Population mental health: Toward a global research agenda Sandro - - PowerPoint PPT Presentation

Population mental health: Toward a global research agenda

Sandro Galea Bo Boston Un University School of Public Health

• 1. Why do we do what we do?

• 2. Signs that we may not be succeeding as much as we may

Patel V, et al. The Lancet Commission on global mental health and sustainable development. Lancet 2018; 392: 1553–98.

https://ourworldindata.org/grapher/mental-and-substance-use-as-share-of-disease?tab=chart&time=1990..2016&country=OWID_WRL

Unremitting nature of mental disorders

20 40 60 80 100 120 140

1900 1904 1908 1912 1916 1920 1924 1928 1932 1936 1940 1944 1948 1952 1956 1960 1964 1968 1972 1976 1980 1984 1988 1992 1996 2000 2004 2008 2012

Age-adjusted mortality rate Time

Accidents Suicide

• 1. NCHS Data Visualization Gallery - Mortality Trends in the United States. CDC National Center for Health Statistics (NCHS). https://www.cdc.gov/nchs/data-visualization/mortality-

trends/index.htm. Accessed February 15, 2019.

• 2. National Center for Chronic Disease Prevention (CDC). HIST293_0049. Washington (DC); 1943. https://www.cdc.gov/nchs/data/dvs/hist293_1900_49.pdf. Accessed February 15,

2019.

• 3. Grove R, Hetzel A. Vital Statistics in the United States, 1940-1960. Washington (DC); 1968. https://www.cdc.gov/nchs/products/vsus.htm. Accessed February 15, 2019.
• 4. CDC WONDER. CDC. https://wonder.cdc.gov/. Accessed February 15, 2019.
• 5. Lee L, Roser M, Ortiz-Ospina E. Suicide. Our World in Data. https://ourworldindata.org/suicide. Published 2016. Accessed February 15, 2019.

Trends in hospital resource use for children with and without a psychiatric diagnosis from 2005 to 2014.

Bonnie T. Zima et al. Pediatrics 2016;138:e20160909

Roehrig, Charles. Mental Disorders Top The List Of The Most Costly Conditions In The United States: $201 Billion Health Affairs. May 18, 2016.

• 3. And how is this affecting what we do to improve

population mental health?

https://www.cdc.gov/nchs/data/databriefs/db283.pdf

Among NIH funding for 2018, only 0.57% was awarded to projects with the terms “population” or “public” in the title $33,608,528,210

$190,821,500

NIH RePORTER. Projects from FY 2018 for which funding data is available. <http://projectreporter.nih.gov/reporter.cfm> Accessed on March 18, 2019.

Proportion of NIH funding awarded to projects, 2009-2019

NIH RePORTER. Search terms included in project titles. <http://projectreporter.nih.gov/reporter.cfm> Accessed on March 18, 2019.

1 2 3 4 5 6 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Percent of total NIH budget Fiscal year

“Genetic”, “genetics”, or ”gene” "Population" or "public"

• 4. Can population health science contribute?

Population health science is the study of the conditions that shape distributions of health within and across populations, and of the mechanisms through which these conditions manifest as the health of individuals

“ ”

1.

Population health manifests as a continuum.

2.

The causes of differences in health across populations are not necessarily an aggregate of the causes of differences in health within populations.

3.

Large benefits to population health may not improve the lives of all individuals.

4.

The causes of population health are multilevel, accumulate throughout the life course, and are embedded in dynamic interpersonal relationships.

5.

Small changes in ubiquitous causes may result in more substantial change in the health of populations than larger changes in rarer causes.

6.

The magnitude of an effect of exposure on disease is dependent on the prevalence of the factors that interact with that exposure.

7.

Prevention of disease often yields a greater return on investment than curing disease after it has started.

8.

Efforts to improve overall population health may be a disadvantage to some groups; whether equity or efficiency is preferable is a matter of values.

9.

We can predict health in populations with much more certainty than we can predict health in individuals.

1.

Population health manifests as a continuum.

2.

The causes of differences in health across populations are not necessarily an aggregate of the causes of differences in health within populations.

3.

Large benefits to population health may not improve the lives of all individuals.

4.

The causes of population health are multilevel, accumulate throughout the life course, and are embedded in dynamic interpersonal relationships.

5.

Small changes in ubiquitous causes may result in more substantial change in the health of populations than larger changes in rarer causes.

6.

The magnitude of an effect of exposure on disease is dependent on the prevalence of the factors that interact with that exposure.

7.

Prevention of disease often yields a greater return on investment than curing disease after it has started.

8.

Efforts to improve overall population health may be a disadvantage to some groups; whether equity or efficiency is preferable is a matter of values.

9.

We can predict health in populations with much more certainty than we can predict health in individuals.

PRINCIPLE 5. Small changes in ubiquitous causes may result in more substantial change in the health of populations than larger changes in rarer causes.

>90% of population experience a trauma some time in their life

Traumatic events include assaultive traumatic events as well as shocking events (e.g. car accident, natural disaster), learning about traumatic events to others, the sudden unexpected death of someone close and any other traumatic event the participant considered traumatic.

In high risk populations ~50% experience past year trauma

https://reliefweb.int/sites/reliefweb.int/files/resources/adsr_2016.pdf

https://reliefweb.int/sites/reliefweb.int/files/resources/adsr_2016.pdf

Galea S, Rockers PC, Saydee G, McCauley R, Varpilah ST, Kruk ME. Persistent psychopathology in the wake of civil war: the path of long-term post-traumatic stress disorder in Nimba County, Liberia. American Journal of Public Health. 2010;100(9):1745-51. PMID: 20634461. URL: http://dx.doi.org/10.2105/AJPH.2009.179697

Galea S, Rockers PC, Saydee G, McCauley R, Varpilah ST, Kruk ME. Persistent psychopathology in the wake of civil war: the path of long-term post-traumatic stress disorder in Nimba County, Liberia. American Journal of Public Health. 2010;100(9):1745-51. PMID: 20634461. URL: http://dx.doi.org/10.2105/AJPH.2009.179697

Experience of traumatic events and depression

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 1-2 3-4 5-6 7-8 > 8 Predicted probability of depression Number of events endorsed Women Men

Predicted value from a multivariable model adjusting for chronic energy deficiency, self-reported socioeconomic status, property ownership, and food insecurity Hadley, C, Tegegn, A, Tessema F, Asefa M, Galea S. Parental symptoms of common mental disorders and children’s social, motor, and language development sub-Saharan

• Africa. Annals of Human Biology. 2008; 35(3):259-275. PMID: 18568592. URL: http://dx.doi.org/10.1080/03014460802043624

Maternal depression and child personal-social development in Gilgel Gibe, Ethiopia

1 2 3 4 5 6 7 8 9 10 3-5.9 mo 6-11.9 mo 12-17.9 mo 18-23.9 mo 24-29.9 mo 30-44 mo Depressed Not depressed

Hadley, C, Tegegn, A, Tessema F, Asefa M, Galea S. Parental symptoms of common mental disorders and children’s social, motor, and language development sub-Saharan

• Africa. Annals of Human Biology. 2008; 35(3):259-275. PMID: 18568592. URL: http://dx.doi.org/10.1080/03014460802043624

Roberts AL, Galea S, Austin B, Cerda M, Wright RJ, Rich-Edwards JW, Koenen KC. Posttraumatic stress disorder across two generations: concordance and mechanisms in a population-based sample. Biological Psychiatry. 2012;72(6):505-11. PMID: 22521146. PMCID: PMC3412195. http://dx.doi.org/10.1016/j.biopsych.2012.03.020.

Scott K et al. Associations between Lifetime Traumatic Events and Subsequent Chronic Physical Conditions: A Cross-National, Cross-Sectional Study. PLoS ONE. 8(11):

• e80573. doi:10.1371/journal.pone.0080573

Kubzansky et al. Th The weight of traumatic stress: a prospective study of posttraumatic stress disorder symptoms and weight status in women. JAMA Psychiatry. 2014 Jan;71(1):44-51. doi: 10.1001/jamapsychiatry.2013.2798.

Roberts AL, Agnew-Blais J, Spiegelman D, Mason SM, Galea S, Hu F, Rich-Edwards JW, Koenen KC. Posttraumatic stress disorder and type 2 diabetes incidence in women: A 22-year longitudinal study. JAMA Psychiatry. 2015;72(3):203-10. PMID: 25565410. https://dx.doi:10.1001/jamapsychiatry.2014.2632

• Implications. Trauma is a ubiquitous driver of population

health across the lifecourse.

PRINCIPLE 6. The magnitude of an effect of exposure on disease is dependent on the prevalence of the factors that interact with that exposure.

How much is risk of depression determined by our genes?

= GE+

= ENV+

= DEP+

= ENV+

Scenario 1

= DEP+ = GE+

= ENV+

Scenario 1

= DEP+ = GE+

= ENV+

Scenario 1

= DEP+ = GE+

= ENV+

Scenario 1

= DEP+ = GE+ RR (DEP+|GE+) = 334 PARP (DEP+|GE+) = 1

= ENV+ = DEP+

Scenario 2

= GE+

= ENV+ = DEP+

Scenario 2

= GE+

= ENV+ = DEP+

Scenario 2

= GE+ RR (DEP+|GE+) = 1.7 PARP (DEP+|GE+) = 0.4

Why?

Under a very plausible assumption of co-occurring causes, any given sample will give us different estimates dependent entirely

• n other factors that distinguish between samples

Figure 2. Logistic Regression Analyses of Risk of Depression for 14 Studies

Source Caspi et al,10 2003 Power et al,31 2008 Laucht et al,32 2009 Overall Kim et al,30 2007 Middeldorp et al,29 2007 Chorbov et al,17 2007 Cervilla et al,15 2007 Chipman et al,16 2007 Taylor et al,26 2006 Wilhelm et al,27 2006 Surtees et al,25 2006 Grabe et al,20 2005 Eley et al,18 2004 Gillespie et al,19 2005

• No. of

Participants 845 1421 309 14 250 732 367 120 735 1844 110 127 4060 999 328 2253 5.0 1.0 0.2

OR (95% CI) Risk per S allele A

5.0 1.0 0.2

OR (95% CI) Risk per stressful life event B

5.0 1.0 0.2

OR (95% CI) Interaction of genotype and stressful life events C

The boxes and lines indicate the odds ratios (ORs) and their 95% confidence intervals (CIs) on a log scale for each study. The size of the box indicates the relative weight of each estimate.

Interaction Between the Serotonin Transporter Gene (5-HTTLPR), Stressful Life Events, and Risk of Depression

A Meta-analysis

Risch et al., JAMA (2009) 301: 2462-71

Although this is the largest genome-wide analysis of MDD yet conducted…we were unable to identify robust and replicable findings

“ ”

Major Depressive Disorder Working Group of the Psychiatric GWAS Consortium. A mega-analysis of genome-wide association studies for major depressive disorder Molecular Psychiatry (2012), 1–15

• Implications. We cannot understand population mental

health without understanding context, including trauma.

PRINCIPLE 7. Prevention of disease often yields a greater return on investment than curing disease after it has started.

Suicide is higher compared to peer countries, and driven by firearms

Raifman J, Sampson L, Galea S. Suicide fatalities averted with lower firearm ownership in the United States. Under review

60

http://www.motherjones.com/mojo/2015/10/mental-health-gun-laws-washington-post-poll

Fatal firearms, temporal trends by race

From 2000 to 2010: Whites: Annual rate change= 0.006 per 100,000, P-trend=0.71 Blacks: Annual rate change= -0.114 per 100,000, P-trend=0.22 Other race: Annual rate change= -0.12 per 100,000, P-trend<0.0001

Data source: CDC, WISQARS. NCHS Vital Statistics System for numbers of deaths. Bureau of Census for population estimates.

61

Lifetime prevalence of psychiatric disorders are comparable in Canada and the U.S.

Schaffer A et al. Community survey of bipolar disorder in Canada: lifetime prevalence and illness characteristics. Can J Psychiatry 2006; 51(1): 9-16. Patten SB et al. Descriptive Epidemiology of Major Depression in Canada. The Canadian Journal of Psychiatry February 2006. Kessler RC et al. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. JAMA 2005; 62 (6). “Mental Health and Mental Illness”. Anxiety Disorders Association of Canada. <http://anxietycanada.ca/english/pdf/kirby.pdf> Accessed November 21, 2014.

4.4 16.9 28.8 2.2 12.2 25.0 5 10 15 20 25 30 35 40 45 50 Bipolar disorder Major depression Any anxiety disorder Bipolar disorder Major depression Any anxiety disorder

Weighted survey prevalence

Canada United States

Firearm homicide rate per 100,000 in 2009

0.53 3.42 0.5 1 1.5 2 2.5 3 3.5 4

Canada United States

Rate per 100,000 population

Beatty, Sarah, Cotter, Adam. (2010) “Homicide in Canada, 2009,” Juristat 30 via “An Overview of Gun Control in US, Canada and Globally.” Coalition for Gun Control. <http://guncontrol.ca/overview-gun-control-us-canada-global/> Accessed November 14, 2014.

Proportion of households owning firearms

15.5 42.8 10 20 30 40 50 60 Canada United States

% of households

“An Overview of Gun Control in US, Canada and Globally.” Coalition for Gun Control. <http://guncontrol.ca/overview-gun-control-us-canada-global/> Accessed November 14, 2014.

65

http://www.motherjones.com/mojo/2015/10/mental-health-gun-laws-washington-post-poll

66

https://www.nytimes.com/interactive/2017/11/06/opinion/how-to-reduce-shootings.html

• Implications. There simply is no substitute for prevention

for some causes of population mental illness.

Treatment, curing us

• nce we get

sick Prevention, keeping us from getting sick

“Healthy People/Healthy Economy: An Initiative to Make Massachusetts the National Leader in Health and Wellness.” 2015. Data from NEHI 2013. <http://www.tbf.org/tbf/56/hphe/Health-Crisis> Tarlov A. Social determinants of health: the sociobiological translation. In: Blane D, Brunner E, Wilkinson R, editors. Health and social organization: towards a health policy for the 21st century. London: Routledge; 1996 pp. 71-93.

• 5. Can we rethink our approach and ask better questions?

Some people are ‘exposed’

Exposed Unexposed

Both exposed and unexposed have disease

Exposed Unexposed Unexposed with disease Exposed with disease

Risk factor Prevalence

Rose G. The strategy of preventive medicine. Oxford: Oxford University Press; 1992.

Identify those who are high risk Risk factor Prevalence

Rose G. The strategy of preventive medicine. Oxford: Oxford University Press; 1992.

Risk factor Prevalence

Rose G. The strategy of preventive medicine. Oxford: Oxford University Press; 1992.

Then decrease their risk

This strategy sees this

Exposed Unexposed Unexposed with disease Exposed with disease

But misses all of this

Exposed Unexposed Unexposed with disease Exposed with disease

Risk factor Prevalence

Rose G. The strategy of preventive medicine. Oxford: Oxford University Press; 1992.

An alternate, population health, strategy

Shifts the entire risk distribution Risk factor Prevalence

Rose G. The strategy of preventive medicine. Oxford: Oxford University Press; 1992.

The population health strategy

Exposed Unexposed

The population health strategy

Exposed Unexposed

The population health strategy

Exposed Unexposed

McMichael AJ. Prisoners of the proximate: loosening the constraints on epidemiology in an age of change. American journal of epidemiology 1999;149(10):887- 897.

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