Thursday, February 24, 2011

Schizophrenia risk is increased with a particular gene mutation

An article posted on February 23rd by the Los Angeles Times:
By Shari Roan

Schizophrenia is a severe, complicated illness. There are no obvious explanations for what causes the condition, which causes hallucinations and delusions. Genes are known to play a big role. The condition is often clustered in families.

Scientists announced a significant step in understanding the genetics of the disease this week. A large nationwide consortium of scientists led by Jonathan Sebat of UC San Diego has identified a gene mutation that is strongly linked to the disorder. Understanding the signaling pathway of this mutation creates a target for future therapies.

Previous research has shown a number of rare gene mutations that increase the risk of schizophrenia. In the new study, researchers looked for specific gene variants, called copy number variants, in 8,290 people with schizophrenia and 7,431 healthy people. Among the discoveries was a duplication in the tip of chromosome 7q. This duplication was found in people with schizophrenia at a rate 14 times that of healthy people.

The duplication affects a particular gene called the vasoactive intestinal peptide receptor 2 gene, which is known to play a role in behavior and learning. In people with schizophrenia, the expression of this gene is much higher, the researchers found. The VIPR2 gene mutation, therefore, will be an important target in developing medications that might alter the symptoms of the illness.

"This discovery might be the best target yet to come out of genetic studies of mental illness," Sebat said in a new release. The research was published online in the journal Nature.

Image courtesy of the National Library of Medicine.

Monday, February 21, 2011

Nova Scotia Mental Health Strategy Background Document

An email received on February 21 from the Nova Scotia Health Research Foundation:
In March, 2010, the Nova Scotia Government announced that it would be preparing a Mental Health Strategy to revamp mental health and addiction services in the province. The strategy will address concerns raised in the May 2010 Auditor General’s report. We were asked by the Minister of the Department of Health and Wellness to support the development of a Mental Health Strategy. In our role, we will oversee a neutral, comprehensive consultation process to ensure that the knowledge and input of stakeholders is included. We are also acting as secretariat to the Mental Health Strategy Advisory Committee, which was appointed by the Minister.

As part of our work, we have developed a background document, the Mental Health Strategy Background Document: A summary of the current state of mental health and addictions services in Nova Scotia. The purpose of this document is to describe the current state of publicly funded mental health and addiction services in Nova Scotia. The document will be a living document and will be updated and modified throughout the consultation process as more information becomes available. We will use the document to focus initial discussions with key stakeholders and will use an updated version to inform public consultations. The document will be updated regularly.

We thought that your organization would be interested in reviewing a copy of the enclosed background document.
To download the entire document (PDF), please click here.

Also see:

Mental Health Strategy

Is Canada making progress in treating mental illness?

Listen to the episode aired yesterday, February 21st:
On Cross Country Checkup: mental illness

It used to be the condition nobody would talk about. Five years ago a Senate report ... the first-ever national study of mental health and addiction, said Canada badly needed a strategy to deal with mental illness.

What has changed since then? Is support for mental health improving?

With guest host Andrew Nichols.


Five years ago a Senate report, the first-ever national study of mental health and addiction, said Canada badly needed a strategy to deal with mental illness.

Today we want to talk about mental health services in Canada.

When that report came out, Cross Country Checkup did a program on it asking Canadians for their views on the subject. The reponse was overwhelming. From people who themselves battled with mental illness, to families having difficulty trying to manage one of their own, to professionals who have identified solutions but don't see them instituted in their work places.

Since then we have been checking back in every few years to see how things are going. To see what has changed since and to find out whether support for mental health is improving?

The co-author of the report was Senator Michael Kirby and he has joined us on each program to update us on the progress. He will join us again later in today's program ... but this is also your chance to talk about the issues and stories ... things that you have seen or experienced that might provide some insight and help the process along.

The Senate Report, called "Out of the Shadows at Last", contained the following quotation:

In no other field, except perhaps leprosy, has there been as much confusion, misdirection and discrimination against the patient, as in mental illness... Down through the ages, they have been estranged by society and cast out to wander in the wilderness. Mental illness, even today, is all too often considered a crime to be punished, a sin to be expiated, a possessing demon to be exorcised, a disgrace to be hushed up, a personality weakness to be deplored or a welfare problem to be handled as cheaply as possible.

Those words were not original to the report. They came from a 1963 study by the Canadian Mental Health Association. DO those words still ring true today? If they do then one of the first hurdles has not been cleared ... removing the stigma that surrounds the disease many would rather not discuss.

There are other hurdles which our guests will outline ... and you, if you have some experience or insight you'd like to share, then give us a call.

  • Louise Bradley, President and CEO of the Mental Health Commission of Canada.
  • Dr. Stan Kutcher, Professor of Psychiatry, Dalhousie University & Sun Life Financial Chair in Adolescent Mental Health.
  • Honourable Mr. Justice Edward Ormston, Ontario Court of Justice, currently the Chair of the Law and Mental Health Advisory Committee for the Mental Health commission of Canada. Prime mover in the development of the First Mental Health Court in Canada in the City of Toronto.

To listen to this episode, please click here.

Friday, February 18, 2011

Today's Ultrashort Stays Raise Questions About Effectiveness

An article published in the February 4th edition of Psychiatric News:
By Mark Moran

The scant research that exists tends to support shorter-term hospitalization over long term, but in most studies what was once considered short term would be long term today.

Twenty-five years ago when Steven Sharfstein, M.D. (pictured), came to the Sheppard and Enoch Pratt Hospital in Maryland, the average length of stay there was 80 days.

In that time, the patient received a diagnosis and an individualized treatment plan including medication and psychotherapy addressing acute symptoms as well as intrapsychic and psychosocial factors, with the active engagement of family members and the formulation of an aftercare plan. It was a protocol that was not atypical for many other freestanding psychiatric hospitals; at general hospitals, the length of stay was often 20 to 30 days.

But today, the same patient entering almost any hospital in the United States for psychiatric care will likely be out the door in five or six days, in what Sharfstein calls the “ultrashort stay.” Such treatment as can occur in that time focuses on crisis stabilization, relief of the most acute symptoms, and de-escalation of dangerousness.

Between Sharfstein's arrival at Sheppard Pratt in 1986 and today, a perfect storm of factors—managed care, the expansion of insurance coverage for outpatient treatment, and a belief in the efficacy of the least-restrictive therapeutic environment—has reduced psychiatric hospitalization to something that looks less like treatment than a kind of holding action or police function whose purpose is ensuring patient and public safety.

“When I give a talk today, I tell people that hospital treatment is an oxymoron,” Sharfstein said in an interview with Psychiatric News. “We no longer really do treatment. What we do is stabilize, evaluate, and keep the patient as safe as we can.”

In an “Open Forum” essay that appears in the February Psychiatric Services, Ira Glick, M.D., Sharfstein, and Harold Schwartz, M.D., argue that the ultrashort five- to six-day hospital stay may actually subvert the goals of recovery and may contribute to the criminalization of mentally ill individuals by releasing patients to the community with no real recovery-oriented, long-term treatment plan.

The authors offered a model for reform of psychiatric hospitalization that revives the therapeutic function of the hospital and leaves enough time for accurate assessment, real engagement with the patient and family, and formulation of an individualized treatment plan aimed at long-term recovery (see How to Make Hospitalization Useful).

“We don't want a return to long-term hospitalization,” Sharfstein said, “but five or six days is too short. The purpose of the article is to raise the concern that in thinking about health reform, the hospital piece has been left out.

“Hospitalization is an opportunity, not a disaster,” he said. “It's an opportunity to bring high-tech resources to bear on the patient's illness and to come up with a better outpatient plan, one that will help the patient adhere to treatment and be better connected to psychotherapy and psychosocial interventions.”

Where Should Recovery Occur?

Yet the belief that recovery-oriented treatment should happen outside the hospital walls is persistent, and in an editorial accompanying the article, Psychiatric Services Editor Howard Goldman, M.D., Ph.D., argues that the appropriate role of inpatient care in the range of services for mental illness has yet to be resolved.

“Not all patients who need 24-hour supervision or confinement . . . need [hospital-level care],” Goldman wrote. “For some patients, freestanding psychiatric hospitals, affiliated with academic centers, are a more appropriate, lower-cost alternative to the general hospital. For many others, 24-hour alternatives may be more appropriate than the acute care hospital.”

In an interview with Psychiatric News, Marvin Herz, M.D., a longtime advocate for outpatient psychosocial interventions, said that while rigid adherence to a five- to six-day protocol serves no one well, he does not favor an expanded role for inpatient care as outlined by Glick and colleagues.

“I see the hospital as part of a broader system of care that ideally provides a continuum,” Herz told Psychiatric News. “In my opinion the definitive treatment in terms of helping the patient function should be in an ambulatory setting, not in the hospital. [Glick and colleagues] proposed an expanded role for the goals and methods of acute inpatient treatment that will inevitably increase length of stay and costs compared to the current inpatient model of crisis stabilization followed by appropriate ambulatory care.”

Anticipating those arguments, Glick and colleagues argued that lower-cost, low-tech models of care for patients who need 24-hour supervision do not now exist outside the hospital. In the meantime, they wrote, many patients have cognitive problems plus psychotic symptoms that prevent them from being “full partners on the treatment team” and from functioning in an outpatient setting.

Schwartz, psychiatrist in chief at the Institute of Living in Hartford, Conn., emphasized that the intensity of resources that can be brought to bear in an inpatient setting — and the crucial “holding environment” of the hospital — are especially important for influencing the trajectory of illness and recovery following a first-episode psychosis.

“We know that rapid, intense, and early intervention with the most resources possible is critical in the long-term outcome of first-episode psychosis,” he told Psychiatric News. “The evidence is very strong that an inadequately treated first episode predisposes to a second and to a downward trajectory. When we discharge people after five days because they are ‘safe,’ even if they remain psychotic and inadequately prepared for adjustment to life in the community, are we sending these patients on a downward course?”

How Much Hospitalization?

What everyone agrees is that research on the role of hospitalization and the appropriate number of days in a hospital for a given diagnosis is sorely lacking. (Goldman, in his editorial, noted that inpatient research “has disappeared.”)

What research exists tends to favor short-term over longer-term hospitalization. One study published in 1979 in Archives of General Psychiatry by Herz and colleagues looked at 175 newly admitted patients to the Community Service of the New York State Psychiatric Institute. Patients were randomly assigned to standard inpatient care, brief hospitalization followed by the availability of transitional day care, or brief hospitalization.

All patients were offered follow-up outpatient treatment. Initial length of stay was 11 days for both brief-hospitalization groups and 60 days for the standard-care group.

The long-term results indicated little differential effect between treatments, but when differences occurred, they generally favored the brief-care groups, according to the report. Similar results were found in a 1980 British study by Hirsch and colleagues published in the British Journal of Psychiatry.

Glick was principal investigator on studies in the 1970s and 1980s looking at long- and short-term hospitalization for patients with schizophrenia and those with other disorders. Generally, those studies showed that some subgroups of patients benefited from longer hospitalization, but that overall no differences in outcome were detectable when taking into account length of stay and diagnosis.

However, it is noteworthy that in all these studies what was considered “short term” at the time would be a long-term stay today.

“Today, patients admitted to inpatient care are either new cases or chronic patients who get readmitted because they are not complying with treatment,” Glick told Psychiatric News. “What happens with these ultrashort stays is that even the diagnosis is deferred — physicians are reluctant to render a diagnosis so the patient is classified as NOS (not otherwise specified). Then they get a blast of drugs — an antidepressant, antipsychotic, and antianxiety medication — told ‘good luck,’ and get sent out the door.

“What we are arguing for is spending the extra time to make a diagnosis, contact the previous doctor to get a careful history of what has been done or not done in the past, and prescribe an individualized treatment,” Glick said. “As in any other area of medicine, you have to do something active and therapeutic. In the case of psychiatric patients, the treatment team needs to include family, significant others, or a case worker—or it won't work.”

Photo credit

Tuesday, February 8, 2011

Cannabis May Influence Onset of Psychosis

An article posted on February 7th by Scientific American:

Research to be published this summer finds that the use of cannabis is associated with the early onset of psychosis.

By Christie Nicholson

Pot is one of those drugs that appears to maintain a fairly good rep, despite its growing bad rep. Consider this research that will be published this June in the Archives of General Psychiatry.

This particular study found that marijuana use is associated with early development of psychosis. Scientists analyzed 83 studies involving over 8,000 subjects who used pot and over 14,000 subjects who did not. They compared the age of onset for psychosis between these groups. And they found that those who used cannabis developed psychosis nearly three years younger than those who did not use any pot.

The researchers proposed some theories behind the pattern. One that cannabis use is a causal factor for schizophrenia, or that it precipitates psychosis in vulnerable people. They also theorize that cannabis might simply exacerbate symptoms of schizophrenia. Or the link could come from the other direction of course, those suffering from schizophrenia may be more likely to use pot.

The evidence here suggests that limiting marijuana use could delay or even prevent some cases of psychosis. And timing is important, since earlier onset of schizophrenia is linked to a worse prognosis overall.

Please click here to listen to the podcast.

Also see:

Cannabis Use and Earlier Onset of Psychosis