Latest NIMH Research News

There are three recent and exciting research study reports from NIMH I want to share. The first discusses the potential of modifying gene expressions to treat schizophrenia. While a major limitation of the study is that it was looking at the brains of mice, it still holds much promise for understanding the mechanisms associated with schizophrenia and developing novel treatments. The second study examined the relationship between bipolar affective disorder and influenza. Researchers have long suspected that prenatal exposure to the flu virus may be a risk factor in developing bipolar disorder and schizophrenia. This current study suggests there is a fourfold increased risk. Finally, over the past several years I have been watching with interest the research on ketamine as an antidepressant agent. Research has been taking place on the use of ketamine as a rapid antidepressant. One of the challenges with ketamine is that it has many unwanted side effects and is a drug of abuse. Researchers have now developed a molecular cousin to ketamine that seems to have similar antidepressant effects without these side effects. Such a medication could revolutionize the treatment of depression like Prozac did when it first came onto the market. One of the drawbacks to current generation antidepressants is that they can takes weeks to reach full effect. Imagine the benefit of a medication that achieved the same or better results in minutes or hours? It could lead to lower rates of inpatient treatment, decrease the risk of suicide, reduce time waiting for services and service utilization. There is still a long way to go before such a medication may be available, but it gives hope to all those affected by mental illness.

ICED Conference

I recently returned from the International Conference on Eating Disorders, which was held this year in Montreal. It’s my first time attending the conference, and I’m very pleased to have had the opportunity. The ICED is the annual conference for the Academy of Eating Disorders, and is attended by some of the best researchers and clinicians in the eating disorder field. The conference took place over 3 ½ days, and included numerous presentations and educational opportunities. I learned more than I could possibly put into a blog post, so instead, I thought I would comment on the theme of the conference, “Crossing Disciplinary Boundaries in Eating Disorders”.

The conference was kicked-off with a keynote address by renowned psychologist David Barlow. Dr. Barlow is well known for his research of cognitive-behavioral treatments for anxiety disorders, and focused his discussion on the idea that it may be more effective to investigate psychiatric disorders from the perspective of what they have in common, versus what separates them. He termed this “lumping” versus “splitting” and noted that the latest version of the DSM, DSM-5 has continued the trend of “splitting”. Interestingly, DSM-5 is slated to be released this month, and the director of the NIMH has gone on record as saying NIMH is moving away from researching psychiatric disorders using the DMS-5 nosology. His comments provoked a response by the American Psychiatric Association, who basically said, “This is the best we can do until you researchers give us better evidence.” Meanwhile, the shortcomings of DSM-5 have led some to question the biomedical framework for psychiatric disorders, while others argue that it encourages mental health practitioners to pathologize normal human behavior. I think this controversy is unfortunate and only serve as fodder for the anti-psychiatry movement. The mental health field has worked extremely hard at reducing the stigma around seeking treatment for mental illnesses. It would be devastating if the current DSM-5 controversy negatively impacted this effort.

Eating disorders, in my opinion, are an excellent example of the “lumping” versus “splitting” issue. Research has shown that for many individuals with eating disorders, their diagnostic presentation changes with time. It is not unusual to have someone develop Anorexia Nervosa during adolescents, but then continue to struggle with a variety of eating disordered behaviors over the course of the lifetime, including binging and purging. In fact, most individuals with an eating disorder end up in the Not Otherwise Specified category because, while clinically impaired, they do not meet the specific criteria for either Anorexia Nervosa or Bulimia Nervosa. This would suggest that there are strong commonalities between disorders that are conceptualized as being separate. On the other hand, Binge Eating Disorder, which is being added to DSM-5, may be more distinct from AN & BN. For example, prevalence rates for men are much higher for BED than for AN or BN and there does not seem to be the diagnostic “crossover” that occurs with AN & BN. However, the inclusion of BED in DSM-5 does continue the trend of “splitting” diagnostic categories, which may or may not be helpful to our understanding of eating disorders.

One of the fascinating things about eating disorders is the interplay between biology and psychology. A classic study informally referred to as the Keys Study showed how starvation can induce behaviors that mimic Anorexia Nervosa (the ethics of the study are a different story). It was one of the first studies to clearly demonstrate the biological underpinnings of eating disorders and how starvation can negatively affect psychological functioning. Another such example is the research that suggests there are different personality traits associated with Anorexia Nervosa and Bulimia Nervosa and how they may impact the development of these illnesses. We desperately need better research into the biological basis for personality traits and how these relate to psychiatric disorders. I think a major shortfall of the DSM-IV was the artificial separation of personality disorders and mental illness. The reality is that the two are intertwined and likely share common pathophysiology in the brain. So I am firmly in the “lumping” camp at this point, and hope that the NIMH RDoC effort helps us develop better dimensional models of psychiatric disorders that delineate the underlying biological mechanisms and associated environmental factors.

Here’s to the Future

First of all, I am very excited to announce that Ascent Counseling is now accepting referrals! It’s been quite a process getting up and running and there is still more to do, but in the meantime, I am looking forward to getting back in to clinical work. If you are interested in requesting services, please go here. I have a lot of big plans for the website and practice that I will be sharing in the weeks and months ahead.

I was going to write an extended post about the recent events in Boston, but honestly, there has been so much coverage about it I don’t feel the need to expound on it any more. Boston is fortunate to have the Trauma Center at the Justice Resource Institute, a leader in the field of PTSD. They are a wonderful resource, especially given the tragedy that occurred. The Marathon bombing was a horrific event and my thoughts go out to everyone affected. It has been heartwarming to see the running community rally around Boston, especially at the London Marathon. Here in North Conway, the Mount Washington Milers are hosting a Boston Memorial Run at King Pine on Saturday, April 27. Registration begins at 9am. Proceeds from the event will go to the One Fund – Boston. I’m planning on attending and hope to see you there!

I will just briefly mention something I was reading about today, which ties in nicely to my previous post about the future of mental health research. It is called the NIMH Research Domaine Criteria or RDoC. Its a very exciting concept that I think will fundamentally change how we classify and develop treatments for psychiatric disorders.

I Am One of the 26 Percent

If you read the Concord Monitor, or are involved with NAMI NH, you probably have kept up on the series of articles over the past few years about the crisis within the NH Mental Health system. A number of these articles were written by a staff writer named Annemarie Timmins. She just published an article today called “I Am One of the 26 Percent” in which she has bravely discloses her own struggles with mental illness. It is a very powerful article, and a reminder that the majority of people who struggle with mental illness do not fit the stereotype many people imagine. I am including the links to all the articles from the Concord Monitor series – they are worth the read. One more reminder that as a society, we need to rethink our approach to mental health care.

A Four-Day Focus on the State Troubled Mental Health System
Mentally Ill Patients Face Spartan Conditions – Long Delays in NH
New Hampshires Mental Health System – From Leader to Failure
Community-Level Care is Key to Help Patients Return Home
Mental Health Court Gives Offenders Treatment – Not Time
In Crisis – Future Uncertain for Mental Health Care in NH
That’s Not the Kind of State We Are – Why NH Needs to Fix Mental Health Care Now

Eating Disorder News

Just a few eating disorder-related news items to pass along in this post. The first is that a parental education law was just passed in Virginia. If you haven’t heard about the controversy regarding the new Victoria Secret “Bright Young Things” product line that targets young teens, I recommend you read this and this. While eating disorders are certainly biologically based brain disorders, there is no doubt that cultural influences that perpetuate the thin ideal contribute to these illnesses. I hope that pressure can be put on Victoria Secret to end this product line. On a more positive note, there was a nice article on CNN recently about a woman who recovered from her eating disorder. While we still have a long way to go in developing effective treatments for eating disorders, one fact that research has shown is that if you intervene when an eating disorder first presents, and are able to treat it effectively, the risk of relapse decreases significantly. That is why programs such as the one being developed in Virginia are so important. The earlier we identify and treat these illnesses, the better chance they will not become chronic conditions. I hope that we see similar legislation in New Hampshire in the near future.

The Future of Mental Health Treatment

Although the treatment of psychiatric disorders has progressed considerably in recent years, the hard truth is that our understanding of these illnesses is incomplete. Case and point is how psychiatric disorders are classified and diagnosed. Clinical diagnoses are based upon observable and reported symptoms. While researchers have worked diligently to make the diagnostic criteria reliable and valid, there are multiple variables that can affect the clinical assessment, including the data and how the clinician interprets the data . The result? An individual can be given vastly different diagnoses at any point during the course of treatment, and often are given multiple diagnoses due to symptom overlap among various psychiatric diagnoses (known in the professional parlance as comorbidity). This can lead to confusion and frustration for the patient and provider alike as treatment fumbles along without a clear plan. If this sounds bad, it is. Whether it is psychotherapy, medication, community-based interventions or inpatient treatment, we still do not fully understand why some people respond to treatment and others do not. The development of evidence-based practices show promise but they are incomplete. Far too many people continue to suffer from severe and persistent mental illness. The new DSM-V revisions aims to put more research behind the diagnostic criteria, and provide clinicians with more valid instruments to ensure their diagnoses are correct and help guide treatment.

For those of us who love research and academia, the intellectual debate about which disorders are included or excluded and the diagnostic criteria associated with each disorder is fascinating and exciting. It also has real-world consequences in terms of insurance reimbursement and research funding. The potential inclusion of Binge Eating Disorder in the upcoming revision is a great example of a diagnostic change that will have a positive impact. But no matter how good or bad (depending on your view) DSM-V turns out to be, we are still basing our diagnostic criteria on inexact science, and that is not good.

There is, however, reason to be hopeful. The advent of fMRI and other brain-imaging techniques, along with genetic research, is helping us improve our understanding of how psychiatric disorders develop and affect brain functioning. Long-term, the hope is that we will be able to classify psychiatric disorders based upon biological markers. Studies like this one that shows shared genetic variations among several major psychiatric disorders has significant implications for how we will diagnose and treat these illnesses in the future. It is quite likely that the reason we see such variability of symptoms among individual diagnoses and comorbidity is directly related to these genetic variations and the resulting impact they have on the development and functioning of the brain. As we gain more understanding of these variables, we can develop targeted treatments based upon biological markers. Two such studies focused on this effort can be seen here and here. For clinicians, it is critical that we stay informed about current research so that we can provide our client’s with the latest evidenced-based treatments. But that is a topic for another day. For now, I think it is sufficient to say that we live during an exciting time as our understanding of the human mind grows exponentially. I believe that future generations will look back on our time period as a turning point in how we understood and treated mental illness. And that, to me, is very exciting!

The Cost of Mental Health

Came across a recent opinion piece by Kathleen Sebelius, Secretary of Health and Human Services. You can read the full text here. One quote which stands out and never ceases to amaze me is the cost associated with mental illness. She writes, “In total, mental health conditions place a greater burden on our economy than cancer or heart disease; and yet more than 60% of people with mental illness do not receive help.” The lack of access to care is something that is felt especially so here in the North Country. In discussions with area providers, one area of concern is the limited access to psychiatric prescribers. The burden of prescribing psychiatric medication is being placed on our primary care physicians, who do an admiral job. Yet, I think they would be the first to say that it would be their preference to leave psychiatric medication prescribing to the specialists. The use of telepsychiatry may be a solution but deployment is still limited in New Hampshire. I am hopeful that as people become more comfortable with the use of this technology, telepsychiatry will be a service that is accessible to everyone.

Mental Health in New Hampshire

As I get Ascent Counseling ready to go live, I thought I would start by publishing the blog. My goal for the blog is for it to focus on current news and information about mental health treatment. With that in mind, I got an email today from NAMI NH about the schedule for state budget meetings. You can access the dates here. If you can’t attend the meeting, make sure to voice your support for mental health funding in New Hampshire. It is critical that NH begin reinvesting in mental health care; it has been neglected for far too long, and they are not fulfilling their promises as outlined in the ten year plan.