Hserv482 07 Mental Health
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Transcript of 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,
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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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