Hserv 534

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Hserv 534 7A Population Health Perspective on
mental illness
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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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JAMA June 4, 2004.
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Zahran MMWR 2004
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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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Zack Public Health Reports 2004
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Muntaner Epi Reviews 2004
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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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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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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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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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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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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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Today's responses
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Rose 2004
pharmacracy
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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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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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SUICIDE
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Suicides per 100,000 Crude Rate by Race 1981-1998
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Suicide (1.6 of all deaths 1990)

• Durkheim 1899 study egoistic, altruistic, anomic
• Determinants very country, time and culture
  specific
• China women predominate, rural 3x urban
• Kerala highest rates in India, Bihar lowest
• Sri Lanka high rates
• US rate lowest for African American women
• Geronocentric societies (Japan, HK, Singapore)
• Where qualify of life good, suicide high, where
  poor homicide high (inversely related to income
  distribution?)
• Religious sanctions (Japan ritualized, sati
  India)
• Means -Hindu, Buddhist self-immolation,
• -tall buildings (HK, Singapore, GG Bridge)
• -agrarian socieites with pesticides (India)

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Suicide

• Increased suicides with conservative (right-wing)
  government rule (Australia and UK)
• Korea case-control study lower social class
  constitutes a high risk for suicide in Korea,
  even after controlling for variables such as age,
  marital status and area of residence.
• Australia SES remained significantly associated
  with suicide after controlling for the prevalence
  of mental disorders and other psychiatric
  symptomatology. Mental conditions and previous
  suicidal behavior may play an intermediary role
  between SES and suicide, but this study suggests
  that an independent relationship between suicide
  and SES also exists.
• Denmark urbanicity with more suicides
• Europelower ses more suicides buffering effect
  of marriage(Denmark, Norway)
• Sweden higher suicide rates in children of
  single-parents
• Scotland greater risk for remote rural males
  (accessible rural better for women)
• US Suicides increase with recessions
• US, Australia, England, Wales saw rises in rural
  suicides in last 2 decades
• Japan increase in lower SEP
• Correlation with homicide ve in Europe and
  negative in Asia Pacific

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Suicide

• Korea case-control study lower social class
  constitutes a high risk for suicide in Korea,
  even after controlling for variables such as age,
  marital status and area of residence.
• S. India suicides a quarter of all deaths in
  young men women
• China, Russia increased suicides everywhere

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Schizophrenia

• Higher rates
• developed countries
• urban areas
• Less recovery in developed countries with more
  treatment facilities
• Lower incidence, lower prevalence in rural poor
  countries

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Schizophrenia

• Social defeat theory
• -outsider, subordinate
• -increased risk for migrants and double the risk
  for next generation where outsider status even
  more humiliating
• -increased risk if come from poorer country of
  color
• -chronic exposure to social defeat may sensitize
  mesolimbic dopamine system (more psychosis)
• Substance use increased sensitivity to
  psychogenic effects of illicit drugs (develop
  psychoses after exposure to doses that would not
  produce in healthy individuals

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Schizophrenia

• Maternal factors
• early life stressors (womb with a view)
• prenatal infections and nutrition
• secure attachment (related to orbitofrontal
  deficiencies)

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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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Koob 1999 from Hennessy 1979
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DIAGNOSIS SLR DisorderICD 11 code googol

• Diagnostic Criteria
• Society becomes organized on agonic national
  modes fostering concern for self-security among
  its members
• Following societal concerns predominate
• -obeisance to rank hierarchy,
• (currently determined by income, consumption and
  wealth)
• -higher ranking individuals receive more
• -lower ranking individuals feel this is their
  due
• -those lower down willingly accept less,
• direct their attention and generosity to those
  above them
• -answer responds to potential threat to self by
  violence

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Treatment SLR Disorder

• EXACT OPPOSITE of today's political policies
• -cutting taxes on the rich
• -cutting taxes on corporations
• -cuts in social spending
• -cuts in foreign aid
• -privatization of profitable concerns
• bandwidth, energy companies
• health care ("ask your doctor about")
• -instilling fear in the populace
• -fostering belief in American Dream
• -promoting consumption instead of advocating
  citizenry (post 911)

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TREATING SLR DISORDER
GENES
POPULATIONHEALTHFORUM Listserve info
Benjamins Law
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