Mental illness: A Population Health Perspective

482 Session 8

First dissemination exercise

DUE IN ONE WEEK

Summary of ideas to here?

Mental Illness in the USProblem?

– How would you know? – Why?

Violence?Substance use?

– nicotine– alcohol– illegal drugs

Depression?Insanity?

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?

Agenda

Violent behaviors, stress and inequality

Mental modes

High rates of significant mental illness in the US and responses, social aspects

Rank differences and substance use

Triune brain evolution

Depression

Age distribution and overall rates of homicide: England and Wales compared with Chicago.

(age and sex of perpetrator)

Source: Cronin H.

Age distribution and overall rates of homicide: England and Wales compared with Chicago.

(age and sex of perpetrator)

Source: Cronin H.

Mental modesAgonic(dominate)Hedonic

(cooperate)Primarily concerned with self-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 personal relationships 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

Mental modesAgonic(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

vertical

DOMINANCE

POWER

COERCION

Health Olympics Age 80

Manton NEJM 1995

Whites

Gil

liga

n, V

iole

nce

http://www.prisonexp.org/

Drug ways of dealing with agonic modes

Nature Neuroscience Feb 2002

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 have impairments 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.

Mental modesHedonic (cooperate)

Appeasement transformed to reassuring,conciliatory gestures between mutually dependent individuals In moments of excitement, arousal level of individual is low (hedonic condition - chimpanzees, bonobos)Absence of fear of punishment characterizes relationship between individualsHave time for integration of reality, inter-personal relations and private feelings and thoughts,

leads to systems-forming faculty (distinctly human, 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

Mental ill-health Olympics

12 month prevalence of DSM disordersAmericas Anxiety Mood Impulse-Control Substance Any Serious

Colombia 10 6.8 3.9 2.8 17.8 5.2Mexico 6.8 4.8 1.3 2.5 12.2 3.7

United States 18.2 9.6 6.8 3.8 26.4 7.7Europe

Belgium 6.9 6.2 1 1.2 12 2.4France 12 8.5 1.4 0.7 18.4 2.7

Germany 6.2 3.6 0.3 1.1 9.1 1.2Italy 5.8 3.8 0.3 0.1 8.2 1

Netherlands 8.8 6.9 1.3 3 14.9 2.3Spain 5.9 4.9 0.5 0.3 9.2 1

Ukraine 7.1 9.1 3.2 6.4 20.5 4.8Middle East and Africa

Lebanon 11.2 6.6 1.7 1.3 16.9 4.6Nigeria 3.3 0.8 0 0.8 4.7 0.4

AsiaJapan 5.3 3.1 1 1.7 8.8 1.5

People’s Republic of ChinaBeijing 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.

Zah

ran

MM

WR

200

4

Zack Public Health Reports 2004

Wilkinson et. al. SSM 2007

MORE EQUALITY

Mental Illness

Mor

e M

EN

TA

L I

lln

ess

Muntaner Epi Reviews 2004

How our brains evolved

Triune Brain: MacLean 1973

Triune Brain

Reptilian brain (R-complex) - evolved in reptilian ancestors 300 million years ago, 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, agonistic threat displays, mating

Triune Brain: MacLean 1973

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 wakefulness

Emotions addressed:- fear, anger- love, attachment, bonding, mating, caring (oxytocin)

Triune BrainPaleocortex behavioral 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 harmony and affiliation

- conscious awareness present,

- behavior less rigidly determined by instincts

Complex organ controlling basic psychophysical responses and attitudes to environment

Triune BrainNeocortex (neo-mammalian)

- cognition and

sophisticated 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)

Brain: Social OrganAdult 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?

Attachment Secure Anxious Disorganized

Same eyes Different eyes Too many or

no eyes

Strangers Comfortable Uncomfortable Frightened or frightening

Synchrony

Rhythm

Pair bonding with primary caregiver

Ambivalent

Or avoidant

Coping with

Stress

Secure base Anxious,

less adapted

unpredictable

Later health better Behavioral & other problems

Mental & other illness

Hispanic Mental Health in US Hispanics 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 linguistic barriers, and

-are more likely not to have mental disorders detected

-seem less likely to suffer from depression and anxiety but tend to have more persistent mental illnesses

-are more likely to somatize distress and to report psychotic symptoms in the absence of 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 socioeconomic and linguistic or educational factors

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

How we deal with mental modes in our pharmacracy

Rose 2004

Rose 2004

In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests

In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively

Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request

Be careful what you ask for…

Medicalization of Ordinary UnhappinessLecture by Prof. Arthur Kleiman

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

Results: Invidious ComparisonsResults: Invidious ComparisonsAdjusting for all Adjusting for all individual & individual & ecological ecological covariates covariates Comparisons: Ln Comparisons: Ln County Median County Median income, relative to income, relative to Cost of LivingCost of LivingOther measures Other measures tried, with similar tried, with similar resultsresults

AllAll Low Low IncInc

Hi IncHi Inc

Cnty Median Cnty Median IncomeIncome

NSNS NSNS 11.511.5

NN 24102410 10221022 13221322

Rich are highly sensitive Rich are highly sensitive to comparisons, while the to comparisons, while the poor are notpoor are not

p-value for rich: 0.001p-value for rich: 0.001

p-value for poor: 0.31p-value for poor: 0.31

5,173 Adults aged 40-45, cohort, 5,173 Adults aged 40-45, cohort, CDC depression scaleCDC depression scale

Rose 2004

Rose 2004

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

Olfson 2006

Psychiatric Diagnoses in Children

Psychopharmacracy in Children

Childhood and early influences

EducationIncome, wealth

Occupationalstatus

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