Prelim 2 Study Guide
Prelim 2 Study Guide HD 3570
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This 15 page Study Guide was uploaded by Izzy Sheck on Saturday January 23, 2016. The Study Guide belongs to HD 3570 at Cornell University taught by Elaine Wethington in Summer 2015. Since its upload, it has received 34 views. For similar materials see Social inequalities in health in Human Development at Cornell University.
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Date Created: 01/23/16
HD 3570 PRELIM 2 STUDY GUIDE Lecture 10 • Historical context ◦ Nazi human experiments in concentration camps during WW2 ▪ lesson known- biochemical warfare experiments conducted by Japanese doctors in China during WW2 ◦ Experiments were done under coercion (forced into it) ◦ Lives of humans were devalued in order to acquire knowledge that might help the dominant social group ◦ Resulted in the Nuremberg Code ▪ 10 principles for ethical experimentation involving humans ◦ Declaration of Helsinki • What impact did th e Nuremberg Code have on the US? ◦ Virtually none for a long time ◦ 1953-1954: the US National Institute of Health established an internal ethics review committee ◦ Applied to the US Public Health Service immediately thereafter ◦ Yet, medical research was cond ucted without fully informed (or any) consent, on low status and vulnerable populations ▪ Ex. Tuskegee Syphilis Study 1932 -1972 ▪ some people in the study had active syphilis and passed it on to other controls and to their families ▪ Ex. US army radiation expe riments with soldiers in the 1950s ▪ CIA experiments with LSD • Why things began to change ◦ 1960s- Thalidomide Crisis- a tranquilizer that had disastrous impact on fetal development ◦ 1962- Kefauver- Harris ammendments to the food, drug, and cosmetics act (FD A) requiring consent in experimental drug studies ▪ Also mandated empirical tests of drug effectiveness (randomized controlled trials) • Abuses came to light ◦ 1963- elderly patients at Jewish chronic disease hospital injected with cancer cells without their informed consent ▪ response was that every research institution receiving funds from USPHS to review federally funded research for human subjects protection ▪ many universities established institutional review boards (including Cornell) ◦ Willow brook school for Mentally Disabled Children ▪ children injected with Hep B ◦ Milgram Studies ▪ cried, broke down, got really upset at the conductor shocking them, but they wouldn’t stop ◦ Stanford Prisoner Study (Zimbardo 1971) ◦ Tearoom Trade Study (Humphreys 1975) • Reform- 1974 National Research Act ◦ US dept of Health, Education and Welfare issues 45 CFR 46 comprehensive regulations protecting human participants ▪ mandated institutional review boards (IRBs) ▪ established national commission for the protection of human subject s of biomedical and behavioral research ▪ resulted in the Belmont report • Belmont report- Principles and Practical Applications ◦ Respect for persons=must respect subject autonomy ◦ Beneficence= maximize potential benefits while minimizing harms ◦ Justice= equitable subject selection and implementation ◦ Informed consent ◦ Assessment of risks and benefits ◦ Selection and treatment of subjects • Recent Events Associated with changes ◦ National Bioethics Advisory Commission (NBAC) - 1995 ▪ advisory body established by Pres ident Clinton in response to new revelations of studies conducted without consent ▪ exposure of studies conducted by the EPA and by the USPHS in Guatemala • The NBAC ◦ wrote 4 reports that urged the federal government to update regulations in order to keep up with new technology ▪ nano technology ▪ genetic analysis ▪ data mining • 2000-2002 Tightening of Federal Oversight ◦ shut downs of research programs at leading universities ▪ University of Pennsylvania- death to Jesse Gelsinger in 2000 ▪ John’s Hopkins University- death of Ellen Roche in 2001 ▪ Duke University- shut down for general noncompliance in 2001 • Critical Issue #1 in Health Research ◦ The Belmont Report stated that researchers must seek fully informed consent from participants ▪ data use issues- who will use the data after it is collected and for what purposes will it be used? ▪ do participants have the right to restrict use of their data after they have given it? ◦ BR stated that individuals are autonomous decision makers ▪ people with diminished autonomy are entitled to protection ▪ limited autonomy- cannot give informed consent ▪ capacity for self-determination “matures” and some may lose this capacity wholly or in part if they develop serious mental disorders • The 2nd Principle- Protection of Vulnerable People ◦ What if privacy of health data is compromised? ▪ Re-analyses of genetic data may reveal vulnerability to diseases ▪ Analyze of small groups of communities may stigmatize them ▪ Inadvertent disclosure of data to insurance companies (pre -existing conditions) ▪ congress has passed new laws limiting access of insurance companies to genetic data banks • The Havasupai ◦ they gave DNA samples to ASU researchers starting in 1990 to study diabetes ▪ samples also used to study other diseases and their origins as a people ▪ subsequently, the Havasupai banned all research ◦ the researcher had included “wider use” on the consent forms ▪ did what she was required to do ◦ A difficult balance between protection and pursuing science ▪ paternalism ▪ minimizing risk should not mean that risks must be eliminated completely • Controversial Harvard Facebook Study ◦ Tastes, ties and time ◦ A group of sociologists downloaded FB profiles from all Harvard freshmen - to study the development of social networks, attitudes, and behaviors in young adults ◦ Harvard supplied housing locations for the students to merge into the data ◦ Harvard IRB approved research - as not requiring informed consent under the regulations - FB approves the study ◦ Researchers continued to download data every year from public profiles ▪ however, their research assistants may have used their status as friends of the students in the study to col lect additional info ▪ if true, this is a violation of the IRB approved protocol ◦ After publication, the researchers released the data ▪ believed that no one in the data set could be identified ▪ howwever, an outside researcher downloaded the data and was able t o identify students relatively easily (deductive identification) ◦ Aftermath ▪ FB increases users’ control over profiles (somewhat) ▪ ethicists began proposing amendments to the federal regulations in order to protect the privacy of online internet users • 2014, FB study ◦ FB manipulated the news feeds for many users, without their knowledge and consent ◦ De-identiied data were sent to Cornell and analyzed ◦ After publication there was a huge outcry Lecture 11 • The US Focus on Health Disparities ◦ NIH funds large research centers and research initiatives across the country to target and reduce health disparities ▪ infant mortality ▪ childhood asthma ▪ heart disease ▪ cancer • The first intervention (beginning in 1970s) targeted prenatal care as a way to reduce infant mor tality ◦ prenatal care reduced infant mortatlity overall in all groups ◦ infant mortality has declined among African Americans, but remains high - the disparity remains while other types of health disparities have decreased • Researchers felt that they do not entirely understand the reasons why health disparities occur and are so persistent ◦ some interest in applying “fundamental cause” theory- but... ◦ most interest is on improving project delivery ◦ 2 under-explored reasons for bad program delivery: ▪ people don’t understand the messages that health care centers deliver ▪ communities/groups don’t trust health care centers ◦ Ex) The doc says that you are doing well with the treatment, but the patient thinks that means that they are cured • Reason 1: Health Literacy ◦ Patient health literacy and systems that fail to recognize lack of understanding of preventive and medical treatments for leading cause of chronic disease and death (person-level) ◦ poor translation of complicated medical and health issues into everyday langu age that less advantaged Americans can implement in their every day lives (system level) • What is health literacy? ◦ NIH definition- the degree to which individuals have the capacity to obtain, process, and understand basic health info and services needed to make appropriate health decisions ◦ Ability to read is a fundamental component ▪ the ability to take action or adhere to a preventive course of action is closely related to the ability to read • Connecting level between people and health systems ◦ complexity of action is required to follow a medical or preventive action is dependent on a number of other skills ▪ listening and comprehension ▪ numeracy (ability to add, subtract, and understand percentages) ▪ conceptual knowledge of a particular condition/disease ▪ health systems are not very good at communicating essential info to less advantaged people • Health Literacy in the US ◦ Assessed english literacy of people 16 and up in the US ◦ Basic Findings: ▪ Considering “below” and “basic” classifications in health literac y, there are wide disparities based on: ▪ 14% of Americans are below basic ▪ 22% basic ▪ only 12% of Americans are “proficient” ▪ 9% of whites are below basic ▪ 24% of blacks ▪ 41% of hispanics ▪ 13% of asians ▪ 25% of native americans ▪ Education (49% of those with less than a high school education are below basic) ▪ Age (29% of adults 65 and older are below basic) • New research/treatments that need to consider health literacy ◦ genome wide association studies ▪ can people really give informed consent for unlimited use of their genetic material? ◦ Havusupai ▪ gave DNA samples to ASU researchers to study diabetes ▪ samples used to study other diseases and their origins as a people ▪ the Havusupai did not agree with the scientific explanation of their origins ▪ so the Havasupai banned all research • Health and fitness applications being tested in the general public ◦ beyond fitbit applications that diagnose disease and track people’s medication adherence etc. ◦ the food and drug administration plans to regulate some a s “treatments” ie. they must meet safety and health info standards (no false advertising) • Incidental findings in research studies and medical treatment that find suspicious growths/tumors when using magnetic resonance imaging (MRIs) • Federal government initiatives to increase health literacy ◦ NIH has special program emphasis ◦ developing better instructions/directions for taking medications ▪ Michael Wolf ▪ promise in intervention studies ▪ non-verbal medication instruction/reminders • Reason 2: Health Systems don’t connect to people very well ◦ community based programs to simplify hospital and health provider instructions ▪ centers for disease control approach- translate into many languages, simplify language etc. ▪ community based participatory research approach (D etroit urban research center) ▪ figure out how different racial and ethnic groups conceieve of causes and treatments that build on their existing knowledge ▪ then educate providers about new communication strategies ▪ can also be used for prevention programs • Goals of Health Literacy Interventions for Patients ◦ learn how to find health info ◦ be able to understand, interpret, and analyze health info ◦ be able to apply health info over a variety of situations ◦ learn how to navigate the health care systme ◦ actively take part in conversations with health care workers ◦ understand and give informed consent for procedures ◦ learn to advocate for one’s rights • Cornell Genetic Ancestry Project ◦ conducted in 2011- 200 cornell studetns recruited to donate genetic material ◦ the investigators gave them info about their ancestry- very surprising • The Application of Stigma to Health Research ◦ a mark of infamy, disgrace, or reproach ex. Scarlet Letter ▪ some diseases have characteristic “marks” eg. small pox, leprosy • The Medicine Buddha ◦ Basis for traditional medicine in parts of Asia ▪ holds out hand in a sign of generosity- even the disabled and lepers are welcome ▪ displays medicine intended to cure both mental and physical disorders • As late as 1965, people getting on to airplanes in the US were subject to visual inspection for “marks” of disease ◦ Ebola Lecture 12 • Stigma as a social fact ◦ severe social disapproval of personal characteristics or beliefs that are against cultural norms ◦ typical application to death- disease believed to result from being “unclean” - leading to rejection or separate from society ◦ formal sociological definition of stigma ▪ the phenomenon whereby an individual with an attribute, which is deeply discredited by his/her society, is rejected as the result of an attribute ▪ socially imposed isolation, social exclusion, discrimination, loss of rights/detention • Peter Hotez, Neglected Infections of poverty in the US ◦ He refers to these as hidden because: ▪ they disproportionately affect the very poorest and most isolated people in the US ▪ they attributed to conditions which are often stigmatized - ▪ lack of sanitation ▪ poor vector control ex. mosquitos ▪ malnutrition ▪ 3rd world living conditions - exposure to parasites • Hotel’s Policy Recommendations to Reduce Health Disparities ◦ improve surveillance (realize that disease exists) ◦ increase understanding of transmission dynamics (increase research) ◦ treat or prevent the infections (primary and secondary medical interventi on) ◦ create vaccines that treat disease (tertiary medical intervention) ◦ improve veterinary disease treatments (control animal sources of infection) ◦ develop rapid diagnostic tests for diseases of poverty • HIV/AIDS ◦ the cause was not immediately determined ◦ cause was frequently attributed to the behavior of the group in which it was first diagnosed ◦ first tendency was to isolate and exclude those who showed the advanced symptoms • Convened scientific panel on AIDS in 1986 ◦ 1980s— some nations quarantined AIDS and HIV patients ◦ Educated everyone, but didn’t quarantine to keep disease from spreading ▪ should have done this • Historic Examples- quarantines as public health measures ◦ quarantine- Scarlet fever ◦ SARS epidemic • Mental Disorder and Illness as Stigmatized Diseases ◦ pre-scientic (pre-20th cent) view of mental disorder and illness ▪ moral deviance and failure ▪ product of a deviant upbringing ◦ connections to non-normative sexuality ▪ promiscuity ▪ STI ▪ masturbation ◦ 19th century (and earlier) treatments emphasized is olation and quarantine ▪ Bethlehem Hospital in London - Bedlam 15th cent. ◦ Mental disorders still treated with imprisonment in many parts of the world ▪ Rural areas of subsaharan Africa • Key Events that Lead to the Contemporary View of Mental Disorders ◦ Freudian revolution (early 20th cent) ◦ Movements to standardize diagnostic criteria - mid 20th cent. ◦ Epidemiological studies to understand the causes of mental disorders- mid 20th cent. ◦ Studies of the brain and the genetic correlates of mental disorders - late 20th cent. • How scientists define mental health and illness today ◦ Mental Health= the state of psychological well-being ◦ Mental Illness= persistent, recurrent disturbance of psychological faculties that impeded or disables normal daily interactions and fulfillment of socially normative activities ◦ Mental Disorder= a discrete disturbance of psychological faculties that has been identified across individuals and which has a distinct and distinguishing system profile ◦ mental disorder preferred over mental illness ▪ mental disorders have distinct symptoms ▪ multiple defined mental disorders with distinct set of symptoms ▪ mental health disorders defined in DSM ◦ mental health is measured by: ▪ multi-item scales capturing negative and positive emotions and affect ▪ happiness ▪ life satisfaction ▪ quality of life ◦ many large, national studies have measured mental health- routinely monitored and compared across studies Lecture 13 • The Measurement of Mental Disorders in the Population ◦ Aim is to identify a discrete entit y (you have it or not) ◦ Based on a serious of questions to determine if you have had a set of critical symptoms over a discrete period of time ◦ Those who make the “screen” for having had the disorder are then asked a series of follow up questions to determ ine fit to the symptom profile • Diagnostic Interview Measures ◦ Administered by lay interviewers rather than clinicians ◦ Have been validated by clinicians and experts using formal “intake” interviews used by clinical psychologists in hospitals • Something in-between ◦ Scales to measure symptoms that characterize disorders ▪ Ex. anxiety, depression, eating disorders ▪ there are not research diagnostic interviews, but measure severity of impairment due to mental distress ▪ Ex. center for epidemiological studies of depression (CESD) ▪ Beck Depression Inventory (used frequently by psychologists) ▪ K-6 Measure of Mental Disturbance • Research on Causes of Mental Disorders ◦ Early studies follow from Durkenheim’s 1897 study of suicide ▪ collected data about the occurrence of suicides by localites ▪ correlated the number of suicides with population characteristics ▪ sometimes with individual characteristics • 1930s- First Epidemiological Study of Mental Disorders in the US ◦ Used hospital records to li st addresses of patients with schizophrenia and mapped the addresses ◦ Discovered that most of the patients lived in low SES areas - Faris and Dunham • Issues with Faris and Dunham’s Study ◦ Concluded that poverty and crowded housing conditions caused schizophrenia ◦ they did not consider the alternative- that those with the disorder “drifted” into low SES neighborhoods to live • US Army Studies during WW2 ◦ 1940s- studies of US army recruits ▪ all recruits were given IQ and mental fitness tests designed to identify off icer candidates ◦ Mental fitness tests were also used to help the army predict who was likely suffer from “battle fatigue” (PTSD) ▪ army researchers noticed regional patterns in “mental fitness” ▪ these differences were poverty related- about 45-50% of American children grew up in poverty during the Great Depression ▪ rural poverty seemed particularly problematic ▪ many of the psychologists in the army went to NIH later • 1940s-1950s: The Midtown Manhattan Study ◦ Leo Srole- sponsored by the new NIH Mental Health program ◦ Face to Face interview study of adult New Yorkers living between 14th and 60th streets ▪ used modern sampling procedures ◦ used a structured interview based on questions developed by the US army research team • 1957- Americans view their mental health ◦ first nationally representative survey of mental health in the US ◦ measured both positive and negative emotions ◦ included questions about many of the social factors explored in the Midtown Manhattan Study (quality of social relationships, marriage, work conditions, physical health, major life events) ◦ also examined who sought help for mental health related issues • 1976- Americans view their mental health replication ◦ longer, more complicated survey ◦ criticized because it did not capture “disorder” as defined by the American Psychiatric Association ▪ counter criticism: psychiatric diagnoses were not specific enough to replicate across practitioners OR put into operation in survey research ▪ followed by the development of the first diagnostic and statistical manual in the US and the international ICD-10 standards (WHO) • 1980s- Epidemologic Catchment Areas ◦ First mental disorder diagnostic interviews - ▪ based on the DSM of the time ◦ Catchment areas: Baltimore, New Haven, St. Louis, LA etc. ▪ not representative of the US po pulation ◦ Experimental instruments were developed ▪ still in use today • Why do diagnostic interviews in a Nationally Representative Sample? ◦ Estimate prevalence of disorders ▪ estimate distribution of disorders by socially -defined groups (gender,race, ethnic ity, education, poverty status) ▪ estimate severity of the disorders and ranges of severity ◦ Estimate co-occurences of different disorders in the same people - COMORBIDITY ▪ depression and anxiety ▪ alcohol use and drug use ▪ depression and alcohol use ◦ Estimate the use of treatments ▪ identify disparities in access to treatment ▪ evaluate the adequacy of treatment that different groups receive ▪ identify intervention targets to improve treatment, access to treatment etc. ▪ the US did not have national estimates of mental disorders until 1990s ▪ other countries were in the lead ▪ WHO mandated that the UN member nations measure mental disorders in the population ◦ Brief History of Key National Surveys of Mental Disorders ▪ SEE if you want • Population gaps that are being filled in ◦ Nationally-representative data on children ◦ teens ◦ Data on mental disorder development, worsening and remission across the life course of individuals ◦ Non-English speaking Americans (ethnically sensitive data in general) ◦ Immigrants • Key Facts about NCS -2 ◦ Face to face nationally representative survey ◦ 9282 english speaking adults age 18 and older ▪ 70.9% response rates ◦ Took place Feb 2001-Dec 2003 ◦ $12 million to do the survey ◦ Diagnostic instruments developed b y teams of experts, then tested in samples of patients diagnosed by professionals • Core Disorders ◦ Anxiety- 28.8% overall lifetime prevalence ▪ panic disorder ▪ agoraphobia ▪ specific phobia ▪ social phobia ▪ generalized anxiety disorder ▪ PTSD ▪ obsessive compulsive disorder • Mood Disorders ◦ 20.8% lifetime ◦ major depressive disorder ◦ dysthymia ◦ bipolar I-II disorders Lecture 14 • National Comorbidity Survey 2 ◦ tested samples of patients diagnosed by professionals ◦ very controversial ▪ ethnic questions ▪ intrusiveness into people’s private feelings and behaviors ▪ participant burden (very lengthy interviews) • Lack of feedback to patients about possible mental disorders ◦ countered by concerns that feedback about having a mental disorder may be unnecessarily alarming if the disorder was temporary or transient (not chronic) ◦ the NIH required that the investigators send in psychological help if a person was suicidal or threatened to harm others • Appropriateness of relying on psychiatric diagnosis categories to measure population mental “illness” ◦ dangers of medicalizing deviant or temporary behavior as a mental disorder ◦ possibility of stigmatizing behavior within the normal range (bereavement, normal sadness, anxiousness, or fear) as abnormal ◦ tendency to define all episodes of strong emotion as requiring treatment (when is clear that some people get well by themselves) • Over diagnosis of disorder in the population ◦ estimates of disorder are very high ◦ unknown impact on health care costs if mild cases of disorder as defined as illness ◦ even psychiatrists argued that the estimates from NCS I were too high ▪ revisions were made in NCS II to eliminate tendency toward over diagnosis • Tendency to classify all episodes as equally severe ◦ critics argued that the most severe episodes of a disorder needed to be distinguished before the seeking of treatment was “counted” • Corrective Measures Added to NCS II ◦ better measures of how severe (or not) an episode of mental disorder was ▪ more measures of symptoms ▪ frequency and intensity ◦ clearer exclusions of bereavement, normal sadness, fear and anxiousness ◦ multiple measures of how disabling an episode was (missed work, problems with relationships) ◦ better measures of seeking treatment • Comorbidity- a review ◦ Any disorder lifetime - 46.4% lifetime prevalence (any level) ◦ 2 or more disorders- 27.7% (mild level) ◦ 3 or more disorders- 17.3% (more serious comorbidity) ◦ Those who have more disorders also tend to have more severe disorders ▪ severity defined by: # of symptoms endorsed, degree of impact on daily life, degree of impact on fulfilling important life roles (parents, employee, student, friendship) ▪ severity definitions differ by diagnosis • The other side of the criticism of NCS II ◦ some critics have argued that too few diagnoses were included ▪ patient advocate groups were particularly active protesting the measurement of eating disorders, self injury, personality disorders, anger management, etc. • Scientific Criticism ◦ Some neuroscientists have argued that the extent of comorbidity among diagnoses suggests that the DSM IV messaged symptoms rather than the underlying brain disorders that cause a variety of symptoms ▪ their argument is particularly compelling because of the comorbidities between different types of mood disorders ◦ Other things included: ▪ brief questions about eating disorders ▪ tobacco use ▪ suicidal ideation and behavior ▪ borderline personality disorder ▪ premenstrual symptoms ▪ neurasthenia (extreme fatigue) ▪ also measured mental health- multiple item measures of positive and negative health symptoms • What about eating disorders? ◦ National Comorbidity Replication had questions about: ▪ anorexia nervosa ▪ bulimia ▪ experimental questions about binge eating disorder ▪ used only with a random half of respondents • Younger people more likely to report 12 month or lifetime eating disorder ◦ 56.2% of those with anorexia nervosa reported at least one “core” other mental disorder (33.8% reported 3 of more disorders- qualified as “serious comorbidity” ◦ 94.5% of those with bulimia reported one core disorder ▪ 64.4% w 3 or more disorders ◦ 78.9% of those with binge eating disorder reported at least one core disorder ▪ 48.9% w 3 or more disorders Lecture 15 • Why cultural tailoring is necessary ◦ The meanings of symptoms need to be explored across different population groups because meanings may not be the same ▪ hallucinations, hearing voices, speaking with the dead all normal practices…but…they were diagnosed as “disorders” in many Western nations ◦ Different languages use not only different words, but different metaphorical phrases for the experience of the same symptom ▪ in some cultures, the symptoms of depression are most frequently described in physical pain ▪ in the US, we use words like sadness, feeling blue, and report sleep and eating disturbances ▪ pain symptoms are not unknown in the US during depressive episodes • Basic Methods of Cultural Tailoring ◦ Dr. Jan Beals ◦ Group interviews of tribal members who discussed the cultural meaning of the sympt oms of mental disorder • The Focus of Beal’s Study ◦ Traditional culture ◦ Assimilative cultural change • Cultural and Social Transformation ◦ Shaghai (modern, urban China) vs. Traditional rural China • World Mental Health Survey - Steps used by Researchers ◦ Reformulation and testing of culturally tailored questions ▪ new questions written based on unique symptoms in a culture ▪ some questions are eliminated or reworded if their meaning is different from DSM meaning ▪ questions are tested in a population of those believed t o have a disorder in a given population (genetically identified by both western researchers and local medical practitioners • Causes and Consequences of mental disorders may be culturally specific ◦ Western notions of cause and consequences may be irrelevant ▪ role impairment may be culturally specific ▪ work is not the same thing across the world ▪ meanings of “stressors” differ across populations ▪ ex. from Brown and Harris- is bigamy equally stressful across the world? ▪ bereavement is another interesting example (more controversial) • Cultural Tailoring of Measures of Causes and Consequences ◦ each country in the world mental health survey has complete control= veto power over the types of measures included in the study ▪ many diagnoses are not included in som e scounties because of fear of offending people ◦ many countries write their own questions about causes and consequences, specific to those cultures ▪ also, culturally tailored questions on seeking care for disorders, including use of traditional healers • Does Exposure to Stressors Cause Mental Disorders? ◦ If exposure to stressors is greater among minorities, and discrimination is defined as a stressor exposure, then members of minority groups should have higher rates of mental disorders • Stressor Exposure and Mental Disorders ◦ Stressor exposure during childhood is important m ◦ Severe chronic stressors during childhood (critical periods of development)seem to be more related to onset of disorder than chronic, uncontrollable stressors later in life ▪ early onset of many mental disorders suggest that the developing brain is very vulnerable to stressor exposure ▪ brain response may be permanently affected and have lasting impact ▪ may be important gene x environment interactions, with stressor exposure perhaps precipi tating recurrent mental disorder episodes • Quick Summary ◦ Most people do not become depressed even after severe events ▪ Brown and Harris reported that 10% become ▪ depression dependent on having exacerbating versus protective factors ▪ ex. social support, co-occuring chronic stress Lecture 16 • Key Research Issues ◦ mental disorders begin (onset) early in life ▪ affects the remainder of one’s life ◦ theories about why childhood stressors are particularly impactful ◦ why the impacts of severe events vary across people • Stressor exposure during childhood is important ◦ severe chronic stressors during childhood (critical periods of development) seem to be more related to onset of chronic recurrent mental disorder than chroni c, uncontrollable stressors later in life • Converging evidence m ◦ Early onset of many mental disorders suggests that the developing brain is very vulnerable to stressor exposure ◦ Brain response may be permanently affected by early events and have lasting im pact • From genetic research ◦ there may be important gene x environment interactions with stressor exposure perhaps precipitating recurrent mental disorder episodes • The Kindling Hypothesis ◦ Those who have genetically -based disorders requires stressor exposure to manifest the disorder ◦ Genetic disposition toward depression ▪ minor stressors lead to initial (first onset episode) ▪ episodes can recur even without stressor exposure ◦ No genetic disposition toward depression ▪ major stressors may lead to temporary episode of depression ▪ depression may recur if stressor exposure is chronic ▪ OR, depression may never recur during lifetime • Causes for depression episodes cannot be distinguished without knowing depression history ◦ no history of depression ▪ depression episode LIKLEY caused by stressful event ▪ depression NOT likely to be recurrent once event has resolved ◦ one previous episode of depression ▪ new depression episode likely caused by persistent of recurrent stressor exposure ▪ depression likely to remit once event/situation has resolved ◦ recurrent or persistent episodes of depression ▪ depression episode can be caused by a relatively minor event ▪ depression is likely to be disabling in some aspects of life and may be associated with causing persistent stressor exposure • When do stressful events cause a depression episode? ◦ most people do not become “clinically” depressed even after very severe events ▪ Brown and Harris- 10% became depressed ▪ unexpected finding ▪ depression was dependent on ha ving exacerbating versus protective factors (ex. social support, co - occuring chronic stress, such as financial strain) • If only 10% become clinically depressed, what else is happening? ◦ onset of disorder other than depression ◦ less vulnerable to depression before the event ◦ effective coping and support? • Brown and Harris- Contextual factors affecting impact of divorce ◦ People who divorce ▪ those who do not have other confidantes ▪ people who have found someone else to be with ▪ those whose parents also divorces • Social factors make a difference ◦ Replacement of significant others ◦ Other social support available ◦ Similar events from childhood make a person more “vulnerable” • What about traumatic events? ◦ natural disaster ◦ war • Known Finding about PTSD ◦ PTSD in the US, Canada, and Europe is more frequently provoked by personal events than by natural disaster, war, or terrorism ◦ Still, the impact of war and disaster experience is frequently studied - opportunity to study the impact of events on people who don’t expect them to happen ◦ Events associated with producing PTSD are more likely to precipitate PTSD in those who: ▪ have a pre-existing mood or anxiety disorder ▪ alcoholism and substance abuse episodes the past or present • Major Studies of Natural Disaster ◦ Jonestown Flood ▪ established that social relationship loss, destruction of a community organization, and continued “re-living” of the disaster are associated with depression and PTSD after natural disasters ▪ collective trauma ▪ disasters that provoked important research ▪ hurricanes hugo, andrew, and katrina ◦ The fear evoked by experiences in a disaster have a major impact ▪ threats to life ex. being caught in flooding (in comparison to destruction of property) ▪ loss of close others ▪ witnessing destruction first hand • Exposure to Hurricane-Related Stressors and Mental Illness after Hurricane Katrina ◦ telephone survey ◦ given a short 6 item screening scale for anxiety and mood disorders ◦ PTSD screen ◦ assessed for hurricane related stressors (ex. illness/injury, death of loved one, lost house, property, power, etc.) • Hurricane Katrina ◦ Illness/injury and physical adversity related to the hurricane were strong predictors of reporting an anxiety or mood disorder ◦ pre-existing mental disorder could not be ruled out as a possible risk factor • Prospective study of Katrina ◦ sample: low income mothers where mental disorder had been assessed prior to Hurricane Katrina ▪ stressors and loss associated with the Hurricane had strong effects on recurrence of mental disorders and on new onsets of mental disorders ▪ social support systems were overwhelmed by the scale and disaster and did not buffer the effects of the disaster • War and Terrorism ◦ Studies conducted in longitudinal samples suggest that war and war-like experiences (terrorist or civilian attacks) have long term impact on mental health • 9/11 ◦ controlling for other risk factors, did the negative effects of the World Trade Center Disaster persist 2 years after the attack? ◦ Did level of exposure to violence or destruction attacks lead to worse outcomes? ◦ Was exposure to the attacks related to a decline in wellbeing between wave 1 and wave 2 ◦ did exposure to the attacks increase the reactivity and vulnerability of survivors to other negative life events post WTCS (testing a stress-vulnerability hypothesis) ▪ Dependent variables ▪ physical health ▪ physical pain, role functioning, body pain and general health status over past 30 days ▪ psychological health ▪ vitality, social functioning, emotional functioning, mental health status over past 30 days ▪ Predictor Variables ▪ Background characteristics ▪ age, education, children in the home, gender, marital status, ethnicity, income ▪ Stress risk factors ▪ Exposure to WTCD, history of panic attacks, negative life events, traumatic events, screening for alcohol dependence ▪ Social psychological resources ▪ social resources- social support ▪ psychological resources- self esteem ▪ Findings ▪ participants with more education and higher income reported better health outcomes after 2 years ▪ greater exposure to the violence and destruction of WTCD was associated with poorer psychological health 2 years after ▪ WTCD did not continue to affect physical and psychological well being 2 years later ▪ most people reported good physical and mental health at wave 2 but people with existing alcohol disorders continued to deteriorate after 2 years Lecture 17 • The Burden of Disease ◦ World Health estimate of comparative importance of diseases, injuries, and risk factors in causing premature death, loss of health and disparity ▪ includes a health metric- the disability adjusted life year (DALY) — an estimate of the years of life lost from premature death and years of life lived in less than full health • Top 10 Causes of DALYs worldwide ◦ 1. lower respiratory infection s ◦ diarrheal diseases ◦ unipolar depressive disorders ◦ heart disease ◦ HIV/AIDS ◦ cerebrovascular disease ◦ prematurity and low birth weight ◦ birth asphyxia and birth trauma ◦ road traffic accidents ◦ neonatal infections • In high income countries (US) ◦ 1. Unipolar depressive disorders • Race/Ethnicity and Mental Disorder ◦ If exposure to stressors is greater among minorities, and discrimination is defined as stressor exposure, then members of minority groups should have higher rates of mental disorders —— not really true ◦ There are pronounced differences in physical health associated with social disadvantage (which includes minority status) ◦ Many members of racial minority groups are socially disadvantaged ▪ education ▪ income ▪ occupational attainment ▪ neighborhood residence • Alternative explanations ◦ Measurement error ▪ underreporting ▪ subcultural differences ◦ Positive coping ▪ greater use of religion ▪ more family and community support ▪ people who form enclaves that protect them from risk factors ◦ Sampling bias ◦ Environmental Affordances (opportunities) and constraints (barriers) promote particular responses to stress exposure ▪ people are motivated to self -regulate the stress response ▪ coping with stress is influenced by social context ▪ some coping is poor health behavior (drinking, overeating, smoking etc.) ▪ over the life course different experiences of chronic stress creates differences between social groups • Testable Prediction from EA model ◦ coping with behavior that threatens health will simultaneously... ▪ reduce negative impact of chronic stress in short run ▪ increase physical health risks and poor health in the long run ▪ some propositions supported by Mezuk et al. • Immigrants and Mental Health ◦ In the stress process model, the immigration experience is viewed as a stressor that will have a negative impact on physical and mental health ▪ data support opposite for physical health ▪ immigrants are "selected" for their good physical health (even refugees) ▪ acculturation to American culture is associated with poorer phy sical health ▪ ex. mental disorders less prevalent among Asians overall, there may be an acculturation impact on Latinos • Explanations ◦ May differ by race/ethnicity - there is no one trend that applies to all groups of immigrants ◦ Positive health selection - there is less evidence to support this for mental health ◦ cultural buffering? • Negative Assimilation ◦ Positive benefits are lost gradually over time ▪ however, other data show that the younger when immigration occurs, the more mental disorders reported ◦ Cultural differences • Are mental disorders increasing in prevalence in western nations? ◦ younger cohorts more likely to report mental disorders ▪ perhaps because estimates of prevalence are done retrospectively (older people less likely to remember) ▪ or # of diagnoses increasing ▪ or symptom criteria changing ex. autism ▪ or “secular” trend toward higher rates of disorder, especially anxiety and mood disorders • Theories for why disorders may be increasing ◦ 19th century theory: industrialization and urbanization incr ease social disorder and loosen connections between people ◦ Late 20th and early 21st century theory: increased economic stress/competition and decline in community organizations and support (family, religion) ▪ younger people are predicted to be the most affected by these 2 trends • 2 major surveys have reported increases in mental disorder ◦ Weissman et al 1991 ◦ WHO mental health surveys ▪ Both surveys used cohort analysis of cross -sectional data comparing different age groups at a single point in time • Retrospective v. Prospective Assessment ◦ Outcomes= anxiety, depression, alcohol, and marijuana dependence from age 18 -32 ▪ prevalence estimates doubled when taking account of prospective (accumulating) information in comparison to retrospective assessment for the age group Lecture 18 • War and Mental Disorder ◦ Modern artillery but war tactics from earlier centuries contributed to high death rates ◦ Historical records suggest that war effects were severe and disabling • Physical and Mental Health costs of traumatic war experiences ◦ health problems of veterans, reconstructed from civil war pension records ▪ cardiovascular- irregular pulse, heart murmurs, heart enlargement, arteriosclerosis, edema, cyanosis, dyspnea, impaired circulation ▪ gastrointestinal- diarrhea, dyspesia, pain, ulcer ▪ nervous system- paranoia, psychosis, hallucinations, delusions, insomnia, memory impairments, anxiety, depression, paralysis, tremor, epilepsy, antisocial behavior etc. • World War I: Shell Shock ◦ Associated with trench warfare and assau lts on enemy trenches ◦ Extreme death rates as a result of automatic weaponry ◦ 1000s of men disabled for the rest of their lives • World War II ◦ Termed “battle fatigue” ◦ 1000 yard stare; prototype for the first diagnosis of a PTSD style disorder ▪ invasion of Normandy ▪ Iwo Jima ▪ Nazi death/labor camp supervisors • 1952 ◦ First version of APA diagnostic and statistical (DSM) included a description of the IWO Jima/Normandy reaction labeled “extreme stress disorder” ▪ because most solderers recovered within a few month, it was believed to be temporary ▪ dropped from DSM II as WW 2 memories faded • 1960s-1970s ◦ Test offensive (1968) was a water shed event for armed forced psychiatry and medicine - unprecedented level of psychiatric casualties ▪ Guerilla “insurgency” war- characterized by not knowing who the enemy really was ▪ High death rates for Marines in combat roles ◦ First studies of death/combat exposure among nurses and mortuary personnel ◦ VA hospitals were later overwhelmed with patients suffering mental and substance abuse disorders • 1980s-1990s ◦ First defined PTSD ◦ Defined as an extreme stress reaction associated with recurrent intrusive thoughts, emotional and psychological “numbing” and poor/ineffective coping with subsequent stressors ◦ Diagnosis widened in DSM IV t o include traumas other than wartime experiences ex. sexual assault • Recent Rise in Veteran/Soldier Suicides ◦ 2005: male vet rate 44.99/1000000 ◦ 2008: 56.77/1000000 BIG increase ◦ rate among active duty soldiers in 2005: 20/1000000 ▪ comparable civilian: 12.5/1000000 • Context: An all volunteer armed forces ◦ small, highly trained units ▪ more investment in individual soldier training ▪ increased incentives to remain in armed forces (more job training) ▪ designed for a generally peaceful time ▪ increase of women in “combat support” roles ◦ defense strategy focused on quick deployment and “small” wars ▪ multiple deployments for the same soldiers ▪ soldiers go back to war zones after minimal rest • What happened? ◦ 1990-1991 Gulf War (Operation Desert Storm) ▪ no impact on suicide rates ◦ operation enduring freedom (OEF: Afghanistan) ◦ operation Iraqi freedom (OIF) (Bruce 2010) ▪ 33% increased risk of suicide among solderers ever deployed to either country ▪ rates of those who were in combat/injured higher still • Causes ◦ estimated that 10-20% of soldiers deployed in Afghanistan and Iraq develop PTSD symptoms ◦ particular concern for army and marine corps ◦ other mental and behavioral outcomes ▪ anxiety ▪ depression ▪ substance abuse ▪ aggression towards self and others ◦ hypothesized causes of soldier mental disorder ▪ longer and more frequent deployments to war zones ▪ wars being fought by a smaller force ▪ frequent family relationship disruptions ▪ combat exposure ▪ insurgency warfare (no front lines, enemy can be anywhere) ▪ trusted locals or local forces being trained by American army are sometimes involved in attacks ▪ isolation from others ▪ soldiers are trained to turn off the “no harm to others” inhibition ▪ also may be associated with family violence • Policy/Program Responses ◦ Army, air force, and marine corps have adopted a 2 year recovery time rule for combat zone deployment ▪ population data from army suggests that mental disorders and behavioral problems are high even one year after returning ▪ takes 3 years for those who have been in combat to return to normal • Emerging High Risk Populations ◦ Those with traumatic brain injury (TBI) due to improvised explosives ▪ soldiers are surviving TBI ▪ TBI may be associated with susceptibility to PTSD ◦ Mortuary units ▪ pick up the dead ▪ prolonged hanging of human remains ▪ highest rates of PTSD • Women Soldiers ◦ Prior to the gulf war 1990 -1991: medical and clerical support roles ◦ First studies were among Vietnam era nurses ▪ heightened PTSD symptoms associated with handling casualties during the Tet offensive ◦ 1990-1991 Gulf War- women were first assigned combat support roles ▪ 1/2 assigned to ordinance handling, supply convoys, fighter support, re -fueling flights, naval support, etc. ▪ no elevation in PTSD rates at that time ▪ less likelihood of combat exposure than men • OEF/OIF ◦ PTSD symptoms are elevated among women, compared to men ▪ more likely to be exposed to combat (insurgency tactics) ▪ women are ore likely to be exposed to casualties/human remains ▪ gender harassment/discrimination • Army STARS ◦ study to assess risk and resilience in service members ◦ based on Framingham Heart Study ▪ includes population of entire cohorts of soldiers, major army bases, surrounding communities ▪ measure both sick and resilience factors ▪ measures neurological changes assoc iated with combat and traumatic experiences ▪ also includes analysis of anonymized service records from 2004 to present ◦ Early findings from Army STARS ▪ Did not completely support the “multiple deployment” hypothesis or “intense combat” hypothesis ▪ 1/3 of suicide attemtps- those who had previous mental disorder ▪ married soldiers had lower risk of suicide during deployment ▪ more women than men • Pending Recommendations for Policy Change ◦ Using brief NCS-style screens before final acceptance/enlistment ◦ More frequent contact between soldiers and families during deployment ◦ Testing new programs to trip “early warnings” for suicide ◦ Traumatic brain injury associated with depression and PTSD • Related Field of Study: Refugee Mental Health ◦ Risk factors for refugees ▪ exposure to war ▪ state sponsored violence and oppression ▪ torture, sexual assualt ▪ internment in refugee camps ▪ human trafficking ▪ physical displacement from home country ▪ loss of family members and prolonged separation ▪ unemployment • Most prevalent disorders in refugees ◦ PTSD ◦ panic attacks ◦ somatization (pain and physical disease without an identifiable cause) ◦ traumatic brain injuries (insurgent violence) ◦ depression • Policies being implemented ◦ CDCO, WHO, Doctors w/o borders ◦ PTSD, anxiety, depression screeni ng ◦ therapists deployed in refugee camps and war zones Lect
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