Bernards Voices

Nature’s Eric Olson interviews Kerry Ressler’s on his research published in Nature 470, February 24, 2011:

Why do some people develop post-traumatic stress disorder, but others emerge from a horrific event relatively unscathed? A molecule involved in orchestrating the brain’s response to stress may hold the key to this difference.

Women are 30 to 50 per cent more likely to develop PTSD than men. (The interview doesn’t address the episodic nature of PTSD. I don’t believe this research tell us anything about an episode’s frequency or intensity–for example, a flashback triggered by a car back fire. Nor does it address the extent with which anxiety episodes are chronic and worsen over time. I have my own personal obsession, I guess would be the word, about whether levels of estrogen and how they change over a woman’s lifetime, impact the intensity of her anxiety or depression.)

During the interview, PTSD is mentioned often by the interviewer, but the researcher, Kerry Ressler, doesn’t seem to differentiate between PTSD, panic and generalized anxiety disorders, as well as depression. The biological factors (the protein: Pituitary adenylate cyclase-activating polypeptide (PACAP), and its modulation by estrogen) impact fear inhibitors and stress responses independent of which anxiety disorder is being discussed. But it does appear that research was conducted on “heavily traumatized subjects,” rats, mice? Why? Because the symptoms were easier to induce and observe? Because the name PTSD is more eye-catching in headlines and grant applications?

Fast forward to minute 6:38 of the podcast:

Related transcript.
Research article abstract.

Dr. Ressler:

I don’t necessarily think that the symptoms at the final common pathway of symptoms level, there is necessarily a difference between men and women, but what we are increasingly learning about complex brain disorders is that there is probably many different ways to get to that disorder.

Mental disorders affect more than 160 million Europeans — 38% of the population — each year, says a report1 issued today by the European Brain Council and the European College of Neuropsychopharmacology. Yet, fewer than a third of those affected receive treatment.

This number is higher than the “1 in 4″ that we in Healthy Outcomes Partnership quote. It is higher because this study includes elderly and children, and also because it includes disorders like insomnia.

Led by Hans-Ullrich Wittchen, a psychologist at the Technical University of Dresden in Germany, the three-year study covered the 27 countries in the European Union (EU) as well as Switzerland, Norway and Iceland. The researchers found that the most common disorders are anxiety, insomnia and depression, which account for 14%, 7% and 6.9% of the total, respectively.

In a previous report also led by Wittchen, health-care costs to the EU for mental disorders were estimated at around €277 billion (US$394 billion). In October, Wittchen and his colleagues will publish a report estimating the present cost of these diseases to governments. Wittchen hints that the true figure, with the addition of new conditions, age ranges and countries, could be more than double the 2005 estimates.

“It’s very rare that you get treatment in the year after onset,” said Wittchen.

The higher figure resulted from the addition of 14 previously excluded disorders, many of which affect children and the elderly. But the frequency of mental disorders has probably not gone up substantially, Wittchen says. “There’s no evidence for changing rates.”

Or listen to the podcast (fast forward to time 6:37).

Kerri Smith reports in Mental disorders affect more than a third of Europeans: Nature News.

From May 10th, The New York Times, Alastair Gee reports that “Hazy Recall as a Signal Foretelling Depression”

–in studies under way at Oxford and elsewhere, scientists are looking … to gain new insights into the diagnosis and treatment of depression. They are focusing not on what people remember, but how.

The phenomenon is called overgeneral memory, a tendency to recall past events in a broad, vague manner. “It’s an unsung vulnerability factor for unhelpful reactions when things go wrong in life,” said Mark Williams, the clinical psychologist who has been leading the Oxford studies.

Some forgetting is essential for healthy functioning — “If you’re trying to remember where you parked the car at the supermarket, it would be disastrous if all other times you parked the car at the supermarket came to mind,” said Martin Conway, a cognitive psychologist at the University of Leeds in England. But, a chronic tendency to obliterate details has been linked to longer and more intense episodes of depression.

This is one of my posts, which is just a string of excerpts from the article, but the article is clear, really speaks for itself.

And an unusual paper suggests that overgeneral memory is a risk factor for post-traumatic stress disorder. Scientists at the University of New South Wales in Sydney, Australia, assessed 46 firefighters during their initial training and again four years later, when all had experienced traumatic events like seeing comrades injured or killed. Those who could not recall the past in specific detail during the first assessment were much likelier to have developed the disorder by the later one.

Is overgeneral memory the chicken or the egg? “perhaps overgeneral memory exists in the first place … to block particular traumatic or painful memories.”

Without detailed memories to draw upon, dispelling a black mood can seem impossible. Patients may remember once having felt happy, but cannot recall specific things that contributed to their happiness, like visiting friends or a favorite restaurant.

Some experts think such insights could also be helpful in treating depression. For example, Spanish researchers have reported that aging patients showed fewer symptoms of depression and hopelessness after they practiced techniques for retrieving detailed memories.

Dr. Williams has found that specificity can be increased with training in mindfulness, a form of meditation increasingly popular in combating some types of depression. Subjects are taught to focus on moment-to-moment experiences and to accept their negative thoughts rather than trying to avoid them.

Slate’s Hang Up and Listen podcast, April 18th, covers 3 topics, including Justin Duchscherer’s depression. Fast forward to minute 33:30–although I enjoy the whole podcast–but it is the last segment which deals with Baltimore Orioles pitcher Justin Duchscherer’s battle with depression. They spend a lot of time talking Joe Posnanski’s article in 2009 Sports Illustrated on Zach Grienke who suffered from anxiety disorder.

An excerpt from Pat Jordan’s Men’s Journal article on Justin Duchscherer.
Jordan’s 2001 New York Times Magazine article on Rick Ankiel.
A 2010 Sports Illustrated feature on baseball players with depression.
The Reds’ Joey Votto missed part of the 2009 season with anxiety problems.
Dontrelle Willis and Khalil Greene have also suffered from social anxiety disorder.

These topics are covered in other HUAL podcasts. They do the best job–i.e. in the context of entertaining discussion about sports–covering mental illness in sports, and sports psychology–dealing with pressure on the soccer or hockey goalie, the pitcher, the field goal kicker.

Another example from Slate, in the HUAL October 25, 2010, podcast, Brandon Roy went to see a sports psychologist this summer.

http://curetogether.com/depression/ig/treatment-effectiveness-vs-popularity

Click here for the live-updated, interactive version of this infographic, with all the dots labeled.

Emily Anthes reported November 4, 2010 in Slate that “dads get blue too.”

Still, PPD for dads remains understudied, under-recognized, and controversial. Even among scientists who research the baby blues in new fathers, there’s debate about whether “postpartum depression” is the right term. One researcher told me that when talking about men, he prefers “depression during the postnatal period.” Whatever you call it, distress after a baby is born is much easier to explain among moms. Pregnancy and childbirth, of course, are hugely taxing and exhausting for women. And, of course, these processes can wreak havoc with a woman’s hormones and, thereby, her psychological wellbeing.

One of the reasons that postpartum depression has garnered so much attention is because it can have serious consequences for children. The AAP’s new report lists the many ways in which kids of depressed moms may be worse-off: They are more likely to have developmental delays, social and emotional difficulties, cognitive and language problems, and more.

In a pilot program launched at a hospital in Essex, England, the nurses and midwives in the maternity ward screen new dads, as well as moms, for signs of mood problems, both during pregnancy and after childbirth. Experienced dads have also been trained to run a fathers-only telephone helpline. It’s a simple intervention and a good place to start.

I blogged on post partum depression in men last May.

In today’s New York Times, Pam Belluck reports on a new study from the Archives of General Psychiatry, and efficacy of treatments for adolescent depression.

About half of adolescents who recovered from major depression became depressed again within five years, regardless of what treatment or therapy they received to get over their initial depression

In the study, nearly 200 adolescents, 12 to 17, received 12 weeks of fluoxetine (Prozac), cognitive behavioral therapy, both, or a placebo pill. (Those not receiving cognitive therapy met with a psychiatrist for basic support.) Placebo-takers who did not improve after 12 weeks could choose any of the other treatments.

Researchers had previously found that those receiving the Prozac-and-cognitive-therapy combination recovered faster from the first depression. So they expected those youths to be less prone to another depression.

But that did not happen. After 36 weeks, improvement for everyone was similar, researchers said, and by two years most completely recovered. But by five years, 47 percent suffered another major depression, no matter what treatment had helped them recover.

The researchers also expected that youths who improved almost fully during the 12 weeks would have less chance of recurrence. They did not, although those showing no improvement at all at 12 weeks were more prone to another depression after recovery than those who showed at least some progress during the 12 weeks. Teenagers who also suffered from anxiety were more likely to become depressed again.

I’ve posted (eg. in March) here many times before on depression: it is progressive, it is chronic, it needs to be attacked aggressively. In my family’s own personal experience it is devastating if not treated.

Dr. Curry said one limitation to the study was that researchers did not look at specific events in the youths’ lives to see if some encountered more stress than others.

I’ve also posted recently (and in August) that having the parents involved in therapy helps. That doesn’t appear to have been considered in this study. My personal theory is that the parents could use the therapy just as much as the kids. We learn so little about how to parent. We do it seat of the pants. And of course we parents may have issues all of our own.

In the August 25th The New York Times, Pamela Paul reports on preschool depression.

Nothing is fun; I’m bored.  Mickey lies. Dreams don’t come true.

Helen Egger, a Duke University child psychiatrist and epidemiologist, discusses the symptoms.

The misery needs to persist across time, in different settings, with different people. Nor is it enough just to be sad; after all, sadness in the face of unachieved goals or a loss of well-being is normal. But the depressed child apparently has such difficulty resolving the sadness that it becomes pervasive and inhibits his functioning.

Persists. Pervasive.

Among the experts interviewed were:

• Joan Luby is a professor of child psychiatry at Washington University School of Medicine.
• Daniel Klein is a professor of clinical psychology at SUNY Stony Brook.

Preliminary brain scans of Luby’s depressed preschoolers show changes in the shape and size of the hippocampus, an important emotion center in the brain, and in the functional connectivity between different brain regions, similar to changes found in the brains of depressed adults. In a longitudinal study of risk factors for depression, Daniel Klein and his team found that children who were categorized as “temperamentally low in exuberance and enthusiasm” at age 3 had trouble at age 7 summoning positive words that described themselves. By 10, they were more likely to exhibit depressive symptoms. And multiple studies have already linked depression in school-age children to adult depression.

Appropriate Treatment:

For a diagnosis of preschool depression to have any meaningful impact, an appropriate treatment must be found. Talk therapy isn’t practical for children who don’t have the verbal or intellectual sophistication to express and untangle their emotions.

And while practitioners quibble over what to label depression, most agree that for any mood disorder, children this age should not be treated in isolation. “Psychotherapy for depressed preschoolers should always involve the caregiver,” Luby says. “Not because the caregiver is necessarily bad or doing anything wrong, but because the caregiver is an essential part of the child’s psychological apparatus. The child is not an independent entity at this age.”

One established method is called Parent-Child Interaction Therapy, or P.C.I.T. Originally developed in the 1970s to treat disruptive disorders — which typically include violent or aggressive behavior in preschoolers — P.C.I.T. is generally a short-term program, usually 10 to 16 weeks under the supervision of a trained therapist, with ongoing follow-up in the home. Luby adapted the program for depression and began using it in 2007 in an ongoing study on a potential treatment. During each weekly hourlong session, parents are taught to encourage their children to acquire emotion regulation, stress management, guilt reparation and other coping skills. The hope is that children will learn to handle depressive symptoms and parents will reinforce those lessons.

I observed one session in which a therapist deliberately invoked feelings of guilt in the same blond 5-year-old who told the puppets “When bad things happen, I do feel bad.” Seated at a table with his mother, he turned to greet a therapist carrying a tray with two teacups, one elaborately painted. She told him that they were to have a tea party, pointing out her favorite teacup and describing the time it took to decorate it. “I’ll let you use my favorite today,” she beamed. As he gingerly took the rigged cup, its handle snapped off. His face darkened. The therapist lamented the break, ostensibly distraught, and excused herself from the room. The boy’s mother, guided via earset by a therapist watching through a two-way mirror, helped her child work through and resolve his feelings.

“Do you feel like you’re a bad boy?” his mother asked. Most parents want to distract their kids from negative emotions rather than let them process the feelings. “They want to wipe it away and move on,” Luby says. In this session, the mother was instead encouraged to draw the child out.

The boy nodded tearfully. “I feel like I’m going to go into the trash can,” he said.

“Who would put you in the trash can?” his mother asked.

“You would,” he replied in an accusatory voice.

“I would never do that,” she said. “I love you. Accidents happen.” The boy seemed to recover, and they chatted about her earrings, which he flicked playfully with a forefinger. Then his face drooped again.

“Are you mad at me?” he asked, and then added, almost angrily, “I never want to do this activity again.”

“You’re not a bad boy,” she consoled him. Often, parents don’t realize that their children experience guilt or shame, Luby says. “In response to transgression, they tend to punish rather than reassure.”

“I am a bad boy,” the boy said, ducking under the table. “I don’t think you love me now.” He started to moan from the floor, whimpering: “I’m so sad. I’m so sad.”

SUCCESS WITH P.C.I.T. rests heavily on parents, who are essentially tasked with reprogramming their child’s brain to form new, more adaptive habits. Not all parents are equipped to handle the vigilance, the consistency, the sensitivity. But early results look promising.

Today’s letters to the editor in the New York Times on grief are informative.

Gordon Livingston writes:

To set two weeks as the time allocated to mourning the loss of a loved one before receiving a diagnosis of major depression — as proposed in the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — is ridiculous.

This is illustrative of one type of reaction. But it misses the point. Sadness isn’t depression. Loneliness isn’t depression. Mourning and major depression do not mean the same thing. Conflating the 2, by either side of this argument, is a disservice. Depression, that persists two weeks, diagnosed by a psychiatrist or psychologist, a trained professional, should be treated.

In the original op-ed piece, “Good Grief,” Allen Francis (Francis was chairman of the DSM-IV taskforce.) writes:

Grievers with severe and potentially dangerous symptoms–for example, delusional guilt over things done to or not done for the deceased, suicidal desires to join the lost loved one, morbid preoccupation with worthlessness, restless agitation, drastic weight loss or a complete inability to function. But people with such symptoms are rare, and their condition can be diagnosed using the criteria for major depression provided in the current manual, the D.S.M. IV.

I have sympathy with that point of view–just use major depression as the diagnosis–but I don’t support the earlier parts of his op-ed designed to inflame the debate.

Below is also a common argument for inclusion in the DSM–health insurance, then, has a mechanism to help offset the expense. This is valuable. Elena Lister writes:

It is precisely because of my respect for the necessity of the grieving process that I can support its recognition in the diagnostic manual. The only way that many patients can afford therapy is with insurance — which covers only certain mental health diagnoses, and even then in very limited ways.

This debate is being waged by well-meaning people. And if words like “ridiculous” were left out … it might serve an additional useful purpose of raising awareness.

I’ve posted on the DSM5 debate before. You can access these posts by cliking on DSM5 in the right sidebar under Tags. I really like the (yes it lasts 1 hour) This American Life podcast on the DSM referenced towards the end of this post.

Adjusting for differences between groups, researchers found that depression raised the risk of dementia by 72 percent. And the more severe the depression, the greater the risk of dementia later.

July 19 New York Times, Roni Caryn Rabin.