Treatment of Mental Health Disorders

It is important to first understand mental health and the types and causes of mental health disorders.

If you think you or a loved one are suffering from mental health issues or symptoms of a mental health disorder, it is important to have a medical consultation with your treating physician, psychologist, or psychiatrist, who will take a complete history to understand your symptoms and condition. A general medical examination is conducted, and blood tests and neuro-imaging tests are advised where needed.

In managing mental health disorders, understanding, support, and cooperation of household members and family is of paramount importance for good and long-term treatment outcomes.

Psychoeducation is the first step which involves learning about the condition, its implications in daily life, its impact on the patient and family, and support and treatment options available. Psychoeducation helps both the patient and family to cope better, as well as improve empathy and understanding, which can lead to a better treatment response.

Treatment approaches are a combination of the following:

• Lifestyle therapy
• Counseling and Psychotherapy
• Support groups, Helplines, and Organizations
• Medicines and Supplements
• Medical Interventions, or Hospital Care

LIFESTYLE THERAPY

This focuses on 5 important aspects.

Diet

Diet and the functioning of the gut have a direct link to mental health and the functioning of neurotransmitters (gut-brain connection). The diet has to be nutritious and eaten at a relaxed pace and at regular times.

The following points should be kept in mind:

• Increase vegetables, fruits, nuts, yogurt (curd), pulses, eggs, fish/chicken, and whole grains
• Decrease foods high in sugar and saturated/trans-fat, refined flour, deep-fried, packaged-preserved foods, and red meats
• Alcohol should be restricted to not more than once or twice a week with 1 or 2 glasses
• Stimulant beverages with caffeine should be kept at 1-2 cups a day.
• Water intake should be around 8-10 glasses or 1.5 L a day.
• Other fluids like buttermilk, coconut water, and green tea (chamomile tea at bedtime) also provide beneficial effects.

Physical activity and Exercise

Adequate physical activity or leading a physically active life can help release endorphins (chemicals that reduce stress and pain), improve mood and sleep, and decrease anxiety.

A regular form of physical exercise should be adopted like brisk walking, cycling, swimming, yoga, aerobics, or dance-exercise forms. This should be done for at least 30-45 minutes a day for 5 days a week. Taking up a sport can also be very helpful. However, physical activity and exercise should be in accordance with one’s age, physique and capacity, and should not be too exhausting or straining to the body. If taking up a new physical exercise or sport, it is best to start under the guidance of a trainer or coach.

In addition, stretching and breathing exercises or techniques practiced for 5-10 minutes a day can also have beneficial effects. It can help reduce anxiety and stress and also improve work capacity and lung function. Breathing techniques can also help at the onset of a panic attack.

Sleep

Sleep has to be adequate in quantity (6-8 hours every night), of good quality (without frequent awakenings or disturbance), and of a set pattern (regularizing sleeping and awakening time). Sound sleep can go a long way in boosting mental and physical health, and decreasing stress, anxiety, and low moods.

Daily living, Stress relief, and Relaxation

Setting a daily routine is very helpful for mental health. Packing limited or few activities, and breaking down tasks into smaller parts that are easier to handle, and less overwhelming or intimidating, is the way to go. Rewarding the completion of a day’s plan or a particular task also helps to improve mental health and motivation. Maintaining a journal or diary is very useful, that can capture triggers, one’s thoughts, interpretations, and responses. This can be a useful tool for analysis and planning therapy for both the treating psychologist or physician, as well as the patient.

Managing stress is a cornerstone for both mental and physical health. It is important to allot time in the day, free of gadgets like mobile phones and laptops, spent with family, friends, or loved ones, and do things that are relaxing and enjoyable. Examples include playing a game, hobbies like music, painting, craft, dance, gardening, and reading. Taking regular vacations and spending time with nature is emotionally and physically rejuvenating.

Mindfulness is the human ability to be fully present in and aware of the moment. It is focusing on where one is and what one is doing in that moment, and not on what is around or what will happen. Taking some time out for mindful meditation for a set time daily is also very beneficial. Meditation can be practiced in various ways like focusing on breathing, imagery, and positive emotions, or by body scanning and tension release technique.

Personal Care and Physical Health

Taking care of one’s health, hygiene and comfort can make one feel good about oneself, and elevate self-esteem and mood. Regular bath, brushing well and rinsing the mouth after meals, dressing in comfortable nice clothes, making one’s hair neatly, applying moisturizer to the skin, using pleasing fragrances and oils like lavender (aromatherapy), etc. can enhance positivity.

Associated physical illnesses with underlying mental illness which when not addressed, gives the patient incomplete relief from his physical symptoms. This is often seen with chronic pains and digestive complaints. On the other hand, the presence of an untreated chronic physical problem can also cause mental health conditions like anxiety and depression.

COUNSELING AND PSYCHOTHERAPY

Various techniques of psychotherapy have evolved over a period of time. Many of them work well on their own, and also enhance the response to medicines. These techniques and therapies require time and patience, commitment, and cooperation of the individual and the family. It may sometimes seem like a challenging, uphill and long journey therefore disappointments and drop-outs do occur. Such treatments are usually given by qualified and experienced psychologists and sometimes even by psychiatrists.

Counseling and talk therapies in the form of structured sessions over a period of time are the most common and basic psychotherapies. These are usually short-term therapies over a few weeks to months, for understanding and targeting particular symptoms or current situations affecting the person, and offering suggestions and advice on how to deal with these. It involves listening, conversations and discussions, followed by guidance.

Psychotherapy refers usually to a longer treatment that focuses on gaining insight into the person’s chronic physical and emotional problems, one’s thought process and responses, and how these are influenced by past events. It consists of cognitive and behavioral therapies (CBT). While cognitive therapy focuses on change in thought processes and beliefs (cognitive restructuring), behavioral therapy focuses on change in behavior and responses to the external environment. Maintaining work books, writing down and recording symptoms, triggers and responses, and also learning by role-plays are part of such therapies. Cognitive processing therapy (CPT) is a type of CBT for reducing symptoms of PTSD by learning how to change disturbing beliefs and create a new understanding and concept of the traumatic event. Behavioral activation therapy (BAT) refers to goal directed environmental engagement activities for positive reinforcement.

Family therapy helps to increase understanding, coping and support, and can help in better response to treatment as well as lower relapses. These are especially useful in depression, anxiety, PTSD, and eating disorders. Interpersonal therapy (IPT) helps one to understand and change maladaptive interactions and responses. Group therapy sessions are also practiced by psychologists for people with similar mental health disorders.

Exposure therapies use the technique of exposing the patient to the stimulus in a controlled way. This helps in phobias and PTSD. Prolonged exposure techniques are used, sometimes along with participant modelling where the therapist models the interaction with the phobic stimulus to help increase the confidence and decrease fear of the patient. Imaginary exposure techniques, or exposure by virtual reality, are also helpful techniques. Interoceptive exposure is a technique of exposure to internal sensations felt during panic or agoraphobia. Exposure and response prevention (ERP) combines exposure of the obsessive stimulus along with not allowing the patient to respond with compulsive actions or reactions, and is useful in OCD. A structured panic control treatment (PCT) is done in stages of counselling, awareness, and education with breathing and mindfulness training, followed by logical analysis by the patient of automatic thoughts, and then finally followed by exposure. Rarely flooding techniques by full exposure to the stimulus, maybe used but have to be done so very cautiously.

In professions like the military, combat, police, etc., psychological debriefing group sessions (also called critical incident stress debriefing- CISD) are done after exposure to traumatic events. As part of training in these professions, graded exposure of possible traumatic events is given (stress inoculation) to prevent severe mental impact or development of PTSD later.

Emotion regulation therapy (ERT) integrates components of cognition and behavior, acceptance, logical discussions, mindfulness, and experiences, to help manage emotions. It helps identify, describe and differentiate emotions, increase acceptance and adaptive ability, decrease emotional avoidance, and utilize emotions for effective decisions, motivation, and managing relationships. It is useful in anxiety and depression disorders. Dialectical behavioral therapy (DBT) implies acceptance and change together, and combines CBT-ERT with mindfulness, positive interpersonal skills, and distress tolerance. It is useful in depression, complex PTSD, and personality disorders. Acceptance of emotions and commitment to therapy (ACT) encourages embracing one’s thoughts, emotions and feelings, not suffering or feeling guilty about them. It then involves committing to facing problems head-on rather than avoiding them. It is often paired with mindfulness and helps in anxiety, depression, OCD, and substance abuse. Emotional freedom technique is an alternate medicine treatment combining acupressure and counseling to relieve physical pain and emotional distress to balance energy systems.

There are also ‘mind coach’ centers and organizations of psychologists and psychiatrists who have developed their own treatment techniques and psychotherapy.

SUPPORT GROUPS, HELPLINES, AND ORGANIZATIONS

There are various support groups, especially for depression, PTSD, and substance abuse. These are especially helpful for sharing experiences, motivation, collective commitment, as well as improving insight and understanding. Helplines are there for the same and are especially useful in suicide prevention.

Many NGOs and social organizations also run rehabilitation centers and residential non-hospitalized treatment centers for various conditions of mental health as well as substance abuse.

It is important to explore and connect with such support avenues in one’s area.

MEDICINES AND SUPPLEMENTS

There are many classes of medicines that are effective and have been used in treating mental health disorders.

Antidepressants

These are the most prescribed class of medicines for mental health conditions. These act by regulating the levels of the neurotransmitters serotonin and/or noradrenaline, which are implicated in depression, and other mental health disorders like anxiety-related disorders and PTSD. Various classes of antidepressants are available:

Selective serotonin reuptake inhibitors (SSRIs – fluoxetine, paroxetine, escitalopram, sertraline).

Serotonin and noradrenaline reuptake inhibitors (SNRIs – duloxetine, venlafaxine, desvenlafaxine).

Atypical antidepressants (trazadone, mirtazapine, vortioxetine, vilazodone, bupropion).

SSRIs and SNRIs act by inhibiting the reuptake of serotonin or/and noradrenaline thereby increasing their action. They may have side effects like dry mouth, weight gain, sleep disturbance, headache, nausea, indigestion or diarrhea/constipation, tremors/nervousness, abnormal thoughts, and decreased sexual drive or performance. It takes at least 4 weeks to perceive significant effects of these medicines on improving mood and emotional stability. There may also be a relapse of the condition or withdrawal symptoms on discontinuation. Therefore, proper medical monitoring is necessary.

Atypical antidepressants may inhibit serotonin/noradrenaline reuptake plus have other actions like modulating serotonin receptors. Bupropion is one of the few antidepressants not frequently associated with sexual side effects, sleepiness, or weight gain, but carries a risk of seizure. It inhibits dopamine and noradrenaline reuptake and is sometimes added to SSRIs.

Esketamine is a new antidepressant delivered as a nasal spray in a health care provider’s office, a clinic, or a hospital. It often acts rapidly, typically within a couple of hours, to relieve depression symptoms.

Tricyclic antidepressants (TCAs – amitriptyline, nortriptyline, clomipramine, doxepin) are antidepressants used selectively and in cases non-responsive to SSRI/SNRIs. They have similar often more severe side effects compared to SSRI/SNRI plus the risk of heart rhythm abnormalities, seizures, glaucoma/blurred vision, hypertension (high BP), and urinary retention.

Monoamine oxidase inhibitors (MAOIs – selegiline, phenelzine) are the older antidepressants, very rarely prescribed now due to side effects similar to TCAs but also high interactions with many common food items and drugs.

Atypical antipsychotics (as add on in more severe resistant depression or with psychotic symptoms) – olanzapine, aripiprazole, and quetiapine

Mood Stabilizers

These are drugs used to treat bipolar disease, and to reduce agitation, emotional instability, and impulsiveness in depression, anxiety, stress disorders as well as schizophrenia and personality disorders. This group includes lithium, and some anti-epilepsy medicines (divalproex, lamotrigine, carbamazepine)

Some side effects include dizziness, nausea, tremors, slurring, increased thirst and urinations, palpitations, weight/appetite changes, sleep disturbance, indigestion/diarrhea, and headache. These drugs should be taken strictly under medical monitoring.

Antianxiety Medicines

Benzodiazepines (alprazolam, clonazepam, diazepam, lorazepam) are the most commonly used antianxiety medicines that also help to fall asleep by their mind calming and muscle relaxant action thereby helping in mood and stress disorders, as well as psychosis. They work by increasing the action of the neurotransmitter GABA. They are used for various anxiety disorders and phobias. They also act fast and are useful in panic. Daytime drowsiness, confusion, dizziness, and headache are some side effects. As they can be habit-forming and require increasing doses with time, they are used for short-term management, till other drugs start to take effect, then withdrawn gradually to prevent withdrawal symptoms.

Gabapentenoid drugs like pregabalin and gabapentin act by decreasing nerve excitability, inhibiting calcium channels, and enhancing the function of the neurotransmitter GABA , so are also useful in anxiety.

Buspirone is an antianxiety drug that takes effect over 3-4 weeks, but has the advantage of not being habit forming, and is also useful to manage the psychic symptoms of anxiety.

D-cycloserine is a drug sometimes used in anxiety, especially phobia along with exposure therapies.

Supportive medicines like those to reduce palpitation and tremor (beta-blockers –propranolol) may be prescribed especially for performance anxiety and social phobia.

Antipsychotic Medicines

These are drugs that act as inhibitors of dopamine D2 receptors and are used to treat schizophrenia, psychosis, and psychotic symptoms in mood, stress, and anxiety-related mental health disorders. The first-generation antipsychotics (typical or neuroleptics – chlorpromazine, thioridazine, haloperidol, fluphenazine, and flupenthixol) are mainly used in schizophrenia. Extrapyramidal side effects are involuntary muscle contractions (tremors, stiffness, abnormal movements, and facial twitches) that can occur as side effects in people taking antipsychotic medications.

Second-generation or atypical antipsychotics (clozapine, olanzapine, quetiapine, risperidone, aripiprazole) are used in schizophrenia as well as in those cases/episodes of depression, bipolar disorder, PTSD, or anxiety when psychotic symptoms like delusions, emotional blunting, obsession, and disorganized behavior/speech are seen. Side effects of atypical antipsychotics include drowsiness, weight gain, and sometimes developing diabetes which is a concern, but extrapyramidal side effects are less common. Overall antipsychotics can increase negative symptoms like tiredness and low mood. Clozapine can cause a rare side effect of a drastic fall in white blood cells (agranulocytosis).

Nutritional Supplements

There is some evidence to show that certain supplements may help as adjunctive or add-on therapy to improve mental health. These include vitamin D, B group vitamins like folic acid and B12, and minerals like iron, zinc, and magnesium. However, more research and conclusive evidence is needed.

Omega 3 fatty acid and amino acid supplements are also sometimes prescribed for general health and mental health. Melatonin is useful as a supplement to improve sleep and circadian rhythm. Sometimes L-theanine (found in tea) as a supplement is given for anxiety.

The gut-brain axis (GBA) consists of bidirectional communication between the central and the gut nervous system, linking emotional and cognitive centers of the brain with gut functioning and signaling by bacteria (gut microbiota). Probiotic supplements can help improve gut microbiota thereby stabilizing the gut-brain axis and interplay of neurotransmitters.

OTHER THERAPIES

There are interventional therapies that are used for mental health disorders, especially in severe or non-responsive cases. Some of them may require hospitalization and longer periods of observation, while many of these may be done as daycare procedures.

Biofeedback is a mind-body technique that involves using visual or auditory feedback to train a person to recognize and control the physical signs and symptoms of stress and anxiety, like increased heart rate, breathing, body temperature, and muscle tension, through electronic guidance and monitoring.

Hypnotherapy is used to identify and resolve root causes of phobias and release suppressed memories in PTSD and dissociative disorders.

Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic fields to stimulate nerve cells of specific areas in the brain. It is used in severe and refractory depression.

Light therapy (by exposure to artificial light) is used to treat seasonal affective disorder (SAD – depression that occurs around fall/winter annually).

Electroconvulsive therapy (ECT) involves a brief electrical stimulation of the brain while the patient is under anesthesia. It is used in patients with severe major depression or bipolar disorder that has not responded to other treatments.

Institutionalization or hospitalization in a mental health facility may be needed in some cases that are resistant to most treatments. There are various levels of such care. These can range from full hospitalization for a period of time to partial hospitalization (8-12 hours, 3-4 times/week). There is also non-hospitalized residential treatment in special centers, and intensive outpatient therapy (3-5 hours, 5 times/week). The choice is based on the severity of the condition and treatment modalities employed. Hospitals and residential centers provide directly supervised nutrition-diet, medication, group therapy or family therapy, and one-on-one counseling and psychotherapy.

Also read:

Mental Health Illness: Awareness, Types and Causes

Mental Health Disorders of Mood, Stress and Anxiety

Psychosis – Schizophrenia and Related Psychotic Disorders