Friday, 25 July 2014

Schizophrenia proven genetic, claims new US study

A new study published in Nature and widely reported in the mainstream media claims to have 'removed any doubt' about a biological cause for schizophrenia.

The study claims that more than one hundred genes associated with dopamine, the immune system and heavy smoking are implicated in causing the condition.

The researchers, from across many different countries, but led by the Stanley Centre for Psychiatric Research at the Broad Institute of MIT and Harvard, looked for genes that were common across of 150,000 participants, 25% of whom were diagnosed with schizophrenia. The over-representation of those with the condition (i.e. 1%, not 25%, of the American population are diagnosed with schizophrenia) was apparently necessary to identify the contributions of multiple genes to the schizophrenia picture.

Commenting on the diffuse and seemingly unrelated collection of genes identified, Steven Hyman, director of the Stanley Centre said:
"Some are very familiar genes expressed in nerve cells, and some are results where you scratch your head and you know you have more work to do."
Fortunately for Hyman, there will be no shortage of funding for continuing research on this theme - thanks to a $650 million donation by Ted Stanley (the largest ever to date in biomedical research), who obviously has more than a passing interest in both schizophrenia and the Stanley Centre.

Hyman made clear the end-game of the research is to wind up not with a list of genes but, rather, novel treatments. His colleague at the institute, former Merck executive, Ed Scolnick, has already developed a pioneering drug development programme which is ready and waiting to get those drugs into the public domain.

Smaller genetic studies have hinted at a link between the immune system and schizophrenia - people with schizophrenia often carry inflammatory blood markers. But equally, studies have implicated stress as a cause of schizophrenia, in which case you would expect to find immune compromise. Twin and adoption studies also clearly demonstrate the role of nurture in the development of the condition, even where there is thought to be a genetic predisposition.

The tone of the publicity being given to this research is authoritative and, combined with what is clearly a very large media spend, it runs the risk of being perceived by the public as ultimate truth - this is certainly the way it is being pitched.

On the very first day of my science degree, the lecturer penned onto the white-board in large capital letters THE SCIENTIFIC PRINCIPLE and, from there, went onto explain, at depth for several lectures, that in science, nothing is ever proven. We formulate hypotheses, yes, and the hypothesis is then either supported or refuted. We never, ever arrive at a conclusive position, simply a working model - that is, we have the humility to understand that life and science are bigger than we are and that our understanding is only valid until such time as further evidence illuminates the proposition.

We would be well advised to scrutinise this research and its context - it is not independent (a thing of the past, as far as anyone can tell) and therefore is bound to be influenced by the commercial aspirations of its funders. Perhaps schizophrenia can be attributed to a specific set of genes, but even if it can, there is too much evidence for the effectiveness of non-genetic interventions in the treatment of the condition to be certain either way.

We need to keep our eyes and ears open as the old order, rooted in morality, gives way to the new. Otherwise we risk falling prey to the obfuscation of reality. Ironically, we'll all be schizophrenic.

Written by Jacqui Hogan

Friday, 18 July 2014

'Pursuit of happiness' is the answer say UK mental health experts

This month, the CentreForum Mental Health Commission concludes what is being described as a 'landmark study on the state of mental health in England'. The 12-month commission has identified five key priorities for implementation between now and 2020. The final report calls for policy makers to:
  • Establish the mental wellbeing of the nation or 'the pursuit of happiness' as a clear and measurable goal of government
  • Roll out a national well-being programme to promote mutual support, self-care and recovery, and reduce the crippling stigma that too often goes hand in hand with mental ill-health
  • Prioritise investment in the mental health of children and young people right from conception
  • Make places of work mental health friendly, with government leading the way as an employer
  • Better equip primary care to identify and treat mental health problems, closing the treatment gap that leaves one in four of the adult population needlessly suffering from depression and anxiety and one to two percent experiencing severe mental illness such as schizophrenia
Now, I don't know about you, but while the intention of these recommendations may be noble, when you start to try to grab hold of these points, it seems there is nothing to sink your teeth into - the image of a toothless doberman springs to mind.

For instance, there is a big difference between establishing 'the mental wellbeing of the nation' and establishing 'the pursuit of happiness' as a measurable goal of government. As any therapist worth their salt will tell you 'mental wellbeing' and 'happiness' are not synonymous - it may well be that, in order to establish mental wellbeing, a period of decided unhappiness may be indicated, whilst difficult feelings are discussed and worked through.

Then there's the reality that what makes one individual 'happy' may not be in the interests of the social good - how about the paedophile whose greatest happiness is derived from, well, paedophilia?

And how exactly would one propose going about measuring the level of societal happiness - should the government decide the parameters? And, in any case, how can measuring in generality possibly tell you anything meaningful about individual suffering?

Moving to the second point, nothing wrong, on the face of it, with the idea of 'rolling out a national well-being programme', but again, who's to say what constitutes well-being? And are we not already steeped in national mental health well-being programmes, from support given through the NHS and other government-funded mental health organisations? Just what is being proposed here? And is there still a 'crippling stigma' surrounding mental ill health? Really? It seems to me that this is one area in which there has been much progress made in the last ten years - to the point where we risk actually enabling sufferers of mental ill health, through sheer sentimentality.

Other gripes - how exactly does one prioritise the mental health of a baby in utero (note the use of the word 'conception' in the third point) apart from letting it live, of course (but that's a whole other story) and is it true that people needlessly suffer from depression and anxiety?

Again, as any good therapist will tell you, depression and anxiety are often the clarion call to growth, the only way an individual can be woken up from painful, destructive and, yes, often crippling ways of being in the world.

At very best, these recommendations demonstrate a lack of insight and understanding into the true nature of mental ill health and at worst, they risk creating more suffering and frustration for those who will be told that the answer to their manifold difficulties is to 'get happy'.

What are your thoughts about the report? Is the pursuit of happiness the answer? Please leave your comments below.

Written by Jacqui Hogan 

Friday, 11 July 2014

An OCD treatment we'll keep coming back to?

Obsessive Compulsive Disorder (OCD) is a condition characterised by unreasonable thoughts and fears (obsessions) that lead to repetitive behaviours (compulsions). The archetypal example is hand-washing, but there are many different forms. In the case of hand-washing, to ease the fear of contamination, one may compulsively wash one's hands until they are chapped and sore (i.e. self-harm), yet still be unable to rid oneself of the conviction of ongoing risk from germs.

In fact, every addiction is an expression of OCD - the alcoholic compulsively returns to drink to ease (often unconscious) obsession, and the food addict returns to the fridge to avoid underlying emotional disturbance. Given the incidence of addiction in our culture, the level of need for effective treatment of OCD is clear.

A German research team has recently reported on an internet-based writing approach, with some promising results.

In an article published in Psychotherapy and Psychosomatics, whose title begins 'No talking, just writing', the team describes how 34 volunteers with DSMIV-classified OCD were randomised into a treatment and a control group, with follow-up at eight weeks and six months. The internet-based writing intervention consisted of 14 sessions and the main outcome measure was change in severity of OCD symptoms.

Symptoms were significantly improved in the treatment group and the effect remained consistent at six-month follow-up. Compliance was excellent, with only four participants (12%) leaving the study prematurely. Of the thirty completers, 90% considered their condition improved and would recommend such intervention to their friends.

So is internet-based writing therapy the way ahead for OCD? Obviously, larger sample sizes are needed, but this research clearly suggests positive potential.

What's your treatment experience with OCD, either as a patient or a clinician? How effective is medication and/or talk therapy in your experience and can you imagine a role for the internet in managing the condition? We'd love to hear your thoughts and insights.

Written by Jacqui Hogan

Friday, 4 July 2014

Herbal doesn't always mean harmless; news for St John's Wort

St John's Wort has, for centuries, been used as a treatment for mental disorders and nerve pain. Named after St John the Baptist whose feast day on 24 June coincides with its full bloom, its five yellow petals are thought to represent a halo, and characteristic red sap the blood of the martyred saint (St John the Baptist was beheaded for calling into question Herod's morality).

It seems there is good justification for its use. A review of 29 trials in 2008 concluded that, in major depression, St John's Wort is superior to placebo, as effective as standard antidepressants and exhibits fewer side effects than standard antidepressants - not bad going for a herbal remedy. Indeed, it is currently the number one alternative treatment for depression in the USA, a common resort for those who are not comfortable with formulations like Prozac.

But a new study published in the Journal of Alternative and Complementary Medicine suggests that care should be exercised when choosing to take, dispense or prescribe St John's Wort. Though a natural extract, it is proven to interact with many commonly prescribed drugs, resulting in impaired effectiveness and, sometimes, treatment failure. Treatments with which it interacts include the contraceptive pill, anticoagulants, some chemotherapy drugs and antihypertensives.

Lead author of the study, Sarah Taylor, rightly observes that 'patients may have a false sense of security with so-called 'natural' treatments like St John's Wort'. What most people don't understand is that just because an agent is derived directly from nature does not mean it is any less potent than a synthetic pharmaceutical - one only needs to look at the case of digitalis (extract of foxglove and powerful heart anti-arrhythmic) or aspirin (derived from willow bark) to prove this point.

This latest research (conducted in the city of Winston-Salem, North Carolina, from medical records compiled between 1993 and 2010) sought to quantify the scale of the potential problem, by looking at how often St John's Wort was taken with other medications, and how often the combination might have been harmful.
In an astonishing 28% of cases, St John's Wort, taken with another drug, may have caused problems for the patient, though this is probably an underestimate, since patients often do not report on the use of natural remedies. 
With results such as these, it's little wonder that France is now banning the use of St John's Wort, and that the United Kingdom, Canada and Japan are introducing drug-herb interaction warnings on packaging.

The good news is that St John's Wort seems to be helping patients with depression and, if it comes with the benefit of fewer side-effects than prescription medications, this can only be a bonus. The greater the awareness of its broader impact (with particular reference to drug interactions), the greater its potential as a safe and viable alternative antidepressant treatment.

Written by Jacqui Hogan