Surgeon General’s Report

Chapter 2: The Fundamentals of Mental Health and Mental Illness

Part 2

Tiffany Wood

Pharmacological Therapies

Rational drug designDesigning drugs by manipulating their chemical structuresGoal: To create more effective therapeutic agents with fewer side effects

Before 1960, discoveries were accidentalKnowledge of actions can help:

Discover the etiologyDevelop more specific drugs

Mechanisms of ActionHow a pharmacotherapy interacts with its target in the body to produce therapeutic effectsBroad categories

Stimulants, Antidepressants

Chemical classesWithin categories; SSRI, Lithium

AgonistMimics the action

AntagonistInhibits or blocks the action

Neurotransmitters: A Brief Overview

Concentrated in separate brain regions and circuits

Each has its own pathway for synthesis, degradation, and reuptake

Each has its own array of receptors

Can excite or inhibit the postsynaptic cell

Neurotransmission1.....Postsynaptic Neuron2.....Presynaptic Neuron3.....Vesicle with

Neurotransmitters4.....Mitochondrion (for

energy production from glucose)

5.....Synaptic Cleft6.....Neurotransmitter

Molecules7.....Postsynaptic Membrane

(with NT receptors)

It’s All Natural, Baby!

Natural products claim to help some mental disordersPreparations not standard, so active ingredient is not known“Food Supplements”-do not have to be approved by the FDAMay be hazardous when taken with prescriptionsNo conclusions-need more studiesSt. John’s wort

Issues of Treatment

Placebo response

Benefits and risks

Gap between efficacy and effectiveness

Barriers to seeking help

Placebo Response

Patients’ attitudes and perceptions influence their health status

HippocratesHad physicians lay their hands on patients in a reassuring manner to help fight disease

Not an active treatment

Found in up to 50% of patients in studies

Placebo group is mandated by the FDA

Ineffectual treatment

Basis is unknown

Benefits and Risks

Most studies only used individuals with one mental disorder and in good physical health

Children, adolescents, elderly excluded

Must consider all possibilities with doctorWeigh pros and cons of each treatment choice

Benefits-to-risk ratio

Gap Between Efficacy and Effectiveness

Treatments work better in a clinical trial setting than in a clinical practice setting

Efficacy-effectiveness gapEfficacy is what works in the trial settingEffectiveness is what typically works

Magnitude of the gap can be very highProblem is that efficacy studies are done under ideal circumstances with white males

Barriers to Seeking Help

Most people do not seek treatmentPatient attitudes toward the service systemNot having the timeFear of hospitalizationThinking no one can help or they can handle it aloneStigma (embarrassment)Cost

Sectors of the De Facto System

The U.S. has a de facto (fragmented) mental health system with four sectors

Specialty mental health

General medical/primary care

Human services

Voluntary support network

Financing of the System

PublicServices directly operated by the government

Services financed with government resources

PrivateServices directly operated by private agencies

Services financed with private resources

Duration and Settings

Acute conditionsBrief treatment

Long-term careResidential careCustodial

InstitutionalCommunity-basedHome-based

Where Do They Get This From?15% U.S. adult population use mental health services each year8% have a diagnosable mental or addictive disorder7% have a mental health problem28% of the adult population have a diagnosable problem

So… Not everyone seeks treatment

21% of children and adolescents use services

History

Coincide with the colonial settlement of the United States

Mid-18th century first asylum built

Reform Movements

Reform Movement

Era Setting Focus of Reform

Moral Treatment 1800-1850 Asylum Humane, restorative treatment

Mental Hygiene 1890-1920 Mental hospital or clinic

Prevention, scientific orientation

Community Mental Health

1955-1970 Community mental health center

Deinstitutionali-zation, social integration

Community support

1975-present Community support

Mental illness as a social welfare problem

Cultural Diversity

U.S. mental health system is not well equipped for racial and ethnic minoritiesFeel fear or ill at easeFour major race or ethnic minority groups

African American (12.8%)Asian/Pacific Islander (11.4%)Hispanic American (4.0%)Native American (0.9%)

Let’s Get Cultured!

CultureDenotes a common heritage and set of beliefs, norms, and values

Cultural identityA reference groupAn identifiable social entity with whom a person identifies with and looks to for a standard of behaviorMay involve: Gender, age, class, religion, sexual orientation

Coping StylesAsian Americans encourage avoidance of troubling internal eventsAfrican Americans and others seek guidance from religious figuresIdioms of distress

Reflect values and themes found in societiesCharacteristic modes of expressing sufferingA common one: African Americans use of somatization

• Expression of mental distress by physical suffering

Family TiesProvide support to individuals with mental health problemsAssociation between family warmth and reduced likelihood of relapseEspecially important to minorities

Prevalence

African AmericansHigher than whites

Due to socioeconomic differences

More likely to use the ER for mental health problems due to lack of healthcare providers in the community

Overdiagnosis of schizophrenia, under of depression

Asian Americans/Pacific IslandersDifficult to determine

Not likely to seek care

We Will Prevail…

Hispanic AmericansFew differences with whites

Native AmericansMore depression, affective disorder, alcohol abuse and dependence, post traumatic stress disorder

Higher suicide rate

Barriers to Treatment

Language

Mistrust

Stigma (embarrassment)

Cost

Clinician biasDiagnosis relies on behavioral signs, not lab tests

Mistrust

African Americans due to segregation, racism, discrimination, forced control

Immigrant families fear deportation of undocumented relatives

Refugees and government mistrust

American Indians on reservations

Improving Treatment for Minorities

Ethnopsychopharmacology

Minority-oriented services

Cultural competence

Ethnopsychopharmacology and Minority-Oriented Services

Ethnic and cultural influences can alter an individual’s responses to medications

Rate of absorption/metabolism of drugs varies

Minority mental care providers

Specialized minority oriented/culturally appropriate programs

Are You Culturally Competent?

DefinedA set of behaviors, attitudes, and policies that come together to enable professionals to work effectively in cross-cultural situations

Need to recognize and respond to cultural concerns

History, traditions, beliefs, value systems

Begins with respect

Are You Still Competent?

If the practitioner can understand the problem as it is experienced by the patient, a sense of trust and credibility begins to form

To be culturally competent is to deliver treatment that is equally effective to all sociocultural groups

I’m Good Enough, Smart Enough, and Doggone It, People Like Me

Self help refers to groups led by peers to promote mutual support, education, and growthHelps with copingAA began in 1935Groups for everythingThree models

Separatist, supportive, partnership

Accomplishments of Consumer Organizations

Consumer is someone who “survived” mental health treatmentsOrganized self help groupsProtection of individual rightsResearch

Participants RespondentsPartnersIndependent researchers

Family Advocacy

Represented by three organizationsNational Alliance for the Mentally Ill (NAMI)

Federation of Families for Children’s Mental Health (FFCMH)

National Mental Health Association (NMHA)

Deinstitutionalization left families to care for their mentally ill

Recovery

Some severe mental disorders were thought to have lifelong deterioration

Recovery is a concept and a process

Hope and restoration of a meaningful life are possible

Not a cure

Not the same as psychosocial rehab

Brace for Impact!

Optimistic attitudes and expectations may help improve the course of illness

Process of recovery is governed by internal factors and external factors interacting

Aides to recovery: medication, community support/case management, self-will/self monitoring, vocational activity, spirituality

Empowerment Scale

Self-efficacy—self esteem

Power—powerlessness

Community activism

Righteous anger

Optimism—control over the future

Let’s Wrap This Up!

Trends over the past 25 years

MRIs can help develop medications

Ultimate goal