Hserv482 07 Mental Health

8/13/2019 Hserv482 07 Mental Health

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Mental illness:A Population Health Perspective

482 Session 8

First dissemination exercise

DUE IN ONE WEEK


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Summary of ideas to here?


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Mental Illness in the USProblem?

How would you know? College students at campus counseling centers?

24.5% (2003-4), 17% (2000) 9% (1994)

Why?

Violence?

Substance use?

nicotine

alcohol

illegal drugs

Depression?

Insanity?


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Agenda

Violent behaviors, stress and inequalityMental modes

High rates of significant mental illness in the US and

responses, social aspectsRank differences and substance use

Triune brain evolution

Depression


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Age distribution and overall rates of homicide:

England and Wales compared with Chicago.

(age and sex of perpetrator)

Source: Cronin H.


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Age distribution and overall rates of homicide:

England and Wales compared with Chicago.

(age and sex of perpetrator)

Source: Cronin H.


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Mental modes

Agonic(dominate)Hedonic (cooperate)

Primarily concerned withself-security

Concerned with

-what others think of us in a

group

-rank hierarchy

-convention

-self-protection

Respond to potential threats

to self, status, social

presentation

Form network of personalrelationships that offer mutual

support

Can give free rein to

-intelligence,

-creativity

-systems of social relations

Attention released from self-protective needs

-can explore and integrate

many new domains


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Mental modes

Agonic(dominate)Hedonic (cooperate)

Higher ranking individuals-accord less to those below

-receive more attention than

those lower in the social scale

Channels of attention develop

-more attention to those of

higher rank

-lower-ranking individuals

have most of their attention

directed to those above


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Health Olympics Age 80

Manton NEJM 1995

Whites

Gilligan,Violence


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http://www.prisonexp.org/


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Drug ways of dealing with agonic modes


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Nature Neuroscience Feb 2002

As we learn more about the neurobiology of


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As we learn more about the neurobiology of

normal and pathological human behavior, a

challenge for society will be to use this

knowledge to effectively guide public policy. For

example, as we understand the neurobiological

substrates that underlie voluntary actions, how

will society define the boundaries of personal

responsibility in those individuals who haveimpairments in these brain circuits?This will

have implications not only for the management

of drug offenders, but also of other offenders

with diagnoses such as antisocial personality

disorder or conduct disorder. At present, critics

of the medical model of addiction argue that this

model removes the responsibility of the

addicted individual from his/her

behavior.However, the value of the medical

model of addiction as a public policy guide is

not to excuse the behavior of the addicted

individual, but to provide a framework to

understand it and to treat it more effectively.

M t l d


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Mental modes

Hedonic (cooperate)

Appeasement transformed to reassuring,conciliatory gesturesbetweenmutually dependent individuals

In moments of excitement, arousal level of individual is low(hedonic condition - chimpanzees, bonobos)

Absence of fear of punishment characterizes relationshipbetween individuals

Have time for integration of reality, inter-personal relationsand private feelings and thoughts,

leads to systems-forming faculty (distinctlyhuman,e.g. chess)

Extensively studied in children in playgroups where (hedonic)leader type children do not escalate threat into aggression, but

initiate play and cooperation contrast with agonistic


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Mental ill-health Olympics


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12 mo nth prevalence of DSM disorders

Americas Anxiety Mood Impulse-Control Substance Any Serious

Colombia 10 6.8 3.9 2.8 17.8 5.2

Mexico 6.8 4.8 1.3 2.5 12.2 3.7United States 18.2 9.6 6.8 3.8 26.4 7.7

Europe

Belgium 6.9 6.2 1 1.2 12 2.4

France 12 8.5 1.4 0.7 18.4 2.7

Germany 6.2 3.6 0.3 1.1 9.1 1.2

Ita ly 5.8 3.8 0.3 0.1 8.2 1Netherlands 8.8 6.9 1.3 3 14.9 2.3

Spain 5.9 4.9 0.5 0.3 9.2 1

Ukraine 7.1 9.1 3.2 6.4 20 .5 4.8

Middle East and Africa

Lebanon 11.2 6.6 1.7 1.3 16.9 4.6

Nigeria 3.3 0.8 0 0.8 4.7 0.4

Asia

Japan 5.3 3.1 1 1.7 8.8 1.5

Peoples Republ ic of China

Beij ing 3.2 2.5 2.6 2.6 9.1 0.9

Shanghai 2.4 1.7 0.7 0.5 4.3 1.1

JAMA June 4, 2004.


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ZahranMMWR2004


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Zack Public Health Reports 2004


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Wilkinson et. al. SSM 2007

MORE EQUALITY

Mental Illness

MoreMENTAL

Illness


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Muntaner Epi Reviews 2004


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How our brains evolved


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Triune Brain:

MacLean 1973


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Triune Brain

Reptilian brain (R-complex)- evolved in reptilian ancestors 300 million yearsago, shared with all vertebrates, and little changed

- contains nuclei vital to maintaining life (CV,resp.), the basal ganglia

- no emotions or cognition of future or past events

Behavioral responses are governed by instinct and

relatively automatic- territorial acquisition, defense, dominance,striving, agonisticthreat displays, mating


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Triune Brain: MacLean 1973

T i B i


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Triune BrainPaleo-mammalian brain (paleocortex)subcortical structures

-limbic system (dopamine)-hippocampus, hypothalamus, thalamus, pituitary gland

homeostatic mechanisms control via hormone levels (HPA)

Balances

- hunger versus satiation

- sexual desire against gratification

- thirst against fluid retention

- sleep against wakefulnessEmotions addressed:

- fear, anger

- love, attachment, bonding, mating, caring (oxytocin)

T i B i


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Triune BrainPaleocortexbehavioral differences from reptiles:

- nursing and maternal care- audio-vocal communication for maintaining mother-

offspring contact

- separation call to maintain mother-offspring

proximity (baby crying)

Play hedonic

- evolved to promote group harmonyand affiliation

- conscious awareness present,- behavior less rigidlydetermined by instincts

Complex organ controlling basic psychophysical responses

and attitudes to environment

T i B i


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Triune BrainNeocortex(neo-mammalian)

- cognition andsophisticated perceptual processes

as opposed to instinctive and affective behavior

- monkeys and apes have brains twice as large as those of

typical mammal of equivalent body size

Neocortex ratio (ratio of this part of the brain to the rest of the

brain is related to group size among animals

Neocortex is the social organ(absence of neocortex in pre-frontal leukotomy -puppy dog)


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B i S i l O


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Brain: SocialOrganAdult human brain 2% of body weight, but consumes

20% of total energy intake ($$$)

Purpose of such a large substrate needing organ

-because we have a big body?

-solve complex problems of food acquisition(frugivory vs folivory), navigating to find it?

-demands of complex social systems?

Why does the fetus develop such a large brain making

birthing difficult?Humans evolved a large body to carry on energetic

costs of feeding a large brain, and especially to

provide for fetal development?


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Attachment


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AttachmentSecure Anxious Disorganized

Same eyes Different eyes Too many or

no eyes

Strangers Comfortable Uncomfortable Frightened or

frightening

Synchrony

Rhythm

Pair bondingwith primary

caregiver

Ambivalent

Or avoidant

Coping withStress

Secure base Anxious,less adapted

unpredictable

Later health better Behavioral &

other problems

Mental &

other illness

Hispanic Mental Health in US


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Hispanic Mental Health in USHispanics largest minority in US in 2004 (41.3 million)

-have less access to health and mental health care and receive less care and lower-quality care

-tend to receive mental health care in primary care settings, often face linguisticbarriers, and

-are more likely not to have mental disorders detected

-seem less likely to suffer from depression and anxietybut tend to have morepersistent mental illnesses

-are more likely to somatize distress and to report psychotic symptoms in the absenceof a formal thought disorder

-do not appear to differ from Caucasians in drug metabolism and pharmacokinetics

-seem to have lower medication adherence, which could be a function of socioeconomicand linguistic or educational factors

-seem to respond well to adapted psychotherapeutic and psychosocial interventionsand receive significant additional benefit from supplemental services such as casemanagement, collaborative care, and quality improvement interventions.


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How we deal with mental modes in our pharmacracy


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Rose 2004


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Rose 2004


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In major depression, rates ofantidepressant prescribing were 53%,

76%, and 31% forSPs making brand-specific, general,and no requests

In adjustment disorder, antidepressantprescribing rates were 55%, 39%, and10%, respectively

Minimally acceptable initial care (anycombination of an antidepressant,mental health referral, orfollow-up within 2 weeks) was offered to98% of SPs in the major depression

role making a general request, 90% ofthose making a brand-specific request,and 56% of those making no request

Be careful what you ask for


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Medicalization of Ordinary Unhappiness

Lecture by Prof. Arthur Kleiman

http://www.uwpsychiatry.org/Webcast_Archive.html

5,173 Adults aged 40-45, cohort,
http://www.uwpsychiatry.org/Webcast_Archive.htmlhttp://www.uwpsychiatry.org/Webcast_Archive.html


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Results: Invidious ComparisonsAdjusting for allindividual &ecologicalcovariates

Comparisons: Ln

County Medianincome, relative toCost of Living

Other measurestried, with similarresults

All Low

Inc

Hi Inc

Cnty Median

Income

NS NS 11.5

N 2410 1022 1322

Rich are highly sensitive

to comparisons, while the

poor are not

p-value for rich: 0.001

p-value for poor: 0.31

5,173 Adults aged 40 45, cohort,

CDC depression scale


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Rose 2004


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Rose 2004

P hi i D f hild


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Psychiatric Drugs for children

US 2,500,000 children on antipsychotic drugs(1992-2005 in UK 3000 children given these drugs)

atypical neuroleptics second-generation antipsychotics

olanzapine (Zyprexa),

clozapine (Clozaril),risperidone (Risperdal)

quetiapine (Seroquel)

Antidepressants

ADHD drugs


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Olfson 2006


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Psychiatric Diagnoses in Children


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Psychopharmacracy in Children


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Childhood

and earlyinfluences

EducationIncome,

wealth

Occupational

status

Social Position

Biological

and other unidentified factors

Common

mental disorders

(neurotic conditions)Physical illness

Stressful life events

Lack of supportive

social networks

Work circumstances

Other known factors

Melzer 2004


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Hserv482 07 Mental Health

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