Grand Cayman, Thursday, 25 May 2023:

The Public Health Department published its eighth monthly Public Health Spotlight on Communicable and Non-Communicable Diseases (NCDs) since the announced changed on August 31, 2022.

From the Desk of Sabrina Turner

So much happens in May.  International Nurses Day, Mother’s Day, Child Month, and Mental Health Awareness Month (US) are all among the many observances and events that take place during this month.

In this month’s Public Health Spotlight, the Department of Counselling Services (DCS) and the National Drug Council have offered global and local perspectives on mental health, focusing on women and children.

In the submission entitled “Understanding Addiction and Mental Health Issues in Women”, Kimberly Febres of Caribbean Haven Residential Centre highlights the contributing factors for substance abuse and mental illness in women.

In “Who’s Coming Through the Doors?”, Jason Dunkely of The Counselling Centre (TCC) provides us with a snapshot of the presenting issues arriving for intake at TCC while also offering readers more information on the services provided by the Centre.

The staff at the National Drug Council offer us tips on being more proactive in our prevention efforts relating to children’s mental health, providing some statistics on global and local trends relating to youth mental health.

Rounding out the submissions is Ms. Febres’ contribution on the impact of adverse childhood experiences, or ACEs- a topic that was well explored at this year’s Alex Panton Foundation’s Symposium, and one that warrants much more discussion and action.

Our Epidemiology Corner provides us with an update on the COVID-19 local data. While the World Health Organisation (WHO) declared that the COVID-19 pandemic is no longer regarded as a Public Health Emergency of International Concern, we must not forget the hard-earned lessons we have learned these past three years, and we must continue to ensure that we practice hand hygiene, stay home when unwell, and continue to utilise the seasonal boosters as they become available.

We remain at your service.

Understanding Addiction and Mental Health Issues in Women

Substance use disorders and mental illnesses require treatment, just like any other chronic condition. Recent statistics from The Substance Abuse and Mental Health Services Administration[1] (SAMHSA) and the National Health Service (NHS)[2] show that addiction and mental illness are prevalent among women. In fact, one in five women experience mental health disorders, compared to one in eight men. Unfortunately, the fear of stigma and repercussions that may follow often become barriers to necessary treatment. Women face unique challenges in these areas and often delay or avoid seeking treatment as they channel their energy into caring for others. It is important for woman to know that they are not alone and there is no shame in seeking support. Understanding causes of mental health issues and how mental health is experienced differently in women is the first step to prevention and treatment. The following are contributing factors for substance use and mental illness in women:

Life Events

Life-changing events such as pregnancy can trigger perinatal depression or exacerbate existing depression, anxiety, or substance use[3]. Many women worry that feeling depressed during or after a pregnancy means they are weak or are not good mothers. However, symptoms of depression are common during these times and seeking support from a medical and/or mental health professional is the best way to protect the health of both mom and baby.

Some women also experience changes in their moods or increased anxiety levels due to menopause. While some mood and energy changes may be unavoidable due to changes in hormones, the impact of moving into a different phase of life on a woman’s mental health is significant.

There is distinct evidence in recent research that women’s mental health and risk of substance use is linked to their histories of trauma. More specifically, trauma in the form of experiencing or witnessing domestic violence, facing physical abuse and/or sexual violence, and surviving a life-threatening event are predictors of addiction and mental illness in adult women.

Socioeconomic and Sociocultural Factors

Women in poverty are twice as likely to suffer from poor mental health, and are at particular risk of stigma and limited resources for health care.[4] Societal pressure and expectations of women are also likely to increase the chance of developing mental health issues or substance use disorders.

Women are more likely to be discriminated against due to their gender, and are more likely to be valued based on their appearance, rather than men, who are valued based on their ambition or leadership qualities. These sociocultural imbalances can account for an increase in stress and overwhelm in women, who often struggle to cope with the pressures of working, parenting, housekeeping, and engaging in social events.

The shame and guilt associated with being in a caregiving role often becomes a barrier for women who need support for their mental health. Women seeking treatment are often over or under-treated due to gender bias. For example, women are far more likely than men to be prescribed opioids, which are highly addictive.[5]

Biology

Female hormones fluctuate widely throughout life, and can have both positive and detrimental effects on the brain. For example, estrogen serves as a protective hormone, maintaining the structure of neurons in the brain, which serves memory and other cognitive functions. On the other hand, production of serotonin, a natural mood stabilizer, tends to be reduced in women as compared to men, which can account for a higher prevalence of depression among women. Conversely, testosterone, which is found in higher amounts in men than women, has anti-depression and anti-anxiety effects. As a result, women are twice as likely to experience depression as compared to men. Women also experience a heightened dopamine response in the brain, which results in faster dependence on substances.

Family history plays a significant role in a women’s risk of developing a mental illness or addiction. Research is split as to whether this is a result of nature or nurture, though there is some evidence that genetics are responsible, particularly for alcoholism.

Ongoing research at the Women’s Research Center at Yale University[6] is now providing some insight into the differences in brain development between men and women that contribute to their experiences of mental health and recovery.

Signs and Symptoms Unique to Women

There are many common symptoms of potential mental illness among men and women which may include some of the following:[7]

•          Persistent sadness or feelings of hopelessness

•          Misuse of substances such as alcohol, illicit drugs, or prescription medication

•          Excessive fear or worry

•          Thoughts of death or suicide or suicide attempts

However, women are more likely to experience physical symptoms such as sleep disturbance, fatigue, or appetite changes, headaches, chronic pain, and high blood pressure.  Once a medical diagnosis for these symptoms is ruled out, the possibility of a mental health concern should be considered. Women are also far more likely to internalize mental illness, which can lead to social withdrawal, loneliness, and increased feelings of sadness.[8]

Substance use disorders can also present differently for women. Women are more susceptible than men to progressing from using an addictive substance to becoming substance-dependent.[9] Due to differences in brain chemistry, women may also experience stronger cravings for substances, which can make it harder to quit and leads to more frequent relapses.

Women are far more likely to self-medicate with substances to alleviate stress and other unpleasant emotions, as opposed to men, who tend to use substances to reinforce social bonds and positive emotions. Women have also reported self-medicating to cope with chronic pain, exhaustion, or to control weight. Due to differences in body chemistry, women are also more likely to suffer physical side effects from substance use, such as cardiovascular issues, brain changes, liver damage, and overdose.

Ways Woman Can Take Care of Themselves

It is well documented that women experience greater stigma than men do when it comes to seeking treatment for addiction and mental health.[10] Society often treats women as moral failures or selfish for taking care of themselves, rather than appearing to have everything together and caring for everyone around them. Unfortunately, this view is damaging rather than helpful, resulting in a higher likelihood of negative long-term effects on the individual and their support system.

Rather than dismissing their own struggles in the effort to try to “keep it together,” women can benefit from reaching out, getting support, and prioritizing their own health in basic ways such as keeping active, eating well, and getting enough rest. On a larger scale, communities can help build support by reducing the stigma associated with seeking treatment for addiction and mental health, and celebrating those that take those steps to recovery. Screening for all women for mental health and substance use disorders by their general care practitioners would go a long way towards flagging potential concerns and offering treatment options early on.

Targeted treatments, such as those offered by the Department of Counselling Services (DCS) bring results and positive outcomes for women with addiction and mental health issues. Caribbean Haven Residential Centre (CHRC) offers evidence-based and gender-specific residential care for women with substance use disorders and co-occurring mental health and trauma histories. A supportive and collaborative treatment approach rooted in trauma-informed individual therapy and the Dialectical Behavioral Therapy model allows women to receive the treatment they need to reduce emotional suffering, improve relationships, cope with stress, and live in the moment.

Due to the many risk factors and societal issues outlined in this article, the women’s programme at CHRC has been historically under-utilized. While DCS constantly works to tailor its services to meet the current best practices and the needs of the community, the team also encourages the community at large to work together to end the stigma that exists towards women seeking recovery. When women (and men!) support each other’s decisions to take care of their mental health, the entire society has an opportunity to heal and grow. Persons seeking information about treatment at CHRC may call 947-9992 or email [email protected]<mailto:[email protected]>.

Who’s coming through the doors?
A snapshot of the change in presenting issues arriving for intake at The Counselling Centre.

Jason Dunkley, MSc, MBACP, CPAM/PL/COUNS/23
I am fortunate enough to have worked at The Counselling Centre (TCC) for 6 years, and even more fortunate to have been the Clinical Supervisor since December 2022.
Upon my arrival in 2017 much of my time was spent providing interventions for substance and alcohol addiction, working with victims of domestic violence, and helping clients work through trauma. However, the last 18 months have seen a significant shift in the type and severity of mental health and welling issues being experienced by the people of the Cayman Islands.

Substance misuse
Although this is no longer the primary clinical issue being treated at TCC, alcohol and substance misuse continue to be a problem in Cayman. This shift in our trends may not be because the severity of the problem in the community has decreased, but more likely that the general public are now more open to the idea that therapy is not just for ‘addicts.’ This means that more people who may not have considered accessing treatment in the past are now doing so.

Trauma
Trauma and addiction often arrive hand in hand. Clients who are not experiencing addiction also come to us seeking help to deal with trauma. However, the severity of what is now being presented has increased massively. More and more clients are now presenting with complex trauma, that is; varied and multiple traumatic events over a prolonged period of time.

Inter-Partner Violence (IPV)
While clients experiencing IPV is sadly nothing new, what we are seeing at TCC is a small increase in the number of men disclosing that they have been victims.

Sexuality and Gender Identification
We are seeing an increase in the number of clients from the LGBTQA+ community. Services are sought to process internal and interpersonal challenges. Where more individuals now feel empowered to live life more congruently, the lack of acceptance from society, and family at times, has an impact on mental health.

Non-Monogamous Relationships
In general, the number of couples seeking services has grown over the last 18 months. We are also starting to see couples seeking support as they face challenges in managing polyamorous or open relationships.

Anxiety in Adults
Where we have become quite familiar with adolescents and anxiety, there has been a sharp increase in adults presenting with this issue. This primarily manifests itself as social isolation, challenges in the workplace, and insecurity in romantic relationships.

How we help
We are a team of 7 therapists, 2 counsellors, 2 intake officers, and a Programme Coordinator.  Clients are assessed at intake and assigned to the therapist that best meets their needs. ALL clinicians at TCC are certified (in various modalities) to work with trauma. We adhere to three different models of couple’s therapy (Gottman, ACT, and EFT). We currently have 3 therapists who are certified EMDR practitioners.  We offer trauma informed yoga groups. We run an anxiety and depression support programme and a weekly anxiety and depression support group.
As the landscape of mental health needs in Cayman changes, so too have clinicians at TCC adapted and developed skills to serve the needs of the community.

Nursing and Mental Health
International Nurses Day is celebrated every year on May 12th, in honour of Florence Nightingale’s birth.  This year’s theme, “Our Nurses. Our Future.”, is part of a global campaign focusing on the importance of nurses in helping to address the global health challenges and to improve global health for all.

One critical issue for all healthcare professionals, but of particular importance in nursing, is the issue of mental health support for those in the profession.  While we all recognise the mental health impact that the COVID-19 pandemic had on the population as a whole, the issues that already existed in nursing pre-pandemic skyrocketed with the demands created by  COVID-19.  “[A] survey of 488 critical care nurses [in the US] found that between October 2020 and January 2021, 44.6% of nurses<https://www.cdc.gov/niosh/topics/healthcare/workstress.html> had high/moderate levels of moral distress and burnout.” 1

Studies show that nurses- and female nurses in particular- are more likely to suffer from burnout and mental health disorders, such as compassion fatigue, depression, trauma and extreme stress.  These were already concerning pre-pandemic, but the exacerbation created by the pandemic- along with the ongoing global health care personnel shortage- means that nurses are still being impacted by the pandemic, even as others have ‘moved on’.

Mental wellness and nursing are intrinsically linked as diminishing mental health impacts the quality of service delivery. “A 2020 report in the American Journal of Health Promotion revealed that nurses with poor mental and physical health were 26% to 71% more likely to report making medical errors, with depression ranking as the leading cause of such errors. “2

Prioritising mental health and wellness among nurses is essential in order to improve and secure the health of any nation.

1 https://dailynurse.com/increasing-mental-health-support-for-nurses/
2 https://onlinedegrees.und.edu/blog/supporting-mental-health-for-nurses-why-it-matters/

Strategies for Improving Nurses’ Mental Health
Destigmatising Mental Health Struggles
Health care organisations can help to reduce the stigma by normalising conversations about mental health and ensuring staff are informed about the resources available to them.
Establishing a Culture of Wellness

Organisations can employ several strategies to establish a workplace culture that prioritises nurses’ mental health, including:
•          Promoting evidence-based interventions like mindfulness and relaxation techniques
•          Developing policies that prioritise staff well-being, which could involve mandatory breaks, providing adequate parental and sick leave, and limits on shift length
•          Appointing a chief wellness officer (CWO) to spearhead efforts to build a wellness culture and provide a voice for the mental health concerns of clinical staff

Addressing Staffing Issues
In addition to limiting shift lengths and providing time for breaks, health care organisations can support the mental health of nurses by ensuring appropriate staffing levels and working around staff shortages. This may involve increasing the use of tele-therapy, which has the dual benefit of providing patients with easier access to medical services while reducing the burden on health care workers.

Providing Access to Mental Health Screenings
Nurses and other health care workers should also have access to free and confidential mental health screenings, along with other support programmes. These programmes can help organisations identify signs of mental health struggles among staff early, preventing burnout and other issues.
Supporting Mental Health for Nurses: Why It Matters (https://onlinedegrees.und.edu/blog/supporting-mental-health-for-nurses-why-it-matters/)

Proactive Prevention: Children’s Mental Health
A Global Perspective
The period of adolescence is a critical and formative time when a child’s mental wellness can be particularly vulnerable to a wide range of physical, social, and emotional challenges. According to the World Health Organisation, 1 in 7 youth between the ages of 10-19 years old experience a mental health condition, with 50% of mental health challenges already being established by the age of 14. Prevention and early intervention arekey components of protecting good mental health in children and can offer protective factors that assist their well-being all the way into adulthood.

A Local Perspective

In recent years, the Cayman Islands has experienced expedited growth in mental health awareness, and a recognition that mental health is a key part of an individual’s overall health and well-being. This growth is especially evident among our young people, with 6 in every 10 students from the 2020 Cayman Islands Student Drug Use Survey (CISDUS)reporting they have been taught about mental health in school, and 85%of students in years 9-12 reporting that they have sought help for their mental health concerns.

While these statistics show our progression as a community towards an improvement in mental health literacy and destigmatisation, the CISDUS has also revealed several risk factors that highlight the importance of having prevention efforts available to protect our youth’s mental well-being. According to the 2018-2022 CISDUS, risk factors for anxiety and depression among youth ages 13-18 include being female, being bullied, substance use, physical abuse, serious contemplation of suicide, and witnessing or engaging in violence. While not all risk factors can be mitigated, early prevention efforts are key for improving children’s resiliency and equipping them with the tools to navigate challenging life circumstances.

Our Children’s Mental Health: Being Proactive

A proactive approach to children’s mental health relies first on are cognition that good mental health requires a life-course approach that begins in early childhood. While there are many uncontrollable factors that can impact ones mental health, prevention can start by building healthy habits such as practising mindfulness, exercising regularly, fostering opportunities for emotional regulation, and healthy self-talk. Proactive prevention can also look like the use of programmes and services that promote mental wellness such as the National Drug Council’s “Healthy Bodies, Healthy Minds” campaign that focuses on the importance of taking care of ourselves and building healthy habits from the inside out. Life is full of challenging situations, but proactive prevention means building resilient children. It is important to give them a wide range of tools so that when difficult moments happen they can persevere, overcome, and continue to emotionally and mentally thrive.

The Impact of Adverse Childhood Experiences (ACEs)

As the body of research and knowledge related to addiction and mental health grows, it becomes more and more apparent that there is an alarming connection to history of trauma. Caribbean Haven Residential Centre (CHRC), a branch of the Department of Counselling Services (DCS), has begun to record data related to traumatic experiences and has noted that the vast majority of adults who struggle with addiction have experienced trauma. Plans and proposals are underway to formalize this research, and this article serves as an introduction.

The framework being used for understanding the trauma an individual has experienced is the Adverse Childhood Experiences (ACEs) questionnaire. ACEs originated in 1995 in a study conducted in California by the Centre for Disease Control, and refers to adverse experiences faced in childhood including abuse, neglect, and household dysfunction.[11] Numerous studies since then have shown that the higher a person’s ACEs score, the more likely they are to experience physical and mental health issues, social impairment, and even early death as adults.

Adults with any history of ACEs are four times more likely to develop a substance use disorder,[12]  and the strongest predictors were emotional, sexual, and physical abuse, parental divorce, and witnessed violence. Additionally, studies have shown that people with ACEs also tend to have lower tolerance for distress, which correlates to using alcohol or other substances as a coping mechanism. This correlation was found to be true across genders and in multiple cultures.[13]

Though the sample size is small as data collection began early in 2023, current figures suggest that about 83% of clients seeking services at CHRC for substance use and co-occurring mental health issues have experiences ACEs. This is consistent with studies conducted in the US and Canada, which indicated that the prevalence of persons who have substance use disorders and have experienced ACEs is 75%.[14]

The implications of this data for the Cayman Islands is that prevention of ACEs, which are alterable conditions, can have a tremendous impact on the reduction of adults experiencing substance use disorders, poor mental health, and also medical conditions. While the evidence is grave, the opportunity to substantially advance and improve public health is evident. Ongoing treatment options for people who experienced ACEs as well as policies and programmes for prevention should be at the forefront of public health initiatives.

Epidemiology Corner
Covid-19 Surveillance Data
April  2023: Data as of 2 May  2023
Locally:
During the month of April 2023, there was a decrease in the number of hospital admissions from 21 admissions in March 2023 to 8 new admissions in April 2023. The data includes patients who were admitted to the hospital for medical care and SARS-CoV2 symptoms and those who tested positive for COVID-19 when screened upon admission. One COVID deaths was reported for the month of April 2023.

Global Updates

On the 4th May 2023, the Director-General of the World Health Organization (WHO) declared that the COVID-19 pandemic is no longer regarded a Public Health Emergency of International Concern[1]. The Director-General stated that whilst COVID-19 cases and deaths continued to decrease, this may in part be related to surveillance efforts decreasing and pandemic fatigue.

Overall, the risk is viewed to have decreased due to high population-level immunity resulting from vaccination and/or infection and improved clinical case management, alongside the current strain circulating, Omicron and its sub-lineages, having a relatively consistent virulence.

On the 10th May, the WHO Emergency Committee for monkeypox (mpox) advised that the outbreak is no longer viewed a Public Health Emergency of International Concern[2]. This is due to the sustained decline in cases detected.

[1] World Health Organization, Statement on the fifteenth meeting of the IHR (2005) Emergency Committee on the COVID-19 pandemic, 5 May 2023. Available online: https://www.who.int/news/item/05-05-2023-statement-on-the-fifteenth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic

[2] Pan American Health Organization, WHO declares end of mpox emergency, calls for sustained efforts for long-term management of the disease, 11 May 2023. Available online: https://www.paho.org/en/news/11-5-2023-who-declares-end-mpox-emergency-calls-sustained-efforts-long-term-management-disease

A Message from the Chief Medical Officer
On the 4th May 2023 the WHO Director-General accepted the advice offered by the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic that COVID-19 is now an established and ongoing health issue which no longer constitutes a public health emergency of international concern (PHEIC).
It is important that the WHO message is not misunderstood to mean that there is no longer any risk, as the WHO also added the important caveat  that their statement ‘must be interpreted within the context that the committee noted that SARS-CoV-2 has been and will continue circulating widely and evolving’.
The COVID-19 pandemic is not over.
The COVID-19 vaccines and boosters, along with a better understanding of the virus and how it is transmitted, have only allowed us to move out of the emergency phase.
We also face the re-emergence of other respiratory infections, including the flu.
I continue to recommend, not just for COVID-19, but for good protection against many infectious diseases that we all:

 *   always practice proper hand hygiene
 *   stay home when unwell
 *   consider wearing masks when in crowded indoor areas (including during air travel), especially if you are clinically vulnerable
 *   get vaccinated and boosted against COVID-19 and  the Flu

________________________________

[1] SAMSHA. 2020. Survey on Drug Use and Health: Women Slides. Retrieved from https://www.samhsa.gov/data/sites/default/files/reports/rpt31102/2019NSDUH-Women/Women%202019%20NSDUH.pdf

[2] NHS. 2016. Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England.

[3] Mental Health Foundation. 2023. https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/women-and-mental-health

[4] Agenda Alliance. 2022. https://www.agendaalliance.org/our-work/projects-and-campaigns/womens-mental-health-facts/

[5] Becker, Jill B. (2017). Sex Differences, Gender and Addiction. Retrieved on September 21, 2018 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5120656/

[6] https://www.everydayhealth.com/womens-health/mental-health-issues-in-women.aspx

[7] National Institute for Mental Health. 2023. https://www.nimh.nih.gov/health/topics/women-and-mental-health

[8] Eaton, N. R., Keyes, K. M., Krueger, R. F., Balsis, S., Skodol, A. E., Markon, K. E., Grant, B. F., Hasin, D. S. (2012). An invariant dimensional liability model of gender differences in mental disorder prevalence: Evidence from a national sample. Journal of Abnormal Psychology, 12(1), 282-8

[9] NIDA. (2017). Sex and Gender Differences in Substance Use<https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women>.

[10] Kulesza, M., Larimer, M. E., & Rao, D. (2013). Substance Use Related Stigma: What we Know and the Way Forward. Journal of addictive behaviors, therapy & rehabilitation, 2(2), 782.

[11] Harvard University, 2023. https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/

[12] Rosalie Broekhof, Hans M. Nordahl, Lars Tanum, Sara G. Selvik. (2023). Adverse childhood experiences and their association with substance use disorders in adulthood: A general population study (Young-HUNT), Addictive Behaviors Reports, Volume 17

[13] Emily O. Norton et al, & Cross-Cultural Addictions Study Team (2023) Childhood Traumatic Experiences and Negative Alcohol-Related Consequences in Adulthood: A Cross-Cultural Examination of Distress Tolerance and Drinking to Cope, Substance Use & Misuse, 58:6, 804-811

[14] Tracie O. Afifi, et al. (2020). Adverse childhood experiences (ACEs), peer victimization, and substance use among adolescents, Child Abuse & Neglect, Volume 106.