Scans reveal key difference in mental disorders

Bipolar Disorder News | 03 April 2013

Scans have revealed a critical difference in the way the brain processes emotions in people with two closely related mental disorders.

In a letter published recently in the prestigious journal Molecular Psychiatry, Australian researcher Professor Gin Malhi shows biological differences in the brain between people with bipolar disorder and those with borderline personality disorder.

Director of the CADE Clinic at the University of Sydney, Malhi says the findings have important implications for treatment as the two disorders are often misdiagnosed.

"Bipolar disorder and borderline personality disorder are difficult to distinguish because emotion dysregulation is a key feature of both," says Malhi.

"The key problem is we don't have biological markers for any psychiatric disorder," says Malhi. "Diagnosis is dependent on symptoms and grouping of symptoms into syndromes."

These groupings are outlined in the Diagnostic and Statistical Manual of Mental Disorders with the latest and fifth edition, DSM5, to be released in May.

Malhi says the two disorders have traditionally been separated as Axis 1 and Axis 2 disorders within the manual. Axis 2 disorders are personality based and therefore long-term disorders, while Axis 1 can come and go and can theoretically be cured," says Malhi.

Wrong treatment

Critically the treatments for the two disorders are quite distinct with those with bipolar treated primarily with medication, while borderline personality disorder is treated psychotherapeutically.

"If patients are misdiagnosed they are not getting the treatment they need," says Malhi.

The study involved imaging the brains of 16 non-depressed bipolar patients, 13 borderline personality disorder patients and 14 controls with no mental illness.

While the brain was being scanned they undertook a task known as the emotional Stroop that makes participants work and engage key networks within the brain.

"The task causes a lot of conflict and if you have to do it repeatedly it is exceptionally taxing," he says. Malhi says he adapted this task to focus on emotional responses and looked at how the regulatory circuits in the brain responded.

He says the study showed a clear difference in the biology of the two mental disorders. "Patients with bipolar are able to function quite normally when well," says Malhi.

"[But] they have to do it at the cost of extra effort in the brain." He likened it to the extra energy a short person would use when trying to keep pace walking with a taller person. "The dorsomedial prefrontal cortex is critical and this is the area that they are drawing on," says Malhi.

Borderline personality disorder patients show heightened activity in the amygdala, which is the area related to our fear response. "It is the key node in the lower part of the brain that co-ordinates emotional understanding … and they are not able to regulate it," he says.

Replication needed

Malhi says the results are "significant" however he stresses the study needs replicating with a larger cohort. He says the finding has "huge" clinical implications and opens the way for better targeted diagnosis and therapy.

"It would be wonderful to put a patient in a scanner, look at their brain and inform our clinical judgments with biological information and direct our therapies accordingly," says Malhi.

However he says the discipline is "still stuck in the previous century in the taxonomy of psychological disorders". "For the first time in the past two decades we have the technology to see the brain functioning [but] these insights and understanding have to be translated into clinical practice."

Most Teens Who Get Off to a Poor Start Don’t Easily Grow Out Of It, Study Indicates

Other News | 03 April 2013

Teenagers’ struggles to connect with their peers in the early adolescent years while not getting swept along by negative peer influences predict their capacity to form strong friendships and avoid serious problems as much as a decade later, concludes a longitudinal study by University of Virginia psychologists that appears today in the journal Child Development.

“Overall, we found that teens face a high-wire act with their peers,” said Joseph P. Allen, the Hugh P. Kelly Distinguished Professor of Psychology in the College of Arts & Sciences at U.Va., who led the study. “They need to establish strong, positive connections with them, while at the same time establishing independence in resisting deviant peer influences. Those who don’t manage this have significant problems as much as a decade later.”

Researchers followed about 150 teens over a 10-year period, starting at age 13, to learn about the long-term effects of their peer struggles early in adolescence. They gathered information from multiple sources – the teens themselves, their parents and peers, and by observing teens’ later interactions with romantic partners. The teens comprised a racially, ethnically and socioeconomically diverse group.

Teens who had trouble connecting well with their peers in early adolescence had difficulty establishing close friendships in young adulthood. Teens who didn’t connect well at 13 also had more difficulty managing disagreements in romantic relationships as adults.

Teens who had trouble establishing some autonomy and independence with peers (especially with respect to minor forms of deviance, such as shoplifting and vandalism) were found to be at higher risk for problems with alcohol and substance use, and for illegal behavior, almost a decade later.

Conversely, teens who were seen as desirable companions – those deemed empathetic, able to see things from different perspectives and control their impulses, and having a good sense of humor – were more likely to have positive relationships in young adulthood.

Teens who were able to establish some autonomy from peers’ influences were more likely to avoid problematic behavior in young adulthood, with teens who showed they were able to think for themselves in the face of negative peer influences using less alcohol as early adults and having fewer problems with alcohol and substance abuse as young adults. But teens who were seen as desirable companions were more likely to have higher levels of alcohol use in early adulthood and future problems associated with alcohol and substance use.

“The findings make it clear that establishing social competence in adolescence and early adulthood is not a straightforward process, but involves negotiating challenging and at times conflicting goals between peer acceptance and autonomy with regard to negative peer influences,” Allen said.

“Teaching teens how to stand up for themselves in ways that preserve and deepen relationships – to become their own persons, while still connecting to others – is a core task of social development that parents, teachers and others can all work to promote,” Allen said.

Teens who managed both of these goals simultaneously – connecting with peers while retaining their autonomy – were rated by their parents as being most competent overall by age 23. “There is a positive pathway through the peer jungle of early adolescence,” Allen said, “but it is a tricky one for many teens to find and traverse.”

The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health funded the study.

Depression and Heart Disease

Depression News | 02 April 2013

Depressive symptoms after heart disease are associated with a markedly increased risk of death or another heart attack. However, less has been known about whether treating heart attack survivors for depressive symptoms could relieve these symptoms, be cost-effective, and ultimately, reduce medical risk? Columbia University Medical Center’s Karina W. Davidson, PhD and her research team now report a patient-centered approach that answers these questions in the affirmative.

With a grant from the National Institutes of Health’s National Heart, Lung, and Blood Institute (NHLBI), Dr. Karina Davidson, director of the Center for Behavioral Cardiovascular Health at CUMC, and her team completed a randomized controlled trial with 150 patients with elevated depressive symptoms two to six months after hospitalization for heart disease. Patients were recruited from seven centers across the United States (NewYork-Presbyterian Hospital/Columbia University Medical Center; Washington University; University of Pennsylvania; Emory University – two sites; and Yale University – two sites); 73 received six months of patient-preference depression care, and 77 received six months of depression care determined by their physician upon notification that the patient had elevated depressive symptoms.

Dr. Davidson will give a presentation about these findings today at the Society of Behavioral Medicine 2013 Annual Meeting & Scientific Sessions (San Francisco, March 20–23). The study was published online on March 7, 2013, in JAMA Internal Medicine.

In the study, those in the patient-preference group were given a choice of therapy or antidepressants, or both. “We tried to help them really think through, what does it take to take a pill every day, what it takes to talk to a person about painful feelings and do homework. We then considered what would fit into their life,” said Dr. Davidson. “Every six to eight weeks, we revisited how their chosen treatment was working for them and helped them make adjustments based upon their feedback.”

Therapy in this study was given virtually (by phone or web-based) by two counselors (one at CUMC and one at Yale), to ensure that patients had access to clinicians of a similar skill set. The virtual therapy also helped connect patients with therapists at times that were most convenient for them. “Maybe 8:00 pm at your home is the right time for you, but not 8:00 pm if you have to go to a clinic or hospital, wait half an hour, and then travel back home afterwards,” said Dr. Davidson, who is also professor of behavioral medicine in medicine, cardiology, and psychiatry, CUMC.

The therapy used in the trial was problem-solving treatment (PST)—a practical, hands-on approach that asks patients to choose the problems in their life that they want to tackle and teaches them how to problem-solve. Patients were assigned homework to try the solutions and then returned to talk about what worked and what didn’t, and tackle the next problem.

“What we want to know is whether this kind of patient-preference, centralized, heart disease-specific depression care was feasible and effective, and whether it also has the tantalizing possibility of being cost-neutral within six months,” said Dr. Davidson.

The findings showed that depressive symptoms were reduced more in the patient-preference, centralized depression care group than in the group of patients receiving usual care. At the start of the trial, patients had an average of 19 points on the Beck Depression Inventory (BDI) depression scale. At the end of the trial, BDI scores in the patient-preference group were significantly reduced, by an average of 3–6 points more than in the other group. Getting below 10 on the BDI puts one in the normal range—and almost half of the group who received patient-preference, centralized treatment got down to the normal range, compared with only one-third of the usual-care group.

Researchers found that running centralized depression care at seven sites nationwide was effective, suggesting that it is feasible to deliver depression care to those who do not have specialists in their area. Overall, the total health care costs for the patient-preference depression treatment group was $325 less than for the usual-care group, even when factoring in the cost of therapy. And fewer hospitalizations were seen in the patient-preference group than in the usual-care group.

“We really wanted to know whether we can treat depressive symptoms in a large group of patients nationwide and if doing so ultimately lowers their risk of death or having another heart attack,” said Dr. Davidson. “Routine management of depressive symptoms in heart disease patients has been poor and lacked an evidence base. With these results, which will help us understand what we can do to relieve the suffering of those who experience both disabling problems, we can now propose a large, national trial more effectively and efficiently.”

The authors declare no financial or other conflicts of interest.

Humanoid robot helps train children with autism

Autism Spectrum Disorders News | 02 April 2013

“Aiden, look!” piped NAO, a two-foot tall humanoid robot, as it pointed to a flat-panel display on a far wall. As the cartoon dog Scooby Doo flashed on the screen, Aiden, a young boy with an unruly thatch of straw-colored hair, looked in the direction the robot was pointing.

Aiden, who is three and a half years old, has been diagnosed with autism spectrum disorder (ASD). NAO (pronounced “now”) is the diminutive “front man” for an elaborate system of cameras, sensors and computers designed specifically to help children like Aiden learn how to coordinate their attention with other people and objects in their environment. This basic social skill is called joint attention. Typically developing children learn it naturally. Children with autism, however, have difficulty mastering it and that inability can compound into a variety of learning difficulties as they age.

An interdisciplinary team of mechanical engineers and autism experts at Vanderbilt University have developed the system and used it to demonstrate that robotic systems may be powerful tools for enhancing the basic social learning skills of children with ASD. Writing in the March issue of the IEEE Transactions on Neural Systems and Rehabilitation Engineering, the researchers report that children with ASD paid more attention to the robot and followed its instructions almost as well as they did those of a human therapist in standard exercises used to develop joint attention skill.

The finding indicates that robots could play a crucial role in responding to the “public health emergency” that has been created by the rapid growth in the number of children being diagnosed with ASD. Today, one in 88 children (one in 54 boys) are being diagnosed with ASD. That is a 78 percent increase in just four years. The trend has major implications for the nation’s healthcare budget because estimates of the lifetime cost of treating ASD patients ranges from four to six times greater than for patients without autism.

“This is the first real world test of whether intelligent adaptive systems can make an impact on autism,” said team member Zachary Warren, who directs the Treatment and Research Institute for Autism Spectrum Disorders (TRIAD) at Vanderbilt’s Kennedy Center.

The initial impetus for the project came from Vanderbilt Professor of Mechanical Engineering and Computer Engineering Nilanjan Sarkar. His original research involved the development of systems to improve the man-machine interface. He did so by outfitting computer/robot users with biosensors and analyzing variations in various readings like blood pressure and skin response to evaluate their emotional state. The information was used to program computers and robots to respond accordingly.

Six years ago, when visiting his cousin in India, Sarkar learned that his cousin’s son had been diagnosed with ASD. “After I learned something about autism, it occurred to me that my research could be valuable for treating ASD,” he said.

At the time, several experiments had been conducted that suggested young children in general, and young children with ASD in particular, found robots especially appealing. “We knew that this gave us an advantage, but we had to figure out how to leverage it to improve the children’s social skills,” Sarkar said.

“You can’t just drop a robot down in front of a child and expect it to work,” added Warren. ”You must develop a sophisticated adaptive structure around the robot before it will work.”

To develop this structure, which they named ARIA (Adaptive Robot-Mediated Intervention Architecture), Sarkar and Warren assembled a team that consists of Esubalew Bekele, a graduate student in electrical engineering and computer engineering, Uttama Lahiri, a graduate student in mechanical engineering who is currently an assistant professor of electrical engineering at the Indian Institute of Technology in Gandhinagar, Amy Swanson, a project manager at TRIAD, and Julie Crittendon, assistant professor of pediatrics at the Vanderbilt University Medical Center.

The team decided that a robotic system had the greatest potential working with young children. “Research has shown that early intervention, individualized to the learner’s needs, is currently the most effective approach for helping children with autism develop the foundational social communication skills they need to become productive adults,” Crittendon said.

So the researchers built an “intelligent environment” around NAO, a commercial humanoid robot made in France, whose control architecture was augmented for the purpose. The small robot stands on a table at the front of the room. Flat panel displays are attached to the side walls. The chair where the child sits faces the front of the room and is high enough to put the robot at eye level. The room is equipped with a number of inexpensive web cameras that are aimed at the chair. Their purpose is to track the child’s head movements, so the system can determine where he or she is looking. To aid in this effort, children in the study wore a baseball cap decorated with a strip of LED lights that allowed the computer to infer where they are looking.

NAO has been programmed with a series of verbal prompts, such as “look over here” and “let’s do some more,” and gestures such as looking and pointing at one of the displays, that imitate the prompts and gestures that human therapists use in joint attention training. The protocol begins with a verbal prompt that asks the child to look at an image or video displayed on one of the screens. If the child doesn’t respond, then the therapist provides increasing support by combining a verbal prompt with physical gestures such as turning her head or pointing. When the child looks at the target then the therapist responds with praise, such as telling the child, “good job.”

The setup allowed the researchers to test the relative effectiveness of the robot-based system and human therapists in joint attention training with a dozen 2- to 5-year-old children, six with ASD and a control group of six typically developing children. They alternated short human-led and robot-led training sessions and compared how the children performed.

The test found that the children in both groups spent more time looking at the robot than they spent looking at the human therapist. During the human-led sessions, the children in the control group spent significantly more time watching the therapist than the children with ASD did. In the robot-led sessions, however, both groups spent about the same amount of time looking at the robot.

“The children’s engagement with the robot was excellent,” Crittendon said, “and we saw improvements across the board in both groups.”

One of the key elements of ARIA is its closed loop design. The robot adapts its behavior to each child automatically depending on how he or she is responding. “There is a saying in the field, ‘If you’ve seen one child with ASD, you’ve seen one child with ASD.’ So one size does not fit all. To be useful, the system must be adaptive,” Warren said.

The cost of robotic systems like this will continue to come down in the future so it should easily pay for itself by supplementing human intervention.”In addition, ARIA is not designed to replace human therapists, who are in short supply, but to leverage their efforts. “A therapist does many things that robots can’t do,” said Sarkar. “But a robot-centered system could provide much of the repeated practice that is essential to learning. The cost of robotic systems like this will continue to come down in the future so it should easily pay for itself by supplementing human intervention.”

Warren hopes that robotic systems can act as an “accelerant technology” that actually increases the rate at which children with ASD learn the social skills that they need. Encouraged by the success of this current study, Sarkar and Warren have started developing robot-mediated autism intervention systems that will address other deficits of children with autism such as imitation learning, role playing and sharing.

The research was supported by a Vanderbilt University Innovation and Discovery in Engineering and Science (IDEAS) grant, National Science Foundation award 0967170, National Institutes of Health award 1R01MH091102-01A1 and by the Meredith Anne Thomas Foundation.

A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise

ADHD News | 01 April 2013

Nearly one in five high school age boys in the United States and 11 percent of school-age children over all have received a medical diagnosis of attention deficit hyperactivity disorder, according to new data from the federal Centers for Disease Control and Prevention.

These rates reflect a marked rise over the last decade and could fuel growing concern among many doctors that the A.D.H.D. diagnosis and its medication are overused in American children.

The figures showed that an estimated 6.4 million children ages 4 through 17 had received an A.D.H.D. diagnosis at some point in their lives, a 16 percent increase since 2007 and a 53 percent rise in the past decade. About two-thirds of those with a current diagnosis receive prescriptions for stimulants like Ritalin or Adderall, which can drastically improve the lives of those with A.D.H.D. but can also lead to addiction, anxiety and occasionally psychosis.

“Those are astronomical numbers. I’m floored,” said Dr. William Graf, a pediatric neurologist in New Haven and a professor at the Yale School of Medicine. He added, “Mild symptoms are being diagnosed so readily, which goes well beyond the disorder and beyond the zone of ambiguity to pure enhancement of children who are otherwise healthy.”

And even more teenagers are likely to be prescribed medication in the near future because the American Psychiatric Association plans to change the definition of A.D.H.D. to allow more people to receive the diagnosis and treatment. A.D.H.D. is described by most experts as resulting from abnormal chemical levels in the brain that impair a person’s impulse control and attention skills.

While some doctors and patient advocates have welcomed rising diagnosis rates as evidence that the disorder is being better recognized and accepted, others said the new rates suggest that millions of children may be taking medication merely to calm behavior or to do better in school. Pills that are shared with or sold to classmates — diversion long tolerated in college settings and gaining traction in high-achieving high schools — are particularly dangerous, doctors say, because of their health risks when abused.

The findings were part of a broader C.D.C. study of children’s health issues, taken from February 2011 to June 2012. The agency interviewed more than 76,000 parents nationwide by both cellphone and landline and is currently compiling its reports. The New York Times obtained the raw data from the agency and compiled the results.

A.D.H.D. has historically been estimated to affect 3 to 7 percent of children. The disorder has no definitive test and is determined only by speaking extensively with patients, parents and teachers, and ruling out other possible causes — a subjective process that is often skipped under time constraints and pressure from parents. It is considered a chronic condition that is often carried into adulthood.

The C.D.C. director, Dr. Thomas R. Frieden, likened the rising rates of stimulant prescriptions among children to the overuse of pain medications and antibiotics in adults.

“We need to ensure balance,” Dr. Frieden said. “The right medications for A.D.H.D., given to the right people, can make a huge difference. Unfortunately, misuse appears to be growing at an alarming rate.”

Experts cited several factors in the rising rates. Some doctors are hastily viewing any complaints of inattention as full-blown A.D.H.D., they said, while pharmaceutical advertising emphasizes how medication can substantially improve a child’s life. Moreover, they said, some parents are pressuring doctors to help with their children’s troublesome behavior and slipping grades.

“There’s a tremendous push where if the kid’s behavior is thought to be quote-unquote abnormal — if they’re not sitting quietly at their desk — that’s pathological, instead of just childhood,” said Dr. Jerome Groopman, a professor of medicine at Harvard Medical School and the author of “How Doctors Think.”

Fifteen percent of school-age boys have received an A.D.H.D. diagnosis, the data showed; the rate for girls was 7 percent. Diagnoses among those of high-school age — 14 to 17 — were particularly high, 10 percent for girls and 19 percent for boys. About one in 10 high-school boys currently takes A.D.H.D. medication, the data showed.

Rates by state are less precise but vary widely. Southern states, like Arkansas, Kentucky, Louisiana, South Carolina and Tennessee, showed about 23 percent of school-age boys receiving an A.D.H.D. diagnosis. The rates in Colorado and Nevada were less than 10 percent.

The medications — primarily Adderall, Ritalin, Concerta and Vyvanse — often afford those with severe A.D.H.D. the concentration and impulse control to lead relatively normal lives. Because the pills can vastly improve focus and drive among those with perhaps only traces of the disorder, an A.D.H.D. diagnosis has become a popular shortcut to better grades, some experts said, with many students unaware of or disregarding the medication’s health risks.

“There’s no way that one in five high-school boys has A.D.H.D.,” said James Swanson, a professor of psychiatry at Florida International University and one of the primary A.D.H.D. researchers in the last 20 years. “If we start treating children who do not have the disorder with stimulants, a certain percentage are going to have problems that are predictable — some of them are going to end up with abuse and dependence. And with all those pills around, how much of that actually goes to friends? Some studies have said it’s about 30 percent.”

An A.D.H.D. diagnosis often results in a family’s paying for a child’s repeated visits to doctors for assessments or prescription renewals. Taxpayers assume this cost for children covered by Medicaid, who, according to the C.D.C. data, have among the highest rates of A.D.H.D. diagnoses: 14 percent for school-age children, about one-third higher than the rest of the population.

Several doctors mentioned that advertising from the pharmaceutical industry that played off parents’ fears — showing children struggling in school or left without friends — encouraged parents and doctors to call even minor symptoms A.D.H.D. and try stimulant treatment. For example, a pamphlet for Vyvanse from its manufacturer, Shire, shows a parent looking at her son and saying, “I want to do all I can to help him succeed.”

Sales of stimulants to treat A.D.H.D. have more than doubled to $9 billion in 2012 from $4 billion in 2007, according to the health care information company IMS Health.

Criteria for the proper diagnosis of A.D.H.D., to be released next month in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, have been changed specifically to allow more adolescents and adults to qualify for a diagnosis, according to several people involved in the discussions.

The final wording has not been released, but most proposed changes would lead to higher rates of diagnosis: the requirement that symptoms appeared before age 12 rather than 7; illustrations, like repeatedly losing one’s cellphone or losing focus during paperwork, that emphasize that A.D.H.D. is not just a young child’s disorder; and the requirement that symptoms merely “impact” daily activities, rather than cause “impairment.”

An analysis of the proposed changes published in January by the Journal of Learning Disabilities concluded: “These wording changes newly diagnose individuals who display symptoms of A.D.H.D. but continue to function acceptably in their daily lives."Given that severe A.D.H.D. that goes untreated has been shown to increase a child’s risk for academic failure and substance abuse, doctors have historically focused on raising awareness of the disorder and reducing fears surrounding stimulant medication.

A leading voice has been Dr. Ned Hallowell, a child psychiatrist and author of best-selling books on the disorder. But in a recent interview, Dr. Hallowell said that the new C.D.C. data, combined with recent news reports of young people abusing stimulants, left him assessing his role.

Whereas Dr. Hallowell for years would reassure skeptical parents by telling them that Adderall and other stimulants were “safer than aspirin,” he said last week, “I regret the analogy” and he “won’t be saying that again.” And while he still thinks that many children with A.D.H.D. continue to go unrecognized and untreated, he said the high rates demonstrate how the diagnosis is being handed out too freely.

“I think now’s the time to call attention to the dangers that can be associated with making the diagnosis in a slipshod fashion,” he said. “That we have kids out there getting these drugs to use them as mental steroids — that’s dangerous, and I hate to think I have a hand in creating that problem.”

Medicines Used to Treat Bipolar Disorder

Bipolar Disorder News | 01 April 2013

Bipolar Disorder is a very challenging condition to treat. While there are few that would argue against the fact that there is a "chemical imbalance," there remain many questions as to which chemicals need to be addressed. Our brain is bathed in many different neurotransmitters. These neurotransmitters serve as the communication devices between neurons. Therefore, without properly functioning neurotransmitters, our brain does not function in a healthy and predictable manner. In the case of Bipolar Disorder, theorists believe that symptoms are a result of a combination of problematic chemicals in several key regions of the brain.

As I mentioned last week, there is not a test that can be performed to identify the presence of Bipolar Disorder. Rather, the condition is a clinical diagnosis, made through close assessment of behaviors and emotions over a period of time.

Back to the issue at hand. That is, if Bipolar Disorder is identified, what do we do about it?

The cornerstone of treatment for Bipolar Disorder is medication. There are several classes of medications used, including mood stabilizers and antipsychotics. Lithium, like most other mood stabilizers, levels out particular neurotransmitters, thereby reducing the fluctuations in brain chemistry. Similarly, antipsychotics are used to calm the brain, especially neurotransmitters such as serotonin and dopamine.

Medication for these patients are very important. That said, many people with Bipolar Disorder dislike taking the medications. Some, like the antipsychotics, are often accompanied by troubling side effects. Moreover, antipsychotic medications often make people feel unable to experience excitement and happiness. This is because these medications decrease dopamine, the "pleasure chemical" in our brain.

While there are benefits to the mood stabilizers in regard to medication, some of them slow cognitive processing. More importantly, some of them, like Lithium, require frequent blood monitoring to avoid toxicity.

Despite the issues related to medication use in Bipolar Disorder, the need for the medications remain. Without medication support, many people with Bipolar Disorder are unable to control the variations in their mood. Nonetheless, some people will benefit from therapy to help learn relaxation techniques and stress avoidance strategies. Well-known to most, stress and a tendency to over-commit are often major triggers for manic episodes.

In addition to treatment for the patient, family members also require support. Psychoeducation is critical for family members, who often find themselves in the midst of a storm they cannot avoid. They tend to be victims of the manic or depressive episodes experienced by their loved one with little power to help. Many, especially children, have great difficulty understanding the aberrant behaviors and unpredictable actions.

While Bipolar Disorder is a life-long condition that will always require treatment, therapy (both psychotherapy and medication therapy) is often beneficial to the person. Treatment may decrease the frequency and intensity of mood episodes. In fact, for some, treatment can eliminate them all together. This can lead some into a false sense of safety, resulting in a discontinuation of treatment. Unfortunately, problems tend to reemerge. In these times, it is important that loved ones support the individual until they are prepared to return to treatment. Unless they are a danger to themselves or others, no one can be forced into treatment. As such, we are often left to watch the disaster occur. We must, however, remain vigilant so that when the storm passes, we can help our loved one pick up the pieces.

Solutions for stage fright prove elusive

Anxiety News | 31 March 2013

Stage fright is the bane of the performer's existence. Severe anxiety has interfered with the work of classical musicians, including guitarist Andres Segovia, cellist Pablo Casals and pianists Glenn Gould and Van Cliburn. Pop performers — from Barbra Streisand and Andrea Bocelli to Carly Simon and Rod Stewart — have suffered intensely from it.

The traditional treatment is a quick swig of beverage alcohol, taken as needed, but that has obvious risks. Today, the possibilities include Valium, hypnotherapy, cognitive behavioral therapy, meditation, and, especially, the class of drugs known as beta blockers, widely known as "the musician's underground drug," or "better living through chemistry."

Beta blockers such as propranolol (often referred to by a brand name, Inderal) are used to treat everything from hypertension to heart attacks to tension headaches. They slow the heart rate, fight off stress hormones and restrain the amygdala, the part of the brain that controls emotion.

That, in turn, calms the fight-or-flight reaction that can make heartbeats race, palms go sweaty, and minds go blank. It can make a nervous musician calm in an audition, or make a difficult solo go more smoothly. A 10 milligram dose (a typical prescription for high blood pressure is 40 milligrams) will keep its taker calm for four to five hours.

A 1987 study by the International Conference of Orchestra Musicians indicated that 27 percent of its polled members said they used beta blockers. In more recent surveys, more than half of professional musicians and music teachers have reported using them. The figures are thought to be higher among conservatory students.

Their use is not without a degree of controversy — they're illegal for Olympians, although use for stage fright is medically approved — and many people who use blockers decline to go on the record about them. A spokeswoman for the Juilliard School responded to a request for comments with a curt, "We're going to pass on that story."

There is disagreement among musicians concerning their use. To St. Louis Symphony Orchestra principal horn Roger Kaza, taking beta blockers for performance anxiety is the equivalent of taking aspirin for a headache. To retired SLSO violinist Darwyn Apple, they give the performer who takes them an unfair advantage over others. To some observers, they can make a performance dull.

A recent Facebook discussion about their use between present and former members of the SLSO grew heated; only two participants responded to requests for interviews on the subject. Although anecdotal evidence suggests that their use is commonplace, some who had been previously open about them clammed up when asked directly.

Kaza plays an instrument known for humbling performers; he takes beta blockers as needed, for auditions, recitals and some orchestral performances "if it's certain repertoire that I know will be a little more anxiety-producing," he said.

Kaza, like others, stressed that the use of beta blockers should not be equated with performance-enhancing drugs, many of them dangerous to the user, such as the steroids, hormones and blood doping used by some athletes to make them stronger or faster.

Those "have nothing to do with the drugs performers take," he said. "Beta blockers are more in the vein of medical impairment/treatment. Think headache/aspirin, sniffles/antihistamine, performance anxiety/beta blockers. It's funny that some people are ashamed of it. If you were against all medicine — if you were a Christian Scientist — that would be one thing, but if you take medications for other things, I don't see the problem."

Fight-or-flight is, he noted, "hardwired" into mammals through eons of evolution. "It clearly has a survival advantage and thus is passed on in the gene pool," Kaza said. Musicians at all levels have a lot on the line when they perform, from earning a living to the satisfaction of doing their best. Fear and anxiety can get in the way of that.

"We're nervous because we're comparing ourselves with a CD that's perfect," he said. "It's an impossible situation."

Apple strongly disagrees. "The playing field is not level," he said of when some performers have what he calls a chemical advantage. "I practiced. I prepared. You have to be balanced and grounded to withstand the unfair competition."

He thinks the use of beta blockers changes more than stage fright. "I can pretty much tell who's used them. There's a whole different sense of energy that comes from them when they're ready to perform that seems really artificial. There's a distance. It's a whole different zone that I don't want to be in."

Instead, said Apple, "I use the adrenaline. There's no holding back. The music is a powerful force, and I don't think it should be corrupted by the use of drugs. Nobody seems to care in the performance industry; the only thing that seems to matter is cranking out the right notes in the right place. But a slip of the fingers does not destroy the artistry and full impact of a piece if you're a performer who's been properly trained."

Kenneth Rybicki, an internist and clinical instructor at Washington University School of Medicine, has prescribed beta blockers for musicians, usually at their specific request.

"My experience is that, for most of them, it's just for once in a while, if they really need something to calm things down," Rybicki said. "But if somebody said to me, Every time we rehearse I get nervous,' I would see if there are any other underlying causes."

Like most of those interviewed for this story, Rybicki stressed the importance of using beta blockers under a doctor's supervision. They can have side effects from sleepiness to diabetes, nightmares and bronchial constriction, and can be fatal for asthmatics.

Dr. Randi Mozenter, a clinical psychologist at Barnes-Jewish HealthCare, deals regularly with musicians and performance anxiety. She doesn't think using blockers is an issue. "It's an individual decision between the person and their physician," she said.

"When people are in situations which are anxiety-provoking, they get the same physiological reaction that they would if they were facing a bear in the woods. It is a very striking response, with sweating, rapid heartbeat, coldness in the extremities. The brain shifts to reacting instead of problem-solving; there can be feelings of impending doom. People end up in emergency rooms every day for (anxiety), thinking they're having a life-ending event."

World first online treatment helps depression and heart disease

Depression News | 29 March 2013

University of Sydney researchers have found a 40 percent improvement in the mental health of people with both depression and cardiovascular disease after using e-couch - a free online program that helps depression or anxiety sufferers regain control of mood to improve their lives.

Published today in Plos One, the study found e-couch to be more effective at improving the health of people with both depression and cardiovascular disease than providing health and lifestyle advice.

The study of 562 participants compared the health outcomes of people who used e-couch, with those who used an equivalent online program that delivered healthy lifestyle information about depression, nutrition, physical activity, blood pressure and cholesterol and heart health.

The participants who used e-couch improved by 40 percent, compared to those just given health information. Participants were also 40 percent less likely to be depressed after using the program.

There were similar improvements in anxiety and people reporting sticking with a medication and healthy lifestyle.

Paper lead author, Professor Nick Glozier, from the University's Brain and Mind Research Institute (BMRI), said the findings had a far-reaching impact, with more 8000 people using the online program every month nationally.

"We saw that using e-couch gave a greater improvement in people's mood and anxiety," he said.

"Interestingly, those who used e-couch also showed better adherence to medical treatments and some improvements in their lifestyle."

E-couch comprises 12 modules of psychoeducation, cognitive behaviour therapy, and interpersonal psychotherapy techniques that have been shown to be effective against depression in younger people without other health problems.

"In high income countries like Australia, cardiovascular disease and depression are the two leading causes of disease burden," Professor Glozier said.

"Depression is more common in people who have cardiovascular disease, and can prevent people from regaining their health.

"Evidence suggests that people with both depression and cardiovascular disease have poorer health outcomes because they are less likely to follow medical treatments and exercise less."

"Our study shows that for people with mild to moderate depression and physical health problems, online interventions targeting mood problems are more effective at improving psychological health and some aspects of physical health than health and lifestyle advice alone."

Protein-Rich Breakfasts Prevent Unhealthy Snacking in the Evening, MU Researcher Finds

Eating Disorders News | 29 March 2013

For a new study, 20 overweight or obese adolescent females ages 18-20 either skipped breakfast, consumed a high-protein breakfast consisting of eggs and lean beef, or ate a normal-protein breakfast of ready-to-eat cereal. Every breakfast consisted of 350 calories and was matched for dietary fat, fiber, sugar, and energy density.

The high-protein breakfast contained 35 grams of protein. Participants completed questionnaires and provided blood samples throughout the day. Prior to dinner, a brain scan using functional magnetic resonance imaging (fMRI) was performed to track brain signals that control food motivation and reward-driven eating behavior.

As reported in the American Journal of Clinical Nutrition, eating the high-protein breakfast led to increased fullness or “satiety” along with reductions in brain activity that is responsible for controlling food cravings. It also reduced evening snacking on high-fat and high-sugar foods compared to when breakfast was skipped or when a normal protein, ready-to-eat cereal breakfast was consumed, says Heather Leidy, assistant professor in the department of nutrition and exercise physiology at the University of Missouri.

“Eating a protein-rich breakfast impacts the drive to eat later in the day, when people are more likely to consume high-fat or high-sugar snacks,” Leidy says. “These data suggest that eating a protein-rich breakfast is one potential strategy to prevent overeating and improve diet quality by replacing unhealthy snacks with high quality breakfast foods.”

People who normally skip breakfast might be skeptical about consuming food in the morning, but Leidy says it only takes about three days for the body to adjust to eating early in the day.

Study participants ate egg and beef-based foods such as burritos or egg-based waffles with applesauce and a beef sausage patty as part of a high-protein breakfast; Leidy also suggests eating plain Greek yogurt, cottage cheese, or ground pork loin as alternatives to reach the 35 grams of protein.

Future research will examine whether regularly consuming high-protein breakfasts improves body weight management in young people.

Bipolar Disorder Treatment for Children

Bipolar Disorder News | 28 March 2013

Bipolar disorder treatment for children often is not effective, and this is also true for the various subtypes (phenotypes) of the condition. But recent research efforts have shown that use of a drug known mainly as an anesthetic has provided impressive results when used by children with a certain phenotype of bipolar disorder.

Bipolar disorder (also referred to as manic-depressive disorder) affects approximately 5.7 million adults in the United States. Although the average age of onset is 25 years old, younger people can develop the disease as well.

The Depression and Bipolar Support Alliance reports that bipolar disorder is more likely to affect children whose parents suffer with the condition. Presence of bipolar disorder in one parent increases the risk to each child by 15 to 30 percent. More than one million children and adolescents who have depression in the United States may actually have early onset of bipolar disorder.

Symptoms of bipolar disorder among young people tend to differ from those in adults. Children and adolescents are more likely to display aggression, irritability, sleep problems, and destructive outbursts when in the manic stage than are adults. During the depressive stage, young people usually have more physical complaints than do adults, such as headache and fatigue, and also to be extremely sensitive to failure or rejection and suffer feelings of worthlessness.

Psychiatrist Demitri Papolos, director of research at the Juvenile Bipolar Research Foundation and a researcher at the Albert Einstein College of Medicine, has published a study concerning the use of a new way to treat children with a subtype of bipolar disorder that he calls “fear of harm.”

Although there is still much controversy among mental health professionals about the presence of bipolar disorder in children and adolescents and the existence of a fear of harm phenotype, Papolos believes there are hundreds of thousands of such individuals.

In an NPR interview, Papolos discussed how he treated a young man, George McCann, who has suffered with bipolar disorder since he was very young. Specifically, McCann has a form of fear of harm phenotype, and he can become very aggressive, particularly if he feels threatened, although his actions are not premeditated.

Papolos reported how McCann responded to treatment withketamine, a drug used mainly as an anesthetic. However, it has been shown to have rapid antidepressive qualities when given intravenously to adults with treatment-resistant depression.

For McCann, once he got over his extreme fear of trying the drug, use of an intranasal form of ketamine, taken every three days, has dramatically improved his life. Papolos has treated about 60 other young people with ketamine, and only two have not had extraordinary responses.

Results of a new study by Papolos and his team appearing in the issue of theJournal of Affective Disorderreported on 12 young people (10 males, 2 females) ages 6 to 19 years who had fear of harm-phenotype bipolar disorder. None of the young people had responded to prior treatment with the typical drug options, including antipsychotics, mood stabilizers, and benzodiazepines.

One to two weeks before and after treatment with intranasal ketamine, the participants were evaluated for symptoms.

Use of ketamine results in “substantial reduction” in mania, fear of harm, and aggressive behavior. Overall, significant improvements were noted in anxiety and behavioral symptoms, insomnia and other sleep problems, mood, and attention.

Much still is not understood about bipolar disorder among young people, and especially about the fear of harm phenotype. However, the results of the work by Papolos and the use of ketamine as a bipolar disorder treatment offer hope and may open new doors to therapeutic possibilities.