person how to solve their problems.
C Sedative medication is good for people who can’t sleep.
D In post-traumatic stress disorder the person keeps remembering the bad event that happened to them.
E Avoiding drinking coffee after lunchtime can help to improve sleep problems.
A is false. Sleep hygiene does not have anything to do with personal hygiene. It is the term used to describe good sleeping habits.
B is false. Instead of telling the person how to solve their problems, problem-solving means helping the person to find their own solutions to their problems.
C is false. In general, sedative medication is not the solution for people who have chronic sleep difficulties because of the risk that they will get addicted to the medicine.
D is true. A person with post-traumatic stress disorder typically has the following symptoms: (1) horrible memories or nightmares about the bad event; (2) not being able to relax because they are expecting more bad things to happen; (3) avoiding anything that reminds them of the bad event.
E is true. Coffee can disturb a person’s sleep if drunk too late in the day.
Read the case study below and answer the questions that follow.
Mr Ato Debela has always been somebody who tends to worry about things more than other people. But since his father died a year ago, his worry has increased. Mostly he worries about how he is going to manage to provide for his wife and three children. He has lots of aches and pains in his muscles, especially in his head and neck. His hands shake and he sweats a lot. He also feels his heart beating faster than usual and sometimes feels as though he can’t breathe properly. At night time he finds it difficult to sleep because he is thinking so much about different things. At the health centre he was given some vitamin tablets but they haven’t helped. He is unable to work properly because of his condition.
One of the nurses working in the nearby health centre tells you about a patient who keeps coming to the clinic with different complaints – one week they have abdominal pain, another week they complain of headaches, the next week they say they feel dizzy. The patient has had a proper examination and all investigations are normal. The nurse asks whether you can help.
Look back at Case Study 16.2. How could you help Mrs Alemtsehay?
As we discussed earlier, Mrs Alemtsehay seems to have a level of depression that needs urgent treatment. You should refer her to the next level health facility which is able to provide mental healthcare. You can also provide her with confidential support and try to encourage her to speak to a family member or community elder about the problem with her husband. You may also be able to put her in touch with local organisations that could help her.