Mortality Gap Widening for the Mentally Ill

The mortality gap between people with schizophrenia and bipolar disorder and the general population continues to widen in the United Kingdom, despite efforts by the government and health professionals to improve mental healthcare, according to a new study.

The findings highlight the challenge faced by the UK government’s recent mental health strategy, which has stated clearly that “fewer people with mental health problems will die prematurely,” write Uy Hoang, MD, from the Department of Public Health, University of Oxford, United Kingdom, and colleagues.

“We do welcome the government’s new policies, but in light of what our results are showing, making good on these policies is going to be a real challenge for them,” Dr. Hoang told Medscape Medical News.

The study was published online September 13 in the British Medical Journal….

by Fran Lowry

Mentally Ill In Indonesia Still Live In Chains

The harsh, tropical sunlight that dapples Bali’s tourist-thronged beaches streams through the fingers of a palm leaf and lands on the shoulders of Nengah, who slumps like a rag doll amid a pile of tattered pillows in the island’s far eastern reaches.

The poor village of Abang is remote, and Nengah spends her days in a heap, staring at hands that lie in her lap like dry leaves.

Today, Nengah is not alone. Neighbors have gathered in the mid-July heat to watch as her brother uses a stone to break a chain that has bound her to a concrete pit — her home — for nearly a decade.

Nengah, whose full name is confidential, suffers from schizophrenia. After the 35-year-old violently attacked her stepmother in a blind rage nine years ago, her family decided they had to restrain her.

Her situation improved after local psychiatrist Luh Ketut Suryani arrived in the village in June to find Nengah naked, caged and filthy. The doctor consulted the family and prescribed medication. Later, Suryani helped get Nengah’s family to free her from bondage.

Nengah’s situation is not unique in Indonesia, where the mentally ill are often locked in chicken coops or chained up in family yards to prevent them from disturbing the community.

A shortage of psychiatrists, limited mental health services, stigma and misinformation about mental illness are some of the reasons people here go without treatment. In a country of 240 million people, there are less than 600 psychiatrists, many of them based in urban centers….

By Sara Schonhardt

Q&A: A Yale Psychologist Calls for the End of Individual Psychotherapy

Is individual therapy overrated and outdated? Yes, says Alan Kazdin, a professor of psychology and child psychiatry at Yale University, writing in the leading journal Perspectives on Psychological Science.

Kazdin contends that treatments for mental health issues have made great strides over the last few decades, but the problem is that these evidence-based therapies aren’t getting to the people who need them. Nearly 50% of the American population will suffer some kind of mental illness at least once in their lifetimes, but the mental health field, which relies largely on individual psychotherapy to deliver care, isn’t equipped to help the vast majority of patients.

TIME spoke with Kazdin about his views and recommendations for change….

By Maia Szalavitz

Mental Health Care Reform Urged by Top Scientists

Psychotherapy experts say that as Americans work to reform the medical care system, they should also redesign how mental health care is delivered.

In a new paper, Yale University’s Dr. Alan Kazdin, a former president of the American Psychological Association, believes that we must acknowledge a basic truth — all of our progress and development in evidence-based psychotherapy has failed to solve the rather serious problem of mental illness in the United States.

In a prior paper, Kazdin urged psychological scientists to rethink the current mental health system in order to make adequate treatment available and accessible to all who need it.

In the current paper, several distinguished scientists have highlighted important points that will need to be addressed before the mental health care system can be overhauled.

The first area of reform is the need to better understanding what types of interventions work — and for whom. Psychological scientists Varda Shoham, Ph.D., and Thomas R. Insel, M.D., contend that knowing which treatments work won’t matter unless we know how to target the interventions to the people who will benefit most. “In the absence of such knowledge,” they argue, “we risk treatment decisions guided by accessibility to resources rather than patient needs – the very problem Kazdin and Blase aim to solve.”

The paper also suggested the need to better integrate several levels of care. Psychologists Drs. Marc S. Atkins and Stacy L. Frazier argue that “only a comprehensive and integrated public health model can adequately address the pervasive societal problems that underlie our country’s mental health needs.” Adopting such a public health approach will require that we pay attention to all levels of mental health care, distributing resources equally from the prevention to intervention stage of the treatment process.

Finally, the researchers believe that they need to do a better job identifying optimal methods of delivery. According to Brian Yates, Ph.D., we have to find more effective ways to deliver treatment — “methods that use less therapist time, less client time, minimize client transportation costs as well as brick-and-mortar space, and use less of other increasingly scarce and costly resources.”

Although a new delivery model for mental health care sounds like a pipe dream, precedent does exist.

As the authors of one commentary point out, the U.S. Department of Veterans Affairs has already developed and implemented new and innovative programs to address the mental health of its veterans.

In sum, the commentaries provide frank insights into the challenges we face in trying to address the mental health burden in the United States.

The new paper is published in the latest issue of Perspectives on Psychological Science.

Source: Association for Psychological Science

By Rick Nauert PhD

Neuroimaging-based markers of bipolar disorder: evidence from two meta-analyses

J Affect Disord. 2011; 132(3):344-55 (ISSN: 1573-2517)

Houenou J ; Frommberger J ; Carde S ; Glasbrenner M ; Diener C ; Leboyer M ; Wessa M INSERM, U 955, IMRB, Department of Medical Genomic, Psychiatry Genetic Team, University Paris Est-Créteil, Creteil, F-94000, France.

BACKGROUND: Bipolar disorder (BD) is often misdiagnosed or tardily detected, leading to inadequate treatment and devastating consequences. The identification of objective biomarkers, such as functional and structural brain abnormalities of BD might improve diagnosis and help elucidate its pathophysiology.

METHODS: To identify neurobiological markers of BD, two meta-analyses, one of functional neuroimaging studies related to emotional processing and a second of structural whole-brain neuroimaging studies in BD were conducted in the present study. Conducting a literature search on studies published up to September 2009 we identified 28 studies that were eligible for the meta-analyses: 13 functional magnetic resonance imaging studies, related to emotional processing and 15 structural imaging studies using whole-brain voxel-based morphometry. Only studies comparing patients with bipolar disorder to healthy controls were considered. Data were extracted or converted to a single anatomical reference (Talairach space). The activation likelihood estimation technique was used to assess the voxel- wise correspondence of results between studies.

RESULTS: In patients with BD, decreased activation and diminution of gray matter were identified in a cortical- cognitive brain network that has been associated with the regulation of emotions. By contrast, patients with BD exhibited increased activation in ventral limbic brain regions that mediate the experience of emotions and generation of emotional responses. The present study provides evidence for functional and anatomical alterations in BD in brain networks associated with the experience and regulation of emotions.

CONCLUSIONS: These alterations support previously proposed neurobiological models of BD and might represent valid neurobiological markers of the disorder. The specificity of these results to unipolar depression remains to be explored.

PreMedline Identifier:21470688

Antipsychotic To Switch or Not To Switch

Hello. This is Dr. Jeffrey Lieberman of Columbia University speaking to you for Medscape. Today, I want to address the question of how and when to switch from one antipsychotic medication or medications to another and what to expect when switching. This is a standard practice in the course of treating individuals with psychotic disorders such as schizophrenia and can be occasioned by a variety of occurrences. You could switch medication because it is not effective and is not controlling symptoms adequately, or, when it is effective, it is not achieving the level of therapeutic response that is desired, meaning that some residual symptoms persist. The medication may be producing unwanted side effects that are posing tolerability or safety problems. For these reasons, you can consider switching to another medication to improve efficacy and symptom control, or to improve tolerability and safety.

Recently, 3 papers reported very rigorous studies that bear on the question of switching.[1-3] Let me comment on these as a way of illustrating the advantages and disadvantages of switching. Generally, when a patient is relatively stable on an antipsychotic medication, albeit with some level of residual symptoms, we tend to think that we can try another medication to see whether it can do better in terms of symptom control, and assuming that other medications will have equivalent or comparable efficacy, there will not be any loss of the ability to maintain the level of response that has been achieved thus far, and medications will produce this cross-tolerance in terms of efficacy. This assumption presumes that switching will have no downside. It may not improve the level of symptom control over that of the prior antipsychotic medication, but it could improve side effects, and it could prove to be more effective, although we can’t be sure of that in terms of symptom control. The only medication that we know has a substantial likelihood of being more effective is the switch to clozapine for residual or refractory symptoms.

However, in 2006 Essock and colleagues[1] reported on outcomes derived from patients enrolled in CATIE [Clinical Antipsychotic Trials of Intervention Effectiveness]. These patients had been randomly assigned to 1 of 5 assigned medications. Thus, some patients were switched from the medication that they were taking when they entered the study to another medication, and some patients stayed on the same medication because they were randomly assigned to the medication that they were previously receiving. Essock and colleagues[1] found that when patients who were stable, albeit residually symptomatic, were switched, there was a higher rate of treatment discontinuation due to destabilization or new side effects associated with switching. This was particularly the case if patients were switched from treatment with olanzapine or risperidone. What this meant was that switching from one medication to another carried some significant risk for destabilization and then required either a switch back to the previous medicine or a switch to a new medication to stabilize patients again. This was an important lesson that switching has risks and that the reason for switching must justify those risks.

A second publication by Essock and colleagues[2] analyzed the practice of trying to reduce patients taking multiple antipsychotic drugs to monotherapy with a single antipsychotic medication. Patients who were receiving multiple antipsychotic medications were randomly assigned to continue these multiple medications or to have one of their medications tapered and discontinued, leaving them on just a single antipsychotic drug. This study found that a proportion of individuals who were taking 2 antipsychotic medications and were assigned to taper and discontinue one of those destabilized and needed to be returned to their
polypharmacy regimen. This only occurred in one third of the patients assigned to eliminate 1 medication; two thirds were able to tolerate monotherapy, and stability was sustained on 1 medication or side effects improved. Thus, this study supports efforts to try and simplify pharmacologic regimens by reducing polypharmacy with antipsychotic medications. This needs to be accomplished carefully and gradually, with the understanding that a proportion of patients will not tolerate that reduction and may need to be returned to their polytherapeutic regimen. Again, there is a risk in simplifying a regimen from poly- to monotherapy.

In a third study, Stroup and colleagues[3] asked this question: Is switching them from their current antipsychotic medication to an
antipsychotic medication with low metabolic liability the correct course of action for patients who suffer from the side effects of
obesity, a high BMI [body mass index], high body weight, or metabolic syndrome? These investigators randomly assigned patients who met the criteria for metabolic syndrome to either switch to aripiprazole; a weight-neutral or low-liability antipsychotic drug; or to stay on their existing regimen with olanzapine, quetiapine, or risperidone. They found that the individuals who switched to aripiprazole experienced statistically significant reductions in weight and alleviation of their metabolic syndrome, but that a substantial number of these patients destabilized and needed to be either returned to their previous medication or treated with additional medications to stabilize them.

The message from this study is that switching from an antipsychotic medication that causes weight gain or metabolic disturbances in glucose and lipids can alleviate those side effects, but there is a potential risk in terms of not being able to maintain the psychiatric stability or level of remission that had previously been achieved. Such a switch will work for some patients but not for all patients. When switching, one has to justify the reasons for switching, make sure that they warrant the risk, and in doing so be prepared to either backtrack or take additional measures to treat and stabilize patients if their mental status or clinical status deteriorates or worsens.

As Oscar Wilde said, “the truth is rarely simple and never pure,” and such is the case with switching antipsychotic drugs. It’s something that we must consider in the course of clinical management of patients, but it’s not a simple or uncomplicated maneuver to accomplish.

This is Dr. Jeffrey Lieberman at Columbia University speaking to you today for Medscape. Thank you very much, and see you

By Dr. Jeffrey Lieberman

Building a Better Antipsychotic Drug by Treating Schizophrenia’s Cause: How Drugs Act On Dopamine-Producing Neurons

The classic symptoms of schizophrenia — paranoia, hallucinations, the inability to function socially — can be managed with antipsychotic drugs. But exactly how these drugs work has long been a mystery.

Now, researchers at Pitt have discovered that antipsychotic drugs work akin to a Rube Goldberg machine — that is, they suppress something that in turn suppresses the bad effects of schizophrenia, but not the exact cause itself. In a paper published in the Journal of Neuroscience, they say that pinpointing what’s actually causing the problem could lead to better avenues of schizophrenia treatment that more directly and efficiently target the disease.

“In the past five years or so, we’ve really started to understand what may be going wrong with the schizophrenic brain,” says Anthony Grace, Distinguished Professor of Neuroscience and professor of psychology in Pitt’s School of Arts and Sciences and professor of psychiatry in the Pitt School of Medicine, who is senior author of the paper….

The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by University of Pittsburgh.

Theme park drops criticized Halloween names offensive to mental health advocates

Mental health advocates were not amused by an Ohio amusement park’s Halloween-themed attractions, prompting the park to announce a name change almost a year after the original offense was made.

Dr. D. Mented’s Asylum for the Criminally Insane, a haunted house, and a music show dubbed The Edge of Madness: Still Crazy, at Cedar Point in Sandusky drew the ire of the National Alliance on Mental Illness when they debuted as part of the park’s HalloWeekends last September.

The group asked the park to shelve both the haunted house and the music show, saying they promoted false stereotypes and misinformation, the Sandusky Register reported last October. Cedar Point declined and the show, as they say, went on.

But in an apparent change of heart, Cedar Point now says it’ll rename the music show The Edge of Madness: Six Feet Under. Dr. D’s asylum gets a new handle, too: Eternity Infirmary.

“A few people were offended (by the names) and so we’re changing them,” Cedar Point spokesman Robin Innes said Thursday. “We certainly weren’t trying to disrespect.”

Call me crazy, but I think this controversy is a bit over the edge. Radio personality Dr. Demento has been doing his shtick since 1970 and I haven’t heard anyone complaining. I assume Paul Simon is Still Crazy After All These Years and no worse for it. And, in my mind, Psycho is still one of the best thrillers ever made.

NAMI likened portraying people with biological brain disorders in a Halloween attraction as akin to using cancer patients to scare people.

What do you think? Is an asylum-themed haunted house an offense to those suffering from mental illness?

By Jayne Clark

The Lieber Institute for Brain Development (LIBD)

The Lieber Institute for Brain Development (LIBD) and the Maltz Research Laboratories is the only institution in the world focused exclusively on understanding the neurodevelopmental origins of schizophrenia and related psychiatric disorders and translating this understanding into improved treatments that change the lives of affected individuals.

Will Students Take a Mental Health Test?

As they return to classes this week, ninth-graders in Wisconsin’s Fond du Lac school district will be sent home with something for parents to sign besides the usual forms for sports activities and field trips: a consent for their children to undergo a mental-health screening.

With rising concern about adolescent depression and suicide, more schools are turning to screening tests to identify those at risk and, if necessary, help them get treatment. Voluntary screenings are being offered through school health classes, school-based health clinics and community agencies, which then can refer children for diagnosis and treatment to school psychologists or local health care providers.

“Parents are often thinking about school physicals and sports physicals as the school year begins, but they also need to think about the critical importance of mental-health screening,” says Laurie Flynn, executive director of the TeenScreen National Center for Mental Health Checkups at New York’s Columbia University. TeenScreen provides free 10-minute computerized questionnaires for schools, such as those in the Fond du Lac district, located about 60 miles north of Milwaukee. The questionnaires are designed to identify several mental-health conditions.

According to the National Institute of Mental Health, half of all cases of mental illness start by age 14, and about 11% of adolescents have a depressive disorder by age 18. Left untreated, such issues can lead to high dropout rates, substance abuse, violence—and suicide, the third-leading cause of death in adolescents. In a study of 2,500 students who went through the Fond du Lac program at six public high schools between 2005 and 2009, published last week in the Journal of the American Academy of Child and Adolescent Psychiatry, nearly 20% were identified as at risk, of whom 73.6% were not receiving treatment at the time of screening. Among that group, more than three-quarters completed at least one visit with a mental-health provider within 90 days after referral to school and community services….

The Wall Street Journal