Caffeine No Substitute for a Nap to Enhance Memory: Equivalent of 2-3 Cups of Coffee Worsens Motor Learning and Word Recall

Hoping to improve your tennis serve? It's probably better to catch a few winks than load up on java after a lesson, results of a NIMH-supported study suggest. Caffeine impaired such motor learning and verbal memory, while an afternoon nap benefited all three types of learning tested by Sara Mednick, Ph.D., and colleagues at the University of California, San Diego. The researchers report on their findings in the November issue of Behavioural Brain Research. CEUs for MFTs
Background

Ninety percent of Americans use caffeine daily, some substituting it for sleep. While the stimulant enhances alertness and concentration, it's been unclear whether it also helps learning and memory. By contrast, daytime naps, like nighttime sleep, benefit both alertness and memory, Mednick and colleagues have shown in a series of studies.

In this first head-to-head day-time comparison, 61 participants trained in the morning on verbal memory, motor, and perceptual learning tasks. After lunch, one group napped (60-90 min), while two other groups listened to a book on tape and received a pill containing either the caffeine equivalent of a little less than a Tall Starbucks brewed coffee (200mg) or a placebo. Later in the afternoon, the three groups were tested to see how well they had learned the tasks.

Findings of This Study

The nap group performed significantly better on a finger tapping motor task and in recalling words, than the caffeine group. The nap group also trumped the other groups on a texture discrimination task of perceptual learning. The placebo group performed better than the caffeine group on all three tasks. Curiously, just thinking that the pill might contain caffeine — the placebo effect — helped as much as a nap on the motor task.

Significance

Evidence suggests that caffeine interferes with tasks that require processing explicit, as opposed to implicit, information - like recalling a specific word, versus remembering how to type or ride a bike. Studies show that consolidation of such explicit verbal memory during sleep depends on lowered levels of the chemical messenger acetylcholine in the brain's memory hub. Yet, by blocking activity of a natural sedative chemical, caffeine boosts acetylcholine in this hub.

"This increase in acetylcholine by caffeine may impair the consolidation process by blocking replay of new memories," proposes Mednick. "Consistent with this, we found that the greater the explicit component of each task, the worse the caffeine group performed."

What's Next?

"Such an impairment of performance runs counter to society's assumption that caffeine typically benefits cognitive performance," she notes. "Apparent improvements with caffeine might actually reflect a relief from withdrawal symptoms. Just as no medicinal alternative to a good night's rest has been discovered, so too caffeine, the most common pharmacological intervention for sleepiness, may not be an adequate substitute for the memory enhancements of daytime sleep, either."

Mednick and colleagues are using new pharmacological agents found to selectively enhance particular stages of nighttime sleep to see if they can enhance memory consolidation during daytime naps. Brain imaging will pinpoint effects on neural circuits. These studies of pharmacologically enhanced naps could lead to improved treatments for memory impairment in mental disorders, based on manipulations of sleep, say the researchers.

Reference
Mednick SC, Cai DJ, Kanady J, Drummond SP. Comparing the benefits of caffeine, naps and placebo on verbal, motor and perceptual memory. Behav Brain Res. 2008 Nov 3;193(1):79-86. Epub 2008 May 8. PMID: 18554731

Autism Intervention for Toddlers Improves Developmental Outcomes

Children with autism who receive a high intensity developmental behavioral intervention starting by age 18-30 months show major improvements in IQ, language, adaptive behavior, and severity of their diagnosis, according to an NIMH-funded study. Continuing Education for Counselors

Background
Current guidelines by the American Academy of Pediatrics recommend screening children for autism spectrum disorder (ASD) by age 18 months. However, no randomized clinical trials of intensive interventions for this age group had been conducted.

To address this gap, Geraldine Dawson, Ph.D., who was at the University of Washington at the time of the study, and colleagues randomly assigned 48 children, ages 18-30 months, to one of two intervention groups:

Early Start Denver Model (ESDM), a comprehensive, developmental behavioral intervention designed for toddlers with ASD as young as 12 months old. ESDM combines aspects of applied behavioral analysis (ABA) with developmental and relationship-based approaches.
Assess and Monitor (A/M), the comparison group intervention in which parents received recommendations on ASD interventions for their children, as well as referrals to local community providers of the interventions. A/M represents typical community-based care.
Children in the ESDM group were provided 20 hours per week of therapy from study clinicians, while their parents received related training to use ESDM strategies for at least five additional hours per week during their daily activities. Parents of all study participants were also free to receive other community services they thought appropriate.

All children in the study had been diagnosed with autism or a milder form of ASD called pervasive developmental disorder not otherwise specified (PDD-NOS). They were assessed yearly for two years or until the child turned four years old, whichever was longer.

Results of the Study
By the first- year assessment, children in the ESDM group gained 15.4 IQ points on average, while children in the A/M group gained an average of 4.4 points.

Over the two-year study period, children in the ESDM group consistently improved on measures of communication skills. They also showed improvements in motor skills, daily living skills, and other adaptive behaviors.

While children in the ESDM group were significantly delayed in their adaptive behaviors compared to typically developing children, they showed similar rates of improvement. In contrast, children in the A/M group fell further and further behind over time.

By the end of the study, more children who had received ESDM received improved diagnoses than children in the A/M group—seven children initially diagnosed with autistic disorder had their diagnosis change to PDD-NOS after receiving ESDM (30 percent), compared to only one child in the A/M group (5 percent).

Significance
According to the researchers, this is the first randomized controlled trial to study a potentially useful intensive intervention for very young children with ASD.

The study's findings suggest that ESDM can help children with ASD achieve better outcomes in terms of IQ, language, and behavioral skills, and in severity of their ASD diagnosis, than if they receive community-based care. Compared to research on other, similar interventions, this study showed greater differences between groups, suggesting that ESDM, delivered at a very young age, may be more effective than other approaches. The researchers noted that parents' use of ESDM strategies at home may have been key to this intervention's effectiveness.

What's Next
The University of Washington research team has been funded through the NIH Autism Centers of Excellence (ACE) program to follow this study's participants to determine whether the effects of ESDM can be sustained over time. In addition, Dr. Sally Rogers, Ph.D., a co-author on the study and co-developer with Dr. Dawson of the ESDM model, is leading a multi-site, randomized clinical trial of ESDM, also funded through the NIH ACE program. With a larger sample size, the investigators hope to better understand factors that predict level of response to the ESDM intervention.

Reference
Dawson G, Rogers S, Munson J, Smith M, Winter J, Greenson J, Donaldson A, Varley J. Randomized, Controlled Trial of an Intervention for Toddlers With Autism: The Early Start Denver Model. Pediatrics. 2009 Nov 30. [Epub ahead of print] PubMed PMID: 19948568.

Brain Emotion Circuit Sparks as Teen Girls Size Up Peers

What is going on in teenagers' brains as their drive for peer approval begins to eclipse their family affiliations? Brain scans of teens sizing each other up reveal an emotion circuit activating more in girls as they grow older, but not in boys. The study by Daniel Pine, M.D., of the National Institute of Mental Health (NIMH), part of National Institutes of Health, and colleagues, shows how emotion circuitry diverges in the male and female brain during a developmental stage in which girls are at increased risk for developing mood and anxiety disorders. LCSW CEUs
"During this time of heightened sensitivity to interpersonal stress and peers' perceptions, girls are becoming increasingly preoccupied with how individual peers view them, while boys tend to become more focused on their status within group pecking orders," explained Pine. "However, in the study, the prospect of interacting with peers activated brain circuitry involved in approaching others, rather than circuitry responsible for withdrawal and fear, which is associated with anxiety and depression."

Pine, Amanda Guyer, Ph.D., Eric Nelson, Ph.D., and colleagues at NIMH and Georgia State University, report on one of the first studies to reveal the workings of the teen brain in a simulated real-world social interaction, in the July, 2009 issue of the Journal Child Development.

Thirty-four psychiatrically healthy males and females, aged 9 to 17, were ostensibly participating in a study of teenagers' communications via Internet chat rooms. They were told that after an fMRI (functional magnetic resonance imaging) scan, which visualizes brain activity, they would chat online with another teen from a collaborating study site. Each participant was asked to rate his or her interest in communicating with each of 40 teens presented on a computer screen, so they could be matched with a high interest participant.

Two weeks later, the teens viewed the same faces while in an fMRI scanner. But this time they were asked to instead rate how interested they surmised each of the other prospective chatters would be in interacting with them.

Only after they exited the scanner did they learn that, in fact, the faces were of actors, not study participants, and that there would be no Internet chat. The scenario was intended to keep the teens engaged –– maintain a high level of anticipation/motivation –– during the tasks. This helped to ensure that the scanner would detect contrasts in brain circuit responses to high interest versus low interest peers.

Although the faces were selected by the researchers for their happy expressions, their attractiveness was random, so that they appeared to be a mix of typical peers encountered by teens.

As expected, the teen participants deemed the same faces they initially chose as high interest to be the peers most interested in interacting with them. Older participants tended to choose more faces of the opposite sex than younger ones. When they appraised anticipated interest from peers of high interest compared with low interest, older females showed more brain activity than younger females in circuitry that processes social emotion.

"This developmental shift suggested a change in socio-emotional calculus from avoidance to approach," noted Pine. The circuit is made up of the nucleus accumbens (reward and motivation), hypothalamus (hormonal activation), hippocampus (social memory) and insula (visceral/subjective feelings).

By contrast, males showed little change in the activity of most of these circuit areas with age, except for a decrease in activation of the insula. This may reflect a waning of interpersonal emotional ties over time in teenage males, as they shift their interest to groups, suggest Pine and colleagues.

"In females, absence of activation in areas associated with mood and anxiety disorders, such as the amygdala, suggests that emotional responses to peers may be driven more by a brain network related to approach than to one related to fear and withdrawal," said Pine. "This reflects resilience to psychosocial stress among healthy female adolescents during this vulnerable period."






Nodes of a brain circuit for social emotion and approach behavior activated more in teenage girls than in boys with age. Functional MRI data (red) superimposed on anatomical MRI images.

Source: NIMH Emotion and Development Branch







Teenage participants were first asked to rate their interest in peers with whom they might communicate in an internet chat room (left). Two weeks later, while in a brain scanner, they were asked to rate how interested the same peers were in interacting with them (right).

Source: NIMH Emotion and Development Branch

Reference
Probing the neural correlates of anticipated peer evaluation in adolescence. Guyer AE, McClure-Tone EB, Shiffrin ND, Pine DS, Nelson EE. July 2009, Child Development.

###
The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the NIMH website.

The National Institutes of Health (NIH) — The Nation’s Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the NIH website.

Same Behavior, Different Brain in Adolescent and Adult Rats

Science Update • January 28, 2011

Same Behavior, Different Brain in Adolescent and Adult Rats
A study that measured the activity of single cells in the brains of rats found striking differences between adolescents and adults even when both behaved identically on a task motivated by a reward. The finding offers clues to the neurological underpinnings of adolescent behavior and this age group's vulnerability to mental illness. MHC Continuing Education
Background
Numerous lines of research suggest that the adolescent brain, in both animals and humans, undergoes substantial change and maturation. By understanding of the nature of these changes scientists aim to clarify why mental illnesses like schizophrenia and mood disorders often have their first onset in adolescence and why rates of substance abuse and risky behavior is greater for this age group than others.

This Study
Researchers David Sturman and Bita Moghaddam at the University of Pittsburgh recorded the activity of single neurons in adolescent and adult rats as they worked for food rewards. The rats learned a very simple task—poking their nose into an illuminated hole—to receive a food reward. Such simple tasks are a building block for more complex behavior and make it possible to measure brain activity matched to action.

As the rats performed the task, investigators recorded the activity of single neurons in the orbitofrontal cortex, a part of the brain that is involved in the expectation of reward. Prior research has found that this part of the brain is not fully developed in adolescents. In this study, even when adult and adolescent rats behaved in exactly the same way in order to get the food reward, the pattern of firing of single cells in their brains was different. In comparison with adults, at key moments in the test—such as when they received the food reward—there was less inhibition of neuronal activity in the adolescents.

There were also differences in the levels of local electrical potentials which result from synchronized firing of groups of neurons. The levels of these potentials may reflect the capacity for coordinated firing of neurons across brain regions. The observed differences between adults and adolescents could be a reflection of less mature, less efficient connections in the brain in adolescents.

Significance
Brain activity represents an ongoing balance between excitatory and inhibitory activity. Earlier research has identified differences in brain activity between adults and adolescents; these investigators drilled down to the activity of single cells to try and identify the neural roots of differences in brain function linked to rewards; the first time scientists have done so in adolescents. The approach used in this work allowed them to watch how the adolescent brain responds to rewards resulting from behavior in real time.

The authors point out that inhibitory activity is important to the coordinated firing of neurons. The reduced inhibition they saw in adolescents suggests that they may respond more intensively than adults to reward. These more powerful responses may help explain the increased vulnerability of adolescents to the rewarding effects of alcohol and drugs. In addition, findings of differences in the regulation of neuronal firing observed in adolescents may ultimately help explain why schizophrenia—a disorder thought to represent an imbalance in inhibitory and excitatory activity in the brain—so often has its onset during adolescence and early adulthood. The exaggerated balance of excitatory and inhibitory activity in the brain observed in this work, superimposed on a genetically determined vulnerability to schizophrenia, might be a factor tipping someone towards illness. Monitoring how the adolescent brain processes events differently than the adult brain offers a powerful way to understand the vulnerabilities of young people at this age and develop means to intervene early.

Reference
Sturman, D.A. and Moghaddam, B. Reduced neuronal inhibition and coordination of adolescent prefrontal cortex during motivated behavior. Journal of Neuroscience 31:1471-1478, 2011.

Behavioral Training Improves Connectivity and Function in the Brain

Children with poor reading skills who underwent an intensive, six-month training program to improve their reading ability showed increased connectivity in a particular brain region, in addition to making significant gains in reading, according to a study funded in part by the National Institute of Mental Health (NIMH). The study was published in the Dec. 10, 2009, issue of Neuron. LPCC Continuing Education
"We have known that behavioral training can enhance brain function." said NIMH Director Thomas R. Insel, M.D. "The exciting breakthrough here is detecting changes in brain connectivity with behavioral treatment. This finding with reading deficits suggests an exciting new approach to be tested in the treatment of mental disorders, which increasingly appear to be due to problems in specific brain circuits."

For the study, Timothy Keller, Ph.D., and Marcel Just, Ph.D., both of Carnegie Mellon University, randomly assigned 35 poor readers ages 8-12, to an intensive, remedial reading program, and 12 to a control group that received normal classroom instruction. For comparison, the researchers also included 25 children of similar age who were rated as average or above-average readers by their teachers. The average readers also received only normal classroom instruction.

Four remedial reading programs were offered, but few differences in reading improvements were seen among them. As such, results for participants in these programs were evaluated as a group. All of the programs were given over a six month schooling period, for five days a week in 50-minute sessions (100 hours total), with three students per teacher. The focus of these programs was improving readers' ability to decode unfamiliar words.

Using a technology called diffusion tensor imaging (DTI), the researchers were able to measure structural properties of the children's white matter, the insulation-clad fibers that provide efficient communication in the central nervous system. Specifically, DTI shows the movement of water molecules through white matter, reflecting the quality of white matter connections. The better the connection, the more the water molecules move in the same direction, providing a higher "bandwidth" for information transfer between brain regions.

At the outset of the study, poor readers showed lower quality white matter than average readers in a brain region called the anterior left centrum semiovale. Six months later, at the completion of the intensive training, the poor readers showed significant increases in the quality of this region. Children who did not receive the training did not show this increase, suggesting that the changes seen in the remedial training group were not due to natural maturation of the brain.

In an effort to further pinpoint the mechanism underlying this change, the researchers deduced that a process called myelination may be key. Myelin is akin to electrical insulation, allowing for more rapid and efficient communication between nerve cells in the brain. However, the directional association between brain changes and reading improvements remains unclear—whether intensive training brings about increased myelination that results in improved word decoding skills, or whether improved word decoding skills leads to changes in reading habits that result in greater myelination.

"Our findings support not only the positive effects of remediation and rehabilitation for reading disabilities, but may also lead to improved treatments for a range of developmental conditions related to brain connectivity, such as autism," noted Just.


Source: Timothy Keller, Ph.D.; Marcel Just, Ph.D.

Left brain image shows the area of lower quality white matter (blue area) among poor readers relative to good readers at the beginning of the study.

Center brain image shows the area where the white matter quality increased (red/yellow area) among poor readers who received the remedial reading instruction.

Right brain image shows that following the instruction, there were no differences between the poor and average readers with respect to the quality of their white matter.

Reference
Keller TA, Just MA. Altering cortical connectivity: Remediation-induced changes in the white matter of poor readers.

New Approach to Reducing Suicide Attempts Among Depressed Teens

A novel treatment approach that includes medication plus a newly developed type of psychotherapy that targets suicidal thinking and behavior shows promise in treating depressed adolescents who had recently attempted suicide, according to a treatment development and pilot study funded by the National Institute of Mental Health (NIMH). The study, described in three articles, was published in the October 2009 issue of the Journal of the American Academy of Child and Adolescent Psychiatry. Continuing Education for Counselors
Background
Youth who attempt suicide are particularly difficult to treat because they often leave treatment prematurely, and no specific interventions exist that reliably reduce suicidal thinking and behavior (suicidality). In addition, these teens often are excluded from clinical trials testing depression treatments. The Treatment of Adolescent Suicide Attempters Study (TASA) was developed to address this need and identify factors that may predict and mediate suicide reattempts among this vulnerable population. A novel psychotherapy used in the study—cognitive behavioral therapy for suicide prevention (CBT-SP—was developed to address the need for a specific psychotherapy that would prevent or reduce the risk for suicide reattempts among teens. CBT-SP consisted of a 12-week acute treatment phase focusing on safety planning, understanding the circumstances and vulnerabilities that lead to suicidal behavior, and building life skills to prevent a reattempt. A maintenance continuation phase followed the acute phase.

In the six-month, multisite pilot study, 124 adolescents who had recently attempted suicide were either randomized to or given the option of choosing one of three interventions—antidepressant medication only, CBT-SP only, or a combination of the two. Most participants preferred to choose their intervention, and most (93) chose combination therapy. Participants were assessed for suicidality at weeks six, 12, 18 and 24.

Results of the Study
During the six-month treatment, 24 participants experienced a new suicidal event, defined as new onset or worsening of suicidal thinking or a suicide attempt. This rate of recurrence is lower than what previous studies among suicidal patients have found, suggesting that this treatment approach may be a promising intervention. In addition, more than 70 percent of these teens—a population that is typically difficult to keep in treatment—completed the acute phase of the therapy. However, many participants discontinued the treatment during the continuation phase, suggesting that treatment may need to include more frequent sessions during the acute phase, and limited sessions during the continuation phase.

The study revealed some characteristics that could predict recurrent suicidality, including high levels of self-reported suicidal thinking and depression, a history of abuse, two or more previous suicide attempts, and a strong sense of hopelessness. In addition, a high degree of family conflict predicted suicidality, while family support and cohesion acted as a protective factor against suicide reattempts. Other studies have found similar results, according to the researchers.

Significance
Although the study cannot address effectiveness of the treatment because it was not randomized, it sheds light on characteristics that identify who is most at risk for suicide reattempts, and what circumstances may help protect teens from attempting suicide again. In addition, the study found that 10 of the 24 suicide events occurred within four weeks of the beginning of the study—before they could receive adequate treatment. This suggests that a "front-loaded" intervention in which the most intense treatment is given early on, would likely reduce the risk of suicide reattempt even more.

What's Next
The effectiveness of CBT-SP—alone or in conjunction with antidepressant medication—will need to be tested in randomized clinical trials. In the meantime, because many suicide events occurred shortly after the beginning of the trial, the researchers suggest that clinicians emphasize safety planning and provide more intense therapy in the beginning of treatment. In addition, they note that therapy should focus on helping teens develop a tolerance for distress; work to improve the teen's home, school and social environment; and rigorously pursue coping strategies for teens who experienced childhood trauma such as abuse.

References
Vitiello B, Brent D, Greenhill L, Emslie G, Wells K, Walkup J, et al.. Depressive symptoms and clinical status during the treatment of adolescent suicide attempters. Journal of the American Academy of Child and Adolescent Psychiatry 2009;48(10):997-1004.

Brent D, Greenhill L, Compton S,Emslie G, Wells K, Walkup J, et al. The treatment of adolescent suicide attempters (TASA): predictors of suicidal events in an open treatment trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2009;48(10):987-996.

Stanley B, Brown G, Brent D, Wells K, Poling K, Curry J, et al. Cognitive behavior therapy for suicide prevention (CBT-SP): treatment model, feasibility and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry. 2009;48(10):1005-1013.

Runaway Vigilance Hormone Linked to Panic Attacks

Translational Experiments in Rats, Humans Suggest New Medication Target
A study has linked panic disorder to a wayward hormone in a brain circuit that regulates vigilance. While too little of the hormone, called orexin, is known to underlie narcolepsy, the new study suggests that too much of it may lead to panic attacks that afflict 6 million American adults. LPC Continuing Education
"Targeting the brain's orexin system may hold promise for a new generation of anti-anxiety treatments," said Thomas R. Insel, M.D., Director of the National Institute of Mental Health (NIMH), part of the National Institutes of Health. "This is a good example of how translational experiments in rats and humans can potentially yield clinical benefits."

NIMH grantee Anantha Shekhar, M.B., Ph.D., and colleagues at Indiana University and Lund University, report on their findings online Dec. 27, 2009 in the journal Nature Medicine. They showed that blocking orexin gene expression or its receptor prevented panic attack-like responses in rats. The study also revealed that panic disorder patients have excess levels of the hormone.

Background
Orexin, also called hypocretin, is secreted exclusively in a circuit emanating from the brain's hypothalamus, known to regulate arousal, wakefulness and reward.

Panic attacks can be experimentally-induced by infusing susceptible humans with a normally innocuous salt called sodium lactate. The salt similarly triggers panic-like anxiety behaviors in susceptible rat strains, suggesting that something is altered in their arousal circuit. Since sodium lactate activated orexin-secreting neurons in panic-prone rats but not in control rats, the researchers hypothesized that something might be orexin.

Results of This Study
The investigators first discovered that increased gene expression in orexin-secreting neurons correlated with increases in anxiety-like behavior in panic-prone rats following sodium lactate infusions. Using a technique called RNA interference, they then protected the panic-prone rats from developing anxiety behaviors following the infusions by first injecting them with a genetically-engineered agent that prevented orexin genes from turning on. Blocking orexin receptors with a drug that specifically binds to it also blocked the anxiety like behavior following the infusions. This mirrored effects, seen in both rats and humans, of benzodiazepine medications used to treat panic disorder.

The excess sleepiness of narcolepsy, traced a decade ago to loss of orexin-secreting neurons in the arousal circuit, might seem to be an opposite state of a panic attack. However, the researchers demonstrated in rats that such sedation could not account for orexin's effects on anxiety. Also in rats, they traced orexin neurons to their end target to pinpoint the specific brain site that accounts for the anxiety effects, disentangled from cardio-respiratory components of the panic response.

Finally, by measuring orexin in cerebrospinal fluid of 53 patients, the researchers showed that those with just panic disorder had higher levels of orexin than those with both panic disorder and depression.

Significance
Taken together, these results and other evidence suggest a critical role for an overactive orexin system in producing panic attacks, say the researchers.

What's Next?
Medications that block the orexin receptor may provide a new therapeutic approach for the treatment of panic disorder, they add.

The research was also supported, in part, by NIH's National Center for Research Resources.

Reference
A key role for orexin in panic anxiety. Johnson PL, Truitt W, Fitz SD, Kelley PE, Dietrich A, Sanghani S, Traskman-Bendz L, Goddard AW, Brundin, L, Shekhar A. Nature Medicine. Epub 2009 Dec 27.

Just Over Half of Americans Diagnosed with Major Depression Receive Care

More Receive Psychotherapy than Medication; Study Provides New Detail on Disparities
Overall, only about half of Americans diagnosed with major depression in a given year receive treatment for it, and even fewer—about one fifth—receive treatment consistent with current practice guidelines, according to data from nationally representative surveys supported by NIMH. Among the ethnic/racial groups surveyed, African Americans and Mexican Americans had the lowest rates of use of depression care; all groups reported higher use of past-year psychotherapy vs. medication for depression. MFT Continuing Education
Background
Depression is a leading cause of disability in the United States. Past research has found that many people with depression never received treatment, and that the percentage of those receiving treatment varies with ethnicity and race. In order to provide comprehensive and up-to-date information on depression care, with a particular emphasis on minority groups, NIMH's Collaborative Psychiatric Epidemiology Surveys initiative (CPES) has combined data from three nationally representative studies: the National Survey of American Life, the National Comorbidity Survey-Replication, and the National Latino and Asian American Study.

This Study
Scientists at Wayne State University, Detroit, MI; the University of Michigan, Ann Arbor; the University of California, Los Angeles; and the Harvard School of Public Health, Boston, MA, carried out the current study, which reports on data from CPES collected between February 2001 and November 2003 from 15,762 residents 18 years and older. The size of the sample makes it possible to examine health care use in ethnic/racial groups with a new level of detail, distinguishing between groups often surveyed as one population. The investigators were able to break out types of care used, and to assess to what extent the care used was consistent with the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorder. Finally, they examined how factors enabling healthcare access—insurance, education, and household income—influenced rates of care.

A central finding was that overall, 51 percent of all those in the study who met criteria for major depression during the prior year received some kind of treatment for it, with only 21 percent receiving care that was consistent with the APA Guidelines.

Other key study findings addressed disparities, types and quality of care received, and factors that enable access to healthcare.

Prevalence and severity of major depression was similar among the five studied ethnic/racial groups—Mexican Americans, Puerto Ricans, Caribbean Blacks, African Americans, and non-Latino Whites. However, African Americans and Mexican Americans were least likely to receive any care or care consistent with practice guidelines. Compared with non-Latino Whites for example, of whom 54 percent with depression received care, 40 percent of African Americans and 34 percent of Mexican Americans did. The rate of care for Puerto Ricans was close to that of Whites, 50 percent.
Across these population groups, psychotherapy was used more frequently than medications (pharmacotherapy). Overall, 34 percent received pharmacotherapy; 45 percent psychotherapy. Psychotherapy was more likely to be consistent with APA guidelines than pharmacotherapy, suggesting that adherence—the extent to which patients completed the recommended therapy—was greater for psychotherapy than pharmacotherapy. The contrast between the rates of Guideline-consistent psychotherapy and pharmacotherapy use was greatest among Caribbean Blacks, African Americans, and Mexican Americans.
Puerto Ricans had rates of treatment use, and treatment that was consistent with care guidelines, that were similar to, or higher than, non-Latino Whites.
Differences in factors enabling healthcare access appeared to contribute substantially to disparities in mental healthcare use, particularly for Mexican Americans. When differences in these enabling factors were controlled for statistically—so in effect, the population groups being compared had the same rates of enabling factors—the degree of disparities in use of care by Mexican Americans was reduced. For Caribbean Blacks and African Americans, statistical control of enabling factors reduced disparities in psychotherapy use, but not use of pharmacotherapy.
Health insurance coverage was associated with a greater likelihood of depression care, but not guideline consistent care. The pattern with education was reversed: education was associated with a greater likelihood of care that was consistent with the APA Guidelines, but not with greater use of care in general.
Significance
This study, with its large sample size and emphasis on minority groups, provides a more nuanced and detailed picture of the care received for major depression among different ethnic/racial groups and of factors that contribute to disparities. Lead author Hector González at Wayne State University said that Mexican-Americans make up over two-thirds of Latinos in the U.S.: "We found in our study that there are some really distinctive differences in mental healthcare use between Mexican Americans and other Latino subgroups that have not been previously reported." Estimates suggest that Latinos will make up close to one-third of the U.S. population by mid-century; the study findings suggest that Mexican Americans should be a focus of efforts to reduce health disparities to ensure the nation's health in coming decades.

All groups were more likely to have received psychotherapy than pharmacotherapy. Caribbean Blacks and African Americans were particularly unlikely to receive pharmacotherapy consistent with APA guidelines; enabling factors such as education, health insurance, and income did not explain the lower rates of medication use. The authors note possible reasons for this, including research indicating that perceived discrimination can shape health care seeking. They speculate that the non-immigrant status of Puerto Ricans—and with that, greater predominance of English language use within this group—may be factors in their relatively high rates of health care use.

Findings from this study will inform future research on adherence to various depression therapies, and the factors that shape differences in care among racial/ethnic groups. "Future studies," say the authors, "should explore the extent to which patients' subjective experiences of racial bias may affect their access and utilization of mental healthcare."

Reference
González, H.M., Vega, W.A., Williams, D.R., Tarraf, W., West, B.T., and Neighbors, H.W. Archives of General Psychiatry 2010;67(1):37-46.

Novel Model of Depression from Social Defeat Shows Restorative Power of Exercise

In a study in a mouse model that mimics the contribution of social stress to human depression, an environment that promotes exercise and exploration alleviated depressive behavior in the mice. The beneficial effect of activity depended on the growth of new neurons in the adult brain. Continuing education for counselors
Background
In the 1990s scientists established that new neurons grow in the adult as well as the immature brain. The functions of neurogenesis, or new neuronal growth, are still being explored, but it is known that stress slows this growth in the hippocampus―a brain center involved in the formation of new memories―and that antidepressant treatment promotes it.

Previous research in animal models has also demonstrated that environmental enrichment―the addition of features in an animal's cage that provide opportunities for exercise and investigation―fosters resilience to stress and can alleviate the depression-like behavior that results from uncontrollable stress. Environmental enrichment has also been shown to promote hippocampal neurogenesis in animals.

This Study
This work, by Michael Lehmann and Robert Schloesser and colleagues in NIMH's intramural research program, focused on the ability of environmental enrichment to reverse depressive behaviors caused by social defeat, a situation paralleling the social stresses that can trigger human depression. Past work in animal models has often used physical stressors such as electric shock, restraint, or forced exercise to create depressive behaviors. In addition, the scientists inserted a gene in mice that made it possible to selectively interrupt the growth of new neurons at a specific time and in a specific population of cells in the hippocampus, avoiding any spillover effects to other tissues.

More on Mouse Behavior
Although "dominant and aggressive" may not sound like descriptors that apply to mice, male mice in the wild live apart from other males and they are intensely aggressive if housed together. In this study, male mice were allowed to interact directly for no more than five minutes at a time and were supervised to make sure one mouse did not injure or kill the other.

Mice naturally cover territory in the wild; if furnished with running wheels in a cage, they will, on their own, run the equivalent of as much as 6 to 10 kilometers in one day.
Stress―in this case social defeat stress―has unmistakable effects on the behavior of mice. Researchers use a variety of tests to describe changes in behavioral tendencies, including observing how boldly the mice explore an unfamiliar cage; how much time they will choose to spend in a dark (safe) vs. light (risky) compartment; and the extent to which they'll indulge their taste for something pleasant like sweetened water. Mice who have been the losers of repeated social defeats are visibly cautious and subdued, even in the judgment of observers who do not know whether they were winners or losers in a conflict.

Test mice in this study were housed across a partition in the home cage of a dominant, aggressor mouse. For 5 minutes per day, the partition was removed, allowing the "intruder" and dominant mouse to interact directly. After 2 weeks, the test mice consistently behaved submissively. The test mice were then divided and placed in either a spare environment, or one enriched with running wheels, and tubes of various shapes and sizes. Some of the mice assigned to either environment were a standard laboratory strain. Others had an inserted gene targeted to a population of hippocampal cells that give rise to new neurons; in mice with this transgene, the antibiotic valganciclovir is toxic to dividing cells so neurogenesis is prevented when the drug was added to the animals' feed.

The nontransgenic test mice in the enriched environment, but not those in the more spartan cages, recovered from the submissive behavior seen after social defeat. The transgenic mice, in which neurogenesis was stopped, remained submissive, resembling the mice housed in the impoverished environment.

In tests to probe affect, or mood, the transgenic mice housed in the enriched environment also resembled mice housed in the impoverished environment in that they showed the same reduced inclination to explore, greater anxiety, and a less than normal interest in sweet solutions which mice usually prefer. Interruption of neurogenesis had no effects on the baseline health and behavior of the animals, so the lack of new neurons did not cause depression, but interfered with recovery.

Significance
This study demonstrates that psychosocial stress in mice can cause behavior resembling human depression, which environmental enrichment can ameliorate as long as neurogenesis is intact.

Key elements of this study included its use of a social stressor, more analogous to the social experiences that can contribute to human depression than the physical stressors often used in research. In addition, the use of the transgene in test animals enabled the scientists to control the interruption of neurogenesis with precision with respect to both timing and location and with no effects on neighboring cells.

According to author Michael Lehmann, "There are multiple avenues through which environmental enrichment can have a positive impact on depression. In this model we use a natural psychosocial stressor with relevance to social stress in humans, to induce depressive-like behaviors. We show that environmental enrichment can facilitate the recovery from social stress, and that adult neurogenesis is a requirement for the rehabilitating effects of enrichment."

The authors suggest that neurogenesis may be central to the ability of an animal to update emotional information upon exposure to a novel environment. With neurogenesis impaired, they may be unable to integrate information on the features of a new, changed environment. The resulting cognitive distortions may trigger symptoms of major depression.

Research suggests that one important consequence of environmental enrichment is its impact on the function of the body's stress response system. Animals in these enriched environments show positive effects on the physiology of stress resilience. In humans, successful antidepressant treatment is reflected in similar beneficial changes. Prior research has also linked neurogenesis with positive changes in the stress response system.

The authors also point out that in humans, physical exercise and positive psychosocial activity have beneficial effects on depression and stress resilience. Forms of entertainment that encourage mental activity, according to Lehmann, such as reading, video games, exercise and outdoor recreation could have longer lasting changes for many suffering from mild depressive symptoms than pharmacologic treatment, without the accompanying side effects.

Reference
Schloesser, R.J., Lehmann, M., Martinowich, K., Manji, H.K., and Herkenham, M. Environmental enrichment requires adult neurogenesis to facilitate recovery from psychosocial stress. Molecular Psychiatry 2010 Dec;15(12):1152-1163. Epub 2010 March 23.

From Neurons to Thought: Coherent Electrical Patterns Observed Across the Brain

Amidst the background hum of electrical signaling generated by neurons in the brain, scientists have found that local groups of neurons, firing in coordination, sometimes create a signal that is mirrored instantaneously and precisely by other groups of neurons across the brain. These transient episodes of coherence across different parts of the brain may be an electrical signature of thought and actions. MFT CEUs
Background
One of the goals of neuroscience research is to identify how thoughts and actions are encoded in the activity of neurons. A challenge has been to extract meaningful patterns from the ongoing tumult of electrical activity in the brain. This global electrical activity is built from the firing of individual neurons. A single neuron responds to a stimulus in an all or nothing manner—if the stimulus reaches a certain threshold, the neuron “fires” an electrical signal. Groups of neurons firing in a coordinated way create a local electrical field that is in itself a signal that can vary in pattern. These local field potentials (LFPs) have been a target of research.

This Study
In this research, Dietmar Plenz and colleagues at NIMH and Duke University pinpointed LFPs in the cortex that surpassed a minimal size threshold, and then searched the rest of the cortex to see what was occurring at the same time. In each case, they found other answering LFPs across the brain that mimicked each other with high precision: there was no degradation or loss of power (amplitude) in the signal. Unlike what is observed after dropping a stone in a pond—with wavelets getting smaller farther from the stone—the intensity of the LFPs was the same across the brain. The investigators call these LFPs coherence potentials. Although LFPs that occur during these transient episodes of coherence are identical to each other, they are also multidimensional and potentially infinitely diverse, providing a means to encode information. Most LFPs do not reach the threshold that characterizes a coherence potential but with those that do, propagation of the LFPs across the brain is extraordinarily rapid. The authors note that the rapid dispersion of such a signal mimics the spread of ideas and behaviors in social networks; a sufficiently provocative idea can spread very swiftly through a population.

Significance
Coherence potentials simultaneously engage groups of neurons in different parts of the brain with diverse functions. This is consistent with the multi-faceted nature of mental associations and memories—a memory focused on a person or object might conjure various kinds of sensations and thoughts—visual, tactile, auditory, and emotional, for example.

These findings emerged from recent work that demonstrated that, like other systems in nature, the cortex exists at a critical state between stability and instability. A characteristic of this state in the brain is the presence of neuronal avalanches—if a stimulus reaches a certain threshold, it will set off cascades of neuronal firing. This dynamic is analogous to when the slope of a sandpile reaches a point at which adding one more grain will trigger an avalanche. The adherence of the cortex to this critical state ensures that the brain can respond to a wide range of stimuli, but not lapse into a chaos of excess activity (such as the too-synchronous firing during epilepsy). Coherence potentials emerge predominantly when the cortex is critical, that is, when it displays neuronal avalanches. Nudging the cortex away from this point, by inhibiting neuronal signaling with medications for example, disrupts these dynamical patterns.

What’s Next
Coherence potentials were present in cells in culture as well as awake monkeys, a robust demonstration that they occur in the functioning cortex. Future studies will be aimed at monitoring coherence potentials in the context of behavioral function with the ultimate aim of making a connection between specific coherence potentials and behaviors.

Reference
Thiagarajan, T.C., Lebedev, M.A., Nicolelis, M.A., and Plenz, D. Coherence potentials: loss-less, all-or-none network events in the cortex. PLoS Biology 2010, doi:10.1371/journal.pbio.1000278.

Effects on Personality May Be Mechanism of Antidepressant Effectiveness

Results of a study of antidepressant treatment for major depression suggest that changes in personality traits seen in patients taking the drug paroxetine (Paxil) may not be the result of the medication’s lifting of mood but may instead be a direct effect of this class of drugs and part of the mechanism by which they relieve depression. MFT Continuing Education
Background
People with a high level of the personality trait neuroticism—characterized by a tendency to experience negative emotions and moodiness—are more likely than others to develop depression. Neuroticism is one of five personality traits that psychologists use as an organizing scheme for understanding personality: the other four traits are extraversion, openness, conscientiousness, and agreeableness. People who take anti-depressants report lower levels of neuroticism and increased extroversion, in addition to a lifting of depression. The assumption has been that these changes in personality measures were the result, not the cause, of a lifting of depression.

Studies in twins suggest that to a large degree the same genetic factors underlie both neuroticism and depression risk. Research also suggests that the neurotransmitter serotonin plays a role in the expression of both neuroticism and extraversion. The class of anti-depressant drugs to which paroxetine belongs—the selective serotonin reuptake inhibitors (SSRIs)—increase the neurotransmitter’s availability in the brain.

This Study
To test the relationship between SSRIs and personality, investigator Tony Tang and colleagues at Northwestern University, Evanston, IL, the University of Pennsylvania in Philadelphia, and Vanderbilt University in Nashville, TN, randomly assigned patients with major depressive disorder (MDD) to receive paroxetine (120 patients), placebo (60 patients), or cognitive therapy (60 patients).

After 8 weeks, medication and cognitive therapy (CT) each proved more effective than placebo in reducing depression. In addition, measures of neuroticism (based on standard surveys) in the groups receiving medication or cognitive therapy dropped, while extraversion scores rose. The changes were striking; while patients receiving placebo also reported small changes in both traits, the changes in patients on paroxetine were four to eight times as large. Patients receiving paroxetine had much greater changes in personality traits than patients receiving placebo even when the degree of improvement in depression was the same. This suggested that the effects on personality traits were not the result of the drug’s lifting of depression. After accounting for decreases in depression in patients receiving CT, the improvement in extraversion, but not neuroticism, remained significant.

In further comparison of paroxetine with placebo, patients who had initially taken placebo were given the option after 8 weeks to take paroxetine. During the placebo phase, there were small changes in neuroticism and extraversion; much greater changes occurred after 8 weeks on paroxetine. Finally, those patients on paroxetine with the greatest degree of change in neuroticism (but not extraversion) were least likely to relapse to depression; the degree of changes in personality in those receiving CT did not affect the chances of relapse.

Significance
While the neurochemical effects of SSRIs are known, how those changes act to reduce depression is not clear. These results contradict the prevailing assumption that changes seen in personality traits in patients taking SSRIs are a result of the drugs’ effects on depression. SSRIs may alter personality directly—and thus lift depression—or may act on a third factor that underlies both. CT may alter personality by a different path. Continued research on how these treatments work can provide a clearer understanding of the mechanism of action of SSRIs and how treatment can be best used to reduce depression and minimize relapse.

Reference
Tang, T.Z., DeRubeis, R.J., Hollon, S.D., Amsterdam, J., Shelton, R., and Schalet, B. Personality change during depression treatment. Archives of General Psychiatry 2009 Dec;66(12):1322-30.

Symptoms of Bipolar Disorder May Go Undiagnosed in Some Adults with Major Depression

Nearly 40 percent of people with major depression may also have subthreshold hypomania, a form of mania that does not fully meet current diagnostic criteria for bipolar disorder, according to a new NIMH-funded study. The study was published online ahead of print August 15, 2010, in the American Journal of Psychiatry. LPC CEUs
Background
Mania is a symptom of bipolar disorder. According to the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), it is generally defined as a discrete period of increased energy, activity, euphoria or irritability that leads to marked impairment in one’s daily life. The DSM-IV states that a manic episode lasts for one week or more, and may sometimes require hospitalization. Hypomania is defined as a milder form of mania that lasts for four days at a time, but does not interfere with one’s daily activities. The majority of people diagnosed with bipolar disorder experience repeated episodes of hypomania rather than mania.

For this new study, Kathleen Merikangas, PhD., of NIMH, and colleagues aimed to characterize the full spectrum of mania by identifying hypomanic episodes that last less than four days among those diagnosed with major depression. They described this type of hypomania as subthreshold hypomania. Merikangas and colleagues used data from 5,692 respondents of the National Comorbidity Survey Replication (NCS-R), a nationally representative survey of American adults ages 18 and older.

Results of the Study
The researchers found that nearly 40 percent of those identified as having major depression also had symptoms of subthreshold hypomania. Compared to those with major depression alone, those with depression plus subthreshold hypomania tended to be younger at age of onset and to have had more coexisting health problems, more episodes of depression and more suicide attempts. They also found that among those with subthreshold hypomania, a family history of mania was just as common as it was among people with bipolar disorder.

Significance
According to the researchers, the findings indicate that many adults with major depression may in fact have mild but clinically significant symptoms of bipolar disorder. In addition, because many with subthreshold hypomania had a family history of mania, the researchers suggest that subthreshold hypomania may be predictive of future hypomania or mania. Previous research has indicated that young people with subthreshold hypomania symptoms are more likely to develop bipolar disorder over time, compared to those without subthreshold hypomania, said the authors.

What’s Next
The researchers suggest that depression and mania may be defined as dimensions, rather than as discrete diagnostic categories. Clinicians should be aware that patients who report repeated episodes of subthreshold hypomania may have a risk of developing mania, the researcher concluded.

Reference
Angst J, Cui L, Swendsen J, Rothen S, Cravchik A, Kessler R, Merikangas K. Major depressive disorder with sub-threshold bipolarity in the National Comorbidity Survey Replication. American Journal of Psychiatry. Online ahead of print August 15, 2010.

National Survey Confirms that Youth are Disproportionately Affected by Mental Disorders

About 20 percent of U.S. youth during their lifetime are affected by some type of mental disorder to an extent that they have difficulty functioning, according to a new NIMH survey published in the October 2010 issue of the Journal of the American Academy of Child and Adolescent Psychiatry. The data support the observation from surveys of adults that mental disorders most commonly start in early life. CCS Continuing Education
Background
Many regional surveys conducted in the United States have indicated that about one in four to five children experience a mental disorder sometime in their life. But until now, no nationally representative surveys had been conducted to determine if these prevalence rates of a wide range of mental health problems hold true across the nation.

Kathleen Merikangas, Ph.D., of NIMH and colleagues analyzed data from the National Comorbidity Study-Adolescent Supplement (NCS-A), a nationally representative, face-to-face survey of more than 10,000 teens ages 13 to 18. They used standard diagnostic criteria set by the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV) to determine lifetime prevalence of mental disorders among the teens. To follow up on the teens' responses, they also collected data via mailed questionnaires completed by one parent or guardian of each teen surveyed.

Results of the Study
Overall, nearly half of the sample reported having met diagnostic criteria for at least one disorder over a lifetime, and about 20 percent reported that they suffered from a mental disorder with symptoms severe enough to impair their daily lives. In addition,

11 percent reported being severely impaired by a mood disorder (e.g., depression or bipolar disorder),
10 percent reported being severely impaired by a behavior disorder such as attention deficit hyperactivity disorder or conduct disorder,
8 percent reported being severely impaired by at least one type of anxiety disorder.
In addition, about 40 percent of those who reported having a disorder also met criteria for having at least one additional disorder. Those with a mood disorder were more likely than others to report having a coexisting disorder. Underscoring the notion that mental disorders manifest early in life, the researchers also found that symptoms of anxiety disorders tended to emerge by age 6, behavior disorders by age 11, mood disorders by age 13, and substance use disorders by age 15.

The researchers also noted strong links between parental characteristics and their teen's disorders. For example, children of parents with less education (e.g., no college degree) were at an increased risk for having any kind of mental disorder. And compared to teens with married or cohabiting parents, those with divorced parents also were at higher risk for a disorder, especially anxiety, behavior and substance use disorders.

Significance
The NSC-A results provide a broader and longer-term outlook compared with last year's National Health and Nutrition Examination Survey (NHANES), which asked respondents about diagnosed disorders and service use within a 12-month window only, and was limited to six disorders.

According to the NCS-A researchers, the percentage of youth suffering from mental disorders is even higher than the most frequent major physical conditions in adolescence, including asthma or diabetes. The results reiterate the importance of developing prevention strategies and promoting early intervention for at-risk children and adolescents.

What's Next
More research is needed to better understand the risk factors for developing a mental disorder in youth, as well as how to predict which disorders may continue into adulthood. In addition, the researchers acknowledge the need for more prospective research to tease apart the complex interplay among socioeconomic, biological and genetic factors that may contribute to the development of mental disorders in youth.

Reference
Merikangas KR, He J, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J. Lifetime prevalence of mental disorders in U.S. adolescents: Results from the National Comorbidity Study-Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry. 2010 Oct. 49(10):980-989.

Attention woes in kids with Tourette syndrome likely caused by co-occurring ADHD

Co-occurring attention deficit hyperactivity disorder (ADHD) may be at the root of attention problems in children with Tourette syndrome (TS), according to NIMH-funded researchers. Their findings also support the theory that children with TS develop different patterns of brain activity in order to function at the same level as children without TS. The study was published in the November 2010 issue of the Journal of the American Academy of Child & Adolescent Psychiatry. LCSW Continuing Education
Background
Tourette syndrome is a chronic neurological disorder associated with repetitive, involuntary movements and vocalizations called tics. Many with TS also experience neurobehavioral problems such as inattention, hyperactivity, and impulsivity—symptoms that overlap with ADHD. In fact, researchers estimate that between 50-90 percent of youth with TS also have ADHD.

To explore the role of co-occurring ADHD in TS, Denis Sukhodolsky, Ph.D., of the Yale Child Study Center, and colleagues studied 236 children, of which:

56 had TS only
64 had ADHD only
45 had TS+ADHD
71 had neither and served as a comparison group.
The researchers used well-known, standardized measures to evaluate the children's performance on tasks requiring:

Sustained attention and inhibitory control—Participants were shown various letters on a computer screen and told to press a button when they saw certain letters but not press the button when they saw a non-target letter.
Cognitive inhibition—Participants were shown an array of dots on sheets of paper and asked to name their color (red, green, blue) as quickly as possible. In related tasks, participants were shown pages with similarly arrayed words ("red," "green," "blue") printed in black ink or a mismatched color of ink (such as "red" printed in green ink) and asked to read the words as quickly as possible.
Fine motor control—Participants placed small pegs in a specially designed pegboard in 30-second trials using only their dominant hand, only their non-dominant hand, and both hands at the same time.
Visual-motor integration—Participants copied 24 geometric designs, presented in order of increasing difficulty.
Results of the Study
Children with TS+ADHD showed similar problems with sustained attention as children with ADHD only. However, unlike those with ADHD only, children with TS+ADHD performed at the same level as the comparison group on all other tasks.

Children with TS only performed at the same level as the comparison group in tasks involving response inhibition and visual-motor integration. They performed at a slightly lower level than comparison children on the fine motor control task. Girls with TS only scored higher than boys with TS only on fine motor control tasks using their dominant hands.

Significance
The study helps to identify brain functions specific to particular disorders and the mechanisms underlying these functions.

Similarities in performance between children with TS+ADHD and those with ADHD only suggest that co-occurring ADHD may underlie attention problems in children who have TS, according to the researchers.

The researchers also noted that the children with TS only didn't show impairment in response inhibition, lending support to a theory that such children develop compensatory brain mechanisms in an effort to control involuntary tics. Past imaging studies have shown that, during tasks involving response inhibition, children with TS have greater than normal activity in brain areas associated with cognitive control.

Differences in fine motor skills between girls and boys with TS may indicate differing developmental pathways and patterns of brain growth between the sexes. Because problems with fine motor control in childhood are associated with more severe tics in adulthood, the researchers highlighted this finding as an area for further study.

What's Next
Future studies may help advance the understanding of how TS arises and changes in brain growth and functioning that are associated with the disorder.

Reference
Sukhodolsky DG, Landeros-Weisenberger A, Scahill L, Leckman JF, Schultz RT. Neuropsychological functioning in children with Tourette syndrome with and without attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2010 Nov;49(11):1155-64.

Case-managed Care Improves Outcomes for Depressed Patients with Multiple Medical Conditions

Science Update • December 30, 2010

Case-managed Care Improves Outcomes for Depressed Patients with Multiple Medical Conditions
People with diabetes or heart disease plus depression fare better if their medical care is coordinated by a care manager who also educates patients about their condition and provides motivational support, compared to those who receive care from their primary care physician only, according to an NIMH-funded study published December 30, 2010, in the New England Journal of Medicine.

Background
Coexisting depression is common among patients with diabetes or heart disease, especially if their medical conditions are poorly controlled. Having depression puts these patients at higher risk for poor self-care and more medical complications, and a higher risk for death. Patients dealing with multiple chronic conditions also tend to incur higher medical costs.

Wayne Katon, M.D., of the University of Washington, and colleagues at Group Health Research Institute in Seattle developed a team-based intervention approach—TEAMcare—that aimed to improve medical outcomes and ease depression symptoms among these patients. They tested the intervention in a randomized controlled trial of 214 participants in 14 primary care clinics in Washington state. The participants all had poorly controlled diabetes and/or heart disease with coexisting depression.

Half of the patients were randomized to a 12-month trial of TEAMcare, in which a medically supervised nurse care manager coordinated their care with their primary care provider (PCP) and other medical professionals. The nurse care manager also helped patients set goals for controlling their medical conditions, provided motivation and education about taking their medications correctly, consulted with patients' PCPs about changes in medications recommended by supervisors, and encouraged better self-care. The other half of the participants received usual care, in which their PCP consulted with them about depression care and medical disease control, but they did not have a nurse care manager coordinating their care.

Results of the Study
Overall, patients in the TEAMcare intervention fared better than those in usual care. Symptoms of depression eased in the TEAMcare group more so than in the usual care group. Patients in the TEAMcare intervention also showed greater improvements in blood glucose levels, blood pressure and "bad" cholesterol levels, compared to patients in usual care. Patients in TEAMcare were also more likely to have their medications adjusted, indicating a desire to fine-tune their care to achieve better results. TEAMcare patients also reported greater satisfaction with their medical care and a higher quality of life.

Significance
Previous research suggests that patients who are more satisfied with their medical care tend to be more motivated to take better care of themselves and therefore have better outcomes. According to the researchers, TEAMcare offers a promising way of improving outcomes in patients with multiple medical illnesses and depression because it provides systematic patient support as well as assistance to PCPs.

The researchers also note that patients with multiple medical conditions tend to have high health care costs. The study results suggest that a proactive, coordinated intervention like TEAMcare may facilitate better, more efficient care of these patients in particular.

What's Next
TEAMcare was tested among a specific population enrolled in one health plan, using highly trained nurse care managers. Further study is needed to determine whether the approach can be cost-effectively applied to broader populations, and whether less experienced nurse care managers could be used without sacrificing quality of care.
CEUs for MFTs
Reference
Katon WJ, Lin EHB, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D. Multi-condition collaborative care for chronic illnesses and depression. New England Journal of Medicine. Dec. 30, 2010.

Most Children with Rapidly Shifting Moods Don’t Have Bipolar Disorder

Relatively few children with rapidly shifting moods and high energy have bipolar disorder, though such symptoms are commonly associated with the disorder. Instead, most of these children have other types of mental disorders, according to an NIMH-funded study published online ahead of print in the Journal of Clinical Psychiatry on October 5, 2010. Continuing Education for Social Workers
Background
Some parents who take their child to a mental health clinic for assessment report that the child has rapid swings between emotions (usually anger, elation, and sadness) coupled with extremely high energy levels. Some researchers suggest that this is how mania—an important component of bipolar disorder—appears in children. How mania and bipolar disorder are defined in children is important because rapid mood swings and high energy are common among youth.

Furthermore, many experts believe that overdiagnosis and misdiagnosis of bipolar disorder in youth may play a role in the increasing numbers of children being diagnosed with and treated for bipolar disorder. In choosing proper treatment, it is important to know whether children with rapid mood swings and high energy have an early or mild form of bipolar disorder, or instead have a different mental disorder.

In the Longitudinal Assessment of Manic Symptoms (LAMS) study, Robert Findling, M.D., of Case Western Reserve University, and colleagues assessed 707 children, ages 6-12, who were referred for mental health treatment. Of the participants, 621 were rated as having rapid swings between emotions and high energy levels, described as "elevated symptoms of mania" (ESM-positive). Parents of the other 86 children did not report rapid mood swings. These participants were deemed ESM-negative.

Results of the Study
At baseline, all but 14 participants had at least one mental disorder, and many had two or more. Attention deficit hyperactivity disorder (ADHD) was the most frequent diagnosis, affecting roughly 76 percent in both the ESM-positive and ESM-negative groups. However, only 39 percent were receiving treatment with a stimulant, the most common medication treatment for ADHD, at the start of the study.

Only 11 percent of those with rapid mood swings and high energy (69 out of 621) and 6 percent of those without these symptoms (5 out of 86) had bipolar disorder, meaning that only this small percentage had ever experienced a manic episode, as defined by the current diagnostic system. Of the children with rapid mood swings and high energy, another 12 percent (75 children) had a form of bipolar disorder that includes much shorter manic episodes.

Compared to children without rapid mood swings and high energy, those with these symptoms:

Reported more symptoms of depression, anxiety, manic symptoms, and symptoms of ADHD
Had lower functioning at home, school, or with peers
Were more likely to have a disruptive behavior disorder (oppositional defiant disorder and/or conduct disorder).
Significance
Given that 75 percent of ESM-positive youth did not meet the diagnostic criteria for any bipolar disorder, the researchers suggest that bipolar disorder may not be common among children who experience rapid swings between emotions and high energy levels. Nevertheless, children with these symptoms experience significant impairments due to mood and behavior problems.

The researchers also noted that ESM-positive and ESM-negative youth were prescribed psychotropic medications—including antipsychotics—at similar rates. Further study may provide insight into how serious mental illnesses should be treated in children.

What's Next
The study participants will be re-assessed every 6 months for up to 5 years, allowing the LAMS researchers to determine which children with rapid mood swings and high energy develop bipolar disorder later in life. Such research may inform efforts to identify early markers or predictors of the illness as well as possible protective factors.

Reference
Findling RL, Youngstrom EA, Fristad MA, Birmaher B, Kowatch RA, Arnold E, Frazier TW, Axelson D, Ryan N, Demeter CA, Gill MK, Fields B, Depew J, Kennedy SM, Marsh L, Rowles BM, Horwitz SM. Characteristics of Children With Elevated Symptoms of Mania: The Longitudinal Assessment of Manic Symptoms (LAMS) Study. J Clin Psychiatr. Epub 2010 Oct 5.

Violence and Mental Illness: The Facts

The discrimination and stigma associated with mental illnesses largely stem from the link between mental illness and violence in the minds of the general public, according to the U.S. Surgeon General (DHHS, 1999). The belief that persons with mental illness are dangerous is a significant factor in the development of stigma and discrimination (Corrigan, et al., 2002). The effects of stigma and discrimination are profound. The Presidents New Freedom Commission on Mental Health found that stigma leads others to avoid living, socializing, or working with, renting to, or employing people with mental disorders - especially severe disorders, such as schizophrenia. It leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking and wanting to pay for care. Responding to stigma, people with mental health problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment (New Freedom Commission, 2003).

This link is often promoted by the entertainment and news media. For example, Mental Health America, (formerly the National Mental Health Association) reported that, according to a survey for the Screen Actors? Guild, characters in prime time television portrayed as having a mental illness are depicted as the most dangerous of all demographic groups: 60 percent were shown to be involved in crime or violence. Also most news accounts portray people with mental illness as dangerous (Mental Health America, 1999). The vast majority of news stories on mental illness either focus on other negative characteristics related to people with the disorder (e.g., unpredictability and unsociability) or on medical treatments. Notably absent are positive stories that highlight recovery of many persons with even the most serious of mental illnesses (Wahl, et al., 2002). Inaccurate and stereotypical representations of mental illness also exist in other mass media, such as films, music, novels and cartoons (Wahl, 1995).

Most citizens believe persons with mental illnesses are dangerous. A longitudinal study of American?s attitudes on mental health between 1950 and 1996 found, ?the proportion of Americans who describe mental illness in terms consistent with violent or dangerous behavior nearly doubled.? Also, the vast majority of Americans believe that persons with mental illnesses pose a threat for violence towards others and themselves (Pescosolido, et al., 1996, Pescosolido et al., 1999).

As a result, Americans are hesitant to interact with people who have mental illnesses. Thirty-eight percent are unwilling to be friends with someone having mental health difficulties; sixty-four percent do not want someone who has schizophrenia as a close co-worker, and more than sixty-eight percent are unwilling to have someone with depression marry into their family (Pescosolido, et al., 1996).

But, in truth, people have little reason for such fears. In reviewing the research on violence and mental illness, the Institute of Medicine concluded, ?Although studies suggest a link between mental illnesses and violence, the contribution of people with mental illnesses to overall rates of violence is small,? and further, ?the magnitude of the relationship is greatly exaggerated in the minds of the general population (Institute of Medicine, 2006). For people with mental illnesses, violent behavior appears to be more common when there?s also the presence of other risk factors. These include substance abuse or dependence; a history of violence, juvenile detention, or physical abuse; and recent stressors such as being a crime victim, getting divorced, or losing a job (Elbogen and Johnson, 2009).

In addition:

•"Research has shown that the vast majority of people who are violent do not suffer from mental illnesses (American Psychiatric Association, 1994)."
•". . . The absolute risk of violence among the mentally ill as a group is still very small and . . . only a small proportion of the violence in our society can be attributed to persons who are mentally ill (Mulvey, 1994)."
People with psychiatric disabilities are far more likely to be victims than perpetrators of violent crime (Appleby, et al., 2001). Researchers at North Carolina State University and Duke University found that people with severe mental illnesses, schizophrenia, bipolar disorder or psychosis, are 2 ½ times more likely to be attacked, raped or mugged than the general population (Hiday, et al., 1999).

People with mental illnesses can and do recover. People with mental illnesses can recover or manage their conditions and go on to lead happy, healthy, productive lives. They contribute to society and make the world a better place. People can often benefit from medication, rehabilitation, talk therapy, self help or a combination of these. One of the most important factors in recovery is the understanding and acceptance of family and friends. LPC CEUs
•"Most people who suffer from a mental disorder are not violent there is no need to fear them. Embrace them for who they are normal human beings experiencing a difficult time, who need your open mind, caring attitude, and helpful support (Grohol, 1998)."

References

American Psychiatric Association. (1994). Fact Sheet: Violence and Mental Illness. Washington, DC: American Psychiatric Association.

Appleby, L., Mortensen, P. B., Dunn, G., & Hiroeh, U. (2001). Death by homicide, suicide, and other unnatural causes in people with mental illness: a population-based study. The Lancet, 358, 2110-2112.

Corrigan, P.W., Rowan, D., Green, A., et al. (2002) .Challenging two mental illness stigmas: Personal responsibility and dangerousness. Schizophrenia Bulletin, 28, 293-309.

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For more information on how to address discrimination and social exclusion, contact the SAMHSA Resource Center to Promote Acceptance, Dignity, and Social Inclusion Associated with Mental Health (ADS Center), a program of the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services at http://promoteacceptance.samhsa.gov, e-mail promoteacceptance@samhsa.hhs.gov, or call 800?540?0320.

Early Mental Health Intervention Reduces Mass Violence Trauma

Early psychological intervention guided by qualified mental health caregivers can reduce the harmful psychological and emotional effects of exposure to mass violence in survivors, according to a national conference report released today. Experts emphasized that although more research is needed, existing data, including studies of other kinds of traumatic events, as well as clinical experience, provide useful guidance to the mental health community in responding to mass violence.

"School violence, shootings in the workplace, and terrorist acts have increased Americans' exposure to mass violence during the past decade, and psychological interventions are increasingly among the first responses to it. It is vital to the health and well-being of the American people that effective interventions reach the people who need them in a timely and efficient manner," said LTC (Dr.) Elspeth C. Ritchie, U.S. Army, chairperson of the planning committee for the conference.

The report calls on the scientific community to develop a national research program to examine the relative effectiveness of early mental health interventions following exposure to mass violence. Early intervention is defined as any form of psychological intervention delivered within the first four weeks following mass violence or disasters. Examples of early interventions include brief, focused psychotherapeutic intervention and selected cognitive behavioral approaches.

The report says that some interventions—including mass education via media outlets—although beneficial, have the potential for unintended harm. The report recommends that the leadership select professionals who have the training, expertise, accountability, and responsibility required to provide these interventions. Also, the report cites some evidence that early intervention in the form of a single one-to-one recital of events and discussion of emotions evoked by a traumatic event does not consistently reduce risk and may even put some survivors at heightened risk for later developing mental health problems.

The report is targeted to those who deliver these interventions to emotionally distressed persons following mass violence, to those who research these issues, and to employers who want to help workers who have experienced this type of emotional trauma. It is also intended to aid officials who must decide what mental health help to include in the local, state, and national responses to survivors of mass violence and terrorism. Prepared by 58 mental health researchers and clinicians from the U.S. and five other countries, the report details what is effective, what is not, and what questions require further research.

The report provides guidance on screening for mass violence trauma-related mental health problems, on follow-up with trauma-exposed persons, and on the expertise, skills, and training for providers of early intervention services. The report also addresses what is known about timing for various types of early interventions.

Participants agreed that it is sensible to expect persons to recover from the trauma of mass violence, although some groups may be more vulnerable, such as those with preexisting mental disorders. They also agreed that most survivors who show no clinically significant symptoms for approximately two months generally do not require follow-up and that participation of survivors in early intervention sessions should be voluntary.

The report includes an outline of a sample training program for an early intervention workforce. Recognizing that persons who arrive first at a scene of mass violence may not be trained to provide early mental health interventions, participants recommended that early response personnel be trained to make appropriate referrals when additional expertise is needed. MFT CEUs
Entitled “Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence. A Workshop to Reach Consensus on Best Practices," the report was developed by the National Institute of Mental Health (NIMH) at the National Institutes of Health in the U.S. Department of Health and Human Services, the U.S. Departments of Defense, Justice, and Veterans Affairs, and the American Red Cross.