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Introduction   

Mental health conditions are common in the United States, with one in five adults suffering symptoms ranging from mild to severe each year. Despite this fairly high prevalence, 2020 data indicates that only 46% of adults with a mental health condition received medical services related to those symptoms (10). Furthermore, experiencing one mental health disorder increases the risk of developing a second or third disorder by two to three fold (13). Comorbid mental health diagnoses also increase the severity of symptoms, negative impacts on quality of life, and risk of suicidal ideations (3)  

Current practices surrounding mental health leave many people at risk of being undiagnosed or untreated and increased awareness and education is needed for medical professionals to help close these gaps in care. This Connecticut mental health training aims to provide a thorough understanding of certain common mental health disorders, how to screen for them and coordinate resources for clients in need, and how to navigate suicide prevention for optimum client safety.  

Epidemiology

Every year, millions of people nationwide suffer from mental health related symptoms that impact their ability to work, attend school, maintain relationships, and enjoy their lives. Recent data indicates that one in five United States adults experiences symptoms of mental illness each year and one in twenty experiences severe symptoms (6). One in six United States children experiences mental illness symptoms each year and suicide is the second leading cause of death in the 10-14 year age group (6).  

As of 2020, anxiety disorders were the most prevalent, with 19.1% of all US adults experiencing some form of anxiety annually. Depression is next, with a prevalence of 8.4%, Post-traumatic Stress Disorder (PTSD) experienced by 3.6%, and bipolar disorder experienced by 2.8% of adults (6).  

There is mild variance among races, with annual prevalence among races outlined as follows:  

• Non-Hispanic multiracial people: 35.8% 
• Non-Hispanic white: 22.6% 
• Non-Hispanic American Indian: 18.7% 
• Hispanic or Latino 18.4% 
• Non-Hispanic black: 17.3% 
• Non-Hispanic Asian: 13.9% 

(6) 

Women are more likely to experience mental illness than men, with 25.8% of women 15.8% of men reporting symptoms annually (NIH). Being part of the LGBTQ community is one of the greatest risk factors, with 47.4% of LGBTQ people experiencing mental illness (6).  

In addition to the factors that increase risk of mental health disorders, experiencing mental health issues also increases other health related risks. Suffering depression increases the risk of cardiovascular and metabolic disorder by 40-50% over the rest of the population, depending on severity. Thirty-two percent of people with mental illness also experience substance abuse disorders, as compared to 10% of the general population (6).  The rate of academic struggles and dropping out of school are 2-3 times higher for children and teens with mental health diagnoses, which in part contributes to the higher rates of unemployment (6.4% vs 5.1%) experienced by people with mental health disorders (6). On a more global scale, it is estimated over $1 trillion is lost in productivity due to depression and anxiety disorders each year (6).  

On the severe end of mental health consequences is suicide, currently the 12th leading cause of death nationwide (12). Overall, there has been a slight decrease in suicide rates in recent years, declining from 14.2 per 100,000 people annually in 2000 to 13.5 per 100,000 people in 2020 (12). Still, suicide is a devastating problem with twice as many people dying by suicide as homicide in recent years. Risk varies by many demographic factors with men being about 4 times more likely to commit suicide than women across all ages. Among women, suicide rate is highest for those ages 45-64, at 7.9 people per 100,000. And among men, the rate is highest for those age 75 and older, at 40.5 per 100,000. By race, American Indians and White men are significantly more affected (12).  

When looking at younger populations, the biggest risk factor seems to be sexuality and gender identity. Gay, Lesbian, and bisexual teens are 4 times more likely to attempt suicide than straight peers and transgender teens are 9 times more likely to attempt suicide than cis-gender peers. Each year, 45% of LBGTQ teens report experiencing serious thoughts of suicide at least once (6).  

Despite these serious implications and high rates of prevalence, less than half of affected people receive appropriate, regular mental health services. These statistics are staggering. This is the reason of why the Connecticut Department of Public Health implemented the Connecticut mental health training CE requirement to improve mental health outcomes. Lack of proximity to resources, prescription problems, delayed or canceled appointments, and complications due to the pandemic or even just symptoms causing poor compliance all serve as barriers to appropriate treatment (6). Healthcare professionals are guaranteed to encounter patients with mental health needs no matter what area of healthcare they work in, and universal improvements in education and preparedness to deal with mental health concerns is desperately needed and can serve to improve outcomes for patients everywhere.

Signs, Symptoms and Criteria for Common Mental Health Diagnoses

Unless you work specifically in mental health, you may only have a vague understanding of what exactly certain mental health diagnoses mean, how they are treated, or what symptoms your clients are dealing with. A more in depth understanding of how mental health problems present and diagnostic criteria is one of the first steps towards better detection and treatment for vulnerable clients. The Connecticut Department of Public Health added this CE requirement of Connecticut mental health training in order to better serve the patient population.

Depression

Known as Major Depressive Disorder (MDD) or Clinical Depression, this is one of the most common mental health disorders. While this disorder may stereotypically be known as being sad or down, the actual criteria for depression is much more detailed and nuanced (9). According to the Diagnostics and Statistics Manual for mental health (DSM-5), MDD is defined as experiencing at least five of the following symptoms for at least a two week time period and at least one of the symptoms must be one of the first two on the list:  

• Sad, depressed, or even flat or detached mood most days, for the majority of the day 
• Decreased or lack of interest or pleasure in any activities throughout the day 
• Decrease in appetite or significant weight loss without trying to lose weight 
• Slowed thought process and movement, noticeable by others 
• Fatigue or low energy levels most days 
• Feeling worthless or unnecessarily guilty most days 
• Decreased ability to think, concentrate, or make decisions most days 
• Recurrent thoughts of death, with or without a plan, or thoughts that things would be easier if one was dead (9)
  

The number, combination, and severity of symptoms will vary by individual. Typically symptoms are severe enough to interfere with a person’s ability to work, attend school, or maintain their relationships as well as they would like. People with depression may also experience excessive worries about their health or increased rates of general physical complaints like headache or abdominal pain. MDD may occur as a single episode, but often occurs in recurrent episodes, lasting for a few weeks to months and then resolving for a period of time before returning. Persistent symptoms lasting two years or more, though often less severe in intensity, is known as dysthymia. Depression can also occur from hormonal changes during or after pregnancy and is known as perinatal depression. Some individuals suffer from depressive symptoms only at certain times of year, typically in the dark and cold months of fall and winter in the northern hemisphere; this is known as seasonal depression (9).  

It is important to separate depression from grief which is a response to loss with similar, often overlapping, but distinguishably different from depression symptoms. In grief, there is an identifiable loss, whereas depression can occur without any particular precipitating event (for “no reason”). Grief involves sad or hopeless feelings intermixed with feelings of joy or peace, whereas depression is persistently low mood. Being close to loved ones often offers comfort or healing in grief, but isolation and withdrawing are more common with depression. And with grief, thoughts of death may occur as a person desires to reunite with a deceased loved one, while in depression thoughts of death center around feeling worthless or hopeless and no longer wishing to live (4).  

Risk factors for depression include personal or family history of any depressive disorder, certain medical conditions that negatively impact quality of life, or even medications taken for other conditions. Major life events or traumas, including death of a loved one, divorce, moving, job changes, birth of  child, abuse, or traumatic events can all increase the risk of subsequent depression (9).  

Anxiety

All people experience worries or stress over things throughout their lives. But anxiety disorders extend beyond normal worries in their frequency and intensity, occurring often enough and at a severity level that interferes with a person’s ability to function at work, school, or in their relationships with others.  There are several distinct disorders that fall under the umbrella of anxiety and the differences lie in the triggers and the expression of symptoms, but the criteria of excessive worry is a common theme across all anxiety disorders (8).  

Generalized anxiety disorder (GAD) is a common form of anxiety that involves a general sense of dread of anxiousness, typically about anything and everything rather than specific events. People with GAD may feel restless, on edge, have difficulty concentrating, become tired easily, be irritable or have difficulty regulating their emotions, have difficulty sleeping, or have frequent general physical complaints like headaches or stomach aches (8).  

Panic disorder involves more extreme physical symptoms of anxiety, known as panic attacks. Sudden, intense bursts of anxiety involving a racing heart, chest pain, shortness of breath, shaking, intense feelings of dread, or an intense desire to flee a situation are considered panic attacks. They may occur in relation to stressful events or for no reason at all. Anyone can experience a panic attack, but experiencing them frequently and being unable to function at work, school, or home because of them is considered panic disorder (8).  

Social anxiety disorder is anxiety triggered by situations with people outside of one’s home. This can be people you know, like classmates or extended family, or strangers like cashiers or healthcare professionals. Symptoms include feeling judged or watched by others, racing heart, being unable to speak up or speak clearly to others, avoiding eye contact, or feeling very self conscious (8).  

Phobias are anxiety related symptoms that center on a very specific trigger or event. People with phobias will do everything they can to avoid the trigger, including refusing to go to a certain place or leave home. Common phobias include agoraphobia (fear of leaving home), blood, heights, airplanes, vomit or vomiting, certain animals (such as snakes, spiders, or dogs), needles or injections, or separation from parents (for children) (8).  

Risk factors for anxiety include exposure to traumatic events (especially early in life), drug or alcohol use, frequent exposure to a stressful environment (at job or school), and family history of anxiety disorders. Certain medications and stimulants like nicotine and caffeine can increase the symptoms of anxiety (8).  

Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) is a type of mental health disorder that develops as a response to experiencing a particularly dangerous, scary, or shocking event. An extreme response of “fight-or-flight” during a high stress event is very normal, but many people recover quickly, within a few days to weeks, and do not experience continued distress after the event is over. For other people, the intense symptoms of fear or anxiety continue long after the danger has resolved (11).  

Symptoms that occur in response to an identifiable event, last more than a month, and are interfering with a person’s ability to function at work, school, or in relationships are considered to have PTSD. Symptoms include:  

• Re-experiencing the event such as through flashbacks or nightmares 
• Avoidance symptoms such as staying away from certain people, places, objects, or even music that serves as a reminder of the event 
• Arousal symptoms of feeling on edge, angry, tense, easily startled, or having difficulty sleeping 
• Cognition and mood symptoms such as difficulty remembering details surrounding the event, negative outlook on the world or about self, feelings of guilt or blame, lack of interest in things 
• Children may experience symptoms of regression such as bedwetting or daytime accidents when previously continent, being unable to speak, acting out the event with toys, increased clinginess or fear of separation from parents or caregivers (10)
  

Risk factors for PTSD include experiencing war (both as a member of the military or a civilian), physical or sexual assault/abuse, car accidents, natural disasters, seeing someone be seriously injured or die, history of mental illness or substance abuse, and having few to no support systems in place during times of stress (11).  

Suicide

Suicide by definition is the death of an individual from self-injurious behaviors and the intent to die from those behaviors. Reckless behaviors resulting in unintentional death are not considered suicide because there was no intent to die. People who attempt or commit suicide often feel worthless, hopeless, or that their life is a burden to others and the only escape from their symptoms or guilt is to end their life (12). Warning signs that individuals may be planning or preparing for suicide include increase agitation and substance use, withdrawing from others, researching methods of suicide, stating they have thought about or have the ability to commit suicide, sleeping too much or not at all, giving away possessions or calling/writing letters to say goodbye to loved ones, or a sudden and extreme improvement in depression symptoms (usually from the resolve to commit suicide) (2).  

A suicide attempt is any self-injurious behavior engaged in as an attempt to die but which ultimately is non-fatal. Suicide attempts can be actions which do not even result in injury, but if death was the individual’s intent, it is considered a suicide attempt. Suicidal ideations are any thoughts, considerations, or detail planning related to ending one’s own life (12).   

The leading method of suicide in recent years is firearms, accounting for more than half of all suicides (11).  

Risk factors for suicide include existing mental illness (especially depression, anxiety, bipolar disorder, or schizophrenia), substance abuse problems, terminal health diagnosis (particularly those that are very painful), persistent bullying or relationship problems, unemployment, highly stressful life events like divorce, family history of suicide or personal past attempts, and childhood trauma or neglect. Having access to guns, knives, pills, or other potentially lethal materials increases the risk of suicide as well (2).  

Case Study

Jason is a 78 year old male who presents at the Internal Medicine office for his annual physical. When the nurse is collecting vitals, she chats with him about his plans for the summer. He states that he and his late wife used to garden together and he has kept up with it for the last 3 years since her death but this year he does not feel up to planning it or doing the work. The nurse asks if he has other plans for how to occupy his time and he states he usually has a group of friends he gets coffee with twice a week, but he hasn’t been waking up early enough to go to it and has decided to sleep in instead. The nurse documents his vitals and reports off to the physician, attributing his “slowing down” to his advancing age. During the visit, his doctor asks how he is coping with his wife’s loss to which Jason replies, “I’m okay. It never gets easier, but you do get used to it.” The physician orders labs to check his iron levels for fatigue and provides a pamphlet for a support group for widows and widowers at the end of the visit. He recommends Jason follow up in another 3-4 months if his fatigue hasn’t improved. 

Screening

Regardless of which area of healthcare you work in, there will always be clients who are struggling with mental health symptoms, even if that is not their primary reason for seeking care at your facility. Routine and standardized screening for these symptoms can help ensure more clients who need help are identified and prevent many from falling through the cracks. Earlier detection of symptoms ultimately leads to better mental health outcomes as well, so simple and routine screenings serve to improve identification and distribution of care to those in need. Improving mental health outcomes is the primary goal of Connecticut implementing this CE requirement of Connecticut mental health training. So who should undergo screening, when should the screenings occur, and what are some of the best or most common screening tools available?  

Let’s start with children since over 50% of all lifetime mental health disorders first appear by age 14.. At every wellness visit, it is recommended to ask general questions about family psychosocial wellness such as childcare resources, availability of food, parent coping with the stressors of parenthood, and normal psychosocial development in the child such as language, eye contact, bonding with family members, play, and age appropriate response to praise and consequences. Families where problems are suspected should be evaluated further. Starting at age 11, the use of more streamlined screening tools is recommended by the American Academy of Pediatrics. The Patient Health Questionnaire (PHQ-9) and/or Pediatric Symptoms Checklist (PSC) should be used annually to detect increased risk of depression, anxiety, or suicidal thoughts. The CRAFFT questionnaire is recommended annually for screening of substance use, starting at age 11. For children who seem anxious or where excessive worries or behavior problems are a concern, a SCARED questionnaire can assess more specifically for anxiety disorders (1).  

Once into adulthood, the PHQ-9 is still a reliable and easy to use tool and should be administered at all annual wellness visits. The General Anxiety Disorder (GAD-7) tool is also quick to administer and can pick up on clients who may be experiencing excessive worries (5). In more acute settings like urgent cares or emergency departments, a simple screening question such as “Do you feel safe at home?” can determine situations that may need acute interventions for clients who may not be receiving regular primary care.  

In addition to annual screening, healthcare providers should be aware of life events that may increase a person’s risk of experiencing a mental health disorder and perform additional screening as needed.  In obstetrics and gynecology settings, women should be screened throughout pregnancy and postpartum for perinatal mood disorders using an Edinburg Questionnaire. Pediatric offices can also screen mothers of infant clients since women often see their child’s pediatrician much more frequently than their own obstetrician or midwife (5). Older adults are more likely to be experiencing declining health, chronic medical diagnoses, or life events such as retirement or the loss of a spouse that increase their risk of depression or anxiety. Assuming their age alone is the cause of certain symptoms should be avoided, while energy and activity levels may indeed decline in later life, a lack of interest or pleasure in things or feelings of hopelessness are not normal signs of aging and should not be brushed off. Updated information on recent life events is important and increased screening should be done accordingly. War veterans, disaster or abuse survivors, and others may find themselves seeking care for physical symptoms related to trauma, but their mental health should be considered and assessed immediately after the event as well as regularly for several months afterwards (5). 

Taking Action

The next step in closing the gap for early detection of mental health disorders is knowing what to do when clients screen positive or when they come to you specifically with a mental health concern or symptoms. A primary goal of the Connecticut mental health training is to prepare nurses with the knowledge and resources needed to get paitents on the right plan of care. Many facilities are surprised once they begin screening, just how many clients present with positive results or the need for further help.  

The first thing to do is gather more information directly from the client. Ask about symptoms they have been feeling, how long it has been going on, recent life events that may be contributing to these feelings, and ways in which the symptoms have been impacting their performance at work, in school, or in other aspects of life. Gather a family history that focuses specifically on mental health disorders to better assess disorders for which a client is at risk. Determine the client’s overall safety; the best way to do this is to ask directly if they are having thoughts of wanting to harm themselves or others. This will help determine if intervention is needed urgently or if a more routine connection with resources is appropriate (2).  

Once more thorough information has been gathered about a client’s particular scenario, providers can determine the best course of action and what resources to connect them with. It is useful for facilities to have a list of resources available. Appropriate resources include providers who can diagnose and prescribe treatment for mental health disorders (this can often be done in primary care settings, but specialists like psychiatry may be more appropriate), therapists or counselors, group therapies or support groups with common themes, and crisis resources like suicide hotlines or facilities that can be accessed 24/7 in the event of a crisis. When connecting clients with resources, plan for appropriate follow up as well to ensure they received the help they needed (2).  

Suicide Prevention

On a broad scale, healthcare professionals can participate in suicide prevention by advocating for screening and early detection of mental illness, as well as identifying risk factors and protective factors for their clients to determine who may need connection with available resources. On a community health level, strengthening available resources and the community’s access to them can promote social change needed for prevention (7).  

On a more individual level, familiarity with what to do when encountering suicidal clients is always useful, though the actually frequency at which you encounter such clients may vary greatly depending on where you work. If you have concerns or a client fails a screening tool, it is always okay to ask them outright if they have thoughts of wanting to hurt themselves. It is a myth that asking someone this will give them the idea and no studies indicate asking this would contribute to suicide risk. If a client indicates they are having thoughts of suicide or self harm, the next steps should be to determine how often these thoughts are occurring and if they have a plan. It can feel awkward to ask these types of questions, but it is extremely important for client safety and studies indicate that most people would like the help and support extended to them. If they admit to having a plan, the next step is to determine if they have the means to enact the plan. If they say they want to take a lethal dose of pills, determine what medicines they have available to them; if they say they have thought about using a firearm, determine if firearms and ammunition are accessible to them (7).  

Clients with an active plan and the means to enact said plan will need crisis intervention and likely involuntary hospital admission. Anyone with thoughts of suicide, even passive ones with no plan, will require further evaluation with a counselor or provider experienced in mental health. Specific plans moving forward for these clients is beyond the scope of this course, but often involve the development of Safety Plans, initiation of psychiatric medication, and connection with resources such as individual or group therapists. The important thing for healthcare professionals in general is to be able to determine when clients are a risk to themselves or others and ensure they are connected with resources before leaving your care (7).  This is what the Connecticut Department of Public Health wants to educate nurses on and is why they implemented a CE requirement of the Connecticut mental health training.

Revisit Case Study

Let’s take a look at Jason’s case again and consider how things might have gone differently with better mental health protocols for the facility.  

Jason is a 78 year old male who presents at the Internal Medicine office for his annual physical. When the nurse is collecting vitals, she chats with him about his plans for the summer. He states that he and his late wife used to garden together and he has kept up with it for the last 3 years since her death but this year he does not feel up to planning it or doing the work. The nurse asks if he has other plans for how to occupy his time and he states he usually has a group of friends he gets coffee with twice a week, but he hasn’t been waking up early enough to go to it and has decided to sleep in instead. The nurse notes the PHQ-9 questionnaire Jason completed at check in and sees the score is 20/27, which is indicative of depression.  

The nurse documents his vitals and reports off to the physician, mentioning Jason’s PHQ score and his lack of interest in his usual activities. During the visit, his doctor asks how he has been feeling lately and if he has been sad or lonely. Jason discloses that he has been feeling down lately and not wanting to do the usual things that he enjoys. His doctor asks if he has any thoughts of suicide or wanting to hurt himself which Jason denies. After a thorough assessment, Jason is diagnosed with MDD and given a trial of fluoxetine. His doctor also recommends Jason establish with a therapist. Follow up is scheduled in 3 weeks to check in on how the new medication is going.  

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