White House Names NIMH a “Champion of Change” for its Suicide Prevention Efforts

Source: White House

The National Institute of Mental Health (NIMH) was named by the White House as a “Champion of Change” on August 25, 2011, for its efforts in supporting research on suicide prevention. Jane Pearson, Ph.D., and Kevin Quinn, Ph.D., of NIMH accepted the award at a ceremony and roundtable event at the White House, where they joined White House policy officials and others for a discussion of suicide prevention best practices. In addition to NIMH, the Suicide Prevention Resource Center (SPRC); Suicide Prevention Action Network; SAVE Foundation; the American Foundation for Suicide Prevention; National Suicide Prevention Lifeline; Blue Star Families; the Gay, Lesbian, and Straight Education Network (GLSEN); the Creative Coalition; and the Trevor Project, all of whom are dedicated to preventing suicide, were honored.

The White House Champions of Change initiative celebrates individuals and organizations from all walks of life who are making an impact in communities and helping the country rise to the challenges of the 21st century.

The roundtable discussion was moderated by Pamela J. Hyde, Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA); Andrea Palm, Senior Advisor for Health at the White House Domestic Policy Council; and Deborah Temkin, Research and Policy Coordinator for Bullying Prevention Initiatives at the Department of Education. The discussion focused on numerous issues important to suicide prevention including:
Media influences: how the media—including social media—has encouraged people to show their support of individuals in crisis ceus for counselors

Best practices: how the SPRC, which acts as a clearinghouse of evidence-based information related to suicide prevention, helps spread the word. The National Suicide Prevention Lifeline also continues to improve counseling services by using best practices.
Working Together: how each organization learns from the others. For instance, NIMH funds research associated with the National Suicide Prevention Lifeline, including research on the training of crisis counselors in an effort to improve counselors’ assessment and referral skills.
Prioritizing Next Steps: including identifying technological opportunities to help reduce suicide,(e.g., developing and testing phone apps for helping someone in crisis).
Early intervention: all agreed that for children, early intervention programs aimed at decreasing aggression and improving problem-solving skills are vital to ensuring children do not become bullies or reach a suicidal crisis.

NIMH is deeply honored to be identified as a Champion of Change. If you or someone you know is in crisis or considering suicide, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), a free, 24-hour hotline that seamlessly connects anyone in suicidal crisis or emotional distress with their nearest crisis center.

Stress-Defeating Effects of Exercise Traced to Emotional Brain Circuit

Evidence in both humans and animals points to emotional benefits from exercise, both physical and mental. Now, in recent experiments with mice, scientists have traced the stress-buffering effect of activity to a brain circuit known to be involved in emotional regulation as well as mood disorders and medication effects. The finding is a clue to understanding the neurological roots of resilience, key to developing new means of prevention and treatment for stress-related illness ceus for counselors

Background
In ongoing research, NIMH scientists have used a mouse model that mirrors particularly well the impact of social stress on mood in humans. Male mice are intensely aggressive when housed together; if these mice are placed in conditions that result in defeat by another mouse, they will behave in a way that mimics depression, much like a human might. Previous research demonstrated that mice housed in an environment with plenty of opportunities for exercise and exploration are relatively unfazed by bullying; they are resilient compared to mice housed in more spartan surroundings. The benefits from activity and stimulation depend on the growth of new neurons in the brain in mice (Novel Model of Depression from Social Defeat Shows Restorative Power of Exercise). A next step was to pinpoint where in the brain changes were taking place in response to exercise that resulted in stress resilience.

This Study
Before any mice were exposed to social defeat, all the mice in the study were housed for three weeks in either impoverished housing, with nothing but wood chip bedding; standard housing with a cardboard tube and place for a nest; or "enriched housing," with running wheels and tubes of various shapes and sizes to explore. After three weeks, half of the mice in each type of housing were then placed for two more weeks in close quarters with another mouse, but prevented from fighting by a barrier to prevent injury.

Mice that had been housed in the impoverished or standard housing, and that had been subject to social defeat, reacted to standard behavioral tests in a way that suggests depression; they were measurably passive and cautious, for example, avoiding light-filled spaces and preferring the safety of darkness. Bullied mice that had been housed in enriched environments behaved just like mice that had not experienced social defeat. As in earlier studies, the enriched environment seemed to protect them from the effects of social stress.

The NIMH investigators carrying out this study, Michael Lehmann and Miles Herkenham, then looked within the brain to see what exercise was changing to protect against stress. They focused on a functional circuit of brain centers known to be involved in emotional processing. In mice that had been housed in an enriched environment, levels of a protein that signals the activity level of neurons were increased in cells in the infralimbic cortex (ILC), a part of this circuit. Parts of the brain closely wired to and "downstream" from the ILC, that is, receiving activating signals from it, showed similar elevated activity. If the ILC was inactivated at the beginning of the experiment, environmental enrichment failed to have a positive effect. But if it was inactivated after the first three weeks of housing, environmental enrichment worked; the parts of the brain that receive signals from the ILC remained activated and the mice were stress resilient. The ILC was, in effect, a gateway for the positive activity in these "downstream" parts of the brain. Once these centers were activated by the ILC, it didn't matter if the ILC was still online.

Enrichment had the opposite effect on a part of the brain that is an important trigger for the body's stress response system. So enrichment seemed to enhance positive behavior, while at the same time, dampened activity in an area linked with an increased stress response.

Significance
A central target of research is understanding how stress contributes to mood disorders and why some animals and people seem resilient to the same stresses that can make others ill. Much recent research is aimed at investigating mental processes and disorders in terms of neural circuits. Abnormalities in how the brain deals with fear memories, for example, are thought to play a role in both anxiety disorders and depression. In rats that have been conditioned to fear a particular sound, stimulation of the ILC can dampen the fear reaction. In the study reported here, experience in the environment had the effect of inoculating the mice against a stressor, through changes in this same circuit in the brain.

The areas of the brain examined in this study are analogous to brain regions with altered function in people with disorders like depression and post traumatic stress disorder. Knowledge of the physiological basis of emotional resilience is crucial to developing strategies to help prevent mood disorders; it can also offer targets for the development of new medications for which there remains a pressing need.

Reference
Lehmann, M.I., and Herkenham, M. Environmental enrichment confers stress resiliency to social defeat through an infralimbic cortex-dependent neuroanatomical pathway. Journal of Neuroscience 31:6159-6173, 2011.

Many School-aged Children with ASD in South Korea Go Undiagnosed

Total population study points to possible higher rates of ASDs when screening the general population and the growing worldwide concern for screening, diagnosis, and services

Source: Getty
The prevalence of autism spectrum disorder (ASD) among children in South Korea appears to be much higher than the range of estimates previously reported in other countries, according to a study partly funded by NIMH. The researchers found that two-thirds of ASD cases occurred in children attending mainstream schools; these children had not been previously diagnosed and had never received treatment for the disorder. The study was published online ahead of print on May 9, 2011, in the American Journal of Psychiatry CEUs for counselors

Background
Recent reports of increased prevalence of ASD have raised concerns among parents, researchers, and policymakers. However, it is still unclear whether these estimates reflect a true rise in ASD occurrence or improved rates of detection and diagnosis. And because different studies use different designs and methods, they may not be truly comparable. There are also limited data on the prevalence of ASD in countries outside of North America and Europe.

To address these issues, Young Shin Kim, M.D., Ph.D., of Yale School of Medicine, and colleagues targeted all children ages 7-12 in a South Korean community representative of the country's general population. The researchers asked parents and teachers about the children's social interactions, and whether they had communication problems or restricted and repetitive behaviors.

The researchers then evaluated 286 children suspected as having ASD based on the answers given. Of these children, 114 attended special education schools, had a history of mental health service use, or were listed in the local disability registry. For study purposes, the researchers considered these children to have a high probability of having ASD. The other 172 children attended regular schools, had never received special education or mental health services, and were not listed in the disability registry.

The study incorporated multiple measures to address potential cultural issues. For example, board-certified Korean child psychiatrists trained in both Korea and the United States conducted the diagnostic assessments using screening and diagnostic tools validated for Korean children. An anthropologist on the research team also organized focus groups with local parents and teachers to identify beliefs that may influence symptom reporting and to address stigma related to ASD.

Results of the Study
Based on diagnostic assessments, the prevalence of ASD among the total study population was 2.64 percent. Among the children attending regular schools, the prevalence was 1.89 percent and boys were 2.5 times more likely to have ASD than girls. Among the high-probability group the prevalence of ASD was 0.75 percent and boys were 5 times more likely to have ASD than girls.

Of the 2.64 percent of all ASD cases, 0.94 percent met diagnostic criteria for autism and 1.7 percent met criteria for other types of ASD, including Asperger's disorder and pervasive developmental disorder not otherwise specified.

Significance
Unlike previous studies that analyzed health records and registries, the researchers attempted to look at each child in every school in a particular community, even children who did not have a record of any special education need. According to the researchers, this method unmasked cases that could have gone unnoticed if they had relied solely on health records. As a result, this study's estimate of ASD prevalence is higher than previously reported estimates, which range from 0.6 percent to 1.8 percent.

However, according to the researchers, the prevalence in the high probability group is similar to reports in other studies that have focused on the same target populations. The major difference in this study was that two-thirds of ASD cases were identified in the general population among children who never had contact with care systems. This particular finding highlights the importance of screening mainstream school populations as well as clinical populations in future studies. The researchers also suggest that the highly structured educational system in South Korea may allow children with less severe ASD symptoms to manage in general education settings, despite their impairments.

What's Next
More research is needed to find out whether these results can be repeated in other populations in Korea and other countries. The researchers note that more rigorous ASD screening may provide a more accurate estimate of the number of people with ASD, and that this number may exceed previous prevalence estimates. Additionally, this study only addressed ASD prevalence, or the current number of people with the disorder. Incidence studies—those that focus on the numbers of new cases—are essential to examine possible environmental and other potential causes of the rising ASD prevalence.

Reference
Kim YS, Leventhal BL, Koh YJ, Fombonne E, Laska E, Lim EC, Cheon KA, Kim SJ, Kim YK, Lee HK, Song DH, Grinker RR. Prevalence of Autism Spectrum Disorders in a Total Population Sample. Am J Psychiatr.

Tired Neurons Caught Nodding Off in Sleep-deprived Rats

Performance Decline Belies Seeming Wakefulness – NIH-funded Study
A new study in rats is shedding light on how sleep-deprived lifestyles might impair functioning without people realizing it. The more rats are sleep-deprived, the more some of their neurons take catnaps — with consequent declines in task performance. Even though the animals are awake and active, brainwave measures reveal that scattered groups of neurons in the thinking part of their brain, or cortex, are briefly falling asleep, scientists funded by the National Institutes of Health have discovered CEUs for counselors

"Such tired neurons in an awake brain may be responsible for the attention lapses, poor judgment, mistake-proneness and irritability that we experience when we haven't had enough sleep, yet don't feel particularly sleepy," explained Giulio Tononi, M.D., Ph.D., of the University of Wisconsin-Madison. "Strikingly, in the sleep-deprived brain, subsets of neurons go offline in one cortex area but not in another — or even in one part of an area and not in another."

Tononi and colleagues report their findings online in the April 28, 2011 issue of the journal Nature. Their study was funded in part by the NIH's National Institute of Mental health and a NIH Director's Pioneer Award, supported through the Common Fund, and administered by NIMH and the National Institute on Neurological Disorders and Stroke.

Previous studies had hinted at such local snoozing with prolonged wakefulness. Yet little was known about how underlying neuronal activity might be changing.

To learn more, the researchers tracked electrical activity at multiple sites in the cortex as they kept rats awake for several hours. They put novel objects into their cages — colorful balls, boxes, tubes and odorous nesting material from other rats. The sleepier the rats got, more subsets of cortex neurons switched off, seemingly randomly, in various localities. These tired neurons' electrical profiles resembled those of neurons throughout the cortex during NREM or slow wave sleep. Yet, the rats' overall EEG, a measure of brain electrical activity at the scalp, confirmed that they were awake, as did their behavior. So neuronal tiredness differs from more overt "microsleep" — 3-15-second lapses with eyes closing and sleep-like EEG - that is sometimes experienced with prolonged wakefulness. It is more analogous to local lapses seen in some forms of epilepsy, suggest the researchers.

However subtle, having tired neurons did interfere with task performance. If neurons switched off in the motor cortex within a split second before a rat tried to reach for a sugar pellet, it decreased its likelihood of success by 37.5 percent. And the overall number of such misses increased significantly with prolonged wakefulness. This suggests that tired neurons, and accompanying increases in slow wave activity, might help to account for the impaired performance of sleep-deprived people who may seem behaviorally and subjectively awake.

Subsets of neurons going offline with longer wakefulness is, in many ways, the mirror image of progressive changes that occur during recovery sleep following a period of sleep deprivation. Tononi suggests that both serve to maintain equilibrium — part of the compensatory mechanisms that regulate sleep need. Just as sleep deprivation produces a brain-wide state of instability, it may also trigger local instability in the cortex, possibly by depleting levels of brain chemical messengers. So, tired neurons might nod off as part of an energy-saving or restorative process for overloaded neuronal connections.

"Research suggests that sleep deprivation during adolescence may have adverse emotional and cognitive consequences that could affect brain development," noted NIMH Director Thomas R. Insel, M.D. "The broader line of studies to which this belongs, are, in part, considering changes in sleep patterns of the developing brain as a potential index to the health of neural connections that can begin to go awry during the critical transition from childhood to the teen years."

Source: Giulio Tononi, M.D., Ph.D., University of Wisconsin-Madison

Reference
Local sleep in awake rats. Vyazovskiy VV, Olcese U, Hanlon EC, Nir Y, Cirelli C, Tononi G. Nature. 2011 April 28.

Combination Antidepressant Therapy May Not Improve Odds of Remission Among Chronically Depressed

A combination of two antidepressants may not be any more effective in treating chronic major depression than a single antidepressant, according to an NIMH-funded study published online ahead of print May 2, 2011, in the American Journal of Psychiatry CEUs for Counselora

Background
When treating depression, doctors sometimes prescribe a second antidepressant medication if a patient does not improve after several weeks. Because some antidepressants work for some people and not others, the hope is that adding another one will increase the odds of remission. However, treatment guidelines generally do not recommend adding another medication until it is evident the first one is not working.

Madhukar H. Trivedi, M.D., at the University of Texas Southwestern, and colleagues aimed to determine if combination antidepressant therapy as a first treatment step might produce a higher remission rate among people with chronic major depression. In the Combining Medications to Enhance Depression Outcomes (CO-MED) trial, 665 adult participants from several sites around the country were randomly assigned to one of three antidepressant combinations:

Escitalopram plus placebo
Bupropion sustained release plus escitalopram
Venlafaxine plus mirtazapine
Although participants did not know which treatments they were receiving, clinicians were aware of their patients' treatment assignments so that they could adjust doses as necessary to manage symptoms and side effects. The measurement of primary outcome was based on a self-reporting scale called the Quick Inventory of Depressive Symptoms.

Results of the Study
After three months, remission rates among the three groups all were around 38 percent. After seven months, remission rates continued to be similar among the three treatment groups and averaged around 45 percent. However, the venlafaxine plus mirtazapine combination was associated with a higher risk for side effects and serious adverse events compared to the other treatment options.

Significance
Despite other research suggesting combination antidepressant treatment may work better than a single medication, neither of the combination therapies in this trial appeared to be more effective than the single medication plus placebo. The researchers suggest that the chronic nature of participants' major depression may be associated with lower remission rates. They also noted that dosage differences may account for the difference in outcomes compared to other studies.

What's Next
Further evaluation is needed to determine if other drug combinations may affect remission rates differently. Results also highlight the need to evaluate biological markers as a means of personalizing treatment and possibly improving remission rates in major depression.

Reference
Rush AJ, Trivedi MH, Stewart JW, Nierenberg AA, Fava M, Kurian BT, Warden D, Morris DW, Luther JF, Husain MM, Cook IA, Shelton RC, Lesser IM, Kornstein SG, Wisniewski SR. Combining medications to enhance depression outcomes (CO-MED): Acute and long-term outcomes: a single-blind randomized study. Journal of American Psychiatry. online ahead of print May 2, 2011.

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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.

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.

High-Tech Treatments

By Beryl Lieff Benderly

A patient arrives in the emergency room of a small hospital in rural Tennessee in acute need of psychiatric evaluation. The attending physician lacks the specialty training to evaluate whether the patient is at risk for suicide or harm to others—requiring hospitalization—and the nearest psychiatric hospital is located more than an hour away. What should the physician do?

In the past, a mobile crisis team would have been dispatched over mountainous roads for an hour's drive to make an evaluation. Today, a high-speed video teleconference between a member of the crisis team and the patient—in real time—takes place instead.

This accelerated evaluation procedure, as described by Susan Dimmick, Ph.D., a project manager at the Oak Ridge Associated Universities, in Oak Ridge, TN, is just one of the many applications of communications technology now available to deliver mental health and substance abuse care efficiently. More than two dozen presenters shared their expertise at a recent conference, "E-Therapy, Telehealth, Telepsychiatry, and Beyond," hosted by SAMHSA's Center for Substance Abuse Treatment (CSAT) in December.

Sheila M. Harmison, D.S.W., L.C.S.W., Special Assistant to the CSAT Director, moderated the conference, which drew researchers and service providers from across the Nation and from Canada to discuss a wide range of innovative programs that use e-mail, text messaging, Web sites, and voice-over-Internet telephone in addition to video teleconferencing. These technologies overcome barriers—including distance, physical immobility, and other disabilities, and social stigma—that prevent many Americans from receiving needed mental health care. Online CEUs for Counselors
Examples of these services include:

Low-income, inner-city mothers who are in recovery from substance abuse stay in daily contact with their counseling program via e-mail.

Children in remote Alaskan villages receive mental health treatment via video teleconference from providers located in facilities hundreds of miles away.

Middle school, high school, and college students participate in personalized substance abuse interventions over the World Wide Web.

Military veterans with post-traumatic stress disorder who live on sparsely settled Indian reservations in South Dakota and Wyoming receive mental health treatment via video teleconference.

Persons undergoing cognitive behavioral therapy for anxiety disorders use palmtop computers to receive messages of reinforcement and assess their own levels of anxiety while they go about their daily activities.

Alcoholics in recovery attend group therapy sessions via streaming video and voice-over-Internet from the privacy of their homes.

"Technology can assist in our larger goal to assure a life in the community for everyone," said CSAT Director H. Westley Clark, M.D., J.D., M.P.H. The goal is not to substitute traditional treatments for mental and addictive disorders, he emphasized. "The goal is to leverage the impact of people-based services."

The use of new communications technology in treatment for these disorders is in its infancy, Dr. Clark continued. "And there does appear to be a reluctance to adopt new technology."

Qualified mental health and substance abuse professionals must make use of these new technologies. Charlatans and quacks are trying to exploit the Internet and entice the unwary into many questionable so-called therapies, Dr. Clark cautioned. "If we in the orthodox community refuse to go ‘into the ether,' others will have no compunction." In other words, research needs to go forward vigorously to evaluate the usefulness of the various technology-assisted treatment approaches. "We have to determine if e-therapy is a reliable resource for substance abuse and mental health treatment," said Dr. Clark. "I think it is."

Kathryn Power, M.Ed., Director of SAMHSA's Center for Mental Health Services, also addressed the conference. "E-health, properly researched and implemented, holds great promise for improving the mental health of millions of Americans nationwide," she said. Not only is e-health incorporated in the goals of the SAMHSA Mental Health Transformation initiative, but through the use of these technologies excellent mental health care is delivered, and research accelerated.

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High-Tech Options
As equipment and service costs continue to decrease and the availability of high-speed broadband connections continues to increase, mental health and substance abuse practitioners find themselves with many advanced options for audio, video, and text technologies.

Wireless connections now match the speed of broadband cable modems, said Brent Carter, a product development officer for Verizon Wireless, in his presentation.

Advanced encryption and other security measures allow wireless communications to meet the privacy and confidentiality requirements of mental health and substance abuse professionals, added Donald "Desi" Arnaiz, M.A., President of Virginia Systems, Inc., and an engineer for Comcast. "Everything that you require for the Health Insurance Portability and Accountability Act—HIPAA—is available to you now."

Mental health and substance abuse treatment providers and other health care providers, however, must be sure to use equipment correctly. When selecting devices, for example, they must make certain that they obtain proper security technology. "Most people don't protect their wireless systems, but care providers must take that extra precaution," said Mr. Arnaiz.

Other recommendations include choosing devices appropriate to the intended purpose and making sure that all devices work together. Correcting errors in the integration of devices is in fact his company's "biggest headache," Mr. Arnaiz said. For practitioners to have a successful program, they must also spend time learning to use the equipment.

Some adaptations in treatment techniques will also be needed to meet the demands of technology, noted Ron Adler, Chief Operating Officer of the Alaska Psychiatric Hospital. His experience with the hospital's TeleBehavioral Health video teleconferencing system convinced him that the benefits vastly outweigh the costs in both time and money. "Build this system and the funding will come and the patients will come," he urged conference participants.