Prevention and Early Intervention
New Approaches in Mental Health
“There’s been a convergence of public attitudes and the technology available to treat mental illness,” says AHFMR researcher Dr. Donald Addington, Professor and Head of the Department of Psychiatry at the University of Calgary.Increased public awareness, as well as more effective medications with fewer side effects, have lifted some of the barriers to treatment and helped to erode the stigma that tended to keep those who suffered from mental illness in the shadows. These changes present AHFMR clinical researchers with an opportunity to make a difference. They can shift their focus to where they believe their efforts will have the most impact—early intervention and, whenever possible, prevention. Their studies provide hope, not only for individuals who suffer from mental illness, but for the mental health of our population as a whole.
Minimizing the impact of schizophrenia
Dr. Donald Addington and Dr. Jean Addington, a psychologist and Associate Professor in the University of Calgary’s Department of Psychiatry, are researchers in schizophrenia, the illness that most often strikes young people just as they are hitting their stride. The average age of onset is 23 in young men and slightly older in women. The Addingtons’ goal is to reach these young people early and minimize the impact of the disease on their lives. “We want to show that we can make a difference in these early stages,” says Dr. Jean Addington, “by treating these people before their illness disrupts their lives.”In addition to operating the Early Psychosis Treatment and Prevention Program, a joint initiative by the Calgary Health Region and the Canadian Mental Health Association of Calgary, the Addingtons developed the PRIME (Prevention through Risk Management and Education) clinic, which is supported exclusively by research funds. PRIME aims to identify young people with pre-psychotic symptoms—the subtle, “something is not quite right” symptoms. Two years ago, they started research with PRIME to see whether early education, psychosocial intervention, or medication could either prevent or delay the onset of a more serious psychotic illness. They now believe they have enough information about their ultra-high-risk (for psychosis) group to justify providing treatment services to them; however, there are no funded services for this group to date.
Although they would like to do more prevention work, it can be quite a challenge to find these young people. “For everybody who ends up having a psychotic episode, there’s a pre-psychotic person out there,” says Dr. Jean Addington. “If you encourage people to get help before they become psychotic, hopefully the symptoms can be controlled before they become severe and more disrupting and disabling.”
With support from the AHFMR Health Research Fund, Dr. Don Addington is developing a set of indicators to evaluate early psychosis programs such as theirs, to identify areas where they can be more effective. Although there are very few established indicators in mental health as yet, work in this area is growing. He and his group will use the indicators first to evaluate their own schizophrenia and early psychosis program, then to compare programs across the country. Dr. Addington has also just received significant funding to develop public education about the early onset of psychosis and its recognition.
The Health Research Fund is also providing support to Dr. Jean Addington for a five-year follow-up study of the patients in the Early Psychosis Program. She hopes the study will demonstrate the long-term effectiveness of the Program.
“In terms of mental health, early prevention is new,” she says, “and in terms of schizophrenia and psychosis, it’s very new. Some of the fear has been that if you try and identify people early, you stigmatize them. But if, for example, you have a history of heart disease in your family, you would want to have the information you need to do what is best for your future health. The same applies to schizophrenia.”
Schizophrenia and brain chemistry
One of the challenges for the Addingtons and others who work in the field of schizophrenia is that individuals can be very ill for a year or even longer—exhibiting the classic symptoms of delusions and hallucinations—and still not be receiving psychiatric help. “That isn’t because of waiting lists or anything like that,” says AHFMR researcher and University of Alberta psychiatrist Dr. Phil Tibbo. “It’s because the individuals aren’t recognizing it, family doctors are not recognizing it, and the families themselves aren’t recognizing it.”What they are overlooking or unable to recognize are the prodromal symptoms, the precursors of full-blown illness. “We need better ways of being able to identify individuals at risk and predict, by looking at these prodromal symptoms, which of these individuals have schizophrenia,” he says. “We know we can do the most for these patients, optimizing their level of functioning, if we get them within the first five years of their illness.”
To improve the chances of identifying affected young people before their illness causes them serious problems, Dr. Tibbo is investigating both non-psychotic adolescents and adults at risk for schizophrenia (having a parent or sibling with schizophrenia) compared to normal and psychiatric controls. He is also following the adolescents over time as they enter and pass through the age-of-onset risk period. His research involves brain imaging with magnetic resonance spectroscopy (MRS) as well as a battery of neuro-cognitive and clinical tests. He is particularly interested in the role that neurotransmitters, glutamate and glutamine, play in schizophrenia. Both of these chemicals are present throughout the brain, but they appear in significant concentrations in the medial frontal lobe, and they can be measured with MRS. Research in animals has shown that abnormalities of glutamate may cause cellular damage and changes in behaviour.
“These kids don’t just wake up one day when they’re 19 and become schizophrenic,” says Dr. Tibbo. “The neurodevelopmental hypothesis about schizophrenia is that there has been something wrong since birth, which causes interactions with normal development of the central nervous system and the brain resulting in the emergence of, psychotic symptoms.” This hypothesis is consistent with the findings of animal studies, which have shown that abnormalities of the glutamate and glutamine system, present from birth, produce symptoms that don’t appear until the animal reaches adolescence.
Although research has looked at individuals who have had their first episode of schizophrenia or who have chronic problems with the illness, no MRS imaging work has been done with the group Dr. Tibbo is studying. “By working with these people who have not yet experienced a psychotic episode, we can look at what causes the illness, and we can see if there are protective factors,” he says. “The goal is to help define better predictors of schizophrenia, so we can start working at better secondary and primary prevention.”
Nipping eating disorders in the bud
Years of experience have taught Dianne Drummond that she and her fellow dietitians are often on the front line when it comes to children with eating disorders. “Parents may not be able to convince their kids to see a doctor,” says Drummond, the Alberta Mental Health Board’s Eating Disorder Promotion and Prevention Specialist for Edmonton and Northern Alberta, “but they may be able to persuade them to get advice on their diet.”Five years ago, Drummond and her co-researcher, Suzanne Hare, received funding from the Grey Nuns’ Women’s Health Fund to develop a tool that would identify children at risk of eating disorders. “We started the project hoping there would be an available tool that schools could use,” says Hare, a clinician dietitian at the Grey Nuns Community Hospital and Health Centre. “We didn’t want to look just at eating disorder behaviours. We wanted to look at risk factors.” While full-blown eating disorders are infrequent in children, the researchers say, the presence of risk factors is much more common. Dieting, for one, is a huge risk for eating disorders in children.
Drummond and Hare developed and validated the Risk of Eating Disorder Inventory (REDI™), a tool which is now being used in the offices of a number of family physicians, psychiatrists, and dietitians, as well as in schools. The REDI has also become a springboard for their current project, which will take them into Grade 5 and Grade 7 health classes to prevent eating disorders in schoolchildren. In the two-year project supported by the AHFMR Health Research Fund, Drummond and Hare will develop and pilot a wellness program; revise it according to student feedback;and train educators to deliver it. The program will be based on a parent workbook and a teacher’s resource manual they have developed (which is now available on CD).
Because recent literature suggests that going into the schools to talk specifically about eating disorders may trigger copycat behaviours, Drummond and Hare’s program focuses on wellness and self- acceptance. “Too often kids think they can make themselves into something that they can’t ever be, like someone they’ve seen on television,” says Drummond. “We help them to explore their own genetic body shapes.” The researchers also encourage students to cast a more critical eye on the media and evaluate what they are seeing. “Often children (and adults!) think that the picture they see is an accurate likeness,” adds Hare. “They don’t realize that anything on TV can be digitally altered.”
As well as being a welcome resource for schools grappling with the issue of eating disorders, the program will have positive spin-offs for Drummond and Hare. As returning students, they will have a ready-made thesis topic for their upcoming master’s degrees.
Preventing relapse of depression…
According to a study conducted by the Harvard School of Public Health and the World Bank, depression is the second leading cause of disease in developed countries like Canada. Dr. Keith Dobson, a professor of Clinical Psychology in the Department of Psychology at the University of Calgary, says his “best estimate” is that at any point in time, 1% of men and 2% of women are suffering from depression.Dobson admits that his estimate probably errs on the conservative side, and notes that some have pegged the incidence of depression as high as 25%. His figure doesn’t include those who experience a mild period of depression, one that is enough to affect their lives but not serious enough to propel them to a therapist’s or physician’s office. Still, in spite of a greater general awareness of depression and much-lauded improvements in pharmaceutical treatments, he says, “people are not seeking help the way they could be.” Even getting help offers no guarantees: approximately 50% of patients treated for depression are likely to suffer a relapse within a year of their recovery.
In a project supported by the AHFMR’s Health Research Fund, Dobson and his team of researchers are following a large sample of women who have had clinical depression, assessing them every two weeks for a year after their point of recovery. In those women who suffer a relapse, the researchers look for any medical conditions or changes in thinking that might have been contributing factors.
“The prediction of a 50% relapse rate is pretty accurate,” says Dobson, who has been studying depression since 1980. In the 135 subjects in his study, the relapse rate has been almost exactly 50%. The challenge is to find a way of predicting who will recover and who will suffer a relapse. Dobson is hoping his research will provide some useful clues as to what can be done for those who seem to recover, only to find themselves clenched in the jaws of depression again.
…and stopping depression before it starts
In other AHFMR-supported research at the University of Calgary, psychiatrist Dr. Scott Patten is using the World Wide Web and interactive voice telephone technology to test interventions aimed at preventing depression, such as cognitive and behavioural techniques, maximizing sleep quality, and reducing drug and alcohol use. Dr. Patten says his intent was to create a cost-effective, confidential way of delivering techniques that reduce the risk of depression. “These are not strategies that would be regarded as treatment strategies, but they are strategies that can help people prevent the intrusion of depression into their lives,” he says. “In principle, the program could be accessible to everybody, so that we might have an impact on the level of population health.”
When we look to the future of treatment for mental illness, it’s important to keep in mind the notions of early intervention and prevention and within the context of population health. “When you look at a problem like depression from a public-health point of view, the priorities are a little bit different than when you are looking at it from a clinical perspective,” says Dr. Patten. “Of course, there have been tremendous advances in treating depression. But when you look at that from a public-health perspective, it’s immediately apparent that the solution isn’t just in developing treatment procedures, because there are a lot of people with depression who will never seek treatment. There is a general principle in public health that prevention, if it can be successfully accomplished, is better than treatment.” Early intervention and prevention are not only the way of the future—they’re a better way to address the many challenges of mental health. It’s as simple as that.
Dr. Donald Addington’s research is supported by the Health Research Fund, administered by AHFMR on behalf of Alberta Health and Wellness. He also receives support from the Calgary Community Lottery Board, the Calgary Health Region/Alberta Mental Health Board and Psychiatric Program, and the Eli Lilly Zyprexa Research Foundation.
Dr. Jean Addington’s research is also supported by the Health Research Fund. She also receives support from the Canadian Institutes of Health Research.
Dr. Philip Tibbo is a Heritage Clinical Investigator, Assistant Professor, and Director of the Post-graduate Training Program in Psychiatry at the University of Alberta, as well as Co-Director of the Bebensee Schizophrenia Research Unit. He is also funded by the National Alliance for Research in Schizophrenia and Affective Disorders (NARSAD), the Canadian Institutes of Health Research, and the University of Alberta Hospital Foundation/Alberta Health Sciences Research Institute.
Dianne Drummond and Suzanne Hare’s research is supported by the Health Research Fund. They also receive funding support from the Caritas Research Steering Committee, Grey Nuns Community Hospital and Health Centre, and the Capital Health Authority.
Dr. Scott Patten is an AHFMR Population Health Investigator and an Associate Professor in the University of Calgary departments of Community Health Sciences and Psychiatry. He is also supported by the Health Research Fund; the National Health Research and Development Program; and the Canadian Institutes of Health Research.
Dr. Keith Dobson, in the Department of Psychology at the University of Calgary, receives support from the Health Research Fund.
Recent publications by Dr. Donald Addington and Dr. Jean Addington:
Addington J, Addington D. Early intervention for psychosis: the Calgary Early Psychosis Treatment and Prevention Program. The Bulletin of the Canadian Journal of Psychiatry 2001; October edition.
Addington J, Jones B, Ko T, Addington D. Family intervention in early psychosis. Psychiatric Rehabilitation Skills. (In press.)
By Dr. Philip Tibbo:
Tibbo P, Nopoulos P, Allen P, Valiakalayil A. Home structure of adolescents at high risk for schizophrenia. Schizophrenia Research 2000; 41:173.
Tibbo P, Valiakalayil A, Paulson L. Neuropsychological evaluations of high-risk adolescents for schizophrenia. Biological Psychiatry 2000; 47(8S):82S.
By Dr. Keith Dobson:
Dobson KS. Chronic processes in depression: differentiating self and other influences in onset, maintenance, and relapse/recurrence. Clinical Psychology: Science and Practice 2000; 7:236-239.
Dozois DJA, Dobson KS. Information processing and cognitive organization in unipolar depression: specificity and comorbid issues. Journal of Abnormal Psychology 2001; 110:236-246.