2 Common mental health conditions

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Contents

• Objectives
• Introduction to mental health conditions
• Depression
• Anxiety
• Recognising common mental health conditions
• Other mental health problems
• Suicide
• Case studies

Objectives

When you have completed this chapter you should be able to:

1. Know more about common mental health conditions.
2. Understand the symptoms and signs of anxiety and depression.
3. Know about alcohol and substance abuse disorders.
4. Understand why mental health is important for HIV management.
5. Understand more about suicide.

Introduction to mental health conditions

2-1 What are negative emotions?

It is normal for people to have negative emotions and feel sad, frightened, disgusted or angry at times in their lives. Emotions are normal responses to the things we see, smell, taste, feel, hear or think about. Adults are usually able to manage the way they respond to their emotions. But strong emotions can be frightening, especially for children and adolescents. Adults need to help young children and adolescents understand and manage their emotions.

2-2 What is a mental health condition?

Mental health conditions are more than just stress or strong emotions. A mental health condition is a problem of the mind that can affect the person’s mood, thinking and behaviour. A person with a mental health condition has difficulty managing their life at home, at work, in school and in the community.

To be mentally healthy, people need to be able to balance all parts of their life.

A mental health condition is a problem of the mind that can affect the person’s mood, thinking and behaviour.

2-3 What are the common mental health conditions?

The most common mental health conditions are depression and anxiety. Depression and anxiety make people get stuck in negative thinking patterns that can go on for weeks or months. This makes it difficult for them to function normally and feel connected to other people.

Examples of less common mental health conditions are eating disorders, addictive behaviours and psychotic disorders such as schizophrenia.

Depression and anxiety are common mental health conditions.

2-4 Why are mental health conditions a problem?

Mental health conditions make it difficult for people to get on with other people and to think clearly. Mental health conditions can also stop children and adolescents from learning and developing. The mind and body are connected, so mental health conditions affect both emotional resilience (toughness), being able to cope with stress and physical toughness such as immunity to disease. This means people with mental health conditions are more vulnerable to substance abuse, addictions and also diseases like TB, cancer, hypertension, diabetes, heart disease and HIV.

If mental health conditions are not noticed and treated early, those affected will struggle for most of their lives. They are also more likely to live in poverty and will find it difficult to move out of poverty.

2-5 How do we know if someone has a mental health condition?

We usually cannot tell just by looking at someone if they have a mental health condition. Only professionals can say for sure if someone has a mental health condition. However, we should always be aware, especially if the person is in a high risk group and seems to be showing some of the symptoms (what people feel) and signs (what we can see) of common mental health conditions.

We can ask the person the three Whooley questions as part of a kind and caring conversation:

1. In the past two weeks, have you been troubled by feeling down, depressed or hopeless?
2. In the past two weeks, have you had little interest in doing things?
3. In the past two weeks, have you been unable to stop worrying or thinking too much?

If the person answers yes to any of these questions, we should ask if they would like help with their feelings. Ideas about ways we can give help are explained in the next chapter. People with common mental health conditions know who they are and should be supported to make decisions for themselves.

Common mental health conditions can often be identified by asking the person how they are feeling.

2-6 What causes mental health conditions?

There is no single cause of a mental health condition. It is usually a combination of inherited and learned ways of managing feelings, thoughts and behaviour, as well as other socio-economic and environmental factors. Toxic stress is an important cause of mental health conditions, especially in babies and children. Most mental health problems start very early in life. When babies and young children experience toxic stress and stop feeling safe and protected, their minds are not able to develop properly. The growth and development of unborn babies may be affected by anxiety in their mother.

2-7 What are the other risk factors for developing mental health conditions?

There are many risk factors for mental health conditions. Some people are more vulnerable than others, even when they experience the same risk factors. These are:

• Poverty and financial problems
• Lack of social support and relationship problems
• Exposure to violence
• Physical sickness
• Big life changes such as pregnancy, divorce or death in the family.

Depression

2-8 What is depression?

When a person is depressed, they have a low mood and feel down, have little interest or enjoyment in life and have low energy, which stops them acting normally. If these feelings last for two weeks or more, the person has a mental health condition called depression (depressive disorder).

People with depression have a low mood, feel down and have little interest or enjoyment in life.

2-9 How do people suffering from depression feel?

People with depression have many of the following feelings, and the feelings last for two weeks or more:

• Sleep disturbances (wake up very early in the morning and then cannot sleep)
• Feel very tired and without energy
• No joy and fun in life
• Little interest to do things they usually like to do
• Feel guilty, bad and worthless
• Struggle to concentrate and remember
• Not interested in eating or only want to eat sweet food
• Movements and responses slow down
• Loss of sex drive
• Have lots of different body aches and pains
• Have thoughts about hurting or killing themselves (suicide).

2-10 How do people with depression behave and what do they look like to other people?

It can be very difficult to notice if people have depression because we can’t see what is happening inside another person’s mind. Signs of depression include:

• The person does not take care of themselves and looks dirty or untidy.
• Their face looks sad and unhappy.
• Their body is hunched up (closed or held small).
• Their body moves very slowly or looks very heavy or tired.
• Their voice is very soft or slow.
• They avoid eye contact.

Anxiety

2-11 What is anxiety?

When a person has anxiety, they feel uneasy, worried or frightened even when there is no reason for them to feel that way. Anxiety is a mental health condition (anxiety disorder) if these feelings last for two weeks or more.

People with anxiety feel uneasy, worried or frightened even when there is no reason to feel that way.

2-12 How do people with anxiety feel and behave?

People suffering from anxiety will notice many of the following:

• Feeling nervous or worried
• Feeling irritable and quick to anger or get upset
• Feeling that something very bad is going to happen
• Feeling tired but unable to relax and sleep
• Finding it difficult to focus and concentrate
• Feeling frightened of being alone.

They may also notice the following body changes:

• Struggle to fall sleep
• The body is tight and tense
• Shoulders are sore and they get headaches
• Shaking, trembling and sweating
• Fast heart and breath
• Not able to eat
• Stomach problems (cramps, vomiting or diarrhoea).

These feelings and signs can be normal if there is something frightening happening. When they happen without any danger and everything is normal, the person may have anxiety.

2-13 What is a panic attack?

This is a form of severe anxiety that lasts from a few minutes to a few hours. The person feels very frightened without any good reason. Often they think that something terrible is going to happen to them or that they are going to die. They feel faint, sweat, tremble (shake) breathe fast and have a very fast heart rate. They may also have chest pain and think that they are having a heart attack. Panic attacks usually occur in people who suffer from anxiety.

With panic attacks people feel very frightened for a short time with no good reason.

2-14 Are anxiety and depression separate mental health conditions?

Yes, and no. Some people have only anxiety, or they only have depression. Other people have both anxiety and depression at the same time.

Recognising common mental health conditions

2-15 What is different about people with common mental health conditions?

People with common mental health conditions have problems with the way they think, feel and behave, which stops them from living normally at home, work and in the community.

2-16 What problems do people with a common mental health condition have with thinking?

They may have problems with:

• Thinking too much or not being able to remember
• Not being able to concentrate and focus
• They often think they are bad or worthless
• They may also struggle to problem solve or think clearly.

2-17 How does a person with a common mental health condition feel?

They often feel:

• Alone and not connected to other people
• Not interested in life
• They can have mood swings and suddenly feel very sad, hopeless or even angry.

2-18 How does a person with a common mental health condition behave?

Many of their usual behaviours may change, for example:

• Eating: They may eat too much or may not feel hungry.
• Sleep: They may sleep too much, struggle to get to sleep or wake up very early.
• Exercise: They may stop doing things they usually enjoy, or move very slowly.
• Connecting: They may struggle to get along with other people or stop seeing them.

Mental health conditions affect everyday life and people have trouble doing the things they used to do. They even struggle to plan their day. They are not lazy or stupid. It’s the mental health condition which changes the way they think and behave.

2-19 How can we know if someone has a common mental health condition?

The best way to know is to ask. We cannot always see or notice if the person is suffering mentally. However, we can all ask people how they are feeling and be kind and supportive to those who are suffering. People can sense that we care when we try to connect with them, and this will usually make them feel a little better.

2-20 How can a suspected diagnosis of a common mental condition be confirmed?

The diagnosis can only be confirmed by a doctor or mental health nurse who is trained in recognising and managing mental health conditions. It is therefore important to refer anyone that you suspect may have a common mental health condition.

2-21 How are mental health conditions noticed in adolescents?

Mental health problems can be very difficult to notice in adolescents, because this is already a time of big changes. It can be difficult to know if the changes in emotions and behaviour are normal or if they are caused by a mental health condition.

Adolescents usually find it difficult to understand and also to talk about their feelings. Some adolescents may feel ashamed to talk about their lives.

There are different ways adults can notice that adolescents may have a mental health condition:

• If an adolescent begins to behave badly or starts to bully others, this can be because they have other worries or feelings. It is easy to think the adolescent is just being difficult. But bad behaviour is often a sign that there is an emotional problem.
• They may start to use alcohol and abuse drugs. This may stop them from doing their chores or school work, or keep them away from their usual friends.
• They may start to spend a lot of time on their own and less time with their usual friends.
• They may not want to go to school or even stop going to school. Their schoolwork may become a problem.
• Teachers may complain about their behaviour at school.
• Some schools screen adolescents for emotional and behavioural problems using the Strengths and Difficulties Questionnaire (SDQ) scale.

Adolescents with mental health conditions often start behaving badly and doing poorly at school.

Other mental health problems

2-22 What are alcohol and substance abuse disorders?

Some people use alcohol or other substances to cope with stress, anxiety or depression, even though this will mostly make their problem worse. Other people develop mental health conditions because they use excess alcohol and abuse substances to manage their emotions.

2-23 What is meant by addiction?

A person is addicted or dependent if they cannot stop using the alcohol or substances even when this causes them harm, or makes them feel awful or do bad things. Not everyone who drinks alcohol or uses substances becomes addicted. Some people become addicted the first time they drink alcohol or use illegal substances. Other people only become addicted after they have used for a long time. Adolescents are at high risk of becoming addicted because their brains are still growing.

Addiction is recognised by asking the person about their drinking or drug-taking practices.

People with addictions cannot stop themselves using a harmful substance such as alcohol or illegal drugs.

2-24 Is anger a mental health condition?

No, anger is not a mental health condition. Anger is a normal emotion that everyone, male and female, experiences when they feel threatened. Anger is a useful sign that tells us something is not right. But anger can also be a sign of depression or anxiety. Anger can become a problem if people don’t know how to manage their anger and behave in ways that harm other people.

2-25 Are HIV infection and mental health conditions related?

Yes. People who have HIV are at greater risk of developing a mental health condition, while mental health conditions put people at a higher risk of getting infected with HIV for several reasons:

• People who are depressed have low self-worth, so they are more likely to use alcohol or abuse substances. People who are drunk or high on illegal drugs often have unsafe sex, which puts them at risk for HIV infection, other sexually transmitted infections (STIs) and pregnancy.
• People with HIV and depression often have problems with adherence to their antiretroviral therapy (ART).
• Pregnant women or girls who are depressed may not be interested in the prevention of mother-to-child transmission (PMTCT) and so increase the risk of spreading HIV to their unborn baby.
• People with depression struggle to attend the clinic regularly.
• Adolescents with depression often drop out of school, which is linked to a low parental support and higher rates of HIV.
• Depression can also make HIV worse as it lowers immunity.

2-26 What is an eating disorder?

An eating disorder is a mental health condition where a person eats too much, resulting in severe obesity, or eats too little and loses too much weight (anorexia). Some people make themselves vomit after eating in order to lose weight (bulimia). All these conditions can cause ill health and should therefore be recognised and referred for correct management.

2-27 What is a psychotic disorder?

With psychotic disorders such as schizophrenia, the person is out of touch with reality and may see or hear things that are not there. Schizophrenia often starts during adolescence. These mental conditions are less common than anxiety and depression, but are very serious and need immediate referral for treatment.

People with a psychotic disorder are out of touch with reality and see and hear things that are not there.

Suicide

2-28 What is suicide?

Suicide means the person ends their life on purpose. This means the person kills themselves. Suicide is a leading cause of death in adolescents. Suicide can affect the whole community. You may know about someone who killed themselves and how this affected their community.

2-29 Do adolescents have a higher chance of suicide?

Yes, adolescents are more likely to commit suicide than adults. Those at greatest risk also:

• Have problems with their mental health, especially depression
• Have often been struggling with other difficulties like moving home, a death in the family, bullying or failing at school
• May have tried to harm themselves before
• May not have positive friends or support at home
• May be struggling with acceptance around gender identity or sexual orientation such as homosexuality or bisexuality.

2-30 Are there warning signs that a person is at risk for suicide?

It is difficult to know if someone is suicidal without asking them. Asking about suicide will not make a person suicidal, but may help them feel better. If we ask, the person will feel that someone cares about them and they are not so alone. We must be careful not to blame or judge the family or anyone else when someone commits suicide.

Sometimes, but not always, suicidal people give warnings. For example, they may start:

• Talking about suicide or death
• Talking about feeling hopeless or guilty
• Pulling away from friends and family
• Speaking about not being around anymore and saying goodbye to people
• Giving away their special things.

There are many reasons why people harm themselves. They may do this because:

• They feel so bad inside that they don’t want to live anymore
• They are trying to ask for help but don’t know how to
• They want to punish someone.

Any person who you think is at risk of suicide must be referred urgently for further assessment and management.

People who you think are at risk of committing suicide must be referred urgently for help.

Case study 1

Andile is 16 years old. His mother brings him to see you and asks for advice on how to help her son. Andile looks like he is in good health and has not been sick over the past year, but he keeps complaining of tiredness and says he struggles to sleep at night. Andile says he has no energy to play soccer with his friends. This is something he used to enjoy. His mother tells you that Andile is always very irritable. She is worried because he used to be a good student but now his teachers are complaining that he has not been doing his homework properly and his marks are poor.

1. Is Andile just being lazy?

Andile may be lazy, but it is more likely that he has or is developing a mental health condition.

2. What makes you think Andile may have a mental health condition?

Andile is an adolescent, so he is in a high risk group. He seems to have many symptoms and signs of depression. For example, he says he struggles to sleep, but at the same time always feels tired. His mother says he is irritable and he is no longer doing well at school. He has stopped seeing his friends and no longer enjoys soccer, which he used to love.

3. How can you check if Andile really does have depression?

We can’t tell just by looking if someone has a common mental health condition. Only professionals can say for sure if someone has a mental health condition. We can ask the three Whooley Questions if we are worried.

4. Won’t asking make Andile feel worse about himself?

No. Asking will make Andile feel seen and let him know that you care. Asking also lets Andile know that many other people may feel this way, otherwise you would not think to ask.

What are the three Whooley questions, and how can they help?

1. In the past two weeks, have you been troubled by feeling down, depressed or hopeless?
2. In the past two weeks, have you had little interest in doing things?
3. In the past two weeks, have you been unable to stop worrying or thinking too much?

It seems that Andile may say ‘yes’ to one and perhaps two questions, suggesting that he is depressed. He should be referred for further assessment and management.

Case study 2

A young girl, Phumelele, comes to see you. She looks very frightened and her eyes are swollen from crying. Phumelele tells you she is unhappy and her life is over, she can’t go home so she plans to kill herself. You recognise Phumelele, she is the daughter of a friend’s cousin.

1. Should you tell Phumelele to stop making such a fuss or you will tell your friend?

No, Phumelele looks very upset. It is important that you try to find out what has happened to make her so upset. When we talk to people about their feelings, it is very important that they feel safe and understand that we will keep confidentiality.

2. Should you ignore what Phumelele said about killing herself?

No, it is important to take note when adolescents say they want to harm themselves. Tell Phumelele this is too big for you to manage alone and that you need to tell your supervisor. You can ask if she would like you to go with her and support her while she talks to her mother.

3. How can you do this without making things worse?

If you are careful and respectful, nothing you say will make this situation worse. It is important to stay calm, not to judge Phumelele and to try to find out why she is so upset. Once she has calmed down, ask her if she meant what she said.

4. What common mental health condition may have caused Phumelele to think of suicide?

Depression. Phumelele is in a high risk group and looks like she has been crying. She seems overwhelmed. The only way to know is to ask her.