Understanding Severe Mental Illness

A January 11th posting by the National Institute of Mental Health:

By Thomas Insel (pictured)

When a tragedy occurs like the shooting in Tucson this past weekend, all of us seek an explanation. While there remain many questions, a leading hypothesis is that the suspect has a serious mental illness (SMI), such as schizophrenia. The topic of violence and mental illness is never an easy discussion: with issues such as stigma, incarceration, public safety, and involuntary treatment in the mix. There is a legitimate concern that talking about violence and mental illness in the same sentence increases the likelihood that people with serious illness will be further marginalized and less likely to receive appropriate care. But tragic events, whether at a Safeway in Tucson or a classroom at Virginia Tech, require us to address this uncomfortable subject with the science available.

Is violence more common in people with SMI? Yes, during an episode of psychosis, especially psychosis associated with paranoia and so-called “command hallucinations”, the risk of violence is increased. People with SMI are up to three times more likely to be violent and when associated with substance abuse disorders, the risk may increase much further (1). But, mental illness contributes very little to the overall rate of violence in the community. Most people with SMI are not violent, and most violent acts are not committed by people with SMI. In fact, people with SMI are actually at higher risk of being victims of violence than perpetrators. Teplin et al found that those with SMI are 11 times more likely to be victims of violent crime than the general population (2).

The most common form of violence associated with mental illness is not against others, but rather, against oneself. In 2007, the most recent year for which we have statistics, there were almost 35,000 suicides, nearly twice the rate of homicides. Suicide is the 10th leading cause of death in the United States (3). Although it is not possible to know what prompted every suicide, it is safe to say that unrecognized, untreated mental illness is a leading culprit.

Treatment may be the key to reducing the risk of violence, whether that violence is self-directed or directed at others. Research has suggested that those with schizophrenia whose psychotic symptoms are controlled are no more violent than those without SMI (4). It’s likely that treatment not only helps ease the symptoms of mental illness, but also curbs the potential for violence as well.

As we learn more about the circumstances surrounding the tragedy in Tucson, we should be working harder to ensure people with SMI receive the care they need. Early intervention offers the best hope to prevent more tragedies in the future.

For more information on SMI and other mental health statistics, please visit NIMH’s Statistics page.


References

1. Swanson JW. Mental disorder, substance abuse, and community violence: an epidemiological approach. In: Monahan J, Steadman HJ, eds. Violence and mental disorder: developments in risk assessment. Chicago: University of Chicago Press, 1994:101-36.


2. Teplin et al. Crime victimization in adults with severe mental illness. Archives of General Psychiatry. 2005 Aug. 62. 911-921.


3. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). www.cdc.gov/ncipc/wisqars.


4. Steadman HJ, Mulvey EP, Monahan J, et al. Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Arch Gen Psychiatry 1998;55:393-401.

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NIMH Head Urges More Emphasis on Mental Illness as Brain Disorder

An article published in the October 15th edition of Psychiatric News:

By Aaron Levin

To catch up with other medical disciplines that have sharply reduced morbidity and mortality, psychiatry must evolve into “clinical neuroscience” and reconceptualize its understanding of the roots of mental disorders.

Research progress on psychiatric disorders must follow the cues of cardiology and oncology, taking major steps forward to find the causes of psychopathology and develop cures for mental illness, stated the director of the National Institute of Mental Health (NIMH).

“We're in the middle of a revolution,” said Thomas Insel, M.D. [pictured] “We have the chance to change the world—not tomorrow, but by staying on course.”

NIMH has laid out that course over the last few years by shifting its grants in directions that it hopes will produce “disruptive innovations,” said Insel in the inaugural lecture of the George Washington Institute for Neuroscience at George Washington University in Washington, D.C., in September.

The new institute is a multidisciplinary center that promotes research and training in the mechanisms of normal and pathological brain function.

Neuropsychiatric illnesses are the leading cause of years lost to disability or death from noncommunicable causes, noted Insel.

Progress Lags in Psychiatric Illness

Advances in research and changes in practice have cut deaths from heart disease by 63 percent since 1965, but similar progress has not happened for mental illness, he pointed out.

“We have to move the agenda,” he said. “Diagnosis still comes by observation, illness is detected late, prediction is poor, etiology is often unknown, prevention is not well developed, treatment is by trial and error, and there are no cures and no vaccines.”

Prevalence and mortality have not decreased, and the culture surrounding them is sunk in low expectations. “This is the only area of medicine where people don't talk about cure and prevention,” he said.

The burden of mental disorders is magnified by its relatively high prevalence (approximately 6 percent) and the fact that these illnesses are chronic disorders and usually begin early in life.

He suggested three main areas on which neuroscience research needs to concentrate to tackle the large public-health problem that mental illness presents: a renewed emphasis on psychiatric disorders as brain disorders, an increasing recognition of the role of child and adolescent development, and achievement of advances in understanding the genetic basis of mental illness risk factors.

Field May Shift to Clinical Neuroscience

Brain lesions may be the realm of neurology, but psychiatric illness is defined by the physiology of neural circuits in the brain, said Insel. A different approach and different training may be needed to understand and treat those illnesses. In 10 years, he suggested, psychiatry might be better termed “clinical neuroscience.”

He cited the example of Area 25 in the subgenual cingulate, a region that becomes overactive in depression, but where activity declines when depression is treated with an SSRI. Imaging studies show brain changes—but only in treatment responders. Deep brain stimulation (DBS) near Area 25 also turns down activity, he noted, and the research on DBS shows how knowledge gleaned from brain mapping, circuitry, and imaging can converge to improve understanding of disease and its treatment.

Second, mental disorders are also developmental disorders, he pointed out. Many begin before age 15, while normal brain development continues until age 25.

The cortex in patients with attention-deficit/hyperactivity disorder (ADHD) seems to take longer to mature. Individuals with the disorder “end up at the same point but two or three years late,” he said. “So is ADHD a disease of attention and behavior in children, or is it one of cortical maturation? The challenge is to see what is going wrong in the organ of interest.”

Third, while genetics are another key component of mental illness, Insel acknowledged that understanding how hundreds of variations map onto brain pathways is a complex challenge. Many variants express only in the human brain and only during development. Many other genes that contribute to mental illness have not yet been identified.

“We need to move from description to mechanism and to approach all of these problems from many levels: molecular, cellular, systemic, individual, and social,” he said.

Learning which early variations in brain structure, circuitry, and function foretell later disorder might lead to interventions that can prevent the development of frank illness.

Eventually, the foundation of brain circuitry, development, and genetics will support a better understanding of pathophysiology, prevention, and personalized medicine, all leading to Insel's goal of a comprehensive public-health approach to psychiatric disorders.

The George Washington Institute for Neuroscience has scheduled a dozen more lectures by other neuroscience researchers between now and next May.

Information about the George Washington Institute for Neuroscience is posted at www.gwumc.edu/neuroscience.

Photograph by David Hathcox

Rethinking Mental Disorders

An article posted May 20th on Care2.com:

By Kristina Chew

Psychiatric or mental disorders such as schizophrenia, bipolar disorder, depression and psychosis are better understood and treated as 'disorders of the brain' according to an article by Tom Insel, M.D., Director of the National Institute of Mental Health, and Philip Wang, M.D., Deputy Director of NIMH. The article, Rethinking Mental Illness, is published in the May 19th issue of the Journal of the American Medical Association. The authors note that, while there have been many 'insights gained from genetics and neuroscience'---such as twin studies that show high heritability for autism, schizophrenia, and bipolar disorder---such research explains only a 'fraction of the heritability' of mental disorders. (For instance, some182 genes have been identified as linked to eating disorders, and some 100 to autism.) These should rather be seen as 'disorders of brain circuits':

"The genetics of mental illness may really be the genetics of brain development, with different out comes possible, depending on the biological and environmental context."

Other advances in the field of genetics contribute to a reconceptualization of mental disorders. Epigenetics looks at the inherited changes in gene expression caused that are caused by something other than than changes in the underlying DNA sequence; Insel and Wang note that:

"The same twin studies that point to high heritability also demonstrate the limits of genetics: environmental factors must be important for mental disorders......The advent of epigenomics [the study of the factors that control genes], which can detect the molecular effects of experience, may provide a powerful approach for understanding the critical effects of early-life events and environment on adult patterns of behavior."

Further, the authors write that the behavioral and cognitive symptoms that indicate 'mental illness' may actually be the 'late stages' of neurological processes that, if detected at early stages, might be better and more fully treated:

"As a result, interventions, rather than being ameliorative or rehabilitative, could become preemptive or even preventive. But this transformation in diagnosis and treatment, which can be informed by recent progress in cardiovascular disease and cancer, will depend on an intense focus on the genetics and circuitry underlying mental illness to ensure new approaches to detecting risk, validating diagnosis, and developing novel interventions that may be based on alter ing plasticity or retuning circuitry rather than neurotransmitter pharmacology."

As an example, in the past several years, autism has gone from being seen as a psychiatric, and even psychogenic, disorder, to a neurological/neurodevelopmental one, with significant consequences in how autism is conceived of, treated and, too, perceived by the public. Autism was once thought to be caused by bad parenting, by 'refrigerator mothers' who were emotionally withdrawn and 'cold,' and therefore did not 'bond' with their children, who 'withdrew into autism'; the damage wrought to families and individuals by these misconceptions is unmeasurable. Seeing autism as a neurodevelopmental disorder---due, perhaps, to 'abnormalities' in synapses in the brain does change how autistic individuals are see by others.

Similarly, understanding that an eating disorder such as anorexia nervosa is biologically based rather than simply putting the blame on parents, on our society's and culture's equating being thin with success, has significant changes on treatment and, again, understanding, and this can make a huge difference in people's (parents, for sure) lives. Societal factors do play a role, but seeing anorexia as biologically based---a recent study of brain imaging has found neurocircuit dysregulation in anorexics---can have real changes for people's lives and, hopefully, for the ultimate outcomes of those diagnosed with these conditions.

Also see:

NIMH Builds New Framework for Understanding Mental Illness

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The National Institute of Mental Health Strategic Plan

From the National Institute of Mental Health (NIMH):

NIMH Vision

NIMH envisions a world in which mental illnesses are prevented and cured.

NIMH Mission

The mission of NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure.

For the Institute to continue fulfilling this vital public health mission, it must foster innovative thinking and ensure that a full array of novel scientific perspectives are used to further discovery in the evolving science of brain, behavior, and experience. In this way, breakthroughs in science can become breakthroughs for all people with mental illnesses.

In support of this mission, NIMH will generate research and promote research training to fulfill the following four objectives:

• Promote discovery in the brain and behavioral sciences to fuel research on the causes of mental disorders

• Chart mental illness trajectories to determine when, where, and how to intervene

• Develop new and better interventions that incorporate the diverse needs and circumstances of people with mental illnesses

• Strengthen the public health impact of NIMH-supported research

To downlaod the NIMH Strategic Plan, click here.

What is the outlook for the future?

From an article posted by the National Institute of Mental Health (U.S.):

The outlook for people with schizophrenia has improved over the last 30 years or so. Although there still is no cure, effective treatments have been developed, and many people with schizophrenia improve enough to lead independent, satisfying lives.

This is an exciting time for schizophrenia research. The explosion of knowledge in genetics, neuroscience, and behavioral research will enable a better understanding of the causes of the disorder, how to prevent it, and how to develop better treatments to allow those with schizophrenia to achieve their full potential.

To read the complete the complete article, click here.