NIMH has published a press release on initial results of an important new study of anti-psychotic medications. The study compares the newer medications with an older medication thought to have a lower incidence of movement disorders.

NIMH: NIMH Study To Guide Treatment Choices for Schizophrenia

In the CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) trial, researchers directly compared an older medication (perphenazine), available since the 1950s, to four newer medications (olanzapine, quetiapine, risperidone, and ziprasidone), introduced in the 1990s. The purpose of the study was to learn whether there are differences among the newer medications and whether the newer medications hold significant advantages over the older medications; these newer medications known as atypical antipsychotics, cost roughly 10 times as much as the older medications.

The size and scope of the trial, with more than 1,400 participants at 57 sites around the country, its 18-month duration, and its inclusion of a wide range of patients in a variety of treatment settings ensure that the findings are reliable and relevant to the 3.2 million Americans suffering from schizophrenia.

At the beginning of the study, patients were randomly assigned to receive one of the five medications. Almost three quarters of patients switched from their first medication to a different medication. The patients started on olanzapine were less likely to be hospitalized for a psychotic relapse and tended to stay on the medication longer than patients taking other medications. However, patients on olanzapine also experienced substantially more weight gain and metabolic changes associated with an increased risk of diabetes than those study participants taking the other drugs.

Contrary to expectations, movement side effects (rigidity, stiff movements, tremor, and muscle restlessness) primarily associated with the older medications, were not seen more frequently with perphenazine (the drug used to represent the class of older medications) than with the newer drugs. The older medication was as well tolerated as the newer drugs and was equally effective as three of the newer medications. The advantages of olanzapine — in symptom reduction and duration of treatment — over the older medication were modest and must be weighed against the increased side effects of olanzapine.

Thus, taken as a whole, the newer medications have no substantial advantage over the older medication used in this study. An important issue still to be considered is individual differences in patient response to these drugs.

NIMH: CATIE Schizophrenia Q&As for Media

...the primary measure of treatment success in the CATIE study was how long a patient benefited from and thus stayed on a medication before they or their doctor decided that it had to be changed. Investigators also recorded why a patient stopped a medication: if the medication did not control symptoms, or if the side effects were not tolerable, or if the patient chose to stop treatment for some other reason. In addition to this primary outcome, the study also examined medication effects on the symptoms of schizophrenia, as well as other important outcomes such as overall level of function.
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This study provides the largest, longest, and most comprehensive independent trial ever conducted to study existing therapies for this disease. It will provide valuable information to help physicians and patients choose the most appropriate medication for them. There is considerable variation among individuals; what works for one does not necessarily work for another. It is important to have a variety of treatment options. The CATIE study provides specific information, on therapeutic effects as well as side effects, about those options.
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The investigators will continue to study other important outcomes, including cost-effectiveness, quality of life, and predictors of response. As additional results from CATIE are analyzed, disseminated, and put into context, the hope is that the cumulative findings will yield a more complete picture of the interaction between patient characteristics, medication, environment, and outcomes.

The complete study is available September 22nd:

Lieberman, J.A., Stroup, T.S., McEvoy, J.P., Swartz, M.S., Rosenheck, R.A., Perkins, D.O., Keefe, R.S.E., Davis, S.M., Davis, C.E., Lebowitz, B.D., Severe, J., Hsiao, J.K. (2005). Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia. New England Journal of Medicine, (353), p.1209-1223.

These first published results offer some interesting outcomes, perhaps a low cost alternative to the high priced newer medications. Perphenazine is better known by it's brand name Trilafon. Its important to note that a positive outcome was defined rather narrowly in this study. More detailed data is said to be forthcoming.

I think the most important issue in using anti-psychotic medications is the long-term side effects, in particular tardive dyskinesia and diabetes. The new medications promised fewer movement disorders. So far, these promises seem to hold true. But the emerging concerns about diabetes has clouded the future of the newer anti-psychotic medications. Doctors are currently advised to watch for metabolic changes as well as the development of movement disorders.

The definitive answers for these two concerns can't be obtained in the 18 months the study followed patients. I would hope someone has discovered this problem and is tracking down those who participated, some as long as five years ago, to gather new data about these critical issues.

Meanwhile, I'll be particularly interested in seeing results related to quality of life and the even more exciting studies of the interaction between patient characteristics, medication, environment, and outcomes. Ultimately, the study may have a significant impact on patient care and understanding the dynamics of recovery.

Medicating young children has always been controversial. For awhile, it appeared as if that suspicion of medication would subside. More and more kids everyday were taking stimulants and others were taking anti-depresants.

Then the controversy about the association of suicide with anti-depressant medication. The whole logic of that argument has always seemed faulty given that kids who are depressed and suicidal are the one's offered anti-depressants. The medication can't be causing behavior that was possible even likely before taking it. However, the evidence suggests something more complex is going on than simple logic can explain.

Now there are more recent studies suggest anti-depressant medication may have unexpected effects on the developing brains of children.

Similarly, researchers are calling to question the long term effects of stimulants used in the treatment of Attention Deficit Hyperactivity Disorder. As with depression, cognitive-behavior therapy is showing initial research results suggesting that it is sometimes as effective or even more effective than medication.

To medicate or not?

Long-term studies increasingly link attention-deficit hyperactivity disorder with poor educational outcomes, even when children are medicated. ADHD kids drop out of high school more frequently, and their academic achievement scores average 8 to 10 percent lower than their non-ADHD peers, despite equivalent IQs. Additional support for these fi ndings will be published by William Pelham of the University at Buffalo and Brooke Molina of the University of Pittsburgh, whose research also hints that stimulant medication may increase the risk of substance abuse later in life.

Millions of parents must decide when their child is diagnosed with attention-defi cit hyperactivity disorder (ADHD)—a decision made tougher by controversy. Studies increasingly show that while medication may calm a child’s behavior, it does not improve grades, peer relationships or defiant behavior over the long term. Consequently, researchers have focused attention on the disorder’s neurobiology. Recent studies support the notion that many children with ADHD have cognitive deficits, specifically in working memory—theability to hold in mind information that guides behavior. The cognitive problem manifests behaviorally as inattention and contributes to poor academic performance. Such research not only questions the value of medicating ADHD children, it also is redefining the disorder and leading to more meaningful treatment that includes cognitive training.

“This is really a shift in our understanding of this disorder from behavioral to biological,” states Rosemary Tannock, professor of psychiatry at the University of Toronto. Tannock has shown that although stimulant medication improves working memory, the effect is small, she says, “suggesting that medication isn’t going to be sufficient.” So she and others, such as Susan Gathercole of the University of Durham in England, now work with schools to introduce teaching methods that train working memory. In fact, working-memory deficits may underlie several disabilities, not just ADHD, highlighting the heterogeneity of the disorder.

“Working memory is a bottleneck for everyday functioning independent of what category you fit into,” comments Torkel Klingberg, a neuroscientist at the Karolinska Institute in Stockholm. Based on Klingberg’s research, Karolinska founded Cogmed—a biotech company that has developed a software program to train working memory. In a recent paper in the Journal of the American Academy of Child and Adolescent Psychiatry, Klingberg reported that 60 percent of 20 unmedicated ADHD children no longer met the clinical criteria for ADHD after five weeks of training. The company has already rolled out its training service in Sweden and Germany, and Karolinska is collaborating with New York University to launch a clinical trial with ADHD kids later this year. “It’s intriguing data,” Tannock remarks.

Here is an article about a modest but potentially significant piece of research. They took existing data and studied any correlation between socio-economic status and mental illness. Not surprisingly to those familiar with the subject, there was a modest but significant association between being socially disadvantaged with a higher incidence of mental illness. The population surveys they used were shown to be inadequate to the task. Specific ideas were suggested on how to better collect such data.

The most important part of this research was the discussion about future research. The study suggests a "nurture" factor to mental illness. While the documentation is not clear, there is justification to pursue better research. While one could argue that the genetic "causes" of mental illness could be higher in generations of poor people, it seems unlikely that multi-generation poverty would amount to the majority of the population surveyed. Nor is genetic tracing of mental illness risk likely to be related to all the factors measured and found to be related.

There can be no doubt now that disadvantaged groups in European populations experience more anxiety and depression, measurable on standard instruments and representing significant suffering for individuals, and serious loss of production and social function, with important consequences for children, communities and work-places. We can begin to define populations at risk, though this will still be rather generalised.

The scientific literature from major population studies currently permits very little detailed comparitive analysis of risk factors other than the three presented above, education, employment, and income / material standard of living, which can be measured in fairly similar ways in all western societies. Social Class or Socio-Economic Group can only be a proxy for these, and, no doubt, other more precise and tangible markers of social position and social experience. We now need focussed investigations into causative factors and possible means of prevention, and evaluations of means of relieving suffering and improving function.

The most exciting part of this discussion is the prospect of breaking down socio-economic factors into what might be considered environmental risk factors for mental illness. My clinical experience says that child abuse and neglect is more directly related to episodes of mental health disability than most seem to believe. Perhaps we can make some progress towards convincing the general population to teach resilience skills and child-rearing in high schools.

Fryers, T., Melzer, D., Jenkins, R., Brugha, T. (2005). . Clinical Practice and Epidemiology in Mental Health, 1(1), 14. DOI: 10.1186/1745-0179-1-14

A number of people maybe wondering just how we can best help children and their parents who have faced the disaster in New Orleans. Here is an approach that has produced convincing research results treating children and their families. Contact the authors for more information. The link is below.

SAMHSA

Trauma-Focused Cognitive Behavioral (TF-CBT) is a psychotherapeutic intervention designed to help children, youth, and their parents overcome the negative effects of traumatic life events such as child sexual or physical abuse; traumatic loss of a loved one; domestic, school, or community violence; or exposure to disasters, terrorist attacks, or war trauma. It was developed by integrating cognitive and behavioral interventions with traditional child abuse therapies that focus on enhancement of interpersonal trust and empowerment. The program can be provided to children 3 to 18 years of age and their parents by trained mental health professionals in individual, family, and group sessions in outpatient settings. It targets symptoms of posttraumatic stress disorder (PTSD), which often co-occurs with depression and behavior problems. The intervention also addresses issues commonly experienced by traumatized children, such as poor self-esteem, difficulty trusting others, mood instability, and self-injurious behavior, including substance use.

Families all over the Gulf Coast are experience the trauma of a natural disaster. Families all over America are watching the events unfold on the nightly news. Certainly the trauma of being present in the event is potentially the most damaging. But watching such catastrophic events unfold even on TV can have some effects, especially on children and adolescents.

Talking about traumatic stress among family members have the effect of rallying the primary circle of support for its members. Sometimes the comfort of the support of your immediate family is enough, sometimes it is not. Here is some guidelines from the American Psychological Association about when to seek help.

Individuals with prolonged reactions that disrupt their daily functioning should consult with a trained and experienced mental health professional. Psychologists and other appropriate mental health providers help educate people about normal responses to extreme stress. These professionals work with individuals affected by trauma to help them find constructive ways of dealing with the emotional impact.

With children, continual and aggressive emotional outbursts, serious problems at school, preoccupation with the traumatic event, continued and extreme withdrawal, and other signs of intense anxiety or emotional difficulties all point to the need for professional assistance. A qualified mental health professional can help such children and their parents understand and deal with thoughts, feelings and behaviors that result from trauma.

Here are some suggestions to help you cope with trauma. Many of these approaches will be helpful for the more quiet effects of vicarious trauma experienced through the television.

- Give yourself time to heal. Anticipate that this will be a difficult time in your life. Allow yourself to mourn the losses you have experienced. Try to be patient with changes in your emotional state.
- Ask for support from people who care about you and who will listen and empathize with your situation. But keep in mind that your typical support system may be weakened if those who are close to you also have experienced or witnessed the trauma.
- Communicate your experience in whatever ways feel comfortable to you - such as by talking with family or close friends, or keeping a diary.
- Find out about local support groups that often are available such as for those who have suffered from natural disasters, or for women who are victims of rape. These can be especially helpful for people with limited personal support systems.
- Try to find groups led by appropriately trained and experienced professionals. Group discussion can help people realize that other individuals in the same circumstances often have similar reactions and emotions.
- Engage in healthy behaviors to enhance your ability to cope with excessive stress. Eat well-balanced meals and get plenty of rest. If you experience ongoing difficulties with sleep, you may be able to find some relief through relaxation techniques. Avoid alcohol and drugs.
- Establish or reestablish routines such as eating meals at regular times and following an exercise program. Take some time off from the demands of daily life by pursuing hobbies or other enjoyable activities.
- Avoid major life decisions such as switching careers or jobs if possible because these activities tend to be highly stressful.

Here are some suggestions about how to care for your children.

The intense anxiety and fear that often follow a disaster or other traumatic event can be especially troubling for children. Some may regress and demonstrate younger behaviors such as thumb sucking or bed wetting. Children may be more prone to nightmares and fear of sleeping alone. Performance in school may suffer. Other changes in behavior patterns may include throwing tantrums more frequently, or withdrawing and becoming more solitary.

There are several things parents and others who care for children can do to help alleviate the emotional consequences of trauma, including the following:

- Spend more time with children and let them be more dependent on you during the months following the trauma - for example, allowing your child to cling to you more often than usual. Physical affection is very comforting to children who have experienced trauma.
- Provide play experiences to help relieve tension. Younger children in particular may find it easier to share their ideas and feelings about the event through non-verbal activities such as drawing.
- Encourage older children to speak with you, and with one another, about their thoughts and feelings. This helps reduce their confusion and anxiety related to the trauma. Respond to questions in terms they can comprehend. Reassure them repeatedly that you care about them and that you understand their fears and concerns.
- Keep regular schedules for activities such as eating, playing and going to bed to help restore a sense of security and normalcy.

An expert from Purdue offers additional suggestions courtesy of AScribe Newswire

If parents have had a conversation with their children about the tragedies surrounding Hurricane Katrina, they need to remember once is not enough, says a child development specialist at Purdue University. "Parents have expressed difficulty in explaining what happened in this and other large-scale public tragedies to their children, but it's important that they realize parents don't need to have all the answers," said Judith Myers-Walls, associate professor of child development and family studies. "This is a great opportunity to teach kids coping mechanisms. By being honest, parents can show their kids how to cope with being afraid."

Myers-Walls recommends the following actions for parents, teachers and other caring adults when children have questions about the hurricane's effects:

- Don't assume that the kids don't know about it.
- Be available and "askable."
- Share your own feelings.
- Help children use creative outlets, such as art and music, to express their feelings.
- Reassure young people, and help them feel safe.
- Support children's concern for people they don't know.
- Look for feelings beyond fear.
- Help children and youth find a way to think about the event and move forward.
- Take action and get involved in positive action to help alleviate others' suffering.

Don't underestimate the effects of trauma. In my experience, trauma is one of the leading contributers to mental health disabilities. Repeated trauma is one of the most common causes. Even once the effects of trauma have led to the long-term effects of post-traumatic Stress Disorder, while a significant life disruptor, successful treatment is possible when the person commits to placing a high priority on treatment.

NewMood is a large study of depression and we are looking for the general public to help us with this research. Anyone can take part whether or not they have ever suffered from depression. We will use questionnaires, sent out by post, to ask about personality and life experiences.

This website has shorter online versions of some of the tasks in the study. Try them out - they're fun!