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Schizophrenia Update

A Free Periodic Newsletter - Series 2, Issue 27 - May 9, 2005

A Summary of Schizophrenia-related News and Events. Note: Please forward this newsletter to others who might benefit. To Subscribe to the newsletter, enter your email address at: www.schizophrenia.com

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Member and Site News, Editorials

  • A View of Dr. Dan Fisher of the National Empowerment Center - an editorial by Marvin Ross
  • Schizophrenia.com interviews Dr. Dan Javitt, schizophrenia and glycine researcher
  • Schizophrenia Awareness Week - May 22-28

Diagnosis and Prevention News

  • Family dysfunction influences Psychosis & Schizophrenia risk

Medication and Treatment Information

In Community, Society, and Media

Biology and Current Research

A View of Dr. Dan Fisher - editorial by Marvin Ross, schizophrenia.com representative at Dr. Fisher's recovery workshop in Ontario

Dr. Daniel Fisher, a psychiatrist who suffers from schizophrenia and who heads the National Empowerment Center, told the audience at his recovery workshop in Hamilton, Ontario that when he first entered psychiatry he found that his ideas ran counter to the newly emerging physiological theories of mental illness. "They were all jumping on the brain and I was jumping off" he said.

While science has made considerable progress in defining the changes in the brain of people with serious mental illness, Fisher continues to espouse controversial views to the point where a number of participants at the Hamilton workshop that I talked to were angered. One family member told me that she could hardly wait to get out she was so outraged by his comments that serious mental illness is an emotional problem and that people do not hear voices they just have loud thoughts.

Others expressed concern about his anti medication bias and one senior psychiatric hospital administrator said that while not agreeing with him it is important to hear other views. While defending the rights of people to present their opinions, I am concerned that Dr. Fisher gives the wrong message and that can be dangerous. Much of what he talks about is "touchy feely" unscientific new age platitudes combined with some common sense and a message that serious mental illness is not physiological. His answers to questions that I posed are at the end of this editorial and are very revealing. Dr. Fisher, as you will see, considers me to be overly simplistic.

How often have we heard someone with severe depression being told to "snap out of it"? Asking the question or expecting the depressed individual to cure their own depression implies that it is not a disease but a personal failure. You can't "snap out of" a broken leg or an occluded blood vessel. But, Dr. Fisher seems to think that you can overcome what he calls a severe emotional distress (SED) that is precipitated by trauma or loss. When an individual suffers this SED, they often are taken over by the mental health system and labeled as severely mentally ill.

He further discounts the medical model by stating "the present mental health care system is based on an illness model in which an expert defines the problem as primarily a defective chemical mechanism in the patient's brain that needs to be repaired by the expert. This model reduces symptoms but interferes with the person's taking an active role in recovery." In that same paper, he states "all of us can achieve self control of symptoms to varying degrees…." And "genuine healing comes from within by an activation of our own healing powers".

This is from a paper he had published in 1994 in Hospital and Community Psychiatry that he handed out at his workshop as if we have not made numerous advances in the past 10 years. First, serious mental illness is just that - an illness of the brain. One needs to look at the many imaging studies of the brains of people having a first episode psychosis compared to normal controls to realize that.

Dr. Fuller Torey has an excellent paper in which he reviews 65 studies of individuals with schizophrenia who had never been treated with medications that indicate significant abnormalities in brain structure.

How can you achieve self-control of symptoms when the symptoms are caused by circumstances beyond your control like abnormalities of the brain? You can't. That is like telling someone with epilepsy that they can will away their seizures.

These notions are the same as those in cancer where it is suggested that you can control your cancer and its spread through imaging, visualization, laughter, prayer, biofeedback, and other similar modalities. I could not find any studies in the medical literature that support this. A few years ago, I did an article on group therapy and its ability to help ameliorate the symptoms of advanced cancer and help to prolong life.

I did a group interview with women who were dying of advanced metastatic breast cancer but who were part of a study to see if group support might help their symptoms and prolong life. All of the women expressed intense dislike for the proponents of the visualization treatment. They all said that the implication is that their failure to control their cancer and get better is their fault. It is not. They were very ill and they were going to die and it was not because they did not want to live or they were not visualizing hard enough. But, the consequence of this New Age concept of will your way to better health is to demean their suffering and their incredible strength.

The same goes for serious mental illnesses like schizophrenia. Dr. Fisher may not need meds for whatever reason but most do. When I asked him why people experience a return of symptoms when they go off meds, he said that it might be because they were not far enough along in their recovery process (see Q and A below). What balderdash! What does that mean?

I can give him all sorts of examples as most can of the return of symptoms that are so bad that people have committed suicide as a consequence. But, here is an example of someone who was recovered. A man with schizophrenia who took his meds, worked full time at a career, was married and was enjoying his retirement and his many hobbies. The doctors decreased his anti-psychotics and his symptoms came back and he had to be hospitalized until the increased dosage kicked in.

I'm not sure how Dr. Fisher would account for that but I think of the comments made in a presentation by Dr. Robert Zipursky of the Centre for Addiction and Mental Health in Toronto. Dr. Zipurski said about 80% of patients will relapse within the first five years if they stop taking their medications. But, even if they are in remission, they should stay on indefinitely because of the cumulative damage each psychotic episode inflicts. "Recovery from relapse may take a long time and it is uncertain," he said. Scientists, he added, still don't know if someone can remain well for five or 10 years without medication, and the risk of not recovering from a relapse is too great. "If you've spent a year or two getting someone well and watching them rebuild their lives . . . to watch them get sick again is not something you would wish on anyone,"

Questions Dr. Fisher:

Q. Some people define recovery as being off all medications. You have said that you are not opposed to using medications as one tool in a person's recovery journey. I have not been able to find your 7 steps to recovery on your website. Does your definition of recovery include not being on medication?

A. We do not define recovery as being off all medication. After all there are many people who take a variety of psychiatric medications but were not labeled mentally ill because there (sic) life was not interrupted by the experience. No, we say that when a person has recovered medication is one tool among many freely chosen by the individual.

Q. One psychiatrist that I talked to stated that your pro recovery position suggests that there are people who are anti recovery. He found that offensive as his goal for his patients is to help them recover. Could you comment on that?

A. I do not believe any psychiatrists are anti recovery, however many do remove hope by saying the person will remain mentally ill their entire life.

Q You say that taking medication should be informed and voluntary. Where do you stand on committal and treatment for people who are so psychotic that they cannot make an informed decision?

A. Except under emergency conditions of a very acute nature, for a person in a hospital, where there is a risk of harm, I am opposed to forced medication. Even under those conditions I think it should be called chemical restraint as it is called for persons with developmental delay

Q. You have said that you are off medications and that you know many people who are. One psychiatrist told me that 25 years ago, the diagnostic criteria for schizophrenia was much broader in North America than in Europe and that some people may have been diagnosed at that time who would not have been today since the North American criteria and now much tighter. It is not possible that some of the people who were diagnosed when you were might have been misdiagnosed?

A. I am tired of hearing that I was misdiagnosed. I still would have met the criteria of schizophrenia

Q. I have seen some very impressive imagings of the brain of people who were having a first psychotic episode and were unmedicated. There were significant differences between those images and normal controls. When these psychotic patients were treated with medications, you could see a significant change in the brain images that were now much closer to the brain images of the normal controls. Does this not suggest that schizophrenia is a neurobiological problem?

A. Our biology is not our destiny. Our brains change over time as we learn new behaviors and patterns of thought. This has been shown with all nervous systems.

Q. If it is then how can anyone go off medication? Is that not like suggesting that someone with epilepsy can go off medication and remain well?

A. Therefore one can have a severe mental illness, and change over time to the extent that medication is no longer necessary.

Q. Researchers are also finding genetic links to schizophrenia. Does this not also imply a physiological cause?

A. It may imply a genetic factor but not the cause. These conditions are very complex and involve a variety of factors. It is not helpful to focus so exclusively on only one factor and say it is the cause.

Q. I know of a number of people who attempt to go off medication and start to become psychotic again. How would you explain this in your recovery model?

A. Perhaps they went off too quickly. There is a rebound effect. Perhaps they were not far enough along in their recovery.

Q.. You told Medscape in an interview in January that you tell people going through a psychotic episode that: "this is not a permanent condition and that other people have recovered." Does that not suggest that you do not believe schizophrenia to be a physiological condition?

A. There is no contradiction between saying these are not permanent conditions and my saying that there is a physiological factor. That factor can be changed over time. As I said there is good evidence that our brains change over time with new learning.

Here are Dr. Fisher's unsolicited comments about my questions:

Overall it appears you have misunderstood my position. The world is not nearly as black and white as you make it seem. There is (sic) mostly shades of grey, in fact mostly grey matter. It is true I emphasize that people can recover and in many cases even completely recover. Our definition is on our website on the home page, right side. However, you must recall that I am a psychiatrist and I prescribe medications. I am not opposed to medication I just feel it is overemphasized


Schizophrenia.com Interviews Dr. Dan Javitt

As a follow-up to our recent special report on glycine supplementary treatment for schizophrenia, we contacted Dr. Dan Javitt, one of the leading researchers/developers in the field. Dr. Javitt generously agreed to answer some of our questions about his work and about the future of glycine treatment, and responded a wealth of detailed and thoughtful information on the subject. This is only the first portion of the interview - we are currently still corresponding on questions about his company that develops glycine treatments, and the future of glycine treatment marketing. More to come in later newsletter editions. In the meantime, many thanks to Dr. Javitt for his contributions!

Read the interview transcript (available at http://www.schizophrenia.com/research/javitt.htm)

Schizophrenia Awareness Week is this week!

The National Schizophrenia Foundation (http://www.nsf.org) has declared May 22-28 to be Schizophrenia Awareness Week. This year's theme is appropriately "Schizophrenia: It's Not What You Think!" Please link to the full newsblog story on schizophrenia.com (May 20, 2005 entry) to read more comments about Awareness Week, and a list of what we as advocates for people with schizophrenia can do now and in the future.

Family Dysfunction Influences Psychosis and Schizophrenia Risk

York University - a top Canadian university - has announced an extended certificate program in "Infant Mental Health" working in concert with the "Sick Kids Hospital". This seems like a good step forward in early identifcation of brain disorders which should result in earlier treatment and better outcomes. Too bad the course isn't available over the Internet - I'm sure a lot of people would be interested in participating.

This Program is designed to provide front-line service providers with essential knowledge and practical skills to encourage positive parent-infant interactions and promote optimal developmental progress in infants. The Program is directed to those interested in working effectively in the field of infant development, prevention and/or early intervention with infants with special needs, and with infants living in high-risk environments.

The Ceritificate is offered by York University - Atkinson
College in collaboration with Infant Mental Health
Promotion Project, The Hospital for Sick Children & Ontario Association for Infant Development

It is a 120-hour non-degree credit Certificate for a broad range of
front-line services providers and managers who wish to acquire
essential knowledge and practical skills to work effectively with infants and their families.

Infant Mental Health Promotion Project (IMP)
The Hospital for Sick Children - CHSRG
555 University Avenue
Toronto, ON M5G 1X8

MORE INFORMATION: Infant Mental Health Program (http://www.atkinson.yorku.ca/~dce/Programs/Certificates/IMH/IMH1.html)

The Hospital for Sick Children - Infant Mental Health Program (http://www.sickkids.ca/imp/)

Increased risk for children if mother has schizophrenia

This paper looks at a large population in Finland in which the authors collected data on all children born to mothers with a psychiatric diagnosis. They were interested in the chance that those born to such mothers might develop a mental illness in their lifetime. They looked at all mothers who were born in Helsinki from 1916 to 1948 and had previously been treated in a psychiatric hospital in Finland and received a diagnosis of a schizophrenia spectrum disorder and gave birth from 1960-1964. 192 children were identified, and they were compared with the children born in the same hospital immediately preceding their birth. Since diagnostic criteria have changed over the years, the charts were reviewed and patients assessed a diagnosis based on current standards.

The authors found that there was a nearly 7 percent chance of developing schizophrenia in an offspring if the mother had schizophrenia versus about a 0.6% chance in the control group in which the mother did not have schizophrenia. Other schizophrenia spectrum disorders yielded similar figures. Mothers with a mood disorder had no children develop schizophrenia though it was a small sample. Overall, mothers with schizophrenia had a 13.5% risk of their child developing a significant psychiatric disorder in their lifetime compared with 1.2% in the control group. In similar studies done previously in New York and Copenhagen the results were similar though they were higher than in this study (Copenhagen study had nearly 17% of offspring develop a psychiatric diagnosis.) However, there are explanations for the difference not the least of which is that diagnostic criteria became more strict in this study. Also, only those diagnosed as inpatients could become part of the study while there are some that will present as outpatients and ever be hospitalized therefore lowering the overall number of cases. There were also increased rates of substance abuse in the high risk mothers but it was found that in this study (different from the other similar studies) that the paternal substance abuse had a greater correlation to the offspring likelihood of similar problems though it was noted that generally the fathers with substance abuse had more significant problems than the mothers with substance use disorders. Both mothers and fathers of the higher risk children were more likely than the control group to have substance abuse in their histories.

Editorial note: even if schizophrenia runs in your family, there are lots of controllable measures you can take to help reduce your own and your child's risk of developing the disease, both during pregnancy and throughout life. See http://www.schizophrenia.com/hypo.html for more details.

Study Title: Cumulative incidence of mental disorders among offspring of mothers with psychotic disorder Results from the Helsinki High-Risk Study

Laura T. Niemi, Jaana M. Suvisaari, Jari K. Haukka, Gunnel Wrede and Jouko K. Lonnqvist

British Journal of Psychiatry (2004), 185:11-17.

Click here to access the article on PubMed, or do a search at http://www.pubmed.com

Medicaid Cuts Hurt Those with Mental Illness

We learned from testimony by Dr. Insel (head of the US National Institute of Mental Health - see "Comments from NIH Head Dr. Insel on Substance Abuse and Mental Illness", also in this newsletter issue) that:

--People with serious mental illness represent the single largest group -- diagnostic group -- of those receiving SSI, (social security).

--Unlike the rest of medicine, most of the costs for both direct and indirect mental illness care are in the public sector. That means that more than 50 percent of all mental health expenditures are paid for by Medicaid / Medicare and state and local governments. Again, quite different from the rest of medicine, where we're often dealing with questions about third-party reimbursements and private insurance coverage.

Medicaid is the single largest payer of mental health services in the country. And just as one example, last year Medicaid wrote for more than half of the prescriptions for atypical antipsychotics, a group of medications that cost the nation over $12 billion. So this is a very large outlay of funds.

Read the recent press release from NAMI (http://tinyurl.com/7o4dw) on how anticipated cuts in Medicaid will have a very significant impact on the mentally ill - likely resulting in more of the mentally ill being poorly treated and ending up in jail. See also "Treating Mental Illness Cuts Costs" - another article in this newsletter issue - to learn how such a vast proportion of mentally ill people turned away from public sector care will ultimately increase the burden of cost for everyone.

Treating Mental Illness Cuts Costs for Everyone

An editorial in the Virginia Roanoke Times acknowledged the efforts of those who participated in a weekend fundraiser for community mental health programs, and made the important but oft-overlooked point that the best way to economize mental health is to treat it.

For example, the article notes that emergency room use by uninsured people with mental health crises is costing the region about $1million per year. This is not even considering the indirect costs accrued from loss in productivity, increased burden on public health and criminal services, increased unemployment rolls, and crowding of jails by people with untreated mental illnesses.

However, as funding for community treatment services is usually below officially-mandated levels (according to the article), it is becoming even more important for citizens to not only advocate for greater funding, but to also contribute their time and energy to fundraisers for mental health services.

A great way to do this during the next two months is to get involved with a NAMI Walk. They are taking place in 38 U.S. States. Visit the NAMI website (http://www.nami.com) for location and registration information.

Source: "How to economize on mental illness: Treat it." The Roanoke Times, May 1 2005. (www.roanoke.com)

New Drugs to Target Negative Symptoms

Prestwick Pharmaceuticals Inc. a Washington, DC company that is developing a new drug for treatment of tardive dyskinesia, another drug called "D-Serine" for the treatment of the negative symptoms of schizophrenia - has announced that they have filed for an initial public offering to raise an estimated $ 74.8 million in preparation for the potential launch of its dopamine depletor, tetrabenazine.

Prestwick said it received fast-track designation for tetrabenazine, and if the New Drug Application (NDA) is filed this quarter, the company would be eligible for FDA approval as early as the first quarter of 2006. The company licensed rights to develop and commercialize tetrabenazine, a selective and reversible dopamine depletor, from UK-based Cambridge Laboratories Ltd. The product is marketed by Prestwick in Canada under the brand name Nitoman and by Cambridge Laboratories in Europe under the brand Xenazine.

The company also received what is termed by the FDA "orphan drug status" (which means that it addresses a relatively small market or number of people) for tetrabenazine in a second movement disorder, tardive dyskinesia, and is planning a Phase III trial in that indication.

The company also plans to file with the FDA an Investigation for New Drug (IND) this year for its schizophrenia drug, D-Serine, a selective amino acid co-agonist (NMDA enhancer). A Phase IIb trial is anticipated to begin next year.

Editor's Note: Incidentally, D-serine is a naturally-made body molecule that occupies a cofactor binding site (called the glycine modulatory site) in the NMDA receptors in the brain, allowing them to fire when they are stimulated by glutamate neurotransmitters. D-serine is one of the compounds showing promise in a new angle of treatment for schizophrenia - enhancing NMDA receptor function through the glycine modulatory site (using glycine, d-serine, or d-cycloserine). Read more about the role of NMDA receptors and glycine in schizophrenia pathophysiology, and how supplementary treatments of glycine or d-serine may help improve negative and cognitive symptoms, in this new schizophrenia.com special report on glycine therapy.

More information on new schizophrenia drugs in development (http://www.schizophrenia.com/newmeds2004.htm)

Developing Weight-Loss Medications - may help counter extra weight-gain from antipsychotic use

On April 28 2005, it was announced that Corcept Therapeutics Inc., of Menlo Park, Calif. has results from two preclinical studies. These results show that their new drug in development (called "Corlux") can induce weight loss following olanzapine-induced weight gain, and prevent the weight gain induced by olanzapine (brand name Zyprexa), one of several atypical antipsychotics that carry a warning of weight gain as a side effect.

This drug is still just in early stage trials - we'll report more as it gets closer to larger scale human trials, and potential general availability.

More Information: Corcept Therapeutics Inc. (http://www.corcept.com/)

News on Stigma - prevalence, prevention, what works and what doesn't

Several news sources this week had something to say about mental illness stigma. The first two summaries deal with the prevalence of stigma (diminishing or otherwise) among Americans according to a Gallup poll, and suggested ways to diminish stigma based on an analysis of techniques (called "social marketing" to target audiences) used by the World Psychiatric Association (WPA) Programme to Reduce Stigma and Discrimination Because of Schizophrenia. The third news story is a response to the first two, citing information from the Treatment Advocacy Center (and other sources) claiming that public anti-stigma campaigns (such as the ones described by WPA) have not worked in the past, and that a better way to manage stigma is to focus efforts on treating people so that there are fewer high-profile criminal incidents involving the mentally ill. Unfortunately, with Medicaid being slashed the way it is (see Medicaid cuts hurt mentally ill - earlier in this edition), it does not appear that such treatment will be available to the majority anytime soon unless something else is done.

The three stories are summarized below:

A PRNewswire press release (http://en.wikipedia.org/wiki/Press_release) entitled "Mental Illness Stigmas Are Receding, But Misconceptions Remain", reported that 90% of Americans surveyed feel that people with mental illness can lead healthy lives, and the vast majority also felt that current psychiatric treatment works, and that visitng a psychiatrist is a sign of strength. However, despite these encouraging statistics, 1 in 5 adults still stated that they personally would never see a psychiatrist "under any circumstances." Additionally, although 75% believed (correctly) that mental illness is caused by a chemical imbalance in the brain, twice as many respondants from that group said they would seek help from a primary care physician, who is not specially trained to diagnose and treat mental illness.

Other statistics from the survey:

Additional significant findings:

* More women than men think that seeing a psychiatrist is a sign of strength (78 percent vs. 61 percent)
* 75 percent of adults surveyed correctly understand that psychiatrists are medical doctors with medical degrees, while 38 percent mistakenly think that psychologists are medical doctors
* Younger adults are significantly more positive than older adults (65+) about mental illness issues, highlighting progress made in younger generations embracing the realities of mental illness

The survey included 1,020 randomly-selected adults (50% men and 50% women) living in private households in the continental United States.

Source: "Mental Illness Stigmas Are Receding, But Misconceptions Remain", PRNewswire press release (http://www.prnewswire.com)

While this survey reports on the prevalence of mental illness stigma, another research study examines the effectiveness of methods used to reduce such stigma. The study specifically investigates the effectiveness of "social marketing", a tool used by World Psychiatric Association (WPA) Programme to Reduce Stigma and Discrimination Because of Schizophrenia. Social marketing, which has been used for successful AIDS prevention and smoking cessation campaigns, relies on segmenting the overall general audience into several more homogenous, demographically-similar sub-groups (for example: school-age youth, police and criminal justice personnel, employers, etc). The article suggests that such sub-groups can be identified using surveys and other analysis tools to identify among which groups of people stigma appears to be most prevalent.

After the target audiences are established, the campaign message and tools for delivery can be specifically designed for the needs and benefit of each different group. The article specifically cited police training and classroom presentations as two examples of interventions that are more cost-effective than attempting to reach a massive general audience, and that also have the potential to cause specific changes in attitudes, actions, or behavior that could improve the quality of life for people with mental illness.

The specific steps used by the WPA programme (now initiated in 20 countries) are as follows:

1. establish a local action committee (the action committee plans and implements the subsequent steps).
2. conduct a survey of sources of stigma
3. select target groups
4. choose messages and media
5. evaluate the impact of interventions, while continuously refining them.

For more detailed information on the anti-stigma program used by WPA, and for tips on how to successfully launch a campaign, see http://www.openthedoors.com. The website is viewable in eight different languages.

Source: "Local Projects of the World Psychiatric Association Programme to Reduce Stigma and Discrimination." Psychiatr Serv 56:570-575, May 2005 (click on the link, or do a search for the abstract at http://www.pubmed.com).

Related to the earlier news story on stigma (above), a news story from a few years back reported that research suggested that anti-stigma campaigns for schizophrenia targeted at the public don't work (echoing the statements of E. Fuller Torrey, DJ Jaffe, and others, who contend that the real anti-stigma effort should be focused on getting all people who have schizophrenia successfully treated so that there are fewer incidences of violence that are so widely covered in the news, to the detriment of the approximately 99% of people with schizophrenia who aren't violent).

See Excerpt below:

"Schizophrenia anti-stigma campaigns aimed at the general public are usually a waste of money, says a mental health researcher who questioned more than 1,600 people.

A better target would be health professionals and mental-health providers, maintains Dr. Heather Stuart (PhD), an epidemiologist at Queens University, Canada and lead investigator in a study into public attitudes and knowledge about psychiatric disorders.

The research by Dr. Stuart and Dr. Julio Arboleda-Florez, head of psychiatry at Queens, was part of the World Psychiatric Association's global program to fight the stigma of schizophrenia. It was conducted with the co-operation of the Schizophrenia Society of Alberta.

While 52% of the respondents who did not work with the mentally ill were rated as high on social distance, 57% of those who worked with psychiatric patients scored high on the social distance scale.

That, Dr. Stuart said, has profound implications—namely that anti-stigma campaigns aimed at the lay public would be a waste of money. She also noted Australia spent $8 million on such a campaign and that it had little impact.


The bottom line is that health-care professionals "have the same attitudes as the guy on the street when we should be expecting more from them," Dr. Stuart said.

She said she feels anti-stigma efforts should be geared toward health-care professionals to raise their awareness."

Comments from NIH Head Dr. Insel on Substance Abuse and Mental Illness

Dr. Insel, head of the National Institute of Health, recently spoke at a US Representative Meeting on Substance Abuse and Mental Health Services (April 27, Washington DC). The following is a very brief set of quotes from Dr. Insel highlighting the extreme importance of providing early and adequate care to those with substance abuse and/or mental disorders.

What Dr. Insel does not address in much detail is the two-way cause and effect relationship between substance abuse and mental illness. Although it is true that people with mental illness are more susceptible to developing substance abuse disorders (due to self-medicating and/or sensitivity of certain reward-center brain circuits in the limbic system), strong scientific evidence is showing that using street drugs can significantly increase a person's risk for developing a mental disorder. A particularly strong link has been identified between cannabis use and schizophrenia/psychosis onset - see http://www.schizophrenia.com/hypo.html#street for more details and links to scientific studies.

A link at the bottom of the article will lead to more lengthy relevant excerpts in the schizophrenia.com newsblog; from there, you have the option of navigating to the entire (very long) transcript of the meeting.

Comments from Dr. Insel:
We often don't recognize that many of the costs of these disorders are different than the cost of other medical illnesses in the sense that here, the indirect cost, that is the cost for social services may be greater than the direct cost -- the cost for treatment.

That's not true for hypertension, diabetes and cancer, but it's true across the board for these kinds of illnesses. And it's one of the facts here that we need to keep in mind when we think about how the nation supports people with these illnesses and what the actual public health burden would be in an economic sense.

People with serious mental illness represent the single largest group -- diagnostic group -- of those receiving SSI, the kind of disability that you asked about before.

It's also true that unlike the rest of medicine, that most of the costs here for both direct and indirect care are in the public sector. That means that more than 50 percent of all mental health expenditures are paid for by Medicaid/Medicare and state and local governments. Again, quite different from the rest of medicine, where we're often dealing with questions about third-party reimbursements and private insurance coverage.

Medicaid is the single largest payer of mental health services in the country. And just as one example, last year Medicaid wrote for more than half of the prescriptions for atypical antipsychotics, a group of medications that cost the nation over $12 billion. So this is a very large outlay of funds.

The other point that we want you to take away from this hearing is to -- and we say this every year, but it's one that I think we don't say enough -- is to remind you and others that these disorders are brain disorders. And our science has now taught us that without question.

What you see here on the screen is the evidence that we've had for some time that those people who are incapacitated by depression, whether it's bipolar depression or unipolar depression, have structural changes that we can now see with brain imaging.

But perhaps even more exciting -- what we've begun to realize in the last year with the advent of functional studies -- is that we can now begin to identify those areas in the brain where function has to change for someone to recover. And those are often areas that we hadn't recognized before as having a very important role in depression, whether we're talking about major depression, depressive disorder or bipolar depression. So we now really think about these as brain disorders.

The big difference between how we think about depression and schizophrenia and how we think about Parkinson's and perhaps Alzheimer's is in these disorders we're not talking about a specific lesion, in the sense that there are dead cells in one area, or there's a hole in the brain in the sense that you might look for some stroke victims; here what we're really interested in are changes in how the brain functions as a system and where the system is no longer functioning in a normal fashion. And we now have the tools to be able to identify that.

So for the first time, we can begin to think about these as brain disorders in a way that allows for different kinds of diagnosis and hopefully, different kinds of treatments.






See a longer version of relevant excerpts at http://www.schizophrenia.com/sznews/archives/001740.html, or access the full transcript (Register or Pay to View) at http://tinyurl.com/bh9sf

More resources for those with dual-diagnosis (both substance abuse and mental illness) are available at http://www.schizophrenia.com/family.htm#dualdiag

Ways to Encourage Attitudes of Recovery in People with Schizophrenia

Study title: An empirical conceptualization of the recovery orientation.
Resnick SG, Fontana A, Lehman AF, Rosenheck RA
Northeast Program Evaluation Center, Yale University School of Medicine, VA Maryland Healthcare System and University of Maryland School of Medicine

In the scientific literature, “recovery” is described as “process representing the belief that all individuals, even those with severe psychiatric disabilities, can develop hope for the future, participate in meaningful activities, exercise self-determination, and live in a society without stigma and discrimination”. Helping people with schizophrenia move towards this recovery orientation is an important part of grass-roots movements and mental healthy advocacy by groups including NAMI ( National Alliance for the Mentally Ill), state mental health systems and the President's New Freedom Commission on Mental Health (see http://www.mentalhealthcommission.gov/index.html for more information)

In this article, the authors propose an empirical (research based) way to think about people’s recovery orientation. They used data from the Schizophrenia Patient Outcomes Research Team (PORT) Client Survey which is the largest systematic survey of the treatment of schizophrenia ever conducted. The PORT asked people with schizophrenia in Ohio and Georgia questions about many different things including measures of clinical status, community adjustment and attitudes about different things. There was a total of 1076 participants.

Based on the analysis of the results, they suggest a way of encouraging recovery attitudes by focusing on 4 areas: the capacity to feel empowered in one's life; self-perceptions of knowledge about mental illness and available treatments; satisfaction with quality of life; and hope and optimism for the future.

For the goal of empowerment, it helps to promote self-esteem and help individuals discover and reach their goals. This involves helping the person to feel empowered to take responsibility to make one's own decisions and take responsibility for treatment, as well as encouraging the feeling that one's treatment and treatment providers match your own treatment goals.

They also talk about the importance of fostering hope - hope for the future, hope for achieving one's goals and the importance of being surrounded by treaters, peers and family members who share realistic optimism and hope.

Knowledge about one's illness, the range of available treatments and ways to navigate the service system is another way that can help people improve their confidence in coping with mental illness. It can help people with schizophrenia attend to their own personal experiences, manage symptoms, and achieve greater independence and less dependence on the mental health system.

Satisfaction with family, social networks, living arrangements, community and safety are also important. These can be encouraged by family psychoeducation that can help with improving communication with family members. Case management services such as assertive community treatment may also help those with schizophrenia maximize their housing opportunities and create housing stability.

Overall, the authors suggest that the evidence-based practice (EBP) movement in science, which promotes treatments that are supported by clinical trials, can help to identify interventions that promote these recovery orientations in people with schizophrenia. These EBPs can help by providing a mechanism for identifying treatments that promote recovery orientations.

Overall, this article highlights the importance of people with schizophrenia and caregivers to be well informed of current advances/treatments that are continuously being introduced, so as to encourage recovery in their loved ones.

Schizophr Res. 2005 Jun 1;75(1):119-28.
Click here to find this article on PubMed, or do a search for the article at http://www.pubmed.com

Gene Therapy for the Brain - could this Alzheimer's research someday apply to schizophrenia treatment?

In a development that highlights the potential to mitigate brain diseases (such as Schizophrenia) via gene therapy, The University of California, San Diego (UCSD) announced today that Alzheimer's Cognitive Decline Slowed In Gene Therapy Patients.

PET scans and cognitive tests have suggested that Alzheimer's disease patients with genetically modified tissue inserted directly into their brains show a reduction in the rate of cognitive decline and increased metabolic activity in the brain, according to a study published in the April 24, 2005 online issue of the journal Nature Medicine by researchers at the University of California, San Diego (UCSD) School of Medicine.

PET scans demonstrated an increase in the brain's use of glucose, an indication of increased brain activity, while mental-status tests showed a slowing of the patients' rate of cognitive decline was reduced by 36 to 51 percent. In addition, researchers examined the brain tissue of a study participant who had died and found robust growth of extensions from the dying cholinergic cells near the site of growth factor gene delivery. Cholinergic neuron loss is a cardinal feature of Alzheimer's disease, a progressive brain disorder affecting memory, learning, attention and other cognitive processes.

"If validated in further clinical trials, this would represent a substantially more effective therapy than current treatments for Alzheimer's disease," said Mark Tuszynski, M.D., Ph.D., UCSD professor of neurosciences, neurologist with the VA San Diego Healthcare System, and the study's principal investigator. "This would also represent the first therapy for a human neurological disease that acts by preventing cell death."

In this first-ever gene therapy for Alzheimer's disease, UCSD physician-scientists took skin cells from eight patients diagnosed with early Alzheimer's disease. The tissue was modified in the lab to express nerve growth factor (NGF), a naturally occurring protein that prevents cell death and stimulates cell function. In surgeries that took place in 2001 and 2002 at UCSD's John M. and Sally B. Thornton Hospital, the genetically modified tissue was implanted deep within the brains of the eight patients who had volunteered for the study.

The human clinical trial was undertaken following extensive studies in primates conducted by Tuszynski and colleagues, which showed that grafting NGF-producing tissue into the brains of aged monkeys restored atrophied brain cells to near-normal size and quantity, and also restored axons connecting the brain cells, essential for communication between cells.

Cognitive outcomes were assessed in the six patients who completed the NGF delivery procedure safely. The Mini Mental Status Examination (MMSE), which evaluates cognitive function, was administered at screening, the time of treatment and at several intervals after treatment. Over an average post-treatment follow-up period of 22 months, the rate of decline on the MMSE among NGF-treated patients was reduced by as much as 51 percent. An additional test, called the Alzheimer's Disease Assessment Scale-Cognitive Subcomponent, or ADAS-Cog, also showed improvements in rates of decline followed the MMSE findings.

In addition to Tuszynski, authors of the paper in Nature Medicine, were Leon Thal, M.D., UCSD chair of neurosciences, director of the UCSD Shiley-Marcos Alzheimer's Disease Research Center (ADRC), and a neurologist with the VA San Diego Healthcare System; Mary Margaret Pay., and others.

The study was supported by the Institute for the Study of Aging and the Shiley Family Foundation

Please see the online newsblog entry about this study for an image of the PET scans referred to in the research - http://www.schizophrenia.com/sznews/archives/001735.html