Or, maybe we’re all mentally ill?

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There’s an argument going on by the folks revising the handbook of mental illness diagnostics-The Diagnostic and Statistical Manual of Mental Disorders (DSM), on what is or is not a mental illness.  The new manual with include 50 more diagnostic categories than the previous version- a new total of 300. Some say this will mean everyone has a mental illness, and some psychiatrists are boycotting the new manual describing it as “unscientific, unsound and ultimately unsafe; that it continues the DSM tradition of pathologizing ordinary behaviors – the new DSM will contain over 300 diagnostic categories, up from DSM-IV TR’s 250; that it narrows “treatment of choice” to the prescription of psychoactive medications despite their known toxicity and suspect effectiveness”.

We know that mental illness is the largest cause of disability in the U.S. If the net is cast so wide that everyone basically has mental illness…..well that wipes out the stigma issue at least. And maybe health care reform would actually take place.

While we debate over semantics, the UK is actually taking action for reform. Last month the National Health Service released a policy statement acknowledging the issue:

“Poor mental health is the largest cause of disability in the UK. It’s also closely connected with other problems, including poor physical health and problems in other areas like relationships, education and work prospects. If we want to improve these aspects of people’s lives, we’ll need to make improvements to mental health and wellbeing.”

This included some actions that they took to back this up:

-Public services had to reflect the importance of mental health in their planning, and put it on a par with physical health

-Local health and wellbeing boards were give a duty to reduce health inequalities in their area, including in mental health.

-They published guidelines on preventing suicide to help health professionals, mental health services, police, prisons and others save more lives.

-They improved mental health services for former members of the military

-They made sure that offenders’ mental health problems are identified as soon as possible, and that they have access to the same mental health services as everyone else.

We could do this too here

Link to U.K. National Health Service policy:

https://www.gov.uk/government/policies/making-mental-health-services-more-effective-and-accessible–2

Link to DSM boycott:

http://www.madinamerica.com/2013/02/dsm-5-boycott-launched/

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Is There Such a Thing as Mental Illness?

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Last night I played a gig in the San Francisco Mission district- home of the hipsters, the homeless and the “hell no, I’m not leaving my rent controlled apartment.” While we were setting up I asked our singer Geoff if he had heard about a new study that showed full-blown psychotic illness was more than halved for those receiving cognitive behavior therapy (CBT) at six, 12 and 18-24 months after treatment started.  Geoff told me his dad (a behavioral psychologist) says that there’s no such thing as mental illness- just people who haven’t learned the correct adaptive strategy.  This study says that young people seeking help who are at risk of developing psychosis should now be offered a package of care which includes at least six months of CBT.  A man covered with cardboard was lying in a doorway next to the club, talking to himself.  I walked past him twice, thinking each time how he might benefit from treatment.

Joan of Arc often comes to mind when I think of psychosis-she heard voices telling her what to do, she took on the establishment, and she was burned at the stake at age 19.  Today she might have been medicated,  institutionalized, or living on the streets (likely, as she was a peasant girl.) Context and public opinion influence our concepts.  A recent study looked at Abraham, Moses, Jesus, and St. Paul from a behavioral, neurologic, and neuropsychiatric perspective and the analysis revealed that these individuals had experiences that resemble those now defined as psychotic symptoms. They hoped the study findings would “translate into increased compassion and understanding for persons living with mental illness.”

Who’s to say what the correct adaptive strategy is? I suppose it has to been defined by the present society.  Walking on water and listening to talking burning bushes was okay 2 to 4 thousand years ago.  I think it’s really exciting that today we have early intervention CBT. Now we just need to figure a way to get it to the people who need it.

Link to the study: Early Cognitive Behavioral Therapy Reduces Risk of Psychosis

http://www.manchester.ac.uk/aboutus/news/display/?id=9880

Link to the study: The Role of Psychotic Disorders in Religious History Considered

http://neuro.psychiatryonline.org/article.aspx?articleID=1476850

 

 

 

Who Owns the Genome?

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I’ve been on both sides of the coin, and what I’ve learned is….

For almost 5 years I worked for a company that held the patent rights on many of the HPV virus sequences, the virus that causes cervical cancer.  That meant that when anyone used a clinical laboratory test to determine whether someone was infected with one of these strains, they had to pay the company I worked for.  This test is run on all sexually active women about once every 3 years, which is a lot of people and a lot of tests.  And a lot of money- each test costs about $100.  What I learned from working for this company is they spent about 15 years doing a clinical trial to elucidate if these strains caused cervical cancer.  They found a large set that did, and some that did not.  Early detection of the virulent strain’s infection means early detection of pre-cancerous cells which equals cervical cancer prevention.  Cervical cancer is 100% preventable by early detection and removal of pre-cancerous lesions. The company I worked for poured a ton of money into the clinical trial. A lot of people worked for the company. The money from the test paid my salary (I trained technicians on proper test procedures).   I paid for graduate school with the money I made when I sold my company stock.

On the other side, during grad school I was in the clinic, counseling patients who had cancer, or had a strong family history of cancer- breast, ovarian, colon and some rarer conditions.  Some of them needed a test to see if they had the gene that was causing their cancer or the cancer in their family.  For some people, this knowledge could be used to opt for risk-reducing surgery- not fun, but lifesaving.  The costs for these tests ran $500- $5,000.  A lot less people needed this test than the HPV test. Fewer tests mean higher prices. A few companies own the patents on these genes. They have poured money into the test development, and they have large numbers of people like me who work for them- and have mortgages and kids etc.  Some people aren’t covered, and we would look for funding, look for ways around. It wasn’t fair.  These genes were (possibly) part of these people’s genome, inside every cell in their body.  And they don’t own the rights to them.

Right now, we don’t own our genome.  The Supreme Court heard arguments yesterday on a  lawsuit filed by the American Civil Liberties Union in 2009 on whether companies should be able to patent genes.

It’s hard for me, someone who has profited from genome intellectual property rights, to say the ACLU is right.  But it is.  We all own the genome, and therefore no one owns the genome.  It’s public domain.  This country and other countries need to put money into research so that scientists can do the work they need.  Sure, call me a socialist, but I know the scientists who do this work, and none of them are doing it for money.  They are only working for a company that will pay them so they can cover their bills.

Dr. Bob Nussman is one of those guys- look what he’s up to here:

http://www.nytimes.com/2013/04/13/health/dna-project-aims-to-make-companys-data-public.html?pagewanted=all&_r=0

The Supreme Court will make a decision in June- here’s what happened yesterday:

http://www.bbc.co.uk/news/world-us-canada-22157410

Just say ge-NO-me

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I have to admit it: I am waiting impatiently for some kind of genetic testing for psychiatric conditions. Some might ask why- even if a test was available now it likely would not impact treatment. Sure, I think a test may encourage early intervention, and more genetic knowledge can lead to refinement in drugs and other treatment. Really though, I just want some tangible evidence.

Each time I find a study that shows some link between genes and psychiatric disease, someone has to rain on my parade. But that’s okay, in science we rain on each other’s parade to prevent the embarrassment of an over-the-top float at someone’s funeral procession.

The Journal of the American Medical Association- Psychiatry has published a study that demonstrates a reproducible connection between some gene variations and schizophrenia. Scientists like to be able to reproduce results because it generally means it wasn’t just a lucky day for some lab assistant, or that someone faked the data so they could knock off early and go to the ballgame. This study looked at 18 previous studies and found 9380 gene variations that were “promising”. That’s a lot of variations, when you consider that sickle cell anemia is caused by only one gene variation. They pared it down to a mere 8107 variations and tested 6298 individuals from 1811 nuclear families. They found a significant similarity in the gene tests, especially in the gene TCF4. They looked to see where these genes had their effects, and not surprisingly many were associated with brain function. Here’s what they had to say:
“To explore the many small effects, we performed pathway analyses. The most significant pathways involved neuronal function (axonal guidance, neuronal systems, and L1 cell adhesion molecule interaction) and the immune system (antigen processing, cell adhesion molecules relevant to T cells, and translocation to immunological synapse).” Their conclusion: “We replicated novel Schizophrenia disease genes and pathogenic pathways.”

(translation: “We were able to reproduce some of the new findings and tie them to the brain and the immune system.”)

John Hardy made this comment on the study:
“This and another recent study convincingly show that there are genetic loci that contribute to the risk of schizophrenia and that these loci map, at least in part, to pathways that make sense……. However, it seems certain that much of the familial clustering will remain unexplained by genetic analysis and will eventually be assigned to shared experience of affected individuals. ”

(translation: “Yeah, there’s some genetic connection, but we’ll never be able to pinpoint it.  Only shared environmental factors can be used to explain why schizophrenia occurs more frequently in some families than others.)

I know that we can’t throw nurture out with the bathwater…but I wonder how hard it will be for the scientific world to accept a mental illness genetic test of multiple variations. We won’t be able to say “yes” or “no” to disease. But we can’t do that with hereditary cancer genetics either- sure, there’s one or two mutations that equal 100% chance of disease, but most equal 80% chance,or 60% chance, or 50% chance. Whole genome sequencing is going to change everything. I can see a near future where we put kids in a high risk schizophrenia group, and advise them not to experiment with marijuana based on their results.
Instead of “just say no” it will be Mom shaking her head and saying- “well your genome just doesn’t recommend partying all night, dear.”

Link to study: http://archpsyc.jamanetwork.com/article.aspx?articleid=1676670
Link to John Hardy’s opinion: http://archpsyc.jamanetwork.com/article.aspx?articleid=1676667

image courtesy of© Suravid | Dreamstime Stock Photos & Stock Free Images

Note: translations are subject to writer’s bias and have not been confirmed with Google Translate

23andMe and Mel or “The truth about my DNA”

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I submitted a sample to 23andMe, paid $99.00 and waited for about two months. The results are in. Here’s what I found out:

My genome is boring.

Yep, that’s right. Boring. Hurray! Boring isn’t bad in a genome- genome drama is usually associated with challenging physical and mental syndromes. This test doesn’t pick up large gene events that result in birth defects, but it does pick up small gene changes that demonstrate increased risk for diseases such as cancer.

But I thought there would be something…well…..interesting. The biggest risk I have is a 20% increased risk of gallstones.

I know nothing about gallstones so I did what every “high risk” American patient does- I called Dr. Google. Here’s what I found:
What causes gallstones? Experts are not completely sure why some people develop a chemical imbalance in their gallbladder which causes gallstones, while others do not. However, we do know that gallstones are more common among:
Overweight/obese people, especially women. A study revealed that a bulging midriff almost doubles a woman’s chances of developing gallstones and the need for surgery to remove them. (I’m not too fat…yet) Women who have been pregnant (not me) People who have recently lost lots of weight. (not me either) Women taking oral contraceptives. (nope) Women undergoing high-dose estrogen therapy (nope) People with a close relative who has had gallstones. (nope) People whose intake of dietary fat is high. (does chocolate count?) People over 60 years of age. (nope) Native American Indians. (nope) People who take statins (cholesterol-lowering drugs). (nope) People with diabetes. (nope) Hormone replacement therapy (HRT) for women during the menopause. (nope)

A study revealed that a gene variant significantly increases the risk of developing gallstones . (significantly! High drama!)

Twice as many women get gallstones than men. (Yea, but I’ve always been a bit of a tomboy, and I’m told I’m “intimidating”)
So there you have it- looks like all of my risk is coming from my genes and from being a woman.

Next up was an increased risk for Psoriasis. Well, that’s no surprise because I actually do have Psoriasis, a very mild case. Oddly enough, it went away for my thirties. Perhaps it will go away again for my sixties, just in time for me to develop gallstones.

All the other increased and decreased risks were very minimal. To be honest I thought, with my family history, that there would be some increased risk in the mental illness category, but everything came through “typical.” This doesn’t mean immunity, everyone is at risk for mental illness, but some people have a higher genetic load. I read through the studies for the genes they test for, and I don’t think they cover enough ground to really give you an idea of your mental illness genetic load. It’s a start, but I wouldn’t make any serious decisions based on this information.

In other news, I’m not a carrier for anything they test for, which doesn’t really matter as I don’t have kids and don’t plan to, I have a slight sensitivity to Warfarin, and I most likely have blue eyes (I do).

Here’s what I like about the 23andMe genetic test experience:

1) It’s affordable. Clinical genetic testing is expensive ($2000 for minimal breast and ovarian gene testing if no family history). This is not a clinical test, although it is run in a CLIA approved lab- which meets some quality standards. It’s the cheap way for the layman to take a look at his or her own genome. To me, that’s a fun time.
2) It covers a lot of ground. I think it’s pretty cool that they give you drug resistance, carrier testing and disease risk, and some fun trait stuff. Plus some ancestry information. There’s something for everyone.

Here’s what I don’t like about the 23andMe genetic test experience:

1) It covers a lot of ground (yeah I know, it’s a ying/yang thing). They don’t just present a list, probably because the FDA slapped them around for not providing counseling. There are lots of disclaimers and check boxes to make sure you understand that if you have a positive result for something serious, you need to talk to a genetic counselor about it, blah de blah. That’s good, but it just takes a while to get through. That’s why people actually see a genetic counselor to help them with info that can be scary and confusing.
2) They have info on malaria and HIV resistance. There is no way I would tell someone that they were less susceptible than another person to malaria or HIV. Even though there’s proof that these reports don’t change behavior, I would not put it past someone who’s had a few cocktails to believe they are invincible. I read the (long) explanation of the resistance and it does mention there’s another strain that is not protected by this mutation. And HIV has an extremely fast mutation rate, so who knows when it could change.

Whew….I’m glad I just have a gallbladder to contend with for now.

Image courtesy of [dream designs] / FreeDigitalPhotos.net

23andMe website:
http://www.23andme.com