tag:theconversation.com,2011:/id/topics/psychiatric-disorders-4808/articlesPsychiatric disorders – The Conversation2023-03-15T12:21:41Ztag:theconversation.com,2011:article/1982822023-03-15T12:21:41Z2023-03-15T12:21:41ZDepression too often gets deemed ‘hard to treat’ when medication falls short<figure><img src="https://images.theconversation.com/files/514748/original/file-20230310-29-jqe5vl.jpg?ixlib=rb-1.1.0&rect=0%2C45%2C5106%2C3332&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A diagnosis of treatment-resistant depression can lead to a sense of hopelessness and despair in some patients.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/worried-young-woman-sitting-on-bed-at-home-royalty-free-image/1393174810">Maria Korneeva/Moment via Getty Images</a></span></figcaption></figure><p>A plumber who shows up to fix a leaking toilet with a single tool is not likely to succeed. The same is true if a mental health professional offers only one approach for a complex problem like depression.</p>
<p>Sadly, the number of people <a href="https://www.who.int/news-room/fact-sheets/detail/depression">struggling with depression</a> <a href="https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide">increased dramatically</a> at the height of the COVID-19 pandemic. <a href="https://doi.org/10.1016/j.jad.2023.01.050">Stress</a> – from school closures to job losses to the death of loved ones – made life more challenging and increased the risk of developing emotional difficulties. For some groups that have experienced discrimination, <a href="https://doi.org/10.1007/s40615-022-01284-9">ongoing inequities</a> made their mental health even worse. </p>
<p>There is a professional debate about <a href="https://doi.org/10.1353/pbm.0.0009">whether depression is a social problem</a> <a href="https://www.psychiatry.org/patients-families/depression/what-is-depression">or a disease</a>. Despite this debate, a 62% increase in <a href="https://www.finance.senate.gov/imo/media/doc/SFC%20Mental%20Health%20Report%20March%202022.pdf">yearly spending on U.S. mental health care</a>, from US$131 billion in 2006 to $212 billion in 2015, has not led to the intended level of improvement for patients. </p>
<p>This makes it clear that the <a href="https://www.hsph.harvard.edu/ecpe/why-leadership-in-mental-health-care-is-needed-now-more-than-ever-and-how-to-implement-change/">current approach is falling short</a>, but there are a host of viable alternatives for helping to treat patients who are suffering with depression.</p>
<p>We are a <a href="https://scholar.google.com/citations?hl=en&user=LFOKsvwAAAAJ&view_op=list_works&sortby=pubdate">health and biological psychologist</a> who treats hospitalized patients with depression and anxiety and a <a href="https://scholar.google.com/citations?user=p3SsTKUAAAAJ&hl=en&oi=ao">doctoral student in social work</a> studying how to improve the lives of socially isolated older adults.</p>
<p>As mental health professionals, we see the effects of the <a href="https://www.psychiatrictimes.com/view/mental-health-america-crisis">ongoing mental health crisis</a> on a daily basis. </p>
<h2>An overreliance on medication causes harm</h2>
<p>More than <a href="https://pubmed.ncbi.nlm.nih.gov/33054926/">13% of U.S. adults take an antidepressant medication</a> for depression or for other reasons. <a href="https://doi.org/10.3389/fpsyt.2019.00407">Many people report feeling better</a> on antidepressants, though there is <a href="https://theconversation.com/in-research-studies-and-in-real-life-placebos-have-a-powerful-healing-effect-on-the-body-and-mind-173845">debate about what causes the improvements</a>. </p>
<p>Unfortunately, nearly 3 in 4 who take these drugs <a href="https://psycnet.apa.org/doi/10.1037/cns0000261">do not get complete relief from antidepressants</a>. As we discussed in a recent paper, people who do not feel better on antidepressants are usually categorized as having a <a href="https://doi.org/10.1016/j.ssmmh.2022.100081">difficult-to-treat type of depression</a> referred to, controversially, as “treatment-resistant depression.” </p>
<p>We see patients <a href="https://doi.org/10.1016/j.psc.2011.11.004">who feel demoralized</a> by the implied and untrue notion that their depression is “incurable” after only trying medication but not <a href="https://doi.org/10.1176/appi.ajp.2021.21050535">lower-risk treatments</a> like psychotherapy and <a href="https://doi.org/10.1016/S2215-0366(20)30036-5">other effective alternatives</a>. We help them find hope again.</p>
<p>The U.S. health care system <a href="https://www.usnews.com/news/health-news/articles/2022-04-20/in-long-run-antidepressants-dont-improve-quality-of-life-study">relies heavily on medication</a> and other <a href="https://pubmed.ncbi.nlm.nih.gov/31612847/">biomedical treatments</a> for depression. But in fact there are numerous non-drug-based solutions for prevention and treatment of depression. </p>
<p>Holistic concepts that promote <a href="https://doi.org/10.1016/j.ssmmh.2021.100052">flourishing</a> and <a href="https://doi.org/10.1027/1016-9040/a000294">thriving</a>, as well as <a href="https://www.va.gov/wholehealth/">whole-health initiatives</a> and <a href="https://doi.org/10.1056%2FNEJMp1917461">mind-body medicine</a> focus on the entire person. These concepts have not yet been fully integrated into approaches to public mental health. </p>
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<figcaption><span class="caption">The word ‘heal’ is derived from the same Latin and Greek words that mean ‘whole.’</span></figcaption>
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<h2>The quest to understand well-being and depression</h2>
<p>There are many hardworking, highly successful people who do not feel fulfilled with life from time to time. When this internal lack of fulfillment also includes other symptoms like a loss of hope and becomes severe enough to disrupt daily life for a period of two weeks or more, it may be medically diagnosed as depression. </p>
<p>In the 1960s, researchers proposed that <a href="https://doi.org/10.1016/j.ssmmh.2022.100098">depression was caused by a chemical imbalance</a> of a neurotransmitter called serotonin in the brain. In 1988, the pharmaceutical company Eli Lilly introduced <a href="https://doi.org/10.1037%2Fa0038550">an antidepressant medication based on that idea</a>.</p>
<p>However, after decades of experiments, researchers have failed to find evidence showing support for the chemical imbalance theory. A recent study highlights the <a href="https://www.ucl.ac.uk/news/2022/aug/opinion-chemical-imbalance-theory-depression-clearing-some-misconceptions">growing realization that antidepressant medications</a> do not work <a href="https://doi.org/10.1038/s41380-022-01661-0">in the simplistic way</a> in which they <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3313530/">have been advertised</a> for decades. </p>
<p>This is important because antidepressants have <a href="https://www.karger.com/Article/Abstract/447034">side effects</a> that can be serious. For a doctor and patient to weigh the risks and benefits of taking an antidepressant, they need accurate information about both. The chemical imbalance theory interfered with that conversation.</p>
<h2>Tools to heal depression</h2>
<p>So what exactly does contribute to overall well-being and happiness to help stave off depression?</p>
<p>A large body of research shows that <a href="https://doi.org/10.3390%2Fbrainsci11121633">biological, psychological and social factors</a> contribute to feeling satisfied in life or to developing depression. Because each individual is unique, there is not a one-size-fits-all formula for well-being. </p>
<p>Many people find relief from depression by talking to a psychotherapist. <a href="https://doi.org/10.1002%2Fwps.20238">High-quality psychotherapy</a> has been shown to be as effective as and <a href="http://dx.doi.org/10.1136/bmjopen-2012-002542">longer-lasting</a> <a href="https://doi.org/10.1038%2Fnrn2345">than antidepressant medication</a> when treating depression. </p>
<p>Therapy <a href="https://psycnet.apa.org/record/2017-55500-019">activates an individual’s hope</a> and natural resilience by <a href="https://doi.org/10.3389/fnint.2022.871227">creating a safe</a> and emotionally warm relationship through which the therapist and client work together toward common goals. In addition to helping clients learn about their emotions, thoughts, relationships and patterns of behavior, a good therapist explores how to help their clients identify everyday activities that can improve wellness.</p>
<p>The things we do on a day-to-day basis, called <a href="https://doi.org/10.1186/1471-244x-14-107">lifestyle factors</a>, function as building blocks for a life without depression. <a href="https://www.johnwbrickfoundation.org/move-your-mental-health-report/">Physical movement</a>, <a href="https://www.health.harvard.edu/blog/diet-and-depression-2018022213309">good nutrition</a>, <a href="https://www.nytimes.com/2013/11/19/health/treating-insomnia-to-heal-depression.html">healthy sleep</a>, <a href="https://www.apa.org/topics/mindfulness/meditation">healthy levels of stress</a> and <a href="https://doi.org/10.1037%2Fa0018555">stress management</a>, <a href="https://doi.org/10.1016/j.jad.2017.04.043">social connection</a>, <a href="https://www.healthexperiencesusa.org/Depression-in-Young-Adults/having-a-purpose-in-life">finding meaning and purpose</a> and <a href="https://doi.org/10.1007/s11126-020-09881-9">spiritual practices</a> all play important roles in preventing and treating depression. </p>
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<figcaption><span class="caption">Exercise is a powerful antidote against depression, anxiety and stress.</span></figcaption>
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<p>These are too often wrongly trivialized as less effective than professional treatment. In fact, though, a <a href="https://theconversation.com/exercise-is-even-more-effective-than-counselling-or-medication-for-depression-but-how-much-do-you-need-200717">recent study</a> showed that exercise is <a href="http://dx.doi.org/10.1136/bjsports-2022-106195">even more effective than medication or counseling</a>. Another eye-opening study showed that <a href="https://doi.org/10.1097/01.nmd.0000217820.33841.53">85% of people who received no treatment</a> still recovered from depression within one year. </p>
<p>As mental health professionals, we find these results both humbling and inspiring. It means that the general public has solutions for depression that the mental health system has too often overlooked. This is consistent with the <a href="https://www.ifm.org/news-insights/healing-works-means-health-care-wayne-jonas-md/">scientific study of healing</a>, which shows that the body has a tremendous and overlooked <a href="https://www.youtube.com/watch?v=gcai0i2tJt0">ability to repair and heal itself</a> under the right circumstances. </p>
<p>Consider the example of <a href="https://doi.org/10.1016%2Fj.crphys.2021.04.002">laughter therapy</a>, a stress hormone-reducing, mood-lifting practice used in 120 countries. Laughter leaders guide <a href="https://laughteryogausa.org/">groups of people</a> in exercises that stimulate contagious laughter. Not everyone will react the same way to laughter therapy, but it is <a href="https://www.yogajournal.com/lifestyle/laughter-cure/">effective at increasing well-being for some people</a>, so it belongs in the tool box of therapies to try.</p>
<h2>Hope comes in many forms</h2>
<p>One research initiative has identified communities, <a href="https://doi.org/10.1177%2F1559827616637066">called blue zones</a>, where people tend to live long, healthy and satisfying lives. The lifestyles of people living in these areas, like Ikaria, Greece, and Okinawa, Japan, are characterized by social connection, consumption of mostly plant-based foods, a high sense of purpose, environments that support physical movement and intentional relaxation. Customs in different countries and environments show that these principles are visible across the globe in many different forms.</p>
<p>Many cultures extol the benefits of being in nature. <a href="https://www.bbc.com/worklife/article/20171211-friluftsliv-the-nordic-concept-of-getting-outdoors">Nordic countries use the word friluftsliv</a>, which means “outdoor life,” to describe the practice of getting outdoors to improve well-being. In Japan, <a href="https://www.japan.travel/en/guide/forest-bathing/">some people practice shinrin-yoku</a>, translated as forest bathing or opening up the senses to <a href="https://www.degruyter.com/document/doi/10.1515/revneuro-2015-0009/html">the natural world’s scents</a>, sights and sounds. </p>
<p>Researchers have also found that access to green space is associated with <a href="https://doi.org/10.3390%2Fijerph110303453">lower levels of depression symptoms</a>. Other studies <a href="https://doi.org/10.1016%2Fj.pmedr.2016.11.007">show that gardening is linked with</a> less depression, stronger social connections and improvement in quality of life. Gardening also gives those with access a chance to move their bodies and eat more homegrown vegetables as part of an <a href="https://doi.org/10.1186/s12888-022-03771-z">anti-depression nutrition plan</a>. </p>
<p>We cannot describe everything on the endless list of life-affirming, research-supported and low-risk methods to decrease stress, boost mood and enhance fulfillment. But here are a few more examples: </p>
<ul>
<li><a href="https://doi.org/10.1155/2017/5869315">aromatherapy</a></li>
<li><a href="https://www.health.harvard.edu/blog/light-therapy-not-just-for-seasonal-depression-202210282840">light therapy</a></li>
<li><a href="https://doi.org/10.1177%2F2156587217715927">yoga</a></li>
<li><a href="https://doi.org/10.3389/fpsyg.2021.647879">music</a></li>
<li><a href="https://www.helpguide.org/articles/mental-health/mood-boosting-power-of-dogs.htm">animals</a></li>
<li><a href="https://www.artandhealing.org/health-concerns/">making art</a> </li>
<li><a href="https://www.cdc.gov/howrightnow/gratitude/index.html#">gratitude practice</a> </li>
<li><a href="https://psycnet.apa.org/doi/10.1037/emo0000324">sexual activity</a> </li>
<li><a href="https://ppc.sas.upenn.edu/">positive psychology</a></li>
<li><a href="https://www.psychologytoday.com/us/blog/the-athletes-way/202008/beyond-fun-and-games-playfulness-may-help-combat-depression#">playfulness enhancement</a></li>
<li><a href="https://doi.org/10.2196%2Fjmir.6482">mobile</a> <a href="https://screening.mhanational.org/content/what-are-best-apps-depression/">apps</a></li>
<li>self-help <a href="https://doi.org/10.1177%2F2515690X18823691">tools like “tapping”</a> to help with strong emotions</li>
<li><a href="https://www.artandhealing.org/unlonely-project/">peer and social</a> <a href="https://mystrength.com/">support programs</a> </li>
</ul>
<p>These seemingly simple interventions are powerful because they lead to health-promoting psychological and <a href="https://www.ncbi.nlm.nih.gov/books/NBK541120/">physiological changes</a>. </p>
<h2>Staying true to what works</h2>
<p>Clinicians, researchers and <a href="https://www.wired.com/2017/05/star-neuroscientist-tom-insel-leaves-google-spawned-verily-startup/">leaders</a> have been trying to identify the <a href="https://clinicaltrials.gov/ct2/show/NCT00021528">best treatment for depression</a> for at least two decades. </p>
<p>This is an unanswerable question. Some treatments work extremely well for certain people and cause terrible reactions for others. When <a href="http://dx.doi.org/10.1136/adc.2004.058222">standard research protocols</a> try to capture these effects, it can <a href="https://doi.org/10.1111/j.0887-378X.2004.00327.x">look like there is no effect of the treatment</a> because the positive effects average out with the negative effects. </p>
<p>A search for the holy grail of a <a href="https://doi.org/10.1016/j.neubiorev.2017.08.019">neurobiological cause for depression</a> has drawn attention away from efforts to implement what is already known about how to <a href="https://www.who.int/europe/about-us/our-work/core-priorities/promoting-health-and-well-being">promote health</a>. </p>
<p>To <a href="https://www.cdc.gov/hrqol/wellbeing.htm#one">live one’s best life</a>, everyone needs safety, shelter, clothing, good nutrition, good sleep, physical movement, <a href="https://doi.org/10.1007/s12671-020-01375-w">loving and kind social connection</a> and a sense of meaning and purpose. There are many ways to help people get there.</p><img src="https://counter.theconversation.com/content/198282/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An overreliance on medication as the first-line treatment for depression can lead some people to be labeled with treatment-resistant depression when there are other viable alternatives for relief.Elissa H. Patterson, Clinical Assistant Professor of Psychiatry and Neurology, University of MichiganJay Kayser, PhD Student in Social Work and Developmental Psychology, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1867372022-11-16T13:29:25Z2022-11-16T13:29:25ZPatients suffering with hard-to-treat depression may get relief from noninvasive magnetic brain stimulation<figure><img src="https://images.theconversation.com/files/477266/original/file-20220802-18-nnapcv.jpg?ixlib=rb-1.1.0&rect=15%2C0%2C5218%2C3931&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Transcranial magnetic stimulation has worked when medication and other therapies have not.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/patient-in-transcranial-magnetic-stimulation-royalty-free-image/548557027?adppopup=true">Monty Rakusen/Image Source via Getty Images</a></span></figcaption></figure><p>Not only is depression a debilitating disease, but it is also widespread. Approximately 20 million adult Americans experience at least <a href="https://www.nimh.nih.gov/health/statistics/major-depression">one episode of depression per year</a>. </p>
<p>Millions of them <a href="https://www.cdc.gov/nchs/products/databriefs/db377.htm#:">take medication</a> to treat their depression. But for many, the <a href="https://www.webmd.com/depression/guide/treatment-resistant-depression-what-is-treatment-resistant-depression">medications don’t work</a>: Either they have minimal or no effect, or the side effects are intolerable. These patients have what is called <a href="https://www.mayoclinic.org/diseases-conditions/depression/in-depth/treatment-resistant-depression/art-20044324">treatment-resistant depression</a>. </p>
<p>One promising treatment for such patients is a type of brain stimulation therapy <a href="https://www.healthline.com/health/tms-therapy#What-is-TMS-therapy">called transcranial magnetic stimulation</a>. </p>
<p>This treatment is not new; it has been around since 1995. The U.S. Food and Drug Administration <a href="https://doi.org/10.1016/j.brs.2021.11.010">cleared transcranial magnetic stimulation in 2008</a> for adults with “non-psychotic treatment-resistant depression,” which is typically defined as a failure to respond to two or more antidepressant medications. More recently, in 2018, the FDA cleared it for <a href="https://www.fda.gov/news-events/press-announcements/fda-permits-marketing-transcranial-magnetic-stimulation-treatment-obsessive-compulsive-disorder#">some patients with obsessive-compulsive disorder</a> and <a href="https://www.fda.gov/consumers/consumer-updates/want-quit-smoking-fda-approved-and-fda-cleared-cessation-products-can-help#">smoking cessation</a>. </p>
<p>Insurance <a href="https://www.mytransformations.com/post/the-ultimate-guide-to-tms-therapy-and-insurance-coverage">generally covers these treatments</a>. Both the psychiatrist and the equipment operator must be certified. While the treatment has been available for years, the equipment to perform the procedure remains expensive enough that few private psychiatry practices can afford it. But with the growing recognition of the potential of transcranial magnetic stimulation, the price will likely eventually come down and access will be greatly expanded.</p>
<h2>Does it work?</h2>
<p>Transcranial magnetic stimulation is a noninvasive, pain-free procedure that has minimal to no side effects, and it often works. Research shows that 58% of once treatment-resistant patients experience <a href="https://doi.org/10.1002/da.21969">a significant reduction in depression</a> following four to six rounds of the therapy. More than 40 independent clinical trials – with more than 2,000 patients worldwide – have demonstrated that repetitive transcranial magnetic stimulation <a href="https://doi.org/10.1136/gpsych-2019-100074">is an effective therapy</a> for the treatment of resistant major depression. </p>
<p><a href="https://medicine.fiu.edu/about/faculty-and-staff/profiles/psychiatry-and-behavioral-health/junquera,-patricia.html">As a professor and psychiatrist</a> who has used transcranial magnetic stimulation to treat some of my patients, I have seen depression symptoms decrease even within the first two weeks of treatment. What’s more, the effects continue after the treatment has ended, typically for six months to a year. After that, the patient has the option of maintenance treatment. </p>
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<figcaption><span class="caption">Transcranial magnetic stimulation helps increase blood flow and dopamine levels in the brain.</span></figcaption>
</figure>
<h2>About the procedure</h2>
<p>For the patient, the procedure is easy and simple. One sits in a comfortable chair with a snug pillow that holds their head in place, puts on earplugs and can then relax, check their phone, watch TV or read a book.</p>
<p>A treatment coil, which looks like a figure 8, is placed on the patient’s head. A nearby stimulator sends an electrical current to the coil, which transforms the current into <a href="https://www.livescience.com/38059-magnetism.html">a magnetic field</a>. </p>
<p>The field, which is highly concentrated, turns on and off rapidly while targeting a portion <a href="https://neuroscientificallychallenged.com/posts/know-your-brain-prefrontal-cortex">of the prefrontal cortex</a> – the area of the brain responsible for mood regulation. </p>
<p>Researchers know that people suffering from depression have reduced blood flow and less activity in that part of the brain. Transcranial magnetic stimulation causes increases in both blood flow and in the levels of <a href="https://www.healthdirect.gov.au/dopamine#">dopamine</a> and <a href="https://doi.org/10.1007/s00702-014-1180-8">glutamate</a> – two neurotransmitters that are responsible for brain functions like concentration, memory and sleep. It’s the repeated stimulation of this area – the “depression circuit” of the brain – that brings the antidepressant effect. </p>
<h2>It is not ‘electroshock’ or deep brain stimulation</h2>
<p>Some people confuse transcranial magnetic stimulation with <a href="https://www.psychiatry.org/patients-families/ect#">electroconvulsive therapy</a>, a procedure used for patients with severe depression or catatonia. With electroshock therapy, the anesthetized patient receives a direct electrical current, which causes a seizure. Typically, people who undergo this procedure experience <a href="https://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/about/pac-20393894#:">some memory loss after treatment</a>. </p>
<p>Transcranial magnetic stimulation is very different. It doesn’t require anesthesia, and it doesn’t affect memory. The patient can resume daily activities right after each treatment. Dormant brain connections are reignited without causing a seizure.</p>
<p>It should also not be confused with <a href="https://www.mayoclinic.org/tests-procedures/deep-brain-stimulation/about/pac-20384562">deep brain stimulation</a>, which is a surgical procedure used <a href="https://theconversation.com/deep-brain-stimulation-can-be-life-altering-for-ocd-sufferers-when-other-treatment-options-fall-short-186109">to treat obsessive-compulsive disorder</a>, tremors, epilepsy and Parkinson’s disease. </p>
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<figcaption><span class="caption">Transcranial magnetic stimulation stimulates the ‘depression circuit’ in the brain.</span></figcaption>
</figure>
<h2>Side effects and access</h2>
<p>Transcranial magnetic stimulation patients undergo a total of <a href="https://www.mindpath.com/resource/what-a-typical-tms-treatment-looks-like/">36 treatments, at 19 minutes each</a>, for three to six weeks. Research has concluded that this is the best protocol for treatment. Some patients report that it feels like someone is tapping on their head. Others don’t feel anything. </p>
<p>Some very minor side effects may occur. The most common is facial twitching and scalp discomfort during treatment, sensations that go away after the session ends. Some patients report a mild headache or discomfort at the application site. Depending on how effective the therapy was, some patients return for follow-ups every few weeks or months. It can be used in addition to medications, or with no medication at all. </p>
<p>Not everyone with depression can undergo <a href="https://www.clinicaltmssociety.org/content/who-cannot-have-tms">this type of brain stimulation therapy</a>. Those with epilepsy or a history of head injury may not qualify. People with metallic fillings in their teeth are OK for treatment, but others with implanted, nonremovable metallic devices in or around the head are not. Those with pacemakers, defibrillators and vagus nerve stimulators may also not qualify, because the magnetic force of the treatment coil may dislodge these devices and cause severe pain or injury. </p>
<p>But for those who are able to use the therapy, the results can be remarkable. For me, it is amazing to see these patients smile again – and come out on the other side feeling hopeful.</p><img src="https://counter.theconversation.com/content/186737/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patricia Junquera does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Patients who undergo transcranial magnetic stimulation say it’s painless, with few to no side effects. The treatment isn’t yet widely accessible, but for those who use it, the effects can be profound.Patricia Junquera, Associate Professor and Vice Chair of Clinical Services, Florida International UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1859972022-09-12T12:15:12Z2022-09-12T12:15:12ZUncovering the genetic basis of mental illness requires data and tools that aren’t just based on white people – this international team is collecting DNA samples around the globe<figure><img src="https://images.theconversation.com/files/483545/original/file-20220908-9329-hl0h3j.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2419%2C1238&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ethical and equitable scientific collaboration could help increase the genetic diversity of genomic data.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/scientists-on-world-map-discussing-during-royalty-free-illustration/1322363700">gmast3r/iStock via Getty Images Plus</a></span></figcaption></figure><p>Mental illness is a growing public health problem. In 2019, an estimated <a href="https://www.who.int/news-room/fact-sheets/detail/mental-disorders">1 in 8 people around the world</a> were affected by mental disorders like depression, schizophrenia or bipolar disorder. While scientists have long known that many of these disorders run in families, their genetic basis isn’t entirely clear. One reason why is that the majority of existing genetic data used in research is overwhelmingly from white people.</p>
<p>In 2003, the Human Genome Project generated the first “reference genome” of human DNA from a combination of samples donated by <a href="https://www.statnews.com/2019/03/11/human-reference-genome-shortcomings/">upstate New Yorkers</a>, all of whom were of European ancestry. Researchers across many biomedical fields still use this reference genome in their work. But it doesn’t provide a complete picture of human genetics. Someone with a different genetic ancestry will have a number of <a href="https://www.yourgenome.org/facts/what-is-genetic-variation/">variations</a> in their DNA that aren’t captured by the reference sequence. </p>
<p>When most of the world’s ancestries are not represented in genomic data sets, studies won’t be able to provide a true representation of how diseases manifest across all of humanity. Despite this, ancestral diversity in genetic analyses hasn’t improved in the two decades since the Human Genome Project announced its first results. As of June 2021, <a href="https://doi.org/10.1038/s41591-021-01672-4">over 80%</a> of genetic studies have been conducted on people of European descent. Less than 2% have included people of African descent, even though these individuals have the <a href="https://doi.org/10.1073/pnas.1017511108">most genetic variation</a> of all human populations.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1492867130622193664"}"></div></p>
<p>To uncover the <a href="https://doi.org/10.1038/s41586-022-04556-w">genetic factors</a> driving mental illness, <a href="https://scholar.google.com/citations?user=lWu2u8kAAAAJ&hl=en">I</a>, <a href="https://scholar.google.com/citations?view_op=list_works&hl=en&hl=en&user=iS0IoKgAAAAJ&sortby=pubdate">Sinéad Chapman</a> and our colleagues at the Broad Institute of MIT and Harvard have partnered with collaborators around the world to launch <a href="https://www.broadinstitute.org/stanley-center-psychiatric-research/stanley-global">Stanley Global</a>, an initiative that seeks to collect a more diverse range of genetic samples from beyond the U.S. and Northern Europe, and train the <a href="https://doi.org/10.1038/s41588-022-01095-y">next generation of researchers</a> around the world. Not only does the genetic data lack diversity, but so do the tools and techniques scientists use to sequence and analyze human genomes. So we are implementing a new sequencing technology that addresses the inadequacies of previous approaches that don’t account for the genetic diversity of global populations.</p>
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<figcaption><span class="caption">Ethically and equitably expanding the diversity of genomics data can help improve care and reduce disparities.</span></figcaption>
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<h2>Global partnerships for global data</h2>
<p>To study the genetics of psychiatric conditions, researchers use data from <a href="https://www.genome.gov/about-genomics/fact-sheets/Genome-Wide-Association-Studies-Fact-Sheet">genome-wide association studies</a> that compare the genetic variations between people with and without a particular disease. However, these data sets are mostly <a href="https://doi.org/10.1038/s41591-021-01672-4">based on people of European ancestry</a>, largely because research infrastructure and funding for large-scale genetics studies, and the scientists conducting these studies, have historically been concentrated in Europe and the United States.</p>
<p>One way to close this gap is to sequence genetic data from diverse populations. My colleagues and I are working in close partnership with geneticists, statisticians and epidemiologists in 14 countries across four continents to study the DNA of tens of thousands of people of African, Asian and Latino ancestries who are affected by mental illness. We work together to recruit participants and collect DNA samples that are sequenced at the Broad Institute in Massachusetts and shared with all partners for analysis.</p>
<p><iframe id="ZIVeg" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/ZIVeg/4/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p><a href="https://doi.org/10.1038/d41586-021-01795-1">Prioritizing the voices and priorities</a> of local communities and scientists is foundational to our work. All partners have joint ownership of the project, including decision-making and sample and data ownership and control. To do this, we build relationships and trust with the local communities we are studying and the local university leaders and scientists with whom we are partnering. We work to understand local cultures and practices, and adapt our collection methods to ensure study participants are comfortable. For example, because there are different cultural sensitivities around providing saliva and blood samples, we have adapted our practices by location to ensure study participants are comfortable.</p>
<p>We also freely share knowledge and materials with our partners. There is a two-way exchange of information between the Broad Institute and local teams on study progress and results, enabling continual learning, teaching and unity between teams. We strive to meet each other where we are by exchanging practices and training scientists to support the development of locally grown and locally led research programs.</p>
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<a href="https://images.theconversation.com/files/474777/original/file-20220719-18-mu7fdh.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Researchers in the GINGER program looking at laptop together and smiling" src="https://images.theconversation.com/files/474777/original/file-20220719-18-mu7fdh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474777/original/file-20220719-18-mu7fdh.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=454&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474777/original/file-20220719-18-mu7fdh.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=454&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474777/original/file-20220719-18-mu7fdh.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=454&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474777/original/file-20220719-18-mu7fdh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=570&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474777/original/file-20220719-18-mu7fdh.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=570&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474777/original/file-20220719-18-mu7fdh.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=570&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The Global Initiative for Neuropsychiatric Genetics Education in Research (GINGER) program is focused on training the next generation of scientists.</span>
<span class="attribution"><a class="source" href="https://gingerprogram.org/">Global Initiative for Neuropsychiatric Genetics Education in Research</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
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<p>Our collaboration with African research groups provides a prime example of <a href="https://doi.org/10.1038/s41588-022-01095-y">our model</a>. For example, our African research colleagues are co-leaders on the grants that fund the lab equipment, scientists and other staff for projects based at their study sites. And we help to support the next generation of African geneticists and bioinformaticians through a <a href="https://www.broadinstitute.org/stanley-center-psychiatric-research/neurogap/global-initiative-neuropsychiatric-genetics-education-research-ginger">dedicated training program</a>.</p>
<h2>Analyzing variation</h2>
<p>Collecting samples from more diverse populations is only half of the challenge. </p>
<p>Existing genomic sequencing and analysis technologies do not adequately capture genetic variation across populations from around the world. That’s because these technologies were designed to detect genetic variations based on reference DNA from people of European ancestry, and they <a href="https://doi.org/10.1126/science.abg8871">reduce accuracy</a> when analyzing sequences that aren’t derived from the reference genome. When these tools are applied to genetic data from other populations, they <a href="https://doi.org/10.1016/j.ajhg.2021.03.012">fail to detect much of the rich variation</a> in their genomes. This can lead researchers to miss out on important biomedical discoveries. </p>
<p>To address this issue, we developed an approach to genome sequencing that can detect more genetic variation from populations around the world. It works by sequencing the <a href="https://www.genome.gov/genetics-glossary/Exome">exome</a> – the less than 2% of the genome that codes for proteins – in high detail, as well as sequencing the 98% of the genome that does not code for proteins in less detail.</p>
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<figcaption><span class="caption">Different types of sequencing methods have pros and cons.</span></figcaption>
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<p>This combined approach reduces the trade-offs geneticists often have to make in sequencing projects. <a href="https://medlineplus.gov/genetics/understanding/testing/sequencing/">High-depth whole genome sequencing</a>, which reads through the entire genome multiple times to get detailed data, is too costly to do on a large number of DNA samples. While <a href="https://www.cancer.gov/about-nci/organization/ccg/blog/2019/low-coverage-seq">low-coverage sequencing</a> reduces costs by reading smaller segments of the genome, it may miss some important genetic variation. With our new technology, geneticists can get the best of both worlds: <a href="https://www.broadinstitute.org/blog/what-exome-sequencing">sequencing the exome in depth</a> maximizes the likelihood of pinpointing <a href="https://doi.org/10.1038/s41586-022-04556-w">specific genes</a> that play a role in mental illness, while <a href="https://doi.org/10.1016%2Fj.ajhg.2021.03.012">sequencing the whole genome less in depth</a> allows researchers to process large numbers of whole genomes more cost-effectively.</p>
<h2>Personalizing medicine</h2>
<p>Our hope is that this new technology will allow researchers to sequence large sample sizes from a diverse range of ancestries to capture the full breadth of genetic variation. With a better understanding of the genetics of mental illness, clinicians and researchers will be better equipped to develop new treatments that work for everyone. </p>
<p>Genomic sequencing opened a new era of <a href="https://doi.org/10.1377%2Fhlthaff.2017.1624">personalized medicine</a>, which promises to deliver treatments tailored to each individual person. This can be done only if the genetic variations of all ancestries are represented in the data sets that researchers use to make new discoveries about disease and develop treatments.</p><img src="https://counter.theconversation.com/content/185997/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hailiang Huang receives funding from the National Institutes of Health and the Brain & Behavior Research Foundation. He is a member of the board of directors with the International Society of Psychiatric Genetics.</span></em></p>Existing genetic data and sequencing tools are overwhelmingly based on people of European ancestry, which excludes much of the rich genetic variation of the world.Hailiang Huang, Assistant Professor of Medicine, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1889182022-08-18T14:12:07Z2022-08-18T14:12:07ZWe studied how COVID affects mental health and brain disorders up to two years after infection – here’s what we found<figure><img src="https://images.theconversation.com/files/479704/original/file-20220817-8116-s4twhd.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5991%2C3988&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">COVID has been linked with a higher rate of psychiatric and neurological disorders.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hands-holding-brain-puzzle-paper-cutout-1814268452">SewCream/Shutterstock</a></span></figcaption></figure><p>The occurrence of mental health conditions and neurological disorders among people recovering from COVID has been a concern since early in the pandemic. Several studies have shown that a <a href="https://www.sciencedirect.com/science/article/pii/S2215036621000845">significant proportion</a> of adults <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(22)00042-1/fulltext">face problems</a> of this kind, and that the risks are greater than following other infections.</p>
<p>However, several questions remain. Do the risks of psychiatric and neurological problems dissipate, and if so, when? Are the risks similar in children as in adults? Are there differences between COVID variants? </p>
<p>Our new study, published in <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(22)00260-7/fulltext">The Lancet Psychiatry</a>, explored these issues. In analyses led by my colleague Maxime Taquet, we used the electronic health records of about 1.25 million people diagnosed with COVID, mostly from the US. We tracked the occurrence of 14 major neurological and psychiatric diagnoses in these patients for up to two years. </p>
<p>We compared these risks with a closely matched control group of people who had been diagnosed with a respiratory infection other than COVID. </p>
<p>We examined children (aged under 18), adults (18-65) and older adults (over 65) separately.</p>
<p>We also compared people who contracted COVID just after the emergence of a new variant (notably omicron, but earlier variants too) with those who did so just beforehand.</p>
<p>Our findings are a mixture of good and bad news. Reassuringly, although we observed a greater risk of common psychiatric disorders (anxiety and depression) after COVID infection, this heightened risk rapidly subsided. The rates of these disorders among people who had COVID were no different from those who had other respiratory infections within a couple of months, and there was no overall excess of these disorders over the two years.</p>
<p>It was also good news that children were not at greater risk of these disorders at any stage after COVID infection. </p>
<p>We also found that people who had had COVID were not at higher risk of getting Parkinson’s disease, which had been a concern early in the pandemic.</p>
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<strong>
Read more:
<a href="https://theconversation.com/covid-long-lasting-symptoms-rarer-in-children-than-in-adults-new-research-165701">COVID: long-lasting symptoms rarer in children than in adults – new research</a>
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<p>Other findings were more worrying. The risks of being diagnosed with some disorders, such as psychosis, seizures or epilepsy, brain fog and dementia, though mostly still low, remained elevated throughout the two years after COVID infection. For example, the risk of dementia in older adults was 4.5% in the two years after COVID compared with 3.3% in those with another respiratory infection.</p>
<p>We also saw an ongoing risk of psychosis and seizures in children.</p>
<figure class="align-center ">
<img alt="A woman sits by a window, hiding her head." src="https://images.theconversation.com/files/479705/original/file-20220817-11701-ygfp4m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/479705/original/file-20220817-11701-ygfp4m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/479705/original/file-20220817-11701-ygfp4m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/479705/original/file-20220817-11701-ygfp4m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/479705/original/file-20220817-11701-ygfp4m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/479705/original/file-20220817-11701-ygfp4m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/479705/original/file-20220817-11701-ygfp4m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Rates of depression and anxiety were higher after COVID, but only for a short time.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/beautiful-young-blonde-caucasian-female-feeling-2057071157">Stock Unit/Shutterstock</a></span>
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<p>In terms of variants, although our data confirms that omicron is a much milder illness than the previous delta variant, survivors remained at similar risk of the neurological and psychiatric conditions we looked at. </p>
<p>However, given how recently omicron emerged, the data we have for people who were infected with this variant only goes up to about five months after infection. So the picture may change.</p>
<h2>Mixed results</h2>
<p>Overall, our study reveals a mixed picture, with some disorders showing a transient excess risk after COVID, while other disorders have a sustained risk. For the most part, the findings are reassuring in children, but with some concerning exceptions. </p>
<p>The results on omicron, the variant currently dominant around the world, indicate that the burden of these disorders is likely to continue, even though this variant is milder in other respects.</p>
<p>The study has important caveats. Our findings don’t capture people who may have had COVID but it wasn’t documented in their health records – perhaps because they didn’t have symptoms. </p>
<p>And we cannot fully account for the effect of vaccination, because we didn’t have complete information about vaccination status, and some people in our study caught COVID before vaccines became available. That said, in <a href="https://pubmed.ncbi.nlm.nih.gov/35447302/">a previous study</a> we showed the risks of these outcomes were pretty similar in people who caught COVID after being vaccinated, so this might not have significantly affected the results.</p>
<p>Also, the risks observed in our study are relative to people who had had other respiratory infections. We don’t know how they compare to people without any infection. We also don’t know how severe or long lasting the disorders were. </p>
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Read more:
<a href="https://theconversation.com/how-does-covid-affect-the-brain-two-neuroscientists-explain-164857">How does COVID affect the brain? Two neuroscientists explain</a>
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<p>Finally, our study is observational and so cannot explain how or why COVID is associated with these risks. Current theories include persistence of the virus in the nervous system, the immune reaction to the infection, or problems with blood vessels. These are being investigated in <a href="https://academic.oup.com/braincomms/advance-article/doi/10.1093/braincomms/fcac206/6668727?searchresult=1">separate research</a>.</p><img src="https://counter.theconversation.com/content/188918/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Harrison receives funding from the National Institute for Health and Care Research, MQ, and The Wolfson Foundation. </span></em></p>People who get COVID continue to face increased risks of developing some neurological and psychiatric conditions, like psychosis and dementia, for up to two years afterwards.Paul Harrison, Professor of Psychiatry, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1792632022-03-16T19:11:16Z2022-03-16T19:11:16ZAI maps psychedelic ‘trip’ experiences to regions of the brain – opening new route to psychiatric treatments<figure><img src="https://images.theconversation.com/files/452287/original/file-20220315-15-1mh1o5b.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3840%2C2160&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Psychedelics have been the subject of a recent surge of interest in their potential therapeutic effects.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/concept-deep-learning-mindfulness-psychology-royalty-free-image/1256602998">metamorworks/iStock via Getty Images</a></span></figcaption></figure><p>For the past several decades, psychedelics have been widely stigmatized as dangerous illegal drugs. But a recent <a href="https://doi.org/10.1038/s41583-020-0367-2">surge of academic research</a> into their use to treat psychiatric conditions is spurring a recent shift in public opinion.</p>
<p>Psychedelics are <a href="https://www.healthline.com/health/what-is-a-psychotropic-drug">psychotropic drugs</a>: substances that affect your mental state. Other types of psychotropics include antidepressants and anti-anxiety medications. Psychedelics and other types of hallucinogens, however, are unique in their <a href="https://doi.org/10.1124/pr.115.011478">ability to temporarily induce</a> intense hallucinations, emotions and disruptions of self-awareness.</p>
<p>Researchers looking into the therapeutic potential of these effects have found that psychedelics can dramatically reduce symptoms of <a href="https://dx.doi.org/10.1177%2F0269881116675513">depression and anxiety</a>, <a href="https://doi.org/10.1038/s41591-021-01336-3">PTSD</a>, <a href="https://doi.org/10.1126/sciadv.abh2399">substance abuse</a> and <a href="https://doi.org/10.1038/s41583-020-0367-2">other psychiatric conditions</a>. The intense experiences, or “trips,” that psychedelics induce are thought to create a temporary window of <a href="https://doi.org/10.1038/s41398-021-01706-y">cognitive flexibility</a> that allows patients to gain access to elusive parts of their psyches and forge better coping skills and thought patterns. </p>
<p>Precisely how psychedelics create these effects, however, is still unclear. So as researchers in <a href="https://scholar.google.com/citations?user=pzTU_S4AAAAJ&hl=en">psychiatry</a> and <a href="https://scholar.google.com/citations?hl=en&user=fOi-AjQAAAAJ">machine learning</a>, we were interested in figuring out how these drugs affect the brain. With artificial intelligence, we were able to <a href="https://doi.org/10.1126/sciadv.abl6989">map people’s subjective experiences while using psychedelics</a> to specific regions of the brain, down to the molecular level.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/452565/original/file-20220316-8368-1jfhj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Gloved hands using forceps to remove a mushroom from a beaker to examine on a Petri dish" src="https://images.theconversation.com/files/452565/original/file-20220316-8368-1jfhj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/452565/original/file-20220316-8368-1jfhj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/452565/original/file-20220316-8368-1jfhj0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/452565/original/file-20220316-8368-1jfhj0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/452565/original/file-20220316-8368-1jfhj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/452565/original/file-20220316-8368-1jfhj0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/452565/original/file-20220316-8368-1jfhj0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Psilocybin, a psychoactive compound found in some mushrooms, has been the focus of many studies for its potential therapeutic qualities.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/psilocybin-and-magic-mushrooms-royalty-free-image/1316793235">24K-Production/iStock via Getty Images</a></span>
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</figure>
<h2>Mapping ‘trips’ in the brain</h2>
<p>Every psychedelic functions differently in the body, and each of the subjective experiences these drugs create have different therapeutic effects. <a href="https://dx.doi.org/10.1177%2F0269881108094300">Mystical type experiences</a>, or feelings of unity and oneness with the world, for example, are associated with decreases in depression and anxiety. Knowing how each psychedelic creates these specific effects in the body can help clinicians <a href="https://doi.org/10.1126/sciadv.abp8283">optimize their therapeutic use</a>.</p>
<p>To better understand how these subjective effects manifest in the brain, we analyzed over 6,000 written testimonials of hallucinogenic experiences from <a href="https://www.erowid.org">Erowid Center</a>, an organization that collects and provides information about psychoactive substances. We transformed these testimonials into what’s called a <a href="https://www.codecademy.com/learn/dscp-natural-language-processing/modules/dscp-bag-of-words/cheatsheet">bag-of-words model</a>, which breaks down a given text into individual words and counts how many times each word appears. We then paired the most commonly used words linked to each psychedelic with receptors in the brain that are known to bind to each drug. After using <a href="https://stats.oarc.ucla.edu/stata/dae/canonical-correlation-analysis/">an algorithm</a> to extract the most common subjective experiences associated with these word-receptor pairs, we mapped these experiences onto different brain regions by matching them to the types of receptors present in each area. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/fOvTtapxa9c?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Natural language processing, which allows computers to interpret human languages, helped in analyzing subjective psychedelic experiences.</span></figcaption>
</figure>
<p>We found both new links and patterns that confirm what’s known in the research literature. For example, changes in sensory perception were associated with a <a href="https://doi.org/10.3389/fphar.2015.00225">serotonin receptor</a> in the visual cortex of the brain, which binds to a <a href="https://www.verywellmind.com/what-is-serotonin-425327">molecule</a> that helps regulate mood and memory. Feelings of transcendence were connected to dopamine and opioid receptors in the <a href="https://doi.org/10.1523/JNEUROSCI.1138-17.2019">salience network</a>, a collection of brain regions involved in managing sensory and emotional input. Auditory hallucinations were linked to a number of receptors spread throughout the <a href="https://doi.org/10.1093/schbul/sbw130">auditory cortex</a>.</p>
<p>Our findings also align with the <a href="https://doi.org/10.1124/pr.118.017160">leading hypothesis</a> that psychedelics temporarily reduce <a href="https://dx.doi.org/10.1146%2Fannurev-psych-113011-143750">top-down executive function</a>, or cognitive processes involved in inhibition, attention and memory, among others, while amplifying brain regions involved in sensory experience.</p>
<h2>Why it matters</h2>
<p>The U.S. is going through a profound <a href="https://www.hhs.gov/about/news/2021/12/07/us-surgeon-general-issues-advisory-on-youth-mental-health-crisis-further-exposed-by-covid-19-pandemic.html">mental health crisis</a> that has been exacerbated by the COVID-19 pandemic. Yet there have been no truly new psychiatric drug treatments since Prozac and other selective serotonin reuptake inhibitors, the most common type of antidepressants, of the <a href="https://www.theguardian.com/society/2016/jan/27/prozac-next-psychiatric-wonder-drug-research-medicine-mental-illness">1980s</a>.</p>
<p>Our study shows that it’s possible to map the diverse and wildly subjective psychedelic experiences to specific regions in the brain. These insights may lead to new ways to combine existing or yet to be discovered compounds to produce desired treatment effects for a range of psychiatric conditions.</p>
<p>Pychiatrist <a href="https://maps.org/product/lsd-psychotherapy/">Stanislav Grof</a> famously proposed, “psychedelics, used responsibly and with proper caution, would be for psychiatry what the microscope is to the study of biology and medicine or the telescope for astronomy.” As psychedelics and other hallucinogens become more commonly used clinically and culturally, we believe more research will <a href="https://doi.org/10.1126/sciadv.abp8283">further illuminate the biological basis</a> of the experiences they invoke and help realize their potential.</p><img src="https://counter.theconversation.com/content/179263/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sam Friedman receives funding from IBM and Bayer. </span></em></p><p class="fine-print"><em><span>Galen Ballentine does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Pinpointing the molecular targets behind the subjective effects of psychedelic drugs could help clinicians and researchers better treat psychiatric conditions.Galen Ballentine, Resident in Psychiatry, SUNY Downstate Health Sciences UniversitySam Friedman, Machine Learning Scientist at the Broad Institute of MIT &, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1494222020-11-17T13:22:32Z2020-11-17T13:22:32ZHoarding, stockpiling, panic buying: What’s normal behavior in an abnormal time?<figure><img src="https://images.theconversation.com/files/369168/original/file-20201112-23-1t4qlhq.jpg?ixlib=rb-1.1.0&rect=5%2C0%2C3958%2C2970&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hoarding, stockpiling and panic buying have all increased during the pandemic. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/man-carries-heap-of-toilet-paper-royalty-free-image/1213254321?adppopup=true">Grace Cary via Getty Images</a></span></figcaption></figure><p>Symptoms of <a href="https://formative.jmir.org/2020/10/e22043/">depression, anxiety and obsessive compulsive disorders</a> have emerged or worsened for many during the pandemic. This is no surprise to clinicians and scientists, who have been increasing worldwide access to mental health information and <a href="https://wellness.med.ufl.edu/">resources</a>. </p>
<p>But what effect has the pandemic had on another common but often misunderstood problem – hoarding? The issue first received attention when people piled up paper towels, toilet tissue and hand sanitizer in their shopping carts <a href="https://www.cnbc.com/2020/03/11/heres-why-people-are-panic-buying-and-stockpiling-toilet-paper.html">at the start of the pandemic</a>, leading some people to wonder whether they or a loved one were showing signs of hoarding disorder.</p>
<p>The short answer is: Probably not. Hoarding disorder goes beyond stockpiling in an emergency. <a href="https://scholar.google.com/citations?user=GuqlxnAAAAAJ&hl=en">I am a psychiatrist</a> at the University of Florida and the director of the <a href="https://coard.psychiatry.ufl.edu/">Center for OCD, Anxiety and Related Disorders</a>. I also recently <a href="https://wwnorton.com/books/9780393713572/about-the-book/reviews">authored a book</a> on hoarding disorder. My work focuses on identifying the causes of hoarding and its impact on individuals and on society.</p>
<figure class="align-center ">
<img alt="Millions of Americans have hoarding disorder." src="https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369172/original/file-20201112-13-nelw40.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Millions of Americans have hoarding disorder, a serious psychiatric illness.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/abandoned-home-royalty-free-image/157568086?adppopup=true">shaunl via Getty Images</a></span>
</figcaption>
</figure>
<h2>Millions have hoarding disorder</h2>
<p>Although often sensationalized in the popular press as a behavioral <a href="https://dailytitan.com/opinion/the-way-the-media-portrays-mental-illnesses-like-hoarding-and-ocd-maintain-harmful-stereotypes/article_f1edb9a1-33ad-521e-98c2-90eef9486df5.html">oddity</a>, <a href="https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder">hoarding disorder</a> is a serious psychiatric illness affecting more than 13 million American adults. The cause is a complex interaction of biological and environmental factors. Doctors have known about hoarding for centuries, although the disorder was only formally recognized by the psychiatric community as a <a href="https://www.psychiatry.org/psychiatrists/practice/dsm">distinct psychiatric illness</a> in 2013. Perhaps the most famous person who had a hoarding disorder was <a href="http://indianmentalhealth.com/pdf/2015/vol2-issue2/The_Aviator.pdf">Howard Hughes</a>. </p>
<p>The disorder is chronic and often lifelong. Although symptoms typically begin in <a href="https://doi.org/10.1002/da.22896">adolescence</a>, they usually do not become problematic until mid- to late adulthood. No one knows exactly why the disorder takes so long to manifest; perhaps as those with hoarding symptoms get older, their ability to decide what to discard becomes increasingly impaired. Or they might have fewer people around, like parents or spouses, to encourage them to get rid of unneeded items. </p>
<p>What is clear is that the increase in hoarding behaviors across the lifespan is not just a result of a lifetime’s accumulation of clutter. About <a href="https://doi.org/10.1016/j.jagp.2016.11.006">7% of adults</a> over age 60 have problematic hoarding; that’s one in every 14 people. </p>
<p>And contrary to popular belief, the defining feature of hoarding disorder is not clutter. Instead, it is the difficulty in discarding what’s no longer needed. The most commonly hoarded items are everyday belongings: clothes, shoes, containers, tools and mechanical objects like nails and screws, household supplies, newspapers, mail and magazines. Those with the disorder report feeling indecision about what to discard, or fear the item will be needed in the future. </p>
<p>This trouble in disposing of items, even common items like junk mail, plastic bags and plastic containers, leads to the accumulation of clutter. Over time, living and work spaces become unusable. In addition to affecting living spaces, hoarding also causes problems between spouses, between parents and their children, and between friends. At its worst, hoarding can also impact one’s ability to work. </p>
<p>Hoarding disorder has a substantial impact on public health, including not only <a href="https://doi.org/10.1016/j.psychres.2007.08.008">lost work days</a> but also increased rates of <a href="https://doi.org/10.1080/13607863.2013.814105">medical illness</a>, <a href="https://doi.org/10.1016/j.jocrd.2018.11.001">depression, anxiety</a>, risk of suicide and <a href="https://doi.org/10.1002/da.22439">cognitive impairment</a>. As many as half of those suffering from hoarding disorder will also suffer from depression, and 30% or more will have an anxiety disorder. </p>
<p>Hoarding-related clutter in homes increases the <a href="https://www.mentalhealthsf.org/wp-content/uploads/2016/12/BeyondOverwhelmed.pdf">risk of falls</a>, pest or vermin infestation, unstable or unsafe living conditions and difficulty with self-care. It may stun you to know that up to 25% of <a href="https://digitalcommons.wpi.edu/iqp-all/592/">deaths by house fire</a> are due to hoarding. </p>
<figure class="align-center ">
<img alt="During the pandemic, stores across the U.S. ran out of common household items, like toilet paper." src="https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369169/original/file-20201112-21-2rao60.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Because of excessive stockpiling and panic buying, stores across the U.S. ran out of common household items during the pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/general-view-of-the-empty-toilet-paper-and-paper-towel-news-photo/1207061653?adppopup=true">Icon Sportswire via Getty Images</a></span>
</figcaption>
</figure>
<h2>Stockpiling and panic buying</h2>
<p>What is the difference between stockpiling, panic buying and hoarding? Will someone who stockpiled toilet paper and hand sanitizer in the early days of the pandemic develop hoarding disorder? Or are they instead rational and thoughtful planners?</p>
<p>While these terms are often used interchangeably, stockpiling and panic buying are not symptoms of hoarding disorder. Nor are they necessarily the result of a psychiatric or psychological condition. Instead, <a href="https://www.merriam-webster.com/dictionary/stockpile">stockpiling</a> is a normal behavior that many people practice in preparation for a known or anticipated shortage. The goal of stockpiling is to create a reserve in case there’s a future need.</p>
<p>For example, people who live in cold climates may stock up on wood for fireplaces and salt for driveways before the winter. Similarly, those who live in the southeast U.S. may stock up on gasoline and water before hurricane season.</p>
<p>That said, stockpiling can be excessive. During a crisis, it can lead to national shortages of essential items. This occurred early in the pandemic, when people bought toilet paper in large quantities and emptied store shelves for everyone else. </p>
<p>Ironically, the more media attention on stockpiling, the more it triggers <a href="https://doi.org/10.1111/bjhp.12480">additional stockpiling</a>. People reading about a potential shortage of hand sanitizer will be driven to buy as much as possible until it’s no longer available for weeks or months.</p>
<p>While stockpiling is planned, <a href="https://en.wikipedia.org/wiki/Panic_buying">panic buying</a> is an impulsive and temporary reaction to anxiety caused by an impending crisis. Items, even if unneeded, may be purchased simply because they are available on store shelves. Panic buying may also include purchasing enormous quantities of a particular item, in volumes that will never be needed, or emptying a store shelf of that item. Panic acquiring, which involves getting free things through giveaways, food pantries or scavenging, also occurs during a crisis. </p>
<p>Unlike those with hoarding disorder, panic buyers and stockpilers are able to discard something no longer needed. Usually, after the crisis has passed, they can easily throw or give these items away. </p>
<h2>How to get help</h2>
<p>For some with hoarding disorder, the pandemic has made it even harder to dispose of unneeded items. Others find their material belongings provide comfort and safety in the face of increased uncertainty. Yet others have used the lockdowns as a reset – time to finally declutter their home. </p>
<p>If you or someone you know has problems with hoarding, help is available. Resources are on the <a href="https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder">American Psychiatric Association</a> website and at the <a href="https://hoarding.iocdf.org/">International Obsessive Compulsive Foundation</a>.</p><img src="https://counter.theconversation.com/content/149422/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carol Mathews receives funding from the National Institute of Health. She is affiliated with the Tourette Association of America, and the International Obsessive Compulsive Foundation. She is the author of the book: Recognizing and Treating Hoarding Disorder: How Much is Too Much? published by W.W. Norton & Co.</span></em></p>The pandemic has put a spotlight on a once little-discussed disorder – hoarding. But hoarding disorder is not what you might think.Carol Mathews, Professor of Psychiatry, University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1411002020-07-08T10:37:43Z2020-07-08T10:37:43ZHow coronavirus affects the brain<figure><img src="https://images.theconversation.com/files/346044/original/file-20200707-194423-102heg6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/artificial-intelligence-concept-floating-brain-model-1672141531">r.classen/Shutterstock</a></span></figcaption></figure><p>Six months into the COVID-19 pandemic, we’re still learning what the disease can do. There are now detailed reports of brain illness emerging in people with relatively mild lung illness, in those who are critically ill and also <a href="https://academic.oup.com/brain/article-lookup/doi/10.1093/brain/awaa240">in those in recovery</a>. </p>
<p>One key thing we’re seeing is that severity of lung illness doesn’t always correlate with severity of neurological illness. Having only minor lung illness doesn’t protect against potentially severe complications.</p>
<p>When it comes to the brain and nerves, the virus appears to have four main sets of effects: </p>
<ol>
<li>A confused state (known as delirium or encephalopathy), sometimes with <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30287-X/fulltext">psychosis and memory disturbance</a>. </li>
<li>Inflammation of the brain (known as encephalitis). This includes a form showing inflammatory lesions – acute disseminated encephalomyelitis (ADEM) – together with the effects of low oxygen in the brain.</li>
<li>Blood clots, leading to <a href="https://jnnp.bmj.com/content/early/2020/05/28/jnnp-2020-323586">stroke</a> (including in <a href="https://www.nejm.org/doi/full/10.1056/NEJMc2009787">younger patients</a>).</li>
<li>Potential damage to the nerves in the body, causing pain and numbness (for example in the form of <a href="https://www.nejm.org/doi/full/10.1056/NEJMc2009191">post-infectious Guillain-Barré syndrome</a>, in which your body’s immune system attacks your nerves).<br></li>
</ol>
<p>To date, the <a href="https://pubs.rsna.org/doi/pdf/10.1148/radiol.2020202222">patterns of these effects</a> seem similar <a href="https://www.nejm.org/doi/full/10.1056/NEJMc2008597">across the world</a>. Some of these illnesses are fatal and, for those who survive, many will bear long-term consequences.</p>
<p>This raises an important question: will COVID-19 be associated with a large epidemic of brain illness, in the same manner that the 1918 influenza pandemic was linked (admittedly somewhat uncertainly) to the epidemic of encephalitis lethargica (sleeping sickness) that took hold until the 1930s? At this stage, it’s hard to say – but here’s what we know about the virus’s effects on the brain so far.</p>
<h2>What’s happening inside people’s heads?</h2>
<p>Firstly, some people with COVID-19 experience <a href="https://theconversation.com/delirium-depression-anxiety-ptsd-the-less-discussed-effects-of-covid-19-138671">confused thoughts and disorientation</a>. Thankfully, in many cases it’s short-lived. But we still <a href="https://n.neurology.org/content/early/2020/06/16/WNL.0000000000010111.abstract">don’t know the long-term effects</a> of delirium caused by COVID-19 and whether long-term memory problems or even dementia in some people could arise. Delirium has been mostly studied in the elderly and, in this group, it’s associated with <a href="https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2598162">accelerated cognitive decline</a> beyond what’s expected if patients already suffer dementia. </p>
<p>The virus also has the potential to <a href="https://pubs.acs.org/doi/abs/10.1021/acschemneuro.0c00122">infect the brain directly</a>. However, most of the physical effects we’ve seen in survivors look like secondary impacts of the virus being present in the brain rather than the effects of direct infection. For example, our immune system can appropriately fight the virus, but may start to attack our own cells – including our brain cells and nerves. This may be through the actions of immune cells and antibodies via an inflammatory mechanism known as a <a href="https://pubmed.ncbi.nlm.nih.gov/32192578/">cytokine storm</a>, or through mechanisms we don’t yet understand. </p>
<p>There are also COVID-19 patients having ischaemic strokes, where a blood clot blocks the flow of blood and oxygen to the brain. Some of these patients have stroke risk factors (for example high blood pressure, diabetes or obesity), though their strokes have been particularly severe. It seems that this is because the blood rapidly becomes thickened in COVID-19 and, in these patients, there have been <a href="https://jnnp.bmj.com/content/early/2020/05/28/jnnp-2020-323586">multiple blood clots in the arteries feeding blood to the brain</a>, even in patients already receiving blood thinners. In others, there is brain bleeding due to weakened blood vessels, perhaps inflamed by the effects of the virus.</p>
<p>Where infection with the coronavirus is associated with inflammation or damage to the nerve endings themselves, individuals may develop burning and numbness and also weakness and paralysis. Often it’s difficult to know if these are the effects of a critical illness on the nerves themselves or if there’s brain and spine involvement. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/346048/original/file-20200707-18-1nhbvnw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/346048/original/file-20200707-18-1nhbvnw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=515&fit=crop&dpr=1 600w, https://images.theconversation.com/files/346048/original/file-20200707-18-1nhbvnw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=515&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/346048/original/file-20200707-18-1nhbvnw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=515&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/346048/original/file-20200707-18-1nhbvnw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=647&fit=crop&dpr=1 754w, https://images.theconversation.com/files/346048/original/file-20200707-18-1nhbvnw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=647&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/346048/original/file-20200707-18-1nhbvnw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=647&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Only a select group of COVID-19 patients have made it into an MRI scanner so far.</span>
<span class="attribution"><a class="source" href="https://flic.kr/p/NWdbyf">NIH Image Gallery/Flickr</a></span>
</figcaption>
</figure>
<p>All of these effects on the brain and nervous system have the potential for long-term damage and can stack up in an individual. But we need to know more about what’s going on in people’s nervous systems before we can accurately predict any long-term effects.</p>
<p>One way of finding out more is to take a look inside patients’ heads using brain-imaging techniques, such as MRI. So far, brain imaging has revealed a pattern of previously unseen findings, but its still very early days for using it in this pandemic. </p>
<p>In <a href="https://pubs.rsna.org/doi/10.1148/radiol.2020202222">one study</a>, patterns found included signs of inflammation and a shower of small spots of bleeding, often in the deepest parts of the brain. Some of these findings are similar to those seen in <a href="https://www.tandfonline.com/doi/abs/10.1080/02699052.2016.1179792">divers</a> or in <a href="https://www.sciencedirect.com/science/article/abs/pii/S1474442209700146">altitude sickness</a>. They might represent the <a href="https://science.sciencemag.org/content/368/6490/455.full.">profound lack of oxygen</a> being delivered to the brain in some patients with COVID-19 – but we are <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31282-4/fulltext">only starting to understand</a> the full scope of the brain’s involvement in the disease. Brain-imaging and postmortem studies for those killed by COVID-19 have been limited to date.</p>
<h2>Parallels with the past</h2>
<p>The 1918 influenza pandemic may have <a href="https://academic.oup.com/aje/article/187/12/2503/5091398">killed 50-100 million people</a> – one in 50 of those infected, and three to six times the number killed in the first world war. <a href="https://www.penguin.co.uk/books/111/1110253/pale-rider/9781784702403.html">Yet it has faded from our collective memory</a>. It’s not often mentioned that this pandemic was linked to an outbreak of brain disease – the “sleeping sickness” encephalitis lethargica. </p>
<p>Encephalitis and sleeping sickness had been linked to previous influenza outbreaks between the 1580s to 1890s. But the 20th-century epidemic of encephalitis lethargica started in 1915, before the influenza pandemic, and continued into the 1930s, so a direct link between the two <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758910/">has remained difficult to prove</a>. </p>
<p>In those who died, postmortems revealed a pattern of inflammation in the seat of the brain (known as the <a href="https://academic.oup.com/brain/article/140/8/2246/3970828">brainstem</a>). Some patients who had damage to areas of the brain involved in movement were locked in their bodies, unable to move for decades (post-encephalitic Parkinsonism), and were only “awakened” by treatment with L-Dopa (a chemical that naturally occurs in the body) by <a href="https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC1550182&blobtype=pdf">Oliver Sacks</a> in the 1960s. It is too early to tell if we will see a similar outbreak associated with the COVID-19 pandemic, though early reports of encephalitis in COVID-19 have shown features similar to those in <a href="https://nn.neurology.org/content/7/5/e789">encephalitis lethargica</a>. </p>
<p>The aftermath of this global event has many lessons for us now in the time of COVID-19. One, of course, is that we may see widespread brain damage following this viral pandemic.</p>
<p>But importantly, it’s also a reminder to consider the political and societal impact of pandemics, and the need to help vulnerable people who have illness afterwards. COVID-19 has already exposed disparities in access to healthcare. Societies will remain judged on how they protect and treat those most at risk from – and sustain the health consequences of – this virus. This will include people with neurological disease arising from COVID-19.</p><img src="https://counter.theconversation.com/content/141100/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Zandi has received funding support from the Medical Research Council, NIHR Biomedical Research Centre, Stanley Medical Foundation, Clare College Cambridge, and honoraria for lecturing from Eisai and UCB Pharma.</span></em></p>The virus seems to have a range of effects on the brain, even in patients with only mild lung illness.Michael Zandi, Consultant Neurologist and Honorary Associate Professor in Neurology, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1121892019-03-19T23:01:16Z2019-03-19T23:01:16ZHaving one mental health disorder increases your risks of getting another<figure><img src="https://images.theconversation.com/files/263964/original/file-20190314-28499-185ko3x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The concept of a shared inheritable risk underlying mental illnesses could lead to a new paradigm shift in drug discovery,</span> <span class="attribution"><span class="source">(Unsplash/Fernando Cferdo)</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>New studies reveal that most psychiatric illnesses are related to one another. Tracing these connections, like the mapping of a river system, promises to help define the main cause of these disorders and the drugs that could alleviate their symptoms. </p>
<p>The Danish Psychiatric Central Research Register is an enormous treasure trove of clinical data documenting every hospitalization for mental illness in Denmark over the course of 16 years. </p>
<p>In a <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2720421">recent study published in January 2019</a>,
Oleguer Plana-Ripoll from Aarhus University in Denmark and his colleagues analyzed records from close to six million Danes. They found that being affected with one mental disorder increased the risk of developing another — pointing to their possible relatedness. </p>
<p>For example, when young women were diagnosed with a mood disorder such as depression before age 20, they had a high risk of developing another disorder such as obsessive-compulsive disorder within the next five years. </p>
<p>The authors provided an interactive web-based tool to help clinicians and researchers see the connections among all types of psychiatric illness in the <a href="https://holtzyan.shinyapps.io/the-nb-como-project">NB-COMO project</a>.</p>
<h2>A canary in the psychiatric coalmine</h2>
<p>This clinical study followed on the heels of a paper published in <em>Science</em> magazine last year by the large international collaborative group called the <a href="http://www.dx.doi.org/10.1126/science.aap8757">Brainstorm Consortium</a>. </p>
<p>Using new statistical methods, these researchers showed that there is a surprising connectivity among people with different mental illnesses at the level of their inherited, genetic backgrounds. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/263963/original/file-20190314-28505-1agrboe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263963/original/file-20190314-28505-1agrboe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263963/original/file-20190314-28505-1agrboe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263963/original/file-20190314-28505-1agrboe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263963/original/file-20190314-28505-1agrboe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263963/original/file-20190314-28505-1agrboe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263963/original/file-20190314-28505-1agrboe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Research shows that many psychiatric disorders can be downstream of one common disturbance early in fetal development.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>They studied a quarter of a million patients and found there was a core cluster of similar genetic variations that showed up in all patients, regardless of the kind of illness they were diagnosed with. </p>
<p>This cluster heralded an increased risk for most disorders and, like a canary in the coalmine, constituted a warning system for the future risk of any psychiatric disorder including major depressive disorder, attention deficit hyperactivity disorder (ADHD), bipolar disorder and schizophrenia. </p>
<h2>A common disturbance in fetal development</h2>
<p>In March 2019, Andrew Schork and colleagues of the Institute of Biological Psychiatry in Denmark published a paper in <em>Nature Neuroscience</em>. They used the iPSYCH study, which is linked to the Danish Psychiatric Central Research Register and contains <a href="https://www.nature.com/articles/s41593-018-0320-0">one of the largest number of psychiatric patients with detailed genetic backgrounds in the world.</a></p>
<p>The results of the Schork study confirmed the findings of the Brainstorm Consortium project and reinforced that idea that variations in a common genetic cluster raises the risk for most psychiatric disorders. They also gained insight into how that might happen. </p>
<p>They found that the level of activity of genes in this common cluster normally shapes how the fetal brain develops into the mature brain. These genes are most active in progenitor cell types of the fetus, which are cells that give rise to the more specialized neuronal networks that are responsible for mood and creative thought in children and adults. </p>
<p>Essentially, if the activities of the genes in the common cluster are not regulated properly at the beginning, in the early days of the developing brain, then multiple specialized mental functions could be affected later in life. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/263969/original/file-20190314-28496-o2iyta.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263969/original/file-20190314-28496-o2iyta.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263969/original/file-20190314-28496-o2iyta.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263969/original/file-20190314-28496-o2iyta.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263969/original/file-20190314-28496-o2iyta.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263969/original/file-20190314-28496-o2iyta.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263969/original/file-20190314-28496-o2iyta.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Research from the Danish Psychiatric Central Research Register may revitalize mental health treatment.</span>
<span class="attribution"><span class="source">(Unsplash/Cristina Newman)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>This model may explain why all psychiatric illnesses are connected — because all of these single disorders are downstream of a common perturbation that occurred early in fetal development. This idea will certainly be tested aggressively in the next few years. </p>
<h2>A paradigm shift in drug discovery</h2>
<p>Of course, superimposed on inherited risk is the influence of environmental factors on individual susceptibilities for mental illness. </p>
<p>We are still learning about how our life history of dietary habits, past infections, medications and traumas interact with susceptibilities encoded by our genetic backgrounds. So it will take some time before the findings of the studies of the Brainstorm Consortium and iPSYCH will be translated to changes in clinical care. </p>
<p>But the concept of a shared inheritable risk underlying mental illnesses could lead to a paradigm shift in drug discovery and development, as researchers look for drugs that target a root cause and ameliorate the symptoms of multiple mental illnesses</p>
<p>The theme for the 2019 meeting of the American Psychiatry Association is <a href="https://www.psychiatry.org/psychiatrists/meetings/annual-meeting">“Revitalize Psychiatry: Disrupt, include, engage and innovate.”</a>
Maybe we are witnessing the first steps toward such revitalization.</p><img src="https://counter.theconversation.com/content/112189/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christine Bear received funding from The Heart and Stroke Foundation and is currently funded by Genome Canada and Genome Ontario</span></em></p><p class="fine-print"><em><span>Stephen W. Scherer is supported by the GlaxoSmithKline-CIHR Endowed Chair in Genome Sciences at the Hospital for Sick Children and University of Toronto. He is also a co-author on the Brainstorm consortium paper for "contributions of data and analysis to the Psychiatric Genomics Consortium."</span></em></p><p class="fine-print"><em><span>Anne Bassett does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Mental health is impacted by both genetic and environmental factors. But new research reveals that many mental health disorders may flow from early disturbances in fetal development.Christine Bear, Professor, Faculty of Medicine, Fellow of the Munk School of Global Journalism, University of TorontoAnne Bassett, Professor of Psychiatry, University of TorontoStephen W. Scherer, Director, McLaughlin Centre for Molecular Medicine, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/923372018-02-26T11:33:57Z2018-02-26T11:33:57ZMental illness and gun laws: What you may not know about the complexities<figure><img src="https://images.theconversation.com/files/207712/original/file-20180223-108150-1pqwuo3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Students from Marjory Stoneman Douglas High School visiting the Florida Legislature on Feb. 21, 2018, to discuss gun control and mental illness. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/School-Shooting-Florida/ae4285a2389a49a784410ccf18e17f8f/1/0">AP Photo/Gerald Strong</a></span></figcaption></figure><p>Every time the country is shaken by a tragic mass shooting and the loss of innocent lives, the same debates are repeated. Besides sending thoughts and prayers for the victims, a common theme – especially when the shooter is not a Muslim – is discussing warning signs of mental illness, and its role in the actions of the murderer.</p>
<p>In a Feb. 28, 2018 meeting at the White House, in addition to suggesting stricter gun laws, the President said he thought due process for mentally ill people was not as important as making sure that they do not have guns. </p>
<p>“I don’t want<a href="https://www.dallasnews.com/news/politics/2018/02/28/trump-gives-cornyn-marketing-tip-gun-bill-call-us-background-check-bill-not-fix-nics"> mentally ill</a> people to be having guns. Take the guns first, go through due process second,” Trump said. </p>
<p>In the past, mental illness has been scapegoated to deflect public outrage about access to assault rifles that can kill tens of people in a matter of minutes. During these heated debates, words such as <a href="http://www.nydailynews.com/opinion/nra-dana-loesch-deflects-questions-town-hall-meeting-article-1.3835143">“crazy,” “nuts” and “maniac”</a> are used to describe the person who committed the act of violence, even before a medical diagnosis is released. </p>
<p>In this debate, many questions arise that those discussing mental illness and gun violence may not even think about: What do we mean by mental illness? Which mental illnesses? What would be the policies to keep guns away from the potentially dangerous mentally ill? Most of these questions remain unanswered during these discussions.</p>
<p>Specifically, no one suggests who will decide whether a patient with mental illness should not have access to firearms – a psychiatrist, an independent forensic psychiatrist, a committee of psychiatrists or a judge? How about those who do not seek psychiatric evaluation and treatment? Should a psychiatric examination be integrated into the background check process for each person who wants to purchase a gun? As severe mental illness can start at any point in life, will gun owners need periodic psychiatric assessment (like a vision exam for renewing a driver’s license)? Who will pay for the visits? </p>
<p>As an <a href="https://scholar.google.com/citations?user=R62YyYIAAAAJ&hl=en">academic psychiatrist</a>, here’s my perspective on the complexities of this issue.</p>
<h2>What is mental illness?</h2>
<p>The term <a href="http://www.psychiatrictimes.com/dsm-5/requiem-dsm">“mental illness”</a> covers a wide range of psychiatric conditions that are addressed and treated by mental health professionals. </p>
<p>You may be surprised to know there are more than 200 diagnoses listed in the most recent version of <a href="https://www.psychiatry.org/psychiatrists/practice/dsm">Diagnostic Statistical Manual of Mental Disorders</a>, which is released by the American Psychiatric Association. This includes conditions such as anxiety disorders like spider phobia, social phobia, social anxiety disorder, post-traumatic stress disorder, hair-picking, pathological gambling, schizophrenia, dementia, different forms of depression and personality disorders, such as antisocial personality disorder commonly known as psychopathy. </p>
<p>Mental illnesses are also very common: Nearly <a href="https://www.nami.org/learn-more/mental-health-by-the-numbers">one in five people experience clinical depression</a> during their lives; one in five experiences an anxiety disorder; <a href="https://www.nimh.nih.gov/health/statistics/schizophrenia.shtml">one in 100 experience schizophrenia</a>; and <a href="http://www.ptsdunited.org/ptsd-statistics-2/">nearly 8 percent</a> of the general population experience PTSD. People who have had higher exposure to trauma, violence and warfare, <a href="https://www.ptsd.va.gov/professional/PTSD-overview/epidemiological-facts-ptsd.asp">such as veterans</a>, have higher rates of PTSD (up to 30 percent). </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/207716/original/file-20180223-108139-1ipof4a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/207716/original/file-20180223-108139-1ipof4a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/207716/original/file-20180223-108139-1ipof4a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/207716/original/file-20180223-108139-1ipof4a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/207716/original/file-20180223-108139-1ipof4a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/207716/original/file-20180223-108139-1ipof4a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/207716/original/file-20180223-108139-1ipof4a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">As many as 1 in 5 people experience depression.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/depressed-man-sitting-head-hands-on-530048185?src=uX7RcHAndNDp_1ku2Y0ayQ-1-1">TZIDO SUN/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Now, when one suggests that <a href="https://www.pbs.org/newshour/health/trump-said-mental-illness-leads-to-gun-violence-heres-why-doctors-disagree">gun access should be restricted for people with mental illness </a>, do they mean all of these conditions? Or just some, or some in defined circumstances? For example, should we remove guns from all veterans with PTSD, or all people with social anxiety, or those who habitually pick their skin?</p>
<p>Needless to say that diagnosing these conditions mostly relies on the person’s report and the physician’s observation, and the ability to rely on their report is important. </p>
<h2>When can a person be potentially dangerous to others?</h2>
<p>Not all mental illness may be a risk of harm to others. In the majority of cases when a patient is involuntarily admitted to a psychiatric inpatient unit, it is not because the person is a risk to others. Rather, it is more often the case that the person is at risk of harming himself, as in the case of a depressed, suicidal patient. </p>
<p>In psychiatric disorders, concerns about harm to others typically arise in acutely psychotic patients with paranoid delusions that convince them to harm others. This may happen in, but is not limited to schizophrenia, dementia, severe psychotic depression or psychotic bipolar illness.</p>
<p>Substance use, which can increase the risk of crime or psychosis, can also lead to intentions to harm others. Other situations, when a person could be a risk of harm to others, are personality disorders with a high level of impulsivity or lack of remorse, such as <a href="https://www.mayoclinic.org/diseases-conditions/antisocial-personality-disorder/symptoms-causes/syc-20353928">antisocial personality disorder</a>. </p>
<p>But the reality is that most people with personality disorders do not seek treatment and are not known to mental health providers. </p>
<p>It’s important to note that those with diagnosed serious mental illness, who are determined by a psychiatrist to be a serious risk of harm to themselves or others, already get admitted to acute or long-term inpatient care and are kept there until they are deemed not dangerous. Of course this happens only if they are brought in for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3392176/">psychiatric evaluation</a> by others or law enforcement. </p>
<h2>What are the facts?</h2>
<p>Even among the 1 percent of the U.S. population with a diagnosis of schizophrenia, it is rare to find people who are a risk of harm to others or at risk of acting violently. Despite the widespread belief that a person with serious mental illness like bipolar disorder or schizophrenia can be dangerous, <a href="http://www.annalsofepidemiology.org/article/S1047-2797(14)00147-1/pdf">only 3 to 4 percent of all the violent acts</a> committed in a given year in the U.S. are committed by people who have been diagnosed with commonly cited mental illness of schizophrenia, bipolar disorder or depression. </p>
<p>Also, these conditions are rather strongly associated with <a href="https://psychiatryonline.org/doi/pdf/10.5555/appi.books.9781615371099">increased risk of suicide</a>, not homicide. Furthermore, risk of violence among severely mentally ill declines in the absence of substance use. In other words, prevention and treatment of substance use can decrease the risk of violence in this population. </p>
<p>Another fact to consider is that the prevalence of severe mental illnesses, is relatively similar across different countries, including those with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3039289/">much lower rates of mass murder</a> than the U.S.</p>
<p>Finally, one has to keep in mind that the presence of a psychiatric diagnosis in a murderer, does not necessarily justify causality, as much as the weapon the person carries. In other words, because mental illness is so prevalent, a percentage of crimes are, statistically, going to be committed by people with a mental illness.</p>
<h2>Consequences of using ‘mental illness’ so vaguely</h2>
<p>I have previously discussed the <a href="https://www.washingtonpost.com/news/posteverything/wp/2018/01/11/why-psychiatrists-should-not-be-involved-in-presidential-politics/?utm_term=.d93dfd7f0529">negative impact of involving mental illness in politics.</a> Every time <a href="http://blogs.bmj.com/bmj/2017/10/06/doctors-need-to-speak-up-against-the-use-of-mental-illness-as-an-insult/">mental illness is linked to acts of violence</a> by the media or politicians, the highly charged emotions of the moment can impact those with mental illness and their families. </p>
<p>When “mental illness” is so vaguely addressed in gun debates, those with a mental illness without an increased risk of violence or impairment in judgment (such as anxiety or phobia) may avoid seeking treatment. I have often had patients who were worried that their diagnosis of depression or anxiety, although well-treated, might be used against them in court regarding child custody. I have repeatedly had to explain to them that their disorder does not provide grounds for justification of impaired judgment.</p>
<p>I personally believe it is common sense to limit everyone’s access to weapons with the potential of killing tens of people in a matter of minutes. Choosing who may or may not have access to them based on mental illness is, as I’ve outlined, very hard indeed.</p><img src="https://counter.theconversation.com/content/92337/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arash Javanbakht does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When mass shootings occur, some people insist the focus should be on mental illness, not gun control. A psychiatrist explains how that view misses the mark.Arash Javanbakht, Assistant Professor of Psychiatry, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/774212017-08-15T13:21:38Z2017-08-15T13:21:38ZHarnessing the body’s own cannabis in the fight against cancer<figure><img src="https://images.theconversation.com/files/178872/original/file-20170719-27696-1xktm1b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/348038528?src=9aizPSvS-2gYtHuLZHO3sQ-1-0&size=medium_jpg">OpenRangeStock/Shutterstock</a></span></figcaption></figure><p>The drugs used to treat cancer after surgery can help to slow disease progression, but they don’t always stop cancer cells from spreading to other parts of the body, nor do they help with pain associated with some cancers such as sarcomas (rare bone cancers). There is a drug, however, that potentially does both of these things: cannabis. </p>
<p>Preparations of cannabis plants have been used for medicinal purposes for <a href="https://en.wikipedia.org/wiki/History_of_medical_cannabis">thousands of years</a>. Scientists are finally starting to test the legitimacy of some of these folk remedies. In recent years, clinical studies have shown that cannabis reduces pain caused by diseases such as multiple sclerosis - indeed, many cancer patients use cannabis for its <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503660/">pain-relieving properties</a>. Some animal and test-tube studies, however, suggest that cannabis may do more than just reduce pain; it may <a href="https://www.ncbi.nlm.nih.gov/pubmed/22555283">kill cancer cells and limit their spread</a>.</p>
<p>However, the development of cannabis preparations and other pharmaceutical agents that mimic the action of cannabis in the body has been hampered by reports of <a href="https://www.ncbi.nlm.nih.gov/pubmed/11157424">psychiatric problems</a> such as depression, psychosis and anxiety.</p>
<h2>Using the body’s own cannabis</h2>
<p>The human body produces chemicals that are similar to the active chemicals (cannabinoids) found in cannabis. These “endocannabinoids” (the Greek prefix “endo” means “within” or “inside”) help relieve pain and boost the body’s immune system. One strategy to boost the action of the body’s own cannabis is by inhibiting the enzymes that break down natural endocannabinoids.</p>
<p>One of these enzymes, called monoacylglycerol lipase (MAGL), is found in healthy tissues such as the brain, bone and the immune system. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28213089">Studies</a>, including our own, have shown that inhibiting the activity of this enzyme reduces the growth of variety of cancer cells in mice. </p>
<p>A paper <a href="https://www.ncbi.nlm.nih.gov/pubmed/21802006">published in 2011</a> showed that treating mice with a drug that blocks the action of MAGL boosted the production of an endocannabinoid called 2-arachidonoylglycerol in healthy cells and in cancer cells. They also showed that the drug reduced the growth of cancer cells and halted their spread to other parts of the body. </p>
<p>In our own research, at the University of Sheffield, we have validated the anti-cancer effects of various MAGL inhibitors on mice with breast and bone cancers. The results will be published in 2018. </p>
<h2>Evading the problem of psychiatric disorders</h2>
<p>There is a risk that experimental drugs that block the action of MAGL may cause psychiatric problems similar to those experienced by some cannabis users. To get around this, we are pursuing a number of strategies to design and test new drugs that only enter and accumulate in tumour cells. </p>
<p>One strategy is called the “ball and chain”. We successfully attached our experimental drug, that blocks the action of MAGL, to a chemical “ball”. Once in the body, the block binds to proteins called folate receptors that exist in large numbers on the surface of tumour cells.</p>
<p>The folate receptor will allow the drug-chain-ball complex to enter tumour cells. Once inside, enzymes will break the “chain” and this will release the drug to block the action of MAGL. This will boost the production of cannabinoids by the tumours that in turn halt the tumour growth and spread to other parts of the body (see figure).</p>
<p>Our studies, carried out in test-tubes, have shown that the ball-and-chain drugs can kill cancer cells and stop them moving. Encouraged by these findings, we are now looking to validate the anti-cancer effects of the new drugs in mice.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/181968/original/file-20170814-28472-1slcpap.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181968/original/file-20170814-28472-1slcpap.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=665&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181968/original/file-20170814-28472-1slcpap.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=665&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181968/original/file-20170814-28472-1slcpap.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=665&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181968/original/file-20170814-28472-1slcpap.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=836&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181968/original/file-20170814-28472-1slcpap.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=836&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181968/original/file-20170814-28472-1slcpap.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=836&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Idris Figure.</span>
</figcaption>
</figure>
<p>The brain is protected by a biological barrier – the “blood-brain barrier” – that only allows the passage of natural substances such as water, gases and other chemicals it needs to function. We do not expect that our new drugs – with their ball-and-chain elements – will be able to gain access to the brain because of their large size. So we don’t anticipate that this new drug will cause any psychiatric problems. But it is still early days and we need to conduct more research to confirm our theory. </p>
<p>We are currently seeking funding to carry out research to find out if the new drugs that stop the body breaking down its own cannabis may be effective in reducing pain in mice suffering from osteosarcoma, a rare form of bone cancer that causes bone pain.</p>
<p>Treatment with drugs that stop the body breaking down its own cannabis in peripheral tissues, or drugs that mimic the action of natural cannabis outside the brain, may be a fruitful way to develop safer cannabis drugs for treating cancer. Who knows, these drugs may even provide a safer alternative to plant-derived cannabis because they can’t cross the blood brain barrier.</p><img src="https://counter.theconversation.com/content/77421/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aymen Idris is an inventor on a patent concerning the use of cannabinoid receptor ligands as treatments of other bone diseases and he received funding from Arthritis Research Campaign. </span></em></p>Harnessing the medicinal benefit of the body’s own cannabis-like substances may provide an alternative to medicinal marijuana.Aymen Idris, Senior Lecturer of Pharmacology, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/510102015-12-04T11:11:40Z2015-12-04T11:11:40ZWhen fear is a weapon: how terror attacks influence mental health<p><em>Editor’s note: This article was updated on March 23, 2016 with information from the terrorist attacks in Brussels.</em></p>
<hr>
<p>Only four months after a series of coordinated <a href="http://www.nytimes.com/interactive/2015/11/20/world/europe/Paris-terror-victims-list.html">attacks in Paris left 130 people dead</a>, Europe was once again the target of chilling acts of terrorism when yesterday, March 22, 2016, two explosions <a href="http://www.nytimes.com/2016/03/23/world/europe/brussels-airport-explosions.html?action=click&pgtype=Homepage&clickSource=story-heading&module=span-abc-region&region=span-abc-region&WT.nav=span-abc-region&_r=0">rocked the airport in Brussels</a> and another ripped through a subway station in the Belgian capital. At least 30 people were killed and several hundred others were wounded in the attack.</p>
<p>The media is naturally reporting extensively on any news related to the terrorist attack, and one can easily spend several hours a day watching, reading and listening to these reports. This exposure can significantly influence your worldviews and how you live your life.</p>
<p>The aftermath of a terrorist attack can make people feel more vulnerable. And as cities go on alert because of the threat of future attacks, fear can color our daily routines and world views.</p>
<p>With my colleague S. Justin Sinclair at Harvard Medical School, I have been studying the <a href="https://global.oup.com/academic/product/the-psychology-of-terrorism-fears-9780195388114?q=daniel%20antonius&lang=en&cc=us">complexity of terrorism fears</a>, and <a href="https://global.oup.com/academic/product/the-political-psychology-of-terrorism-fears-9780199925926?q=daniel%20antonius&lang=en&cc=us">how fear can affect</a> and motivate people.</p>
<p>It is probably not a surprise that a terror attack can have a major impact on people’s mental health. But what sort of effects are common, and how long do they last? </p>
<p>To answer that question, we can turn to a growing body of research examining the psychological aftermath of terror attacks.</p>
<h2>Increases in PTSD symptoms are often seen after terror attacks</h2>
<p>In 1995 and 1996, France experienced a wave of bombings that killed 12 and injured more than 200. A 2004 retrospective study examined post-traumatic stress disorder rates in the victims and found that <a href="http://dx.doi.org/10.1176/appi.ajp.161.8.1384">31 percent experienced post-traumatic stress disorder</a>. </p>
<p>Symptoms of post-traumatic stress disorder (or <a href="http://www.apa.org/topics/ptsd/">PTSD</a>) can include flashbacks, nightmares or intrusive thoughts about the event. People may also avoid situations that remind them of the trauma, or have intense feeling of anxiety they didn’t have before. </p>
<p>Research has also found an increase in psychiatric symptoms among people living in a city when it is attacked.</p>
<p>For instance, a survey of Madrid residents one to three months after the attacks on a commuter rail line in 2004 <a href="http://www.ncbi.nlm.nih.gov/pubmed/16568454">found an increase</a> in post-traumatic stress disorder and depression.</p>
<p>Further research suggests that this increase is temporary. </p>
<p>In a 2005 study of London residents conducted <a href="http://www.ncbi.nlm.nih.gov/pubmed/16126821">a few weeks after the July 7 attacks</a>, 31 percent of respondents reported a significant elevation in stress levels and 32 percent reported an intention to travel less. A follow-up study conducted seven months later found that the elevated stress levels were significantly <a href="http://dx.doi.org/10.1192/bjp.bp.106.029785">reduced</a>. But, the study also noted that a residual level of worry remained. Many people reported relatively high levels of perceived threat to self and others, and a more negative world view. </p>
<p>We would expect to see an increase in psychiatric disorders among people who were directly affected, or who lived in the city at the time of the attack. But this can also happen in people who weren’t living in a city when it was attacked.</p>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/12215130">survey</a> conducted soon after the September 11 attacks found that 17 percent of the U.S. population living outside of New York City reported symptoms related to post-traumatic stress disorder. Six months later, that dropped to 5.6 percent.</p>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/17143080">2005 review</a> of psychological research about the effect of September 11 highlighted the uptick in psychiatric symptoms and disorders immediately after the attacks and the relatively quick normalization in the following 6-12 months. However, people living closer to the area attacked, and thus more directly exposed, were more vulnerable to developing post-traumatic stress disorder than people living farther away.</p>
<p>Why do symptoms of post-traumatic stress disorder increase in people who weren’t directly exposed? The explanation might be the intense media coverage of terror attacks.</p>
<p>In the aftermath of September 11, a U.S. study of more than 2,000 adults found that more time spent watching television coverage of the attacks was associated with <a href="http://www.ncbi.nlm.nih.gov/pubmed/12150669">elevated rates of post-traumatic stress disorder</a>. </p>
<p>In essence, a media-related <a href="http://www.psychology-lexicon.com/cms/glossary/36-glossary-c/2057-contagion-effect.html">contagion effect</a> is created where people live and relive the attacks when they watch or read stories about them. This overexposure may, as argued by some, produce <a href="http://www.ncbi.nlm.nih.gov/pubmed/17516775">a subjective response of fear and helplessness </a> about the threat of future attacks in a minority of adults.</p>
<h2>Fear changes behavior, at least for a little while</h2>
<p>Fear is a natural response to events like the attacks in Paris or Brussels. While everyone feels and reacts to fear differently, it can push people to make different decisions about employment, whom to socialize with, using public transportation such as buses and trains, congregating in public and crowded places, and traveling on airplanes. </p>
<p>If you look at these changes across an entire population, you can see how fears of terrorism can have significant consequences on both the national and global economy. Tourism and shopping may be particularly vulnerable. For example, <a href="http://traveltips.usatoday.com/effects-911-airline-industry-63890.html">airlines suffered</a> major economic losses after 9/11 and were forced to lay off large numbers of employees.</p>
<p>While stock markets in New York, Madrid and London <a href="http://www.nytimes.com/2015/11/17/business/dealbook/the-fallout-from-attacks-is-measured-in-more-than-stock-markets.html?_r=0">dropped after the attacks</a>, they rebounded relatively quickly. </p>
<p>Similarly, after the recent attack in Paris, there was reportedly a <a href="http://www.forbes.com/sites/laurielaird/2015/11/16/the-paris-attacks-and-the-economic-impact-of-terrorism/">limited impact on the nation’s stock market</a>.</p>
<h2>Attacks can change how people relate to government</h2>
<p>Terrorists use fear as a psychological weapon, and it can have serious psychological implications for individuals and whole countries. </p>
<p>An <a href="https://global.oup.com/academic/product/the-psychology-of-terrorism-fears-9780195388114?cc=us&lang=en&">underlying sense of fear</a> can linger for years after an attack. In prolonged conflicts with multiple attacks, such as the <a href="http://www.bbc.co.uk/history/troubles">Troubles in Northern Ireland</a> or the <a href="https://en.wikipedia.org/wiki/Israeli%E2%80%93Palestinian_conflict">Israeli-Palestinian Conflict</a>, chronic fear and anxiety have arguably resulted in a high levels of segregation and suspiciousness. </p>
<p>This underlying fear may also affect <a href="https://global.oup.com/academic/product/the-political-psychology-of-terrorism-fears-9780199925926?cc=us&lang=en&">political engagement and trust in government policymaking</a>.</p>
<p>People generally tend to place larger degrees of trust in their government’s ability to keep them safe from future violence following large-scale terrorist attacks. For example, prior to the September 11 attacks, the public’s trust in the US government was in decline, but the attacks primed people’s fears, and trust in the US government to protect and keep the public safe from future attacks <a href="http://onlinelibrary.wiley.com/doi/10.1111/0162-895X.00294/abstract">rose to a level</a> not seen in decades. </p>
<p>However, increased trust in the government may also come without fear. In countries where there already are high levels of trust in the government, fear has been found to play a less important role.</p>
<p>A study examining the association between fear and trust in Norway right before, right after and 10 months after the 2011 terror attack found that <a href="http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780199925926.001.0001/acprof-9780199925926-chapter-14">high levels of existing trust</a> may actually buffer against the negative effects of terrorism fears, while still creating a rallying effect around governmental policies. </p>
<p>The threat of terrorism does not, of course, have the same effect on everyone. Most people arguably respond to threats of future terrorism in a rational and constructive manner. For instance, very compelling research suggests that anger may actually function as a protective factor. In the context of feeling angry, people tend to have a larger sense of being in control, a preference for confrontation and <a href="http://dx.doi.org/10.1111/1467-9280.01433">feeling optimistic</a>; whereas with fear comes a greater sense of not feeling in control and pessimism.</p>
<p>The paradox of the fear that terrorism inspires is that while it can negatively affect people and societies, it can also serve to strengthen resilience.</p><img src="https://counter.theconversation.com/content/51010/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel Antonius does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It is probably not a surprise that a terror attack can have a major impact on people’s mental health. But what sort of effects are common, and how long do they last?Daniel Antonius, Director, Division of Forensic Psychiatry, University at BuffaloLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/478202015-12-02T11:05:25Z2015-12-02T11:05:25ZWhat clues does your dog’s drool hold for human mental health?<figure><img src="https://images.theconversation.com/files/103945/original/image-20151201-26568-1ld7n8o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There goes some precious DNA....</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/graemebird/2478467142">Graeme Bird</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>Dogs were the <a href="https://theconversation.com/new-dna-analysis-says-your-poochs-ancestors-were-central-asian-wolves-49271">first animals people domesticated</a>, long before the earliest human civilizations appeared. Today, tens of thousands of years later, dogs have an unusually close relationship with us. They share our homes and steal our hearts – and have even evolved <a href="http://barkpost.com/dogs-love-us-like-family/">to love us back</a>. Sadly, they also suffer from many of the same difficult-to-treat psychiatric and neurological diseases we do.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/103939/original/image-20151201-26582-1tcleck.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/103939/original/image-20151201-26582-1tcleck.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/103939/original/image-20151201-26582-1tcleck.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=733&fit=crop&dpr=1 600w, https://images.theconversation.com/files/103939/original/image-20151201-26582-1tcleck.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=733&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/103939/original/image-20151201-26582-1tcleck.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=733&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/103939/original/image-20151201-26582-1tcleck.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=921&fit=crop&dpr=1 754w, https://images.theconversation.com/files/103939/original/image-20151201-26582-1tcleck.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=921&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/103939/original/image-20151201-26582-1tcleck.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=921&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Beskow, in fine spirits.</span>
<span class="attribution"><span class="source">Elinor Karlsson</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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</figure>
<p>I learned this firsthand about six years ago, when my sister Adria adopted Beskow, a beautiful, boisterous, black and white mutt. Beskow became my constant companion on my morning runs along the Charles River. Her joy in running was obvious to everyone we passed, and she kept me going mile after mile. </p>
<p>When not running, though, Beskow suffered from constant anxiety that left her stressed and unhappy – on edge around other dogs and prone to aggressive behavior. Beskow had trouble even playing outdoors, since she was compelled to attend to every sound and movement. Working one-on-one with skilled behaviorists and trainers helped immensely, but poor Beskow still never seemed able to relax. Eventually, Adria combined the intensive training with medication, which finally seemed to give Beskow some relief. </p>
<p>Beskow’s personality – her intelligence, her focus and her anxiety – was shaped not only by her own life experiences, but by thousands of years of evolution. Have you ever known a dog who would retrieve the same ball over and over again, for hours on end? Or just wouldn’t stay out of the water? Or wasn’t interested in balls, or water, but just wanted to follow her nose? These dogs are the result of hundreds of generations of artificial selection by human beings. By favoring useful behaviors when breeding dogs, we made the genetic changes responsible more common in their gene pool.</p>
<p>When a particular genetic change rapidly rises in prevalence in a population, it leaves a “signature of selection” that we can detect by sequencing the DNA of <a href="http://genomesunzipped.org/2010/09/detecting-positive-natural-selection-from-genetic-data.php">many individuals from the population</a>. Essentially, around a selected gene, we find a region of the genome where one particular pattern of DNA – the variant linked to the favored version of the gene – is far more common than any of the alternative patterns. The stronger the selection, the bigger this region, and the easier it is to detect this signature of selection. </p>
<p>In dogs, genes shaping behaviors purposely bred by humans are marked with large signatures of selection. It’s a bit like evolution is shining a spotlight on parts of the dog genome and saying, “Look here for interesting stuff!” To figure out exactly how a particular gene influences a dog’s behavior or health, though, we need lots more information. </p>
<p>To try to unravel these connections, my colleagues and I are launching a new citizen science research project we’re calling <a href="http://darwinsdogs.org/">Darwin’s Dogs</a>. <a href="http://iaabc.org/">Together with animal behavior experts</a>, we’ve put together a series of short surveys about everything from diet (does your dog eat grass?) to behavior (is your dog a foot sitter?) to personality (is your dog aloof or friendly?). </p>
<p>Any dog can participate in <a href="http://darwinsdogs.org/">Darwin’s Dogs</a>, including purebred dogs, mixed breed dogs, and mutts of no particular breed – our study’s participants will be very genetically diverse. We’re combining <a href="http://doi.org/10.1016/j.cell.2013.09.006">new DNA sequencing technology</a>, which can give us much more genetic information from each dog, with powerful new <a href="http://doi.org/10.1038/nrg3382">analysis methods that can control for diverse ancestry</a>. By including all dogs, we hope to be able to do much larger studies, and home in quickly on the important genes and genetic variants. </p>
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<a href="https://images.theconversation.com/files/103941/original/image-20151201-26574-6ny0rs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/103941/original/image-20151201-26574-6ny0rs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/103941/original/image-20151201-26574-6ny0rs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/103941/original/image-20151201-26574-6ny0rs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/103941/original/image-20151201-26574-6ny0rs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/103941/original/image-20151201-26574-6ny0rs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/103941/original/image-20151201-26574-6ny0rs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/103941/original/image-20151201-26574-6ny0rs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A beagle considers making the saliva donation.</span>
<span class="attribution"><span class="source">Stephen Schaffner</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Once an owner has filled out the survey, there’s a second, crucial step. We send an easy-to-use kit to collect a small dog saliva sample we can use for DNA analysis. There’s no cost, and we’ll share any information we find.</p>
<p>Our plan is to combine the genetic data from many dogs and look for changes in DNA that correlate with particular behaviors. It won’t be easy to match up DNA with an obsession with tennis balls, for instance. Behavior is a complex trait that relies on many genes. Simple <a href="http://www.nature.com/scitable/topicpage/gregor-mendel-and-the-principles-of-inheritance-593">Mendelian traits</a>, like Beskow’s black and white coat, are controlled by a single gene which determines the observable characteristic. This kind of inherited trait is comparatively easy to map. Complex traits, on the other hand, may be shaped by tens or even hundreds of different genetic changes, each of which on its own only slightly alters the individual carrying it. </p>
<p>Adding to the complexity, environment often plays a big role. For example, Beskow may not have been as anxious if she’d lived with Adria from puppyhood, even though her genetics would be unchanged. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/103946/original/image-20151201-26546-hlyirx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/103946/original/image-20151201-26546-hlyirx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/103946/original/image-20151201-26546-hlyirx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=648&fit=crop&dpr=1 600w, https://images.theconversation.com/files/103946/original/image-20151201-26546-hlyirx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=648&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/103946/original/image-20151201-26546-hlyirx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=648&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/103946/original/image-20151201-26546-hlyirx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=814&fit=crop&dpr=1 754w, https://images.theconversation.com/files/103946/original/image-20151201-26546-hlyirx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=814&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/103946/original/image-20151201-26546-hlyirx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=814&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Darwin’s Dogs team member Jesse McClure extracts DNA from a sample.</span>
<span class="attribution"><span class="source">Elinor Karlsson</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>To succeed, we need a lot of dogs to sign up. Initially, we’re aiming to enroll 5,000 dogs. If successful, we’ll keep growing. With bigger sample sizes, we’ll be able to tackle even more complex biological puzzles. </p>
<p>This is a huge effort, but could offer huge rewards. By figuring out how a genetic change leads to a change in behavior, we can decipher neural pathways involved in psychiatric and neurological diseases <a href="http://doi.org/10.1016/S0278-5846(00)00104-4">shared between people and dogs</a>. We already know these include not just anxiety, but also <a href="http://www.nytimes.com/2011/12/02/us/more-military-dogs-show-signs-of-combat-stress.html">PTSD</a>, <a href="http://doi.org/10.1186/gb-2014-15-3-r25">OCD</a>, <a href="http://doi.org/10.1038/tp.2014.106">autism spectrum disorders</a>, <a href="http://doi.org/10.2460/javma.2001.219.467">phobias</a>, <a href="http://doi.org/10.1016/S0092-8674(00)81965-0">narcolepsia</a>, <a href="http://doi.org/10.1111/epi.12138">epilepsy</a>, <a href="http://doi.org/10.1016/0197-4580(95)02060-8">dementia and Alzheimer’s disease</a>.</p>
<p>Understanding the biology underlying a disease is the first step in developing more effective treatments – of both the canine and human variety. For example, <a href="http://doi.org/10.1016/S0092-8674(00)81965-0">genetic studies of narcolepsy in Doberman pinschers</a> found the gene mutation causing the disease – but only in this one dog population. Researching the gene’s function, though, led to critical new insights into the molecular biology of sleep, and, eventually, to <a href="http://dx.doi.org/10.2147/NSS.S56077">new treatment options for people</a> suffering from this debilitating disease. </p>
<p><a href="http://darwinsdogs.org">Darwin’s Dogs</a> is investigating normal canine behaviors as well as diseases. We hypothesize that finding the small genetic changes that led to complex behaviors, like retrieving, or even personality characteristics, like playfulness, will help us figure out how brains work. We need this mechanistic understanding to design new, safe and more effective therapies for psychiatric diseases. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/103943/original/image-20151201-26582-7fy2k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/103943/original/image-20151201-26582-7fy2k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/103943/original/image-20151201-26582-7fy2k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/103943/original/image-20151201-26582-7fy2k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/103943/original/image-20151201-26582-7fy2k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/103943/original/image-20151201-26582-7fy2k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/103943/original/image-20151201-26582-7fy2k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/103943/original/image-20151201-26582-7fy2k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Beskow with one of her loving family members.</span>
<span class="attribution"><span class="source">Adria Karlsson</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>And Beskow? Six years later, she is as wonderful as ever. While still anxious some of the time, the medication and training have paid off, and she enjoys her daily walks, training and playtime. She still gets very nervous around other dogs, but is a gentle, playful companion for my sister’s three young children.</p>
<p>We are now sequencing her genome. In the next few months, we should have our first glimpse into Beskow’s ancestry. We know she is a natural herder, so we’re curious to find out how much her genome matches up to herding breeds, and which genes are in that part of the genome.</p>
<p>Of course, we can’t figure out much from just one dog – if you are a dog owner, please <a href="http://darwinsdogs.org">enroll your dog today</a>!</p><img src="https://counter.theconversation.com/content/47820/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elinor Karlsson receives funding from the NIH and the Worcester Foundation.</span></em></p>Researchers want your canine’s DNA to help unravel the connections between genes and behavior – for dogs and human beings.Elinor Karlsson, Assistant Professor of Bioinformatics and Integrative Biology, UMass Chan Medical SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/371702015-10-12T03:51:41Z2015-10-12T03:51:41ZHealth Check: seven nutrients important for mental health – and where to find them<figure><img src="https://images.theconversation.com/files/98007/original/image-20151012-23288-t3ve32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While nutrient supplementation can have a role in treating certain psychiatric disorders, all kinds of nutrients should, in the first instance, be consumed as part of a balanced wholefood diet.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/nakrnsm/3815441846/">PROPatrick Feller/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Dietary nutrients are critical for brain structure and function, so they have a potentially profound impact on mental health. An increasingly <a href="http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)00051-0/abstract">robust body of research</a> points to the detrimental effect of unhealthy diets and nutrient deficiencies, and to the protective value of healthy diets – along with select nutritional supplements as required – for maintaining and promoting mental health. </p>
<p>Research literature suggests dietary improvement and nutritional interventions may help reduce the risk, or even arrest the progression, of certain psychiatric disorders. <a href="http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)00051-0/abstract">Clinical studies</a> support the use of certain nutrients, which influence a range of neurochemical activities beneficial for treating mental disorders, as medicinal supplements.</p>
<p>Evidence from clinical research supports the use of several nutritional medicines for certain psychiatric disorders: omega-3 fatty acids; N-acetyl cysteine (NAC); S-adenosyl methionine (SAMe); zinc; magnesium; vitamin D; and B vitamins (including folic acid). Other natural compounds such as amino acids, plant-based antioxidants and microbiotics (derived from fermented food or laboratory synthesis) are also known to influence brain health. </p>
<p>But while some evidence supports these natural compounds as having brain chemical-modulating effects, or having a role in treating certain mental disorders, we cannot currently name particular foods as being effective for the treatment of mental illness. The best nutritional advice at this point is to cultivate an unprocessed wholefood diet, with judicious prescriptive use of nutrients (if required) based on advice from a qualified health professional. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/98010/original/image-20151012-23309-1jxpwuh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/98010/original/image-20151012-23309-1jxpwuh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=353&fit=crop&dpr=1 600w, https://images.theconversation.com/files/98010/original/image-20151012-23309-1jxpwuh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=353&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/98010/original/image-20151012-23309-1jxpwuh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=353&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/98010/original/image-20151012-23309-1jxpwuh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=444&fit=crop&dpr=1 754w, https://images.theconversation.com/files/98010/original/image-20151012-23309-1jxpwuh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=444&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/98010/original/image-20151012-23309-1jxpwuh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=444&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Oily fish such as sardines are the best source of omega-3 fats.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/jmenj/9434507959/">Jeanne Menj/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>In the meanwhile, here are seven key nutrients that may positively influence brain health, and the foods they appear in.</p>
<p><strong>1. Omega-3</strong> </p>
<p>Polyunsaturated fats (in particular omega-3 fatty acids) <a href="http://www.ncbi.nlm.nih.gov/pubmed/23538073">have a vital role</a> in maintaining proper neuronal structure and function, as well as in modulating critical aspects of the inflammatory pathway in the body. Taking omega-3 supplements appears beneficial for addressing symptoms of depression, bipolar depression and post-traumatic stress disorder. And it may potentially help <a href="http://www.ncbi.nlm.nih.gov/pubmed/20124114">prevent psychosis</a>.</p>
<p>Omega-3 fats can be found in nuts, seeds and oysters, although the highest amounts exist in oily fish such as sardines, salmon (especially King salmon), anchovies and mackerel. Due to higher levels of mercury, larger fish, such as mackerel, should be consumed in moderation.</p>
<p><strong>2. B vitamins and folate</strong></p>
<p>We need B vitamins for a range of cellular and metabolic processes, and they have a critical role in the production of a range of brain chemicals. Folate (B9) deficiency <a href="http://www.psychiatrist.com/JCP/article/Pages/2009/v70s05/v70s0503.aspx">has been reported</a> in depressed populations and among people who respond poorly to antidepressants.</p>
<p>Several studies have assessed the antidepressant effect of folic acid (the synthetic form of folate) with antidepressant medication. <a href="http://www.psychiatrist.com/JCP/article/Pages/2009/v70s05/v70s0503.aspx">Some show positive results</a> in enhancing either antidepressant response rates or the onset of response to these medications. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/98012/original/image-20151012-23319-13i4uq6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/98012/original/image-20151012-23319-13i4uq6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/98012/original/image-20151012-23319-13i4uq6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/98012/original/image-20151012-23319-13i4uq6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/98012/original/image-20151012-23319-13i4uq6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/98012/original/image-20151012-23319-13i4uq6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/98012/original/image-20151012-23319-13i4uq6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Nuts are a good source of folate, amino acids and minerals.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/addiction/62824084/">Ahmed Al Masaood/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Folate is found in abundance in leafy green vegetables, legumes, whole grains, brewer’s yeast and nuts. Unprocessed meats, eggs, cheese, dairy, whole grains and nuts are, in general, richest in B vitamins. If you’re going to take supplements, it’s advisable to take B vitamins together as <a href="http://www.ncbi.nlm.nih.gov/pubmed/23253391">they have a synergistic effect</a>.</p>
<p><strong>3. Amino acids</strong></p>
<p>Amino acids are the building blocks for creating proteins, from which brain circuitry and brain chemicals are formed. Some amino acids are precursors of mood-modulating chemicals; tryptophan, for instance, is needed to create serotonin. Another example is cysteine, a sulphur-based amino acid that can convert into glutathione – the body’s most powerful antioxidant. </p>
<p>When given as a supplement, an amino acid form known as N-acetyl cysteine (NAC) converts into <a href="https://en.wikipedia.org/wiki/Glutathione">glutathione</a> in the body. We have <a href="http://www.ncbi.nlm.nih.gov/pubmed/23369637">evidence that it’s helpful</a> in bipolar depression, schizophrenia, trichotillomania and other compulsive and addictive behaviours. Another amino acid-based nutrient known as S-adenosyl methionine (SAMe) <a href="http://www.ncbi.nlm.nih.gov/pubmed/24856557">has antidepressant qualities</a>. </p>
<p>Amino acids are found in any source of protein, most notably meats, seafood, eggs, nuts and legumes.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/98013/original/image-20151012-23319-wauedl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/98013/original/image-20151012-23319-wauedl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/98013/original/image-20151012-23319-wauedl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/98013/original/image-20151012-23319-wauedl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/98013/original/image-20151012-23319-wauedl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/98013/original/image-20151012-23319-wauedl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/98013/original/image-20151012-23319-wauedl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Amino acids are found in sources of protein such as meat.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/wurzeltod/357151207/">Suzanne Gerber/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p><strong>4. Minerals</strong> </p>
<p>Minerals, especially zinc, magnesium and iron, have important roles in neurological function. </p>
<p>Zinc is an abundant trace element, being involved in many brain chemistry reactions. It’s also a key element supporting proper immune function. <a href="http://www.ncbi.nlm.nih.gov/pubmed/25012438">Deficiency has been linked</a> to increased depressive symptoms and there’s emerging evidence for zinc supplementation in <a href="http://www.ncbi.nlm.nih.gov/pubmed/21798601">improving depressed mood</a>, primarily alongside antidepressants. </p>
<p>Magnesium is also involved in many brain chemistry reactions and <a href="http://www.ncbi.nlm.nih.gov/pubmed/19085527">deficiency has been linked</a> to depressive and anxiety symptoms. Iron is involved in many neurological activities and <a href="http://www.biomedcentral.com/1471-244X/13/161">deficiency is associated with</a> anxiety and depressive symptoms as well as developmental problems. This is, in part, due to its role in transporting oxygen to the brain.</p>
<p>Zinc is abundant in lean meats, oysters, whole grains, pumpkin seeds and nuts, while magnesium is richest in nuts, legumes, whole grains, leafy greens and soy. Iron occurs in higher amounts in unprocessed meats and organ meats, such as liver, and in modest amounts in grains, nuts and leafy greens, such as spinach. </p>
<p><strong>5. Vitamin D</strong></p>
<p>Vitamin D is a fat-soluble compound that’s important as much for brain development as it is for bone development. Data suggests low maternal levels of vitamin D are <a href="http://www.ncbi.nlm.nih.gov/pubmed/22796576">implicated in schizophrenia risk</a>, and deficiency is linked to <a href="http://www.ncbi.nlm.nih.gov/pubmed/23377209">increased depressive symptoms</a>. But there’s little evidence to support the use of <a href="http://www.ncbi.nlm.nih.gov/pubmed/24423304">vitamin D supplements for preventing depression</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/98015/original/image-20151012-23300-uz3k8j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/98015/original/image-20151012-23300-uz3k8j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=362&fit=crop&dpr=1 600w, https://images.theconversation.com/files/98015/original/image-20151012-23300-uz3k8j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=362&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/98015/original/image-20151012-23300-uz3k8j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=362&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/98015/original/image-20151012-23300-uz3k8j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=456&fit=crop&dpr=1 754w, https://images.theconversation.com/files/98015/original/image-20151012-23300-uz3k8j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=456&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/98015/original/image-20151012-23300-uz3k8j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=456&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Vitamin D can be synthesised via sunlight.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/naturesdawn/4299041739/">Dawn Ellner/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Vitamin D can be synthesised via sunlight: 15 minutes a day on the skin between 10am and 3pm during summer, although be sure to seek professional health advice regarding skin cancer concerns. Aside from sunlight, vitamin D can also be found in oily fish, UVB-exposed mushrooms and fortified milk.</p>
<p><strong>6. Plant-based antioxidants</strong></p>
<p>An increase in oxidative stress and damage to brain cells has been <a href="http://www.ncbi.nlm.nih.gov/pubmed/22271002">implicated in a range of mental disorders</a>, including depression and dementia. Antioxidant compounds (such as “polyphenols”, which are found in fruits and certain herbs) may “mop up” free radicals that damage cells to <a href="http://www.ncbi.nlm.nih.gov/pubmed/22334236">provide a natural way</a> to combat excessive oxidation.</p>
<p>Consuming natural antioxidant compounds through your diet is better than taking supplements of high doses of synthetic vitamin A, C or E, as the oxidative system is finely tuned and excess may actually be harmful. </p>
<p>Fruits and vegetables contain these antioxidant compounds in relative abundance, especially blackberries, blueberries, raspberries and goji berries; grapes; mangoes and mangosteen; onions; garlic; kale; as well as green and black tea; various herbal teas; and coffee.</p>
<p><strong>7. Microbiotics</strong></p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/23384445">Research</a> shows a connection between the bacteria in our guts and brain health, which may affect mental health. When the composition of the gut microbiota is less than optimal, it can result in inflammatory responses that <a href="http://www.ncbi.nlm.nih.gov/pubmed/21135322">may negatively affect</a> the nervous system and brain function. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/98009/original/image-20151012-23283-125i0an.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/98009/original/image-20151012-23283-125i0an.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/98009/original/image-20151012-23283-125i0an.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/98009/original/image-20151012-23283-125i0an.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/98009/original/image-20151012-23283-125i0an.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/98009/original/image-20151012-23283-125i0an.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/98009/original/image-20151012-23283-125i0an.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Diets high in sugary, fatty and processed foods are associated with depression and poor brain health.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/brizzlebornandbred/9375507295/">Paul Townsend/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>A balanced microfloral environment is supported by a diet rich in the foods that nourish beneficial bacteria and reduce harmful microbial species, such as <em>Helicobacter pylori</em>. Beneficial microflora can be supported by eating fermented foods such as tempeh, sauerkraut, kefir and yoghurt, and also by pectin-rich foods such as fruit skin. </p>
<h2>What now?</h2>
<p>Diets high in sugary, fatty and processed foods <a href="https://theconversation.com/you-are-what-you-eat-how-diet-affects-mental-well-being-27115">are associated</a> with depression and poor brain health. While nutrient supplementation can have a role in maintaining proper brain function and treating certain psychiatric disorders, nutrients should, in the first instance, be consumed as part of a balanced wholefood diet.</p>
<p>There is now enough research evidence to show the importance of nutrients for mental as well as physical well-being. A <a href="http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)00051-0/abstract">discussion about diet and nutrition</a> should be the starting point in conversations about mental health, just as it is for physical health.</p>
<p><em>If you’re interested in participating in a clinical trial prescribing nutrients for treating depression (SE Queensland and Victoria only), visit <a href="http://nutrientsdepressionstudy.com/">nutrientsdepressionstudy</a>.</em> </p>
<p><strong>Acknowledgement</strong>: Dr Drew Ramsey contributed to this article.</p><img src="https://counter.theconversation.com/content/37170/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jerome Sarris has received funding from Integria Health, Blackmores, Bioceuticals, Pepsico, HealthEd, Soho-Flordis, Pfizer, Elsevier, the Society for Medicinal Plant and Natural Product Research, CR Roper Fellowship, and The National Health and Medical Research Council. He is affiliated with The International Society for Nutritional Psychiatry Research. </span></em></p>A growing body of research points to the detrimental effect of unhealthy diets and the protective value of healthy diets – along with select nutritional supplements as required – for maintaining and promoting mental health.Jerome Sarris, Senior Research Fellow, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/469672015-09-01T22:30:33Z2015-09-01T22:30:33ZAnti-psychotic drugs designed to treat mental illness are being used to manage challenging behaviour<figure><img src="https://images.theconversation.com/files/93562/original/image-20150901-13412-1pl0q4t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An easier route?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-227823916/stock-photo-sad-man-looks-out-the-window.html?src=xfMb-4nr4lyG1M07fyUHdg-1-56">Man by Shutterstock</a></span></figcaption></figure><p>Intellectual disability <a href="http://aaidd.org/intellectual-disability/definition#.VeV3I-hVhBc">is characterised by</a> impairment in cognition (intellect) and difficulties in day-to-day life skills. It is fixed and lifelong, although with the right support most people with intellectual disability can lead active and fulfilling lives. </p>
<p>People with an intellectual disability have not always been treated well. One criticism of the care they receive is that drugs used to treat mental illness (known as “psychotropics” because of their effect on the brain) are prescribed too readily and without good reason. Although this criticism has been voiced for many years now, the true level of psychotropic drug prescribing has remained largely unknown. In <a href="http://www.bmj.com/cgi/doi/10.1136/bmj.h4326">research published in The BMJ</a> we looked at how frequently psychotropic drugs were prescribed to people with intellectual disability and under what circumstances. </p>
<p>Data on mental illness rates and psychotropic drug prescribing were collected from a large database of real-life GP care over the past 15 years. Just over 33,000 people with intellectual disability were included, and were drawn from all over the United Kingdom. The major finding of our research is that whereas almost two-thirds of people with intellectual disability have been prescribed a psychotropic drug, only around one third have a record of mental illness. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/93516/original/image-20150901-13392-9p76ev.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/93516/original/image-20150901-13392-9p76ev.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/93516/original/image-20150901-13392-9p76ev.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/93516/original/image-20150901-13392-9p76ev.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/93516/original/image-20150901-13392-9p76ev.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/93516/original/image-20150901-13392-9p76ev.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/93516/original/image-20150901-13392-9p76ev.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The wrong prescription.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-288763475/stock-photo-prescription-pill-bottle-spilling-pills-on-to-surface-isolated-on-a-white-background.html?src=cIuCT0aLLwcd3Lz_6CothA-1-38">Pills by Shutterstock</a></span>
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<p>There are therefore a large number of people who have been prescribed psychotropic drugs but who do not have a diagnosis of mental illness. This suggests that these drugs might be used inappropriately, or without justification, in some cases.</p>
<h2>Anti-psychotics</h2>
<p>We then looked in more detail at one particular group of psychotropic drug, the anti-psychotics. Anti-psychotics are powerful drugs that are designed to treat severe mental illnesses, such as schizophrenia and bipolar disorder. </p>
<p>Although people with intellectual disability develop severe mental illness at <a href="http://www.ncbi.nlm.nih.gov/pubmed/17197653">higher rates</a> than the general population, our results show that the majority (more than 70%) who were prescribed an anti-psychotic drug by their GP did not have a diagnosis of severe mental illness. </p>
<p>So who is being prescribed anti-psychotic drugs, if not those with severe mental illness? To answer this question we looked at associations between other conditions (in addition to intellectual disabilities) and prescription of anti-psychotics. </p>
<p>People who have intellectual disabilities and either behavioural disturbance, autism or dementia were significantly more likely to be prescribed anti-psychotic drugs. Older age was also associated with increased chances of being prescribed an anti-psychotic drug. This means, therefore, that prescriptions for anti-psychotic drugs are being given to people with conditions which <a href="https://theconversation.com/story-of-antipsychotics-is-one-of-myth-and-misrepresentation-18306">ordinarily should not be managed</a> with anti-psychotic medication.</p>
<h2>Addressing other issues</h2>
<p>Should we be concerned about this? Put simply, yes. Any treatment that is given should offer a reasonable chance of success, but there is little research evidence <a href="http://www.cochrane.org/CD000377/BEHAV_antipsychotic-medication-for-challenging-behaviour-in-people-with-learning-disability">that anti-psychotics are helpful</a> for people <a href="http://bit.ly/1PIuM8q">with intellectual disability and challenging behaviour</a>. </p>
<p>Added to this they may be harmful; these are potent drugs that can cause serious unwanted side-effects, such as sedation, movement disorders (stiffness and shakiness), and changes in metabolism that can predispose to weight gain and diabetes. Indeed, <a href="https://www.nice.org.uk/guidance/ng11">clinical guidelines of best practice</a> for managing challenging behaviour do not recommend the routine use of anti-psychotic drugs and advocate holistic management to address psychological and social issues that may contribute to the behaviour.</p>
<p>Our research did not focus on why there is disproportionate use of psychotropic medication in people with intellectual disability and further work is needed to establish the reasons behind these findings. It might be that alternative management strategies, such as behavioural programmes or enhanced social care, do not work or are simply not available when they are needed. Medication is a relatively inexpensive intervention that can be offered almost immediately – but convenience should not override clinical best practice.</p>
<p>People with an intellectual disability have a right to good care. Appropriate support, and medication where required, can allow people with intellectual disability to fulfil their potential and live the lives that they want to live. We must develop strategies to reduce inappropriate psychotropic prescribing in and invest in effective alternatives.</p><img src="https://counter.theconversation.com/content/46967/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rory Sheehan receives funding from The National Institute for Health Research (NIHR)</span></em></p>People with intellectual disabilities and either behavioural disturbance, autism or dementia are significantly more likely to be prescribed anti-psychotic drugs.Rory Sheehan, Academic Clinical Fellow, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/308452014-09-09T05:33:10Z2014-09-09T05:33:10Z‘Physician heal thyself’ may be impossible task for a psychiatry profession in crisis<figure><img src="https://images.theconversation.com/files/58349/original/j5styvv2-1409925751.jpg?ixlib=rb-1.1.0&rect=0%2C45%2C1024%2C697&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Madness.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/james_nash/2533278341/sizes/l/in/photolist-4RRHoM-i7UFKw-cNFTBw-7tykpR-oPm2mv-8RWDDs-8TKF5E-8vkPAT-8vPW8V-8vSXYj-nDfWmP-2ULVHs-8wZWYf-8vkPCD-8voSrY-6mf4Ns-4akrjK-e7ypCX-8TGANa-e6HSXL-agpoKy-aeWkQp-aeWku8-LLnKu-4Dhfhw-agpp2s-ffqZuz-ffaT7M-9E5RSf-5o72Ff-8YVUrv-8TKFUs-7nobBV-9gGivD-9gGiwK-9dmPJy-9E5R8J-5yQCX-9E5RAJ-dZMFR1-6mC1wz-68PbqS-4BpgDK-39XCr-98Rpdg-8hLf8N-66hyEc-9E2WGR-bWrXv4-cdPtdy-5fXHe7/">James Nash (Cirrus)</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The announcement by Dinesh Bhugra, president of the World Psychiatric Association, that <a href="http://bit.ly/WmhUPG">an independent commission</a> will investigate what psychiatrists of the future will look like signals what all mental health researchers have known for the past 50 years: that the profession is in crisis.</p>
<p>The challenges the profession faces are legion and can be divided into two types. The first relate to whether those in our midst <a href="https://theconversation.com/record-use-of-antidepressants-just-papers-over-the-cracks-of-modern-life-25959">who are miserable</a>, unintelligible or egocentrically incorrigible <a href="https://theconversation.com/under-new-psychiatric-guidebook-we-might-all-be-labelled-mad-14132">should be met with a form of presumed pre-eminent medical expertise</a>. This is a tribal issue – and some professionals, such as clinical psychologists and nurses, are making bids to legitimacy to compromise, share or even fully displace medical authority. In other words, non-medical professions are trying to undermine medical dominance in the field and assert their own autonomous theory and practice.</p>
<p>The second set of challenges relate to whether the mental health industry as a whole can respond in an effective and compassionate way to people who are deemed by their fellows (or themselves) to be psychologically abnormal.</p>
<h2>The tribal challenges</h2>
<p>Medical authority over psychological abnormality in society was only consolidated at the end of the 19th century in Western Europe and North America. Prior to that “lay managers” of asylums had implemented forms of “moral treatment,” mixing strict daily routines and compassionate fortitude, which brought lunacy back into the moral fold of society from an alienated state out of touch with shared expectations of daily life. As insanity defied a moral order, the insane had to be challenged to re-integrate into normal expectations of contemporary society.</p>
<p>Once psychiatrists won the battle and each asylum had its own “medical superintendent,” then an increasingly biological approach became evident. This biomedical emphasis went hand in glove with a dominant political philosophy of the time: eugenics. The eugenic consensus of the time assumed that a range of deviance, like lunacy, idiocy, epilepsy, prostitution, inebriation, was the product of a tainted gene pool of the fecund lower social orders. </p>
<p>In Britain, where eugenics started, the main focus was on social class, but this shifted to a racial emphasis elsewhere. Today’s psychiatry has strong eugenic roots in this 19th-century political philosophy. Its current <a href="http://www.ncbi.nlm.nih.gov/pubmed/18575381">obsession with genetics</a> maintains that tradition.</p>
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<img alt="" src="https://images.theconversation.com/files/58453/original/9fzqch5s-1410174521.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/58453/original/9fzqch5s-1410174521.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=463&fit=crop&dpr=1 600w, https://images.theconversation.com/files/58453/original/9fzqch5s-1410174521.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=463&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/58453/original/9fzqch5s-1410174521.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=463&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/58453/original/9fzqch5s-1410174521.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=582&fit=crop&dpr=1 754w, https://images.theconversation.com/files/58453/original/9fzqch5s-1410174521.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=582&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/58453/original/9fzqch5s-1410174521.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=582&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Shell shock countered eugenic assumptions.</span>
<span class="attribution"><a class="source" href="http://commons.wikimedia.org/wiki/File%3AShellshock2.jpg">PD-BRITISHGOV</a></span>
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<p>However, during World War I this eugenic approach came into crisis in Britain, as officers and gentlemen and working-class volunteers broke down with predictable regularity in the trenches, with the first group actually <a href="http://books.google.co.uk/books/about/The_Anatomy_of_Madness.html?id=fikDW5RBSJQC">having higher rates</a> of “shell shock”. These were “England’s finest blood”, so eugenic claims about genetic inferiority were tantamount to treason. In 1926 when the Royal Commission on Lunacy and Mental Disorder was set up to review the organisation and content of services for the mentally ill, not a single asylum doctor was appointed to its inquiry team. </p>
<p>Suddenly non-biological theories and interventions were let into the trade. For example, prior to the war, psychoanalysis was derided and rejected in the medical profession, but by 1920 in Britain there emerged the Tavistock Clinic, the British Psychoanalytical Society and the Medical Section of the British Psychological Society (with the latter being dominated by psychotherapy-orientated “shell-shock doctors”). These two factions (biological psychiatrists and medical psychotherapists) were joined by another: social psychiatrists. And during the Great Depression, this inter-war period, like the war before it, made it very evident that mental stability was precarious in the face of environmental stressors.</p>
<h2>The industrial challenges</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/58455/original/nk4qmv4k-1410175489.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/58455/original/nk4qmv4k-1410175489.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/58455/original/nk4qmv4k-1410175489.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/58455/original/nk4qmv4k-1410175489.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/58455/original/nk4qmv4k-1410175489.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/58455/original/nk4qmv4k-1410175489.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/58455/original/nk4qmv4k-1410175489.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Who decides who is mad? The Vanity of Small Differences by Grayson Perry.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/11561957@N06/7671068240/sizes/l">failing_angel</a></span>
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<p>The above three-way factionalism still remains today, with drug companies now a key player in shaping biomedical knowledge and offering corrective interventions with putative magic bullets for the conditions defined by diagnostic psychiatry. But this matter of internal fracturing in the psychiatric profession and the bids for legitimacy from nearby professions – like psychologists seeking to lead new forms of psychological therapy and be responsible for the discharge of detained patients – is only part of the picture. </p>
<p>Whoever runs the show, the central question remains: what is the point of the mental health industry? Is it to ameliorate distress? Is it to remove madness forcibly from society? Is it to contain those who others find offensive or chronically burdensome – those deemed to be “personality disordered”? In other words, is the industry in the business of healing or social control, or both?</p>
<p>If it is both then the crisis that Bhugra and his commission will struggle with will be about squaring a circle in society. Not only has the psychiatric profession not squared this circle but neither have its professional competitors. While we still retain “mental health law”, in the form of the Mental Health Act and other legislation, the tension between offering treatments – which are anxiously sought and gratefully received – and imposed and resented forms of control like sectioning, will be integral to the mental health industry.</p>
<p>Over the years various groups have kept reconsidering the same malaise: the “anti-psychiatrists” of the 1960s, the New Social Movement of user critics of the 1980s – such as Survivors Speak Out and the Campaign Against Psychiatric Oppression, <a href="http://bit.ly/1tElG5v">which sought to</a> abolish psychiatry or reform its oppressive aspects – and more recently, those attacking diagnostic psychiatry and failed medicinal solutions. </p>
<p>These matters of coercive social control, of the necessity or otherwise of “mental health law”, of ineffective and iatrogenic drug treatments (ones that actual cause illness or disease), of the shaping role of big pharma and of the choice between unique psycho-social formulations and creating categories of diagnosis, are unresolved and maybe irresolvable. </p>
<p>These incorrigible features of the mental health industry will be there for the foreseeable future, whether or not the psychiatric profession succeeds in retaining its medical dominance. Even if it loses the battle to its user and professional critics, the industrial challenges just noted will still haunt all parties new and old. </p>
<p><strong>You can read Peter Woodruff’s response, Psychiatrists alleviate mental illness – don’t attack them, <a href="https://theconversation.com/psychiatrists-alleviate-mental-illness-dont-attack-them-31814">here</a>.</strong></p><img src="https://counter.theconversation.com/content/30845/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Pilgrim does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The announcement by Dinesh Bhugra, president of the World Psychiatric Association, that an independent commission will investigate what psychiatrists of the future will look like signals what all mental…David Pilgrim, Professor of Health and Social Policy, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/173312013-08-27T13:27:46Z2013-08-27T13:27:46ZA blood test alone won’t be enough to test for suicide risk<figure><img src="https://images.theconversation.com/files/30026/original/7dtz7t2b-1377597182.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Too simplistic to predict suicidal tendency</span> <span class="attribution"><span class="source">Chandra Marsono</span></span></figcaption></figure><p><a href="http://dx.doi.org/10.1038/mp.2013.95">A new study</a> has suggested that it may be possible to develop blood tests for suicide by identifying biomarkers in the blood. Although it has its limitations, the study is an important step towards a more comprehensive understanding of the psychiatric map behind suicide. </p>
<p>Almost <a href="http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/">one million people die from suicide every year</a>. And according to the World Health Organisation, suicide rates have increased by as much as 60% in the last 45 years. </p>
<p>It is therefore crucial that we identify risk factors and introduce preventative measures to tackle the problem. But the problems that lead people to suicide are extremely diverse and complex. Suicidal behaviour is found in many different patient groups: those with mood disorders, who abuse alcohol or drugs, and people with schizophrenia, among others.</p>
<p>Biomarkers, which are the indicators of biological changes in disease states, are increasingly being used to understand a <a href="http://www.news-medical.net/news/20130827/Comprehensive-test-of-biomarkers-have-prognostic-and-diagnostic-value-in-Parkinsons-disease.aspx">range of medical conditions</a>. For psychiatric disorders, biomarkers can be blood tests, or tests indicating the changes in brain activity.</p>
<p>Some studies have already identified potential cognitive markers of suicide behaviour in <a href="http://ajp.psychiatryonline.org/article.aspx?articleID=102306">elderly depressed patients</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/20860871">bipolar patients</a>. These include poorer decision-making, inability to learn from past experiences and impulsive or compulsive behaviours. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21216267">Neuroimaging</a> has also shown abnormal brain activity in patients showing suicidal behaviour. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/19376453">Studies into families</a> have indicated that regardless of what the actual diagnosis is behind those who attempt suicide, their relatives are at higher risk for suicide. This suggests that some genetic factors might underlie suicidal behaviour. Accordingly, biomarkers such as the variation in the genes that regulate the brain chemical serotonin, <a href="http://www.ncbi.nlm.nih.gov/pubmed/10822348">have been suggested</a> as one genetic biomarker of suicidal behaviour.</p>
<p>However, we don’t yet have any reliable biomarkers which can predict a risk of suicidal behaviour. Compiling a combination of factors and tests might help to locate those most at risk more reliably than is possible to do now. A predictive biomarker could indicate underlying biological changes, for example, which could then allow clinicians to predict a specific behaviour or the course of an illness. </p>
<p><a href="http://dx.doi.org/10.1038/mp.2013.95">The new study</a>, published in Molecular Psychiatry, investigated four different groups of patients. These were a cross-section of people suffering bipolar disorder, two groups made up of patients with bipolar disorder or schizophrenia, and a group of suicide completers whom were accessed through the coroner’s office to test the validity of any biomarkers the researchers identified. Possible markers were based on <a href="http://www.ncbi.nlm.nih.gov/pubmed/18301394">previous research</a> conducted with a variety of psychiatric disorders. </p>
<p>The study has some significant limitations - the sample was male only, and the researchers also mainly investigated war veterans, which has obvious drawbacks. But it did nevertheless introduce some potential markers that were associated with suicidal behaviour. They showed that some markers can help predict the hospitalisations due to suicidal behaviour. While we aren’t yet at the stage where we could use a blood test to help predict risk, it moves us one step closer to this in the future.</p>
<p>The research is interesting, but we still <a href="http://dx.doi.org/10.1016/j.neubiorev.2013.03.022">need more research</a> to confirm the predictive value of these tests for suicide. The National Institute of Mental Health has announced <a href="http://www.ncbi.nlm.nih.gov/pubmed/20595427">a strategy</a> to approach behavioural disturbances as domains instead of established diagnoses. Research domains can help understanding biological reasons of behavioural disturbances, for example, impulsivity, independent of the type of mental disorder. This should lead to development of better biomarkers and treatments.</p>
<p>If we can find a way to combine different techniques and introduce some hybrid tests which can tap into different levels of pathological changes, this could be used at the initial clinical assessment of patients. This would provide the clinicians with a clearer picture of the risks when they plan holistic and comprehensive long-term treatment for people suffering psychiatric illness.</p>
<hr>
<p><em>We thank Professor Peter B. Jones for giving feedback on this article.</em></p><img src="https://counter.theconversation.com/content/17331/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Muzaffer Kaser is funded by IDB-Cambridge International Scholarhip and receives support from his affiliated institution, Bahcesehir University, Istanbul, Turkey.
</span></em></p><p class="fine-print"><em><span>Barbara Sahakian consults for Cambridge Cognition, Servier and Lundbeck. She holds a grant from Janssen/J&J. She holds shares in CeNeS. She is President of the British Association for Psychopharmacology and is President-Elect of the International Neuroethics Society. She is funded by a grant from the Wellcome Trust and the BCNI is jointly-funded by the Medical Research Council and Wellcome Trust.</span></em></p>A new study has suggested that it may be possible to develop blood tests for suicide by identifying biomarkers in the blood. Although it has its limitations, the study is an important step towards a more…Muzaffer Kaser, Psychiatrist, PhD candidate, University of CambridgeBarbara Jacquelyn Sahakian, Professor of Clinical Neuropsychology, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/141922013-05-20T13:07:31Z2013-05-20T13:07:31ZFive new mental disorders you could have under DSM-5<figure><img src="https://images.theconversation.com/files/24079/original/g5vr75t5-1368797027.jpg?ixlib=rb-1.1.0&rect=3%2C13%2C1020%2C645&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sufferers of internet disorder might find it starts to impose on real life, such as causing difficulties in socialising.</span> <span class="attribution"><span class="source">Flickr/Fle</span></span></figcaption></figure><p>Since it was first published in 1952, the DSM has been the has been the diagnostic bible for many psychiatrists. Each time the manual is updated, new conditions are introduced, often amid much controversy. DSM-5, the latest edition published on Saturday, is one of the most controversial yet.</p>
<p>Many conditions we’re now familiar with were codified in the DSM, including body dismorphic disorder, schizophrenia and bipolar disorder.</p>
<p>Inclusions and removals can be hugely controversial. Autism is in the manual, for example, but Asperger’s isn’t. Homosexuality was only removed in 1974.</p>
<p>Below, five experts explain some of the most noteworthy new additions, and why they’ve been included.</p>
<hr>
<h2><strong>Hoarding disorder</strong></h2>
<p><strong>David Mataix-Cols:</strong> Most children have collections at some point and <a href="http://www.ncbi.nlm.nih.gov/pubmed/22322013">approximately 30% of British adults define themselves as collectors</a>. This is a pleasurable, highly social and benign activity, which contrasts with another disabling form of object accumulation: hoarding disorder. </p>
<p>The symptoms include persistent difficulty in discarding possessions due to a strong perceived need to save items and distress in discarding them. This results in the accumulation of a large number of possessions that fill up and clutter key living areas of the home, to the extent that their intended use is no longer possible. </p>
<p>Symptoms are often accompanied by excessive acquiring, buying or even stealing of items that are not needed or for which there is no available space. </p>
<p>Using DSM-5, hoarding disorder can only be diagnosed once other mental disorders have been ruled out. </p>
<p>With a prevalence of at least <a href="http://www.ncbi.nlm.nih.gov/pubmed/20189280">1.5% of the UK population</a>, the disorder is associated with substantial functional disability, family conflict, social isolation, risk of falls and fires, evictions and homelessness.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hoarding syndrome can leave key living areas unable to be used.</span>
<span class="attribution"><span class="source">Shadwwulf </span></span>
</figcaption>
</figure>
<h2>Binge eating disorder</h2>
<p><strong>Christopher Fairburn:</strong> The inclusion of binge eating disorder in the DSM-5 was expected and uncontroversial for the deciding committee. It’s already listed as a provisional diagnosis in the DSM-4.</p>
<p>The disorder is characterised by recurrent over-eating episodes and a sense of loss of control at the time. Sufferers don’t have the extreme dieting, vomiting and laxative misuse seen in people who have bulimia. It is the loss of control over eating that is the distressing feature of binge eating disorder, or BED.</p>
<p>BED is very different from anorexia nervosa and bulimia nervosa. These disorders are <a href="http://www.rcpsych.ac.uk/expertadvice/problemsdisorders/anorexiaandbulimia.aspx">largely confined to young women</a> and they share many features including highly distinctive concerns about shape and weight and extreme weight control behaviour, such as dieting. None of this is present in people with BED.</p>
<p>BED is typically seen among those who are middle aged. Men <a href="http://www.namedinc.org/statistics.asp">make up about a third of cases</a>. The disorders also differ in their response to treatment. Unlike anorexia and bulimia, people who suffer from binge eating disorder respond well <a href="http://www.nimh.nih.gov/health/publications/eating-disorders/complete-index.shtml">to a variety of treatments</a>.</p>
<h2>Skin picking disorder</h2>
<p><strong>Jon Grant:</strong> Skin picking has been documented in medical literature since the 19th century but only now has it been recognised in the DSM-5.</p>
<p>Skin picking disorder affects around <a href="http://www.trich.org/dnld/ExpertGuidelines_000.pdf">2-5% of people in the US</a>. It is not simply a harmless habit nor merely a symptom of another disorder. Skin picking may result in significant tissue damage and often leads to medical complications such as local infections and septicemia. </p>
<p>Sufferers of the disorder are diagnosed according to five criteria including recurrent skin picking that causes skin lesions; repeated attempts to cut down or stop, and that the skin picking causes significant distress or problems in social situations, work, or other important areas in life. </p>
<p>Skin picking also can’t exist due to the physical effects of a substance or a medical condition, or be linked to another mental disorder - for example because someone has body dysmorphic disorder. These criteria separate people who only pick their skin occasionally. </p>
<p>Data from multiple researchers around the world consistently show that skin-picking disorder has distinct characteristics, important neurobiological links, and documented responsiveness to treatments - both <a href="http://bmo.sagepub.com/content/26/3/361.short">Cognitive Behaviour Therapy</a> and <a href="http://www.trich.org/treatment/article-medications-grant.html">medication</a> can work.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Skin picking disorder can cause significant distress or problems in social situations.</span>
<span class="attribution"><span class="source">Flickr/Chris@APL</span></span>
</figcaption>
</figure>
<h2>Somatic symptom disorder</h2>
<p><strong>Christopher Lane:</strong> Somatic comes from the Greek word for “of the body”, the focus of the disorder. DSM’s earlier family of medically unexplained ailments grouped together problems as different as hypochondria and body dysmorphia and so the <a href="http://bit.ly/12GAijJ">American Psychiatric Association proposed somatic symptom disorder</a>. </p>
<p>It’s a new, stand-alone disorder for people who experience a “disproportionate” sense of anxiety about their health and at least one physical symptom, such as a persistent headache. </p>
<p>People can be diagnosed with the new disorder if their physical symptoms are distressing and/or disruptive to their daily life for at least six months, and they also have one of the following: disproportionate thoughts about the seriousness of their symptoms; or a high level of anxiety about their symptoms or health; or they devote excessive time and energy to their symptoms or health concerns. </p>
<p>There have been concerns because the threshold of “disproportionate” and “excessive” is difficult to quantify and the disorder could be used as a catch-all for many people.</p>
<h2>Internet addiction</h2>
<p><strong>Karen M. von Deneen, Jie Tian:</strong> While not yet officially codified within a psychopathological framework, internet addiction is growing in prevalence and has attracted the attention of psychiatrists, educators, and the public. </p>
<p>Internet addiction is a newly identified condition associated with loss of control over internet use. It leads to negative psychosocial and physical results, such as impairment of academic failure, social deficits, criminal activities and even death. This consists of three main subtypes: excessive gaming, sexual preoccupations, and e-mail/text messaging.</p>
<p>The DSM-5 now includes a newly-created <a href="http://www.dsm5.org/Newsroom/Documents/Addiction%20release%20FINAL%202.05.pdf">category of behavioural addictions</a>, in which gambling will be the sole disorder. Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual’s appendix instead, with the goal of encouraging additional study.</p>
<p>Present treatment has included <a href="http://www.guardian.co.uk/world/2009/jul/14/china-internet-electric-shock-treatment">electric shock therapy</a> and <a href="http://www.telegraph.co.uk/health/children_shealth/7467200/Rehab-clinic-for-children-internet-and-technology-addicts-founded.html">internet rehab</a>, but these have not been satisfactory. More research needs to be done to understand the underlying mechanisms of this addiction.</p><img src="https://counter.theconversation.com/content/14192/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Fairburn receives funding from the Wellcome Trust and National Insitutes of Mental Health. He receives no commercial funding. In 1995, he wrote the book Overcoming Binge Eating</span></em></p><p class="fine-print"><em><span>Christopher Lane is the author of five books on literature and psychology including Shyness: How Normal Behavior Became a Sickness.</span></em></p><p class="fine-print"><em><span>David Mataix-Cols, Jie Tian, Jon Grant, and Karen M. von Deneen do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Since it was first published in 1952, the DSM has been the has been the diagnostic bible for many psychiatrists. Each time the manual is updated, new conditions are introduced, often amid much controversy…Christopher Fairburn, Professor of Psychiatry, University of OxfordChristopher Lane, Professor of English, Northwestern UniversityDavid Mataix-Cols, Professor and Honorary Consultant Clinical Psychologist, King's College LondonJie Tian, Professor of Automation, Chinese Academy of SciencesJon Grant, Professor of Psychiatry and Behavioral Neuroscience , University of ChicagoKaren M. von Deneen, Associate Professor, Xidian UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/141362013-05-19T23:11:23Z2013-05-19T23:11:23ZDSM-5 tells us more about psychiatry than psychiatrists<figure><img src="https://images.theconversation.com/files/23517/original/z6db8w96-1368198808.jpg?ixlib=rb-1.1.0&rect=0%2C2%2C1576%2C1002&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">DSM-5 has been described as the bible of psychiatry but the assumption that professionals use it for their own gain is far fetched.</span> <span class="attribution"><span class="source">PA</span></span></figcaption></figure><p>DSM-5, the latest version of the Diagnostic and Statistical Manual of the American Psychiatric Association, was published in the US at the weekend.</p>
<p>Given that not even its most passionate supporters would call it a good read, it had already attracted unusual levels of attention. There has already been an avalanche of serious comment pieces, magazine articles, <a href="http://boycott5committee.com/">blogs</a> and the <a href="http://www.dailymail.co.uk/news/article-2268791/Binge-drinkers-reclassified-mild-alcoholics-argue-scientists.html">occasional sensationalist Daily Mail headline</a>.</p>
<p>Why is it proving so controversial? The DSM is nothing more than a list of psychiatric disorders, accompanied by descriptions and explicit criteria for their diagnosis. It’s also not new – it’s the fifth such revision – although given the propensity of the association to trot out revisions on a regular basis, there have been at least eight since 1952.</p>
<p>The DSM is important in the US – unless your disorder is in the manual you won’t be treated. Or more accurately, you can be treated but your therapist won’t be reimbursed by your insurance company, which amounts to the same thing.</p>
<p>But the manual also important because it tells us something about the state of psychiatry.</p>
<h2>Mission creep?</h2>
<p>Early versions of the DSM did not attract much attention or controversy. Much of American psychiatry was dominated by psychoanalysis, which doesn’t give central importance to diagnostic categories as every patient is considered a unique individual. It was not until DSM III came along in 1980 that people really started to take notice – and to complain.</p>
<p>The first problem was the increasing number of diagnoses. In 1917, the APA recognised 59 psychiatric disorders. When DSM-I was published in 1952 it had 128. By 1987 there were 253. DSM-IV has 347.</p>
<p>We are promised that DSM-5 (now designated by digits rather than Roman numerals to make revisions easier) will reduce the total for the first time. I’m not holding my breath.</p>
<p>Given that the real number of mental disorders, whatever that may be, is unlikely to be increasing at a similar exponential rate, it’s not surprising that the cry has gone up <a href="http://dsm5response.com/">that this represents psychiatric mission creep</a> – a dastardly plot by the profession to extend its influence into more and more aspects of our daily lives and thoughts.</p>
<p>Indeed, there is evidence for a medicalisation of the normal, the eccentric and the odd. It seems increasingly difficult to find shy children anymore – instead it’s now a social phobia. Who these days is called bookish or eccentric, as opposed to someone suffering from Asperger’s?</p>
<p>When you bring big pharmaceutical companies into the picture – who have occasionally been caught colluding in the creation or expansion of psychiatric disorders in order to create new markets for their drugs – it’s not surprising that the new DSM is being greeted with a storm of criticism.</p>
<h2>The difficulty of classification</h2>
<p>But the reality is a little different. Psychiatric classification is difficult because we are restricted to largely symptomatic descriptions of disorders, as opposed to leukaemias or endocrine disorders, for example, which are based on very detailed knowledge of the actual pathological processes that underlie clinical symptoms.</p>
<p>Psychiatry is not at that stage yet, and as Gary Greenberg<a href="http://www.newyorker.com/online/blogs/elements/2013/04/psychiatry-dsm-melancholia-science-controversy.html?mbid=social_retweet&mobify=0">pointed out recently</a> in the New Yorker, things have not changed much since the superintendent of a Massachusetts asylum wrote in 1886: “in the present state of our knowledge no classification of insanity can be erected on a pathological basis.”</p>
<p>We are on the brink of new discoveries that will transform our understanding of major mental disorders such as schizophrenia and bipolar and <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)62129-1/abstract">a recent Lancet paper reported</a> common genetic markers linking five major disorders. But until that point it’s not surprising that when it comes to classification, a hundred flowers still bloom.</p>
<p>One common assumption is that it is the psychiatrists that are seeking to extend the boundaries. But you can argue that teachers also have an incentive to promote the growth of psychiatric labels – children with ADHD or Asperger’s are likely to make you eligible for more classroom assistants than difficult or unruly children. Some parents will prefer to put their child’s problematic behaviours down to genes or disordered development than inconsistent or absent parenting.</p>
<p>When Allen Frances, one of the architects of DSM-IV but now the leading critic of DSM-5, started to repudiate his own contribution to expanded diagnostic boundaries in autism, he was greeted with open hostility <a href="http://www.nytimes.com/2012/01/20/health/research/new-autism-definition-would-exclude-many-study-suggests.html?_r=0">from many parents of children who had been diagnosed</a> with one of its looser definitions.</p>
<p>The raging arguments over DSM have been more muted in the UK. Unlike the US, it isn’t necessary to be a perfect fit with a DSM category to be treated. A GP may decide to treat unhappiness as a case of depression, but it won’t involve consulting the APA’s latest bible.</p>
<p>Many mental health professionals will also be shaking their heads at the outrage that DSM-5 has generated, in particular the claim that it’s all an underhanded plot by the professionals.</p>
<p>For psychiatrists, the biggest threat is the opposite. Far from extending our empire, most of us are faced with the biggest reductions in funding and services we can remember.</p>
<p>In a recession, mental health services suffer first and foremost compared to acute care.</p>
<p>For most psychiatrists the current reality is trying desperately to protect services to ensure that those whose mental disorders are indisputable – in any classification system – do not lose out. The idea that we are looking for new markets seems far fetched.</p>
<p><em>A <a href="http://www.kcl.ac.uk/iop/news/events/2013/june/DSM-5-Conference.aspx">two-day conference into DSM takes place at the Institute of Psychiatry</a> from June 4th-5th.</em></p><img src="https://counter.theconversation.com/content/14136/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Wessely is a member of the ICD-11 Stress Disorders working party</span></em></p>DSM-5, the latest version of the Diagnostic and Statistical Manual of the American Psychiatric Association, was published in the US at the weekend. Given that not even its most passionate supporters would…Simon Wessely, Professor of Psychological Medicine, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/141272013-05-19T23:11:19Z2013-05-19T23:11:19ZExplainer: what is the DSM?<figure><img src="https://images.theconversation.com/files/23539/original/8dnxvjpz-1368351346.jpg?ixlib=rb-1.1.0&rect=432%2C198%2C2203%2C1401&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Psychiatric diagnosis relies on identifying a patient's signs and symptoms rather than clinical tests.</span> <span class="attribution"><span class="source">PA/Ben Birchall</span></span></figcaption></figure><p>Traditional psychiatry uses the approaches of medicine to try to understand mental health problems and guide treatment. This means relying on diagnosis – identifying what are believed to be mental illnesses from their signs and symptoms, in the same way that doctors in other branches of medicine diagnose physical health problems.</p>
<p>There are two widely used systems in psychiatry: the World Health Organization’s International Standard Classification of Diseases, Injuries and Causes of Death - <a href="http://www.who.int/classifications/icd/en/">or ICD</a> - and the American Psychiatric Association’s Diagnostic and Statistical Manual - <a href="http://www.dsm5.org/Pages/Default.aspx">or DSM</a>. The latest edition of the DSM was published this weekend.</p>
<p>Both ICD and DSM were first published immediately after the World War II and have been revised extensively over the years. But there hasn’t been a new edition of DSM since DSM-IV was published in 1994 - almost 20 years ago.</p>
<p>ICD is technically the international standard classification system and forms the basis for NHS procedures in the UK. But the American DSM is also extremely influential and is widely used in research and academic fields and for planners, for example keeping hospital records. That’s why the publication of its fifth edition is important.</p>
<h2>The nature of psychiatric diagnosis</h2>
<p>The diagnosis of mental health problems is extraordinarily complex – and controversial. The basic aim of diagnostic manuals is to explain the underlying nature and structure of mental health problems. They attempt to describe patterns observed in nature, for example how a patient behaves, without (the authors claim) making assumptions about why. </p>
<p>However, the complexity of mental health problems can lead to difficult decisions. It also means the manuals themselves are also complex: what criteria are included; the rules about which disorders are included and which aren’t; and the relationships between different families in the manuals, for example between obsessive compulsive disorder and impulse control disorder. This also leads to significant differences in opinion.</p>
<h2>Families of illnesses</h2>
<p>The manuals are designed to group similar types of diagnoses together. For instance, diagnoses that are all concerned with anxiety of various kinds are listed together. And they are generally seen as separate from problems such as learning disabilities. </p>
<p>Including problems such as children’s learning disabilities, relationship and personality difficulties, emotional problems and problems of later life such as dementia, can be problematic. DSM-5 has come under critcism for changes in some of these areas. One example discussed widely is that idea that it might be possible to receive a diagnosis of “major depressive episode” when one is still grieving for the death of a loved-one. Bereavement was specifically excluded from previous versions.</p>
<p>The ICD and DSM are different, and to an extent are rival systems, but there is huge overlap. This allows researchers and clinicians to translate diagnoses from one system to another - a bit like cross-referencing between two dictionaries.</p>
<p>DSM uses what is called a “multi-axial” scheme to classify diagnoses. Psychiatrists use multiple axes to diagnose and treat patients. Primary diagnoses form a first tier called Axis I and includes depression and schizophrenia. So-called developmental and personality disorders lie in Axis II and includes autism. Related issues such as the degree of disruption caused to a person’s life are assessed on remaining axes. In practice, Axes I and II diagnoses tend to be used in a similar way.</p>
<p>Psychiatric diagnosis echoes and resembles conventional medical diagnosis, but there are no useful biological markers or tests for illnesses like you might get if you were treating someone with diabetes – which makes many people sceptical of biological explanations per se. </p>
<p>Diagnosis of a person’s problems is inevitably based on their descriptions of their feelings, thoughts and behaviour and on the observations of the person trying to make the diagnosis. </p>
<p>It also means that decisions about the criteria for each diagnosis – the structure and content of DSM and ICD - are essentially made by committee. In the case of DSM, a taskforce.</p>
<h2>New approaches</h2>
<p>Different clinicians – and particularly psychiatrists and psychologists – differ as to what particular problems should be included or what the criteria should be. Some also question <a href="http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health">the reliability of psychiatric diagnoses</a>, whether we should think of problems as illnesses to be treated or that a broadening of psychiatric diagnoses means a wider variety of personal problems could attract a diagnosis. One widely discussed example is that it might now be possible to receive a diagnosis of “major depressive episode” when one is grieving for the death of a loved-one. </p>
<p>Others fear the opposite: that diagnoses, and therefore psychiatric support, will be taken away. This has <a href="http://www.medpagetoday.com/MeetingCoverage/APA/32578">particularly been the case with changes to the definition of autism</a> and the exclusion of Asperger’s from DSM-5.</p>
<p>While the publication of DSM-5 has catalysed criticism, it is also pushing new approaches into the spotlight.</p>
<p>The director of the US National Institute of Mental Health, the largest funder of mental health research in the world, <a href="http://nyti.ms/12Cfr2k">said this month that it was moving away</a> from a DSM-style approach to focus on biology, genetics and neuroscience, allowing disorders to be defined by causes, not symptoms.</p>
<p>New research will continue to develop our understanding of the causes and treatment of mental illness. But public debate and controversy over the way we should approach it won’t be very far away. </p><img src="https://counter.theconversation.com/content/14127/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Kinderman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Traditional psychiatry uses the approaches of medicine to try to understand mental health problems and guide treatment. This means relying on diagnosis – identifying what are believed to be mental illnesses…Peter Kinderman, Professor of Clinical Psychology, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/141322013-05-19T23:11:15Z2013-05-19T23:11:15ZUnder new psychiatric guidebook we might all be labelled mad<figure><img src="https://images.theconversation.com/files/23518/original/vchff3n5-1368199512.jpg?ixlib=rb-1.1.0&rect=1%2C3%2C1022%2C682&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medication misuse is out of control in the US and more psychiatric labelling in DSM-5 will not help.</span> <span class="attribution"><span class="source">Whale05/Flikr</span></span></figcaption></figure><p>“We are all mad here” explains the Cat to Alice when she wonders about the strangeness of Wonderland. Well, life is starting to follow art. If people make the mistake of following DSM-5, the new diagnostic manual in psychiatry that was published on Saturday, pretty soon all of us may be labelled mad.</p>
<p>When I worked on the taskforce for DSM-4, we were very concerned about taming diagnostic inflation - but we only partly succeeded. Then four years ago, I became aware of the excessive enthusiasm around all the new diagnoses being proposed for DSM-5, including many that were untested. I hate to rain on anyone’s parade, but I knew this would be disastrous for the millions of people who were likely to be mislabelled, stigmatised and given excessive treatment.</p>
<p>In the US, the “sick” are distinguished from the “well” by the diagnostic and statistical manuals developed by the American Psychiatric Association.</p>
<p>The problem is that definitions of mental disorders are already written too loosely and are applied much too carelessly by clinicians, especially by the GPs who do most of the prescribing of psychiatric drugs.</p>
<p>And things are about to get much worse. Under DSM-5 diagnostic inflation looks set to become hyperinflation and will lead to an even greater glut of unnecessary medication. I would qualify for a bunch of the new labels myself – and you might too.</p>
<p>The grief I felt when my wife died would now be called “major depressive disorder”; forgetfulness in older age “mild neurocognitive disorder”; my gluttony now “binge eating disorder”; and my hyperactivity “attention deficit disorder”. As for my twin grandsons’ temper tantrums, this could be misunderstood as “disruptive mood dysregulation disorder”. And if you have cancer and your doctor thinks you are too worried about it, there’s “somatic symptom disorder.” It goes on, but you get the idea.</p>
<p>About <a href="http://www.ncbi.nlm.nih.gov/pubmed/15939837">half of Americans already qualify for a mental disorder</a> at some point in their lives and the rates keep skyrocketing, especially among kids. In the past 20 years, the prevalence of autism has increased, childhood bipolar <a href="http://www.nimh.nih.gov/news/science-news/2007/rates-of-bipolar-diagnosis-in-youth-rapidly-climbing-treatment-patterns-similar-to-adults.shtml">has multiplied 40-fold</a> and <a href="http://www.nice.org.uk/nicemedia/pdf/CG72FullGuideline.pdf">attention deficit disorder has tripled</a>.</p>
<p>One consolation: the kids are not suddenly getting much sicker – human nature is pretty stable. But the way we label symptoms follows fickle fashions, changing quickly and arbitrarily. And freely giving out inaccurate diagnoses can lead to grave harms – medication that isn’t needed, stigma, lower self confidence and reduced self expectation.</p>
<p>There are also downstream effects. Many parents were panicked about the alarming rise in rates of autism and fell for <a href="http://www.guardian.co.uk/society/2013/apr/25/measles-mmr-the-essential-guide">the disproven belief that it was caused by vaccination</a>. Trying to avoid a false epidemic of autism caused by nothing more than changed labelling meant they stopped vaccinating their kids and exposed them to the very real measles outbreak that recently occurred.</p>
<p>And medication use is out of control – 20% of Americans regularly use a <a href="http://www.medscape.com/viewarticle/753789">psychotropic drug</a>; <a href="http://www.nytimes.com/2013/04/01/health/more-diagnoses-of-hyperactivity-causing-concern.html?pagewanted=all">10% of teenage boys are taking a stimulant for ADHD</a>; 25% of our active duty troops <a href="http://usatoday30.usatoday.com/printedition/news/20091217/milhealth17_st.art.htm">report abuse of a prescribed med</a>; and the US has more deaths <a href="http://www.cdc.gov/injury/about/focus-rx.html">from prescription drug overdoses</a> than from street drugs.</p>
<p>In the UK you are protected against the worst effects of diagnostic and drug exuberance. Doctors use ICD-10, the classifications compiled by the World Health Organisation, not DSM-5; they follow prudent guidelines from Nice, which sets the standards for health treatment in the UK; the British-based Cochrane group <a href="http://en.wikipedia.org/wiki/Cochrane_Collaboration">emphasises evidence-based medicine</a>; GPs do less prescribing; and drug companies exert much less power and cannot advertise directly to consumers as they do in the US.</p>
<p>But the measles outbreak and ADHD rates prove the UK is not out of the woods. Bad ideas from America sometimes have much more influence than they deserve.</p>
<p>My advice is to be an informed consumer. Never accept a diagnosis or a medication after a cursory evaluation. A psychiatric diagnosis can be a turning point in your life – as important as choosing a spouse or a house. Done well, it can lead to life-improving treatment; done poorly it can lead to an inaccurate label and a harmful treatment.</p>
<p>People who have mild and transient symptoms don’t need a diagnosis or treatment. The likelihood is they are visiting the doctor on one of their worst days and will get better on their own. Medication is essential for severe psychiatric problems but does more harm than good for the worries and disappointments of everyday life. Better to trust time, resilience, support and stress reduction.</p><img src="https://counter.theconversation.com/content/14132/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Allen Frances has two published books critical of DSM-5: Saving Normal and Essentials of Psychiatric Diagnosis</span></em></p>“We are all mad here” explains the Cat to Alice when she wonders about the strangeness of Wonderland. Well, life is starting to follow art. If people make the mistake of following DSM-5, the new diagnostic…Allen Frances, Professor Emeritus of Psychiatry, Duke UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/120472013-04-18T19:57:37Z2013-04-18T19:57:37ZMental disorders: debunking some myths of the DSM-5<figure><img src="https://images.theconversation.com/files/21436/original/4xp8fdnb-1363670497.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The DSM-5 doesn't attempt to define what is "normal"; and having a DSM diagnosis is not the same as being “insane”.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>The fifth edition of the <a href="https://theconversation.com/topics/dsm-v">Diagnostic and Statistical Manual of Mental of Mental Disorders</a> (DSM-5) is due to hit psychiatrists’ and psychologists’ shelves next month. Produced by the American Psychiatric Association (APA), the DSM provides a standardised system of diagnosing mental disorders. </p>
<p>From its first edition in 1952, and with each new edition about every 15 to 20 years, the DSM has always had its critics. But as the arrival of DSM-5 approaches, their clamour is becoming louder. </p>
<p>As a member of the <a href="http://www.dsm5.org/MeetUs/Pages/NeurocognitiveDisorders.aspx">DSM-5’s Neurocognitive Disorders Work Group</a>, I’m familiar with some of the procedures involved in bringing the manual into shape. So let’s look at four key criticisms about the DSM-5 – and whether they’re warranted. </p>
<h2>1. It’s impossible to classify mental disorders</h2>
<p>The primary purpose of the DSM-5 is to enable physicians or other clinicians to reliably diagnose patients who present with a mental disorder. The manual also outlines treatment pathways for the diagnosis, and the likely outcome over time.</p>
<p>Unlike other disciplines of medicine, a mental disorder cannot be confirmed by a pathologist peering down a microscope or a biochemist measuring molecules in the blood. Aside from a few exceptions, there is no other way of truly knowing whether a disease really exists.</p>
<p>Inevitably, there will be differences of opinion about what constitutes a disorder, and some of these will be major ones. But using the DSM, two clinicians working remotely from each other should reach the same diagnosis for a particular patient.</p>
<h2>2. The DSM is just a money maker</h2>
<p>Critics have argued the DSM “enterprise” has been very lucrative for the APA, and that book royalties are the primary motivator for producing yet another edition. </p>
<p>Considering that about <a href="http://www.huffingtonpost.com/allen-frances/dsm-5-costs-25-million-apa_b_1554405.html">US$25 million</a> has already been spent on the fifth revision process, as estimated by the chair of the task force, it does not appear to be a great investment if book royalties were the primary objective.</p>
<p>Neuroscientific knowledge is exploding exponentially, so revisiting the classification of mental disorders after two decades is certainly not premature.</p>
<h2>3. Under the DSM-5, more people will be diagnosed with a mental disorder</h2>
<p>The process of revising the DSM is extremely rigorous, and any proposal for a new disorder or a major revision of existing criteria needs to come on the back of strong scientific evidence. </p>
<p>There are 13 DSM-5 working groups, broken down into categories such as mood disorders, eating disorders, and substance-related disorder. Any new proposal must be accepted by other members of the advisory group, all of whom are experts in their field. </p>
<p>The total number of disorders in DSM-5 is yet to be announced, but its chair David Kupfer <a href="http://www.slate.com/articles/health_and_science/medical_examiner/2013/04/diagnostic_and_statistical_manual_fifth_edition_why_will_half_the_u_s_population.html">has said</a> the total number of disorders will not be more than in the DSM-IV: 297. </p>
<p>It’s important to note that the illnesses clinicians encounter in the psychiatric clinic is often a more severe form of a phenomenon that pervades society. Psychiatrists must therefore identify if it is severe or deviant enough to warrant attention. </p>
<p>The DSM-5 is intended to help them make that decision. They often end up applying a threshold at which a particular set of symptoms become a disorder or a diagnosis. The threshold is guided by the level of distress or dysfunction that the individual is suffering. </p>
<p>It is therefore not a culturally influenced whim, but culture does influence the decision. Differences in such thresholds lead to the controversies in the diagnosis of <a href="https://theconversation.com/moving-the-diagnostic-goalposts-medicalising-adhd-8675">attention-deficit hyperactivity disorder</a> (ADHD), for example, or when <a href="https://theconversation.com/why-prolonged-grief-should-be-listed-as-a-mental-disorder-4262">bereavement becomes depression</a>.</p>
<h2>4. The DSM is trying to redefine what’s normal</h2>
<p>The DSM-5, and any other classification of mental disorders, is not an attempt to define what is normal. Being normal is not the same as “not having a DSM-5 diagnosis”, and having such a diagnosis is not the same as being “insane”, as some have wrongly argued about the DSM. </p>
<p>Insanity is in fact a legal term, and “mad” or “crazy” are stigmatising lay terms that do not apply to the vast majority of people with a DSM-5 diagnosis, and should not in fact be used for anybody. </p>
<p>Many individuals, including physicians, find it difficult to accept that mental illness, not unlike physical illness, is common and most of it is not madness or insanity. The <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/4326.0">2007 National Mental Health Survey</a> showed that one in five Australians experienced a mental disorder in the previous 12 months. </p>
<p>When dealing with the imperfections of psychiatric neuroscience, it is clear that the debate on the appropriateness or otherwise of the classification system will continue as the mental health profession ponders what is worth treating and society delineates what is worth helping. </p>
<p>The DSM-5 must simply be regarded as psychiatry’s next faltering step. It’s not above criticism, but is probably the best manual of mental disorders that we are likely to have for some time. </p>
<p>A truly uncontroversial DSM-6 will have to await major breakthroughs in our understanding of psychiatric disorders. Let’s hope we don’t have to wait for more than a generation.</p><img src="https://counter.theconversation.com/content/12047/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Perminder Sachdev receives funding from National. Health & Medical Research Council, the Australian Researhc Council, the National Institute of Health (USA) and Alzheimer's Australia.
He is affiliated with the Centre for Healthy Brain Ageing (CHeBA), University of New South Wales, and the Neuropsychiatric Institute, the Prince of Wales Hospital, Sydney.</span></em></p>The fifth edition of the Diagnostic and Statistical Manual of Mental of Mental Disorders (DSM-5) is due to hit psychiatrists’ and psychologists’ shelves next month. Produced by the American Psychiatric…Perminder Sachdev, Scientia Professor of Neuropsychiatry, Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.