The Implications of an Evolutionary Perspective on Mental Health ...

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The Implications of an Evolutionary Perspective on Mental Health Promotion a

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Andrew Joyce , Peter Howat & Bruce Maycock

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School of Pharmacy

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Centre for Behavioural Research in Cancer Control, Division of Health Science

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WA Centre for Health Promotion Research, School of Public Health Curtin University, Perth, Australia Available online: 14 Feb 2012

To cite this article: Andrew Joyce, Peter Howat & Bruce Maycock (2005): The Implications of an Evolutionary Perspective on Mental Health Promotion, International Journal of Mental Health Promotion, 7:4, 14-22 To link to this article: http://dx.doi.org/10.1080/14623730.2005.9721956

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Andrew Joyce Research Associate, School of Pharmacy Peter Howat Director, Centre for Behavioural Research in Cancer Control, Division of Health Science Bruce Maycock

The Implications of an Evolutionary Perspective on Mental Health Promotion

Associate Director, WA Centre for Health Promotion Research, School of Public Health

Downloaded by [134.7.248.132] at 17:49 01 April 2012

Curtin University, Perth, Australia

Keywords: evolution; prevention; depression; cardiovascular disease

Evolutionary perspective Theories and studies from an evolutionary perspective can inform the practice of medicine (Nesse & Williams, 1995) and public health (Eaton, Strassman et al, 2002), where a

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Although Darwin formulated his theory of evolution in the nineteenth century, it is only recently that evolutionary theories have penetrated medicine (Nesse & Williams, 1995) and health promotion (Eaton, Strassman et al, 2002). This paper examines the implications of an evolutionary perspective for mental health promotion. Borrowing from the literature of evolutionary psychopathology, neuroendocrinology and social determinants of health, it will show how an evolutionary perspective reveals that mental health promotion can assist in reducing the prevalence of depression and cardiovascular disease. An evolutionary perspective can also provide direction for mental health promotion policy and program development.

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knowledge of Darwinian selection pressures can assist in explaining disease causes and manifestations. Current antiviral treatment of HIV is based on evolutionary principles (Palumbi, 2001) and the understanding of Alzheimer’s disease, atherosclerosis and prostrate diseases is aided by applying evolutionary principles (Wick et al, 2003). Health promotion practice can be shaped by understanding how the discrepancy between the environment suited to our genome and our modern environment may be responsible for the Western world’s high rate of degenerative diseases (Eaton, 2003; Eaton, Cordain & Lindeberg, 2002; Eaton, Strassman et al, 2002). An evolutionary viewpoint can assist in addressing the major public health problems of physical inactivity (Eaton, 2003) and inappropriate diets (Friedman, 2003; Wargovich & Cunningham, 2003). An evolutionary understanding of mental illness can assist in efforts to prevent the high rates of depression and cardiovascular disease. Evolutionary theories have been presented to account for the occurrence of high rates of mental illnesses (Baron-Cohen, 1997). Rather than being interpreted as diseases, mental illnesses such as depression and anxiety can be construed as defence mechanisms that are exacerbated by modern environments (Nesse & Williams, 1995). A consideration of the physiological mechanisms behind the stress response (Carrasco & Van de Kar, 2003) reveals that an evolutionary understanding of mental illness has much in common with a social determinants understanding of human health (Marmot &

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Wilkinson, 1999) and highlights directions for preventing both depression and cardiovascular disease. Given predictions that by 2020 heart disease and depression will be the two most common world-wide causes of disease burden (Murray & Lopez, 1997), an evolutionary perspective has much to offer mental health promotion aimed at reducing the prevalence of depression and cardiovascular disease.


Evolutionary psychopathology Genetic disorders, such as Down’s syndrome, are rare, occurring at the frequency of 1 in every 10,000–15,000 births in the USA. Sickle cell anaemia is a known genetic disorder of greater frequency, caused by a recessive gene that reduces the oxygen-carrying capacity of the haemoglobin molecule. In individuals heterozygous for this trait there is the advantage of increased resistance to malaria (Wilson, 1997). Thus these genes that predispose to illness may have been selected to suit certain environmental pressures (Nesse & Williams, 1995). Common mental illnesses, like chronic diseases, are caused by a complex interplay of genetic and environmental factors. Unlike other chronic diseases, the incidence of mental illnesses is relatively high during late adolescence and middle age (Public Health Division, 1999), which makes these health problems very interesting from an evolutionary perspective. Their timing coincides with key reproductive and child rearing-years, in contrast with a disorder like Alzheimer’s disease, which predominantly affects older people (McGuire et al, 1997). There may have been very compelling reasons why genes that now predispose to mental illness were selected for in our past environment – genes which rather than hindering human life, actually promoted its continuance. Wilson has calculated the predicted rates of genes that predispose to bipolar illness, based on epidemiological rates for bipolar illness and the genetic contribution to the illness from twin concordance rates (1998). This is compared with the rate expected from spontaneous mutations. The rate for these genes so exceeded the rate expected from mutation that Wilson (1998) concluded that they have been selected for in our past. Wilson contends that they lead to a disorder because of the mismatch between the environment in which the genes were selected for and today’s environment. Already it is clear that at least some pathological syndromes are expressions not of genetic error but of past advantageous selection stretched by the current environment beyond the healthy range of phenotypic expression. (Wilson, 1998, p393)


There is consensus on the important role that evolutionary theory can have on our understanding of psychiatry and, more broadly, human health, but arguing for the adaptive qualities of specific traits is more speculative (Kagan, 1997). The functional role of anxiety is more obvious than that of other psychiatric problems such as depression or schizophrenia. Nesse (1998) highlights how specific DSM categories correspond to specific situations. Fear or anxiety of snakes, spiders, heights, storms, darkness, blood, strangers, separation and leaving the home range all correspond to well-known phobias, and thus natural selection would seem to have shaped emotional responses to different situations to aid our survival. In panic, people and animals often freeze to avoid detection and enable time to examine options (Marks & Nesse, 1997). Humans are not born with the ability to fear snakes and spiders, but are easily primed to fear these animals, whereas we are not easily primed to fear the modern threats to health of cars and cigarettes (Marks & Nesse, 1997). Given the current symptoms and experiences of depression, its functionality is less obvious, and at the extreme end of a continuum may represent a predisposed genetic vulnerability that is in no sense functional (Nettle, 2004). However, it has been contended that depression plays an important role in motivating and organising social relations (Price et al, 1997). Humans are very sensitive to social relationships, and the agreed upon social problems that humans faced include recognising and investing in one’s own offspring, selecting good-quality mates, detecting and relating to co-operators rather than exploiters or enemies, and recognising when to challenge and when to submit (Gilbert, 1998). To cope with these social problems, humans required a motivational system to register these things as important, strategies for solving such problems and a feedback mechanism to register how successful or not they were with such problems (Nesse & Williams, 1997). Just as symptoms such as coughing, vomiting and high temperature have the functions of removing disease or invader, it is contended that depression may also be an evolved strategy to cope with certain situations (Nesse & Williams, 1997). Some initial signs of depression, such as indicating low self-worth or showing signs of lack of interest, may be useful in eliciting help from other people (McGuire & Troisi, 1998). In correlation-based research, Hays and colleagues (1998) found that receiving instrumental help was related to an increase in depressed affect, which is consistent with other studies that have found a positive relationship between receiving support and depressed affect (Leathers et al, 1997). The increased levels of depression for those


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receiving help might represent other people responding to signs of depression (Hays et al, 1998; Leathers et al, 1997). When a sample of older people were studied who were all requiring assistance, it was found that bereaved older adults with high-information, tangible and emotional support had less psychological distress than people scoring low on those support indices (Krause & Markides, 1990). Thus certain symptoms of depression lead to receiving increased assistance, although prolonged depression and social withdrawal can deter other people from helping (McGuire & Troisi, 1998). Depression can also be viewed as functional in overcoming a loss. The onset of depression may facilitate a process of relinquishing goals and relationships that are no longer workable or achievable, and pursuing new activities. Therapists have long known that many depressions only go away after a person finally gives up some long-sought after goal and turns his energy in another direction. (Nesse & Williams, 1997, p9) In this model the biochemical change is not the cause of distress, but the process that facilitates an appropriate emotional and behavioural response to the environmental stressor. This argument does not imply withholding of medication to treat depressive symptoms (Nesse, 1998), rather that further research on the origin and function of positive and negative emotions is required so that its use is judicious (Nesse, 2004). Changes in serotonin levels could mediate the appropriate response to the environment from a survival perspective (Gilbert, 1998). In situations of loss or anticipated loss, reduced serotonin activity, felt as depression or anxiety, may be the most suitable response, as it facilitates flight behaviour, be that running away or submitting. Animal studies have shown that submission in the face of an attacker is more likely to reduce or halt the attack (Dixon, 1998). Depression can serve a number of functions: recruiting assistance, avoiding further loss and avoiding situations associated with a loss which would prolong survival of oneself and kin or friends. If there is a clear function for depression, then why is its clinical manifestation so obviously deleterious? An individual difference model proposes that those diagnosed with clinical depression represent the extreme end of a continuum (Nettle, 2004), as the genetic contribution to depression represents a quantitative rather than qualitative difference across the population (Lesch, 2004). If there is a normal distribution around anxiety and depression, shaped by natural selection, then those at the extreme end would be more vulnerable to depressive prob-

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lems (Nettle, 2004). This argument is also compatible with what Nettle (2004) has termed a dysregulation model as represented by Wilson (1998) and Nesse (1998); irrespective of an individual’s genetic predisposition, there is something peculiar about current environments that are producing high rates of emotional distress.

Possible social causes of mental and physical health disorders The preceding discussion on the function of anxiety and depression supports the argument that the human body has been well-designed for short periods of stress; feelings of anxiety and depression motivate an appropriate behavioural response to a short-term crisis. However, if these emotional and/or physiological systems are turned on for long periods of time, even at lower levels, it may be detrimental to health (Bruner & Marmot, 1999). The peculiarity of our modern social environments may be contributing to the high rates of emotional distress. The ancestral social environment of small, close-knit communities with co-operation and restricted competition is very different from the modern environment of dispersed social groups with endless opportunities for social comparison (Gilbert, 1998). The lack of a valued social position and role within a small community may be one of the predetermining factors in the rise of depression and cardiovascular disease (CVD). Epidemiological evidence concurs with theories that argue that the vastly different social environments currently being experienced are injurious to human health (Gilbert, 1998). Increased social activity has been related to a decrease in risk of all-cause mortality (Berkman & Syme, 1979; Glass et al, 1999; House et al, 1982; Kaplan et al, 1988). Higher levels of social support have been related to decreased incidence of depression (Hays et al, 1998; Hraba et al, 1997), and decreased risk of cardiovascular disease (Hemingway & Marmot, 1999). A review of 81 studies found strong evidence linking social support with cardiovascular, endocrine and immune function. It was concluded that social support has a very important role in preventing some of the leading causes of death – cardiovascular disease (CVD), cancer and respiratory illnesses (Uchino et al, 1996). A recent extensive literature review concluded that depression, social isolation and a lack of good social support independently cause CVD to a similar extent to known risk factors such as smoking (Bunker et al, 2003). A number of other reviews have concluded that depression is a significant risk factor for CVD (Hemingway & Marmot, 1999; Lett et al, 2004; Zellweger et al, 2004).




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Immunological change, hypothalamic pituitary adrenal (HPA) dysfunction and autonomic nervous dysfunction have all been implicated as pathophysiological mechanisms linking depression with cardiovascular disease (Lett et al, 2004; Zellweger et al, 2004). Increased cortisol production and decreased serotonin receptor levels are common in depression (Lopez et al, 1999), and excessive cortisol production as a result of HPA dysregulation is implicated in the aetiology of cardiovascular disease (Miller & O’Callaghan, 2002). The pathophysiology of depression/anxiety and cardiovascular disease is common, and thus whatever is contributing to depression is likely also to predispose to CVD later in life. The operation of the stress response highlights the interconnected nature of physiological systems. Stressful stimuli produce a range of neuroendocrine responses that are mutually regulating, such as the co-ordination of the HPA system and serotonin function (Carrasco & Van de Kar, 2003; Dinan, 1996). Recent studies suggest that these systems are integrated and linked at multiple sites (Carrasco & Van de Kar, 2003; Dinan, 1996; Lopez et al, 1999). In response to stressful stimuli, the hypothalamus produces corticotropinreleasing hormone (CRH). CRH then stimulates the pituitary gland to produce adrenocorticotropic hormone (ACTH), which stimulates the adrenal cortex, which produces corticosteroids. The HPA axis acts as a negative feedback system where, in humans, the production of cortisol inhibits the production of CRH, which initiates the ‘stress response’ (Miller & O’Callaghan, 2002). HPA activity also influences norepinephrine and epinephrine production, which is released in larger quantities in conditions of acute stress (Wurtman, 2002). These systems regulate cardiovascular functions such as the constriction of blood vessels and fat utilisation (Guyton, 1986). Serotonin, important in mood regulation (Carrasco & Van de Kar, 2003), is linked at multiple sites along the HPA axis, influencing the production of CRH at the hypothalamus and cortisol from the adrenal gland (Dinan, 1996). Cortisol production also affects serotonin receptor activity in the hypothamalus and hippocampus (Lopez et al, 1999). These systems are well-designed for short-term stressful events, the classic fight/flight response, but chronic and/or early stress can severely compromise these systems. Environmental stress beyond an organism’s coping ability will impact negatively on the interlinked hypothalamic pituitary adrenal (HPA) and serotonin systems (Carrasco & Van de Kar, 2003). Dysregulation of these systems can result in an increase in the production of cortisol, which can then negatively affect certain serotonin receptors located in the hypothalamus and hippocampus (Lopez et al, 1999).


Chronic stress and/or high steroid levels reduce the levels of a serotonin receptor found in the hippocampus which is associated with depressed mood (Lopez et al, 1997). Another serotonin receptor, the loss of which is implicated in impulsive and aggressive behaviour, has been found to have reduced functioning capacity when there is chronic stress and/or high cortisone levels (Lopez et al, 1997). Current research on the effects of anti-depressants also highlights the interconnected nature of these systems. The effect of anti-depressants had been traditionally thought to act upon serotonin re-uptake, whereby the blocking of reuptake facilitated increased serotonin transmission (Dinan, 1996). However, anti-depressants may be acting to decrease HPA activity, which then prevents the decrease in serotonin receptor expression (Lopez et al, 1998). As these systems are highly interconnected, stressful events will influence the conduct of both the HPA and serotonin systems. If this stress occurs early in life, there may be permanent alterations to neuroendocrine function. Rodent studies have shown that early disadvantage, such as prolonged maternal deprivation, may alter the resting levels of the HPA and serotonin systems through permanent reduction in serotonin receptors (Lopez et al, 1997). On the other hand, animals reared in a nurturing environment have shown healthier development such as an increased number of corticosterone receptors in the hypothalamus (Lopez et al, 1997). Primate studies have shown that phenotypic expressions of emotional and behavioural problems require both genetic predispositions and early life stressors, which interact to alter negatively serotonin systems (Barr et al, 2003; Bennett et al, 2002), while genetic predispositions to depressive traits can be attenuated by very supportive rearing (Suomi, 1997). Stressful life events can impair immunological function, together with changes to HPA function. KiecoltGlaser and colleagues (2002) reviewed the research on the immunological effects of negative emotions and then linked these immunological changes with disease outcomes. Negative emotions, most noticeably depression, have been shown to promote the production of pro-inflammatory cytokines. Cytokines attract immune cells to the site of infections and, while important for the early response to infection or injury, their over-production can have deleterious long-term effects. Stressful events can promote short-term increases in cytokine production, and negative emotions can also contribute to long-term dysfunction of the immune function by pro-inflammatory cytokine over-production. The functioning of the immune system is also interlinked with HPA function. Production of cortisol can have a negative impact on the immune sys-


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tem and conversely, immune dysregulation can promote CRC, which stimulates the stress response (Kiecolt-Glaser et al, 2002). A variety of animal and human studies have demonstrated that the HPA, serotonin and immune systems are protected by positive relations and impaired by stressful events. It has also been demonstrated that these systems are highly inter-related, so a stressful event should have multiple repercussions on physiological systems. For example, early life or prolonged stress should impact negatively on both HPA and serotonin function, which, as mentioned, are important cardiovascular and mood regulation systems. If these systems are highly integrated, then it would be expected that certain diseases would co-occur, which is exactly what medical research is discovering, particularly on the co-morbidity of depression and cardiovascular disease.

Implications of an evolutionary perspective: targeting the social environment The first step in program or policy planning is to define the nature of the problem and decide whether the problem is significant (Maycock et al, 2001). Certainly, as depression and cardiovascular disease will be the most prominent diseases of the future (Murray & Lopez, 1997), the significance is clearly established. The difficulty with mental health promotion lies in clearly defining the problem in a way that provides direction for policy and program developers. The large number of risk and protective factors linked with depression (Commonwealth Department of Health and Aged Care, 1998) means that health promotion professionals are faced with a large set of priorities from which to choose. It has already been demonstrated that an evolutionary perspective assists in focusing attention on the importance of positive social relations in preventing depression and thus also cardiovascular disease. It will also be demonstrated in the last section of the paper that an evolutionary perspective can assist the development of policies and programs directed to promoting positive social relationships. Sanders (2002) has argued for broad-scale implementation of parenting programs, based on a claim for their importance in preventing mental health problems in children. This priority fits within a number of policy frameworks and policy documents, produced through the Commonwealth Government, on mental health promotion (Commonwealth Department of Health and Aged Care, 2000a, 2000b), early childhood health (Commonwealth Taskforce on Child Development Health and Wellbeing, 2003) and social capital (Productivity Commission, 2003).

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When applying an evolutionary perspective, the benefits of such a program, promoting positive relations and reducing the likelihood of negative childhood experiences, are broader. As reviewed, promoting strong relationships early in life could have a positive influence on life-long cardiovascular and immune function. These government frameworks overlap in approach without acknowledging each other, and do not adequately capture the potential significance of mental health promotion programs to prevent cardiovascular disease. An evolutionary perspective could assist in developing health promotion policy that is integrated, supports well-designed and well-evaluated mental health promotion programs and recognises the multiple benefits of mental health promotion programs. Applying an evolutionary perspective has much to offer program development. Two age groups that are commonly researched and viewed as priority groups for social connection interventions are teenagers and older people (VicHealth, 1999). These two groups may be at particular risk of social alienation. In our ancestral past, adolescents would have had clear and narrowly defined social roles in a small social group setting (Eaton, Strassman et al, 2002). Today, adolescents who lack strong social connections are at risk of health behaviours such as drug use, risk of unintentional injury and suicidal ideation (Resnick et al, 1997). Foraging people are purported to have lived well into older age, and their life expectancy was greater than that of early agricultural communities (Eaton, Cordain & Lindeberg, 2002), and greater than what would be expected from other primates (Hawkes et al, 1998). It has been proposed that human longevity is due to the purposeful roles of older people in foraging for their families (Hawkes et al, 1998) and transmitting knowledge to young children (Lewis, 1999). However, today older age is associated with role loss and isolation (Heller et al, 1991). When young and older people have been questioned about what is important to their health, strong social connections with a few people rates very highly. However, often school-based programs or social support programs for older people concentrate on larger group-style activities. A project that consulted teenagers on what they thought were important aspects for their health and wellbeing found that feeling loved and supported by family was rated as the most important protective factor (Fuller et al, 1998). Thus small programs providing teenagers with purposeful social roles or only addressing parent connection within a school (Fager & Brewster, 1999) may be appropriate health promotion targets if larger social programs have difficulties in altering the social landscape of a school (Wyn et al, 2000).




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Farquhar (1995) interviewed older people about how they defined quality of life. Reasons for describing their life as positive included social contacts, and reasons for describing their lives in negative terms included reduced social contacts. Farquhar concluded that family, friends and activities are as valued as general health and functional status. Meaningful social activities may be one of the most effective contributors to psychological well-being (Lawton et al, 1999). When older people have been consulted about what type of social program they would like, ‘something small’ is a common response (Howat et al, 2004; Mansourian, 2000). Older people are most often studied as recipients of support, and this does not recognise the amount of help and support that older people provide to individuals and the community. In a sample of 351 older adults, 39% indicated they would like to provide support more often to other people (Krause & Markides, 1990). Mayer and colleagues (1999) commented on the need for older people to have a sense of purpose in their lives, and that older people should not be characterised only as passive recipients of support. From an evolutionary perspective and based on epidemiological and qualitative research, a strong sense of connection and purpose within a small group setting would seem a fundamental requirement for positive health, a ‘primal’ need, as described by Nesse & Williams (1995). Any move to increase social connection could decrease the prevalence and severity of depression and cardiovascular disease. This work thus belongs to more than just mental health promotion, and needs to be recognised for its multiple benefits. A more integrated evolutionary understanding of human health that recognises the multiple benefits of improving social environments may assist in furthering this policy and program agenda.

Conclusion Mental health promotion could benefit from applying an evolutionary perspective in much the same way as other medical and public health areas. An explanation of mental illness that uses evolutionary theory is consistent with a social determinants view of health, and highlights the importance of early childhood experiences and the broader social environment for both mental health and cardiovascular health outcomes. Programs and policies that increase the likelihood of nurturing environments for early childhood and provide different groups of people, particularly adolescents and older people, with a sense of purpose are critical. An evolutionary perspective can inform the development of mental health promotion policies and programs,


and demonstrates the potential of mental health promotion to assist in reducing the prevalence of depression and cardiovascular disease.

Address for correspondence Dr Andrew Joyce, Research Associate, School of Pharmacy, Curtin University of Technology, GPO Box U1987, Perth, Western Australia 6845. Tel: (+61 8) 9266 4404, Fax: (+61 8) 9266 2769, Email: [email protected].

Acknowledgements The authors would like to thank Professor James Chisholm and Kate Miller for their comments on earlier versions of this paper.

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