Transcript MAPP_SDHO_04_29_11 - Maine Association of Psychiatric

Social Determinants
of
Mental and Physical Health
MAPP Annual Meeting
April 29, 2011
Edward Pontius, MD, DFAPA
Medical Director / ACCESS Team
Portland, Maine
Maine Medical Center Dept of Psychiatry Grand Rounds, 12/07/10
Maine Medical Association Public Affairs Committee, 02/09/11
University of New England Department of Social Work, 02/16/11
Maine Housing, 03/04/11
(followup) Maine Medical Center Dept of Psychiatry Grand Rounds, 03/22/11
Brunswick Housing Authority, 04/08/11
Social Determinants
of Mental Health Outcome
• INTRODUCTION
• What can explain increasing prevalence and
severity of mental and physical illness?
• How can we understand the connection
between social factors and health?
• What difference does it make?
• Next Steps- what we can do to address
SDOH-related suffering, disability, mortality
and social cost
• Conclusion
Income Inequality Across the World
It’s About Fairness…
US Income Inequality:
Gini Coefficient by State in 2007
When Did Awareness of
Fairness Develop?
• Social primates developed acute awareness of relative
social advantage in competitive and cooperative
circumstances- likely 30 million years ago.
• Failure to develop and maintain strong social support is
a dangerous condition.
• Food source insecurity, predation, and aggression from
within and outside the social group are issues
• Social primates can implement an emergency
phenotypic adaptation in response to uncertain social
support
Nature 425, 297-299 (18 September 2003)
Monkeys reject unequal pay
Sarah F. Brosnan1 & Frans B. M. de Waal1
Living Links, Yerkes National Primate Research Center,
Emory University, Atlanta, Georgia 30329, USA
Deliberate cut marks on a 9,000-year-old human bone excavated in a west country cave
more than a century ago suggest that prehistoric Devonians may have been cannibals.
Scientists at Oxford University have examined a fragment of human bone from Kents
Cavern, near Torquay in Devon, after a curator spotted it in a mass of animal bone in a
museum store. They concluded that it was part of the forearm of a human adult, and that
the seven cut marks were deliberately made with a stone tool around the time of death.
Anxiety in US College Students
Male, Female
1952-1993
(Whitaker, Anatomy of an Epidemic, 2010)
Life is uncertain…
Eat dessert first!
It’s about safety…
Adverse Childhood Experiences Study
Robert Anda, MD
CDC
Vincent Filetti, MD
Department of Preventative Medicine
Kaiser Permante Medical Center, San Diego
V
The 10 Categories of
Adverse Childhood Experience
• Childhood abuse before age 18
o Emotional Abuse
o Physical Abuse
o Sexual Abuse
• Neglect
o Emotional
o Physical
• Growing up in a seriously dysfunctional household as
evidenced by:
-Witnessing domestic violence
-Alcohol or other substance abuse in the home
- Mentally ill or suicidal household members
- Parental marital discord (as evidenced by separation or
divorce)
- Crime in the home (as evidenced by having a household
member imprisoned)
Central Dogma of Molecular Biology:
DNA => RNA => Protein
BROKEN GENES => BROKEN BRAINS
Frances Crick
Central Dogma of Molecular Biology:
DNA => RNA => Protein
BROKEN GENES => BROKEN BRAINS
Few genes found that explain major mental illness
Frances Crick
Central Dogma of Molecular Biology:
DNA => RNA => Protein
BROKEN GENES => BROKEN BRAINS
Few genes found that explain major mental illness
Difficult to explain persistence of illness
given low reproductive fitness associated with some highlyheritable illness (Uher, 2010)
Frances Crick
Why Heritability Must Be Non-Genetic
Central Dogma of Molecular Biology:
DNA => RNA => Protein
BROKEN GENES => BROKEN BRAINS
Few genes found that explain major mental illness
Difficult to explain persistence of illness
given low reproductive fitness associated with some highlyheritable illness (Uher, 2010)
New non-genetic mechanisms found that could explain
persistent and heritable illnesses with current low
reproductive fitness- Epigenetic mechanisms
Frances Crick
Epigenetic MechanismsModulating Gene Expression
Hongerwinter
Dutch Hunger Winter 1944-1945
A food blockade lead to famine that caused 18,000 deaths
Six decades later children exposed to the famine during the first 10 weeks
after conception had less DNA methylation of the imprinted IGF2 gene than
their unexposed same-sex siblings
Hongerwinter
Dutch Hunger Winter 1944-1945
A food blockade lead to famine that caused 18,000 deaths
Six decades later children exposed to the famine during the first 10 weeks
after conception had less DNA methylation of the imprinted IGF2 gene than
their unexposed same-sex siblings
Audrey Hepburn
Youths and adults also suffered life-long impact. At 14 years old, Audrey Hepburn suffered the Hongerwinter...
Hongerwinter
Dutch Hunger Winter 1944-1945
A food blockade lead to famine that caused 18,000 deaths
Six decades later children exposed to the famine during the first 10 weeks
after conception had less DNA methylation of the imprinted IGF2 gene than
their unexposed same-sex siblings
Audrey Hepburn
Youths and adults also suffered life-long impact. At 14 years old, Audrey Hepburn suffered the Hongerwinter...
Which may explain her life-long devotion to humanitarian causes- particularly the suffering of children...
Hongerwinter
Dutch Hunger Winter 1944-1945
A food blockade lead to famine that caused 18,000 deaths
Six decades later children exposed to the famine during the first 10 weeks
after conception had less DNA methylation of the imprinted IGF2 gene than
their unexposed same-sex siblings
Audrey Hepburn
Youths and adults also suffered life-long impact. At 14 years old, Audrey Hepburn suffered the Hongerwinter...
Which may explain her life-long devotion to humanitarian causes- particularly the suffering of children...
Many believe that the Hongerwinter caused her chronic illnesses, including depression and 3 pack/day smoking by
1960...
Hongerwinter
Dutch Hunger Winter 1944-1945
A food blockade lead to famine that caused 18,000 deaths
Six decades later children exposed to the famine during the first 10 weeks
after conception had less DNA methylation of the imprinted IGF2 gene than
their unexposed same-sex siblings
Audrey Hepburn
Youths and adults also suffered life-long impact. At 14 years old, Audrey Hepburn suffered the Hongerwinter...
Which may explain her life-long devotion to humanitarian causes- particularly the suffering of children...
Many believe that the Hongerwinter caused her chronic illnesses, including depression and 3 pack/day smoking by
1960...
Hongerwinter
Dutch Hunger Winter 1944-1945
A food blockade lead to famine that caused 18,000 deaths
Six decades later children exposed to the famine during the first 10 weeks
after conception had less DNA methylation of the imprinted IGF2 gene than
their unexposed same-sex siblings
Audrey Hepburn
Youths and adults also suffered life-long impact. At 14 years old, Audrey Hepburn suffered the Hongerwinter...
Which may explain her life-long devotion to humanitarian causes- particularly the suffering of children...
Many believe that the Hongerwinter caused her chronic illnesses, including depression and 3 pack/day smoking by
1960...contributing to her death by cancer at age 63...
Mechanisms for Adaptation to
Stressful, Unpredictable Environments
The hypothalamic–pituitary–adrenal axis has been the focus of extensive
research with regard to the phenotypic plasticity this system shows in
response to environmental influences on mammalian development. This
review proposes that the mesolimbic dopamine system is similarly reactive
to indicators of environmental adversity during development. Physical,
physiological, and toxicological stressors encountered during perinatal
development have been routinely demonstrated to affect dopamine
neurophysiology, most likely through consequent exposure to maternal
glucocorticoids or a reduction in oxygen supply. However, findings remain
inconsistent with regard to the nature of impact these events have on the
dopamine system. Both hyper- and hypo-dopaminergic changes have been
noted. This review argues that the directionality of change is a function of
chronicity and severity of the insult, and that both resultant phenotypes are
adaptive developmental responses, despite their potential for conferring
vulnerability for psychopathology in humans.
Mechanisms for Adaptation to
Stressful, Unpredictable Environments
Marshmallow Test
Click on screen for
Marshmallow Test Video
Exponential vs Hyperbolic Discounting…
MEDICAL HYPOTHESES
Volume 69, Issue 1, Pages 195-198 (2007)
Hyperbolic discounting may be reduced to electrical coupling in dopaminergic
neural circuits
Taiki Takahashi
Received 22 October 2006; accepted 24 October 2006. published online 02 January
2007.
Summary
Loss of self-control in drug addicts (e.g. cocaine and amphetamine dependent patients) has been associated with hyperbolic discounting of delayed
rewards (i.e., inconsistency in intertemporal choice). Neurobiophysical mechanisms underlying hyperbolic discounting are still unknown in spite of recent
extensive work in neuroeconomics. Understanding of neuronal mechanisms of hyperbolic discounting is important for establishing neuropharmacological
treatment of addiction. At the cognitive level, previous studies have indicated that psychophysics of time-estimation (i.e., Weber–Fechner law and
Steven’s power law of time-perception) may explain inconsistency in intertemporal choice. Regarding neuronal substrates of time-estimation, drugs of
abuse dramatically change time-estimation, indicating that dopaminergic activities may mediate time-estimation. With respect to neuronal changes
induced by drugs of abuse, recent studies have revealed that gap junction proteins (e.g., connexin 36) in dopamine neurons are increased by an selfadministration of dopaminergic drugs such as cocaine and amphetamine. However, it has been yet to be examined how the enhanced electrical coupling
due to substance administration induces addiction. Furthermore, a recent biophysical modelling study has demonstrated that the effect of the
psychophysical laws are potentiated by non-synaptic electrical coupling between neurons via gap junctions.
HYPERBOLIC vs. EXPONENTIAL Discounting…
In HYPERBOLIC DISCOUNTING, valuations fall very rapidly for small delay
periods, but then fall slowly for longer delay periods.
This contrasts with EXPONENTIAL DISCOUNTING, in which valuation falls
by a constant factor per unit delay, regardless of the total length of the delay.
The standard experiment used to reveal a test subject's hyperbolic
discounting curve is to compare short-term preferences with long-term
preferences. For instance: "Would you prefer a dollar today or three dollars
tomorrow?" or "Would you prefer a dollar in one year or three dollars in one
year and one day?" For certain range of offerings, a significant fraction of
subjects will take the lesser amount today, but will gladly wait one extra day
in a year in order to receive the higher amount instead. Individuals with such
preferences are described as "present-biased".
Individuals using hyperbolic discounting reveal a strong tendency to make
choices that are inconsistent over time—they make choices today that their
future self would prefer not to make, despite using the same reasoning. This
dynamic inconsistency happens because hyperbolic discounts value future
rewards much more than exponential discounting.
What Is the Value of the Future?
Hyperbolic vs. Exponential Discounting…
Homo Sapiens 1.0
•
•
•
•
Plan A – Altricial Investment
Long Term Stable Social
Environment
Investments in Long-Term
Goals Have Likely Payoff
Social Systems Support
Development Valuing LongTerm Goals
Future Generations Gain
Benefit of Complex Cultural
Meme Transmission
•
•
•
•
•
Plan B – Precocial Shift
Insecure Social Environment
Best Bet Is For Short-Term
Payoffs
Social Systems Support
Development Valuing
Immediate Goals
Future Generations Gain
Benefit of Continued Survival
Price of Vulnerability to StressRelated Chronic Illness
Adverse Childhood Experience
Social Determinants of Mental Health
Social Determinants
of Mental Health Outcome
• Introduction
• How are we doing with mental health outcome?
• What can explain increasing prevalence and severity
of mental illness?
• HOW CAN WE UNDERSTAND THE CONNECTION
BETWEEN SOCIAL FACTORS AND MENTAL
ILLNESS?
• What difference does it make?
• Next Steps- what we can do to address SDOHrelated suffering, disability, mortality and social cost
• Conclusion
Whitehall Studies
Sir Michael Marmot, MD
University College London
TREND IN “PERCENT WHO CAN BE TRUSTED” AND
GINI INDEX IN U.S. OVER YEARS 1964-1998
Social Determinants
PHYSICAL ENVIRONMENT
SOCIAL ENVIRONMENT
SOCIAL ENVIRONMENT
PUBLIC POLICY (health policy, income distribution, taxes)
SOCIAL PRACTICES
SOCIAL SIGNALS OF UNCERTAIN ENVIRONMENT
(INCOME INEQUALITY)
ADVERSE CHILDHOOD EXPERIENCE
DEVELOPMENTAL MODULATION EPIGEN EXP
ADAPTATION APPROP TO UNCERTAIN ENV
PRESENTISM- DEVALUED FUTURE
INCREASE CHRONIC ILLNESS
What We Can Do…
Resilience Research
• Child Psychologist Dr. Emmy Werner
demonstrated factors contributing to resilience
in child development in a 40 year longitudinal
study of all 698 infants born on the island of
Kauai, Hawaii in 1955.
• Her work demonstrated the usual association of
risk factors with worse health and social
outcomes. However 1/3 of high-risk children
had good outcomes.
• Key protective factors for children
demonstrating resilience included a strong bond
with a non-parent caretaker.
NOTE: Assessing ACE in 100,000 patient evaluations
lead to
35% Reduction in Doctor Office Visits
11% Reduction in ED visits
3% Reduction in Hospitalizations
Assessing
Adverse
Childhood
Experience
The Consultation Project
•
•
•
•
The Consultation Project is a state-wide cooperative consultation project between the Maine
Association of Psychiatric Physicians, the Maine Academy of Family Practice and the DHHS
Office of Adult Mental Health Services providing all primary care providers access to a
psychiatrist.
Developed by Dr. David Moltz in 2003 in cooperation between the Maine Association of
Psychiatric Physicians and the Maine Academy of Family Practice, this has become a national
model for a number of other states. Dr. Moltz is a Distinguished Life Fellow of the American
Psychiatric Association and has received national recognition for this project.
The project links volunteer psychiatrists with primary care practices throughout the state.
An ongoing consultative relationship is developed in which the rural practitioner contacts the
psychiatrist they have been assigned as needed for advice and guidance. The contacts are by
telephone or email and are in the nature of “informal consultation” rather than actual treatment or
supervision. The primary care provider (PCP) is an independent practitioner who is serving as the
medical home for the patient for whom the consultant makes suggestions, but leaving the medical
home as the site for the final decisions to be made. The relationship allows the facilitation of a long
term advisory relationship between the psychiatrist and the various primary care practices which
are paired.
The Post-Partum Depression Project
•
The Postpartum Depression Project was
developed with the support of a grant from the
American Psychiatric Association in
recognition of the frequency, under diagnosis
and under treatment of postpartum depression
and the long term serious adverse effects of
untreated maternal depression on women and
their children. Postpartum depression is the
most common complication of childbirth and
affects approximately 15% of mothers. In
addition, a work group convened as a result of a
bill (LD 792) promoting education about PPD
introduced to the 123rd Maine Legislature
concluded that there is a strong need for
widespread education among healthcare
providers about the significance of PPD, the
viability of screening, and the possible
treatment options.
The Post-Partum Depression Project
•
The focus of this project is to provide training
programs across medical and mental health
specialties and easy access to educational
materials to aid in the screening, assessment,
and treatment of women who experience
depression during pregnancy or the postpartum
period. Psychiatrists involved with the project
who have developed expertise in this area are
available to provide educational presentations.
There are additional resources posted on this
website that can be of assistance with screening
evaluation and treatment. The ultimate goal is
to increase the recognition and treatment of
depression both during pregnancy and the
postpartum period and to encourage
collaboration between psychiatry and other
specialties in pursuit of this goal.
The Post-Partum Depression Project
•
In addition, psychiatrists participating in the
Consultation Project have received training
regarding assessment and treatment of perinatal
mood disorders, particularly psychotropic
medication usage, and will be available to
provide informal consultation to practitioners in
other specialties such as Obstetrics and Family
practice. For information about how to become
involved with this resource please read more
about the Consultation Project (
http://www.mainepsych.org/project.htm ). For
more information about the PPD Project please
contact P. Lynn Ouellette M.D. at
[email protected] .
Next Steps…
New Ways of LivingCould Diversified CoHousing
provide a way to ensure that
children in Maine have the benefit
of sufficient caring and competent
adults to reduce risk of ACE?
Could new patterns of living bring
Maine adults and families into
networks supporting healthier diets
and lifestyles?
Social Determinants
of Mental Health Outcome:
What We Can Do
•
•
•
•
INTRODUCTION
Review of SDHO
Do Social Determinants Influence Response to Natural Disasters?
What Can We Do To Ameliorate Social Factors?
• Resilience research
• Access to Care
• Preventing Post-Partum Depression
• Consultation Project
• Reviewing ACE Histories with Patients
• Exploring New Housing Options
• A Key Social Factor: Health Care Access (Dr. Caper)
• Conclusion
Next Steps…
It is no measure of health
to be well-adjusted to a
profoundly sick society.
Krishnamurti
Next Steps…
• Learn More about SDOH/SDOMH
• Help patients and the community to
understand the role that social factors play in
illness
• Add review of ACE to your routine clinical
evaluation of new patients with relevant
• Engage with others concerned about
economic policy issues
• Given biologic basis for health consequences
of economic inequality, working for a more
just society is working to promote health
Next Steps…
Never doubt that a small group of
thoughtful, committed citizens
can change the world. Indeed, it
is the only thing that ever has.
Margaret Mead
Social Determinants
of Mental Health Outcome
• INTRODUCTION
• What can explain increasing prevalence and
severity of mental and physical illness?
• How can we understand the connection
between social factors and health?
• What difference does it make?
• Next Steps- what we can do to address
SDOH-related suffering, disability, mortality
and social cost
• Conclusion
Social Determinants
of
Mental and Physical Health
MAPP Annual Meeting
April 29, 2011
Edward Pontius, MD, DFAPA
Medical Director / ACCESS Team
Portland, Maine
Maine Medical Center Dept of Psychiatry Grand Rounds, 12/07/10
Maine Medical Association Public Affairs Committee, 02/09/11
University of New England Department of Social Work, 02/16/11
Maine Housing, 03/04/11
(followup) Maine Medical Center Dept of Psychiatry Grand Rounds, 03/22/11
Brunswick Housing Authority, 04/08/11
Next Steps…
It is no measure of health
to be well-adjusted to a
profoundly sick society.
Krishnamurti
Next Steps…
• Learn More about SDOH/SDOMH
• Help patients and the community to
understand the role that social factors play in
illness
• Add review of ACE to your routine clinical
evaluation of new patients with relevant
• Engage with others concerned about
economic policy issues
• Given biologic basis for health consequences
of economic inequality, working for a more
just society is working to promote health
Next Steps…
New Ways of LivingCould Diversified CoHousing
provide a way to ensure that
children in Maine have the benefit
of sufficient caring and
competent adults to reduce risk
of ACE?
Could new patterns of living
bring Maine adults and families
into networks supporting
healthier diets and lifestyles?
Could Diversified Cohousing
Help Address SDHO?
Could Diversified Cohousing
Help Address SDHO?
Could Diversified Cohousing
Help Address SDHO?
Next Steps…
Never doubt that a small group of
thoughtful, committed citizens
can change the world. Indeed, it
is the only thing that ever has.
Margaret Mead
Social Determinants
of
Mental and Physical Health
MAPP Annual Meeting
April 29, 2011
Edward Pontius, MD, DFAPA
Medical Director / ACCESS Team
Portland, Maine
Maine Medical Center Dept of Psychiatry Grand Rounds, 12/07/10
Maine Medical Association Public Affairs Committee, 02/09/11
University of New England Department of Social Work, 02/16/11
Maine Housing, 03/04/11
(followup) Maine Medical Center Dept of Psychiatry Grand Rounds, 03/22/11
Brunswick Housing Authority, 04/08/11
Social Determinants
of Mental Health Outcome
• INTRODUCTION
• What can explain increasing prevalence and
severity of mental and physical illness?
• How can we understand the connection
between social factors and health?
• What difference does it make?
• Next Steps- what we can do to address
SDOH-related suffering, disability, mortality
and social cost
• Conclusion