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 - PowerPoint PPT Presentation
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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
Transcript
Social Determinants of
Mental and Physical HealthMAPP Annual Meeting
April 29, 2011Edward Pontius, MD, DFAPAMedical Director / ACCESS Team
Portland, Maine
Maine Medical Center Dept of Psychiatry Grand Rounds, 12/07/10Maine Medical Association Public Affairs Committee, 02/09/11
University of New England Department of Social Work, 02/16/11Maine Housing, 03/04/11
(followup) Maine Medical Center Dept of Psychiatry Grand Rounds, 03/22/11Brunswick 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 paySarah F. Brosnan1 & Frans B. M. de Waal1Living Links, Yerkes National Primate Research Center,
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 StudentsMale, Female1952-1993
(Whitaker, Anatomy of an Epidemic, 2010)
Life is uncertain…Eat dessert first!
It’s about safety…
Robert Anda, MDCDC
V
Vincent Filetti, MDDepartment of Preventative MedicineKaiser Permante Medical Center, San Diego
Adverse Childhood Experiences Study
The 10 Categories of Adverse Childhood Experience
• Childhood abuse before age 18 o Emotional Abuseo Physical Abuseo Sexual Abuse
• Neglecto Emotionalo 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 highly-heritable 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 highly-heritable 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 Mechanisms- Modulating Gene Expression
Hongerwinter Dutch Hunger Winter 1944-1945A 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 1944-1945A 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
Youths and adults also suffered life-long impact. At 14 years old, Audrey Hepburn suffered the Hongerwinter...
Audrey Hepburn
Hongerwinter Dutch Hunger Winter 1944-1945A 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
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...
Audrey Hepburn
Hongerwinter Dutch Hunger Winter 1944-1945A 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
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...
Audrey Hepburn
Hongerwinter Dutch Hunger Winter 1944-1945A 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
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...
Audrey Hepburn
Hongerwinter Dutch Hunger Winter 1944-1945A 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
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...
Audrey Hepburn
Mechanisms for Adaptation to Stressful, Unpredictable Environments
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.
MEDICAL HYPOTHESESVolume 69, Issue 1, Pages 195-198 (2007)Hyperbolic discounting may be reduced to electrical coupling in dopaminergic neural circuitsTaiki 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 self-administration 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.
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 Long-Term 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 Stress-Related 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 SDOH-
related suffering, disability, mortality and social cost • Conclusion
Whitehall StudiesSir Michael Marmot, MD
University College London
TREND IN “PERCENT WHO CAN BE TRUSTED” ANDGINI INDEX IN U.S. OVER YEARS 1964-1998
Social Determinants
PHYSICAL ENVIRONMENTSOCIAL 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 Visits11% Reduction in ED visits3% Reduction in Hospitalizations
Assessing Adverse
ChildhoodExperience
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 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] .
The Post-Partum Depression Project
Next Steps…New Ways of Living-
Could 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 HealthMAPP Annual Meeting
April 29, 2011Edward Pontius, MD, DFAPAMedical Director / ACCESS Team
Portland, Maine
Maine Medical Center Dept of Psychiatry Grand Rounds, 12/07/10Maine Medical Association Public Affairs Committee, 02/09/11
University of New England Department of Social Work, 02/16/11Maine Housing, 03/04/11
(followup) Maine Medical Center Dept of Psychiatry Grand Rounds, 03/22/11Brunswick 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 Living-
Could 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 HealthMAPP Annual Meeting
April 29, 2011Edward Pontius, MD, DFAPAMedical Director / ACCESS Team
Portland, Maine
Maine Medical Center Dept of Psychiatry Grand Rounds, 12/07/10Maine Medical Association Public Affairs Committee, 02/09/11
University of New England Department of Social Work, 02/16/11Maine Housing, 03/04/11
(followup) Maine Medical Center Dept of Psychiatry Grand Rounds, 03/22/11Brunswick 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
