New Evidence Said to Challenge Psychiatry’s Basic Paradigms
Psychiatry is at a crossroads, according to Patrick Bracken, M.D., Ph.D., clinical director of the West Cork Mental Health Service in Ireland, at APA’s annual meeting in San Francisco in May.
“Accumulating evidence challenges the current paradigm underlying psychiatric thinking and practice,” said Bracken. The problem lies deeper than just “too many drugs.”
“Psychiatry faced three great quests over the last 30 years—the quest for valid classification systems, the quest for biological and psychological causal pathways in mental illness, and the quest for technological treatments used independently of context—and all are falling apart in front of our eyes,” he maintained.
Bracken faults the profession’s adherence to what he calls the “technological paradigm,” an approach to understanding psychiatric symptoms and diagnoses mainly as broken mechanisms or processes that need fixing.
Psychiatry is at a crossroads, according to Patrick Bracken, M.D., Ph.D., clinical director of the West Cork Mental Health Service in Ireland, at APA’s annual meeting in San Francisco in May.
“Accumulating evidence challenges the current paradigm underlying psychiatric thinking and practice,” said Bracken. The problem lies deeper than just “too many drugs.”
“Psychiatry faced three great quests over the last 30 years—the quest for valid classification systems, the quest for biological and psychological causal pathways in mental illness, and the quest for technological treatments used independently of context—and all are falling apart in front of our eyes,” he maintained.
Bracken faults the profession’s adherence to what he calls the “technological paradigm,” an approach to understanding psychiatric symptoms and diagnoses mainly as broken mechanisms or processes that need fixing.
Read the whole story
· ·
Next Page of Stories
Loading...
Page 2
Open Data by Thomas Insel
A couple of weeks ago, President Obama launched a new open data policy (pdf) for the federal government. Declaring that, “…information is a valuable asset that is multiplied when it is shared,” the Administration’s new policy empowers federal agencies to promote an environment in which shareable data are maximally and responsibly accessible. The policy supports broad access to government data in order to promote entrepreneurship, innovation, and scientific discovery.
If the White House needed an example of the power of data sharing, it could point to the Psychiatric Genomics Consortium (PGC). The PGC began in 2007 and now boasts 123,000 samples from people with a diagnosis of schizophrenia, bipolar disorder, ADHD, or autism and 80,000 controls collected by over 300 scientists from 80 institutions in 20 countries. This consortium is the largest collaboration in the history of psychiatry.
More important than the size of this mega-consortium is its success. There are perhaps three million common variants in the human genome. Amidst so much variation, it takes a large sample to find a statistically significant genetic signal associated with disease. Showing a kind of “selfish altruism,” scientists began to realize that by pooling data, combining computing efforts, and sharing ideas, they could detect the signals that had been obscured because of lack of statistical power. In 2011, with 9,000 cases, the PGC was able to identify 5 genetic variants associated with schizophrenia. In 2012, with 14,000 cases, they discovered 22 significant genetic variants. Today, with over 30,000 cases, over 100 genetic variants are significant. None of these alone are likely to be genetic causes for schizophrenia, but they define the architecture of risk and collectively could be useful for identifying the biological pathways that contribute to the illness.
We are seeing a similar culture change in neuroimaging. The Human Connectome Project is scanning 1,200 healthy volunteers with state of the art technology to define variation in the brain’s wiring. The imaging data, cognitive data, and de-identified demographic data on each volunteer are available, along with a workbench of web-based analytical tools, so that qualified researchers can obtain access and interrogate one of the largest imaging data sets anywhere. How exciting to think that a curious scientist with a good question can now explore a treasure trove of human brain imaging data—and possibly uncover an important aspect of brain organization—without ever doing a scan.
However, not all scientists are comfortable sharing data. Some point out that data collected under different conditions or with different assessment tools should not be combined. Some have expressed concern that data will be “misinterpreted” if analyzed without the input of the researchers who collected the data. And others worry about the competitive disadvantage of sharing data before publication. In an academic culture that rewards the first to report a finding and for which publication is critical for promotion, sharing might seem unfair to early career scientists and unacceptable to more established investigators. Finally, privacy concerns may be a complex—though not insurmountable—barrier to sharing data, both for scientists and for research participants. We must not minimize these concerns. But as an agency that is ultimately focused on improving the health of patients, NIMH must find a way to balance the concerns of the academic community with our public health mission.
If “information is a valuable asset that is multiplied when it is shared,” then the question for publicly funded research is not if, but how to share. Currently, NIH policy expects a data sharing plan for all proposals over $500,000 per year in direct costs. However, some research communities have developed their own “subcultures” in which sharing is expected—and executed—for all grants, not just those over the $500,000 threshold. For example, all researchers conducting NIH-funded genome-wide association studies submit their data to the NIH Database for Genotypes and Phenotypes (dbGaP), as expected by the NIH GWAS Data Sharing Policy. In other areas, such as autism research, NIH expects all funded clinical studies to deposit data in the NIH National Database for Autism Research (NDAR).
These two trans-NIH data sharing efforts are a great start. But as a community, can we do better in other areas, such as clinical trials, by defining our standards for data sharing? For example, should we develop common data elements and create repositories for shared data in other research fields? What is the right balance between providing qualified researchers with access to data at the earliest opportunity while respecting the needs of those who collected the data? How can we incentivize sharing and data mining when many investigators do not have the funding to analyze their own data sufficiently? Should some data not be shared? NIH has been developing resources to facilitate this conversation, such as key elements to consider when preparing a data sharing plan (pdf).
The culture of science is changing. Just look at the Broad Institute’s global alliance on sharing of genomic and clinical data: over 70 health care, research, and disease advocacy organizations have taken the first steps dedicated to enabling secure sharing of data. Public demands for access, transparency, and accountability are increasing. New scientific journals are supporting more access to data. Scientists are demanding and finding the value in sharing and cooperation. I suspect the PGC, the Human Connectome Project, and NDAR are the front wave of what will be a sea change in the conduct and reporting of science. Having a new open data policy provides even more reason to create the tools and rules needed to support these changing times.
Learn more about: Basic Research, Genetics, Imaging, NIMH. View all posts about: Basic Research,Genetics, Imaging, NIMH.
Read the whole story
· · ·
A National Dialogue by Thomas Insel
June 3 marked the first White House Conference on Mental Health in 14 years. President Obama opened the event by describing how many people “suffer in silence” rather than seeking help:
Source: WhiteHouse.gov
We see it in the veterans who come home from the battlefield with invisible wounds of war, but who feel like seeking treatment is somehow a sign of weakness – when, in fact, it’s a sign of strength.
We see it in the parents who would do anything for their kids, but who often fight their mental health battle alone – afraid that reaching out would invite judgment or reflect badly on them.
And we see it in tragedies that we have the power to prevent.
With these remarks, the President launched the National Dialogue on Mental Health, bringing together 200 mental health experts, a dozen members of Congress, and celebrities like Glenn Close and Bradley Cooper to start a national conversation about youth and mental health. The White House has also launched a website, mentalhealth.gov, with its tag line “Let’s talk about it.”
Noting that less than 40 percent of people with mental disorders seek treatment, the President stressed the need to do a better job recognizing mental health issues, especially in children. Acknowledging that we must ensure that treatment is available, the President described how the Affordable Care Act will expand mental health care to 60 million more Americans, and he detailed new investments to increase the mental health workforce. He also noted how new investments in science, including the BRAIN initiative, should bring better treatments for those who need them.
It’s hard not to draw a parallel to the June 1999 White House conference, which was precipitated by the school shootings in Littleton, Colorado six weeks earlier. Hosted by Tipper Gore and President Clinton, the focus was on youth mental health and reducing stigma. Fourteen years later, the conversation leaders are different, but the issues are much the same. Again we are in the wake of a school shooting; again we turn our attention to mental health in youth; and again we are discussing how to overcome negative attitudes toward those with mental disorders. But this begs the question: why are we still having the same conversation about the same issues in mental health? How do we refocus this discussion?
First of all, much has changed in the past 14 years that should be enriching our dialogue: the era of genomics has transformed biomedical science; the revolution in mobile technology reaches countless adolescents and holds potential as an avenue to change behaviors; and the advent of health care reform will help more people get the treatment they need. All of these have the promise to transform mental health care and mental health research.
Second, we need not only a national dialogue but a national action plan. “Let’s talk about it” is a good place to start, but for a 19-year-old in the grip of a psychotic episode or a 16-year-old on the path to serious mental illness, we urgently need an action plan to alter the course of their illness. This year, the 100,000 young Americans who will have a first episode of psychosis will join over two million adults with schizophrenia. The majority of people with mental illness delay seeking care, which is especially serious for people with psychotic disorders. In the United States, individuals with psychosis go untreated for, on average, 110 weeks.1 Among other serious consequences, untreated psychosis poses an increased risk for substance use and suicide, both of which contribute to the elevated mortality associated with these disorders. Our best hope of reducing mortality from serious mental disorders will come from realizing that just like other medical illnesses, we need to diagnose and preempt the illness before the symptoms become manifest. At the White House conference, Vice President Biden spoke to this point directly, stressing that we must intervene earlier, as we do today for cancer and heart disease.
Recognizing this call to action, NIMH is preparing for a surge of research focused on predicting and preventing serious mental illness. New initiatives will seek to change the treatment paradigm from one of treating chronic illness to one of preempting the illness long before symptoms emerge. We have two landmark NIMH studies to build upon: The North American Prodrome Longitudinal Study (NAPLS) is a consortium of clinical research centers studying ways to identify individuals earlier who are at risk for an initial psychotic episode. Through NAPLS, we have the opportunity to create a toolkit to improve prediction of psychosis using biosignatures and neurocognitive testing. The Recovery After an Initial Schizophrenia Episode (RAISE) project is a large-scale research effort to explore whether using early and aggressive treatment will reduce the symptoms for individuals who have already had a psychotic episode and prevent the subsequent gradual deterioration of functioning. RAISE will be expanded with the aim to reduce the duration of untreated psychosis by linking community mental health care to primary care and school mental health resources.
We must make sure that the next White House conference on mental health is a celebration of progress. Science is the path on which progress is made. Investing in programs focused on early diagnosis are the best hope for creating more precise diagnostics and more effective preventive interventions to ensure better outcomes. Let’s start writing a new chapter in the chronicle on mental health. Our nation’s youth deserve to be part of a better story.
References
1 Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients. Arch Gen Psychiatry. 2005 Sep 62:975-983.
Read the whole story
· · · ·
Desde el pasado viernes, 14 de junio, y hasta el 19 de Octubre de 2013, Puerto Rico abrirá sus...
No comments:
Post a Comment