Acupuncture and Depression
I have been using acupuncture for over 25 years and one of the reasons for doing my advanced training in China was to examine its use in neurological and psychiatric disorders.
It was interesting to discover that even in hospitals specializing in traditional Chinese medicine, the doctors usually used conventional antidepressants and antipsychotics rather than acupuncture, although I had seen many Western acupuncturists claim that they could treat depression.
My own experience with treating acupuncture has been disappointing. By contrast, it is often very good indeed for anxiety, and I have shown many people how to follow up with simple acupressure if they experience anxiety or panic.
There is new research that seems to endorse my lack of success in treating depression and why the Chinese doctors used Western medicine.
There had been a number of small studies (e.g. 1. 2. 3. 4. 5. 6.) of acupuncture in depression that had shown promise, as well as some huge Chinese studies that had claimed good results.
One of the problems with much of the Chinese research is that it is normally done without control groups and with very broad criteria. Many only rate whether someone is “cured,” “much better” or “no better.”
Despite the promise of the early studies, three recent reviews (1. 2. 3.) suggested that the evidence for acupuncture in depression was inconclusive.
This new study was published in the Journal of Clinical Psychiatry in November of this year and involved 151 patients with Major Depressive Disorder. The study ran for four years. This was a well-conducted clinical trial by researchers who had originally found some promising results in a pilot study (Allen JBJ, Schnyer RN, Hitt SK. The efficacy of acupuncture in the treatment of major depression in women. Psychological Science 1998; 9: 397-401). Although well tolerated, the research failed to support the use of acupuncture as a single therapy for depression.
This is important: depression carries an appreciable mortality and morbidity and there are real ethical problems about withholding treatments that have been shown to work.
It also does not mean that acupuncture has no place in the treatment of depression: it may be a useful adjunctive treatment – particularly if the individual has comorbid anxiety – and it may help with treating the side effects of conventional medicines. There is also another important point: we need to be sure that we are measuring the right thing when doing studies on acupuncture: the Western doctor may want to see if depression gets better. The acupuncturist may be more interested in improving the overall well being of the individual as well as helping an individual’s search for meaning.
Regular readers will remember that last month I commented on some promising research on the use of qigong in depression. Why the different results from the different studies? There are many schools of acupuncture, t’ai chi ch’uan and qigong, as there are many different medicines for depression. One of the difficulties in the critical evaluation of these forms of treatment is that we have to assess the effectiveness not just of acupuncture, but of different schools of acupuncture and sometimes of different practitioners: a daunting but not impossible task. Not only are there many school in China, there are also Japanese, Korean and Vietnamese variants of traditional acupuncture, Western acupuncture and electro- and laser acupuncture. We use clinical observations to guide us to research the most promising types of intervention, whether they are forms of acupuncture, herbal remedies, homeopathy or anything else.
My "job" is to bring you the best and most rigorous research so that you can make decisions about what is most likely to help you.
Social Adversity and Schizophrenia
People who are interested in the interaction of genes, environment, brain and mental illness might be interested to look at a brief article posted over at the Psychiatric Resource Forum.
The article summarizes some very important new data on social adversity and the subsequent dvelopment of major mental illness. The research has been looking at a huge puzzle: why are serious mental illnesses so much more common in Afro-Caribbeans and Africans living in England and other parts of Western Europe? It was initially thought that it might all be due to over-diagnosis, but with deatialed work done in England, the Caribbean and Africa it has now become clear that that isn’t it.
There may be a contribution from vitamin D deficiency: dark skinned people who are recent immigrants cannot make as much in their skin as they need. But that is not a cause but a potential contrbutor. That being said I am going to have something more to say about causality in medicine in a post in the next day or two.
A second line of research has identified some key brain structures that if abnormal, dramatically increase the change that a "high risk" person will develop schizophrenia. By "high risk" we mean a significant family history of the illness.
This is important material and represents a major step forward in our understanding of major mental illness and a move away from the medical model that has dominated so much of psychiatry over the last 30 years.
Hearing Voices
In 1973, there occurred a notorious episode in the history of psychiatry. A psychologist named David Rosenhan did an infamous experiment in which he had a group of eight people present themselves to twelve hospital emergency rooms claiming that they were hearing the words, “Empty, “Dull” or “Thud.”
Most were admitted and given psychiatric diagnoses. The second part of the experiment consisted of asking staff at a psychiatric hospital to detect non-existent ‘fake’ patients. They did rather badly. A paper about this was published in the journal Science, with the title, “On Being Sane in Insane Places.”
In its day, this paper was considered a damning critique of psychiatry and a plank in the ant-psychiatry movement that was in full swing at the time. In truth, it tells us only that if you lie to doctors and nurses you may deceive them. And second it is only a criticism of bad psychiatry. The idea of diagnosing schizophrenia or any other mental illness on the basis of hearing a single word is absurd. At least 40% of the population will at some time hear their name being called, particularly in times of stress or after bereavement. And very many people in the general population will occasionally hear a word being spoken. It is diagnostic of nothing.
I sincerely hope that none of the people that I’ve taught in 45 countries around the globe would EVER diagnose schizophrenia or any other mental illness simply on the basis of hearing voices, a.k.a. auditory hallucinations. As I’ve stressed time and again, the only purpose in making a diagnosis is to guide treatment and prognosis. Simply hearing voices can guide neither.
This topic came up during one of the things that I was doing to advocate for patients, because September 14th 2006 was World Hearing Voices Day, and I received some very interesting information from a UK based organization, the Hearing Voices Network. (There’s also a nice article here as well.)
There is some excellent research on people who hear voices yet are not mentally ill. Many of these people do not feel the need for any treatment and not only peacefully coexist with them, but regard them as a blessing. Most of the research has been done by Professor Marius Romme and Sondra Escher from Maastricht University in the Netherlands, Richard Bentall from the University of Manchester, and Gordon Claridge at Oxford.
About 4% of the general population hears voices, and most of them are not mentally ill. It is essential for us to understand the notion of dimensional rather than categorical diagnoses. I’m mentioning it again, because it prevents us falling into the error of labeling people for no readily apparent reason. For some people their voices are supportive and comforting.
One of several studies has shown that the form and content of auditory hallucinations is much the same whether someone has been labeled with a mental illness or not. Trauma and abuse can reactivate voices, or make them threatening.
The key to the hearing voices is whether or not they are causing distress to the individual or to those around them. There are four major coping strategies typically used by people who hear voices: distraction, ignoring the voices, selective listening to them, and setting limits on their influence.
The biggest danger for people who are hearing voices and are suffering from cognitive impairment or a mental illness, is that the voices may form the basis for delusions. As people are trying to make sense of their experiences, they may develop highly creative explanations.
I once worked with someone who was not hearing voices, but feeling odd sensations coursing along her limbs. She got a textbook of Chinese medicine, and became convinced that she was feeling the flow of Qi in her body. But because she also felt the sensations in places that were nowhere near the channels and meridians, she became convinced that it was her mission to redefine not just the courses of the channels, but to re-write the whole of Chinese medicine according to the sensations in her body.
Her attempt to make sense of her experiences made her grandiose and delusional. She became unable to care for herself, eventually became very distressed and was grateful to have some treatment which eradicated the sensations, which in turn caused the delusions to evaporate.
So treat each person as an individual and forget the unhelpful and stigmatizing labels.
Psychiatric Diagnosis
Several months ago I wrote about the advantages of seeing psychiatric problems on a spectrum rather than independent categories. And that it is also essential to look at the whole person: there is currently a terrible tendency in medicine and in psychiatry to reduce people to the neurotransmitters in their brains, which is not just a very limiting way of seeing an individual, it’s just plain rude.
One of the reasons why it is essential to look at the whole person is that the agenda of a physician and of a person asking – or being sent – for help may be entirely different. A doctor may want the voices to go away, and for the person to stop being fearful about the things that the TV is saying to them. The person may want help with making sense of their experiences. If someone believes that they are feeling this way because they’ve been abandoned by God, you can pour medications into them until you are blue in the face: they will not help the core problem. Yes, of course you can re-balance their dopamine, serotonin, GABA and acetylcholine receptors. But if their core belief has to do with abandonment, your efforts are unlikely to be crowned with success.
These issues came up again when I had the privilege of speaking to a meeting of the National Alliance of the Mentally Ill in Natchez, Mississippi last week.
There were all the usual questions about advances in mental health, and on the chances for recovery. My answer to that one is always the same: the chances for recovery from any mental illness – including schizophrenia and bipolar disorder – are better than they have ever been. The largest single barrier is expectation. If doctors, psychologists and therapists assume that nothing can be done apart from controlling symptoms, then it is unlikely that people will get better. We all know what will happen if we start the day assuming that’s it’s going to be terrible.
I’d like to highlight two blogs – here and here – that were started by the same person after she had recovered from a psychotic episode. She contacted me after my earlier posts. She has an excellent website which she started after an exchange with two psychiatrists who said essentially the same thing:
“If the person can be cured, then it is NOT schizophrenia. Schizophrenia is a chronic mental illness that has no cure.”
This is not true: but rather than being an indictment of psychiatry, it’s an indictment of bad psychiatry. We have a great deal of evidence that the brain is a highly plastic organ, and that many of the typical changes seen even in unmedicated people with the illness can return toward a normal pattern. This shouldn’t be a surprise: it has been known for many years that at least a third of people who carried a diagnosis of schizophrenia recover completely. To say that the recovery indicates that the original diagnosis was wrong is an extraordinary piece of circular reasoning.
The statement also implies that the writer doesn’t see a difference between healing, treatment and cure, which for me are three different interactions.
There is also another point that I made in Natchez: psychiatric diagnoses are still descriptive and are therefore largely at the level of the rest of the medicine of 100 years ago, when a person might be diagnosed with “dropsy,” “anasarca” or “icterus.” Terms now rarely used because we understand the underlying pathology. In the same way terms like schizophrenia will eventually give way to descriptions based on the biological, psychological, social and spiritual issues going on in a person.
Because the diagnoses are descriptive, getting too worried about the precise one is unlikely to be helpful. I once had a family become very angry with me. Their son had seen many specialists, who had all offered different diagnoses. After many day’s observation and exhaustive investigations, the one that I came up with did not please them. Because I wanted to treat their son as a human being with a problem that had responded to an antipsychotic and therapy, but they wanted him to have a less intimidating diagnosis. I tried in vain to explain that these were all just descriptors, and the important thing was that he was getting better with our treatment.
The reason for making a diagnosis at all is so that we can communicate, that it may guide treatment and allow us to offer some advice about prognosis. If someone has a heart attack, it is usually not too difficult to diagnose it. The reason for the diagnosis is not so that we can write it on a form or so that we can label someone, but because it can help guide us.
I certainly don’t agree with every one of points made in the articles that he’s posted, but that’s just fine. Active debate is always better than ignoring each other. Or as Winston Churchill once said, “Jaw, jaw, is better than war, war.”
On the main points in these blogs, I think that we are in complete agreement:
- Even without drugs it is possible to induce mania and psychosis in just about anyone: sleep deprivation, arousal and sensory overload will usually do it in a few days. If someone has a family history of psychiatric problems it will likely take half as long. If they have a personal history it might take a quarter as long.
- Recovery should be the aim for anyone with a psychiatric problem.
- Recovery is not necessarily the same as cure.
- Not all people diagnosed with “psychiatric problems” have them: some are having genuine spiritual experiences: I’ve seen many people going through kundalini and other types of spiritual awakening who had been given psychiatric diagnoses. I used to get some raised eyebrows when I had a string of referrals from clergy and spiritual teachers that usually read something like, “I don’t know if this person is psychotic or possessed. Please could you see them and advise me.”
- The quest for meaning and purpose is essential to our humanity. I have seen some of the most damaged of people with large traumatic holes in their brain trying to extract meaning and purpose from what had happened to them. Psychotic, manic, depressed and cognitively impaired, but still trying to work out the meaning for them personally.
The major psychiatric illnesses can be very hard to help: I regularly see everyone else’s problems when I travel: 45 countries and 47 states at last count. But it’s very unusual to find someone for whom we can do nothing.
But I never let clinicians give up: the people who come to us for help deserve better than that.
And for people who got through the process on their own, I congratulate you. But I beg you, please don’t suggest to everyone that they can do the same thing. Many need outside help that addresses all five dimensions of their being.
Cutting and Self-injury
There’s an extremely disturbing trend: ever-increasing numbers of young people who are cutting themselves. Once rare, and something usually seen only in people with serious psychiatric illness, many school children encourage and goad each other into doing it, and there are websites dedicated to cutting, on which young people compare notes and even give each other advice on how to conceal what they are doing, by cutting themselves in places like the lower back.
We have been offered a great many explanations for this worrying development, but not much in the way of evidence. We know that most people who cut themselves are female adolescents or young adults, and apart from the obvious physical dangers, there is evidence that this behavior may lead to a more serious psychological condition called Borderline Personality Disorder. This can be a serious problem that carries a high risk of suicide. It is also of some theoretical interest, because there seem to be genuine cultural differences in borderline personality disorder. An estimated 5.8 million to 8.7 million Americans, mostly women, suffer from it, but it is far less common in most of Western Europe and Australia. Research over the last decade has indicated that the condition is becoming more common in these regions. People with the borderline personality disorder have a wide spectrum of difficulties that are marked by emotional instability, difficulty in maintaining close relationships, eating disorders, impulsivity, chronic uncertainty about life goals and addictive behaviors such as using drugs and alcohol. They also have major impact on the medical system by being among the highest users of emergency and in-patient medical services. Glen Close’s character Alex Forrest in the movie Fatal Attraction, had some of the features that we might expect in some with borderline personality disorder.
Researchers from the University of Washington in Seattle have reported that adolescent girls who engage in cutting behavior have lower levels of the chemical transmitter serotonin in their blood. They also have reduced levels of activity in the parasympathetic nervous system as measured by what is called respiratory sinus arrhythmia, a measure of the ebb and flow of heart rate as we breath. Low levels of this measure are typically found in people who are anxious or depressed. The study included 23 girls aged 14 to 18, who engaged in what psychologists call “parasuicidal” behavior. Participants were included if they had engaged in three or more self-harming behaviors in the previous six months or five or more such behaviors in their lifetime. The comparison group consisted of an equal number of girls of the same ages who did not engage in this behavior.
In line with previous research, the adolescents in the parasuicide group reported far more incidents of self-harming behavior than did their parents.
The findings of low serotonin and low parasympathetic activity support the idea that the inability to regulate emotions and impulsivity can trigger self-harming behavior. The primary problem is an inability to manage their emotions: the people who cut themselves have excessively strong emotional reactions and they have extreme difficulty in controlling those emotions. Their self-harming behavior may serve to distract them from these emotions.
A characteristic feature of borderline personality disorder is not just self-injurious behavior but also stress-induced reduction of pain perception. Reduced pain sensitivity has been experimentally confirmed in patients with the condition. The increasing incidence of the condition in Europe is attracting many European investigators and colleagues from Mannheim in Germany have recently traced the neurological circuits involved in this stress-induced reduced pain perception.
There is good evidence that people who cut themselves are more likely to have been victims of sexual abuse or violence as children, though that obviously does not mean that every person who harms themselves has had something bad happen to them in childhood. Sadly the research has become more complex because of the numbers of people who have been given false memories of abuse by well-meaning psychologists.
Treating people who cut themselves, whether or not they have borderline personality disorder can be very challenging. The first thing is to treat any underlying mood or anxiety disorder. A combination of medications and psychotherapy is normally used, with people making claims for the value of different types of therapy. Many therapists also say that they have helped people who cut themselves with tapping therapies, acupuncture, homeopathy and qigong. I’ve not been able to find any credible research evidence to support the use of those therapies, though I’ve also seen some success stories.
We also have the puzzle about why cutting and borderline personality disorder seems to have been less common in other parts of the world and are now increasing. There is research to show that it’s not just a matter of recognition or of calling the illness something else in Europe. I have a friend who is a senior academic at an Ivy League University, and an expert on borderline personality disorder. During a sabbatical in Scotland some 15 years ago, he could not find a single case. This matters, because if we can identify what’s changed, we may have some clues about treatment. There are hundreds of candidates, including environmental stress, diet and toxins.
There’s an important new study in which 13 children with autism showed marked improvement in some of their challenging behaviors when they were given 1.5gms of omega-3 fatty acids each day. This was only a six week study, but it needs to be replicated using larger numbers. It is also important to be alert to the possibility that some makes of omega-3 fatty acids on the market contain mercury. The one that we have found best so far has been OmegaBrite. http://www.omegabrite.com/ It will also be useful to see if dietary supplementation will help self-injurious behavior in other types of people.
Here is a list of some of the better information sites about self-harm.
The key to success with helping complex problems, as I point out in great detail in Healing, Meaning and Purpose, is a comprehensive approach:
Combinations are Key
The Epigenetic Code
In Healing, Meaning and Purpose I reveal some of the extraordinary changes that are occurring in our understanding of genetics and inheritance. Even if you are currently learning genetics in college, it is quite likely that some of what your professors are teaching may already be out of date. I say that with the greatest possible respect: I find that in some of my fields of expertise, I am often having to update my teaching materials every week.
One of the remarkable discoveries that is generating huge amounts of new information is what we call epigenetics. This is the study of a form of inheritance that can occur without fundamental changes in gene sequences. This has to do with the idea that there is a second layer of programming on top of our DNA. A code that can change over our lifetimes in response to environmental change. Diet, hormones, chemicals in the environment, stress and even thought, emotion and behavior, can all change the ways in which our genes are expressed. Some of these epigenetic changes can be passed on to other generations. In other words, there can be an inheritance of acquired characteristics. Something that has been denied for over a century.
Let me give you a simple example. Studies of a particular species of mouse have shown that maternal diet has an effect on the coat color of the offspring. This was the result of what is known as methylation that altered gene expression. These changes in coat color were carried on to the next generation: the grandchildren of the mouse given the special diet. This created quite a stir, because it had been thought that epigenetic changes in cells are erased each time that a cell divides. Obviously that was not happening. We now have many examples of epigenetic changes being passed on to the next generation and the next. There are literally hundreds of scientific papers on the subject.
As I have written before in my last book and CDs, in articles and in reviews at Amazon and elsewhere, the traditional view of genetics has been one of genetic determinism. That we are all little robots whose entire lives are dedicated to nothing more than passing our DNA from one generation to the next. And the genes even dictated how we did that. I still know many gene jockeys who are convinced that the whole of human behavior will ultimately be explained by our genes, and that free will is therefore a myth.
I’m just as sure that they are wrong.
Let me give you an example. Identical twins have identical DNA, yet we have known for fifty years that one twin may get a genetic illness that the other does not. And the brains of identical twins, though they start out identical, quickly become quite different from each other because of the impact of the environment. Twin studies of mental illness have been going on at the Institute of Psychiatry in London since 1960. Every patient coming to the hospital is asked by the clerical staff if he or she is a twin. And there has been groundbreaking research on mentally ill twins at the National Institute of Mental Health for decades. And what have we learned? Though there may be a genetic component in schizophrenia, when we look at people with schizophrenia who have identical twins, only half of the twins have the illness, despite having the same DNA. The key difference is at the epigenetic level.
Marcus Pembrey from the Clinical and Molecular Genetics Unit at the Institute of Child Health, part of University College, London, has been at the forefront of the work on epigenetics. Marcus has had the opportunity to study the unusually detailed historical medical records of the isolated northern Swedish city of Overkalix. He and his colleagues found something astonishing. The grandsons of men who experienced famine during mid-childhood went through puberty earlier and had longer life spans, while the grandsons of men who were well fed in early childhood had an increased likelihood of diabetes. For females, the effect was similar but it was tied to the grandmother, rather than the grandfather. Presumably these responses are designed to adjust our early growth and reproduction to be ready for unpredictable changes adverse events in the environment. I would call this epigenetic resilience.
In a separate study done in Bristol in England, Marcus studied two generations of families, and found that fathers who had started smoking before age 11 had sons who were significantly heavier than average. There was no similar effect on daughters.
There is already some evidence that epigenetic factors may play a role in the development of bipolar disorder and schizophrenia. Many of us are becoming excited about the potential benefit that may flow from a better understanding of genetic and epigenetic mechanisms in major psychiatric disorders.
There is a new journal called, appropriately, Epigenetics that contains a treasure trove of important information. The editor is Moshe Szyf, form McGill University in Canada, and he recently pointed out that one single gene could have as many as 700 epigenetic programs associated with it.
His own research has linked epigenetic change to social interactions: the way in which we behave toward one another can lead to a change in how our genes operate.
Rats whose mothers groom and lick them when they are young grow up to be much calmer than rats whose mothers neglected them. There is, of course, nothing surprising about that. We all understand the importance of good child rearing. But what was surprising was the finding that epigenetic changes are the cause. By nurturing their young, the rat mothers activated a gene that suppressed the creation of cortisol, one of the stress hormones.
Pups who were neglected did not have that gene activated, so they produced more cortisol and were therefore more stressed out.
Knowing this, the researchers were able to increase the well-nurtured rats’ stress by injecting them with methionine, an amino acid commonly found in food supplements.
Here we have proof that the link between food and mood is not just due to transient chemical changes in the neurotransmitters of the brain, but that a chemical in our diet could cause fundamental changes in the way in which our genes work. In this case a rat’s emotions and state of mind. The implications for all of us are extraordinary.
Since 2003, a consortium of public and private firms in Europe has been working on the first Human Epigenome Project (HEP), and it hopes to have completed 10% of the map by the end of this year. As you can see, it is a lot more complicated than mapping the human genome, and epigenetic codes are constantly moving targets. The first reports from HEP have indicated that at least 20% of the genes studied so far can have their behavior modified by the environment. The food that we eat, the chemicals that we ingest and the attitude of our parents and peers can all change the way in which our genes function.
As Marcus Pembrey has said, “Child care has a whole new meaning.”
This is all crucially important, because one of our most important discoveries has been that human beings have been undergoing extremely rapid physical as well as psychological and social change, and that is one of the reasons why the Laws of Healing have been changing over the last century.
Medical Terminology and Clear Communication
During the Second World War, there was so much worry about the possibility that Axis spies had penetrated the United Kingdom, that there was a whole campaign entitled, “Careless Talk Costs Lives.”
We sometimes see a similar problem in medicine, and in particular in psychiatric practice when we use terms that may cause great and unnecessary distress.
When somebody is unwell, it is hard for them and for their family to take everything in. research has shown that people only remember accurately 30-40% of what a doctor, nurse or therapist says to them. That is why I recently wrote the piece on clarity of communication.
Another problem is vocabulary. It is calculated that a medical student has to learn aorund 6,000 new words during his or her training. Young doctors and nurses often forget that what they mean by a word is often very different from what a non-medic may mean. That is why we try hard to define eveything on this blog.
You might be interested to look at an example on the Psychiatric Resource Forum blog. This one discusses paranoia. It’s an important word, but one which means something diferent to the specialist from its common use in conversation.
I think that it is valuable for you to be armed with as much information as you can, and I plan to continue highlighting terms that can lead to distress and misunderstanding.
Disclosure
There’s a sad situation rumbling around the psychiatric and neurological worlds this week.
The Chairman of the Department of Psychiatry at Emory University in Atlanta is reported to be stepping down as Editor of the prestigious journal Neuropsychopharmacology, after failing to disclose that he had a financial interest in a treatment about which he had written approvingly.
The editor says that this was simply a clerical error, as on the previous occasion in 2003 when he published an article in which there was a conflict of interest.
This is all a great shame: the treatment that he talked about in this paper – vagal nerve stimulation – really does appear to be a genuine advance in the management of treatment resistant depression.
It is also eminently avoidable. Anybody who is an expert in their field will likely be asked to consult to a wide range of bodies. I have advised many pharmaceutical companies, governments and non-governmental agencies around the globe. Whenever I lecture, wherever it is in the world and whatever the subject, I always show a slide with a list of all the people with whom I have worked, and my office constantly updates the list, so that it can be appended to every document that we send out. And because I consult so widely, I don’t hold stock in any pharmaceutical or medical devices companies.
But here is another piece of failed disclosure. There is a comment to the report at the Scientist. The writer says that “Psychiatry has the greatest conflict of interest possible–they are prescribing drugs and, in this case, mechanical "treatments" for conditions that have no verifiable physical cause.”
This is absolutely and totally untrue. There are mountains of data confirming the physical component of most major psychiatric illnesses. And every day, all over the world, people in their tens of thousands are saved and their lives restored by pharmacological treatments used together with psychological and social help.
This is the same nonsense promulgated earlier this year by Tom Cruise. It reminds me of the critics of Galileo who refused to look through his telescope.
The writer herself fails to disclose that she is also involved in Scientology.
Toxoplasmosis, Behavior and Mental Illness
This title may seem odd, but this item may actually turn out to have enormous implications for all of us.
A couple of years ago I read a fascinating book: Parasites and the Behavior of Animals, in which the author – Janice Moore from Colorado State University – cataloged some of the extraordinary ways in which parasites can impact the behaviors of a vast array of animals. As difficult as it is to interpret studies of parasites in humans, I kept coming back to some odd observations about an illness with which I’ve been involved for more than 30 years: schizophrenia. I kept wondering if some of the odd observations made over the years could be explained by the parasites?
What kind of odd observations?
- Reports of mental illness have been found throughout history, yet this strange illness that we now call schizophrenia seems to have been very rare until about 1750, when it increased dramatically throughout Western Europe. I have had the privilege of working at the Bethlem Royal Hospital from which got the word “bedlam.” I know of the incredible records kept there. Something began to change in some of the types of patients being admitted at that time. I have also had the opportunity to look at some of the records at the Philip’s Hospital in Southern Germany, which has been in existence since 1533. Again the records show the sudden appearance of many cases of something that had been quite rare until then. 1750 marked the early years of the industrial revolution in Europe and the mass migration of people from the countryside to the new and very crowded cities
- There has been recent evidence that being born and raised in a city increases your chance of developing schizophrenia.
- There is increasing evidence that acute episodes of psychosis, mania and depression are associated with increases in circulating inflammatory mediators. There is also intriguing new data that both psychosis and depression can be improved by giving people COX2 inhibitors.
- There has also been the strange observation that bipolar disorder may have been becoming more common in recent years, over and above our greater ability to recognize the illness.
Several years ago the well-known psychiatrist E. Fuller Torrey first suggested that a small protozoal parasite called Toxoplasma gondii might be responsible for all of these observations. Cats can carry it, which is why pregnant mothers are advised not to pet their cats during pregnancy.
The idea that such a complex disease as schizophrenia might sometimes be caused by a parasite caught the media’s attention, but in recent years the story – but not the ongoing research – died down a bit.
There was an excellent and provocative blog item by Carl Zimmer about this almost three weeks ago, but I wanted to check everything out before responding. He gave a brief review of a new paper published in the Proceedings of the Royal Society, by Kevin Lafferty from the University of California in Santa Barbara. Lafferty has attempted to correlate the varying rates of Toxoplasma in different countries with predominant personality traits and therefore – since our societies are aggregates of all our personalities, cultural characteristics.
That may all sound far-fetched, but I don’t think that it is. And I don’t think that the Proceedings would have taken a completely half-baked proposition.
I have also found a report published in the journal the Proceedings of the Biological Society. Four eminent authors, including Torrey, revisited the while issue of Toxoplasmosis and mental illness. When the parasite gets into the nervous system it can alter behavior: Rats are normally programmed to avoid cats, but once infected they are attracted to cats. Over the last few days I’ve been plowing the world literature, and I’ve learned some very interesting things that support the idea that Toxoplasma may be playing a role in several different types of psychiatric illness.
There is strong evidence that schizophrenia, bipolar disorder and major depressive disorder lie on a spectrum. The illnesses are not the same, but people often switch from one type of clinical presentation to another. The precise type if illness would be determined by the interaction of genes, physical and Intrapsychic environment. Nobody would be sufficiently naïve to try and reduce the whole of psychiatric illness to a single bug. Mental illness is a great deal more than just a physical problem, and apart from anything else, the rates of Toxoplasma infections show remarkable variations around the globe, while the rates of major mental illness are much the same everywhere.
So what have I learned?
- There are a remarkable numbers of studies showing that many people with schizophrenia have antibodies to Toxoplasma, including people having their first attack of the illness
- Blood donors infected with Toxoplasma have decreased levels of novelty-seeking
- In women who become infected, there are some marked changes in personality.
- Toxoplasma affects the dopamine systems of the brain that we know are intimately involved in mood, cognition, movement and motivation.
- Some drugs used to treat psychosis (haloperidol) and mood disorder (valproic acid) inhibit the replication of Toxoplasma gondii. The valproic acid already does it at concentrations lower than we normally aim for when treating humans.
- There is some intriguing work going on into the use of antibiotics to kill Toxoplasma and reverse its behavioral effects.
In the last few years, so many illnesses have turned out to have infectious origins, from peptic ulcers to arteriosclerosis and some cancers. Perhaps some mental illnesses will be next.
Last year Barry Marshall and Robin Warren were awarded the Nobel Prize in Physiology or Medicine for their pioneering work on Helicobacter. I have a strong sense that there are more prizes to come on the interaction between infectious agents, inflammation, genes, the psyche and the environment.
Perhaps the reason that some antipsychotics and mood stablizers can reverse some of the neurological damage associated with schizophrenia and bipolar disorder is becuase they are killing off the causative agents and allowing the brain to repair itself.
I shall keep you posted!
