Wellness in Psychiatry-The Dawn of a New Era Focus on Definitions. Neurobiology & Interventions Rakesh Jain, MD, MPH.

Wellness in Psychiatry-The Dawn of a New Era

Focus on Definitions. Neurobiology & Interventions

Rakesh Jain, MD, MPH

The World Health Organization Defines Health as:

“…a state of complete physical, mental and social well-being and not merely the absence of disease or

infirmity.”

World Health Organization. Promoting Mental Health. Concepts, Emerging Evidence, Practice. 2004.

Definitions

World Health Organization. Promoting Mental Health. Concepts, Emerging Evidence, Practice. 2004; Slade M. BMC Health Serv Res. 2010;10:26.

“recovery is not about ‘getting rid’ of problems. It is about seeing people

beyond their problems – their abilities, possibilities, interests and dreams – and recovering the social roles and relationships that give life

value and meaning.”

Warwick-Edinburgh Mental Well-Being Scale (WEMWBS)

Tennant R et al. Health Qual Life Outcomes. 2007:5:63.

WEMWBS – Population Sample

Tennant R et al. Health Qual Life Outcomes. 2007:5:63.

All the time

Often

Some of the time

Rarely

None of the time

Maternal Well-Being and Developmental Difficulties in Children

Tough SC et al. BMC Pediatrics. 2010;10:19.

Low Risk

Elevated Risk

Moderate Risk

High Risk

0%

10%

20%

30%

40%

17%

23%

30%

37%

SF-8 Health Survey(Poor Mental Health)

% E

leva

ted

Dev

elo

pm

enta

l D

iffi

cult

ies

in C

hil

dre

n

P=0.004

Money Appears to Not be Able to Buy Mental Health!

Mental Health Before and After a Win

GHQ, General Health Questionnaire. Higher score means worsening

Gardner J, Oswald AJ. J Health Econ. 2007;26(1):46-60.

x

0.61x

0.06x0.05x

Physician Heal Thyself…!

Murfett A, Charman D. Aust Fam Physician. 2006;35(9):748-750.

Pattern of well-being in GP respondents

Frequency Percent

Excellent 51 10.6

Very good 130 27.1

Good 221 46.0

Poor 67 14.0

Total 469 97.7

Missing 11 2.3

Total 480 100.0No difference between men and women

No difference by ethnic groupsNo difference between self-employed, associates, or salaried

Concepts in this Emerging Field

Positive

Mental

Health

Mental

Well-bein

g

Cover both affect and psychological functioning

Covers the overlapping concepts of hedonic and eudemonic well-being

Has consequences for both health and social outcomes

Stewart-Brown S et al. Health Qual Life Outcomes. 2009;7:15.

Mental Well-Being is Much More than Absence of Symptoms

Burgdorf J, Panksepp J. Neurosci Biobehan Rev. 2006;30(2):173-187.

Presence of fitness

decrements

Presence of fitness

increments

Absence of fitness

decrements

Absence of fitness

increments

Valence

ArousalPANA

−PA −NA

NA, Negative Affect PA, Positive Affect

Mental Wellness: A Huge Payoff for Everyone, Including Those With Psychiatric Disorders

Mental Wellness lowers risk of mental illness

Mental illness episode

length/depth reduced by Mental

Wellness

Burgdorf J, Panksepp J. Neurosci Biobehan Rev. 2006;30(2):173-187; Slade M. BMC Health Serv Res. 2010;10:26.

Imaging HappinessSignificantly increased BOLD signal during happiness scripts compared to emotionally neutral scripts are seen on the left dorsomedial prefrontal cortex, dorsal anterior cingulate gyrus, insula, and dorsal postero-lateral prefrontal cortex, as well as on the thalami, left hypothalamus, and left middle temporal gyrus. In the bottom row, foci of significantly increased BOLD signals during happiness scripts compared to irritability scripts are shown on the left anterior insula, left hypothalamus, thalamus bilaterally, inferior and middle temporal gyri bilaterally, and right posterior insula, while areas of decreased BOLD effect are seen on the left dorsomedial prefrontal and dorsal anterolateral prefrontal cortices, subgenual cingulate gyrus, and left lingual gyrus.

Cerequeira CT et al. Braz J Med Biol Res. 2008;41(12):1076-1085.

Psychological Well-Being is Connected to Limbic System Functioning

van Reekum CM et al. J Cogn Neurosci. 2007;19(2):237-248.

PWB, Psychological Well-Being ScaleActivity in the ventral Anterior Cingulate Cortex in response to negative vs. neutral image

Scatterplot of dispositional pessimism and telomere length (TL) (r=−0.55, P=0.001).Study investigated whether dispositional tendencies towards optimism and pessimism were

associated with TL and IL-6 in a sample of 36 healthy postmenopausal women. Pessimism was independently associated with shorter TL (β=−0.68, P=0.001) and higher IL-6 concentrations (β=0.50, P=0.02).

Pessimism Accelerates Telomere Shortening and Increases IL-6

O’Donovan A et al. Brain Behav Immun. 2009;23(4):446-449.

Optimism Mitigates Biological Impact of Stress

Double-blind, placebo-controlled study showed that acute psychological stress increased serum levels of interleukin-6 (IL-6) and negative mood in 59 healthy men. Further analysis of this sample investigated the relationship between dispositional optimism and stress-induced changes in immunity and mood.

Brydon L et al. Brain Behav Immun. 2009;23(6):810-816.

Positive Affect May Diminish the Risk of Cardiovascular Events

Cubic spline analysis of the incidence rate ratio comparing each level of positive affect to a score of 1. Solid line indicates point estimate and dashed lines indicate 95% confidence interval. Dotted line indicates no association. Study examined the association between positive affect and cardiovascular events in 1,739 adults. There were 145 (8.3%) acute non-fatal or fatal ischaemic heart disease events during the14 916 person-years of observation. In a proportional hazards model controlling for age, sex, and cardiovascular risk factors, positive affect predicted coronary heart disease (adjusted HR, 0.78; 95% CI 0.63–0.96 per point; P<0.02).

Davidson KW et al. Eur Heart J. 2010;31(9):1065-1070.

Health Behavior is Affected by Quality of Mental Health

Steptoe A et al. J Pers. 2009;77(6):1747-1776.

65

70

75

80

85

90

95USAEastern and Central EuropeansAsians

Life satisfaction

% n

on

-sm

okers

Happiness Influences Inflammation

Happiness and fibrinogen stress responses. Shown is the mean increase in plasma fibrinogen after acute mental stress in the 5 happiness quintiles, adjusted for gender, age, grade of employment, BMI, smoking, baseline fibrinogen, and GHQ. Error bars are SEM. Differences in fibrinogen stress responses across happiness quintiles were significant (P=0.011).

Steptoe A et al. Proc Natl Acad Sci U S A. 2005;102(18):6508-6512.

Fib

rin

og

en g

/L

How Does Positive Mental Well-Being Affect Our Health?

Steptoe A et al. J Pers. 2009;77(6):1747-1776.

Shared Neuroendocrine, Inflammatory, Autonomic, &

Immune Pathways

Positive Health

Behaviors

Shared Genetics

So, what should we tell our Family?

• The ‘new’ standard of recovery is NOT just a mere absence of symptoms, but presence of Positive Affect and Mental Wellness

• All, even those with mental illness, can and should aim for this new standard of full recovery and optimum mental functioning

Complete State Model of Mental Health

Slade M. BMC Health Serv Res. 2010;10:26.

INCOMPLETE MENTAL ILLNESS

COMPLETE MENTAL HEALTH

INCOMPLETE MENTAL HEALTH

COMPLETE MENTAL ILLNESS

High subjective well-being symptoms

Low subjective well-being symptoms

Low mental illness

symptoms

High mental illness

symptoms

Struggling Flourishing

LanguishingFloundering

Neurobiological Driven Rationale: Combination May Be the Gold Standard Therapy in

Depression

• Layous K et al. J Altern Complement Med. 2011;17(8):675-683.

Limbic Hyperactivity

Dorsal Cortex Emotional/Cognitive

Dysregulation

Pleasure Circuit

Dampening

Pharmacotherapy Cognitive-Behavioral Therapy

Positive Activity Interventions

Pharmacotherapy +Cognitive-Behavioral Therapy +Positive Activity Interventions

35 45 55 65 75 85 95

rest/sleep

working

home computer

grooming, self care

other

watching television

relaxing, nothing special

shopping, errandspreparing food

eatingwalking, taking a walk

playing

exercising

not mind wandering

pleasant mind wandering

unpleasant mind wandering

neutral mind wandering

making love

talking, conversation

listening to music

praying/worshipping/meditating

taking care of your children

reading

doing housework

listening to radio, news

commuting, traveling

Kittingsworth MA, Gilbert DT. Science 2010. vol 330:932

How

Are

You

Fee

ling

Rig

ht

Now

?

0 = very bad - - - - - - - - - - - - - - - - - - - - - - - - - - -100 = very good

No Inherit Conflict BetweenNegative & Positive Mental Health

Yesterday’s Remission

Today’s Remission

The Interacting Spheres of a Health-Promoting Whole-School Environment

Wyn J et al. Aust N Z J Psychiatry. 2000;34(4):594-601.

Curriculum:teaching and

learning

Partnerships and services

Organization: ethos and

environment

Seligman - Creator of the Field of Positive Psychology and Positive Psychotherapy (PPT)

Seligman’s Theory of Authentic Happiness

Seligman ME. Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment. 2002.

1. The Pleasant Life, which consists in having as much positive emotion as possible and learning the skills to prolong and intensify pleasures

2. The Engaged Life, which consists in knowing your character (highest) strengths and re-crafting your work, love, friendship, play, and parenting to use them as much as possible

3. The Meaningful Life, which consists in using your character strengths to belong to and serve something that you believe is larger than just your self

4. The Achieving Life, which is a life dedicated to achieving for the sake of achievement

Happiness – The Seligman Model

Seligman M et al. Am Psychol. 2006;61(8):774-788.

Positive Emotion (the pleasant

life)

Meaning (the

meaningful life)

Engagement

(the engaged

life)

Positive Psychotherapy

Seligman M et al. Am Psychol. 2006;61(8):774-788.

Randomized controlled trials of PPT show efficacy in mild, moderately, and severely depressed individuals, with moderate to large effect sizes and

sustained at 1 year follow-up.

6-Week Group Therapy

Week 1 Using your Strengths

Week 2 Three Good Things/Blessings

Week 3 Obituary/Biography

Week 4 Gratitude Visit

Week 5 Active/Constructive Responding

Week 6 Savoring

PPT – Is It Effective in Patients With Depression?

Seligman M et al. Am Psychol. 2006;61(8):774-788.

P<0.04 at 6 months and 1 year

6 weekly group sessions with homework assignments

0

4

8

12

16

20 PPT, n = 19Control, n = 20

BD

I S

co

res

Mindfulness Based Cognitive Therapy (MBCT) – Promising New Therapy

M-ADM = Medication (anti-depressant continuation)MBCT= Mindfulness based CTPla+Clin = Placebo plus clinical management

Segal Z, et al. Arch Gen Psychiatry 2010. 67(12):1256-1264

Bringing Happiness to the Masses

Clinical Practice and Wellness Measurement - WHO-5

WHO-5

Scoring:

The raw score is calculated by totaling the figures of the five answers. The raw score ranges from 0 to 25, 0 representing worst possible and 25 representing best possible quality of life.

To obtain a percentage score ranging from 0 to 100, the raw score is multiplied by 4. A percentage score of 0 represents worst possible, whereas a score of 100 represents best possible quality of life.

Interpretation:

It is recommended to administer the Major Depression (ICD-10) Inventory if the raw score is below 13 or if the patient has answered 0 to 1 to any of the five items. A score below 13 indicates poor wellbeing and is an indication for testing for depression under ICD-10.

Monitoring change:

In order to monitor possible changes in wellbeing, the percentage score is used. A 10% difference indicates a significant change (ref. John Ware, 1995).

Wellness(Positive

Psychology, Resilience, etc.)

Models are Changing: Are We Ready? Disease Model vs. Disease to Wellness Model

Absence of Symptoms

Absence of Symptoms

Disease

Disease

Difference between Treating Depression and Offering Positive Mental Health

Depressive SymptomsDepressive SymptomsDepressive SymptomsDepressive Symptoms

Goal achieved ??

Time for a round of congratulations???

P o s i t i v e M e n t a l H e a l t hPositive Mental HealthPositive Mental HealthPos i t i ve Menta l Hea l th

In Conclusion – Paradigm Shift Aiming toward Wellness

Depressive SymptomsDepressive Symptoms

Depressive Symptoms

Depressive Symptoms