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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 US

How would you know? Why?

Violence? Substance use?

nicotine alcohol illegal drugs

Depression? Insanity?

Mental Illness in the US

How would you know?
College students at campus counseling centers?
24.5% (2003-4), 17% (2000) 9% (1994)


Violence? Substance use?

nicotine alcohol illegal drugs

Depression? Insanity?

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 modes Agonic(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 selfprotective needs -can explore and integrate many new domains

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

Health Olympics Age 80

Gilligan, Violence


Manton NEJM 1995

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.

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 (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 modes Hedonic (cooperate)

Mental ill-health Olympics

12 mo nth p re val en ce of DSM di so rd ers Americas An xi ety Co lomb ia 10 Mexico 6.8 United States 18 .2 Europe Be lgi um 6.9 Fran ce 12 German y 6.2 Ita ly 5.8 Ne the rl an ds 8.8 Sp ain 5.9 Ukra in e 7.1 Middle Eas t and Africa Le ban on 11 .2 Ni geri a 3.3 As ia Ja pan 5.3 Pe opl es Re publ i c of Chi na Be ij in g 3.2 Sh angh ai 2.4

Moo d 6.8 4.8 9.6 6.2 8.5 3.6 3.8 6.9 4.9 9.1 6.6 0.8 3.1 2.5 1.7

Impul se -Control 3.9 1.3 6.8 1 1.4 0.3 0.3 1.3 0.5 3.2 1.7 0 1 2.6 0.7

Su bstan ce 2.8 2.5 3.8 1.2 0.7 1.1 0.1 3 0.3 6.4 1.3 0.8 1.7 2.6 0.5

An y 17 .8 12 .2 26 .4 12 18 .4 9.1 8.2 14 .9 9.2 20 .5 16 .9 4.7 8.8 9.1 4.3

Se ri ous 5.2 3.7 7.7 2.4 2.7 1.2 1 2.3 1 4.8 4.6 0.4 1.5 0.9 1.1

JAMA June 4, 2004.

Zahran MMWR 2004

Zack Public Health Reports 2004

Mental Illness


More MENTAL Illness

Wilkinson et. al. SSM 2007

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 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)

Triune Brain
Paleocortex behavioral differences from reptiles: - nursing and maternal care - audio-vocal communication for maintaining motheroffspring 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 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)

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?

Brain: Social Organ

Same eyes Strangers Synchrony Rhythm

Different eyes

Too many or no eyes Frightened or frightening

Comfortable Uncomfortable Pair bonding Ambivalent with primary Or avoidant caregiver Anxious, less adapted Behavioral & other problems

Coping with Secure base Stress Later health better

unpredictable 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 lowerquality 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 Unhappiness Lecture by Prof. Arthur Kleiman

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

Results: Invidious Comparisons

Adjusting for all individual & ecological covariates Comparisons: Ln County Median income, relative to Cost of Living Other measures tried, with similar results


Cnty Median NS Income 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

Low Hi Inc Inc NS 11.5

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

Social Position
Childhood and early influences Occupational status


Income, wealth
Common mental disorders (neurotic conditions)

Physical illness Stressful life events Lack of supportive social networks Work circumstances Other known factors

Biological and other unidentified factors

Melzer 2004