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Surgeon General’s Report
Chapter 2: The Fundamentals of
Mental Health and Mental Illness
Part 2
Tiffany Wood
Pharmacological Therapies
Rational drug design
Designing drugs by manipulating their
chemical structures
Goal: To create more effective therapeutic
agents with fewer side effects
Before 1960, discoveries were accidental
Knowledge of actions can help:
Discover the etiology
Develop more specific drugs
Mechanisms of Action
How a pharmacotherapy interacts with its target in
the body to produce therapeutic effects
Broad categories
Stimulants, Antidepressants
Chemical classes
Within categories; SSRI, Lithium
Agonist
Mimics the action
Antagonist
Inhibits or blocks the action
Neurotransmitters: A Brief
Overview
Concentrated in separate brain regions and
circuits
Each has its own pathway for synthesis,
degradation, and reuptake
Each has its own array of receptors
Can excite or inhibit the postsynaptic cell
Neurotransmission
1.....Postsynaptic Neuron
2.....Presynaptic Neuron
3.....Vesicle with
Neurotransmitters
4.....Mitochondrion (for
energy production from
glucose)
5.....Synaptic Cleft
6.....Neurotransmitter
Molecules
7.....Postsynaptic
Membrane (with NT
receptors)
It’s All Natural, Baby!
Natural products claim to help some mental
disorders
Preparations not standard, so active
ingredient is not known
“Food Supplements”-do not have to be
approved by the FDA
May be hazardous when taken with
prescriptions
No conclusions-need more studies
St. John’s wort
Issues of Treatment
Placebo response
Benefits and risks
Gap between efficacy and effectiveness
Barriers to seeking help
Placebo Response
Patients’ attitudes
and perceptions
influence their health
status
Hippocrates
Had physicians lay
their hands on
patients in a
reassuring manner to
help fight disease
Not an active
treatment
Found in up to 50%
of patients in studies
Placebo group is
mandated by the
FDA
Ineffectual treatment
Basis is unknown
Benefits and Risks
Most studies only used individuals with one
mental disorder and in good physical health
Children, adolescents, elderly excluded
Must consider all possibilities with doctor
Weigh pros and cons of each treatment choice
Benefits-to-risk ratio
Gap Between Efficacy and
Effectiveness
Treatments work better in a clinical trial
setting than in a clinical practice setting
Efficacy-effectiveness gap
Efficacy is what works in the trial setting
Effectiveness is what typically works
Magnitude of the gap can be very high
Problem is that efficacy studies are done
under ideal circumstances with white males
Barriers to Seeking Help
Most people do not seek treatment
Patient attitudes toward the service system
Not having the time
Fear of hospitalization
Thinking no one can help or they can
handle it alone
Stigma (embarrassment)
Cost
Sectors of the De Facto System
The U.S. has a de facto (fragmented) mental
health system with four sectors
Specialty mental health
General medical/primary care
Human services
Voluntary support network
Financing of the System
Public
Services directly operated by the government
Services financed with government resources
Private
Services directly operated by private agencies
Services financed with private resources
Duration and Settings
Acute conditions
Brief treatment
Long-term care
Residential care
Custodial
Institutional
Community-based
Home-based
Where Do They Get This From?
15% U.S. adult population use mental
health services each year
8% have a diagnosable mental or addictive
disorder
7% have a mental health problem
28% of the adult population have a
diagnosable problem
So… Not everyone seeks treatment
21% of children and adolescents use
services
History
Coincide with the colonial settlement of the
United States
Mid-18th century first asylum built
Reform Movements
Reform
Era
Movement
Setting
Focus of
Reform
Moral Treatment 1800-1850
Asylum
Humane,
restorative
treatment
Mental Hygiene
1890-1920
Mental hospital
or clinic
Prevention,
scientific
orientation
Community
Mental Health
1955-1970
Community
mental health
center
Deinstitutionalization, social
integration
Community
support
1975-present
Community
support
Mental illness as
a social welfare
problem
Cultural Diversity
U.S. mental health system is not well
equipped for racial and ethnic minorities
Feel fear or ill at ease
Four major race or ethnic minority groups
African American (12.8%)
Asian/Pacific Islander (11.4%)
Hispanic American (4.0%)
Native American (0.9%)
Let’s Get Cultured!
Culture
Denotes a common heritage and set of beliefs,
norms, and values
Cultural identity
A reference group
An identifiable social entity with whom a
person identifies with and looks to for a
standard of behavior
May involve: Gender, age, class, religion,
sexual orientation
Coping Styles
Asian Americans encourage avoidance of
troubling internal events
African Americans and others seek
guidance from religious figures
Idioms of distress
Reflect values and themes found in societies
Characteristic modes of expressing suffering
A common one: African Americans use of
somatization
• Expression of mental distress by physical suffering
Family Ties
Provide support to
individuals with
mental health
problems
Association between
family warmth and
reduced likelihood of
relapse
Especially important
to minorities
Prevalence
African Americans
Higher than whites
Due to socioeconomic differences
More likely to use the ER for mental health problems
due to lack of healthcare providers in the community
Overdiagnosis of schizophrenia, under of depression
Asian Americans/Pacific Islanders
Difficult to determine
Not likely to seek care
We Will Prevail…
Hispanic Americans
Few differences with whites
Native Americans
More depression, affective disorder, alcohol
abuse and dependence, post traumatic stress
disorder
Higher suicide rate
Barriers to Treatment
Language
Mistrust
Stigma (embarrassment)
Cost
Clinician bias
Diagnosis relies on
behavioral signs, not lab tests
Mistrust
African Americans due to segregation,
racism, discrimination, forced control
Immigrant families fear deportation of
undocumented relatives
Refugees and government mistrust
American Indians on reservations
Improving Treatment for
Minorities
Ethnopsychopharmacology
Minority-oriented services
Cultural competence
Ethnopsychopharmacology and
Minority-Oriented Services
Ethnic and cultural influences can alter an
individual’s responses to medications
Rate of absorption/metabolism of drugs
varies
Minority mental care providers
Specialized minority oriented/culturally
appropriate programs
Are You Culturally Competent?
Defined
A set of behaviors, attitudes, and policies that
come together to enable professionals to work
effectively in cross-cultural situations
Need to recognize and respond to cultural
concerns
History, traditions, beliefs, value systems
Begins with respect
Are You Still Competent?
If the practitioner can understand the
problem as it is experienced by the patient,
a sense of trust and credibility begins to
form
To be culturally competent is to deliver
treatment that is equally effective to all
sociocultural groups
I’m Good Enough, Smart Enough,
and Doggone It, People Like Me
Self help refers to groups led by peers to
promote mutual support, education, and
growth
Helps with coping
AA began in 1935
Groups for everything
Three models
Separatist, supportive, partnership
Accomplishments of Consumer
Organizations
Consumer is someone who “survived”
mental health treatments
Organized self help groups
Protection of individual rights
Research
Participants
Respondents
Partners
Independent
researchers
Family Advocacy
Represented by three organizations
National Alliance for the Mentally Ill (NAMI)
Federation of Families for Children’s Mental
Health (FFCMH)
National Mental Health Association (NMHA)
Deinstitutionalization left
families to care for
their mentally ill
Recovery
Some severe mental disorders were thought
to have lifelong deterioration
Recovery is a concept and a process
Hope and restoration of a meaningful life
are possible
Not a cure
Not the same as psychosocial rehab
Brace for Impact!
Optimistic attitudes and expectations may
help improve the course of illness
Process of recovery is governed by internal
factors and external factors interacting
Aides to recovery: medication, community
support/case management, self-will/self
monitoring, vocational activity, spirituality
Empowerment Scale
Self-efficacy—self esteem
Power—powerlessness
Community activism
Righteous anger
Optimism—control over the future
Let’s Wrap This Up!
Trends over the past 25 years
MRIs can help develop medications
Ultimate goal