Chair of DSM-5 Task Force Discusses Future of Mental Health Research

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Statement by David Kupfer, MD

The promise of the science of mental disorders is great. In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting. In the absence of such major discoveries, it is clinical experience and evidence, as well as growing empirical research, that have advanced our understanding of disorders such as autism spectrum disorder, bipolar disorder, and schizophrenia.

This progress will soon be recognized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The new manual, due for release later this month, represents the strongest system currently available for classifying disorders. It reflects the progress that we have made in several important areas:

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What It’s Like to Have Schizophrenia

It’s not pretty, that’s for sure. For years I hid my terrifying symptoms from everyone until I nearly lost my mind — and my life.

Here are four things you’ve probably heard about people who have schizophrenia. Since I’ve struggled with the disease for almost my entire life, I’m more than qualified to tell you if they’re true or false.

1. They hear voices. Yep, I hear them. Those are real, at least to me.

2. They’re paranoid. True. For years I was pretty sure people were out to get me.

3. They commit violent crimes. No, that’s not a symptom. Those of us with schizophrenia tend to be secretive and avoid human contact. We’re more likely to hurt ourselves. Which brings me to:

4. They commit suicide. Unfortunately, true. About 40 percent of us try it, and 10 to 13 percent succeed. The voices I heard told me to kill myself, and I came pretty close to doing it — until I finally got help.

People are talking about mental-health issues these days, and that’s a good thing. But it’s so important to separate the myths from the realities. That’s why I want to tell my story.

Looking back, I think I had symptoms of schizophrenia as early as kindergarten. Remember those “stranger danger” films when you were little, where a man gets out of his car, offers you candy, and then kidnaps you? Well, I became terrified of those men and started having nightmares about them trying to capture me. When I’d get off the bus after school, I’d run home as fast as I could. If I saw a car coming, I’d hide in the bushes so the men couldn’t get me. And I figured out right away that I should keep this a secret and not tell my parents or friends. These were early versions of the delusions, paranoia, and extreme secrecy that became part of my pattern for years.

By Lisa Halpern, Ladies Home Journal

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The DSM: A “Dictionary,” Not a “Bible”

NIMH Director Thomas Insel set the mental health world abuzz last week when he blogged that the National Institute of Mental Health will be “re-orienting its research away from DSM categories.” A new edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) is due to be released later this month.

“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each (psychopathology),” said Insel in “Transforming diagnosis” (Director’s Blog, April 29). He said that people “with mental disorders deserve better” than a menu of diagnoses that ensures clinicians use the same terms in the same ways but lacks scientific basis.

“(Y)ou know what?” he told the New York Times. “Biology never read that book” (“Psychiatry’s guide is out of touch with science,” May 6). Insel said psychiatric diseases need to be defined by their biology, genetics and neuroscience – their causes – not by their symptoms.

–The Treatment Advocacy Center

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Model Cell System Offers Insights Into Epilepsy, Schizophrenia, Other Neuropsych Disorders

Medical researchers have manipulated human stem cells into producing types of brain cells known to play important roles in neurodevelopmental disorders such as epilepsy, schizophrenia and autism. The new model cell system allows neuroscientists to investigate normal brain development, as well as to identify specific disruptions in biological signals that may contribute to neuropsychiatric diseases.

….”Unlike, say, liver diseases, in which researchers can biopsy a section of a patient’s liver, neuroscientists cannot biopsy a living patient’s brain tissue,” said Anderson. Hence it is important to produce a cell culture model of brain tissue for studying neurological diseases. Significantly, the human-derived cells in the current study also “wire up” in circuits with other types of brain cells taken from mice, when cultured together. Those interactions, Anderson added, allowed the study team to observe cell-to-cell signaling that occurs during forebrain development.

In ongoing studies, Anderson explained, he and colleagues are using their cell model to better define molecular events that occur during brain development. By selectively manipulating genes in the interneurons, the researchers seek to better understand how gene abnormalities may disrupt brain circuitry and give rise to particular diseases. Ultimately, those studies could help inform drug development by identifying molecules that could offer therapeutic targets for more effective treatments of neuropsychiatric diseases.

In addition, Anderson’s laboratory is studying interneurons derived from stem cells made from skin samples of patients with chromosome 22q.11.2 deletion syndrome, a genetic disease which has long been studied at The Children’s Hospital of Philadelphia. In this multisystem disorder, about one third of patients have autistic spectrum disorders, and a partially overlapping third of patients develop schizophrenia. Investigating the roles of genes and signaling pathways in their model cells may reveal specific genes that are crucial in those patients with this syndrome who have neurodevelopmental problems.

–Medical News Today

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Let’s Learn from the Failures of US Mental Health Policies

This is Prevention Week, part of Mental Health Awareness Month in the U.S. Too bad that the policies promoted by Prevention Week’s creators, the US Substance Abuse and Mental Health Services Administration (SAMHSA), make it more likely that people with the most severe psychotic disorders — schizophrenia and bipolar disorder — will remain ill.

To see the problem, just imagine that you are the parent of someone you think may be developing or already has schizophrenia. You go to the SAMHSA website because this is the well-funded U.S. agency in charge of supporting treatment for mental illnesses.

You urgently need some kind of overview about schizophrenia. Let me know if you find it.

In looking for basic information about schizophrenia, you might not think to click on “What a Difference a Friend Makes.” This is because your son or daughter’s friends fled when the delusional behaviour started. Click on this anyway and you can see the one meager paragraph that I could find on the entire SAMHSA website that discusses schizophrenia. The random comments mention the use of medication.

You may have heard somewhere else that anti-psychotic medications have a good success rate in helping people recover from psychosis and maintain their sanity. I can’t find any of this research on SAMHSA’s site. However, there are numerous links, amidst the vast resources on recovery, to psychiatric survivor groups ready to explain why medications should be avoided. In the information on recovery, I couldn’t find any links to the informative list of strategies for managing schizophrenia that are easily found on the science based US National Institute of Mental Health website.

by Susan Inman, The Huffington Post

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“My Son Needs Help,” Father Says of NFL Player

Former Detroit Lions player, Titus Young, is making headlines after his father told the Free Press his son suffers from a brain disorder following a series of off-the-field incidents, including three arrests in less than a week.

The football player was released from the Lions in February following a series of “bizarre behaviors.” He was reportedly receiving periodic counseling and was prescribed to medications. “Titus wasn’t taking his medicine regularly,” the football player’s father told the Free Press.

While the details of Young’s condition remain unclear, what is clear, according to the football player’s father is that “his son suffers from a mental health disorder and desperately needs help…We just want Titus to get well.”

–The Treatment Advocacy Center

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I Did Not Believe I Was Delusional, Let Alone Psychotic

The CIA was not spying on me. Nor were FBI agents looking to bring me down. On the other hand, I did not belong to either of these groups and was neither the President, Jesus Christ, nor Cleopatra. These, I had heard, are the content of delusions that characterize schizophrenia; its delusions are grandiose, and based (albeit flimsily) on the culture we see in the media. For example, having a radio transistor in your tooth is a common delusion of people suffering from schizophrenia — but I would assume this is just since the ubiquity of such technology. Naïve, I thought that if you were not pulled into these “standard” delusions, you could not have schizophrenia.

Given that logic, I did not consider myself to have schizophrenia. When mental health professionals labelled some of my beliefs as delusions, I was not convinced. I was worried, though: microscopic rats were eating my brain. “That’s the schizophrenia talking,” the hospital staff would say to me. “It is not real; it is a delusion.” But I was terrified of these brain-eating rodents, especially as they flooded my system via the countess forced injections I endured while certified — over 10 hospitalizations in five years.

“Erin, rats cannot even fit inside your head,” they’d all say. Furthermore, they’d expect me to use my understanding of neuroscience (I have a Master’s degree in the field) that felt like as a slap in the face. Did they not understand that the rats’ existence and constant consummation of my brain transcended science? It was of the Deep Meaning.

This “Deep Meaning” was to me the ultimate reality, while again doctors and nurses spoke of delusion. How could I expect them to understand, anyway? I reasoned. After all, this Deep Meaning was revealed only to me, the Chosen One. I had great responsibility: I was chosen to have my brain regenerate after being eaten by the rats, in order for there to be scientific study of this phenomenon. Regeneration in the brain is limited and its widespread occurrence in my brain would be an amazing breakthrough for neuroscience. Since this was, in my mind, based in science, it was obviously not a delusion.

by Erin Hawkes, The Huffington Post

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California Misses Opportunity to Provide Treatment for Seriously Ill

A storm is brewing over the most effective way to implement California’s Laura’s Law so that services reach those who need them most. We recently celebrated legislative efforts to amend the life-saving mental illness treatment law, but these legislative strides were halted by California Senate President Pro Tem Darrell Steinberg.

While we consider it progress that the Senate Pro Tem eliminated funding hurdles by clarifying that money from the Mental Health Services Act can be used to implement the law, this does not mean services will reach people with the most severe mental illnesses who need them the most.

The Sacramento Bee published today three letters that demonstrate how passionately people feel that Steinberg’s amendments gut the core of the law, which makes treatment possible for people who are too sick to realize they are ill.

“Steinberg’s plan will eliminate the funding hurdle but misses the opportunity to make treatment more accessible to the sickest and most vulnerable Californians by removing other barriers to implementing Laura’s Law.”

“His new proposals are for voluntary services and do not help the seriously ill who are too psychotic to know they are ill. To help people living under lice-infected clothing, who are eating out of dumpsters, screaming they are the Messiah requires implementing Laura’s Law.”

“[I]deological arguments keep getting in his way. That is the is the battle between those who believe acceptance of mental health treatment must always be through a person’s free will decision and those who recognize psychosis robs some people with mental illness of the ability to realize they are ill and need treatment.”

We commend Steinberg on his plan to make it easier to fund assisted outpatient treatment (AOT), but he is missing an opportunity remove other barriers that would make treatment more accessible for the sickest and most vulnerable Californians.

–Treatment Advocacy Center

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The Problem With How We Treat Bipolar Disorder

The last time I saw my old self, I was 27 years old and living in Boston. I was doing well in graduate school, had a tight circle of friends and was a prolific creative writer. Married to my high-school sweetheart, I had just had my first child. Back then, my best times were twirling my baby girl under the gloaming sky on a Florida beach and flopping on the bed with my husband — feet propped against the wall — and talking. The future seemed wide open.

I don’t think there is a particular point at which I can say I became depressed. My illness was insidious, gradual and inexorable. I had a preview of depression in high school, when I spent a couple of years wearing all black, rimming my eyes in kohl and sliding against the walls in the hallways, hoping that no one would notice me. But back then I didn’t think it was a very serious problem.

The hormonal chaos of having three children in five years, the pressure of working on a Ph.D. dissertation and a genetic predisposition for a mood disorder took me to a place of darkness I hadn’t experienced before. Of course, I didn’t recognize that right away. Denial is a gauze; willful denial, an opiate. Everyone seemed in league with my delusion. I was just overwhelmed, my family would say. I should get more help with the kids, put off my Ph.D.

by Linda Logan, The New York Times

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Brain Scans Give Clues to Antidepressant’s Effects

Brain scans during memory tests might help predict which depressed patients will be helped by a fast-acting drug, a new study reports.

Major depression is marked by feelings of sadness, loss, anger or frustration that can interfere with daily life for many weeks. Symptoms can also include memory loss and trouble focusing.

Most depression-fighting drugs must be taken for several weeks before working, which can cause an agonizing wait for patients. Because different people respond to different medications, patients may need to try several drugs over a month or more before getting symptom relief.

Several years ago, NIH researchers discovered that a drug used to treat motion sickness could also rapidly reduce symptoms of depression. But the drug, called scopolamine, didn’t work in all patients.

To try to predict the drug’s effects, the researchers used MRI to track brain activity in adults with and without major depression. People with major depression are known to have unique patterns of brain activity when asked to pay attention to the emotional content of images. They also tend to remember negative information (such as sadness) better than positive or neutral information.

The researchers found that scopolamine relieved symptoms in 11 of the 15 participants who had major depression. Scopolamine’s effectiveness was linked to activity in a specific brain region when patients were asked to remember the emotions on faces that flashed by. Activity in this same brain region was also altered by infusions of scopolamine.

The findings suggest that activity in this brain region might provide early clues about how well scopolamine will work in different patients. Ongoing studies are exploring how the brain’s response to emotional images might help guide treatment strategies for major depression.

–National Institutes of Health

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