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

Population mental health: Toward a global research agenda Sandro Galea University School of Public Health Bo Boston Un

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 140 120 Age-adjusted mortality rate 100 80 Accidents 60 Suicide 40 20 0 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 Time 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 $190,821,500 $33,608,528,210 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 6 “Genetic”, “genetics”, or ”gene” "Population" or "public" 5 Percent of total NIH budget 4 3 2 1 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Fiscal year NIH RePORTER. Search terms included in project titles. <http://projectreporter.nih.gov/reporter.cfm> Accessed on March 18, 2019.

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 ”

Population health manifests as a continuum. 1. The causes of differences in health across populations are not necessarily an 2. aggregate of the causes of differences in health within populations. Large benefits to population health may not improve the lives of all individuals. 3. The causes of population health are multilevel, accumulate throughout the life 4. course, and are embedded in dynamic interpersonal relationships. Small changes in ubiquitous causes may result in more substantial change in the 5. health of populations than larger changes in rarer causes. The magnitude of an effect of exposure on disease is dependent on the 6. prevalence of the factors that interact with that exposure. Prevention of disease often yields a greater return on investment than curing 7. disease after it has started. Efforts to improve overall population health may be a disadvantage to some 8. groups; whether equity or efficiency is preferable is a matter of values. We can predict health in populations with much more certainty than we can 9. predict health in individuals.

Population health manifests as a continuum. 1. The causes of differences in health across populations are not necessarily an 2. aggregate of the causes of differences in health within populations. Large benefits to population health may not improve the lives of all individuals. 3. The causes of population health are multilevel, accumulate throughout the life 4. course, and are embedded in dynamic interpersonal relationships. Small changes in ubiquitous causes may result in more substantial change in the 5. health of populations than larger changes in rarer causes. The magnitude of an effect of exposure on disease is dependent on the 6. prevalence of the factors that interact with that exposure. Prevention of disease often yields a greater return on investment than curing 7. disease after it has started. Efforts to improve overall population health may be a disadvantage to some 8. groups; whether equity or efficiency is preferable is a matter of values. We can predict health in populations with much more certainty than we can 9. 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 0.8 0.7 Predicted probability of depression 0.6 0.5 0.4 Women Men 0.3 0.2 0.1 0 0 1-2 3-4 5-6 7-8 > 8 Number of events endorsed 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 10 9 8 Depressed Not depressed 7 6 5 4 3 2 1 0 3-5.9 mo 6-11.9 mo 12-17.9 mo 18-23.9 mo 24-29.9 mo 30-44 mo 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+

Scenario 1 = DEP+ = ENV+ = GE+

Scenario 1 = DEP+ = ENV+ = GE+

Scenario 1 = DEP+ = ENV+ = GE+

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

Scenario 2 = DEP+ = ENV+ = GE+