surgeon general’s report chapter 2: the fundamentals of mental health and mental illness part 2...
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Surgeon General’s Report
Chapter 2: The Fundamentals of Mental Health and Mental Illness
Part 2
Tiffany Wood
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Pharmacological Therapies
Rational drug designDesigning drugs by manipulating their chemical structuresGoal: To create more effective therapeutic agents with fewer side effects
Before 1960, discoveries were accidentalKnowledge of actions can help:
Discover the etiologyDevelop more specific drugs
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Mechanisms of ActionHow a pharmacotherapy interacts with its target in the body to produce therapeutic effectsBroad categories
Stimulants, Antidepressants
Chemical classesWithin categories; SSRI, Lithium
AgonistMimics the action
AntagonistInhibits or blocks the action
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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
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Neurotransmission1.....Postsynaptic Neuron2.....Presynaptic Neuron3.....Vesicle with
Neurotransmitters4.....Mitochondrion (for
energy production from glucose)
5.....Synaptic Cleft6.....Neurotransmitter
Molecules7.....Postsynaptic Membrane
(with NT receptors)
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It’s All Natural, Baby!
Natural products claim to help some mental disordersPreparations not standard, so active ingredient is not known“Food Supplements”-do not have to be approved by the FDAMay be hazardous when taken with prescriptionsNo conclusions-need more studiesSt. John’s wort
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Issues of Treatment
Placebo response
Benefits and risks
Gap between efficacy and effectiveness
Barriers to seeking help
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Placebo Response
Patients’ attitudes and perceptions influence their health status
HippocratesHad 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
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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 doctorWeigh pros and cons of each treatment choice
Benefits-to-risk ratio
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Gap Between Efficacy and Effectiveness
Treatments work better in a clinical trial setting than in a clinical practice setting
Efficacy-effectiveness gapEfficacy is what works in the trial settingEffectiveness is what typically works
Magnitude of the gap can be very highProblem is that efficacy studies are done under ideal circumstances with white males
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Barriers to Seeking Help
Most people do not seek treatmentPatient attitudes toward the service systemNot having the timeFear of hospitalizationThinking no one can help or they can handle it aloneStigma (embarrassment)Cost
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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
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Financing of the System
PublicServices directly operated by the government
Services financed with government resources
PrivateServices directly operated by private agencies
Services financed with private resources
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Duration and Settings
Acute conditionsBrief treatment
Long-term careResidential careCustodial
InstitutionalCommunity-basedHome-based
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Where Do They Get This From?15% U.S. adult population use mental health services each year8% have a diagnosable mental or addictive disorder7% have a mental health problem28% of the adult population have a diagnosable problem
So… Not everyone seeks treatment
21% of children and adolescents use services
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History
Coincide with the colonial settlement of the United States
Mid-18th century first asylum built
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Reform Movements
Reform Movement
Era 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
Deinstitutionali-zation, social integration
Community support
1975-present Community support
Mental illness as a social welfare problem
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Cultural Diversity
U.S. mental health system is not well equipped for racial and ethnic minoritiesFeel fear or ill at easeFour major race or ethnic minority groups
African American (12.8%)Asian/Pacific Islander (11.4%)Hispanic American (4.0%)Native American (0.9%)
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Let’s Get Cultured!
CultureDenotes a common heritage and set of beliefs, norms, and values
Cultural identityA reference groupAn identifiable social entity with whom a person identifies with and looks to for a standard of behaviorMay involve: Gender, age, class, religion, sexual orientation
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Coping StylesAsian Americans encourage avoidance of troubling internal eventsAfrican Americans and others seek guidance from religious figuresIdioms of distress
Reflect values and themes found in societiesCharacteristic modes of expressing sufferingA common one: African Americans use of somatization
• Expression of mental distress by physical suffering
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Family TiesProvide support to individuals with mental health problemsAssociation between family warmth and reduced likelihood of relapseEspecially important to minorities
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Prevalence
African AmericansHigher 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 IslandersDifficult to determine
Not likely to seek care
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We Will Prevail…
Hispanic AmericansFew differences with whites
Native AmericansMore depression, affective disorder, alcohol abuse and dependence, post traumatic stress disorder
Higher suicide rate
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Barriers to Treatment
Language
Mistrust
Stigma (embarrassment)
Cost
Clinician biasDiagnosis relies on behavioral signs, not lab tests
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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
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Improving Treatment for Minorities
Ethnopsychopharmacology
Minority-oriented services
Cultural competence
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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
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Are You Culturally Competent?
DefinedA 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
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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
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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 growthHelps with copingAA began in 1935Groups for everythingThree models
Separatist, supportive, partnership
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Accomplishments of Consumer Organizations
Consumer is someone who “survived” mental health treatmentsOrganized self help groupsProtection of individual rightsResearch
Participants RespondentsPartnersIndependent researchers
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Family Advocacy
Represented by three organizationsNational 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
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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
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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
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Empowerment Scale
Self-efficacy—self esteem
Power—powerlessness
Community activism
Righteous anger
Optimism—control over the future
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Let’s Wrap This Up!
Trends over the past 25 years
MRIs can help develop medications
Ultimate goal
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