Mental and behavioral health ELIZABETH C. KATz, EUGENE M. DUNNE, SAMANTHA LOOKATCH AND JOSHUA S CAMINS CHAPTER OUTLINE work, school, home). Within the broader category of mental MENTAL HEALTH/BEHAVIORAL DISORDERS AND SUICIDE 252 A. Definitions 252 gnostic categories. The most prevalent of the emotional disorders, and therefore the most costly to individua B. Epidemiology 253 C. Costs 254 and society, are depression and anxiety. Table 21-1 outlines mood(depressive), anxiety, and trauma disorders, the mental IL. RISK AND PROTECTIVE FACTORS 255 health disorders that are the focus of this chapter. A, Biologic Risk Factors 255 B. Psychological Risk Factors 256 C. Social risk factors 256 BEHAVIORAL DISORDERS D. Environmental Risk Factors 256 Behavioral disorders involve substance use or participation E. Culture/Diversity 257 n non-drug-related risky behaviors (e.g, gambling, overeat Protective Factors 257 ng), also known as behavioral addictions, to such an extent III PREVENTION AND HEALTH PROMOTION that they appear compulsive ("out of control" of the indi- STRATEGIES 257 vidual) and pose serious threats to the participant's health A. Theoretical Framework 257 and well-being. Behavioral disorders represent extreme cases B. Public Policy 258 of typical behaviors(e.g, alcohol dependence; overeat C. Media Campaign point of obesity) D. Screening 258 Substance use, both licit(e.g, alcohol, tobacco)and illicit E. Psychosocial Interventions 259 (e, g,, cocaine, heroin), varies along a continuum(Fig. 21-1 ef Interventions 259 Misuse of a substance is often indicative of a risk for more 2. Longer-Term pathological use. Pathological use may be characterized by macologic Interventions 260 IV. SUMMARY 261 HIV infection, incarceration ), tolerance(need to take n 8. continued substance use despite serious consequences of REVIEW QUESTIONS, ANSWERS, AND EXPLANATION experience It withdrawal whether other beh ors, such as overeating, excessive video game or Internet use, and sexual behavior, may be considered behavioral addic- Depression, anxiety, schizophrenia, and substance abuse tions. The following arguments favor the behavioral addic- prominent among the mental health and behavioral disor- tion concept ders. Affecting more than 450 million people worldwide and associated with substantial morbidity and mortality, these Such behaviors often appear compulsive (outside the individual's control). disorders are critical targets for prevention efforts because of Participation is continued despite experiencer their toll on individuals and socie egative consequences. y resp addiction is also involved in excessive pursuit of these MENTAL HEALTH/BEHAVIORAL DISORDERS AND SUICIDE Research also suggests that substance and behavioral orbid. Although strong evidenc A. Definitions upports the inclusion of pathological gambling and exces MENTAL HEALTH DISORDER sive Internet use within the broader of addictive disorders, evidence supporting other behavioral addictions Mental health disorder is a broad term that refers to a set of (e.g,, kleptomania, sexual addiction)is less compelling emotions, cognitions, and behaviors that cause distress to However, others consider the evidence in support of the food individuals or others are abnormal from the bective of addiction concept, specifically as it relates to compulsive the society or culture, and result in harm to self or others overeating and bulimia, to be compelling. Obesity is dis- in functional impairment in one or more domains (i.e, cussed in Chapter 19
CHAPTER 2 Mental and Behavioral Health Table 21- Mood, Anxiety, and Trauma Disorders: Key Conditions and Descriptic Category Defning Conditions Category Description Mood( depressive Major depressive disorder Pervasive and persistent feelings of sadness or loss of Dysthymic disorder Weight loss/gain; decreased energy or agitation; poor Anxiety disorders sorder with or without agoraphobia anxiety impulsive disorder Trauma disorders Anxiety disorder resulting from exposure to traumatic event Acute stress disorder rape, war/combat, natural disaster,terrorism Individual perceives self or other person to be at risk of Individual reexperience event through vivid dreams or memories, with dissociation an Modified from American Psychiatric Association: Diagnostic and statistical manual of mental disorders, ed 4 n), Washington, DC 2000, APA. set of shared and unique criteria, The mood disorders category also cludes bipolar disorder, which is not addressed in this chapter. The trauma disorders are included in the anxiety disorders category in DSM-IV-TR; however, because their prevention and treatment are often different from other anxiety disorders, they are treated as a separate category in this chapter. Experimentation Trying a substance one or more times MisuseHconsesiuen! use that has not resulted in serious Abuse Continued use in spite of problems or use in dangerous situations Dependence eristic withdrawal ymptoms, and functional Figure 21-l Continuum of substance use SUICIDE (age 18 or older)met criteria for a mental health disorder in he past year. Table 21-2 outlines prevalence estimates for Suicide is a purposeful act directed toward ending one's mood(depressive), anxiety, and trauma disorders. Whereas suicide is intended to refer to successful completion of the act, the term suicide attempt is intended to refer to any ct of self-harm, including parasuicidal behavior such BEHAVIORAL DISORDER cutting, regardless of the intent of the behavior or the Figure 21-2 presents rates of licit and illicit substance use. utcome Suicidal ideation refers to thoughts about killing Among licit substances, alcohol is most often used, with 52% or harm of individuals age 12 or older reporting tobacco use in the ast year, followed closely by tobacco products, used by 28% of individuals age 12 years and older. While not as pre revalent as alcohol and tobacco, illicit substances are used at alarming MENTAL HEALTH DISORDERS rates and include marija juana, cocaine, heroin, and amphet amines. Evidence indicates abuse of prescription medica Mental health disorders affect a large segment of the U.S. tions (i.e,, use for nonprescribed purposes such as " getting population. Research suggests that about one in five adults high"or to help study) has been increasing in recent years
SECTION 3 Preventive medicine and public health Table 21-2 Prevalence Estimates for Depressive, Anxiety, and Trauma Disorders 口 Adults(aged26to49) Disorders Prevalence 口 Older adults(age50+) Mood 11% for any mood dis all ages sorder, all ages 6%6-8% for any mood As many as 30%0 experience subclinical depressed mood lasting 2 or more weeks Suicidal thoughts ade a plan Made an attempt Anxiety Figure 2-3 Past-yea lence estimates for suicidal ideation eria for disorder 3.6%o for posttraumatic stress disorder(PTSD), attempts in young adults age 18-24, adults age 26-49, and older adults 50 and older.( From Substance Abuse and Mental Health Services 5%6-51% meet criteria for PtSD (lifetime) after Administration: Suicidal thoughts and behaviors among adults: the NSDUH report,rockville,Md,2009,OffceofAppliedStudieshttp:// depend on severity of trauma and www.samhsa.gov/data/2k9/165/suicide.htm) methodologic issues* the U.S. population. Eating or food addictions are believed to affect 3%, with women affected more often than mel CONCURRENT MENTAL HEALTH AND BEHAVIORAL DISORDERS There is a high degree of comorbidity among mental health 100.0 disorders and between mental health and behavioral disor- 口 Youth(1 ders. Specifically, anxiety and depression are present concur- 80.0% a Young adults(18 to 25 years) rentlyinabout 50%of patients. Amongsubstance-dependent individuals, 60%to 80%of adults and 60% of youth have a comorbid mental health disorder. Moreover, approximately 25% to 30% of depressed and anxious adults meet criteria 40.0% for a substance use disorder. Behavioral addictions (e. g gambling, overeating, Internet overuse)are often associated 20.0% with other behavioral and drug addictions, as well as psychi atric disorders Suicide accounted for more than 32 000 adult deaths in serious thoughts about killing themselves than make a ide. Research also suggests Note: NR= Not reported; Binge drinking is defined as consuming 5 more alcoholic beverages in a sitting for males and 4 or more that for every one successful suicide, there are as many as drinks for females 20 attempts. Among youth, estimates suggest that between 9.4%(ages 12 to 13)and 12.7%(ages 14 to 17)were at erious risk for suicide by virtue of having had serious sui Figure 21-2 Past-month prevalence estimates for substance use, cidal ideation or having made a previous attempt. Among 2009. Binge drinking, cigarette smoking, illicit substances, and prescription those at high risk, 37% made a suicide attempt in the past rug use in persons age 12 and older, adolescents age 12-17, and youn adults age 18-25.(Modified from Substance Abuse and Mental Health year(Fig. 21-3) Services Administration: Results from the 2009 National Survey on Drug use and Health, Rockville, Md, 2010, Offce of Applied Studies; and National Institute of Alcohol Abuse and Alcoholism: NIAAA council C. Costs approves definition of binge drinking.) Mental health and behavioral disorders are stly Among behavioral addictions, pathological gambling is costs primar result from mental health care utilization estimated to affect 1% to 2% of the U.S. population, Sexual the costs associated with substance use disorders include behavior considered pathological is estimated to affect 50 both health care utilization (outpatient treatment; In regard to problematic Internet use, whereas 6% of users pitalization) as well as incarceration and interdiction can be considered addicted, this represents less than 1% of effor
CHAPTER 2 Mental and Behavioral Health through injection/intravenous drug use(IDU) or risky sexual practices with infected partners. Drug use during 5193181051810 pregnancy is associated with withdrawal symptoms among infants after birth and an increased risk of offspring develop 150 88100 SUICIDE Following a successful suicide, bereavement of family and friends can be lengthy and complicated. In addition to grief, surviving family members and friends feel guilty, con fused, depressed, and anxious and may even experience su cidal thoughts or make suicide attempts themselves. 8 I. RISK AND PROTECTIVE FACTORS Figure 21-4 Overall economic impact of mental health and ehavioral disorders. Annual estimate: year of estimate: 1998(alcohol). Factors that affect the development of mental and behavioral 2007(tobacco), 2002(illicit drugs ); year of estimate: 2002. (a from Dozois health disorders fall within several broad categories: biologic, DIA,Westra HA: In Dozois DIA, Dobson KS, editors: The prevention of anxiety 1 Whereas some may be directly modifiable through educa- hological, social, environmental, and cultural American Psychological Association; b from Substance Abuse and Mental Health Services Administration: State estimates of substance use and mental health tion or treatment(e. g, negative thinking), other risk fac disorders from the 2008-2009 National Surveys on Drug use and Health (e.g., temperament)may not. However, some suggest that a NSDUH Series H-40, HHS Pub No SMA ll-4641, Rockville, Md, 20ll, Office diathesis-stress model may serve as the most useful frame work for understanding the development of mental health disorders and behavioral problems. This model suggests MENTAL HEALTH DISORDERS that preexisting biologic and psychological vulnerabilit predispose a vulnerable individual to problematic emotions In addition to economic impacts, mental health disorders are and behaviors when facing stress that exceeds one's ability to associated with the following.: cope. Thus, it is important to be able to recognize these a Educational and occupational impairment nonmodifiable factors because they may help identify those Difficult social relationship most in need of prevention and intervention efforts Stress and mental health problems in family members caring for an affected person A. Biologic Risk Factors ■ Poor quality of life a Development of, and impaired recovery fre Genetics have been found to account for 30% to 40% of an individual's risk for anxiety and depression2,2 and 50%to Substance abuse/dependence 60%of risk for substance dependence(although heritability Death by suicide or other causes estimates for drug dependence are more variable than for alcohol dependence). Research on addictio gests that although environmental e prom BEHAVIORAL DISORDERS inent role in the early stages of us genetics is more influential in the to pathologi Substance use disorders cause significant morbidity and cal use. 2 mortality both in the United States and worldwide. Alcohol Endophenotypes represent inherited traits that are risk tobacco, illicit substances, and prescription medications are factors for disorder and are both present and detectable before all responsible for a substantial number of avoidable deaths the disorder is expressed. Table 21-3 lists traits that represent because of their deleterious health effects. Specifically, exces ossible endophenotypes for mental health and behavioral sive use of both licit and illicit substances is associated with disorders. Other biologic factors associated with dysphoric ardiovascular disease and many different types of cancer. mood(either anxiety or depression) include the following By impairing attention, concentration, and judgment, alcohol consumption is believed to be a causal factor in risky Hormonal changes(e. g, mood disorder with postpartum sexual practices,incre onset the risk of unwanted pregnan- Pediatric autoimmune neuropsychiatric disorders associ- cies and sexually transmitted infections(STIs), aggressiv behavior, and fatal motor vehicle crashes. Smoking during ted with streptococcal infections(PANDAS), associated pregnancy is associated with premature birth as well as low with a rapid onset of tics, Tourette s syndrome, and birth weight, which increase the risk for attention-deficit obsessive-compulsive disorder in children yperactivity disorder (ADHD), conduct problems, and Amount of daylight(e.g, mood disorder with seasonal poor school achievement. pattern) Nonprescription use of medications accounts for a sub- Disturbances of the circadian rhythm" stantial number of emergency department admissions and The pharmacologic properties of drugs explain why the tly increases the are used. In particular, users often report that they use sub isk of contracting infectious diseases(e. g, HIV, hepatitis B) stances" to feel good, to feel better, to alter consciousness
256 SECTION 3 Preventive medicine and public Health Table 21-3 Inherited Temperaments or Traits Indicative of Risk for Anxiety, Mood( Depressive), and Substance use Disorders Disorder Traits Anxiety and dency toward introversion, shyness, and caution in Increase risk ( tendency to be fussy, agitated, and irritable) Negative affect(tendency toward negative, depressed, irritable, or angry mood) Increase ris Alcohol dependence Facial flushing Decrease risk Decreased sensitivity to effects of alcohol Increase risk Alcchol nd drug avioral disinhibition, sensation seeking, impulsivity, impaired ex Psychiatric disorders Increase risk Increase risk modified from Dozois DJA, Dobson KS, editors: The prevention of anxiety and depression: theory, research, and practice, Washington, DC, 2004, American Psychological +Modified from Miller WR, Carroll KM, editors: Rethinking substance abuse: what the science show, and what we should do about it, New York, 2006, Guilford. tModified from Giegling L, Olgiati P, Hartmann AM, et al: Personality and attempted suicide. Analysis of anger, aggression and impulsivity, J Psychiatr Res 43: 1262-1271, 2009 d to do better (e. g, steroids to enhance physical perfor- such drugs are safer than illicit substances and pose no mance, prescription lulants to enhance academic serious health risks, o performance) The extent to which an individual believes that others The presence of one disorder may be a risk factor for would benefit from the persons death(" perceived burden another. Specifically, anxiety often precedes, and thus may be sameness")and that the individuals basic needs for affilia a causal factor in, the development of depression. Exter- tion are not being met(thwarted belongingness")are risk nalizing disorders during childhood(e. g, conduct disorder, factors for suicidal ideation. Suicide risk increases when ADHD) are associated with an increased risk of substance suicidal thoughts are combined with an increased acceptance se problems that persist into adulthood. Other potential of suicide as a viable option and feelings of hopelessness associations between psychiatric and substance use disorders One of the best predictors of future suicide attempts is past include the following suicidal behavior. Pathological substance use causes anxiety, depression and other mental health disorders by increasing stress or C. Social Risk Factors impacting sensitive neural systems. Anxiety, depression, and other mental health disorders Among vulnerable individuals, exposure to anxious parents o cause pathological substance use because substances help or to substance-using peers"increases the risk of develop to regulate negative moods ing an anxiety or substance use disorder, respectively. Psychiatric and substance use disorders share genetic risk Parental depression significantly increases the risk of de factors(e.g, difficult temperament, negative affectivity) Press wy of emotional availability and bonding, or family and other risks(e. g, maladaptive responses to stress, lack disruption D irect exposure to a threatening stimulus a Psychiatric and substance use disorders reciprocally infl (e.g, trauma, social evaluation) will also lead to the devel ence one anothe opment of specific phobias and traumatic stress disorders Direct-to-consumer advertising of psychotherapeutics may play a role in perceptions of these drugs and nonmedical B. Psychological Risk Factors use. Excessive attention and glorification of suicides in the media are believed to increase the risk for copycat Individuals' thoughts, beliefs, expectancies, and self- behavior naped through an interaction of emperaments, sensitive neural systems, hormones, and early D. Environmental Risk Factors learning experiences and thereby influence of mental health and behavioral disorders. Thus, both Stress and adverse early environments, such as those charac- depression and anxiety are associated with maladaptive terized by child abuse and neglect, domestic violence, dis- thought patterns, although the content of the maladap, 6 factors for anxiety and depression, behavioral problems, e crimination, and poverty, are among the most significant risk thoughts associated with anxiety and depression differs. Similarly, beliefs about the effects of a substance, known as and suicide. Beyond stress, other environmental risk factors outcome expectancies, influence the age of onset and level of for mental and behavioral health disorders are as follows substance use. Positive expectancies(beliefs that drinking will produce positive outcomes)are associated with increased Social isolation use, but negative expectancies do not appear to deter use. Inadequate transportation, housing, education, employ- Moreover, one explanation for the increase in nonmedical use of prescribed medications includes the perception that Poor parenting practices