Mental illness: A Population Health Perspective

1. Mental illness: A Population Health Perspective 482 Session 8 First dissemination exercise DUE IN ONE WEEK

4. Summary of ideas to here?

5. Mental Illness in the US • Problem? • How would you know? • Why? • Violence? • Substance use? • nicotine • alcohol • illegal drugs • Depression? • Insanity?

6. Mental Illness in the US • Problem? • 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?

7. 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

8. Age distribution and overall rates of homicide: England and Wales compared with Chicago.(age and sex of perpetrator) Source: Cronin H.

9. Age distribution and overall rates of homicide: England and Wales compared with Chicago.(age and sex of perpetrator) Source: Cronin H.

10. 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

11. 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

12. Agonic Culture stress

14. Health Olympics Age 80 Whites Gilligan, Violence Manton NEJM 1995

15. Agonic Culture

16. Agonic Culture http://www.prisonexp.org/

17. Drug ways of dealing with agonic modes

19. Nature Neuroscience Feb 2002

20. 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.

21. 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 individuals Have time for integration of reality, inter-personal relations and 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

22. Mental ill-health Olympics

24. JAMA June 4, 2004.

25. Zahran MMWR 2004

26. Zack Public Health Reports 2004

27. More MENTAL Illness MORE EQUALITY Mental Illness Wilkinson et. al. SSM 2007

29. Muntaner Epi Reviews 2004

31. How our brains evolved

33. Triune Brain: MacLean 1973

34. 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

35. Triune Brain: MacLean 1973

36. Triune Brain • Paleo-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)

37. Triune Brain • Paleocortex 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) • Playhedonic • - 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

38. Triune Brain • Neocortex (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)

40. Brain: Social Organ • Adult 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?

43. AttachmentSecure Anxious Disorganized

44. 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.

45. How we deal with mental modes in our pharmacracy

46. Rose 2004 pharmacracy

49. Rose 2004

50. 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…