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.

Broken Promises

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Also see:

Operation Maple

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.


Introduction

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.


Guests

• 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.
  

• Michael Kirby, Chair of the Mental Health Commission of Canada.
  

• 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.

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.”

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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

Mental Health Commission of Canada - Winter 2011 Newsletter

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To view the entire newsletter, please click here (PDF).

RG1678 looks promising for the treatment of schizophrenia

A January 28th posting by Gerson Lehrman Group:

Summary

This article will explore RG1678, a new schizophrenia drug from Roche.

Analysis

RG1678 (molecular structure pictured) is a new compound under investigation by Roche for the treatment of schizophrenia. It is a unique drug in that it targets the negative symptoms of schizophrenia such as apathy and social withdrawal. The currently available medications for schizophrenia usually target the positive symptoms such as delusions and hallucinations. Another very interesting thing about RG1678 is its mechanism of action. It acts as a glycine reuptake inhibitor which normalizes glutamate neurotransmission by increasing synaptic levels of glycine. Elevation of extracellular synaptic glycine concentration by blockade of GlyT1 has been hypothesized to potentiate NMDA receptor function and may represent a new approach for the treatment of schizophrenia and cognitive disorders. Namenda is another drug which also works at the NMDA receptor to affect cognitive function.

RG1678 is currently in Phase 3 studies at Roche and the early results look very promising. Side effects to date have been mild and include anxiety and dose dependent mild elevation of hemoglobin. RG1678 may represent a fresh approach to the treatment of a difficult and debilitating illness.

By Gregg L. Friedman MD, Hallandale Beach, FL

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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Tragic cases show how much we misunderstand mental illness

An opinion piece published in the January 8th edition of The Chronicle Herald:

By Lezlie Lowe (pictured)

How many times have I heard this?

"She had everything."

Last time was New Year’s Day, when a family member and I were chatting about the November suicide of Daron Richardson, the 14-year-old daughter of Ottawa Senators assistant coach Luke Richardson.

Daron was a top student and hockey ace. She had, as it goes, everything.

Well, sure she did. She had pools, private school and iPods, but not her health — not her mental health.

It’s not uncommon to hear this logic tossed around: the better off a person is, the less likely he or she will suffer from psychiatric disorders.

And it’s true; mental distress is more prevalent in lower income households in Canada. But wealth, by no means, acts as a prophylactic against depression or psychosis. Just ask the family of Ali Reza Pahlavi, the son of the former Shah of Iran, who suffered from depression and shot himself Tuesday.

Mental illness isn’t a plague of the underprivileged or the fate of those who aren’t smart enough or committed enough or canny enough to seek out help, take their medication and stay in treatment.

Mental illness can be tweaked by our actions, sure. But it isn’t a choice. Ask yourself: if your best friend developed pancreatic cancer, would you ever say, "I just can’t understand it. He had everything."

And what of convicted killer Glen Douglas Race?

Race was a normal Dartmouth kid. Did he have everything? Perhaps not yachts, ponies and private jets, but by all accounts he had all the things most of us need to get by. And more than many have. Nevertheless, Race faced steady psychotic episodes. He was diagnosed with paranoid schizophrenia in 2001 in his second year at Dalhousie University.

To say Race’s illness was debilitating is an understatement. Race has been sentenced to life in prison for the upstate New York killing of Darcy Manor, a husband and father of two. He also stands accused of the first-degree murder of two Halifax men, Michael Paul Knott and Trevor Charles Brewster. Race’s parents and brother spoke publicly Wednesday, offering condolences to the families of the victims and raising this issue: Race needed more help than his family could give. And, more importantly, Race needed more help than the Nova Scotia mental health care system could offer.

Several families are in mourning now, Glen’s mother Donna Race said, because her son didn’t get the care his illness required.

The Involuntary Psychiatric Treatment Act, which could have forced Race into care and kept him from harming others, didn’t become law until July 2007, two months after the then 26-year-old was arrested trying to cross the U.S.-Mexico border with a rifle.

That policy is in place now. And it’s something. But it’s not enough. Our financial commitment to mental health still demonstrates a grave misunderstanding of its pervasiveness and seriousness.

As the Race family pointed out this week, in a painful and oft-repeated reminder, the system needs cash.

One in five Nova Scotians suffers from mental illness and Nova Scotia spends less than five percent of its health care budget on mental health.

In June, auditor general Jacques Lapointe released a report saying the province was failing to meet mental health treatment standards. Moreover, those failures were inadequately unmonitored, with no plan for a fix.

In short? We treat mental health like a joke; like it’ll clear up on its own.

Especially, we imagine, when those suffering from it have everything.

(llowe@herald.ca)

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2010 Federal Disability Report

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To download the entire report, please click here (PDF).

Mental health beds full up

An article published in the January 5th edition of The Chronicle Herald:

Capital Health faced with ‘unrelenting demand’ for admissions since September

By John McPhee, Health Reporter

Capital Health’s psychiatric care system has been under "almost unrelenting" pressure this fall, the head of psychiatric services said Tuesday.

Every one of the district’s 69 mental health acute care beds has been filled since September.

Ian Slayter [pictured] doesn’t know why there has been such a continuous need for admission.

"Our length of stay has decreased a little bit but we still have a lot of people coming for care," he said. "Any particular week, it’s not more than usual, but we’ve had week after week of almost unrelenting demand for beds."

Those who are waiting for acute care beds are either kept in the emergency department where they were admitted or, more preferably, sent to a psychiatric bed in a nearby health district, Slayter said.

Compounding the problem, patients often stay in psychiatric beds after they’re ready to be discharged. That’s because there’s often nowhere in the community — such as supported apartments or nursing home beds — for them to go, Slayter said.

"It’s like filling up a bathtub. Sooner or later you’re gong to overflow."

A woman who contacted The Chronicle Herald said she was turned away from the Cobequid Community Health Centre’s emergency department this week, even though she was told she needed treatment.

The elderly Beaver Bank woman, who didn’t want to be identified, said she was previously treated and hospitalized for acute anxiety.

"One doctor tried to get me in the hospital (but) another doctor told me that the beds were filled," she said. "We have a desperate problem here."

Slayter couldn’t comment on the woman’s specific case, but said hospitals don’t send anyone home who needs to be admitted.

"If the people assessing the patient feel they need to be in hospital . . . then we will keep them in emergency until we have a bed to send them to," he said.

Psychiatric services has been trying to deal with the shortage of psychiatric beds with several programs, Slayter said.

"We’ve been taking some of the more complex cases and building residential placements for people," he said. "It costs quite a bit of money — it’s a 24-hour support service — but when no one else has been willing to take them, we’ve done that in several cases over the past couple of years."

In another program, 35 to 40 people have been placed in supported apartments, where people live alone but they can call for help any time of the day, he said.

And plans are in the works for a psychiatric intensive care unit at the East Coast Forensics Hospital in Dartmouth. Five to 10 beds will be established in early spring for people at a high risk of harming themselves or others.

(jmcphee@herald.ca)

Laura Burke on CBC Radio's The Current

From the CBC Radio 1 program, The Current:

From the Heart

The story of a poet who was diagnosed with schizophrenia and her struggle to separate her medical condition from her muse.

To listen to the segment, please click here.

Ontario's doctors welcome report on mental health

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A December 23rd media release from the Ontario Medical Association:

Ontario's doctors welcome the government's release of Respect, Recovery, Resilience: Recommendations for Ontario's Mental Health and Addictions Strategy, and look forward to reviewing the report in detail. The Expert Advisory Panel and the All-Party Select Committee are to be commended for the extensive work and consultation process that has been undertaken in order to develop a broad range of recommendations. Ontario's doctors are eager to get down to business with a comprehensive plan to help patients access the care they need and deserve.

"Patients with mental illness or addictions and their families have been calling for improvements for far too long," said Dr. Mark MacLeod, President of the Ontario Medical Association (OMA). "With a decade of research already completed, it's time to take action to ensure that patients have timely access to quality care."

The OMA shares many of the same concerns outlined in the report; the existing lack of service integration and access to appropriate treatment and counselling services need serious attention. More needs to be done to ensure there's a program in place to allow for a collaborative approach to coordinate their care.

"For patients living with mental illness and addiction, time is crucial. We have to identify and implement the best methods to reduce wait times for patients requiring specialized psychiatric care to ensure that they receive the care they so urgently need." Dr. Desi Brownstone, Chair, OMA Section of Psychiatry

"Patients deserve a coordinated effort to give them the opportunity to live fulfilling lives which goes beyond the boundaries of medicine. We need to do a better job of providing social supports such as housing and employment for our patients. This will go a long way in addressing the well-being of patients in Ontario. This is important for all patients, but particularly applies to patients with mental illness, where a collaborative approach within and beyond medicine will better meet their needs." Dr. Ross Male, Chair, OMA Section of General and Family Practice

"Children and young adults suffering from mental illness and addictions are falling through the cracks of the health care system. We need to ensure our children have timely access to the care they need which is close to home and coordinated by their community paediatrician, to help manage their illness and their lives. We need to work together to implement a strategy that addresses the gaps in patient care, that children and their families face every day." Dr. Hirotaka Yamashiro, Chair, Pediatrics Section, OMA


For further information:

Contact OMA Media Relations at 416-340-2862 or 1-800-268-7215 ext. 2862

One mom's fight to get her daughter help

And article posted on December 15th by MSN News:

By Michael MacDonald, The Canadian Press

Maureen Bilerman [pictured, left] knew something was wrong when her normally shy 13-year-old daughter suddenly became incorrigible, her thoughts and actions disjointed, sometimes destructive.

"It was a light-switch effect," recalls the mother of two, her even tone hinting she has told this story many times before. "She cut our leather chair ... and became really defiant in a way she never was. Her thinking became skewed, distorted. So we right away tried to get her help."

But Bilerman's sense of urgency soon turned to frustration and anger — raw emotions common among parents and critics across Canada who say provincial governments are failing mentally ill children and youth.

"We're the best-case scenario and she's still falling through the cracks," says Bilerman, a newly minted mental health activist who has struggled for the past three years to get her daughter Sarah the help she needs.

Unfortunately, her story is not that unusual.

In a typical Canadian class of 30 students, six will suffer from some form of mental illness, but only one will receive treatment.

"I don't care in what province you're talking about, what town or what service you're looking for, you will find a waiting list that is unacceptable," says pediatrician Diane Sacks, a mental health expert and a member of the Mental Health Commission of Canada.

"There's just not enough services for kids."

For Bilerman, a writer with a background in marketing and broadcasting, that harsh reality became apparent in the spring of 2008, when Sarah overdosed on a bottle of Tylenol.

At the hospital, she was told all six beds at the Child and Adolescent Psychiatric Unit at the Moncton Hospital were full.

"They said, 'There's nothing we can do.' So they sent us home."

But Sarah was still having suicidal thoughts.

For the next six weeks, Bilerman monitored the girl 24 hours a day.

"She would be at the end of her rope, beyond suicidal, in a total state," Bilerman says, adding that the pair would head to the local emergency ward almost every week.

Again and again, they were told the Moncton facility was full and there was no other place for them to go.

The girl was prescribed drugs to stabilize her moods, but they didn't help much.

Bilerman didn't give up. She pushed hard, finally persuading health officials to admit her daughter to the unit, where a month-long stay produced a diagnosis of bipolar disorder, otherwise known as manic-depressive illness.

By that time, it had been almost a year since Sarah started showing signs of mental distress.

The diagnosis represented a big step forward for the Bilerman family, but it was only the beginning of another difficult journey.

Sarah, now 16, has since overdosed three more times.

Doctors have prescribed 20 different combinations of medication, none of which have stabilized her for very long.

The girl often stays out all night long, leaving her mother worried for her safety.

The constant stress has left its mark on the rest of Bilerman's family, which includes husband Shawn and 13-year-old daughter Rachel.

However, Bilerman's life took a sudden, positive turn four months ago when she heard a radio interview with the province's child and youth advocate, Bernard Richard.

The former cabinet minister, who is pushing for creation of a centre for children and youth with "complex needs," inspired Bilerman to take action.

She later learned that Richard has been advocating for a short-term treatment and co-ordination centre ever since he completed a disturbing report in 2008, titled Connecting the Dots.

"It was like the story of our life," says Bilerman, who recently founded DOTS NB, which stands for Development of Treatment Services for mental health in New Brunswick.

Richard's report includes graphic accounts of the challenges faced by children and youth with mental illness, suggesting too many of them are ending up in jail, penalized for behaviour that requires treatment, not punishment.

The proposed centre would offer a safe place for youth in crisis, intensive help for families dealing with mental illness and programs that would help troubled children and youth make the transition back into the community.

"The response has been amazing," Bilerman says, adding that she has been delivering speeches — up to five a day — to universities, churches, service groups and other groups.

Earlier this month, Bilerman led about 1,000 people in an unusual demonstration that grabbed the attention of the provincial government. At one point, the protesters joined hands, creating a kilometre-long human chain linking Fredericton's community mental health centre with the provincial legislature — a symbolic connecting of the dots.

Later, Bilerman presented Premier David Alward with hundreds of letters that tell stories similar to her own.

Bilerman wants Alward to approve Richard's proposal.

"It's integration of services across the province and closing some of the gaps that we know youth are falling through," she said after the rally.

Richard said the government has to act.

"When we don't provide the right responses to these kids, they end up in the justice system, in the prison system, over and over again costing millions of dollars over their lifetime," he said. "That's not to mention the hurt and damage they cause to their families, to themselves, and their neighbours and friends."

Alward said the province must do better.

"We have a responsibility, certainly as a people in New Brunswick, to move forward," he said.

The province's social development minister, Sue Stultz, says she is awaiting Richard's final report early next year before deciding how to proceed.

Photograph by David Smith, The Canadian Press

Mental health, the criminal justice system, and you: Understanding the process, and the people that can help

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Posted by the Grand River (Ontario) Branch of the Canadian Mental Health Association:

Published by the Kitchener Human Services and Justice Coordinating Committee, this booklet is an introductory guide to the criminal justice system. With special emphasis on the Region of Waterloo Mental Health Court, this publication is aimed at helping those with mental health issues who have been charged with a criminal offence as they navigate their way through the court process. While it cannot replace the services of a criminal defence lawyer, it does provide basic information and a list of community resources that can help those with mental health issues. The booklet is dedicated to the memory of Martin Tarback, a fixture on the streets of Waterloo for over 20 years, whose schizophrenia pulled him away from a loving family and friends at a young age, but whose spirit and courage was an inspiration to many.

To download the entire booklet, please click here (PDF).

Committed to improvement

A letter to the editor published in today's edition of The Chronicle Herald:

I am disappointed in the comments in your newspaper of Stephen Ayer, executive director of the Schizophrenia Society of Nova Scotia, that recommendations from the Hyde report will not be instituted quickly and suggesting a lack of action on my part.

Judge Anne Derrick’s first recommendation in her report was that the provincial government needs to develop a mental health strategy. Before her report was even written, I had appointed a mental health strategy advisory committee representing a board spectrum of people with first hand-knowledge of the justice system, schizophrenia and other mental illnesses and disorders. Work on the strategy is well underway and we will provide for consultation in the New Year. The president of the Schizophrenia Society of Nova Scotia is on this committee.

Additionally, I have visited Mental Health Services at Capital Health and at the IWK Health Centre to discuss what can be done to improve wait times and program outcomes, and steps are being taken on these fronts. Our government’s first budget included funding for an expanded Mobile Crisis Service here in the Capital District.

Is there more to do? Absolutely, and I am committed to seeing that it is done. Mental health services are an integral part of Better Care Sooner, our plan to implement the Ross report. Judge Derrick’s extensive recommendations offer an opportunity for Nova Scotia’s justice and health care systems to make real and positive changes — and we will.

Maureen MacDonald, Minister of Health

Changing attitudes about mental illness

An article published in today's edition of The Chronicle Herald:

Hyde Report a positive step, says schizophrenia society boss

By Ian Fairclough | FIVE QUESTIONS

Last week, a provincial court judge released a long-awaited report from the inquiry into the death of Howard Hyde, a Nova Scotia man with schizophrenia who died in jail a day after being arrested by police.

The report contained 80 recommendations and was welcomed by Stephen Ayer [pictured], the executive director of the Schizophrenia Society of Nova Scotia.

Q: What’s the most important lesson to be learned from the death of Howard Hyde?

A: There are three really important lessons; it’s hard to pick one of them.

The most important lesson is a combination of the need for increased education around mental illness and what to do when encountering a person who is in a state of psychosis.

There is also the need for communication not only with the individual who is in the psychotic state, but also communication between different agencies that would be interacting with that person, from the mobile mental health crisis team to 911 to the responding officers. Communications has to be better.

In relation to that is response. If we could increase the education and training of people who respond to situations where an individual is in a crisis with a psychotic episode, they would be able to communicate effectively between themselves and the other agencies or services involved, and then the response would be the most appropriate response for that individual.

Q: What’s the first thing that should be done?

A: We have to have some empathy and some humanity in terms of dealing with people who have a psychiatric emergency, no matter what the circumstances may be.

Q: What do you think it would take to change the way police and the justice system deal with mental health consumers?

A: One of the deputy sheriffs did a great job trying to calm Mr. Hyde down to the best of his ability. He took two hours to talk to Howard Hyde to get some insight into what was going on, so there are people who are understanding and empathetic within the system already.

I’m sure there are more than (him). I think police and correctional services need to take a look at their staff and identify people who would be most appropriate for training in regard to working with people who are having a psychiatric emergency and being able to understand how to deal with it appropriately and get the person the help they need.

Q: How are the supporters of people with schizophrenia reacting to the results of the inquiry?

A: Very positively, and I am as well.

As I reflect now on the report and having delved deeper into it over the last couple of days, my response is the same as it was initially. This is an incredible piece of work by an incredible person — Judge Derrick — and when this was released, I said it’s a watershed day for the people of Nova Scotia and all people who live with mental illness in their families. It’s so comprehensive and the recommendations are so thorough and so important. I continue to believe that and hope the report will be taken seriously by government and others who need to make changes within the way they provide services.

Q: How optimistic are you that at least some of these recommendations will be instituted quickly, and how likely do you think it is that they’ll all be accepted?

A: In terms of the word quickly, I’m not very optimistic at all. In fact, I’m quite pessimistic, because this government has shown that even though it talks the talk, so to speak, and we have a health minister who is a former social worker and who worked at the Nova Scotia Hospital years ago and campaigned on the fact that mental health was going to be a high priority, when push comes to shove and the rubber hits the road, she’s nowhere to be found in terms of making some changes.

That includes support for community organizations such as ours that are on the front lines dealing with crisis calls.


BY THE NUMBERS

• About one per cent of Nova Scotians are living with schizophrenia.

• About 23,000 family members are affected by schizophrenia in that they are trying to help their loved ones deal with it.

• About 30 per cent of people with schizophrenia completely recover, and another 40 per cent recover well enough to work with limitations. The other 30 per cent are so affected they are difficult to treat.

• The Hyde Inquiry [report] contained 80 recommendations among its 462 pages.

• In the past year, the Schizophrenia Society of Nova Scotia answered more than 500 crisis calls and provided advice, information and assistance.

Source: Schizophrenia Society of Nova Scotia


(ifairclough@herald.ca)

Photograph by Peter Parsons, The Chronicle Herald.

Hyde report: Call to action

An editorial published in the December 10th edition of The Chronicle Herald:

In Judge Anne Derrick, Howard Hyde finally has an advocate who sees the bigger pic­ture. Sadly, proper perspective is the very thing he desperately needed from someone — anyone — the day he died three years ago.

That much is obvious from reading Judge Derrick’s findings into the chain of events that led to the death of this emotionally disturbed man. But those who comb through the inquiry report looking to pin blame will be disappoint­ed. Howard Hyde — who suffered from schizo­phrenia, was off his medications and experi­encing psychosis — was not a victim of in­competence. He was a victim of incoherence.

During every step of his odyssey in police, medical, court and correctional custody, Mr. Hyde came across professionals acting profes­sionally. Even the most controversial and publi­cized episode — which led to Mr. Hyde’s mul­tiple Tasering at a Dartmouth police station — is not a slam-dunk of police misbehaviour.

Judge Derrick notes that the booking officer who produced a tool with which to cut the lace on Mr. Hyde’s shorts before putting him in a cell did not mean to provoke or panic him.

“S/Cst. MacCormick uttered the words: ‘We’ll have to cut one of those balls off’ innocently, with no appreciation of the effect they would have on Mr. Hyde," she wrote.

Judge Derrick makes it clear that the Taser­ing did not cause Mr. Hyde’s death. Nor did he die of schizophrenia, as the medical examiner unhelpfully concluded. He did die some 30 hours later as a result of a struggle with Burn­side jail correctional officers whose use of force, and of a restraint hold, she determined to be “reasonable and proportionate."

Ultimately, the real problem was not the performance of Mr. Hyde’s custodians per se, but crucial omissions cascading through the chain of custody. From the moment he was first picked up by police on a domestic abuse com­plaint, a pattern developed whereby relevant facts weren’t passed along. Legal and medical professionals got their wires crossed, made incorrect assumptions, acted on incomplete information. Cops were unaware of mental health resources available to them and guards didn’t know how to de-escalate confrontations with the emotionally disturbed.

Clearly, the province must begin by training its sights on retraining front-line staff.

(edits@herald.ca)

Hyde’s partner praises inquiry findings

An article published in today's edition of The Chronicle Herald:

By Clare Mellor

Karen Ellet [pictured] says she still mis­ses Howard Hyde’s amazing voice.

“I miss his voice, his beauti­ful singing voice," the Dart­mouth woman said Thursday.

Ellet, who was Hyde’s com­mon- law wife, said she has been dealing with her grief since he died on Nov. 22, 2007, after a violent conflict with jail guards at the Central Nova Scotia Correctional Facility in Dartmouth.

But she is taking comfort in the recommendations result­ing from the provincial inquiry into his death.

If the suggestions outlined in a report released Wednesday are adopted, they will make a huge difference in the way mentally ill people in crisis are dealt with, Ellet said.

“I am very pleased. She is a very compassionate judge," she said of Anne Derrick, the provincial court judge who helmed the 11-month fatality inquiry.

She said Hyde would be pleased with Derrick’s report, too.

“He would be ecstatic about it," Ellet said. “He would like to see (the recommendations) implemented, so the (report) is not sitting on a library shelf."

In her report, Derrick rejected a medical examiner’s conclusion that Hyde died of excited delirium and found in­stead that the struggle with the jail guards played a role in his death.

Hyde, a 45-year-old musician who was diagnosed with schizo­phrenia in his 20s, was having a psychotic episode at the jail when he was forced to lie on his stomach with his hands behind his back. The restraint technique may have interfered with his ability to breathe, Derrick found.

“He did not die because he was mentally ill," she wrote in her report.

Ellet said she still has difficulty thinking of the emotional and physical pain that Hyde endured in the last 30 hours of his life.

On the night of Nov. 21, 2007, Ellet called a crisis hotline to complain that Hyde had assault­ed her while in a psychotic state.

Police arrested Hyde, but not before Ellet told them her hus­band had not been taking his medication and needed psychiat­ric help.

“Howard didn’t understand why he was in jail," she said. “He couldn’t comprehend his sur­roundings."

Ellet said she has been keeping a low profile due to her grief, but she believes it is important for her to speak up about the changes she thinks Hyde would have wanted to see in the justice system and in society at large.

“I believe he would want to have a professional such as a mental health provider to be with people who have a mental illness when they are in crisis, to speak on behalf of them," she said.

Ellet said Hyde would want all professionals to be issued hand­books so they could learn more about the signs and symptoms of mental illness and how to handle somebody who is having a psy­chotic episode. “Howard would want more housing available (for mentally ill people)," she said. “Howard found it horrific to know that people with mental illness are living in shelters and on the streets. It really upset him. He wished he could have done something but he didn’t know what to do."

Ellet said Hyde also would have wanted more research into the development of psychiatric drugs.

“Not all medications agree with each particular person," she said. “There are so many side­effects."

More mental health funding and clubhouses, support groups and associations in support of the mentally ill would also be on Hyde’s list, Ellet said.

“I believe there is a large amount of fundraising that can make miracles happen to help (prevent) people with mental challenges from living on the streets," she said.

“Mental illness is no different from somebody walking around with diabetes."

Some of Derrick’s recommen­dations concern stun guns — she said they should not be used on people in a state of agitation due to a psychological disturbance, and changes should be made in the training for how to use them.

The judge also recommended that crisis intervention training be provided to all correctional officers at the Dartmouth jail and that several aspects of training in general be improved for jail guards in the province and for front-line police officers and doctors.

Ellet said it is poignant that the report on Hyde’s death came out on the 30th anniversary of the murder of John Lennon.

Hyde, who sang and played the saxophone, was also an extraor­dinary musician, she said.

“Howard had the musical ability to play anything," she said. “He had the most astound­ing voice you can imagine."

Also like Lennon, Hyde de­spised war. “He just wanted peace in the world," Ellet said.

(cmellor@herald.ca)

Also see:

N.S. to factor Hyde inquiry into mental health plan


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Culture shift needed in society, system

An opinion piece published in today's edition of The Chronicle Herald:

By Marilla Stephenson (pictured)

In the end, who failed Howard Hyde?

Perhaps, to some degree, we all did.

There is really no way to dress up the realities of mental illness. It is not pretty, and it can be a very tough challenge to support people in crisis. The people who live closest to those who suffer from mental illnesses are victims of the illnesses, too.

There is also no way to disguise or excuse how our society has continued to respond to people who experience mental illnesses. The stigmas are clear and well understood, even by young children in our schools. The branding begins early.

Hyde is the Dartmouth man who died in custody in 2007. He suffered from schizophrenia. The police were told of his mental illness when he was taken into custody over allegations of domestic abuse. He later died after an intense struggle with prison guards.

Provincial court Judge Anne Derrick released the fatal inquiry report into Hyde’s death on Wednesday. She firmly rejected a previous finding by a pathologist that he had died due to a condition termed "excited delirium."

Derrick dismissed that finding as a "red herring" that did not exist in Hyde’s case.

She also found that while the repeated use of a Taser on Hyde during his time in police custody "worsened the situation," it was not the cause of his death. She did, however, remind justice officials that so-called stun guns are to be used as an alternative to lethal force rather than as a front-line option to subdue suspects who are emotionally disturbed.

His death was accidental, Derrick found, but it came as a direct result of his struggle with prison guards.

In the comprehensive list of 80 recommendations, Derrick tossed the ball firmly into the hands of the provincial government.

She begins by calling for the establishment of a long-promised, but still absent, mental health strategy. It is clearly not by accident that this basic framework is at the top of the list as a necessary building block from which other improvements would naturally evolve.

The judge also calls on the province to increase funding for mental health, but not to do it by reallocating funds from within the existing envelope of health-care funding. This reflects the fact that mental health issues have for too long languished on the list of health-care priorities.

We are left with a fractured, often inaccessible mental health system where vanishing waiting lists are proudly waved around by government as proof of treatment for patients. Improvements are being made, and Derrick’s report makes note of policy changes that have already occurred in the justice system in the wake of Hyde’s death.

But it is hard to comprehend that none of the guards involved in the struggle with Hyde minutes before he died had any training to help them deal with prisoners who suffer from mental illness.

One seemingly innocuous recommendation, No. 49 on Derrick’s list, speaks volumes. Directed at justice system staff and other front-line officials who are in contact with prisoners who suffer from mental illness, it is brief and to the point:

"Training should have, as its overarching purpose, the development of a culture of respect and empathy for persons with mental illness in the justice system."

This is a statement that reaches beyond the justice system and into our society as a whole. While mountains have been moved in reducing the acceptance of stereotypes linked to mental illnesses, many of the most basic government services — justice and health among them — are still handcuffed by systemic ignorance.

The judge called for alternatives for people with mental illness who come in conflict with the law, and says the responsibility reaches well beyond the justice system.

"As the evidence before the inquiry has vividly illustrated, grasping this nettle is not just the responsibility of the justice system; creativity and commitment to change are required of the health system and the community, too."

The principles of respect and empathy provide a good place from which to start.

( mstephenson@herald.ca)

Also see:

Howard Hyde Inquiry Ignores Ableism As Cause of Death


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Report: Fatality Inquiry into the Death of Howard Hyde

The Honourable Judge Anne S. Derrick (pictured) filed her report from the Fatality Inquiry into the Death of Howard Hyde on Wednesday, December 8th, 2010.

The report is available by clicking here (PDF).

Video recordings of all the Inquiry hearings are available by clicking here.

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Also see:

Jailhouse restraint blamed

Patients' Souls Called Medicine's Missing Link

An article published in the December 3rd edition of Psychiatric News:

By Mark Moran

Small changes, beginning with the attitude clinicians bring to a patient encounter, can transform psychiatric and other medical care.

The notion that your patients have a “soul” and that your treatments can touch or transform something less (or more) substantial than a neurotransmitter may sound, in the context of modern biomedical science, quaint today.

But author and psychotherapist Thomas Moore, Ph.D. {pictured], believes the souls of patients in the care of modern medicine are in need of urgent attention. And so too, he says, are the souls of their doctors.

Moore is the bestselling author of The Care of the Soul: A Guide for Cultivating Depth and Sacredness in Everyday Life, the 1992 book that asserted that the greatest poverty in today's technologically triumphant culture is a lack of attention to the soul.

In a new work, Care of the Soul in Medicine, published this year by Hay House Publishers, Moore asserts that this soul-poverty extends to modern medicine.

In an interview with Psychiatric News, Moore said modern medical care has come to be dominated by a highly mechanistic philosophy deriving from the relatively recent 18th century while jettisoning a far more ancient wisdom about care of the soul that dates to the time of classical philosophers.

Much of his new book is focused on care of the soul in general-medical settings, especially in hospitals and in the care of the dying. But Moore said the message of his book should resonate with psychiatrists.

“I understand the field has become more biological,” he said. “My sense is that people entering medicine today get this very intelligent, up-to-date training in biomedical science. And when I talk to psychiatrists about a spiritual approach to healing, it doesn't seem to them to have that intelligence behind it.

“But I would want psychiatrists to know there is a whole world of knowledge and wisdom outside the biological tradition that goes back several thousand years,” Moore said. “They should give a philosophical and spiritual approach to the patients in their care another look, and they may find that it can be very substantive and would complement their biological work.”

Transforming the Medical Setting

But what is the “soul,” and how does one care for it?

The question itself invites speculation that has kept philosophers busy for centuries. But for the purpose of his book and his message to physicians, Moore speaks of the soul as where one cradles the meaning of one's relationships and memories, the sense of mystery about one's own life, and one's understanding of the meaning of illness and death.

To care for the soul in medicine then would be to adopt practices that seek not just the “cure” of disorders, but care for and attention to patients' significant relationships, poignant memories, spiritual quests and interests, as well as their understanding of their illness. Such an approach, he believes, calls for changes in the way doctors are trained and in the way they approach their patients, but it also entails a transformation of the settings in which care is provided to include incorporation of nature, art, and music into the architecture of hospitals and doctors' offices.

His remedies for what ails modern medicine may seem to some either quixotic or “unscientific” (or even “antiscientific”), but his thoughts echo those of such respected thinkers as biomedical ethicist Daniel Callahan, Ph.D., who has written extensively of the need to return to “caring over curing.”

“You don't have to talk too long to patients and their families, as well as doctors and nurses, before they express a common feeling that contemporary medicine, for all its technological virtuosity, lacks something,” he said. “Patients and families will talk about how the medical establishment is just so huge and they feel like a piece of machinery. When I tell them about how images and architecture can transform a healing environment—about how the way a hospital room looks and feels can be a part of healing—they are a little surprised, but they know what I am saying. So I seem to be giving people a language for talking about things they know intuitively.”

Moore is careful not to be critical of physicians — “they get enough criticism,” he said—and noted that after the success of his 1992 book, it was the medical establishment that came to him. As part of his research for the book, he was invited to spend two days each month over a two-year period at St. Francis Hospital in Hartford, Conn.

“When I first wrote Care of the Soul, I didn't have medicine in mind at all,” Moore said. “But I began getting invitations to talk at medical schools, and right up to the present time I have been visiting medical schools, hospitals, and cancer wards all over the country and in Ireland.”

Reclaiming an Ancient Wisdom of the Soul

What does Moore, an admirer of Carl Jung (but he is not, he said, a Jungian), think of the widespread use of pharmacologic agents to treat psychiatric disorders?

“It's a complicated issue, and I have nothing against the use of pharmacologic treatments in conjunction with other approaches,” he said. “But I think it goes hand in hand with the prevailing philosophy of our time that is based on treating people as mechanical systems. If you see the brain as a collection of neurochemicals, you are going to use chemicals to treat people.

“That's the underlying mythology of our time. It is useful as far as it goes, but I think it leaves much to be desired and ignores a vast trove of wisdom about the soul that predates the 20th century.”

His recommendations for reform seem to require changes in a medical system that is itself vast and unwieldy. But Moore believes that even small changes—beginning with the attitude clinicians bring to a patient encounter—can be transformative, even of a 15-minute med check.

“I think psychiatrists would find their work so much more pleasurable and fulfilling if they could reach past the prevalent biological view of a human being and enjoy the complexity of human life,” Moore said. “They could allow themselves to be instructed by the arts, by fiction and drama, painting and music and allow those to inform their practice. It would humanize their work so that they would have a warmer and more fulfilling experience in a context that would be incredibly rich, even if they only had 15 minutes.”

It's not the amount of time spent with a patient that's key, he said. “I can spend 50 minutes with a patient and it seems like nothing. It's where you are coming from that makes the difference.”

Photo courtesy of Thomas Moore, Ph.D.

Gene-Environment Interactions Could Influence Several Psychiatric Disorders; 'Schizophrenia Gene' May Also Trigger Anxiety, Depression

A December 3rd media release from Johns Hopkins University:

BALTIMORE, Dec. 3 (AScribe Newswire) -- Male mice born with a genetic mutation that's believed to make humans more susceptible to schizophrenia develop behaviors that mimic other major psychiatric illnesses when their mothers are exposed to an assault to the immune system while pregnant, according to new Johns Hopkins research.

What was most surprising to researchers was that the mental illnesses the mice developed didn't look like schizophrenia, which they were genetically predisposed to, but more like mood and anxiety disorders, suggesting that one gene mutation can lead to different mental illnesses when influenced by the same environmental factor.

"Psychiatric diseases have genetic roots, but genes alone do not explain the entire disease," says Mikhail V. Pletnikov, M.D., Ph.D. [pictured], an associate professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine and the study's leader. "When we study genes in conjunction with environmental challenges, we can better understand how diseases develop."

Pletnikov hopes his research, which appears in the December issue of the journal Biological Psychiatry, may be a small step toward eventually finding ways to prevent mental illnesses in humans. "The main goal here is to understand how gene-environment interactions take place on the molecular level so that you can find suitable drug targets, ultimately stopping these diseases before they happen," he says. "It all can start before birth."

Pletnikov and his team studied a mutant human form of the Disrupted-in-Schizophrenia 1 gene (mhDISC1), breeding mice in the laboratory with this mutation. This genetic variation is believed to be associated with vulnerability to major mental illnesses in humans. The mhDISC1 mice were impregnated, and at the ninth day of gestation (the equivalent to the middle or end of the first trimester in a human pregnancy), one group was given a drug to stimulate the immune system, forcing it to react as if it had been exposed to a virus like influenza or a parasite like toxoplasma. The rest of the pregnant mice - whose fetuses also had the mutated gene- were kept as a control group and their immune systems were left unchallenged.

The study found that prenatal immune stimulation in mhDISC1 mice produced behavioral abnormalities that were not present in the unchallenged mice: elevated anxiety, depression-like responses, an altered pattern of sociability and a weakened response to stress. The unchallenged mice did not show those behaviors, even though they also had the mutant gene. Pletnikov says the findings suggest that the same mutation, in this case mhDISC1, can lead to different illnesses, depending on interactions with environmental factors.

This may provide an explanation, he says, for why the extended Scottish family in which scientists first discovered this genetic mutation had members who suffered not solely from schizophrenia but also from major depression and bipolar disorder. "This one gene mutation can lead to very different clinical manifestations," Pletnikov says.

Along with the behavior differences, Pletnikov and his team also found that parts of the brain, including the amygdala and the hypothalamus, were smaller in the mice that had been prenatally challenged. A similar abnormality can be found in those same areas of the brain in humans with major depression and bipolar disorder.

Previous studies have suggested that the prenatal immune response to a microbe - be it a major illness or just transient flu-like symptoms barely noticed by the pregnant woman - may be responsible for the increased incidence of adult psychopathology in humans. But this hypothesis, Pletnikov says, has been difficult to prove. Using this mouse model, he suggests, is a valuable way to study the relationship between gene-environment interactions and mental illness, and should be replicated to find more of these interactions to gain a better understanding of these relationships.

Future studies, he says, will try to sort out whether different timing or stimulating different parts of the immune system might lead to specific types of mental illness, as well as explore the consequences of other environmental adverse events such as stress or drug abuse.

Other Johns Hopkins researchers on the study include Bagrat Abazyan, M.D.; Jun Nomura, Ph.D.; Geetha Kannan; Koko Ishizuka, Ph.D.; Kellie L. Tamashiro, Ph.D.; Frederick Nucifora, Ph.D.; Vladimir Pogorelov, Ph.D.; Chunxia Yang; Carlos Pardo, M.D.; Susumu Mori, Ph.D.; Atsushi Kamiya, M.D., Ph.D.; Akira Sawa, M.D., Ph.D.; and Christopher A. Ross, M.D., Ph.D.

The study was supported by the National Institute of Mental Health, Autism Speaks, the National Alliance for Research on Schizophrenia and Depression, the Mortimer W. Sackler Foundation, the Cell Science Research Foundation and the National Institutes of Health/National Institute on Drug Abuse-Intramural Research Program.

For more information: http://www.hopkinsmedicine.org/psychiatry/research/neurobiology/research_labs/behavioral_pletnikov.html

- - - -

CONTACT: Stephanie Desmon, Johns Hopkins Medicine Media Relations and Public Affairs, 410-955-8665, sdesmon1@jhmi.edu

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Government funding of mental health services in Nova Scotia

From a June 1st, 2010, PowerPoint presentation made by the Nova Scotia Department of Health:


Please click on the image to magnify it.