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Mental illness:

A Population Health Perspective

482 Session 8

First dissemination exercise

Summary of ideas to here?
Mental Illness in the US
How would you know?
Substance use?
illegal drugs
Mental Illness in the US
How would you know?
College students at campus counseling centers?
24.5% (2003-4), 17% (2000) 9% (1994)
Substance use?
illegal drugs
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
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 Form network of personal
self-security relationships that offer mutual
Concerned with support
-what others think of us in a Can give free rein to
group -intelligence,
-rank hierarchy -creativity
-convention -systems of social relations
-self-protection Attention released from self-
Respond to potential threats protective needs
to self, status, social -can explore and integrate
presentation 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.
Mental modes
Hedonic (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
Mental ill-health Olympics
12 mon th p revalen ce of DSM di sorde rs
Ame ricas An xi ety Mood Im puls e-Contro l Sub stan ce An y Seri ous
Colo mbia 10 6.8 3.9 2.8 17 .8 5.2
Mexico 6.8 4.8 1.3 2.5 12 .2 3.7
United Sta tes 18 .2 9.6 6.8 3.8 26 .4 7.7
Bel gium 6.9 6.2 1 1.2 12 2.4
Fra nce 12 8.5 1.4 0.7 18 .4 2.7
Germa ny 6.2 3.6 0.3 1.1 9.1 1.2
Italy 5.8 3.8 0.3 0.1 8.2 1
Neth erlan ds 8.8 6.9 1.3 3 14 .9 2.3
Spa in 5.9 4.9 0.5 0.3 9.2 1
Ukra ine 7.1 9.1 3.2 6.4 20 .5 4.8
Middle Ea st and Africa
Le bano n 11 .2 6.6 1.7 1.3 16 .9 4.6
Nige ria 3.3 0.8 0 0.8 4.7 0.4
Japan 5.3 3.1 1 1.7 8.8 1.5
Peo ple s Repu blic of China
Bei jing 3.2 2.5 2.6 2.6 9.1 0.9
Sha ngha i 2.4 1.7 0.7 0.5 4.3 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)
- 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 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
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
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?
Secure Anxious Disorganized
Same eyes Different eyes Too many or
no eyes
Strangers Comfortable Uncomfortable Frightened or
Synchrony Pair bonding Ambivalent
Rhythm with primary Or avoidant
Coping with Secure base Anxious, unpredictable
Stress less adapted
Later health better Behavioral & Mental &
other problems 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 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.
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 &
All Low Hi Inc
ecological Inc
Comparisons: Ln Cnty Median NS NS 11.5
County Median Income
income, relative to
Cost of Living N 2410 1022 1322
Other measures
tried, with similar Rich are highly sensitive
results to comparisons, while the
poor are not
p-value for rich: 0.001
p-value for poor: 0.31
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)


ADHD drugs
Olfson 2006
Psychiatric Diagnoses in Children
Psychopharmacracy in Children
Social Position
and early
mental disorders
Physical illness (neurotic conditions)

Stressful life events

Lack of supportive
social networks

Work circumstances

Other known factors

and other unidentified factors Melzer 2004