Chapter 4- Clinical Assessment, Mental Health, and Mental Disorders
Defining mental health and psychopathology
• € The Canadian mental health association defines mental health as the ability to strike “a balance in all
aspects of your life social, physical, spiritual, economic, and mental.
• € Mental illness is characterized by a lack of balance: alterations in thinking, mood or behaviour associ-
ated with significant distress and impaired functioning over an extended period of time.
• € Optimism and wisdom are components of good mental health and healthy social functioning.
• € Researchers have found that optimism and generatively in middle aged adults were related to adaptive
parenting strategies with adolescents.
• € Feelings of personal integrity and hope were protective factors against depression among a group of
older Albertans receiving psychiatric treatment.
• € To the extent that characteristics such as wisdom, optimism, and hope are absent, mental disorder or
psychopathology may become more likely.
• € A self help movement of “psychiatric survivors” is active in Canada, which takes the view that defining a
persons problems as “mental illness” and offering psychiatric treatment may mask the true social cause
of the problem and make matters worse.
• € The important point in differentiating normal from abnormal behaviour is that behaviours must be inter-
preted in context.
Most clinicians use the diagnostic and statistical manual of mental disorders- IV-TR to identify a disorder, but
the criteria do not always reflect the different forces that affect older versus younger people.
• € Chronic disease, disability and functional impairment can affect psychological well being
• € Physical problems may provide clues about underlying psychological difficulties (marked changes in ap-
petite may be a symptom of depression).
• € Physical health is a very important dimension to look at in diagnosing psychopathology in adults and
should be among the first avenues explored.
Psychological and developmental forces
• € Changes in attention, memory, and intellectual performance must be considered carefully in interpreting
• € The nature of a person’s relationship with other people, especially family members and friends is a key
dimension in understanding how psychopathology is manifested in adults of different ages.
• € The social norms and cultural factors we all experience also play a key role in helping define psycho-
pathology. They influence people’s behaviours and affect our interpretation of them.
Ethnicity, aging and mental health
• € Cultural influences should always be considered in evaluating people’s behaviour and designing effect-
ive ways to treat problems. Eg- first nations people experiences a lifetime of inadequate health care,
stress of discrimination by the time they reach old age and it’s likely that there are lingering mental
health problems for these older people. 2
• € Recent immigrants especially Chinese and Tamil elders experiences family and personal stress, loneli-
ness, and an impoverished spiritual life.
• € Resulting mental health problems were often unrecognized by family members or concealed to avoid
stigmatization in their cultural group.
• € Rates of depression among Canadians of Asian, south Asian, and African descent were lower than
rates among English Canadians, who in turn had lower rates than Jewish people.
Principles of multidimensional assessment
• € Assessment helps a clinician describe and understand the thought feelings and behaviours or other
characteristics of people in meaningful ways. It involves gathering medical, psychological and social in-
formation about people through various means (interviews, observation, tests)
Six principles for assessing older adults
1. Age and functioning are not linearly related in clinical settings
Need to consider relationship between functional status and mental health
2. It is necessary to recognize the influence of comorbidity in clinical settings.
A clinician needs to be aware that some conditions are likely to occur together
3. A major task in assessment is to distinguish normal from pathological processes
Important for clinicians to use assessment techniques that are age and culture sensitive and that provide norm-
ative information for diverse groups
4. Clinical gerontologists should emphasize brief assessments
First use a screen, a measure designed to alert the assessor to the likelihood that a problem exists. Second-
use a diagnostic tool to explore the specific problem uncovered by the screen.
5. Assessments results must emphasize patient’s strengths and weaknesses and treatment
An assessment should not be carried out just to identify a person’s problem. It should determine a person’s re-
sources and abilities.
6. Multiple methods of assessment are optimal
A standardized memory test can identify specific areas of loss, and a family assessment can uncover problems
in functional independence
Steps in a multidimensional assessment
• € The minimum data set instrument is used in many parts od Canada as a means of planning care and
reament for medical and psychological problems. This assessment tool contains questions about phys-
icaa nnd mental health and function aility. This approach involves 5 axis: clinical disorders, personality
disorders and mental retardation, general medical conditions, psychosocial and environmental prob-
lems, global assessment of functioning.
• € Mental status exams are especially useful as a quick screening measures of mental competence that
reveal cognitive impairment.
• € Psychological functioning typically is assessed through interviews, observations, and tests.
• € How well an older adult handles their daily activities should also be an important component of any as-
• € 3 dimensions of social functioning: ties with ones social network, the content of interactions with
member of the social network, and the number and quality of interactions with network members.
Factors influencing assessment
• € Two areas of concern are biases(positive or negative) and environmental conditions (where the assess-
ment occurs, sensory or mobility problems, and health of the client) 3
• € Environmental conditions (in hallways, noisy emergency room) are not ideal places and can create inac-
• € Clinical interview consists of questions posed to a client by a trained therapist or practitioner regarding
the history and current symptoms of mental health problems. Can be helpful to obtain historical inform-
ation determine appropriate follow up procedures, build rapport with client and evaluate effect of treat-
• € Self report instruments are self guided surveys and questionnaires that are designed to screen for men-
tal health problems and concerns.
• € Psychophysiology assessment examines the relation between physical and psychological functioning.
One measure (EEG) measures brain wave activity.
• € Direct observation is useful when the problem involves specific behaviours (eating disorders)
Age related issues in therapy
• € Therapy for mental disorders involves 2 approaches: medical treatments and psychotherapy
• € A major issue in psychotherapy is establishing whether a particular psychotherapeutic approach is ef-
• € Researchers agree that depression is one of the most common mental disorders. At any time about 4%
of all Canadian adults report experiencing depressive symptoms.
• € The rate of major depressive disorder actually declines across adulthood.
• € The most prominent feature of depression is dysphoria which is feeling down or blue, and is marked by
• € It is common for older depressed adults to withdraw, not speak to anyone, confine themselves to bed
• € Physical symptoms of depression include: insomnia, changes in appetite, diffuse pain, troubled breath-
ing, headaches, fatigue, and sensory loss.
• € Characteristic of a major depressive illness is that the symptoms last at least two weeks.
• € Some researchers have found that rates of depression vary across ethnic groups (South Asian and
black Canadians had rates of depression lower than those of English Canadians).
• € Women are diagnosed with being depressed more than twice as often as men
• € Classic depressive syndrome declines in frequency with age, and the depletion syndrome increases.
• € Diagnosis of depression should never be made on the basis of test score alone.
• € Biological theories focus most on genetic predisposition and changes in neurotransmitters
• € Most common theme of psychosocial theories of depression is loss. Bereavement is the type of loss
that has received the most attention.
• € The behavioural approach argues that people with depression engage in fewer pleasant activities an