(Aug. 16, 2016) Common respiratory, urinary tract and other infections may play a role in triggering acute mania in bipolar disorder, according to a newly released study.
 Based on a sample of 602 individuals hospitalized for symptoms of bipolar disorder and selected other psychiatric conditions, Robert Yolken, MD,* and colleagues found that the patients with acute mania were substantially more likely to be taking antibiotics for infection than patients with schizophrenia or depression and
than non-psychiatric patients.
The authors conclude that patients with a history of mania should be monitored closely for bacterial infections by their healthcare providers and promptly treated with antimicrobial medications when infections develop.
"The control of bacterial infections in individuals with susceptibility to mania and other acute psychiatric conditions might result in the prevention of acute episodes and a marked improvement in their health and well-being," the researchers said.
Infection and Mania, Depression, Schizophrenia
Over the past two years, a growing body of research has examined the possible role of infection and inflammation in causing schizophrenia, bipolar disorder and depression. Previous studies have found the immune system to be activated during acute mania, but the cause of immune activation was not identified.
In "Antimicrobial medications and mania," researchers used the records of antibiotic prescriptions for 1,157 patients hospitalized at Sheppard Pratt Health System in Baltimore to explore the possible role of bacterial infection in activating the immune system in patients with acute mania, bipolar depression, unipolar depression and schizophrenia.
In the study population, 7.7% of the patients with acute mania were found to be prescribed antibiotics. This compared with 1.3% of the non-psychiatric control group. Patients hospitalized with the other three psychiatric conditions also were more likely than the controls to be given antibiotics such as tetracycline or penicillin for infections but at much lower rates than those with acute mania.
The research team identified three possible theories for the association between infection and acute mania:
- Underlying bacterial infection that activates the immune system, which then triggers the onset of mania
- Decreased immunity to infection in bipolar disorder
- Acute mania as a response to the antibiotics themselves
The third theory was considered less likely because many individuals in the study developed mania and were hospitalized before they were diagnosed with infections and given antibiotics.
The study was funded in part by the Stanley Medical Research Institute, a supporting organization of the Treatment Advocacy Center, whose mission includes promoting the development of innovative treatments for and research into the causes of severe and persistent psychiatric diseases.
* Dr. Yolken is a member of the Treatment Advocacy Center board of directors.
Doris A. Fuller
Chief of Research and Public Affairs
References:
Next Week: The Perilous Psychiatrist Shortage
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(Aug. 9, 2016) New research estimates the direct and indirect cost of schizophrenia to US society in 2013 was $155 billion - $44,773 per individual with the disease. By comparison, major depression affects 6 times as many people but was estimated in 2015 to cost $210.5 billion, only 35% more.
 The majority of the economic impact was from the lost work productivity of individuals with the disease and their caregivers: $117 billion. Unemployment was the single biggest contributor to cost impact at $59 billion (37.9% of total).
The second most significant cost impact resulted from the lost productivity of those who took care of individuals with schizophrenia. Martin Cloutier and colleagues reported that time devoted to caregiving by family members increased from 484 hours per year in 2002 to 1,040 in 2013. Total caregiver cost: $52.5 billion or 34% of the total economic impact of schizophrenia.
Closing psychiatric hospital beds - a practice known as "deinstitutionalization"- may have contributed to the cost impact on caregivers, the authors said. "A push for increased family intervention for schizophrenia patients can be beneficial and is recommended by many international clinical guidelines, but this intervention comes at a high emotional and economic price to caregivers."
The non-health care costs of law enforcement and incarceration were also "significant contributors" to overall cost, according to the study.
Crucial Data for Important Conversations
"The economic burden of schizophrenia in the United States in 2013," published in the Journal of Clinical Psychiatry, updates or supplies information crucial to the national discussion of mental illness treatment policy, where direct costs and/or cost offsets - cost increases in one category that are offset by cost reductions in another - heavily influence public policy and practice. Among these:
- Criminal justice - $14.3 billion/9.2% of total
The cost of schizophrenia to law enforcement was estimated at $7 billion in 2013, nearly 5% of the total cost impact of the disease. Incarceration costs were estimated at $3.6 billion, or 2.3% of total cost impact. Judicial, legal and police protection costs totaled $3.5 billion, for an additional 2.3%.
- Suicide - $3.3 billion/2.1% of total
Only the cost impact of early death by suicide was reported. Similar costs associated with early mortality from co-occurring medical conditions (e.g., heart disease) were not assessed, which means the cost impact of early death is underestimated.
- Emergency room care - $2.6 billion/1.7% of total
The authors said direct health care costs reflected an emphasis on acute care of patients with schizophrenia, including the use of ERs for individuals in crisis.
- Shelters for the homeless - $1.9 billion/1.2% of total
The cost of schizophrenia had not been reported since 2002, when the economic burden was estimated at $62.7 billion. Calculations in 2013 were made based on the schizophrenia prevalence rate of 1.1% used by the National Mental Health Institute and assumed in all Treatment Advocacy Center studies and analysis. A prevalence rate of 0.5% was assumed by researchers in 2002.
Adjusted for the current prevalence assumptions, population growth, inflation and changed federal policies, the 2013 costs are "consistent" with the earlier ones, the researchers said. The study reflected only the cost differences between an individual with schizophrenia and one without.
The cost of severe bipolar disorder, which affects more than twice as many people as schizophrenia, was not within the study's scope.
Doris A. Fuller
Chief of Research and Public Affairs
References:
Next Week: Antibiotics and Mania in Bipolar Disorder
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(Aug. 2, 2016) Poor mental health can worsen financial health, and people with bipolar disorder are among those at the highest risk for negative impacts.
"It has long been accepted that financial problems can worsen mental health, but our evidence shows that mental health problems can also have a detrimental effect on personal finances," the Money and Mental Health Policy Institute said in releasing Money on Your Mind.
"Financial issues and mental health problems become a vicious cycle; each feeds off the other, creating a trap that can be exceptionally hard to break out of out."
"Money on Your Mind"
The study of money and mental health reports on a survey of nearly 5,500 respondents in Britain diagnosed with a range of mental health conditions, including bipolar disorder, schizophrenia, depression and 12 other diagnoses.
 The occurrence of financial decisions that worsened financial health (e.g., overspending, putting off bills, taking out ill-advised loans) was high across all the diagnoses, according to the study, but consistently highest in those with bipolar, alcohol or drug dependence, borderline personality disorder or ADHD/ADD.
More people with bipolar disorder than any other condition reported that their mental illness made their financial situation worse - 88%, compared with 85% for personality disorder and 84% for schizophrenia or other psychotic condition. Experiencing a manic episode was identified as one of seven major drivers that resulted in higher spending.
Individuals with bipolar disorder also were more likely than individuals with other disorders to report that their financial situation worsened their mental health - 91%, compared with 85% of those with schizophrenia or psychosis.
The most commonly identified financial impact of poor mental health was to the ability to make "sensible, rational or balanced decisions" about money. "Most of these respondents detailed financially damaging actions they took while unwell, which they described with words such as 'reckless,' 'incomprehensible, 'stupid' or 'idiotic,'" the report said.
Financial Impacts
Impacts of bad financial decisions included going without "essentials" such as food or heating and being dependent on others to survive. The respondents reported that these impacts had impacts of their own, including feelings of worthlessness or feeling guilty about their children going without as a result, the study said.
Earlier this year, a report from the National Alliance for Caregiving detailed the financial impact mental health conditions have on caregivers in On Pins & Needles: Caregivers of Adults with Mental Illness. Nearly 65% of the 1,601 respondents caring for adults with mental illness reported that their care recipients depended completely or significantly on them for financial support. This compared with 49% of all caregivers.
One in four caregivers of adults with mental illness reported feeling "high financial strain" as a result of caregiving, compared with 16% of adults without mental health issues.
Doris A. Fuller
Chief of Research and Public Affairs
References:
Next Week: Mental Illness and Prisoners: Prevalence, Outcomes and Interventions
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(July 26, 2016) Bipolar disorder is a serious mental illness associated with risk for relapse, hospitalization, unemployment and suicide, among other poor outcomes. Mood-stabilizing medication is the standard of care for the condition, but the possible role of supplementary psychotherapy is of interest to many patients and clinicians.
 Matthijs Oud and a team of international researchers conducted the first comprehensive systematic review and analysis of psychological therapies that have been tested for their effectiveness in treating bipolar disorder. They found the evidence for psychotherapies to be "much stronger" than was available "only a few years ago" but also found that the preponderance of studies on the subject were of low or mediocre quality.
Despite the quality issue, "Overall, on the basis of this review, we would recommend the use of psychological interventions in the treatment of people with bipolar disorder to reduce relapse rates and to reduce depressive symptoms," the authors concluded. "Although there is insufficient evidence to recommend one specific treatment over the others, the best evidence is for individual structured psychological interventions, and there is weaker - but still promising - evidence for group and family interventions and for collaborative care."
"Almost all" the psychological interventions were supplementary to medication therapy. The studies reviewed involved more than 6,000 participants, primarily in North America and Europe.t three days of July shed additional light on the condition and impacts of inmates with serious psychiatric disease.
Psychotherapies Reviewed
The psychotherapies reviewed included
- Individual therapy, either face-to-face or online, including cognitive behavioral therapy and medication adherence therapy;
- Group therapy;
- Family psychoeducation;
- Collaborative care;
- Integrated therapy (combining cognitive and interpersonal therapies);
- Family-focused therapy; and
- Interpersonal and Social Rhythm Therapy (known as IPSRT).
The authors found:
- Moderate-quality evidence that individual psychological therapy reduced the risk of relapse by one-third;
- Moderate-quality evidence that collaborative care reduced hospital admissions by one-third;
- Low-quality evidence showing a substantial reduction in relapse rates for people who received family psychoeducation;
- Evidence that group therapy reduced risk of relapse and possibly improved some symptoms; and
- "No evidence" of benefit for other types of psychological interventions such as IPSRT.
The authors said their findings are consistent with previous reports that psychotherapy may reduce the transition to psychosis, that family interventions reduce relapse in both early and established cases of schizophrenia, and that psychotherapy is the most effective treatment for major depression.
Encouraging to Families
In their discussion of "implications for practice," the authors made special note of the value of family-based therapies for treating bipolar and schizophrenia.
"It is also worth considering family psychological interventions, not just because the trials show some promise, but also because the benefits of family interventions for psychosis (including schizophrenia and bipolar disorder) suggest that relapse rates can be reduced in both early and later psychosis," they said. "It seems likely, on the basis of this broader evidence as well as the evidence in this review, that family interventions could be beneficial for people with bipolar disorder and should be made available routinely to help reduce relapse rates....
"It is important to keep in mind that people with bipolar disorder are often only partially adherent to pharmacotherapy, which may contribute to the recurrence of symptoms and to relapse. Group or family psychoeducational interventions and collaborative care could help these people develop skills related to medication use, stress management, recognizing early symptoms and coping with symptoms. Such skills could reduce risk of relapse and improve response."
The research team suggested further study to establish the long-term effectiveness of psychological intervention and the comparative strengths among different psychotherapies. Studying treatment results separately for people in different phases of the disease (e.g., manic, depressive, non-symptomatic) would also be useful, according to the authors.
Doris A. Fuller
Chief of Research and Public Affairs
References:
Next Week: Money and Mental Health
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(July 19, 2016) Innumerable studies worldwide have found that being mentally ill increases the risk of arrest and incarceration and for death, victimization, violence and other suffering once behind bars. Now, four unrelated reports published within just three days of July shed additional light on the condition and impacts of inmates with serious psychiatric disease.
 Each report illuminates a different aspect of mental illness behind bars. Each also illustrates the need for more systematic study of the issue. Following are summaries of what these disparate sources tell us and comments on additional research that is needed.
Individuals with serious mental illnesses in county jails: A survey of jail staff's perspectives
Treatment Advocacy Center and Public Citizen's Health Research Group (July 14, 2016)
This survey of personnel at 230 county jails in 39 states found serious mental illness to be almost universal in the surveyed facilities.
Among the findings:
- More than 95% reported having some inmates with serious mental illness during the year-long survey period.
- Three-quarters reported seeing "more or far more" seriously mentally ill inmates during the 2010-2011 survey period than 5 to 10 years earlier.
- Most jails reported "major problems" with its mentally ill inmate population, including the need to monitor mentally ill inmates more closely for suicide, victimization and violence. Only 1.7% of the responding jails reported encountering no special problems associated with serious psychiatric disease among their inmates.
- Inmates with mental illness were more likely to be segregated than treated. Nearly 70% of the jails reported isolating inmates with serious mental illness; 45.2% reported offering "some sort of mental health treatment"; only 41.7% reported offering pharmacy services.
- Fewer than 25% of the jails offered a support system for mentally ill inmates after release.
Comment: An estimated 1.8 million US jail bookings annually involve people with serious mental illness. Illuminating as they may be, surveys are no substitute for official collection of comprehensive data about the diagnoses, treatment and impacts of these inmates.
Mental health of prisoners: Prevalence, adverse outcomes, and interventions
The Lancet Psychiatry (July 14, 2016)
This systematic review of international studies on prisoner mental health between 2003 and 2015 found inmates with serious mental illness consistently overrepresented within correctional settings and on multiple measures of inmate vulnerability.
Among the findings:
- 1 in 7 prisoners had major depression or psychosis, and many had comorbid substance abuse conditions. Women were more likely than men to have comorbid disorders.
- Women prisoners with serious mental illness were 6 times more likely to die of suicide than women in the general community. Male prisoners were 3-6 times more at risk than unincarcerated men.
- Self-harm short of suicide was reported in 20-24% of female prisoners and 5-6% of male prisoners.
- Mentally ill prisoners were disproportionately involved in prison rule-breaking and violence, more likely to be charged with violating rules than other prisoners and twice as likely to be injured in a prison fight.
Comment: Without systematic data collection on mentally ill inmates, the United States relies on more limited local or regional studies, media and anecdotal reports (see below) As a result, comparable, comprehensive information is not available to the US public and policymakers.
Sandra Bland died one year ago: And since then, at least 810 people have lost their lives in jail
The Huffington Post, July 13, 2016
The jail suicide rate in 1986 was 107 per 100,000 inmates. By 2006, it had dropped more than 60%, a reduction attributed to improvements in medical and psychiatric screening of new inmates. Even so, the suicide rate in jail was more than three times that of the general population, Dana Liebelson and Ryan J. Reilly report in this analysis of jail deaths. Sandra Bland, a 28-year-old Texas woman jailed following a traffic stop, was among those who killed themselves in jail in 2015.
"Deaths inside American jails frequently go unnoticed, sometimes even unrecorded," the authors write. "Unlike prisons, jails hold people for only short periods-about 21 days on average-and many of their inmates have not been convicted of a crime. Additionally, jails typically aren't required to release public information about people who die within their walls. The federal government publishes only generalized data years after deaths occur, making it nearly impossible to identify the most dangerous facilities. So we attempted to fill the gap."
Among the findings:
- 811 jail fatalities occurred in the year following Bland's July 13, 2015, death - an average of more than two per day and more than four times the number of unarmed people killed by police during the same period.
- Suicide accounted for 31% of the deaths, and 26% of the suicides occurred in the first three days of incarceration, even when the arrest resulted from minor charges unlikely to result in prison time. Suicide has been the leading cause of jail death every year since 2000.
- African-Americans were overrepresented in jail deaths, a reflection of their overrepresentation in jails and prisons overall.
Comment: The Department of Justice collects and reports detailed information on mortality in local jails and state prisons. Despite the growing suicide rate behind bars, the prevalence and role of mental illness in these and other deaths in correctional facilities is not included in its annual report.
Driving mentally ill to treatment elsewhere costly
Victoria Advocate (July 16, 2016)
After a Texas county closed its last psychiatric bed, area law enforcement was conscripted to provide transportation of people in psychiatric crisis to other counties, this analysis by the local newspaper found.
"Since the Crossroads' last inpatient mental health treatment center closed in 2010, area law enforcement have driven mentally ill people almost 228,000 miles for treatment elsewhere, enough to circle the earth nine times," Jessica Priest reports.
"And they've spent about $321,150 for their efforts, records show."
In Calhoun County, which has 16 deputy sheriffs, "One deputy does most of the transports, sometimes travelling up to 16 hours round trip," according to the report. In Jackson County, where the department has only six deputies, officers stood by more than 100 hours at the local hospital in the month of June waiting for mentally ill patients they transported to be assessed or admitted to a bed.
Comment: Priest said the distance and cost of transporting mentally ill individuals is understated because several counties don't keep track of how many mental health transports they perform and thus cannot assess the staffing and cost impacts of such transportation.
In Conclusion
The United States incarcerates more mentally ill prisoners than any other democracy. Study and reporting on their plight and their impact on the criminal justice system and communities are admirable and growing. If evidence-based public policy and to remedy the conditions being reported are to be implemented, relevant, systematic collection of data by state and federal agencies must begin
Doris A. Fuller
Chief of Research and Public Affairs
References:
- AbuDagga, Azza et al. (14 July, 2016). Individuals with serious mental illnesses in county jails: A survey of jail staff's perspectives. Public Citizen's Health Research and Treatment Advocacy Center.
- Fazel, Seena et al. (14 July, 2016). "Mental health of prisoners: Prevalence, adverse out comes, and interventions." The Lancet Psychiatry.
- Liebelson, Dana and Reilly, Ryan. (13 July, 2016). "Sandra Bland died one year ago: And since then, at least 810 people have lost their lives in jail." The Huffington Post.
- Priest, Jessica. (16 July, 2016). "Driving mentally ill to treatment elsewhere costly." Victoria Advocate (Texas).
- Torrey, E. Fuller et al. (2014). The treatment of persons with mental illness in prisons and jails. Treatment Advocacy Center.
Next Week: Psychological interventions for adults with bipolar disorder: A literature review
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(July 12, 2016) The toll of being principle caregiver for a mentally ill loved one, already well-documented, has expanded with the Treatment Advocacy Center's release of Raising Cain: The Role of Serious Mental Illness in Family Homicide. The first study to examine the relationship between psychiatric disease and family violence found that a serious mental illness is present in nearly 30% of all family homicides.
Based on a review of the relevant literature from 1960 to 2015, the role of diseases such as schizophrenia and bipolar disorder was estimated to be a factor in 50% of cases when parents kill children and nearly 70% when children kill parents. An emerging pattern of mental illness in homicides against grandparents also was found.
More from E. Fuller Torrey
E. Fuller Torrey, MD, conducted the research as lead author, a role he has repeatedly assumed since founding the Treatment Advocacy Center in 1998. Dr. Torrey's record of exposing important issues that have been overlooked is well-established. When asked about the impact of this body of work, he demurs, explaining that he, "focuses on what interests him." Thankfully, his interests include an unrelenting focus on the plight of individuals and families living with untreated severe mental illness.
Previous Treatment Advocacy Center studies Dr. Torrey conducted include:
- Clozapine for treating schizophrenia: A comparison of the states (2015), documenting how dramatically the use of "gold-standard" medication for psychotic disorders varies among the states
- The treatment of persons with mental illness in prisons and jails: A state survey (2014), reporting that individuals with serious mental illness are 10 times more likely to be in prisons or jails than in state psychiatric hospitals
- No room at the Inn: Trends and consequences of closing public psychiatric hospitals (2012), finding that state hospital bed populations declined 14% nationally from 2005-2010
Other Contributions
For decades, Dr. Torrey's unique vision and iconoclastic research has reshaped our understanding of mental illness and its treatment. In 1983, one of his first books, Surviving Schizophrenia: A Family Manual, radically departed from psychiatry orthodoxy by declaring that disease, not bad mothers, caused schizophrenia. The proposal electrified - or infuriated - psychiatrist colleagues who, for decades, had embraced the Freudian conviction that "schizophrenogenic mothers" were to blame. With this single book, now in its sixth edition, generations of mothers (and fathers) had authoritative proof that their children's suffering was not their fault.
Dr. Torrey continues to challenge the status quo in his research, focusing on the role of infection in schizophrenia. Previously considered heretical by many researchers, Torrey's work is now widely recognized as opening important research avenues for medicine all across the world.
His analysis of our nation's policies around mental illness feature that same willingness to question convention. His book, American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System, and his personal advocacy for changes to the mental health system have been widely credited for catalyzing the reform efforts being seen in the halls of Congress today. The Helping Families in Mental Health Crisis Act, which was passed by the House of Representatives on a vote of 422-2 on July 6, includes a host of reforms championed by Dr. Torrey in hearings and in his book.
Raising Cain adds critical new evidence to the case for mental health policy reform that delivers timely and effective treatment for serious mental illness. What's not new is that it came from Dr. E. Fuller Torrey.
John Snook
Executive Director
Treatment Advocacy Center
References:
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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(July 5, 2016) As the National Alliance on Mental Illness (NAMI) is convening its annual national conference in Denver, a new study validating the effectiveness of the organization's signature family education program has been published in Psychiatric Services, a journal of the American Psychiatric Association.
 The study, "Generalizability of the NAMI Family-to-Family education program: Evidence from an efficacy study," was conducted by researchers from the New York University school of social work at the behest of NAMI-New York City. The researchers recruited 121 individuals who enrolled in a Family-to-Family (FTF) course in the US between September 2013 and July 2014 and agreed to participate in an assessment of the program when they finished.
The Findings
"After completing FTF, individuals had improved family empowerment, family functioning, engagement in self-care activities, self-perception of mental health knowledge and emotional acceptance as a form of coping," according to Micaela Mercado and colleagues. "Scores on the coping subscales and for emotional support and positive reframing also improved significantly. Displeasure in caring for the family member, a measure of subjective burden, significantly declined."
The study sample was small - 38 of the enrollees in the study did not complete follow-up assessments, leaving 83 participants - and did not have a control group for comparison. Nonetheless, the findings were consistent with three previous studies of Family-to-Family effectiveness, adding to the program's evidence base.
"Improvements in empowerment, coping, family functioning, self-care and knowledge, as well as reductions in subjective burden, are consistent with previous FTF studies," the authors wrote. "This study demonstrated gains in additional aspects of coping, including positive reframing and emotional support. Scores on a validated measure of self-care also improved, extending the findings of previous studies."
Family-to-Family is a free, 12-week program developed by Joyce Burland, PhD, in the early 1990s to educate families and friends of people living with mental illness. Taught by trained family-member volunteers, classes meet in person in communities nationwide. The program was intended to fill a gap that existed between the extensive evidence base showing the value of family psychoeducation and limited access to programs providing such training, according to Mercado and her colleagues. It is listed in the National Registry of Evidence-based Programs and Practices published by the Substance Abuse and Mental Health Services Administration.
Despite widely available mental health services in New York City, the authors said "family members of adults living with serious mental illness experience substantial unmet need for education and support. In our experience, FTF has helped to address that unmet need."
Caregiver stress is a significant issue for family members living with serious mental illness. A February 2016 study published by the National Alliance for Caregiving reported that three-quarters of surveyed caretakers experienced "high emotional stress" from performing their responsibilities. About 4 in 10 said they found it difficult to take care of their own health, and 6 in 10 said caregiving had made their own health worse.
The Boston Globe on June 26 published a not-to-be-missed report on family violence associated with serious mental illness in Massachusetts. The Treatment Advocacy Center will release a new national study on the same subject during the NAMI convention.
Doris A. Fuller
Chief of Research and Public Affairs
References:
Next week: Beyond Raising Cain: The role of serious mental illness in family homicides
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(June 28, 2016) The search for a successor to Dr. Tom Insel as director of the National Institute of Mental Health (NIMH) - the nation's central agency for mental illness research - is nearing its conclusion.
With an announcement of the new director expected shortly, the British Journal of Psychiatry has published an editorial from 20 eminent psychiatrists and psychiatric researchers calling for the NIMH to put more emphasis on funding research into prevention and treatments that will bring immediate relief to individuals living with mental illness.
"Rethinking Funding Priorities"
 The transition to new NIMH leadership, the authors write, "presents a critical opportunity to examine US mental health research funding priorities."
"Despite spending more than any other country on healthcare ($4,271 annually/person), the USA ranks 37th in global health outcomes and fails to serve even half of its residents needing mental health services."
The authors laud the search for neurobiological mechanisms of mental illness that someday may result in discovering the causes of diseases such as schizophrenia and lead to new treatments for them. But they maintain that high-income countries, including the US, "must balance longer-term investment in identifying neurobiological mechanisms of disease with shorter-term funding of novel prevention and treatment strategies to alleviate the current burden of mental illness."
Calling mental health research funding a "form of social investment," they call upon the NIMH under its new leadership to "diversify" its investment to avoid over-investing in long-term scientific discovery at the expense of "less risky investments that yield immediate albeit potentially more modest benefits." Among the research they say merits higher priority:
- developing sustainable interventions to overcome disparities in access to effective treatment and outcomes;
- crafting technologies and implementation strategies to disseminate scalable, cost-efficient interventions;
- devising approaches to empower people to overcome barriers to engagement and retention in treatment; and
- deploying preventive interventions to reduce the burden of mental illness, including clarifying how to implement best practices in suicide prevention.
"In sum, too often our mental health research funding neglects immediate public health needs to focus on future discoveries, reflecting the drive for technological solutions for disorders that are unequally distributed and partly socially determined," they say.
"Alleviating the Terrible Burden"
In conclusion, the joint statement calls for "an increase in public discussion of how to apportion funding resources across mental health research domains" that is global in scope.
"Paramount in these discussions must be alleviating the terrible burden that individuals and families living with mental illness face every day," they say in closing. "As Harry Hopkins, co-architect of the 1940s New Deal, replied to members of Congress who opposed allocating federal funds to lift the economy out of the Great Depression, claiming that the economy would sort itself out 'in the long run': 'People don't eat in the long run, they eat every day.'"
All the authors are current or former members of the NIMH National Advisory Health Council. They include past presidents of the World Psychiatric Association and the American Psychiatric Association.
Doris A. Fuller
Chief of Research and Public Affairs
References:
Next week: New study reports on the effectiveness of NAMI Family-to-Family education
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(June 21, 2016) Often overlooked in debates over the merits and drawbacks of antipsychotic medication is its role in reducing suicide by individuals with schizophrenia, who die approximately 20 years younger than their unaffected peers in the United States.
 "One way anti-psychiatry groups trivialize psychosis and marginalize psychiatry is by emphasizing the adverse effects of antipsychotic medications while denying or minimizing their benefits," writes Ronald Pies, MD, in the June issue of Psychiatric Times. "To be sure, the well-recognized metabolic, neurological and cardiovascular risks associated with many antipsychotic medications must be taken very seriously. Moreover, antipsychotics (APs) are often used when they are not needed....
"On the other hand, there is convincing evidence that in patients with chronic schizophrenia, APs play a crucial role in maintaining remission, averting relapse, improving quality of life and - importantly - reducing overall mortality" (author's emphasis).
In other words, despite their medical side effects, antipsychotic drugs appear to save lives.
Antipsychotics and Suicide Prevention
Pies writes that "even many psychiatrists" may be unaware of the role antipsychotic medications play in reducing suicide among individuals with schizophrenia, whose lifetime risk of killing themselves is at least 10 times that of the general public. He cites research that "the only consistent protective factor for suicide" is delivery of and adherence to effective medication, particularly clozapine, the only medication approved by the FDA for the prevention of suicide.
While clozapine is well-documented for its effectiveness in reducing suicidal behavior (e.g., suicide attempts, hospitalizations and rescue interventions), Pies reports "there is accumulating evidence that antipsychotic medication in general is associated with decreased risk of suicide" in schizophrenia. He cites studies with findings of:
- Excess mortality mostly in schizophrenia patients not taking antipsychotic medications (26 suicides in patients not taking APs vs 1 in patients taking them out of a population of 2,230 patients)
- 400% increase in risk of attempted suicide among patients who stopped taking prescribed olanazapine or risperidone for at least 30 days
- Maximum anti-suicide benefits at higher dosages of antipsychotics
"It would be incorrect to infer from this brief review that the optimal treatment of schizophrenia is simply a matter of giving patients antipsychotic medication," writes Pies, a professor of psychiatry at SUNY Upstate Medical University and Tufts University School of Medicine. Psychosocial services such as assertive community treatment, supported employment and family-based services also confer important benefits, he said
"But there is little question that, for patients suffering the chronic, debilitating symptoms of schizophrenia, antipsychotic medication is a critical component of treatment - and may literally be lifesaving."
Doris A. Fuller
Chief of Research and Public Affairs
References:
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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(June 14, 2016) Multiple studies have found that growing up in a city doubles the risk of developing schizophrenia or other psychotic disorders in adulthood. Research also has found that children who experience psychosis are at significantly higher risk for developing schizophrenia and other mental health disorders as adults.
 Given the personal and economic toll of psychiatric diseases and the fact that two-thirds of the world's population is projected to be living in cities by 2015, the question of "Why?" urbanicity is associated with psychosis is an urgent one.
Childhood Psychosis "Surprisingly Prevalent"
In search of answers, a team of researchers from King's College in London and Duke University in North Carolina analyzed the neighborhood characteristics of more than 2,200 12-year-olds participating in a longitudinal twin study in Great Britain. An advance report on the team's findings was published May 6 in Schizophrenia Bulletin online ("Why are children in urban neighborhoods at increased risk for psychotic symptoms? Findings from a UK longitudinal cohort study").
Joanne Newbury and colleagues note that psychotic symptoms are "surprisingly prevalent" among children in the general population. Although such symptoms typically are short-lived, children who experience them are at "significantly elevated risk" for schizophrenia and other psychotic and mental health conditions as adults, including substance abuse, depression, post-traumatic stress and suicidal behavior. The authors said the trajectory is "consistent with the neurodevelopmental model of schizophrenia," which holds that serious psychiatric disease begins developing at the neurological level during childhood or early adolescence, long before symptoms are manifest.
The participant twins were equally likely to be living in urban or suburban/small town/rural settings. At the age of 12, 5.9% of the 2,232 children reported experiencing at least one psychotic symptom (e.g., hallucinations, paranoid delusions). However, city children were 80% more likely to have experienced symptoms: 7.4% of the urban-dwelling children compared 4.4% of the non-urban children.
The pattern held true independent of family socioeconomic status, psychiatric history, maternal psychosis and/or whether the neighborhood was affluent or economically deprived. The same association was not found between urbanicity and depression or anxiety.
Risk and Mitigation Factors
The study analyzed four neighborhood social characteristics for their potential role in the association: social cohesiveness and supportiveness among neighbors; social control, including the likelihood of neighbors intervening in neighborhood problems; neighborhood disorder, whether physical or social; and direct experiences of being victimized (e.g., mugged).
Children who lived in neighborhoods with higher social cohesion and social control at the age of 5 were "significantly less likely to experience psychotic symptoms" at the age of 12, the analysis found, while children living in neighborhoods with higher levels of disorder and crime victimization at 5 years old were "significantly more likely" to experience psychotic symptoms by the age of 12. Low social cohesion combined with crime victimization explained nearly 25% of the association between urbanicity and psychosis in childhood.
"From a child's perspective, growing up in a crowded neighborhood characterized by insecure/ nonexistent social support networks, unfriendly/unpredictable interactions between neighbors, and fear of/ exposure to crime could promote psychotic symptoms in various mutually compatible ways," according to the authors.
The researchers speculated that prolonged exposure to neighborhood-level social stressors "could dysregulate the hypothalamic-pituitary-adrenal axis, dopaminergic system and/or neurodevelopment" to increase risk of psychotic symptoms, particularly among children with a genetic predisposition, but these possible mechanisms were beyond the scope of the study.
"The present findings therefore underscore the emerging need to identify the social, psychological and biological pathways leading from neighborhood-level exposures to childhood psychotic symptoms," the authors concluded - and, by extension, into adult schizophrenia and other serious mental illness.
"Urbanicity," they said, "is a key area for psychosis research."
Doris A. Fuller
Chief of Research and Public Affairs
References:
Next Week: Beyond Raising Cain
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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