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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. Problem? How would you know? Why? Violence? Substance use? nicotine alcohol illegal drugs Depression? Insanity?.

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mental illness a population health perspective

Mental illness: A Population Health Perspective

482 Session 8

First dissemination exercise


mental illness in the us
Mental Illness in the US
  • Problem?
    • How would you know?
    • Why?
  • Violence?
  • Substance use?
    • nicotine
    • alcohol
    • illegal drugs
  • Depression?
  • Insanity?
mental illness in the us1
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?
  • 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
Mental modesAgonic(dominate)Hedonic (cooperate)

Primarily concerned with self-security

Concerned with

-what others think of us in a group

-rank hierarchy



Respond to potential threats to self, status, social presentation

Form network of personal relationships that offer mutual support

Can give free rein to



-systems of social relations

Attention released from self-protective needs

-can explore and integrate many new domains

mental modes agonic dominate hedonic cooperate1
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


Health Olympics Age 80


Gilligan, Violence

Manton NEJM 1995


Agonic Culture


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.

mental modes hedonic cooperate
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


More MENTAL Illness


Mental Illness

Wilkinson et. al. SSM 2007


Triune Brain:

MacLean 1973

triune brain
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 brain1
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 brain2
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
triune brain3
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)
brain social organ
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?
hispanic mental health in us
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.

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

results invidious comparisons

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
  • Rich are highly sensitive to comparisons, while the poor are not
  • p-value for rich: 0.001
  • p-value for poor: 0.31
psychiatric drugs for children
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

Childhood and early influences

Physical illness

Stressful life events

Lack of supportive

social networks

Work circumstances

Other known factors

Social Position






mental disorders

(neurotic conditions)



and other unidentified factors

Melzer 2004