Omega-3 Fatty Acids and Mood Disorders

By Sari Harrar from  Today’s Dietitian Vol. 14 No. 1 P. 22
Research suggests omega-3s can help mild to major depression and even schizophrenia.
Long recognized for their heart-health benefits, omega-3 fatty acids are emerging as an effective therapy for mood disorders ranging from major depression and postpartum depression to bipolar disorder and schizophrenia.

“Research suggests depression rates have risen as our intake of omega-3s has fallen over the past 50 to 100 years,” says omega-3 expert Gretchen Vannice, MS, RD, an independent nutrition research consultant based in Portland, Ore., and the author of The Omega-3 Handbook. “Studies show they help many mood disorders. So could getting enough of certain omega-3 fatty acids help reduce depression rates? Many experts think that among people who don’t have a genetic predisposition for mood disorders, they might.”
Yet giving your clients the green light to consume omega-3s for mental health benefits isn’t as simple as saying “swallow three fish oil capsules and call me in the morning.” It takes the right combination of fats, in addition to other therapies a client may be using, to get results, research shows. And many people with mood disorders should speak with their doctors first to avoid making mistakes like stopping other depression treatments.

But it’s a conversation worth having. According to the Centers for Disease Control and Prevention, nearly 10% of Americans are battling some type of depression. Forty percent of those have major depression.1 Another 2.6% of Americans are living with bipolar disorder, and 1.1% have schizophrenia. Meanwhile, about 10% to 15% of women experience depression during pregnancy, and up to one in five new mothers lives with postpartum depression.2 These disorders make daily living a struggle—and can be life-threatening. Ninety percent of suicides, for example, occur in people with treatable psychiatric illnesses, according to the American Foundation for Suicide Prevention.

Fats on the Brain
Enter the good fats. The human body uses omega-3s in many ways. They seem to be especially important for a well-functioning central nervous system, for the transmission of signals from the eyes to the brain, for heart health (some omega-3s protect against abnormal heart rhythms, reduce triglycerides, lower the risk of blood clots, and discourage the growth of plaque in artery walls), and they even promote healthy brain development in babies during pregnancy and breast-feeding.3

While your body can synthesize other types of fat from dietary components such as carbohydrates and proteins, it can’t make its own omega-3s. We have to get them from food or fish oil supplements. Omega-3s come in three varieties:

• Docosahexaenoic acid (DHA): Found in fatty cold-water fish such as salmon, mackerel, halibut, sardines, tuna, and herring, DHA concentrates in the brain’s gray matter and the retinas in the eyes.
“DHA molecules are long-chain fatty acids. They’re fluid and flexible,” Vannice explains. “They become part of the membrane of brain cells and work at synapses, where chemical signals jump from cell to cell.”

• Eicosapentaenoic acid (EPA): Also found in cold-water fish, EPA seems to have a unique role in maintaining a healthy mood.

“EPA doesn’t become part of a brain cell’s structure the way DHA does. It seems to help by reducing inflammatory processes in the brain and by balancing out metabolic pathways,” Vannice says. “Many studies show that DHA alone doesn’t work for depression. You need a little more EPA than DHA to get results. We’re still trying to understand exactly why, but we know it matters.”

In addition, some EPA is converted to DHA in the body.
• Alpha-linolenic acid (ALA): Found in flaxseed, canola oil, pumpkin seeds, purslane, and walnuts, and in small amounts in Brussels sprouts, kale, spinach, and salad greens, ALA doesn’t directly influence mood management although it may help with heart health. The human body converts a small percentage into EPA and DHA.4

While most Americans get plenty of ALA, we’re woefully low in the consumption of DHA and EPA. The American Heart Association recommends people eat fish twice a week, which, on average, would give you the recommended dose of 500 mg of DHA and EPA daily. But most adults and kids get closer to 100 mg or less, Vannice says. As a result, blood levels of these fats are low—and even lower in people with depression.

Do Good Fats = Better Moods?
Research from laboratory and population studies and clinical trials that tested omega-3 supplements in people with various types of depression suggests that raising EPA and DHA levels can make a difference. Omega-3 researcher David Mischoulon, MD, PhD, director of research in the Depression Clinical and Research Program at Boston’s Massachusetts General Hospital and an associate professor of psychiatry at Harvard Medical School, says EPA and DHA “are thought to be active as antidepressants” in the brain. From their catbird seat in cell walls, omega-3s help with what brain researchers call “second messenger systems” that carry messages from outside into cells.

Mischoulon and others who study the effects of omega-3s on depression have found the following:
• EPA plus DHA can improve primary depression. When M. Elizabeth Sublette, MD, PhD, of the New York State Psychiatric Institute and her team of researchers reviewed 15 trials involving 916 participants, they concluded that supplements with at least 60% EPA improved depression symptoms. Their meta-analysis was published online in the September 2011 issue of the Journal of Clinical Psychiatry. A Canadian study published in the August 2011 issue of the same journal found that a similar 60/40 ratio of EPA/DHA eased depression somewhat in people with depression who didn’t have anxiety disorders.
“The human brain likely benefits from a combination of EPA and DHA since they occur together in nature and both have apparent benefits for depression and suicide,” Mischoulon notes.

• Omega-3s help some aspects of bipolar disorder. In an analysis led by researchers from Australia’s University of Melbourne, Mischoulon and colleagues concluded that omega-3s could have a significant effect on bipolar depression but not on bipolar mania.5

• Low omega-3 levels are associated with suicide and self-harm. In response to increasing rates of suicide in the military, researchers from the National Institutes of Health (NIH) recently found that low blood levels of omega-3s were widespread and raised suicide risk by as much as 62%. The study was published online in the August 2011 issue of the Journal of Clinical Psychiatry.

“A previous placebo-controlled trial demonstrated that 2 g of omega-3 fatty acids per day reduced suicidal thinking by 45% as well as depression and anxiety scores among individuals with recurrent self-harm,” says researcher Capt Joseph R. Hibbeln, MD, acting chief of the Section of Nutritional Neurosciences at the National Institute on Alcohol Abuse and Alcoholism’s Laboratory of Membrane Biochemistry and Biophysics in a press release from the NIH. He and other study authors concluded that “ensuring adequate omega-3 nutritional status is likely to benefit, and unlikely to harm, people at risk for suicide.”

• Omega-3s help menopausal depression. When 20 menopausal women with major depression took 2 g of EPA plus DHA daily for eight weeks, 70% found their mood improved, and 45% found their depression went into remission. Mean scores on the Montgomery-Asberg Depression Rating Scale fell from 24.2 to 10.7. And the study participants enjoyed a bonus—fewer hot flashes—according to researchers from Massachusetts General Hospital in the March 2011 issue of Menopause.

• Omega-3s improve depression during and after pregnancy. Low-dose DHA/EPA supplements lifted major depression for 15 pregnant women in a 2006 study published in Acta Neuropsychiatrica. Other research has found that women with higher intakes of omega-3s after pregnancy are at lower risk of postpartum depression.6

In a small 2006 study published in the January issue of Acta Psychiatrica Scandinavica, 16 new mothers with postpartum depression took 0.5 to 2.8 g of EPA/DHA daily for eight weeks. Depression scores dropped about 50% in all groups. The researchers say that lifting postpartum depression is good for mothers and their babies: “Children of affected mothers may experience impaired attachment, and [postpartum depression] may adversely affect behavioral and cognitive development. Some women refuse medications during pregnancy and/or breast-feeding because long-term effects of antidepressants on the infant are unknown. Omega-3 fatty acid supplementation is associated with health benefits and is an attractive potential treatment.”

• Omega-3s may protect against schizophrenia. In a 2010 study published in the February issue of Archives of General Psychiatry, 81 people at extremely high risk of schizophrenia took 1.2 g of omega-3s or a placebo daily for 12 weeks. At the end of the study, 28% in the placebo group had developed the disorder compared with 5% in the omega-3s group.

“Intervention in at-risk individuals holds the promise of even better outcomes, with the potential to prevent full-blown psychotic disorders,” the study authors wrote.

Using Omega-3s Safely and Wisely
While low-dose omega-3s are a safe choice for most people, experts say people with depression and other mood disorders shouldn’t try to use this fat as a home remedy for depression. “I prefer that they at least talk to a physician first,” Mischoulon says. “Depression is a potentially dangerous illness because of the risk of disability and suicide, so a doctor’s input is important.”  

Here are some guidelines you can use while counseling patients who suffer from depression:
• Safest dose: For general good health, adults and kids should get omega-3s by eating two or more servings of fatty cold-water fish per week. That’s the recommendation of the American Heart Association and the Omega-3 Fatty Acids Subcommittee organized in 2006 by the American Psychiatric Association.7 “That works out to about 500 mg per day, which you also can get from fish oil capsules or other products [see sidebar],” Vannice says. People with mood disorders may benefit from 1,000 mg of EPA plus DHA daily from fish oil supplements, according to the subcommittee, but they should consult a doctor first.

• Don’t stop taking antidepressants, lithium, or any other medications or treatments. “They shouldn’t necessarily be viewed as a replacement for standard antidepressants or for psychotherapy, if these are being used,” Mischoulon says.

Suggest clients get their doctor’s approval before starting any dose of omega-3s if they’re pregnant, nursing, taking blood thinners, or have a bleeding disorder. Omega-3s can reduce blood clotting; if clients are already taking a blood thinner for this purpose, the combination could be dangerous.

— Sari Harrar is an award-winning freelance writer specializing in health, medicine, and science. Her articles have appeared in national magazines, including O, The Oprah Magazine; Reader’s Digest; Good Housekeeping; Better Homes and Gardens; and Organic Gardening.

Alternatives for Fishy Burps
It’s an unpleasant turn-off—and a big reason clients stop taking fish oil supplements. “People feel embarrassed about fishy burps and may not tell their dietitian, so this is a good area for an RD to become familiar with,” says Gretchen Vannice, MS, RD. She recommends these strategies for minimizing unpleasant “repeats”:

Take fish oil capsules with food. Suggest clients pair them with the largest meal of the day.
Try a higher-quality supplement. “Spending a few more dollars could alleviate the problem.” Look for enteric-coated capsules, too.

Switch to a spoonable fish oil. Recommend clients try Coromega (http://www.coromega.com/), an orange-flavored gel that delivers 350 mg of EPA and 230 mg of DHA. Or have them try Barlean’s Omega Swirl (www.barleans.com/omega_swirl.asp), which has a fruit smoothie taste and consistency and provides 350 mg of EPA and 350 mg of DHA in 2 tsp. Barlean’s is also good for kids who can’t or won’t swallow fish oil capsules.
— SH

References
1. Centers for Disease Control and Prevention. Current depression among adults—United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010;59(38):1229-1235.
2. Centers for Disease Control and Prevention. Prevalence of self-reported postpartum depressive symptoms—17 states, 2004-2005. MMWR Morb Mortal Wkly Rep. 2008;57(14):361-366.
3. Linus Pauling Institute. Micronutrient information center: essential fatty acids. http://lpi.oregonstate.edu/infocenter/othernuts/omega3fa. December 2005. Updated April 2009.
4. Harvard School of Public Health. The Nutrition Source. Ask the expert: omega-3 fatty acids. http://www.hsph.harvard.edu/nutritionsource/questions/omega-3/index.html.
5. Sarris J, Mischoulon D, Schweitzer I. Omega-3 for bipolar disorder: meta-analyses of use in mania and bipolar depression. J Clin Psychiatry. 2011;Epub ahead of print.
6. Hibbeln JR. Seafood consumption, the DHA content of mothers’ milk and prevalence rates of postpartum depression: a cross-national, ecological analysis. J Affect Disord. 2002;69(1-3):15-29.
7. Freeman MP, Hibbeln JR, Wisner KL, et al. Omega-3 fatty acids: evidence basis for treatment and future research in psychiatry. J Clin Psychiatry. 2006;67(12):1954-1967.

Posted at http://www.darkestclost.blogspot.com/

"Off-label" Use of Antipsychotic Drugs for Some Conditions Not Supported by Evidence

What mom thinks matters

Fred Markowitz

Attitudes of family members can impede recovery from mental illness
DeKalb, Ill. – A new study led by a Northern Illinois University sociologist shows that while family members often provide critical support, they also can sometimes be the source of stigmatizing attitudes that impede the recovery of mentally ill relatives.

“Negative attitudes of family members have the potential to affect the ways that mentally ill persons view themselves, adversely influencing the likelihood of recovery from the illness,” said lead researcher Fred Markowitz, an NIU professor of sociology.

Markowitz and his colleagues, Beth Angell from Rutgers and Jan Greenberg from the University of Wisconsin-Madison, published their findings in the June issue of Social Psychology Quarterly, a peer-reviewed journal of the American Sociological Association.

Over an 18-month period, the researchers studied 129 mothers of adult children with schizophrenia.
“In short, what mom thinks matters,” Markowitz said. “It’s a chain of effects that unfolds.

“We found that when those with mental illness exhibited greater levels of initial symptoms, lower self-confidence and quality of life, their mothers tended to view them in more stigmatized terms—for example, seeing them as ‘incompetent,’ ‘unpredictable’ and ‘unreliable,’ ” Markowitz said. “When mothers held these views, their sons and daughters with mental illness were more likely to come to see themselves in similar terms—what social psychologists call ‘the reflected appraisals process.’ Importantly, when the individuals with mental illness took on these stigmatizing views of themselves, their symptoms became somewhat greater and levels of self-confidence and quality of life lower.”

A long line of research has shown that the stigma associated with mental illness can be a major impediment to recovery, affecting self-esteem and even job prospects. But research has not historically examined the links between stigma, reflected appraisals, identity formation and recovery, Markowitz said.

“Our study is part of research that is starting to more fully examine how stigma affects the self-concept and identity of those with mental illness,” he said.

Markowitz and his colleagues believe it is important to acknowledge that many of the sentiments conveyed toward ill relatives grow out of positive intentions and reflect attempts to cope with the difficulties of having a relative with serious mental illness. Yet, stigmatizing attitudes are of concern because of their potential adverse effects.

“This study highlights the notion that recovery from mental illness is not simply a matter of controlling symptoms as indicated by a strictly ‘psychiatric’ perspective,” Markowitz said. “It is, to a certain extent, a social-psychological process.

“The ways in which people, including family members and service providers, think about persons with mental illness affect the beliefs and actions of the individuals with mental illness, in turn shaping the trajectory of recovery.”

Switching Antipsychotics May Reduce Metabolic Risks

NIMH-funded study examines whether switching to a different antipsychotic can reduce side effects while maintaining effectiveness

Patients experiencing cardiovascular or metabolic side effects while taking an antipsychotic medication may fare better if they switch to a different medication provided they are closely monitored, according to an NIMH-funded study. The study was published online ahead of print July 18, 2011, in the American Journal of Psychiatry.

Antipsychotic medications can effectively treat psychotic symptoms among people with schizophrenia or related disorders. However, the medications, especially some of those that are most commonly used, are associated with serious metabolic side effects that can lead to heart disease or diabetes. Even when patients do experience these side effects, doctors are often reluctant to change a patient’s medication regimen if the patient’s psychotic symptoms are controlled by the existing medication.

“Treating the symptoms of schizophrenia is a delicate balancing act between risks and benefits,” said National Institute of Mental Health Director Thomas R. Insel, M.D. “The possible benefits of switching medications to reduce metabolic risks must be carefully weighed against the potential risk of symptom relapse or medication failure.”

Scott Stroup, M.D., of Columbia University and colleagues aimed to determine if a medication switch could be made safely and without sacrificing clinical stability. For the Comparison of Antipsychotics for Metabolic Problems (CAMP) study, they enrolled 215 patients from 27 clinical sites whose psychotic symptoms were stabilized on one of three frequently used antipsychotics (olanzapine, quetiapine or risperidone) but were experiencing serious metabolic side effects such as weight gain and high cholesterol levels. Half of the patients were assigned to stay on their current medication, while the other half were switched to aripiprazole, another antipsychotic that is generally associated with fewer metabolic risks. All of the participants received a behavioral intervention that included a diet and exercise program designed to reduce the risk of cardiovascular disease.

After 24 weeks, the researchers found that those who switched to aripiprazole had improved cholesterol levels and other metabolic factors, and lost more weight (average of 8 lbs) than those who stayed on their original medication (average of 1.5 lbs). Those who switched also did not experience any more illness relapses or worsening of psychotic symptoms compared to those who stayed on their original medication. However, those who switched to aripiprazole were more likely to discontinue the new medication compared to those who stayed on their original medication. Almost 44 percent of those who switched discontinued the aripiprazole compared to 24.5 percent of those who were assigned to stay on their current medication.

The authors suggest that the high discontinuation rate for switchers may have been related to the fact that the study was open label, meaning both the patient and the clinician knew what drug the patient was taking. Some patients who were switched may have felt uncomfortable changing from a medication they knew worked for them, and therefore stopped the new medication. In addition, because clinicians were encouraged to closely monitor and intervene before a patient experienced severe problems, many may have discontinued aripiprazole when the clinician first determined that the patient was having difficulties, but before full-blown treatment failure occurred.

“For patients whose symptoms are stabilized but who are overweight or experiencing other metabolic problems, clinicians may want to consider switching to a medication that is less likely to cause metabolic problems. However, because switching is not always successful, clinicians must monitor patients carefully to avoid illness exacerbation,” said Dr. Stroup. “If switching medications is not an option, then adding a medication like metformin or a statin could help reduce cardiovascular risks while maintaining symptom stability,” he concluded. He also noted that the study’s behavioral intervention that focused on improved diet and exercise habits benefited even those who did not switch medications.

Reference

Stroup TS, McEvoy JP, Ring KD, Hamer RH, LaVange LM, Swartz MS, Rosenheck RA, Perkins DO, Nussbaum AM, Lieberman JA. Comparison of antipsychotics for metabolic problems (CAMP):a randomized trial examining the effectiveness of switching from olanzapine, quetiapine, or risperidone to aripiprazole to reduce metabolic risk. American Journal of Psychiatry. Online ahead of print July 18, 2011.

How to Live Successfully When You Hear Voices

by Karen Taylor

Working to Recovery (WTR) has always specialized in working with people who hear voices. In this article, Karen Taylor, who has a background in psychiatric nursing, describes the organization’s approach to working with people who hear voices and how WTR helps people recover their lives and live with their voices.

Can you hear voices and be healthy? Can people who hear overwhelming and distressing voices be helped to find ways to live successfully with their voices? Over the past 20 years, research and practice originating in Europe and developed in partnership with voice hearers indicate that this is indeed the case.

This empowering approach to assisting people—both adults and children—who hear voices and are distressed by them starts from the premise that voices are related to real feelings and emotions that need to be investigated and understood. Therefore, voices need to be accepted as a part of oneself rather than eradicated. This perspective has made a significant impact on the way voice hearers and mental health services regard the voice experience, leading to the development of a vigorous peer support network and important changes in the practice and treatments offered by service providers.

A measure of the success of this approach is that there are now networks and activity in more than 23 countries around the world, with an emergent network being established in the United States.

Need to promote recovery. WTR was born out of the need to promote recovery. Established in 2002 by Ron Coleman and myself, the Scotland-based WTR offers training and consulting services around the world to many different kinds of agencies and organizations specializing in mental health practice.

Ron, who survived the psychiatric system for more than 10 years, started his recovery journey when he became a member of a hearing-voices group in Manchester, England, in the early 1990s. After listening to other voice hearers in the group for a year without saying anything at all, he started to speak up. He began by sharing his own experiences, and as an expert (by experience), soon developed a deep understanding of the issues facing people who hear voices. As Ron says of this period in his life:

“At my very first hearing-voices group, a fellow voice hearer asked me if I heard voices. When I replied that I did, she told me that they were real. This does not sound like much, but that one sentence has been a compass for me, showing me the direction I needed to travel and underpinning my belief in the recovery process.”

People around him realized the massive potential he had as a public speaker and innovative thinker on mental health and recovery. Over the next few years, Ron developed and ran training days and spoke at meetings and conferences on the subject of hearing voices, evidencing the possibility and hope of recovery.

Talking with patients, negotiating with voices. Then he started to write. With Mike Smith, a psychiatric nurse he’d befriended, Ron wrote a workbook for voice hearers, Working With Voices. This book has been the foundation of many of WTR’s subsequent training programs and is based on how Ron gained control of his voices. To enable voice hearers to understand their voices better in a systematic way, the workbook asks the voice hearer to consider the ways in which life events and voices can be connected, describes a variety of long-term coping mechanisms, and offers a range of ways that can help the person hearing voices cope better with the experience. The objective of the workbook is to help voice hearers respond to the challenges the voices throw up in a resilient and positive way and ultimately to gain ascendancy over them.

Our best-known workshop is a 1-day event, also called “Working With Voices.” This workshop helps workers understand voices better and develop their confidence, so as not to be afraid of talking with their clients about them. As a psychiatric nurse, I know how important and liberating this is. When I started nursing, it was common practice to be taught to not engage in conversation

with a consumer about his or her voices, as this would be colluding with the consumer in a false belief or delusion and could be harmful. I have yet to see any evidence for this claim; in fact, the research shows the opposite: the simple process of talking to people about their voices reduces anxiety and even lessens hospital stays.

Ron and I have also developed a 2-day workshop for voice hearers and workers, where we bring workers and voice hearers together to work, in pairs, through the Working With Voices workbook. We then bring the larger group together to discuss their findings. As part of the training, Ron runs a hearing-voices group with the voice hearers who are in attendance, to assist workers in better understanding the process. What I find astonishing, no matter where in the world we run this workshop, is the number of workers who will confess that they have learned more about their partner voice hearer during those 2 days than in the previous years of working with them. I believe this is because, unfortunately, we learn to not ask the right questions, learn to take a life history with no interest in the “life story,” and forget the person behind the diagnosis.

Our latest workshop on hearing voices concerns a technique called “voice dialoguing,” which involves voice hearers talking back to their voices and negotiating with them. This is something some voice hearers have always done. We teach workers how to talk to the voices heard by the voice hearer with the objective of finding out more information about the characteristics of the voices, negotiating with the voices themselves, and showing the voice hearer how to do this if he or she has not engaged with these voices before. This may seem bizarre, but it works and has been proven to help the voice hearer gain control of his or her voices.

Significant progress. In our work with voice hearers, we have found that the most common reason a person hears voices is that the hearer experienced sexual, emotional, or physical abuse as a child. In many cases, one of the dominant and controlling voices is that of the abuser. Sometimes, another of the voices is that of the abused child. The recovery work in these cases concentrates on restoring the person’s “emotional innocence,” as many of the voice hearers carry considerable and overwhelming shame and guilt about their experiences, which is not theirs to carry. Once this takes place, there is often significant progress in their journey toward full recovery.

I feel honored to have carried out this work over the past 13 years. I have met many wonderful, talented people who had all but given up on life but, through the influence and support of Ron and other recovered voice hearers, have started to make the journey toward recovery for themselves. I can honestly say that setting up WTR has been the best thing that Ron and I have ever done, and I look forward to many more years of sending our message out to the world.

Ron Coleman and WTR associate Paul Baker will be visiting the United States to conduct a 2-week lecture and training tour in October 2011. They hope that sharing their experiences and knowledge with interested groups and individuals will help stimulate the further development of work with people who hear voices in North America. For more information about this tour, contact Karen Taylor at karen@workingtorecovery.co.uk.
Posted in Recovery to Practice Newsletter. Reposted at darkestcloset.blogspot.com

I am not a superhero

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Schizophrenia Awareness Week

In honor of Schizophrenia Awareness Week, here are some chilling reminders of the not-so-distant past.
Warning: this images, published as ads in medical journals may disturb some individuals.

http://www.bonkersinstitute.org/medshow/thorazsenile.html

http://www.bonkersinstitute.org/medshow/thorazine.html

Reposted at darkestcloset.blogspot.com

Stem Cells of People who experience Schizophrenia Could Lead to Breakthrough in Treatment

A new method for recreating the brain cells of patients with schizophrenia is being described as a breakthrough in treating the condition. Scientists used a technique to reprogram the skin cells of schizophrenic patients to become stem cells and then coaxed them become neurons. These were then compared to brain cells derived from the skin cells of healthy volunteers. That would allow scientists to test the effects of antipsychotic drugs. (Voice of America, 4/13/11)

Minds On the Edge

This is a video of a discussion on treatment of mental illness. It is created from two hypothetical situations of individuals who experience severe mental illness. It also features Dr. Fred Friese.
http://www.mindsontheedge.com/watch/

Reposted at darkestcloset.blogspot.com

PARENTS OF ADULTS WITH MENTAL ILLNESS FACE THE CHALLENGES OF BEING AN AGING CAREGIVER

Parents face a host of challenges when caring for a child with a serious mental illness (SMI), such as schizophrenia and bipolar disorder. As the parents age and face their own age-related problems, the care burdens can become even greater when the child becomes an adult. A recent AHRQ-funded study looked at the subjective burden and personal gains of older parents who cared for adult children with SMI. It found that various supportive measures in the home can create opportunities for the adult child to help their aging parents, while at the same time helping the parents cope with caregiving challenges. http://r20.rs6.net/tn.jsp?llr=87kw7ieab&et=1104894294000&s=155&e=001knmwUl_ELJTnDiqP4zfkiRlkC2AxWv-lgx-ZQISmI99yEGtLGgHWRU5GteqERqN_c8Z1Dcgrf2zS14faDxODQU2KnvEwoX0IQGO6URsN_fOZOSGJ0sVVZSl5glTTGdg-LLz3bjihQJNl1t_yQdt6lQ==

FDA panel advises more testing of 'shock-therapy' devices

By David Brown Washington Post Staff Writer Friday, January 28, 2011; 10:10 PM

An expert panel advising the Food and Drug Administration decided Friday that electroconvulsive therapy (ECT) machines should undergo the same rigorous testing as new medical devices coming onto the market - a decision that could drastically affect the future of psychiatry's most controversial treatment.

The majority of the 18-member committee said not enough is known about ECT, also known as "electroshock" or simply "shock" therapy, to allow the devices to be used without more research into its usefulness and hazards.

If the agency follows the panel's advice, which it usually does, the two companies whose machines are used in the United States will have to provide evidence of the therapy's safety and effectiveness either from existing research or new studies. If the FDA isn't convinced, the devices could be removed from use.

The panel's opinion is the latest chapter in ECT's seven-decade history, during which the treatment has been lauded as a lifesaver, villified as a form of legally sanctioned torture, and has seen its popularity rise in recent years after a long decline.

ECT machines deliver an electrical current to the brain, inducing a generalized seizure in which the patient briefly loses consciousness. How that may be therapeutic or cause permanent memory loss - the side effect most frequently mentioned by patients - isn't known.

About 100,000 Americans undergo ECT each year, usually getting about a dozen treatments over several weeks. Some then get "maintenance" ECT every few weeks, as the therapeutic effect, when it occurs, often doesn't last. The treatment is most often used for depression and has also been prescribed to patients with schizophrenia, catatonia, and more recently, to some violent children with autism.

"It was the best possible outcome we could have gotten," said John Breeding, 58, a clinical psychologist from Austin who says the procedure should be banned. He testified before the panel at a two-day meeting in Gaithersburg.

For some patients, ECT epitomizes what they view as the coercion and lack of respect for the patient's point of view that is unique to psychiatry. That's also largely how it's been depicted in popular culture, most famously in the book and film "One Flew Over the Cuckoo's Nest," where it was a tool of punishment and social control of mental patients.

"I lost not only my memories of the time I was subjected to this torture but I was robbed of almost all memories from about 2003, two years before treatment, to 2008, three years after treatment stopped," testified Evelyn Scogin, a special-ed teacher who got ECT after a suicide attempt. Her statement was read by a friend because Thursday's snowstorm stranded her in the Charlotte airport.

Other patients described ECT as a lifesaving, if mysterious, treatment worthy of wider use.

Among them was Kitty Dukakis, the 74-year-old wife of 1988 Democratic presidential nominee and former Massachusetts governor Michael Dukakis. She first got ECT at age 63, and continues to get it once a month.

"It is not an exaggeration to say that I don't think I would be alive without ECT. It has been a miracle in my life," she said.

One proponent, a nurse from Baltimore, drove through the snow on her day off to read a grateful Christmas card from a patient, choking up as she did.

"I actually think it's more controversial than abortion," Amy Lutz, a 40-year-old mother of five from Villanova, Pa., said of ECT, which her 12-year-old autistic and manic-depressive son gets regularly.

She brought with her two poster-size photographs of the boy, his face and hands bloodied from self-inflicted blows. She told the committee that ECT, tried after a half-dozen other therapies, stopped the violent behavior and increased her son's achievement in school.

A 1976 law requiring safety and effectiveness of all new medical devices permitted ones in longstanding use, including ECT machines, to stay on the market. Later, however, Congress told the FDA that those grandfathered-in devices either had to undergo rigorous testing or be officially "reclassified" as already-proven to be safe and effective (although, in some cases with special warnings about their use).

In addition to patient testimony, the advisory panel heard FDA staffers describe their analysis of hundreds of ECT studies.

As a group, the studies tended to be poorly designed and with too few patients to allow the drawing of firm conclusions. Many failed to follow patients long enough to discover the duration of ill effects. Ones done decades ago studied techniques and electricity dosages different from current practice.

The FDA staff reported the existing research suggests that for depression, ECT is more effective than placebo or "sham" shocks and after a month more effective than antidepressants.

In terms of hazards, the FDA staff's review found the treatment is associated with "impairment in orientation, memory and global cognitive function immediately after ECT and up to 6 months." Certain aspects of memory may return to baseline after six months. "Autobiographical memory" - recollection of events in one's life - appears to be at greatest risk. High-dose electric current and current applied to both sides of the brain are associated with more thinking and memory problems.

Panel member Christopher A. Ross, a psychiatrist and neuroscientist at Johns Hopkins University, asked if the published studies identified any risk factors that predisposed patients to memory loss and thinking impairment.

"Evidence-based data for that issue just doesn't exist," said Peter G. Como, a neuropsychologist at the FDA.

Panel Chairman Thomas G. Brott, a neurologist at the Mayo Clinic's campus in Jacksonville, Fla., said he was amazed that essentially no research had been done on ECT's effects using functional MRI imaging, repeated brain wave (EEG) studies, or autopsy examinations of patients.

"I tried to look and saw very little. I concluded that the evidence is not there to decide either way," he said.

FDA Orders New Cautions on Antipsychotic Drugs

By John Gever, Senior Editor, MedPage Today

Published: February 22, 2011

http://r20.rs6.net/tn.jsp?llr=sqa5umdab&et=1104622119011&s=9110&e=001zc3xfKsSKtg4N1-pYs_DXy5sGZyl_JqZRQ6S__GGivGRdDhhjQAGnT87c4ApeeqM-vZNl8MnT4Kirqg6R8hwMg5U5l4iRyJO-vyN-gJSz1DYsjxvzjDHy8MJ3cp6-5Ae0Vu--LIef1TRTx1HZDtN2FvUT8QEEmyzZtadl_Vib0I= 

WASHINGTON -- All antipsychotic drugs, including older agents as well as second-generation products, must contain new label information regarding their use in pregnancy, the FDA said.

In particular, the new labeling will address the risk of extrapyramidal symptoms (EPS) and withdrawal syndromes in newborns.

"FDA has updated the Pregnancy section of drug labels for the entire class of antipsychotic drugs to include consistent information about the potential risk for EPS and/or withdrawal symptoms in newborns whose mothers were treated with these drugs during the third trimester of pregnancy," the agency said in a notification to healthcare professionals.

The FDA has identified 69 episodes of neonatal EPS or withdrawal in adverse event reports submitted to the agency through October 2008.

Among the symptoms listed in the reports: agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding disorder.

However, blood levels of the drugs involved were not provided in the reports, the agency said, so it was "not possible to determine whether the events resulted from antipsychotic drug toxicity or withdrawal."

Onset of symptoms ranged from birth to one month later, and the severity varied as well. The FDA indicated that some infants recovered within hours while others needed intensive care and prolonged hospitalization.

Most of the cases also involved other potential causes of the symptoms, such as other psychotropic drugs and medical problems associated with the pregnancy or delivery.

"However, there were some cases which suggest that neonatal EPS and withdrawal may occur with antipsychotics alone," the FDA said.

The agency's announcement did not indicate which specific antipsychotic drugs were named in the adverse event reports.

In any event, the FDA is requiring the standardized cautions be carried on all antipsychotic drugs -- 20 different types sold under 23 brand names are included in the order. These range from the first antipsychotic drug used in modern practice, chlorpromazine (Thorazine), to such newer agents as aripiprazole (Abilify) and quetiapine (Seroquel).

All the products are approved to treat schizophrenia; some also have been cleared for bipolar disorder.

The official order can be read at http://r20.rs6.net/tn.jsp?llr=sqa5umdab&et=1104622119011&s=9110&e=001zc3xfKsSKtiUHzIcX1zPrMMeu7RbjgzLOGeS1R5vSEPycP_IGuIFgPwJ3u9br8C6AnbII2XdxeN_WyjYhK84BTUjtiLIYWmDr2X3r0OK45YMuKbnSEBZPwQp673XT2FfUpvaiukBE7ud1I-1iwEiVQ==. 

When Mental Health Meds Are Out Of Reach, Hospitalization More Likely

Too often, mental health patients have problems accessing or paying for their prescription drugs under Medicaid. The results - longer hospital stays and more emergency room visits - are hard on patients and costly for the entire health care system, a new study finds.

Lead author Joyce West, Ph.D., and colleagues analyzed Medicaid data from 10 states and found that psychiatric patients who reported access problems with their medication visited the emergency department 74 percent more often than those who had no such difficulties.

Of the 1,625 patients West and colleagues tracked, almost a third could not access the clinically indicated or preferred medication because Medicaid did not approve it. Patients with medication access issues experienced 72 percent more acute hospital stays compared to patients without access problems.

Access problems included prescribed medication being discontinued, temporarily stopped or not covered. Some patients had problems making the co-payment.

"What's particularly troubling is that it can often take several trials and many months, if not longer, to find an appropriate medication regimen that a patient responds to," said West, policy research director at the American Psychiatric Institute for Research and Education and an assistant professor of mental health at Johns Hopkins University.

The study appears in the November-December issue of the journal General Hospital Psychiatry.

"There are major clinical risks to psychiatric patients when they're stable on their medication and then switch to a different medication," West said. "Policies to facilitate medication continuity are critically important for this highly vulnerable population."

Policymakers can save money in the Medicaid program by clamping down on medication, but other areas including emergency room visits will undeniably increase, said Ken Duckworth, medical director for the National Alliance on Mental Illness and assistant professor at Harvard Medical School.

"It's another piece in a body of evidence that says what you're doing when you're restricting access to psychiatric drugs is squeezing the balloon," Duckworth said. Psychiatric hospitalization costs $800 to $1,000 a day. "So it is quite expensive for the system," Duckworth said.

Duckworth said incarceration it particularly is important for patients with conditions such as schizophrenia, bipolar disorder and borderline personality disorder to take medications consistently. TERMS OF USE: This story is protected by copyright. When reproducing any material, including interview excerpts, attribution to the Health Behavior News Service, part of the Center for Advancing Health, is required.

General Hospital Psychiatry is a peer-reviewed research journal published bimonthly by Elsevier Inc.

West JC, et al. Medicaid medication access problems and increased psychiatric hospital and emergency care. Gen Hosp Psych 32(6), 2010.

Source:
Health Behavior News Service
http://www.medicalnewstoday.com/articles/211062.php

Videos of Individuals Speaking about Living with Schizophrenia

New York Times Features Videos of Individuals Speaking about Living with Schizophrenia or Schizoaffective Disorder

The New York Times has posted videos in which seven individuals talk about living with schizophrenia or schizoaffective disorder. The interactive site offers readers a chance to comment. To watch the videos or participate in the discussion, go to:http://www.nytimes.com/interactive/2010/09/16/health/healthguide/te_schizophrenia.html

Smoking pot may hasten onset of mental illness

By Nancy Lapid

NEW YORK | Mon Feb 7, 2011 5:19pm EST

NEW YORK (Reuters Health) - Smoking marijuana has been linked with an increased risk of mental illness, and now researchers say that when pot smokers do become mentally ill, the disease starts earlier than it would if they didn't smoke pot.

This means that serious psychiatric diseases that might not have shown up until kids were in their teens or twenties - or might never had developed at all - are starting in children as young as 12 who smoke marijuana.

The link between using pot and developing serious mental illness is strongest in the youngest smokers - 12- to 15-year-olds, or kids even younger, said Dr. Matthew Large in an interview with Reuters Health.

"We have to (tell) people who have marijuana in their pockets not to give it to younger people," said Large, who headed up the research at the University of New South Wales in Sydney, Australia.

Large and his colleagues looked at thousands of patients with psychotic disorders like schizophrenia. People with psychotic disorders lose touch with reality -- usually starting in adolescence or young adulthood.

The authors of the new study found that in the subjects who had been pot smokers, the psychotic symptoms began nearly 3 years earlier than in those who had not been marijuana users.

People with schizophrenia often have hallucinations (they see things that aren't there) and delusions (they're often convinced something improbable is true, when it isn't); they also tend to have unusual or bizarre behavior, social problems, and general difficulty in coping with life. According to the National Institute of Mental Health, approximately 2.4 million American adults, or about one in every 100 people over age 18, have schizophrenia.

The vast majority of young people who use marijuana don't develop psychosis. And so far, no one's been able to prove that smoking marijuana actually causes psychotic disorders like schizophrenia, but the new research adds to "growing evidence" that it does, at least in some people, said Dr. Michael T. Compton at George Washington University Medical Center in Washington, DC, who worked on the study.

A number of studies had already suggested that people develop schizophrenia at a younger age if they've been using pot - even if they weren't heavy users -- but not all researchers agreed.
To get a better sense of the evidence, Large and Compton and their colleagues systematically combined and analyzed data from 83 studies involving more than 22,000 people with psychotic disorders like schizophrenia: 8,167 who used marijuana or other substances, and 14,352 who did not.

"Those who used marijuana had an earlier age at onset of the disorder, by (about 32 months) on average, than those who had not used marijuana," Compton said in e-mail to Reuters Health.

Why was there disagreement in the past over whether this effect really exists? The reasons lie in the way the individual studies might have been done, the researchers say in their article, published in the Archives of General Psychiatry.

In their larger analysis, they made sure to account for several factors that authors of the individual studies might not have considered. For example, psychosis develops earlier in boys than in girls - but Large and Compton found that even when they adjusted for that difference, the pot smokers still developed psychotic symptoms earlier.

Also, older people are less likely to be smoking pot than younger patients, so if the individual studies had different proportions of various age groups, the results might have been skewed. Taking that factor into account, the researchers still found that marijuana users developed mental illness at a younger age.

They also tried to see whether their findings could be explained by the year the research was done (because pot may have become more potent over time), whether the research had been done according to good scientific principles, and whether the investigators had defined the start of mental illness according to the date it was diagnosed instead of the date the symptoms started (the date symptoms started is more accurate). But they kept coming back to the same result: people with psychotic disorders who smoked marijuana had symptoms of mental illness at a younger age than those who didn't use pot.

The researchers did not look at whether family history of psychosis played a role in determining who was most vulnerable to marijuana's apparent early-triggering effect.

Are there some kids who are more at risk of psychosis from smoking pot than others? "I'm sure there are," Large said. Kids with a family history of psychosis, or those with some psychotic symptoms but not full-blown schizophrenia are at particular risk, he said. But also at risk are kids who are struggling, not doing well at school or living in bad situations at home.

One study found that compared to people who didn't use marijuana, people over 18 who did use it had twice the risk of mental illness, but kids under 15 had five times the risk, Large said.
There are two main messages to take away from this work, Large said. One is that there's probably something in marijuana that triggers schizophrenia. What that is, isn't clear yet. "Schizophrenia is still a mystery," he said. "Psychotic illnesses are horrible for the people who have them, and terrible for their families too."

The second message is far more important, he believes. Public health campaigns on the dangers of marijuana are focusing on older users, Large said, and overlooking the pre-teens and young adolescents who get their pot from older peers and even older siblings at home.
"Even if the onset of psychosis were inevitable (for a particular individual)," Large's team writes, "an extra 2 or 3 years of psychosis-free functioning could allow many patients to achieve the important developmental milestones" of adolescence. That extra time could allow a young person to finish school and gain other skills that might reduce the lifelong disability that so often accompanies mental illnesses.

Whereas most studies like his are presented at medical conferences, Large said he's not going to bother traveling around to announce his results to other doctors. Instead, he said, he wants to talk about his results in public forums.

"I'm not a marketing expert," he said, "but we have to find a way to tell young kids to hold off." We might not be able to convince them to never use pot, he added, but they need to wait until they're older - a message, he acknowledged, that will be tricky to deliver.

SOURCE: bit.ly/epp4be Archives of General Psychiatry, online February 7, 2011.

Recent "State of the Union" with DR. Fred Frese

Frederick J. Frese, Ph.D., Associate Professor of Psychiatry, Northeastern Ohio Universities College of Medicine, and RTP Steering Committee Member, was featured on CNN’s “State of the Union,” discussing the mental health aspects of the Arizona shootings.

To watch the video clip, please visit:

http://www.cnn.com/video/data/2.0/video/politics/2011/01/16/sotu.01.16.frese.earley.cnn.html