Identifying Mental Health vs Mental Illness Concerns in Farmers with Disabilities

1. Identifying Mental Health vs Mental Illness Concerns in Farmers with Disabilities Peggy Mack, Ph.D.(c), APRN, BC National AgrAbility Workshop November 8, 2005 Email: Peggymack02@aol.com

2. Learning Objectives This session has helped me improve my understanding THAT • Mental health (emotional health) and physical health are equally important. • Stress effects an individual’s mental health and physical health. • Mental health problems, mental illnesses, can be identified and treated.

3. What’s Mental Health? • Mental Health = Emotional Health • Emotions - examples: love, pleasure, dislike, anxiety - give meaning to everything in life” - originate in the brain • Science – emotional signals, emotional pathways, in the brain. - technology (MRI, PET scans) Citation: National Institute of Mental Health. Seeing Our Feelings: Imaging Emotion in the Brain. Publications. NIMH Publication No. 01-4601. Bethesda (MD): National Institute of Mental Health, National Institutes of Health, US Department of Health and Human Services; 2001 (updated 2005, September 9). Available from http://www.nimh.nih.gov/publicat/feel.cfm#2, accessed October 31,2005.

4. Sad vs Happy? What challenges our mental health?

5. Genetics Perceptions Learned Coping Health: Physical and Mental • Stress

6. Challenges to Mental Health • Stress – how do we know we’re stressed? • stress is universal, but also unique (due to our perceptions, genetics, coping). • Our Perceptions - how we view something; • based on values, beliefs, morals. • Genetics – how we’re wired, heredity. • Learned Behaviors - coping strategies • how we handle our problems

7. What does constant stress do? Like a rubber band that is stretched out, 24/7. The brain responds with heightened arousal. Continual vigilance - flight or fight response What Happens When There’s Always a Fire to Put Out?

8. Stress Effects an Individual’sMental Health and Physical Health. • Physical response from the body – fly or fight. • Physical health problems: high blood pressure, headaches, backaches, etc. • At the same time - Emotional response from the brain – fly or fight. • Emotional health problems: irritability, tearfulness, etc. Can lead to mental illness, such as depression, or even to suicide.

9. LinkingPhysical and Mental Health Examples from the scientific literature: • Arthritis – considered a disability. • Pain - associated with arthritis. • Intermeshing of pain, arthritis, and depression, seems to be related. When pain is not alleviated, depression occurs. • Brain’s amydagla – provides a physiological connection with the psychological response to depression. Neugebauer, V., & Li, W., & Bird, G.C., & Han, J.S. (2004). The amygdale and persistent pain. The Neuroscientist. Vol.10, no.3, 221-234. Wang, P.S. & Beck, A.L.& Berglund, P.& McKenas, D.K. & Pronk, N.P. & Simon, G.E. & Kessler, R.C. (2004). Effects of Major Depression on Moment-in-Time Work Performance. American Journal of Psychiatry.161: 1885-1891.

10. Science, Stress, Physical and Mental Health • Susceptible genes alter under stress and factor in the development of depression (Caspi et al 2003). • Persons may be predisposed to develop depression based on genetic makeup and their ability to cope effectively with stress (Garcia, 2002). • Changes in specific hormones and stressful life events with major depression, duplicated the work of Caspi, et al., in a follow-up study with twins (Prescott, Kuhn, Vittum, Riley, and Kendler,2004). • Stress, unchecked, not coped with effectively, leads to permanent structural changes in the brain (Hariri, et al. 2002; Saplosky, 2003) • Citations: Caspi et al., 2003; Garcia, 2002; Hariri, et al., 2002; Prescott, Kuhn, Vittum, Riley, and Kendler, 2004; Saplosky, 2003; Science, 2003. (See next slide w/ full citations).

11. The Science Connections Physical and Mental Health • Caspi, A; Sugden, K; Moffitt, T.E.; Taylor, A; Craig, I.W.; Harrington, H.L.; McClay, J; Mill, J; Martin, J.; Braithwaite, A.; Richie Poulton, R. (2003). Influence of Life Stress on Depression: Moderation by a Polymorphism in the 5-HTT Gene. Science, 301(5631), 386-389. • Garcia, R. (2002). Stress, Metaplasticity, and Antidepressants. Current Molecular Medicine, 2, 629-638. • Hariri, A.R.; Mattay, V.S.; Tessitore, A.; Kolachana, B.; Fera, F.; Goldman, D.; Michael F. Egan, M.F.;Weinberger,D.R. (2002). Serotonin Transporter Genetic Variation and the Response of the Human Amygdala. Science, 297(5580), 400-403. • Prescott CA, Kuhn JW, Vittum J, Riley BP, and Kendler KS. (2004, abstract). Environment interactions in psychiatric disorders; substantive findings and methodological challenges. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics. 130B (1), 10-11. • Sapolsky, R. (2003). Taming Stress: an emerging understanding of the brain’s stress pathways points toward treatments for anxiety and depression beyond Valium and Prozac. Scientific American. 289(3), 86(10). • Science (2003). Decoding Mental Illness. Vol.302. 19.

12. Key Points – so far • Mental health (emotional health) and physical health are equally important. • Science connects physical, mental health. • Stress effects an individual’s mental health and physical health.

13. Key Points – so far Science shows that: • Stress can cause structural brain changes. • Structural changes in the brain leads to mental illnesses, such as depression.

14. How Do We Identify Mental Health Problems? Two ways: • specific signs, symptoms; or • duration of specific signs, symptoms, as described in the DSM-IV* DSM-IV = Diagnostic Statistical Manual Citation: American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders. Washington DC: Author.

15. Identifying Mental Health Problems Depression • based on # of symptoms and duration. • different levels of severity. • all documented in the DSM-IV. Example: Forms of depression described in DSM-IV: minor depression, major depression, bipolar.

16. Why be Concerned about an Emotional, Mental Illnesses? • Science shows emotional illnesses effect physical illnesses. • Mental illnesses, such as depression can lead to suicide if not treated appropriately.

17. National Institute of Mental HealthCurrent Suicide Rates In U.S. http://www.nimh.nih.gov/suicideresearch/suichart.cfm

18. Identification of a Mental Health Problem - An Example – Major Depression Major Depression signs, symptoms, and duration required are: • Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.” Source: DSM-IV

19. Identification of a Mental Health Problem with DSM-IV Diagnosis - Major Depression - Signs and Symptoms • irritability; • loss of interest/pleasure in activities; • fatigue/loss of energy; • feelings of worthlessness/guilt; • diminished ability to think/concentrate; • significant weight loss/gain (not associated with dieting); • sleeping too much or having insomnia; • recurrent thoughts of death/suicide (Would my family be better off without me? ) (Life’s not worth it.) Source: DSM-IV

20. Correlations of Mental Health Challenges, Stress, and Our Responses:Behavioral – Psychological - Physiological

21. Mental Health and Physical Health are Equally Important Vignette #1 Mr. Poultry Farmer has arthritis. The arthritis is severe in his hips and arms. His other major health problem is poor circulation, and his heart has pacemaker. “It’s my heart and I had to put in a pacemaker ….and because of the [circulation problems], ….. the leg swells up. …(I) get ulcers on the leg….I have arthritis in my waist, you know. So I have all these problems. I have (a) problem in bending …” “So my wife, I’m xx y.o., she’s xx y.o., she helps me as best as she could, but we have nobody.” “You know, and like I said, it does cause a lot of stress on us, because, you know, like say, my wife, you know, she gets more stressed …. because I can’t do anything. And she has to go …. and help me. And …she has her aches and pains too.”

22. Stress Effects an Individual’s Mental Health and Physical Health Mental Health Challenges –Stress: Relationships Strain Family Support Systems. “So, it ends up sometimes that we end up in argument, you know, because my wife says, “You’re doing too much”, you know, and I say, “What am I going to do, you know?” And then, you know, then the next day she says, “We should do this, we should do that.” It’s very stressful on us, you know….”

23. Mental Health Challenges – Stress: Finances and a Strain on Resources “I don’t have no children that live home, I don’t have no grand children that live here to send anybody to help me. I can’t, with a small farm like this, afford to pay somebody to do it. If I get somebody to tend the chickens, I have to give them 40 percent of my gross…I have to give them 40 percent of my gross and still do all my repairs and everything. That’s how they would do it. I can’t get somebody. I simply give them $100 a week and come and pick up the dead chickens. I can’t.”

24. Mental Health Challenges – Stress: Job Performance “So because I’ve not been able to do some of the things, because one is the bending, I can’t stoop. So sometime, you know, like when the feed line stays on the ground …. If somebody is wrong with the feed line and leaking line, (I) cannot get down there to fix it until when the flock is over to bring it up here where I can reach it, even the water or anything. …. You’d have to ….stop all the feed and take that out and this is something we can’t do….

25. Mental Health Challenge – Stress: Perceptions of Fairness (Values) “They (Chickens) sit down there on the wet floor. You see the floor keep wetted, if the floor keep wetted and they sit there when they sit down on the floor, all the feathers come off the and skin gets all scarred. So then the company says, “We can’t sell that as a whole chicken, we have to cut it up.” So, when they cut up chicken and you go in the supermarket you see parts are more expensive but with the farmer they say when you have to cut up the chicken we get less money.”

26. Mental Health Challenges – Stress: Job Security “All these things, you know, and they not only effect you financially, it effects you because they (poultry supervisor) come and they complain, as you see, and then they can tell you, “Listen, mate, if you don’t do better we drop you.”

27. Mental Health Challenges – Stress: Cost/Benefit Job Expectations “You know, it’s stress enough …. these chicken companies, every day they want more and more and more, you know? They want more and more. I mean, I don’t need that much money because I’ve got old houses that were built in xxxx. I have (to) compete with the newer people. So I have to keep improving my houses. Every time they want more and more and more, you know, and they don’t give you any more money.”

28. Mental Health Challenges – Stress - Job Demands & Coping “You know, I mean, we can’t go anywhere, because, you know, when you have chickens, you can’t leave. We can go to the store or something like that, you’ve got to be here. And then when the chickens go you have two weeks to three weeks but then you have to get your house ready. And with our state of health, when a younger man go in there and do a house in a day, it takes us a few days to do it, because, my wife, we go there and to a little bit and stop and go back tomorrow and do a little bit and stop. So it takes us a longer. We’ve got to pay to do a lot of things that other farmers can do for themselves. Because of our disability, you know?

29. Stress: Physical & Mental Health Complications • “ I don’t have difficulty falling asleep. I have difficulty, I get up, you know, and I keep getting up.” They prescribe “x” DRUG for me. • So when I got the first prescription I took in the prescription, $270 for a month’s supply. So I have to stop using “x” DRUG and I go to “y” DRUG which costs me $20-something a month. I can’t afford (the $270). • I was on cholesterol, uh, the cholesterol pill. They had me on 20 milligrams. I cut it to 10, you know, because I couldn’t afford the 20. My wife is using it, too. And then I stopped using it. so expensive and so far the last time I went and they checked your blood and your everything, it was all right. But the doctor said I can’t guarantee, I have to see him in December, you’ve got to go check the blood again and then he see.”

30. Stress: Physical & Mental Health Complications • But twice before that I had pains in my chest in the night and they had to take me. And most of these things happen after I spent a lot of time in the chicken house. • If I go in there and I have a lot of things, and the doctor tells me you’re not supposed to be in the chicken house. • You know, my doctor, I said, “Doc”, he said, “I know, but you can’t spend much time in there. So sometimes I go in there and I feel so bad and I have to come out for some fresh air and my wife and then I can’t get back to the house because I can’t walk to come that far on my own.”

31. Mental Illness Can Be Identified “I’m not thinking suicide thoughts, but I think whatever happens, happens. Whatever happens, happens, you know, I feel like that a lot. Whatever happens, because, you know, I see my wife have to work so hard,….. and my children they have their own (lives) …. So what’s the sense in living? But I can’t take my own life. But sometimes I do wish that I wasn’t living…”

32. Mental Illness Can Be Treated “And sometimes I voice and, you know, and my wife says, ‘Why do you have to talk like that?’ and she gets mad with me.” “She gets mad, ‘Don’t you care about anybody? Do you care about the children? Do you care about your grandchildren?’ Yes, I do, I love all my children and my grandchildren, but sometimes I just can’t take it, the pain. I have so much pain that I can’t sleep because of the pain, you know …”

33. Mental Health Problems Can Be Identified and Treated - Vignette #1

34. With Mental Health Identification – Treatment Options • Treatments - Antidepressants (SSRIs) - Talk therapy, with professionals. - Support groups

35. Mental Health and Physical Health are Equally Important - Vignette #2 Mr. Grain Farmer is divorced, remembering his prior marriage and his health problems. “Well, I never cried a tear after she left. Something can get on your nerves so bad. I couldn’t sleep.”

36. Stress Effects an Individual’s Mental Health and Physical Health “So the last two years she was here, I just slept downstairs on the sofa. It wasn’t working.” “… I got depressed. I got so I couldn’t sleep.”

37. Major Depression:Suicidal with Plan “One time I did (think of suicide). Yeah. I thought about taking a garden hose and putting it in the window of my pick-up.” “Yeah, I thought, I even had a road picked out back of XXXX where I was going to do it because it was like things just weren’t working, you know.”

38. Suicidal Thoughts are a Cry for Help… Not Sympathy. Emergency Treatment is Indicated. “And she knew I was in that kind of shape. She knew it. Because she made me call her, like, two or three times a day to let her know where I was.” “But she was real sympathetic for a while then she got so she wasn’t sympathetic. She was like, “Oh, you’re just wanting sympathy yourself” and “Get out of it”, you know. She only had so much patience and when she used it up she’d let you know.”

39. Mental Health Problems, Mental Illnesses, Can be Identified and Treated. “I take Effexor, one a day. I’ve been doing it for eight, ten years, and this, it makes me relax. If I miss two or three days I tense right up.” “I’ve been taking that ever since Dr. X said let’s try it when I was really hurting bad. I was to the point where, especially in winter time and rainy days, I’d get really depressed. I didn’t even have enough energy to hang my clothes up sometimes.”

40. Depression Medicine Helps – Treatment Works “But I’ve been divorced XXXX years. I waited a year before I divorced her… mean, not because I wanted her back. But I just made up my mind I…. So I just waited a year.” "(started the medicine)…At least ten years ago. …Yeah, and see, long as I take all this, I feel great.”

41. Summary • There’s an inter-relationship with one’s physical and mental health, that’s impacted by various challenges. • Challenges are usually based on stress. • Stress is modulated by our perceptions of a stress event, the coping behaviors we’ve learned, and our wiring, our genetics.

42. Summary - continued • When stress is overwhelming, we have physical and emotional health symptoms. • Stress is expressed in: • Behavioral terms • Psychological terms, and • Physiological terms. (correlated with DSM-IV- summarized next slide).

43. Stress & Responses - Behavioral, Psychological, and Physiological

44. Schematic • Designed by Peggy Mack, January 2004. • * Caspi et al., 2003; Hariri, et al., 2002; Prescott, Kuhn, Vittum, Riley, and Kendler, 2004;Saplosky, 2003; Science, 2003.

45. The Take-Home Message • Mental illnesses, emotional problems, can be identified and can be successfully treated.

46. Worksheets Depression Signs and Symptoms

47. Worksheet – DepressionSigns and Symptoms

48. Questions? • Thank you. • Email: PeggyMack02@aol.com