Social inequality,scientific inequality,and the future of mental illness

Background

Despite five decades of increasingly elegant studies aimed at advancing the pathophysiology and treatment of mental illness, the results have not met expectations. Diagnoses are still based on observation, the clinical history, and an outmoded diagnostic system that stresses the historic goal of disease specificity. Psychotropic drugs are still based on molecular targets developed decades ago, with no increase in efficacy. Numerous biomarkers have been proposed, but none have the requisite degree of sensitivity and specificity, and therefore have no usefulness in the clinic. The obvious lack of progress in psychiatry needs exploration.

Methods

The historical goals of psychiatry are reviewed, including parity with medicine, a focus on diagnostic reliability rather than validity, and an emphasis on reductionism at the expense of socioeconomic issues. Data are used from Thomas Picketty and others to argue that our failure to advance clinical care may rest in part on the rise in social and economic inequality that began in the 1970s, and in part on our inability to move beyond the medical model of specificity of disease and treatment.

Results

It is demonstrated herein that the historical goal of specificity of disease and treatment has not only impeded the advance of diagnosis and treatment of mental illness, but, in combination with a rapid increase in socioeconomic inequality, has led to poorer outcomes and rising mortality rates in a number of disorders, including schizophrenia, anxiety, and depression.

Conclusions

It is proposed that Psychiatry should recognize the fact of socioeconomic inequality and its effects on mental disorders. The medical model, with its emphasis on diagnostic and treatment specificity, may not be appropriate for investigation of the brain, given its complexity. The rise of scientific inequality, with billions allocated to connectomics and genetics, may shift attention away from the need for improvements in clinical care. Unfortunately, the future prospects of those suffering from mental illness appear dim.

     

Information Mismatch: Cancer Risk Counseling with Diverse Underserved Patients

As genetics and genomics become part of mainstream Medicine, these advances have the potential to reduce or exacerbate health disparities. Gaps in effective communication (where all parties share the same meaning) are widely recognized as a major contributor to health disparities. The purpose of this study was to examine GC-patient communication in real time, to assess its effectiveness from the patient perspective, and then to pilot intervention strategies to improve the communication. We observed 64 English-, 35 Spanish- and 25 Chinese-speaking (n = 124) public hospital patients and 10 GCs in 170 GC appointments, and interviewed 49 patients who were offered testing using the audio recordings to stimulate recall and probe specific aspects of the communication. Data analyses were conducted using grounded theory methods and revealed a fundamental mismatch between the information provided by GCs and the information desired and meaningful to patients. Several components of the communication that contributed to this mismatch and often resulted in ineffective communication included: (1) too much information; (2) complex terminology and conceptually difficult presentation of information; (3) information perceived as not relevant by the patient; (4) unintentional inhibition of patient engagement and question-asking; (5) vague discussions of screening and prevention recommendations. Our findings indicate a need to transform the standard model of genetic counseling communication using evidence-based principles and strategies from other fields of Medicine. The high rates of limited health literacy in the US, increasing access of diverse populations to genetic services, and growing complexity of genetic information have created a perfect storm. If not directly addressed, this convergence is likely to exacerbate health disparities in the genomic age.     

Counting your blessings: Positive memories among grateful persons

We conducted two studies investigating the relationship of gratitude to autobiographical memory of positive and negative life events. Gratitude was assessed with an attitudinal measure and college students were asked to recall both positive and negative events from their past. In both studies, a significant positive relationship was found between trait gratitude and a positive memory bias. In Study 2 it was found that gratitude still reliably predicted positive memory bias after controlling for depression. Further, it was found that a positive intrusive memory bias was associated with gratitude in both studies. Thus, an important component of gratitude may be an enhanced tendency to recall positive events from one's life.     

Mental-state attribution drives rapid, reflexive gaze following

When presented with a face stimulus whose gaze is diverted, observers’ attention shifts to locations fixated by the face. Such “gaze following” has been characterized by some previous studies as a consequence of sophisticated theory of mind processes, but by others (particularly those employing the “gaze-cuing” paradigm) as an involuntary response that is triggered directly and reflexively by the physical features of a face. To address this apparent contradiction, we modified the gaze-cuing paradigm using a deception procedure to convince observers that prerecorded videos of an experimenter making head turns and wearing mirrored goggles were a “live” video link to an adjacent room. In two experiments, reflexive gaze following was found when observers believed that the model was wearing transparent goggles and could see, but it was significantly reduced when they believed that the experimenter wore opaque goggles and could not see. These results indicate that the attribution of the mental state “seeing” to a face plays a role in controlling even reflexive gaze following.     

A comparison of the mechanical effect of arm swing and countermovement on the lower extremities in vertical jumping

The purposes of this study were to quantify and compare how arm swing and countermovement affect lower extremity torque and work during vertical jumping and to gain insight into the mechanisms that enable the arm swing and countermovement to increase jump height. Five participants maximally performed two types of vertical squat jumps with (SJA) and without (SJ) an arm swing and two types of countermovement vertical jumps with (CJA) and without (CJ) an arm swing. The participants jumped from a force platform and all performances were videotaped with a high-speed video camera (200Hz). Jump heights, joint torques and work were calculated by combining kinematic and kinetic data. It was found that of the four jumping conditions, the participants jumped highest when they used an arm swing with countermovement (i.e., CJA). The increase of the countermovement jump height with an arm swing is the result of the increase of the lower extremity work. In the hip joint, the increase in torque caused by the countermovement predominantly occurred at the beginning of the propulsion phase, while the increase in torque caused by the arm swing occurred in the rest of the propulsion phase. A key finding of our study is that arm swing and countermovement have independent effects on lower extremity work, and their effects are additive in CJA to produce greater jump height.     

Transfer of movement sequences: bigger is better

Experiment 1 was conducted to determine if proportional transfer from "small to large" scale movements is as effective as transferring from "large to small." We hypothesize that the learning of larger scale movement will require the participant to learn to manage the generation, storage, and dissipation of forces better than when practicing smaller scale movements. Thus, we predict an advantage for transfer of larger scale movements to smaller scale movements relative to transfer from smaller to larger scale movements. Experiment 2 was conducted to determine if adding a load to a smaller scale movement would enhance later transfer to a larger scale movement sequence. It was hypothesized that the added load would require the participants to consider the dynamics of the movement to a greater extent than without the load. The results replicated earlier findings of effective transfer from large to small movements, but consistent with our hypothesis, transfer was less effective from small to large (Experiment 1). However, when a load was added during acquisition transfer from small to large was enhanced even though the load was removed during the transfer test. These results are consistent with the notion that the transfer asymmetry noted in Experiment 1 was due to factors related to movement dynamics that were enhanced during practice of the larger scale movement sequence, but not during the practice of the smaller scale movement sequence. The findings that the movement structure is unaffected by transfer direction but the movement dynamics are influenced by transfer direction is consistent with hierarchal models of sequence production.     

Ethnic and gender subgroup differences in assessment center ratings: a meta-analysis

Assessment centers are widely believed to have relatively small standardized subgroup differences (d). However, no meta-analytic review to date has examined ds for assessment centers. The authors conducted a meta-analysis of available data and found an overall Black-White d of 0.52, an overall Hispanic-White d of 0.28, and an overall male-female d of -0.19. Consistent with our expectations, results suggest that Black-White ds in assessment center data may be larger than was previously thought. Hispanic-White comparisons were smaller than were Black-White comparisons. Females, on average, scored higher than did males in assessment centers. As such, assessment centers may be associated with more adverse impact against Blacks than is portrayed in the literature, but the predictor may have less adverse impact and be more "diversity friendly" for Hispanics and females.