(Apr. 13, 2016) #ManInTree took social media by storm last month, when Cody Lee Miller, 28, climbed up an 80-foot tree in downtown Seattle and spent nearly 25 hours at its peak before emergency personnel were able to coax him down. A large group of spectators reportedly gathered at the scene, cheering “man in tree!” as Miller, armed with a knife, threw pinecones and branches at police officers and cars below.

But behind the hashtag is a very real and very sick man left without care until he literally went out on a limb and committed an act providing indisputable evidence of the danger he posed. If he hadn’t posed such a public danger, it is likely Miller would continue to be denied the help he so clearly needs.

Miller was diagnosed with mental illness over a decade ago. His mother, Lisa Gossett, first noticed something was “off” when Miller reached his late teens and began hoarding knives in his bedroom and warning of an “evil presence” in their home.

Gossett tried to get her son into treatment numerous times but was told there was nothing anyone could do unless he posed a danger to himself or others.

Herein lies the root of the problem. In Washington, the law states that a person needs to be a danger to self or others before he or she is able to receive treatment. This means families must watch their loved ones descend, sometimes slowly, into dangerous territory because the law does not allow them to push the “help” button until the person reaches the crisis stage.

But by this point, it is sometimes too late. Letting someone deteriorate to the point of crisis often results in an encounter with law enforcement and entanglement within the criminal justice system. Like every state in the nation, Washington incarcerates more individuals with severe mental illness than it hospitalizes – with nearly 3 times as many people with mental illness behind bars than receiving treatment in a hospital.

Make no mistake; this could have very easily become a tragedy in which onlookers and society at large watched as a man suffering from severe mental illness plummeted to his death. Fortunately, this didn’t happen in Miller’s case, but tragic outcomes are occurring at an ever-increasing rate to many others like him who are abandoned by the treatment system, including fatal interactions with law enforcement, suicide, victimization, and incarceration, to name a few.

Policymakers can’t see the forest for the trees. They must recognize this event for what it is: a clear sign that the mental health system isn’t working. Requiring dangerousness just to get care is dangerous and not what the state’s laws require. Treatment for someone in need like Cody Lee Miller is available under the state’s progressive “gravely disabled” standard. But only if it is understood and used by those making treatment decisions – something that is obviously not happening now.

How many more tragedies need to occur in Washington before those in power close the gaps in the system and protect the state’s most vulnerable citizens, their families and their communities?

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(Apr. 12, 2016) The first step in helping individuals with mental illness is not to hurt them, says psychiatrist Allen J. Frances.

“Unfortunately, the US approach of exclusion and neglect often makes people get much sicker, rather than helping them get well,” he writes in a recent “Saving Normal” column he authors for Psychology Today. “The specific forms of mistreatment have changed dramatically during the past 50 years, but their cumulative dehumanizing impact has been a constant.”

On Antipsychotics

In “Setting the record straight on antipsychotics,” the professor emeritus and former chair of the department of psychiatry at Duke University School of Medicine discusses the role of medication in improving or worsening psychiatric outcomes. Frances says “dangerous misuses of antipsychotic medication,” including “reckless over-prescription,” can worsen outcomes. But he cites evidence that the majority of people with chronic severe mental illness “will have relapses that are always disruptive and often dangerous” without maintenance medication.

The former chair of the DSM-IV task force faults psychiatry critics who claim, in the face of substantial research to the contrary, that antipsychotics cause or worsen psychotic symptoms and should not be taken long-term as a result. “This generalizing, and the proselytizing that often comes with it, has dangers for others who go on to have a very different lived experience. Influenced by popular books and blogs, people who truly need antipsychotic medications discontinue them-sometimes with disastrous consequences.”

Writes Frances, “even factoring in all the side effects, going off antipsychotic medication is usually a bad bet for the severe and chronically ill. The consequences of relapse can be unpredictable and sometimes horrible…. Patients, families and prescribers need to understand both the real benefits and the very real risks of antipsychotic medications. The mistaken idea that antipsychotics cause psychosis is an unnecessary and dangerous distraction from what is already a tough enough risk/benefit calculation.”*

Frances catalogues the mental health system failures in the United States in a column entitled, “World’s best and worst places to be mentally ill.” The US is arguably “the worst place in the developed world to have a severe mental illness,” he says because of failures including a focus on scientific research to the exclusion of clinical research, underfunding of mental health programs and overarching American attitudes toward mental illness.

* Allen details the evidence for and against antipsychotic therapy for chronic psychotic disorders in a Huffington Post blog, “Do antipsychotics help or harm psychotic symptoms?”

 
Doris A. Fuller
Chief of Research and Public Affairs

References:

• Frances, Allen J. (16 February 2016). “Setting the record straight on antipsychotics.” Psychology Today.
• Frances, Allen J. (1 February 2016). “Do antipsychotics help or harm psychotic symptoms?” Huffington Post.
• Frances, Allen J. (28 Dec 2015). “World’s best and worst places to be mentally ill.” Psychology Today. 

Next week: How many psychiatric beds does America need?

Research Weekly is a summary published as a public service of the Treatment Advocacy Center and does not necessarily reflect the findings or positions of the organization or its staff. Full access to research summarized may require a fee or paid subscription to the publications.

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(Apr.11, 2016) The time for mental health reform is now. A new resource from the Treatment Advocacy Center offers a snapshot of the most pertinent federal bills that have the potential to impact the lives of nearly 8 million people living with severe mental illness in the United States.

The overview includes what the bills seek to accomplish, the key players involved, potential obstacles and next steps.

The legislative process is moving and this resource will be updated regularly - check back for the most up-to-date information on each bill.

Click here to access this new resource.

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(Apr. 8, 2016) We don’t know enough about the causes and treatments of serious mental illness, but the 2016 Schizophrenia International Research Society Conference that ended April 6th in Florence, Italy, dramatically illustrated how much more data and science are being generated that patients and families living with diseases typically see.

Nearly 1,000 posters and hundreds of presentations reported findings from neurobiological, epidemiological, developmental, genetic, clinical, psychosocial and other studies of schizophrenia, bipolar disorder and major depression. Some – like UCLA’s findings about the impact of exercise on symptoms – have immediate practical value. Others, including the brain mechanisms at work in severe and persistent mental illness, remain shapes on the horizon. 

The Office of Research and Public Affairs (ORPA) provided a daily summary of a single conference session, which barely scratched the surface of the research shared during the four-day event. Following are 28 further quotes and notes from conference posters, presentations and news ORPA tweeted from the conference.

Treatment

We know there is an association between shorter duration of untreated psychosis and better functional and symptomatic outcomes, but we don't yet know if the relationship is causal.

Patients with psychosis who receive support from relatives obtain superior recovery outcomes, with fewer relapses and improved rates of mortality.   70 to 80% of first-episode patients achieve remission in the first year of treatment and remain in remission if they receive comprehensive care.

Early response or non-response to medication in schizophrenia predicts future response.

Identifying patients who don't respond to medication as early as possible suggests making early transfer to clozapine and long-acting injectable antipsychotics to avoid relapse.

Switching to long-acting injectable antipsychotics can provide “meaningful and significant improvement in caregiver burden.”

Medication dosages were successfully reduced in 98 Spanish patients with serious mental illness who received assertive community treatment (ACT).

"Remarkable improvement" was seen following electroconvulsive treatment (ECT) in psychiatric patients who had responded poorly to medication.

A drug commonly used to treat rheumatoid arthritis significantly improves symptoms of schizophrenia.

Medication does not rehabilitate people with schizophrenia. We have to know how to rehabilitate people, not just medicate them.

We all know the prognosis of untreated schizophrenia. What is the prognosis for treated schizophrenia? There is a lack of research investigating their long-term outcomes.

Lifestyle

Various forms of exercise are associated with schizophrenia symptom reduction, improved quality of life and increased social functioning. When aerobic exercise is added to cognitive training, patients in a UCLA study are improving thee times as much as those receiving cognitive training alone.

Every substance - alcohol, cannabis, hard drugs - is associated with significantly higher mortality in schizophrenia and bipolar disorder.

60% of individuals with schizophrenia and 40% with bipolar smoke cigarettes, leading to higher mortality in these groups. Smoking may contribute to the development and worsening of depressive symptoms in schizophrenia.

21st-Century Interventions

People with serious mental illnesses have relapse signatures that are unique to patients and stable over time but different from person to person. Theoretically, identifying and monitoring patient relapse signatures could reduce relapse.

Psychosis-specific language use may be detectable in the social media patterns of people with psychotic delusions. Analyzing user data from Facebook, Twitter, Tumblr media language could be a way of predicting oncoming psychosis.

Smartphone apps have been found to monitor positive symptoms of schizophrenia more effectively than negative symptoms.

ClinTouch is an experience-driven app designed in 2010 for people with psychosis.

Smartphone apps for psychosis management did not suffer from phone loss, phone breakage or significant refusal of patients to participate – surprising skeptics.

3% to 5% of psychotic patients using a smartphone app for symptom management became paranoid or distressed. “It's not safe for everyone.”

Other Topics 

Mental health literacy is one of the biggest challenges we face in our field - the tremendous lag between the onset of symptoms and people getting onto treatment

Men typically make up the majority of participants in schizophrenia studies. Women are more commonly found in bipolar disorder studies.

Schizophrenia patients report similar levels of happiness compared to healthy controls even though they experience less satisfaction and life success.

There are considerable differences in the incidence of psychosis between western countries and urban/rural areas. Northern, big European cities like London and Amsterdam have much higher incidences of schizophrenia than Southern European countries like Spain and Italy.

The most common theme of delusions – paranoia or persecution - occurs most often with an older age of psychosis onset.

The prevalence of major mental illness is "much higher" in all categories of homicide within families than in the overall population.

Social isolation can be as much as 10 times higher among mental health caregivers than in the general population.

Negative symptoms predict work outcomes and social interactions.

References

Abstracts of all findings reported in conference posters are available by downloading the mobile conference app: SIRS2016. 

The Office of Research and Public Affairs is reporting daily from the Schizophrenia International Research Society Conference. For news and reports from the conference, follow us on Twitter.

Next week: Research Weekly returns to its normal schedule with a new analysis of psychiatric hospital bed shortages.

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(Apr. 7, 2016) E. Fuller Torrey, MD, founder of the Treatment Advocacy Center, began his career as a psychiatrist more than 40 years ago. At the closing session of the 2016 Schizophrenia International Research Society Conference in Florence, Italy, he paused from his continuing work long enough to peer into the crystal ball of mental illness research and share some reflections on the future.

Joined by three other research pioneers in a session called, “Second chance: What would senior schizophrenia researchers do if they could start over again?” Torrey shared views of both the field and where he would focus if he were starting now.

The Outlook for Research

• Psychiatry and neurology will merge into one field.
  “It’s not that the neurologists want it, it's just logical. There's only one national health institute studying the heart; it makes sense for there to be one institute studying the brain. Schizophrenia and bipolar will be considered as brain diseases in the same way multiple sclerosis and Parkinson’s are.”
• Schizophrenia will be recognized as a “network disease.”
  “It’s not a disease of just one part of the brain but of the connections among the parts of the brain, including the ones that have evolved most recently.”
• Genes will play a relatively small role in the etiology of schizophrenia. 
  “Schizophrenia is not a genetic disease; it’s a disease with probably several hundred predisposing genes. For the last 50 years, we have been looking for bad mothers and bad genes. There are predisposing mothers and predisposing genes, but neither bad mothers nor bad genes cause schizophrenia. We constantly mistake familial associations for genetic causes.”
• We will learn that the majority of cases of schizophrenia are infectious in origin, with the transmission taking place in childhood.

If He Were Starting Over

If he were starting out today, Torrey said, he would conduct longitudinal studies beginning in childhood, continue collecting brains for research and study the role of infectious agents in serious mental illness.

He described four project areas begging for answers to “Why?”

• Schizophrenia and rheumatoid arthritis
  The two diseases occur in about 1% of the population but have a known negative association: the 1% that develops one disease typically doesn’t develop the other. Both conditions became prominent in the early 1800s, are associated with the same chromosome and occur most commonly in individuals raised in urban households they share with domestic cats. A drug commonly used to treat rheumatoid arthritis significantly improves symptoms of schizophrenia. 
• Schizophrenia in immigrant populations
  The schizophrenia rate is higher among first- and second-generation immigrants than in the native populations where they relocate.
• Schizophrenia clusters among childhood playmates
  A high prevalence of schizophrenia among children who grow up together suggests that something infectious is at work.
• Variable prevalence in different locations
  Considerable differences in the incidence of psychosis exist between western countries and between urban and rural areas. Big northern European cities like London and Amsterdam have a much higher incidence of schizophrenia than is found in Southern European countries like Italy and Spain.

Game Changers

Close to 200 years of research experience was reflected in the panel, which also included Sir Robin Murray, MD, of the Institute of Psychiatry at King’s College in London; Eve Johnstone, MD, of the University of Edinburgh; and William Carpenter, MD, of the University of Maryland. All four started in the world of the "schizophrenogenic" mother, said Mark Weiser, MD, of the University of Tel Aviv, who summed up the panel.

“These are the people who made the breakthrough to seeing schizophrenia as a brain disease,” he said.

“All of us are disappointed we are not further ahead,” Torrey said in conclusion. “At the same time, schizophrenia is the most fascinating, intriguing disease” with much ground left to be broken by the scientists who follow.

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(Apr. 6, 2016) Hallucinations, delusions and paranoia can be terrifying but are typically manageable with medication. The so-called "negative symptoms" of schizophrenia spectrum disorders - the ones that dampen motivation and social engagement - are also disabling but have proven much more difficult to reduce. More than half of schizophrenia patients are reported to experience negative symptoms - even in a first episode - and the symptoms tend to persist over long periods of time. They are not treated by medications.

Why Negative Symptoms Are Important

Negative symptoms are important because of their impact on quality of life.

"Negative symptoms tend to remain present after positive symptoms resolve and impose a significant burden upon patients, families and caregivers," Joseph Ventura, PhD, of UCLA told an audience at the 5th Schizophrenia International Research Society (SIRS) Conference, meeting April 2 to 6, 2016, in Florence, Italy. "Positive symptoms are very distressing to family members, but they're even more distressed when a son or daughter doesn't want to participate with their family, doesn't want to go to school or work, and is withdrawing from social life."

Negative symptoms predict work outcomes and social interactions, said Christopher Bowie, PhD, of Queen's University in Canada. And they are a major reason why the percentage of people with schizophrenia who live independently in the community has remained essentially unchanged for more than 100 years, even while positive symptoms became more controllable, according to Natalia Ojeda, PhD, of the University of Deusto in Spain.

A Role for Cognitive Remediation

Cognitive remediation (CR) has already proven to be effective in reducing cognitive symptoms, such as poor working memory and concentration. Used in both individual and group settings, it is a behavioral therapy that relies largely on activities such as practicing repeated and personalized tasks, receiving tailored feedback from a therapist and learning methods to compensate for deficits.

In their independent research - and from a meta-analysis of 45 published studies conducted by Matteo Cella, PhD, of King's College in London - all four presenters at "Negative symptoms: Why they are so important and yet so difficult to treat” reported statistically significant reductions in the impacts of negative symptoms.

Ojeda described the University of Duesto’s REHACOP program, under study in long-term inpatients with schizophrenia and psychotic disorders in Spain. The program uses more than 300 exercises and oriented tasks to develop social cognition, social skills and daily living skills and to provide psychoeducation. Ojeda said the design and repetition are intended to make the skills more “automatic” so they can be maintained after the intensive treatment period.

Ventura said UCLA has randomized psychiatrically stabilized patients in its AfterCare Research Program to compare the effects of receiving CR with another UCLA treatment strategy called Healthy Living. The CR program includes two hours a week of computerized training plus one hour weekly in a group setting for the first six months, followed by one hour a week of computerized training and an hour of group training for the second six months. Healthy Living focuses on the physical health complications of schizophrenia and second-generation antipsychotics with training in nutrition, exercise, relaxation and stress reduction. Participants in both programs receive employment support.

At six months into the program, patients in CR were found to be experiencing small gains in social functioning and statistically significant reductions in negative symptoms related to their experience of life (the ability to work, go to school and engage socially) compared with the Healthy Living group, which showed little change. By 12 months, gains were also apparent in their expressive symptoms (verbal and nonverbal communication), and moderate gains were seen in social functioning. 

Bowie of Queen’s University reported on an analysis of a previous study of 68 patients who received CR for cognitive symptoms that found participants experienced mild reductions in the severity of negative symptoms. 

Cella said the King’s College meta-analysis identified 45 studies involving more than 2,500 patients from 14 countries, including the US, reporting findings that cognitive remediation reduced overall symptoms of schizophrenia, including negative symptoms. 

Caveats

The presenters noted several caveats to the general success story.

The programs and studies they described remain under study. It is not known what aspect of CR produces the improvements (e.g., intensive contact with a therapist, the cognitive boost of being treated, increased self-esteem?). Because response to schizophrenia treatment tends to be highly individualized, CR could turn out to be good for some patients and bad for others. It requires intensive services that are not widely available. It does not restore the functions that schizophrenia damages; ongoing maintenance treatment likely will be needed, creating another service need.

Nonetheless, said Til Wykes, PhD, of the Institute of Psychiatry in London, findings like the ones reported credibly fuel promise that “maybe now we do not have to be so pessimistic about positive symptoms.” 

The Office of Research and Public Affairs is reporting daily from the Schizophrenia International Research Society Conference. For news and reports from the conference, follow us on Twitter.

Next: 'Dr. Torrey on the Schizophrenia Research Crystal Ball'

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(Apr. 5, 2016) The research is “a done deal”: People with schizophrenia and bipolar disorder die younger than the rest of the population. What’s not “done” is finding the answer to “why” and then implementing practices that would change the answer.

“There are more editorials than basic research in this area,” John McGrath, MD, of the University of Queensland, Australia, told an audience at the 5th Schizophrenia International Research Society Conference meeting in Florence, Italy, from April 2 to 6, 2016. “We really have to do better.”

In a session entitled “Schizophrenia and mortality: Different aspects, different solutions,” researchers from Denmark, Netherlands, Australia, and the United States described three modifiable conditions that influence early mortality.

Substance Abuse

“Substance misuse is a risk factor for mortality, and people with schizophrenia have an increased risk for mortality, so are the two related?” was the question examined by Danish researchers using the national patient registry maintained since the 1960s in Denmark.

The answer: yes, and strongly.

One-third of all death in schizophrenia occurred in people with a co-occurring substance abuse disorder, according to Carsten Hjorthøj, MD, of Copenhagen University Hospital. The survey examined deaths for individuals born in 1955 or later.

Compared with the general population:

• Men with schizophrenia (SZ) and co-occurring substance abuse were 8 times more likely to die than men in the general population – twice the death rate for men with SZ alone. The risk factor for men with bipolar disorder (BP) and substance abuse was 6 times, again twice the risk for men with BP alone.
• Women with SZ and co-occurring substance abuse were 9 times more likely to die than women without co-occurring substance abuse – about twice the death rate of women with SZ alone. Women with BP and co-occurring substance abuse were 7 times more likely to die, again twice the risk for women with BP alone.

“Every substance identified – alcohol, cannabis and hard drugs – was associated with significantly higher mortality in SZ and BP,” Hjorthøj said. The highest association was with the combined use of alcohol and hard drugs. Tobacco use was not analyzed because it is not recorded by the registry.

Tobacco 

Tobacco use was among the variables researchers at Sheppard Pratt Health System of Baltimore examined in studying the natural death causes for 1,136 patients with SZ or BP treated at the hospital from 1999 through 2012. In the study, tobacco use emerged as the strongest modifiable risk factor for early death from schizophrenia and a factor in early death in bipolar disorder. 

During the study period, 6.1% of the population with schizophrenia died (average age: 54.4). After adjusting for all other variables except age, smoking increased death risk 6 times more than other factors. Smoking also was implicated in early mortality in bipolar disorder, but those results are still under study. 

Faith Dickerson, PhD, of Sheppard Pratt, called the reduction in smoking since the US Surgeon General’s 1964 report linking cigarette use to specific diseases “a tremendous public health story that has not included patients with schizophrenia and bipolar.” Today, there are more ex-smokers than current smokers in the US, and less than 25% of the general population smokes, Dickerson said. But 60% of those with schizophrenia and 40% with bipolar disorder use tobacco. 

Homelessness 

Homeless people with a schizophrenia spectrum diagnosis have “very high mortality rates,” according to a Dutch study using Denmark’s comprehensive registries for homelessness, patients and cause of death. The impact was greater on women than on men.

Marieke Pijnenborg, PhD, from the University of Groningen, reported that for the population born 1982 to 1993, schizophrenia reduced life expectancy 22 years in homeless men and 17 years in homeless women compared to the Danish general population. 

Schizophrenic women who were homeless were 11 times more likely than other schizophrenic women to die from suicide, homicide or accident during the study period. That’s nearly three times the increased risk of death in homeless schizophrenic men, who were 4 times more likely to die from those conditions than housed men with SZ. 

Risk of death from diseases and other medical conditions also was higher among homeless individuals with psychotic conditions but not as significantly. 

All homelessness is associated with early mortality, Pijnenborg said, but psychiatric diagnosis was found to be associated with half the deaths in the homeless population.

Data as a Weapon for Change

In summary of all the presentations, McGrath said the data on early death and mental illness should be “leveraged against governments” to advocate for building research capacity to learn more and to advocate for more intervention. 

“This is an urgent issue,” McGrath said. “We have to use our data as a weapon against politicians. There are good data coming through. We have an obligation to translate it into better outcomes.” 

The Office of Research and Public Affairs is reporting daily from theSchizophrenia International Research Society Conference. For news and reports from the conference, follow us on Twitter.

Next: Negative symptoms: Why they are so important and yet so difficult to treat

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(Apr. 4, 2016) One of the standing criticisms about the treatment of schizophrenia and other psychotic disorders is the heavy reliance on medications, which do not address the full range of symptoms and have side effects, many of them significant.

This is not for lack of interest in the alternatives, based on projects and studies described during “Improving identification and treatment of early phase psychosis” on the opening day of the 5th Schizophrenia International Research Society Conference, underway from April 3-6, 2016, in Florence, Italy.

“Improving identification and treatment” focused on 21st-century tools and strategies that illustrate both the opportunities and obstacles to improving outcomes.

Social Media

The Internet and social media are “powerful potential tools” to enhance mental health literacy, facilitate early identification of symptoms and engage adolescents and young adults as they begin to experience psychotic symptoms, according to John Kane, MD, of Hofstra University.

Few online resources encourage potentially psychotic youth to seek professional evaluation, he said. Instead, most lead to unmonitored chat forums that lack a unified message, promote stigma and/or normalize potentially psychotic experiences. Kane described a current campaign of Facebook, Twitter and Instagram ads that have reached 10,000 college students with a screening for psychotic disorders and an opportunity to consult at no cost with a professional for those who scored positively.

“Mental health literacy is one of the biggest challenges we face in our field,” he said. “The average person knows very, very little about mental illness, particularly psychotic disorders.” Because young people experiencing early signs of psychosis typically reach out first to family or friends, he said, “clearly, we have to reach out to families and friends about how to respond.”

Social media offers a means to do so, but its translation into action remains in doubt. Of the 10,000 students reached by the campaign, he said, fewer than 1,000 have taken the screening quiz, and only one respondent has sought a consultation.

Social Marketing

Connecticut has operated a comprehensive early intervention program for psychosis for nearly a decade. Now STEP, as the program is called, is conducting a five-year study to determine whether the period between the onset of psychosis and initial treatment (the “duration of untreated psychosis” or DUP) can be reduced in a 10-town regional around New Haven by changing the route that patients follow to find their way into treatment.

Vinod Srihari, MD, of Yale University, described the project as a multi-media social marketing campaign to educate the public about mental illness and to “make a pitch” for individuals with emerging symptoms to seek help sooner through “pathways to care” advertised by the campaign.

Srihari said reaching the target audiences required using words and phrases that are “not the ones we would have chosen as clinicians.” Googling “schizophrenia” may produce accurate and detailed information about psychosis, he said, but people experiencing early signs of psychosis are more likely to search “Am I going crazy?” Or “Am I losing my mind?” Reflecting that reality, the posters designed by the project for its website and on public buses pose questions like, “Feeling paranoid?” “Seeing or hearing things?”

The effort – based in New Haven and localized to surrounding towns – can be viewed on Mindmapct.org. The project launched in February 2015 and is funded for five years.

Mobile Behavioral Modeling

Social media and social marketing are active tools that require participants to engage with them, said Dror Ben-Zeev, MD, of Dartmouth University. Dartmouth is actively at work on the potential role of mobile applications for studying, assessing, treating or preventing psychotic illness. These include person-to-person mobile applications, automated applications that are visible (e.g., appointment reminders) and automated applications that are invisible (e.g., tracking sleep).

Ben-Zeev described the capabilities of CrossCheck, a mobile application he called “a new paradigm for illness monitoring and relapse prevention in schizophrenia.” The app uses a combination of observational and self-report data to determine the participant’s “relapse signature” – the changes in patterns of movement, speech or sleep unique to a patient that may indicate the onset of psychotic symptoms. The goal is to increase the amount of time between relapses and decrease the number of relapses.

Ben-Zeev described a study in which small groups of inpatients and outpatients given smartphones responded positively to the app. He also acknowledged that privacy concerns remain to be resolved before widespread use of applications that run in the background to monitor behavior is likely.

Dartmouth describes and reports on its work on mh4mh.org.

First-Episode Intervention

Coordinated, specialized response to a first episode of psychosis has been practiced in Europe for decades and is currently being implemented across the US as “RAISE,” “NAVIGATE, “STEP” (in Connecticut) and under a variety of other names.

Christopher Correll, MD, of Hofstra University, described a review of nine randomized, controlled trials of early intervention for psychosis: five from Europe, two from the US and two from Mexico. Correll said the goal of the review was to answer “Why use coordinated, specialized care?” Compared with “care as usual,” is coordinated care more effective? Combined, the studies reported on 2,000 patients with an average age of 27 years, most of them male.

Correll said all the studies reported statistically significant “small to medium” reductions in relapse, re-hospitalization and hospital days with greater remission of symptoms and improved likelihood of being employed or in school at the end of the early-intervention treatment. But the good news came with a large caveat.

“Once you stop the intervention, the effects dwindle,” he told the audience. “The advantages seem to disappear after coordinated specialized response stopped.”

In a closing overview of the session, Robert Zipursky, MD, of McMaster University, noted that only 1% to 5% of overall functional and symptomatic outcomes likely result directly from duration of untreated psychosis. “So we have to be skeptical about whether investing in (first-episode psychosis intervention) will significantly change outcomes.”

 
The Office of Research and Public Affairs is reporting daily from the Schizophrenia International Research Society Conference. For news and reports from the conference, follow us on Twitter.

Next: Schizophrenia and Mortality

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(Apr. 4, 2016) No parents should have to go through what we recently did. Our daughter has serious mental illness and was living in a group home. But when the home failed to monitor her medications she stopped taking them and started to deteriorate. When she became psychotic, she ran away and the home refused to tell my husband or me. After contacting the group home on three different occasions and each time being told she was “not home,” we started to get suspicious. Only after she was missing two critically important days was the truth finally revealed to us by a county official. Where was my daughter? Was she OK? Being an advocate for the seriously mentally ill, I know that when persons with serious mental illness stop taking their medications and go missing, things don’t always turn out well.

Like any parent, we called local hospitals to see if she was admitted. But they wouldn’t tell us, for the same reason the group home wouldn’t tell us she was missing. HIPAA, a patient-privacy law, prevented them from giving us that information. But my daughter was off medications and deteriorating. She was potentially dangerous. Even the police were prevented from immediately looking for her. Their hands were tied, because in spite of her mental illness, she had a ‘right’ to be missing. It was only after they were reasonably certain that she had been off her medication long enough to become dangerous, could they begin their search. Their first step? To ask me for dental records and DNA and tell me they would search landfills for her body. No mother should have to face that.

After being missing for 28 days, my daughter was eventually found in Brooklyn, terribly deteriorated in every way. She is now recuperating in a hospital costing taxpayers far more than keeping her in community treatment does.

None of this should have happened. My daughter is in Kendra’s Law, a program that allows judges to order someone who has serious mental illness and a history of dangerousness associated with refusing treatment to stay in mandated and monitored treatment while they live in the community. So what went wrong? Kendra’s Law is underfunded and HIPAA prevents the law from working its best.

There is a bill pending in the house that would fix this insanity. The Helping Families in Mental Health Crisis Act (HR2646) proposed by Representatives Tim Murphy (R-PA) and Eddie Bernice Johnson (D-TX) creates a tiny exemption in HIPAA. It would allow doctors to disclose to family members of the seriously ill a basic subset of the information they already freely disclose to paid insurance companies if the information is needed to protect health safety and welfare. The bill also includes funding for Kendra’s Law and for desperately needed hospital beds for the seriously ill in who cannot be safely treated in the community.

[HR 2646] has 186 cosponsors from both parties but Congressman Eliot Engel of the Bronx, and lower Westchester, who sits on a key committee is not yet one of them. We need Congressman Engels’ support to help move this bill and help those like my daughter who have an incapacitating brain disease.

Please call Eliot Engel at (202) 225-2464 and urge him to cosponsor HR 2646. I don’t want your family to ever have to go through what mine did.

BARBARA BIASOTTI
NEW WINDSOR, NEW YORK

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(Mar. 31, 2016) Two men suffering from untreated severe mental illness have been killed by Vermont police in the past two-and-a-half years, sparking questions about the way law enforcement interacts with individuals in psychiatric crisis (“Police shooting reignites mental-health debate,” Burlington Free Press, Mar. 27).

Burlington police this Monday responded to a call from a property manager claiming a tenant was threatening harm to himself and others. When officers arrived at the apartment building, they found Ralph “Phil” Grenon – a 76-year-old diagnosed with paranoid schizophrenia – wielding two large kitchen knives. Grenon refused to talk to police and barricaded himself inside his apartment.

After a five-hour standoff, police finally entered the apartment and Grenon, still armed, advanced toward them and was fatally shot, according to the police report.

Grenon’s daughter, Niki Grenon Carpenter, said she had been trying to have her father committed to a psychiatric hospital, but to no avail.

"I wanted him hospitalized weeks ago and was told their hands were tied," Carpenter said. "It isn't until a situation such as my father's escalates to the point that it did can action be taken, and in his case it was too late. Preventive care is key — proper dosing, proper supervision, all the things that were lacking.”

Grenon’s death bears resemblance to the fatal Burlington police shooting of Wayne Brunette, 49, in late 2013. Both men had long histories of mental illness and had displayed instances of threatening behavior or violence before their deaths.

In the wake of Brunette’s shooting, former Police Chief Michael Schirling criticized the lack of mental health resources available for those suffering with mental illness, noting a 400 percent increase in mental-health related calls over the previous five years. He described a “cascading effect,” in which the lack of programs and hospital beds for those suffering from serious mental illness has stressed community services.

Still, if the Department of Mental Health’s January report to the Vermont Legislature is any indication, there remains an ongoing (and unmet) demand for an increase in hospital beds available for individuals with acute mental health needs.

Vermont offers just 8.3 public psychiatric beds per 100,000 people – far below the 50 bed minimum standard required to provide adequate treatment for individuals with severe mental illness.

The state must address this shortage and provide a bed instead of officer-involved shootings, incarceration, homelessness, and all of the other consequences of non-treatment. Otherwise, tragedies like these will continue to happen.

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