Midterm Review Flashcards
Biomedical Model (definition, cause, treatment, and classification)
Definition: biological dysfunction of the brain/a disease of the brain
Cause: has specific causes - genetic, biological, acquired
Treatment: psychopharmaceuticals, ECT
Classification: Mental health and illness as distinctive, binary, mutually exclusive categories
psychological-behavioural model (definition, cause, treatment, and classification)
Definition: common patterns of thinking, feeling and behaving with adverse consequences on an individual (psychological)
Cause: personal experience and perspectives
Treatment: psychotherapy - trying to change patterns of thinking, feeling and behaving
Classification: mental health and mental illness as two extremes on a continuum
Social model (definition, cause, treatment, and classification)
Definition: mental illness as socially constructed, is defined and redefined based on what counts as socially appropriate
Cause: power and culture, social problems
Treatment: social interventions and social programs; e.g. supported housing and employment, skill building programs, changing social conditions
Classification: mental illness as rational, describing one’s distance from what is ‘normal’
Bio-psychosocial model
- biological factors, social conditions, and individual experiences all contribute
- “social” refers to social determinants of health
- responses try to consider all factors in relation to mental health in an individual, problems are not just psychological but rooted in social environment
What is “madness”?
An elastic concept that helped explain a range of unusual, bizarre, or irrational human behaviours
Factors contributing to the medicalisation of mental illness (asylum era)
- challenges to the authority and power of the Church in Europe
- The scientific revolution - idea that science could solve problems
- The enlightenment - skepticism about religion and the supernatural
- Increased urbanisation - led to increased visibility of people who appeared “mad”
Shifts to become increasingly seen as a medical problem
What is moral treatment?
A philosophy that emphases humane benevolence in treatment rather than restraint and punishment and attempted to restore mental health
- often pointed as the foundation of the asylum movement
what is social control?
Critical perspective on the asylum era by Foucault and Scull as efforts to remove “problematic people” from society (control rather than care)
- individuals deemed problematic due to behaviour violating social norms were defined as mentally ill and then were confined to asylums or prisons
What was the shift to increase regulation of psychoactive substances and how was this accomplished?
Shift: unregulated sales of psychoactive substances led to high levels of use and problems related to opiates and cocaine (late 19th century)
Accomplished through the licensing and regulation of physicians and restricting the legal treatment of illness to physicians
And regulation of pharmaceutical companies
4 Acts that brought stronger regulations for psychoactive drugs (not Kefauver Amendment)
- US 1906 Food and Drug Act
- requirement to disclose substances in labelling - US 1914 Harrison Anti-Narcotic Act:
- physician prescription for sale of cocaine and opiates - Canada Opium and Narcotic Drug Act 1929
- Britain Dangerous Drugs Act 1920
Immediate impact and implications of the regulation of psychoactive substances
Immediate impact: reduced physicians prescribing of psychoactive drugs, “non-medical” sales became illegal and criminalised
Implications: access to psychoactive drugs became officially managed by physicians and medical industry - substances are now fully medicalised
Kefauver Amendment to the federal food, drug, and cosmetic Act
Requires companies to demonstrate not just safety, but that they are “effective”
- BUT not more effect than existing or competing medications, just more effective than a placebo
Case Study 1 - Antidepressants and the placebo effect (Krish)
SSRIs for the treatment of MDD:
- 25% of the response to the drugs was a true effect of medication
- 50% of the response to the drugs was due to the placebo effect
All available data (published and unpublished): placebo effect accounts for 80% of patient response to the medication
75% of published trials show significant benefit of medications compared to placebo
Unpublished trials show only 12% of trials demonstrated benefits
conclusions: prescribing SSRIs is “insufficient” and recommend that psychotherapy, exercise, and acupuncture provide the same benefit, with lower risk of side effects
And relapse rates are higher in relation to ADMs compared to other treatments
Case Study 2 - Is cognitive therapy enduring or are antidepressants iatrogenic (illness caused by medical examination or disease)
Belief that severe depression requires ADMs was tested
After 8 weeks: PLA 25%, ADM 50%, CBT 43% (ADM most effective)
After 16 weeks: ADM 57.5%, CBT 58.3% (CBT was slightly more effective than ADM)
Patients who did CBT were much less likely to relapse
Patients taking placebo were likely to relapse
ADM got strong continuation medication effect & relapse risk reduced 50%
Conclusion:
- CBT has more enduring positive results and a reduced risk of relapse compared to ADMs
- ADM interferes with CBT reducing its enduring effect, but placebo does not have this effect
- Therefore, potential iatrogenic effects of ADM, meaning the medication and side effects may lead to disease or negative outcomes
- This could explain why we don’t see improvements related to the prevalence of depression
- Unmedicated patients typically do better than medicated ones, but those receiving meds may be more unwell or more severe
Case Study 3 - Antidepressant medication and psychotherapy (Benoit Mulsant)
- The high rate of prescription of antidepressants is partially attributable to lack of access to CBT
- wait times to access a psychiatrist in Ontario are 3-12 months
Capacity problem: Ontario is estimated to have 15 psychiatrists per 100,000 population
Access problem: health insurance does not cover psychologists and counsellors - psychotherapy only available through private insurance and for wealthier patients (90 day pills of ADMs costs less than 1 psychotherapy session)
Side effects:
- ADMs can lead to suicide
- poor quality therapy may result in worsening of depression or anxiety
Case Study 4 - Biases in the reporting of antidepressants
- Publication Bias: unpublished results obscure true picture of effectiveness, as these trials more often show negative effects, medications not more effective than placebo
- Outcome reporting bias: negative effects not mentioned in a published paper
- Spin bias: may include negative outcome but focuses on other outcomes/analyses
- Citation bias: publications showing positive results are cited 3 times more often than those with negative results
All 5 Schizophrenia Prevalence Estimates (and their sources)
DSM - 0.3-0.7% - globally
NIMH - 1.1% (changed to 0.3%) - globally
MSDPS 1.8% in the US
WHO 1% Globally
CARMHA 0.36% in BC
Tiered Service Model Pyramid
Tier 1 (very bottom): mental health and wellness promotion/substance use prevention
- population-based health promotion
- example: health literacy
- low service intensity
- high number of people (population-based!)
Tier 2: Targeted prevention & early intervention
- prevention and identification of early symptoms
- motivational approaches
- peer support for people at risk
Tier 3: Assessment and general treatment
- diagnosis
- counselling and basic treatment
- targeted for people w identified problems
Tier 4: specialised intervention
- targeted to people diagnosed w mental disorders and/or substance use disorders
- specialised care
Tier 5: Highly specialised care
- targeted to people w complex and severe mental health and/or substance use
- high service intensity
- low number of people (specialized)
The spectrum of psychoactive substance use
Beneficial - use that has positive health and/or social impacts (prescribed or moderate consumption of alcohol)
Non-problematic - recreational or casual that doesn’t really have health or social effects
Problematic - use at an early age and negative health impacts for individuals, friends/family, or society
Chronic Dependent - use that becomes a habit and compulsive despite negative health and social effects
Major Depressive Disorder (MDD)
- severely low mood
characterised by anhedonia (lack of enjoyment and pleasure and interest) - sense of worthlessness
- changes in appetite
- low energy
- thoughts of death
- symptoms must last at least two weeks to be diagnosed
- WHO: #1 cause of disability globally
- elimination of the bereavement exclusion (previously loss of loved one would NOT be deemed major depression)
Persistent Depressive Disorder (previously called dysthymia)
- chronic low mood over a period of 2 years or more
- symptoms include MDD characteristics, but diagnosis requires the presence of fewer symptoms
Symptoms must last at least two years (persistent):
- feeling low, limited/excess appetite, sleep disruptions, lethargy, sense of failure, lack of hope/faith in self/future
Less intense than MDD, but longer term
Premenstrual Dysphoric Disorder (PMDD)
New to DSM-5
- changing mood and appetite, irritability, during the luteal phase of the menstrual cycle (time between ovulation and menstruation)
- distinguished from premenstrual syndrome by the severity of symptoms and increased impact on daily functioning
some critics note that the addition of “disorder” is overly medicalising a natural biological process and women’s bodies/minds (constructing these as “inherently ill”)
- further controversy: creation of this diagnosis coincides with the extension of a patent for a medication intended to treat it (new medication “Sarafem”, is Prozac renamed - fem used for feminine)
Disruptive Mood Dysregulation Disorder (DMDD)
new to DSM-5
- diagnosis applied to children between the ages of 6-18
- Children w DMDD exhibit extreme anger and irritability that seems disproportional to the triggering situation (unwarranted)
- added to DSM to address (mis)diagnosis of bipolar disorder among children
Controversy - questions validity and utility
- clinical descriptions overlaps with Oppositional Defiant Disorder
- children with DMDD are often treated with antipsychotics (why not antidepressants?)
- some claim it medicalises what may be normal phases of emotional development among children, and labelling influences processes related to identity
- Allen Frances (chairperson of DSM-4) encourages practitioners to ignore DMDD and refuse to diagnose it
Bipolar Disorder
Involves experiencing episodes of mania (high energy) and episodes of depression, previously termed “manic depression”
- mania is a key diagnostic feature
- mania episodes: elevated moods and increased engird lasting at least a week
- some people w mania report decreased need for sleep, inflated self esteem, flight of ideas, distractibility, may engage in compulsive and potentially harmful activities (substances, sex, gambling)
