GH 514

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GH 514 13A Population Health Perspective on
mental illness
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Reticence not to give richEVERYTHING!!!!!
Paper or plastic? If we can get them asking the
wrong question, the answers don't matter.
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http//ucatlas.ucsc.edu/
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ACLS Professional Provider Manual Epinephrine
"Although epinephrine has been used for years in
resuscitation, there is little data to show that
it improves outcomes in humans" pg 49
Highest Life Expectancy And disability free years
Lowest Life Expectancy And disability free years
Life expectancy disparity is 16 years
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TREATING SLR DISORDER
GENES
POPULATIONHEALTHFORUM Listserve info
Benjamins Law
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Healthy Life Expectancy at Age 60, 2002
LONG, HEALTHY PRODUCTIVE LIVES
Developed by the World Health Organization,
healthy life expectancy is based on life
expectancy adjusted for time spent in poor health
due to disease and/or injury
Years
Data The World Health Report 2003 (WHO 2003,
Annex Table 4).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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"more egalitarian societies (i.e., those with a
less steep differential between the richest and
the poorest) have better average health" pg. 59
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Individualism?

• Who doesn't abide by this credo?

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PAPER DUE
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YOUR THOUGHTS

• Big picture ideas on mental health
• What causes mental illness?
• Why?
• How is the US doing in the mental health olympics?

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Agenda

• Available studies show the US to have the most
  mental illness, of any country, and trends show
  increases over the last decades.
• Studies found significant relationships between
  inequality in a society and various health
  outcomes, including self-assessed health,
  mortality measures, teenage birth rates and
  rates of violent crime.
• Relative poverty within populations may be a
  critical risk factor for mental health but poorer
  countries fare better than richer ones
• The escalating rates of mental illness observed
  may represent an adaptive response to the
  increasing hierarchy in this country.

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Mental ill-health Olympics
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JAMA June 4, 2004.
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Zahran MMWR 2004
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Zack Public Health Reports 2004
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Muntaner Epi Reviews 2004
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Mental Illness
Wilkinson et. al. SSM 2007
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James, Affluenza 2007
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Patel 2007
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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

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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

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Agonic Culture
stress
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Health Olympics Age 80
Whites
Gilligan, Violence
Manton NEJM 1995
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NYT Feb 11, 2001
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Agonic Culture
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Agonic Culture
http//www.prisonexp.org/
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Drug ways of dealing with agonic modes
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Nature Neuroscience Feb 2002
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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 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.
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HOMICIDE Olympics
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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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Seattle, 75th and Aurora, Sept.30, 2006
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VIOLENCE AND INEQUALITY Daly 2001
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VIOLENCE AND INEQUALITY Daly 2001
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Mortality Ratios
Kruger, D. J. and R. M. Nesse (2004). Sexual
selection and the MaleFemale Mortality Ratio.
Evolutionary Psychology. 2(66-85).
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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 (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

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Human Pre-history Evolutionary Neuro-psychiatry
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Triune Brain MacLean 1973
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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

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AGONIC dominate MENTAL MODE (R complex)
Drawing Gini Curl
Source RH Frank. Choosing the right pond. 1986.
O.U.P.
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National Geographic June 2004
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Triune Brain MacLean 1973
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Triune Brain

• Paleo-mammalian brain (paleocortex) subcortical
  structures
• -limbic system
• -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)

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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)
• 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

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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)

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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?

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Today's responses in the USA Therapeutic
community (1970s) Biological psychiatry My
experience 1993
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Rose 2004
pharmacracy
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How does the Socio-Economic-Political environment
get under the skin?Mid Life

• Sympatho-adrenal-medullary (SAM) response to
  threatening/challenging circumstances,
  transformed in low SEPS circumstances to "learned
  helplessness"
• cannot solve problems of daily living and convert
  physiological responses to learned helplessness,
  ie switch SAM response to HPA defeat reaction
  with increased cortisol secretion (Lundberg
  hypothesis)
• EVOLUTIONARY BASIS FOR DEPRESSION

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Rose 2004
US doctors 5x more like to Rx antidepressants to
children
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Rose 2004
Medicalization of Ordinary Unhappiness Lecture by
Prof. Arthur Kleiman Available as audio file on
CD on reserve for Hserv 534
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Medicalization of Ordinary Unhappiness Lecture by
Prof. Arthur Kleiman http//www.uwpsychiatry.org/W
ebcast_Archive.html
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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
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Rose 2004
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Rose 2004
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Rose 2004
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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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Brave New World, Aldous Huxley, Soma the drug
given to everyone so that they were numbed to
society's condition, numbed to its social
problems. Huxley described a society with
immense social problems where soma blunted the
pain that people might feel about the situation.
The people were happy and they got what they
wanted and never wanted what they could not get.
Soma had "All the advantages of Christianity
and alcohol none of their defects."
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Attachment Secure Anxious
Disorganized
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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.

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Social Position
Occupational status
Income, wealth
Common mental disorders (neurotic conditions)
Education
Biological and other unidentified factors
Melzer 2004
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Competition outcomesthrough dominance /
attraction
Dominance upperness
HEDONIC cooperate
AGONIC dominate
POWER
Social Integration approach closeness friendlines
s ingroup orientation (insider) love
Social Isolation withdrawal distance hostility ou
tgroup orientation (outsider) hate
AFFILIATION
Submission lowerness
Stevens 1996
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Competition outcomesthrough dominance /
attraction
Dominance upperness
Lack of control
HEDONIC cooperate
AGONIC dominate
POWER
Social Integration approach closeness friendlines
s ingroup orientation (insider) love
Social Isolation withdrawal distance hostility ou
tgroup orientation (outsider) hate
AFFILIATION
Control
Submission lowerness
Stevens 1996
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Competition outcomesthrough dominance /
attraction
Dominance upperness
fight
Lack of control
HEDONIC cooperate
AGONIC dominate
POWER
flight
Social Integration approach closeness friendlines
s ingroup orientation (insider) love
attractiveness
Social Isolation withdrawal distance hostility ou
tgroup orientation (outsider) hate
AFFILIATION
co-operation
withdrawal
Control
yielding
Submission lowerness
Stevens 1996
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Societal Loss of Reciprocation Disorder
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Classification of major disorders
Spacing Disorders (outsider status)
Borderline Status
Disorders of attachment and rank (insider status)
Dominance
HEDONIC
Social integration
Social Isolation
AGONIC
Competition
Submission
Stevens 1996
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Attention-deficit/hyperactivity disorder
dimensions and environtypes. Personal
characteristics in quotes environmental
dimensions in parentheses.
Jensen et. al. 1997