Educating people about the brain is a good thing

Thomas Insel's latest post on his NIMH director's blog focuses on March being Brain Awareness Month. Although as Insel admits, we don't know much about the working of the brain, what we do know is important, fascinating and people should be more aware of it. I think it's important to emphasise the dynamic nature of the brain.

I just don't think Insel's so good on the limits of brain neuroscience, starting with his claim that mental disorders are brain disorders. Of course, there's a sense in which such a statement is merely tautologous. But, he goes further to state that "with the powerful tools of neuroscience, we can now use the brain to understand the mind" but then doesn't explain how exactly. He's even not correct, I don't think, about Freud's project for a scientific psychology. Freud may well have thought that psychoanalysis may have eventually been replaced by chemical treatment, but he believed his theory of the mind would endure (read John Heaton's book). I'm sure Insel does not agree with Freud that his theory of the mind was scientific.

What's wrong with believing in the chemical imbalance theory of depression?

Recruits from an undergraduate psychology course with a past or current episode of depression were led to believe that the purpose of a study (Kemp et al 2014) was to improve understanding of how people respond to learning the cause of their depression. They were administered the Rapid Depression Test (RDT), which they were deceived into believing is a "test of neurotransmitter levels whose results would allow participants to determine whether or not their depressive episode(s) were caused by a chemical imbalance in the brain".

The test entailed swabbing the inside of the participants' cheeks with a sterile cotton swab and placing the cotton swab into a sterile collection container. Participants were told their saliva sample would be tested in the lab. The experimenter returned 10 minutes later with the results.

In the chemical imbalance condition, participants were informed that test results indicated that their past/current depression was caused by an imbalance in the neurotransmitter serotonin. Participants were presented with a bar graph of their test results depicting very low serotonin levels relative to levels of other neurotransmitters, all of which were in the normal range. Participants in the control condition, on the other hand, were told their past/current depression was not the result of a chemical imbalance, based on purported test results (and a corresponding bar graph) indicating that all neurotransmitter levels were in the normal range.

The chemical imbalance test feedback made participants significantly more likely to attribute their depression to chemical imbalance, demonstrating that the intervention was effective. Self-stigma was unaffected but chemical imbalance feedback made participants significantly more pessimistic about prognosis. There was some evidence of lowered perceived ability to regulate negative mood states. Participants in the chemical imbalance condition rated pharmacotherapy as more likely to be effective than psychotherapy. By contrast, expectancies for pharmacotherapy and psychotherapy did not differ significantly in the control condition.

The authors conclude that doctors may be causing harm by encouraging belief in chemical imbalance. The theory may be used as a means of getting patients to take their medication (eg. see my eletter). It can be a surprise to patients when they discover the theory has never been proven. They might be even more upset when they realise they might have done better not to believe it.

(With thanks to blog by Kermit Cole on Mad in America)

Do mood stabilisers treat mood instability?

What is mood instability? As the article by Marwaha et al (2012) says there is a "lack of a clear, accepted and well-validated definition". However, the impression given when people are prescribed so-called mood stabilisers is that we know what we are talking about.

13.9% of the population aged over 16 in the 2007 Adult Psychiatric Morbidity Survey answered yes to the question "Do you have a lot of sudden mood changes?" Marwaha et al take this as their definition of mood instability. And, patients referred to mental health teams commonly complain of this symptom (without perhaps being very clear about what they mean). For example, Gilbert et al (2005) found that 83.8% of patients referred to two city CMHTs in Derby ticked mood instability on a checklist and this was the most commonly endorsed symptom of any on the list.

In an article this month in BJPsych, Bilderbeck et al (2014) interviewed 28 patients referred to secondary mental healthcare teams (including a specialist mood disorder clinic) in Oxfordshire and Buckinghamshire. Mood instability had been cited as a reason for referral. What was found was that patients placed a primary emphasis on finding an explanation for their problems. Not everyone was helped by a formal diagnosis of, say, bipolar disorder. For example, receiving a diagnosis could be experienced as dismissive, in a way that was linked to a perceived lack of adequate explanation and/or support. What may be more important than a diagnosis is a good professional relationship with the doctor.

In an accompanying editorial, Robert Dudas makes the common statement that "few people would now challenge the view that it [bipolar disorder] is a major mental illness with a strong biological vulnerability" without being clear whether he is being more than trite in referring to the biological dimension. Nor does he discuss the expansion in the diagnosis of bipolar disorder (eg. see previous post).

Dudas also makes reference to another qualitative study of the process of making sense of a diagnosis of bipolar disorder. This study again notes the ambivalence about the diagnosis. More should be made of this finding. Maybe patients are right to be uncertain about psychiatrists focusing too much on mood instability as a mental disorder. I am, of course, not saying that 'tranquility of the mind' may not be important for wellbeing but mood instability is not uncommon and may clearly be a reflection of personal difficulties rather than necessarily a mental illness as such.

Pharma pipeline for schizophrenia

I've been told in an email that these are the pharma pipleine presentations at the 4th Schizophrenia International Research Society Conference in Florence in April this year. (I've added some links):-

Targacept
Dr. David Hosford – Targacept Pharma Pipeline
La Roche
Dr. Dragana Bugarski-Kirola - Efficacy and Safety of Adjunctive Bitopertin versus Placebo in Subjects with Persistent Predominant Negative Symptoms of Schizophrenia Treated with Antipsychotics – update from the SearchLyte Programme (see media release)
Omeros 
Dr. Yu - Early Clinical Results of the Phospodiesterase 10 Inhibitor OMS643762 in Development for the Treatment of Schizophrenia and Huntington’s Disease
Dr. Jonathan Rabinowitz
Randomized, Double-Blind, Active-Controlled, Phase 2/3 Study to Determine the Short-Term (6-Week) and Long-Term (6 Month) Cognitive and Anti-Psychotic Efficacy, Safety and Tolerability of CYP-1020 Compared to Risperidone
Ragy Girgis
Dopamine-1 Receptor Stimulation in Schizophrenia: a Randomized, Clinical Trial
Intracellular Therapies
Kimberly Vanover, ITI-007 a New Approach to the Treatment of Schizophrenia

Hey, I thought the pipeline was supposed to have dried up (see previous post)! Even NIMH admits "treatment development" has been slow (see recent Director's blog by Thomas Insel), although its solution with so-called experimental medicine seems biased towards neural pathways rather than psychosocial treatments (which apparently need to demonstrate their worth through phoney neural pathways). Seems as though I was wrong (although I was just being hopeful!) about abandoning diagnostic crieria for research with RDoC (see previous post).

The reason for these changes according to Insel is that "The pharmaceutical industry pipeline for medications is depleted, after several decades of 'me too' drugs" made by competing companies. He goes on, "Industry has reduced investments in medications for mental disorders and payers are raising questions about the quality of evidence for psychosocial treatments." As proposed by Marcia Angell (see my book review), what's really needed is (1) license approval only to be given to genuinely innovative drugs, rather than as at present to me-too drugs (2) an "Institute for Prescription Drug Trials" within the National Institutes of Health to take over from drug companies, who should no longer be permitted to control clinical testing of their own drugs.

Onward Christian soldiers

Article in Journal of Nervous and Mental Disease discusses why psychiatrists came to different conclusions about whether Anders Breivik was insane in 2011, when he detonated a fertilizer bomb near government buildings in Oslo, killing eight people, and then killed a further 69 people on a nearby island where the Labor Party was holding a youth camp (see previous post). Breivik didn't invent the Knights Templar. Luckily it's not psychiatrists that make the final decision on insanity in court.