CH1 Mental Health and Mental Illness as Social Issues(1).pdf

MENTAL HEALTH & MENTAL ILLNESS AS SOCIAL ISSUES Dr. Denise Paquette Boots CHAPTER 1*DO NOT SHARE CONTENT OR SLIDES WITHOUT EXPRESS PERMISSION OF DR. BOOTS...

MENTAL HEALTH & MENTAL ILLNESS AS SOCIAL ISSUES Dr. Denise Paquette Boots CHAPTER 1*DO NOT SHARE CONTENT OR SLIDES WITHOUT EXPRESS PERMISSION OF DR. BOOTS 1  TRIGGER WARNING ▪This class deals with difficult situations, violence against self and others, and sensitive family issues that can be distressing to read about, discuss, and reflect upon ▪I urge each of you to consider carefully your own mental health as we discuss these issues from a clinical and sociological perspective, noting that it is normal to be disturbed by some of what you hear and see ▪Please consult your syllabus for available mental health support on our campus and within our community if these topics impact you negatively and consider reaching out for resources ▪Note that while we will consider difficult topics, I will never present material just to shock you or disturb you ▪I am sensitive to the fact that some of you struggle with mental health disorders and/or have family or friends who do; this course is about positive mental health advocacy and public policy and is never intended to further the stigmatization of the millions who have mental health challenges 2 INTRODUCTION ▪ In 1973, David Rosenhan published “On Being Sane in Insane Places” ▪ Article reported results of what would go on to become one of most famous of all social studies ▪ Article begins with a question: “If sanity and insanity exist, how shall we know them?” ▪ Research involved sending pseudo-patients to mental hospitals to determine what diagnoses and treatments they would receive ▪ Main conclusion was that mental health professionals inaccurately applied diagnoses of major mental illness (usually schizophrenia in remission) while interpreting the subjects’ normal behaviors consistent with these diagnoses 3 DEFINING MENTAL ILLNESS ▪ How do we know what mental illness (or health) is? ▪ If we do not know what mental illness is, how do we develop social policies that are appropriate and effective? ▪ A valid definition of mental illness continues to preoccupy researchers and policymakers ▪ A distinction between mind and body underpins insurance models that historically have funded and delivered mental and physical health services separately ▪ Considering mental illness as one condition or disease is an oversimplification ▪ Debates ongoing regarding what constitutes mental illness 4 DEFINING MENTAL ILLNESS ▪ One approach to defining mental illness is to conceive of it as a deviation from normal reactions or feelings given one’s life circumstance - The difficulty with this approach is that what is considered normal or deviant is socially and culturally defined\ - Persons with countercultural lifestyles appear bizarre to more conventional persons, but their patterns of dress and action are not necessarily discordant with peers’ beliefs and values ▪ Another major way of identifying deviations from “normal” is through recognition of personal suffering that is not justified by the circumstances of an individual’s life - Displaying anxiety or depression when living under favorable life circumstances means that person may be considered psychiatrically disordered 5 DEFINING MENTAL ILLNESS ▪ Definitions of mental illness also often to take into account some determination of how much symptoms interfere with our functioning in common roles ▪ Dominant paradigm for defining mental illness in the United States specifies that a disorder must produce “clinically significant distress or impairment in social, occupational, or other important areas of functioning” (American Psychiatric Association 1994, p.7) - How significant distress or impairments are defined, however, is not clear 6  DEFINING MENTAL ILLNESS ▪ An important concept in the realm of mental health policy is “severe and persistent mental illness” (SPMI) - This term is usually intended to convey a history of serious acute episodes, psychiatric comorbidities, continuing residual disability, and high levels of medical and psychosocial need ▪ Notion of “severe and persistent” speaks to the trajectory of the condition and not the diagnosis ▪ As a result, difficult to obtain accurate count of this population group, although we have estimates ▪ For example, while diagnosis of schizophrenia (SZ) encompasses a large proportion of patients with SPMI, diagnosis itself is not true measure of chronicity ▪ Course of disorder and level of function vary greatly ▪ For estimation purposes– commonly based on duration of illness or treatment and disability (defined as inability to work, or pronounced difficulty in carrying out activities in daily living) 7 DEFINING MENTAL ILLNESS ▪ First national review of mental health policies in United States took place in the late 1950s ▪ It contended that national efforts should concentrate on needs of people with most severe impairments: “A national mental health program should recognize that major mental illness is the core problem and unfinished business of the mental health movement, and that the intensive treatment of patients with critical and prolonged mental breakdowns should have first call on fully trained members of the mental health professions” (Joint Commission on Mental Illness and Health 1961, p. xiv) ▪ Period following this report was marked by the large-scale movement of people out of mental hospitals into the community as well as major health initiatives, such as Medicaid ▪ This policy change substantially shifted many responsibilities such as financing of care of severe mental disorders, to the federal government 8 DEFINING MENTAL ILLNESS ▪ Under the Clinton Administration, the first Surgeon General’s Report on Mental Health took a broad stance on definition of mental illness and kinds of problems meriting attention on the national agenda: “The Nation’s contemporary mental health enterprise, like the broader field of health, is rooted in a population-based public health model. The public health model is characterized by concern for the health of a population in its entirety…In years past, the mental health field often focused principally on mental illness in order to serve individuals who were most severely affected” (U.S. Department of Health and Human Services 1999, pp. 3-4) ▪ Research and policy in this recent period have tended to focus more on common mental disorders such as depression, and less on disorders that are usually more severe but affect fewer people, such as schizophrenia 9 DEFINING MENTAL ILLNESS ▪ Most experts now agree on the benefits and strategies such as screening for mental health problems in primary care ▪ With passage of Federal Patient Protection and Affordable Care Act (ACA) of 2010, affirmation of its constitutional status by the U.S. Supreme Court, and its many provisions improving behavioral health services through health homes, collaborative care, and other approaches, program initiatives focusing on behavioral health within general medicine will increase ▪ By applying formal clinical criteria to community samples, researchers have concluded that about 50% of the U.S. population will meet the criteria for one or more types of common mental illness sometime in their lifetime 10 THE CONSEQUENCES OF MENTAL ILLNESS ▪ One of most tragic consequences of mental illness is suicide ▪ Risk suicide varies significantly by age, and since 2000, middle-aged persons have highest rates ▪ There are also important race and gender differences in suicide ▪ Men tend to have higher rates of completed suicide than women ▪ White and American Indian males have particularly high rates compared to the other racial groups 11 US SUICIDE TRENDS Suicide ranks as 12th leading cause of death in the US overall 4th leading cause of death for people ages 35 to 54 2nd leading cause of death for 10-14 and 24-34-year-olds ^^ and 3rd leading cause of death for individuals 35-44 years old There are TWO TIMES as many suicides in US as homicides Males commit suicide at rates 4 times higher than females For males suicide rate highest for those 75 years of age and older For females suicide rate highest for those 45-64 years of age Highest rates of suicide by ethnicity include American Indian and Alaskan Natives (43.4/100,000), followed by Whites (30/100,000), then Blacks (14.8/100,000), Hispanics (12.5/100,000) and Asians (10.5/100,000) ▪ Nationally, the suicide rate increased 37% between 2000-2018 and decreased by 5% between 2018-2020 ▪ However, suicide rates have returned to their peak in 2022 with over 49,476 deaths or over 135 suicides PER DAY (COVID has made this worse)^ ▪ 2021 Healthiest state with regard to suicide rates: New Jersey ▪ Least healthiest state with regard to suicide rates: Wyoming 12  US SUICIDE TRENDS ▪Firearms were involved in over half of all suicides per the CDC ▪Firearms chosen method for almost 60% of male suicides (35% of females) ▪Suffocation is 2nd most likely method followed by poisoning ▪ Societal costs associated with suicide and suicide attempts were estimated at $93.5 billion ▪ Including lifetime medical fees and lost work costs ▪ While there has been steady rise in deaths by suicide over the past two decades, 2021 report by The Well Being Trust released found that 75,000 additional people could die from what they called “deaths of despair,” (which includes suicide and substance use) because of Covid-19 ▪ Establishment of new 988 call system for 24/7 crisis intervention and support seeks to stop suicides and help those struggling with ideas of self-harm ▪ 2021 there were an estimated 3.5 million people who contemplated suicide, 1.7 million attempts, and 48,183 deaths by suicide THIS IS A PUBLIC HEALTH CRISIS 13 NIH SUICIDE RATES IN US (2021) 14 WELL BEING TRUST EXECUTIVE REPORT 2020 15 COVID & IMPACT ON SUICIDE RATES ▪The long-term impact of COVID on society is yet to be determined, but preliminary data and mental health studies show a strong detrimental impact on MH onset and suicidality ▪Communities have faced significant mental health challenges related to COVID-19–associated morbidity, mortality, and mitigation activities (Czeisler et al, 2020) ▪ During June 2020, U.S. adults reported considerably elevated adverse mental health conditions associated with COVID-19 ▪ 11% of US adults expressing suicidality ▪ Younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse mental *combination of physical distancing, economic stress, barriers to mental health outcomes, increased substance use, and elevated suicidal ideation health treatment, pervasive national anxiety, and a spike in gun sales are creating what JAMA Psychiatry referred to as “a perfect storm” for suicide mortality 16  US SUICIDE TRENDS Pinpointing general reasons that suicide rates rise/fall is challenging in part because causes of suicide are complex Risk factors include health factors: Depression, substance use problems, serious mental illness and serious physical health conditions (including pain), environmental factors (such as access to lethal means and stressful life events including divorce, unemployment, relationship problems or financial crisis) and historical factors (including previous suicide attempts, a family history of suicide and a history of childhood abuse or trauma) At individual level, there is never a single cause of suicide, but rather multiple causes There is no obvious culprit for an increase in suicides—nor is there a single, easy solution we can import from other nations to turn the trend around 17  US SUICIDE TRENDS ▪Yet there are clues- socioeconomic changes may be part of the puzzle ▪Globally, suicide rates have often fallen when living conditions have improved and vice versa ▪Princeton University economists Case and Deaton (2015) have shown that deaths from suicide, drugs and alcohol have risen steeply among white, middle-aged Americans since 2000 (PNAS, Vol. 112, No. 49, 2015) ▪They argue these “deaths of despair” are linked to a deterioration of economic and social well-being among the white working class (Mortality and Morbidity in the 21st Century, Brookings Papers on Economic Activity, Spring 2017) ▪In addition, suicides have increased most sharply in rural communities, where loss of farming and manufacturing jobs has led to severe economic declines over the past quarter century - Adults with a mental illness are less likely to be employed (Mechanic, Bilder, and McAlpine 2002) - Having a severe mental illness also correlated with lower levels of income when employed (Kessler et al. 2008) 18 THE CONSEQUENCES OF MENTAL ILLNESS ▪ Difficult to know what proportion of suicides is due to mental illness ▪ However, there is a high level of agreement between diagnosis based on psychological autopsies and those based on information from clinicians who treated the victim (Kelly and Mann, 1996) ▪ Cavanagh and colleagues (2003) did a systematic review of studies using psychological autopsy methods ▪ Authors examined the frequency of evidence that suicide victims had previously met the criteria for DSM disorder - They estimated as many as 1/2 to 3/4 of all suicides could be avoided if mental illness could be prevented - They found mental disorder to be a stronger correlate of suicide than other factors such as social isolation, physical health problems, or recent stressful life events 19  THE CONSEQUENCES OF MENTAL ILLNESS ▪ According to Luoma, Martin, & Pearson (2000), many persons who commit suicide have had contact with health services prior to their death ▪ As many as 3/4 of suicide victims visited a primary care physician and 1/3 had contact with a mental specialist within the year prior to their suicide– this is a failure of our healthcare system ▪ Hospital emergency rooms (ER) represent a particularly promising point of intervention, since this is where many persons who attempt to harm themselves first appear in medical system - This group is almost 6 times more likely to commit suicide following hospital discharge than persons in the general population (Olfson, Marcus, and Bridge, 2012) ▪ A randomized controlled trial study by the WHO in Brazil, India, Sri Lanka, Iran, and China assessed the effects of an intervention among people who were originally seen in the ER following a suicide attempt - This ER intervention reduced subsequent deaths by suicide eleven-fold (Fleischmann et al. 2008) 20  THE CONSEQUENCES OF MENTAL ILLNESS ▪ Druss and colleagues (2011) studied a nationally representative sample of Americans, some with a diagnosis of mental illness (schizophrenia, affective disorders, substance use, and other mental disorders) and some without, for a period of 17 yrs. - Controlled for socioeconomic status (SES), health system factors such as having health insurance, and baseline health status including the presence of comorbid physical conditions: obesity, and self-assessed general health status - Death occurred about 8 yrs. earlier on average for those with a mental illness - Causes of death for people with a mental disorder coincided with those for the general population, including cardiovascular disease (34%), cancer (21%), and pulmonary disease (14%) - Controlling for demographics, SES, health system factors, and health status reduced the relationship between mental disorder and risk of death to non-significance - In particular, SES and health system factors each accounted for about 1/4 of the excess mortality among persons with mental disorder, highlighting the need to address such risks for this population 21  THE CONSEQUENCES OF MENTAL ILLNESS ▪Disability associated with mental illness (e.g., depression, anxiety, and impulse control disorders) exceeds that of many chronic illnesses (e.g., arthritis, asthma, heart disease, and cancer) in 4 key areas of life: ▪home, work, social interaction, & ability to form and maintain close relationships with others (Druss et al. 2009) - Overall, having MI associated with greater impairment than physical disorder in each area of functioning - Depression and bipolar disorder feature the greatest level of impairment, exceeding that of chronic illnesses such as chronic pain syndrome and heart disease - Greatest impairments for persons with mental disorder occur in the domains of social functioning and relationships whereas chronic physical disorders are more likely to interfere with functioning inside the home and work activities - MI and socioeconomic disadvantage also coincide; evidence that having an externalizing disorder (e.g., impulse control or substance use) is strongly associated with terminating school early 22 CONSEQUENCES OF BEHAVIOR DISORDERS IN CHILDHOOD ▪ There is much variability on link between MI and poor general health depending on type and stage of disorder as well as life circumstances, but childhood behavioral disorders represent one area where gravity of consequences can be assessed ▪ Children are one of society’s most vulnerable populations but also group with tremendous future potential in life ▪ For this reason, it is apt to focus on behavior disorders during childhood as one key indicator of impact of MH problems ▪ Resistance to authority during childhood, as reflected in delinquency, drinking, and sexual behavior, is correlated with the development of employment difficulties, problems with the law, alcoholism, drug abuse, and early death in adulthood ▪ Children in this troubled group often begin to stand out early in their school years due to low IQ, poor reading, and poor school performance in general, as well as truancy 23  CONSEQUENCES OF BEHAVIOR DISORDERS IN CHILDHOOD ▪ Farrington and other scholars have followed people throughout their lives in the United Kingdom where four major birth cohort studies were conducted (1946, 1958, 1970, and 2000) - Richards et al. 2009 did not directly assess disorders, but instead relied on early reports from teachers or parents concerning poor conduct (such as fighting, lying, and disobedience) and emotional problems (such as fearfulness, worries, and solitariness) - Results indicate that behavioral problems in childhood have much stronger repercussions into adulthood than emotional problems - Having a severe, or even mild, conduct disorder in childhood or adolescence goes along with a range of negative outcomes over time, such as lower educational attainment and earnings, greater risk of teenage parenthood, disengagement from economic activity, and problems with the law ▪ Rolf Loeber & PYS to be discussed in lecture 24 THE IMPORTANCE OF MENTAL PROFESSIONS ▪ A critical resource in operation of the mental health system is supply of MH professionals within different disciplinary specializations ▪ Changes in the organizational location of professionals, their assigned responsibilities, and nature of their interaction with each other have often been a focus for mental health program and policy innovations ▪ No mental health professions existed prior to the founding of mental hospitals ▪ Within field of medicine, a professional specialty of psychiatry was born out of the asylum system of the 1800s ▪ Psychology practitioners were university-trained specialists in a new academic field that originally grew out of, and then separated from, philosophy ▪ In 1917, the American Association of Clinical Psychologists was established 25  THE IMPORTANCE OF MENTAL PROFESSIONS ▪ In MH care there are other professionals and paraprofessionals- marital therapists, mental health counselors, rehabilitation specialists, and more- as well as subspecialties within categories, such as geriatric and forensic psychiatry and dual-diagnosis practitioners ▪ Four main groups that define the core mental health professions: 1) psychiatrists, 2) psychiatric nurses, 3) clinical phycologists, and 4) psychiatric social workers ▪ In 2009, in order to examine supply issues, researchers grouped MH professionals into two categories, non-prescribing and prescribing personnel (Thomas et al. 2009) 26  SOCIETAL BURDENS AND POLICY DILEMMAS ▪ Disability, morbidity, and mortality associated with mental illness not only have consequences for individuals and their families, they also create a major social burden ▪ Substance Abuse and Mental Health Services Administration (SAMSA) estimates mental and substance use disorders (M/SUDs) treatment spending from all public and private sources is expected to total $280.5 billion in 2020, which is an increase from $171.7 billion in 2009 (including costs of ACA) ▪ M/SUD treatment spending growth is likely to slow from recent trends and lag behind growth in all-health spending ▪ One major reason for the slower spending growth for M/SUD treatment is expected to be large number of prescription drugs used to treat M/SUDs that will lose patent protection through 2020--loss of patent protection will allow entry of generic drugs, with an anticipated rapid switch by consumers to these lower-cost medications ▪ In addition, few if any new innovative drugs are expected to enter the market 27  SOCIETAL BURDENS AND POLICY DILEMMAS ▪ Closure of state psychiatric hospital beds is also contributing to slower M/SUD spending growth ▪ 9 state hospitals and nine percent of state hospital beds closed between 2009 and 2012 ▪ Although the closure of state psychiatric hospitals is a long-run trend going back to the 1950s, closures accelerated in recent years as a result of state financing pressures stemming from the recession ▪ A new Lancet Commission report on mental health said that mental disorders are on the rise in every country in the world and will cost the global economy $16 trillion by 2030 ▪ Estimates are conservative because they do not take into account many indirect costs like crime and incarceration, the effects of family disruption on children, special education and social welfare programs, family caregiving for members with mental illness, and homelessness ▪ Defining mental health illness therefore shapes the scope and purpose of mental health policy 28 SOCIETAL BURDENS AND POLICY DILEMMAS ▪ U.S. mental health policy reflects a delicate act of balancing responsibilities among local, state, and federal governments ▪ Prior to the 1950s, states played the lead role, but the impetus shifted to the federal level with such reforms as the Community Mental Health Centers Act and Medicaid and Medicare ▪ Americans with Disabilities Act (ADA) of 1990 has so far had small effects on persons with mental illness due to narrow court interpretations of the law’s applicability ▪ The Federal Patient Protection and Affordable Care Act (ACA) of 2010 holds promise of greatly augmenting the ability of individuals with mental disorder to access treatment and care 29 SOCIETAL BURDENS AND POLICY DILEMMAS ▪ In a mental health policy system like in the United States, however, almost nothing is uniform, and it will be essential to track the way key coverage issues are diced from one part of the country to another ▪ The U.S. MH care system remains deficient and disorganized ▪ Fact is most people who meet the criteria for a MH problem still do NOT receive treatment (e.g., quality of care varies widely, programs have long waiting lines, limited coverage period) ▪ Gaps in system tend to be particularly pronounced within minority racial and ethnic communities ▪ Serious issues with MH and homeless and prison populations ▪ How does MH impact corrections? 30 CONCLUSION ▪ Two central questions asked throughout this book are: ▪ i) why psychiatry and mental health services have not reached a point of greater maturity, confidence, and public support and ▪ ii) why mental health care often seems to stand apart from the progress and purposefulness one finds in other major disease sectors ▪ The answers lie in our public policy choices, both the approaches we have adopted and those we have rejected or ignored ▪ Debates surrounding mental health care are vital and consequential ▪ Part of the responsibility of policymakers is to understand the consequences of mental illness and to configure programs and policies that may alleviate distress and neglect Mental illness is real, and so is the suffering of people with mental illness and their families and friends 31