Non-Communicable Diseases, Emergency Care and Mental Health Module: 16. Mental Health Problems in Daily Life

Study Session 16  Mental Health Problems in Daily Life

Introduction

In the course of your daily work, you will commonly find people who have the following problems:

• physical complaints that don’t seem to have a medical cause
• worries that seem too much
• difficulty with sleep.

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.

Learning Outcomes for Study Session 16

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)

16.1  Physical complaints without an identifiable medical cause

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:

• A medical cause is actually present, but can’t be detected with the facilities available.
• The physical complaint is due to undetected depression or anxiety.
• The physical complaint is due to somatisation. This is when mental or social distress (e.g. chronic poverty, marital problems) comes out as a physical symptom (Figure 16.1). Often the person doesn’t realise that this is happening. For example, a woman who is distressed because she is not able to get pregnant may develop a chronic headache as a result of her distress. Somatisation can also occur as part of depression.

Figure 16.1  A person with multiple physical complaints characteristic of somatisation.

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.

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:

• Medical investigations give no abnormal results
• The person has three or more physical complaints
• The physical symptoms don’t fit in with usual patterns of any known disease
• Other features of depression (e.g., low mood, hopelessness, loss of interest, guilt, etc.) or anxiety (e.g., excessive worry) are also present (depression was covered in Study Session 12 and you will learn more about anxiety in Section 16.2)
• The symptoms are chronic
• The person has repeatedly consulted healthworkers.

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.

16.1.1  Physical complaints without an identifiable medical cause: what can you do to help?

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:

• make sure that the person has been properly medically assessed
• screen for depression, anxiety and alcohol misuse/abuse.

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:

• Reassure the person that there doesn’t seem to be a serious or dangerous cause for their symptoms.
• It can be difficult to explain to people that their physical symptoms may come from mental distress. They may think that you don’t believe them or that you are saying they are crazy. Instead, ask them about any life difficulties.
• You can explain that:
  • Physical symptoms can be made worse by worrying about life’s problems.
  • Worry can make people tense their muscles which in turn can lead to pain, e.g. tension headaches.
  • If we feel sad, worried or frightened then we become more sensitive to pain.
• If the person is repeatedly attending different health facilities or looking for treatment from traditional healers, build up their trust and encourage them to come to you first if they have any new physical complaints.
• Be prepared to review the assumption that symptoms are due to somatisation. If an underlying physical condition is present then it will usually progress and become easier to detect with time.
• Medication is not indicated unless the person also develops depression. In that case, the health centre staff may prescribe antidepressant medication (see Study Session 12).

16.2  Anxiety disorders: worries that seem too much

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.

Figure 16.2  A person who is suffering from anxiety.

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):

• Show the person that you take their problem seriously.
• Screen for depression and refer for treatment if needed (see Study Session 12).
• If they are using alcohol and/or khat then advise them to stop (see Study Session 14).
• Suggest cutting back on coffee as this can make anxiety worse.
• If they have sudden attacks of severe anxiety, tell them to breathe into a paper bag. This will help to calm them down.
• Depending on the person, regular exercise could help.
• For the person who worries about lots of different things at the same time, problem solving (a simple, structured way to approach problems; see Box 16.2) can also be a useful approach.

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.

16.3  Difficulty with sleep

Figure 16.3  A woman who is unable to sleep at night.

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.

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:

• Try to work out whether there is an obvious reason for it.
• Screen for depression (see Study Session 12) or anxiety (Section 16.2). If present, refer for treatment.
• Ask the person about their use of alcohol, khat and coffee. If present, explain that these stimulants may be affecting their sleep and advise them to cut down or stop.
• If you think they have got into bad sleeping habits, you can use the advice in Table 16.2 on sleep hygiene — that is, getting into good sleep habits.

16.4  Violence, accidents and mental health

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.

16.4.1  Mental health problems due to life-threatening violence or accidents

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:

• Depression (see Study Session 12)
• Anxiety (see Section 16.2 above)
• Alcohol misuse (see Study Session 14)
• Post-traumatic stress disorder.

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:

• horrible and persistent memories or nightmares about the bad event
• unable to relax because they are expecting more bad things to happen
• avoiding anything that reminds them of the bad event.

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.

16.4.2  Intimate partner (‘domestic’) violence

Figure 16.4  A woman being beaten in her home.

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).

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.

Summary of Study Session 16

In Study Session 16, you have learned that:

1. Physical complaints without an identifiable medical cause are often caused by depression, anxiety and/or somatisation.
2. It is important to detect and treat the mental health causes of a person’s physical complaints so that their suffering can be relieved, they won’t spend lots of money on unhelpful treatments, and they won’t repeatedly attend health facilities.
3. Always remember that unexplained physical complaints could have a physical cause that is difficult to detect – be prepared to review the diagnosis of somatisation if new evidence comes to light.
4. People who worry too much can be helped with simple advice and the specific techniques of relaxation exercises and problem solving.
5. Sleep problems are common and disabling. You can help to identify the cause of the sleep problem, refer for treatment if needed and advise on healthy sleep habits.
6. Self-medication of anxiety and sleep problems, for example by drinking alcohol, chewing khat or taking sedative medication, is a common problem and often makes the problem worse.
7. If a person is exposed to severe violence or a life-threatening accident then they are at increased risk of developing a mental illness.
8. Intimate partner violence is a common problem that mainly affects women. You can help by detecting the problem, screening for mental illness and informing the woman of any local organisations that could help them.

Self-Assessment Questions (SAQs) for Study Session 16

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.

Read the case study below and answer the questions that follow.