Bipolar treatment can be improved – by focusing less on antidepressants and more on lithium

by Daniel Smith, The Conversation

Credit: Shutterstock

Bipolar disorder is a serious condition of mood and behaviour that affects one in 50 people globally. Sufferers swing between episodes of mania (feeling high and overactive) and depression (feeling low, lethargic and hopeless). Sadly, it is estimated that as many as one in ten people with bipolar disorder will die by suicide.

28 jun 2019--In our recent research we used NHS data on more than 23,000 patients in Scotland to assess trends in treating bipolar disorder between 2009 and 2016. Our work was concerned with two main areas: the use of antidepressants and the use of lithium.

Antidepressants are effective for moderate to severe depressionand probably work by increasing the transmission of neurotransmitters such as serotonin and dopamine in the brain. Lithium is a mood stabiliser with a wide range of actions in the brain, including a neuroprotective effect that makes the brain more resilient under stress.

For some time now, we have known that antidepressants are not particularly effective for depressive episodes in people with bipolar disorder. In fact they may make some patients worse rather than better by causing mania (many experience their first episode of mania after taking antidepressants). In contrast, lithium is recommended around the world as the first-line, and most effective, medication for preventing mania and depression.

Decline of lithium as a treatment

What we found was surprising and disappointing. The most commonly prescribed treatments for bipolar disorder were antidepressants, despite their limited effectiveness and increased risk of making the long-term prognosis of bipolar disorder worse.

Only about one in five patients was taking lithium as their sole medication, and many were on combinations of different medications. There was also a very clear year-on-year decline in the use of lithium alongside greater use of antipsychotic medications. Antipsychotics primarily block dopamine pathways in the brain and are useful for mania and bipolar depression.

These findings suggest that many patients with bipolar disorder are not getting the best possible medications for their condition. This was a Scottish study but similar work in England and in other European countries have found a consistent decline in the use of lithium in recent years.

When I started as a trainee psychiatrist 20 years ago lithium clinics were commonplace in the NHS. Although their primary function was to monitor blood lithium levels in patients and keep an eye on thyroid and kidney function, (both of which can be affected by lithium), these clinics were busy and sociable places that provided a lot of informal support to patients.

But as expensive—and, we now know, less effective – alternatives to lithium were successfully promoted by drug companies, there has been a move away from lithium clinics. This change in prescribing culture occurred even though there was no evidence that lithium was less effective than other medications. But because of its potential toxicity and side effects in some patients, requiring regular blood monitoring, it is seen as less convenient for busy doctors.

Many of the current generation of psychiatrists now lack confidence in starting lithium therapy, in part because of a perception that it is complicated to prescribe. And of course side effects can be serious, such as long-term damage to kidney function, although the most recent data suggests that they can be managed successfully if properly monitored.

The reality is that lithium is cheap and can be life-changing for many patients with severe bipolar disorder. And is still only one of the few medications in psychiatry proven to be have a specific anti-suicidal effect.

What needs to be done

The key to successful management of bipolar disorder is the long-term prevention of episodes of mania and depression. Lithium is the best medication for this, but there are also psychological approaches that can prevent relapse.

Many antidepressants prescribed to bipolar patients have been shown to be less effective than lithium. Credit: Shutterstock

The most effective is group psychoeducation, where patients are taught about bipolar disorder and how to manage it within a supportive peer environment. Unfortunately, the provision of group psychoeducation across the NHS is very patchy at best.

One of the current drivers of this lack of emphasis on prevention is a greater focus on the "crisis care" of mental health within the NHS. This is of course very important, but we also need long-term therapeutic relationships and continuity, plus models of care that focus on the prevention of illness episodes.

The situation is worse for people with less severe forms of bipolar disorder, who often find themselves not unwell enough to qualify for psychiatric services but also too unwell for GPs to look after effectively. Very few GPs, for example, would be comfortable starting lithium therapy without input from their local psychiatric service.

In my clinical work I get referrals from colleagues to provide second opinion assessments of complex or difficult to treat bipolar disorder. In the past, these referrals tended to be for older patients who had been in the system for many years. But a worrying trend recently is an increase in younger people with bipolar disorder, possibly because of greater awareness that the condition usually starts during late adolescence. Almost none have been treated with lithium therapy, even though it could radically alter the long-term course of their illness.

Overall, the message we get from families—and many colleagues in mental health services would agree—is that the provision of care for bipolar disorder in the UK has become a lower priority and that the quality of long-term care could be much improved.

This issue doesn't need fancy new treatments—we know what works. The challenge is to do simple things effectively: fewer antidepressants; more lithium; more group psychoeducation. When it comes to treating people with bipolar disorder we need to look more at preventing fires rather than putting them out.

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Provided by The Conversation 

Physician, heal thyself: how depression affects cancer caregivers

Ashley Sumrall was an early career brain oncologist when she got a case that would stay with her for the rest of her career

27 jun 2019--Losing a patient is far from rare in her field: 90 percent of the people she sees will go on to die as a result of their illness.

But David was different. A former White House aide, he had come into her care after years of experimental trials failed to halt the advance of his glioma.

She believed he would be a difficult case because of his initial refusal to accept muscle-destroying steroids but over time she became so involved in his care that losing him was akin to losing a member of her own family.

"It sounds cliched, but it's truly a disease that affects their whole family. So you're caring for the individual and their spouse or caregiver, their adult children, you know, you're connected to that whole family," the assistant professor at the Levine Cancer Institute in North Carolina told AFP.

Cancer is a devastating diagnosis for the patient and their loved ones, but an under-examined area is its impact for those involved in its care, who are at higher risk for anxiety, depression and burnout.

Burnout

A report last year by the American Psychiatric Association found that a doctor commits suicide every day in the US, the highest rate of any profession—28 to 40 per 100,000, which is more than twice the rate for the general population.

"We know that physicians in general don't ask for help for their mental and physical health as soon as others," said Bill Eley, an oncologist and associate dean of the Emory University School of Medicine in Atlanta, Georgia.

"For oncologists, people die, and you walk with them through that. And we're ill prepared for the stress that's physical, emotional and spiritual, that we undergo."

Burnout and the ever present pressure of showing value—the US hospital system measures how busy doctors are, but doesn't account for how valued they are by patients—are factors most commonly quoted by professionals who study the problem.

But the stressors are even more intense for oncologists for several reasons, explained Michelle Riba, a psychologist and director of the PsychOncology Program at the University of Michigan Rogel Cancer Center.

"We have long relationships, we often hold the key to their survival. There's no room for errors, it's a pressure cooker," she said.

Eley agreed: "We see tragedy after tragedy. And we go see the next patient. And we go see the next patient. And there's very little attention to processing grief and sadness and suffering in our systems."

Longer relationships

Beyond that is the amount of suffering patients undergo in the cancer treatments prescribed by their doctors, including the most dreaded chemotherapy and all the destructive side effects it brings.

One case that Eley recalls vividly was a 28-year-old woman who had a rare cancer called sarcoma. The treatment left her unable to swallow and she was left drooling, "which just makes it all the more painful."

And although cancer treatments today are more advanced and life-prolonging than ever before, that too, paradoxically, brings its own challenges, adds Eley.

"Thankfully we have longer and longer relationships with our patients. And I think when you have relationships with people, and you lose them, they die, you are sad, and you suffer."

At one point early on in his career, Eley lost interest in the things in life that gave him joy, such as dancing.

"I did come become numb for a number of years, where I did not feel much," he said.

"But I came through it, because a great colleague, who helped me and mentored me that I gained an outlook on life that we can start again.

The antidote, he said, was forming strong relationships with colleagues, mentors, patients and their families.

For Sumrall, David's case was a reminder that the work she does is about more than just "giving chemo."

"I let my boundaries down in a way that I had not done in years. His kids were similar to mine in age, and I adored the patient and his wife," she said, adding she was still in touch. "It could be easy to 'give up' after experiencing loss in such a way.

"In fact, my team probably loses 50 patients per year. For us, we view those opportunities as a chance to help others gently transition to their next phase, and the pain we feel is miniscule compared to theirs."

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© 2019 AFP

Chronic conditions—not infectious diseases—are top five causes of early death in China

by Institute for Health Metrics and Evaluation

Credit: CC0 Public Domain

Chronic diseases, such as stroke, ischemic heart disease, and lung cancer, now represent the leading causes of premature death in China, according to a new scientific study.

25 jun 2019--The rise in non-communicable diseases reflects declines in maternal and child mortalityover nearly three decades, largely the result of economic growth and increasing levels of education. In addition, China has instituted national programs targeting infectious diseases.

"Like many countries, China has reached a tipping point over the past three decades," said Dr. Maigeng Zhou, a lead author on the study and Deputy Director, National Center for Chronic Non-Communicable Disease Control and Prevention at the Chinese Center for Disease Control and Prevention. "Going forward, the burden of chronic health problems, especially among the elderly, will far exceed infectious diseases."

A part of the Global Burden of Disease (GBD), the study spans 1990 to 2017, filling a major gap in understanding health problems at the local level. The analysis, published today in the international medical journal The Lancet, provides comparable estimates of mortality, disability, and associated risk factors for 34 provinces by age and sex. The GBD produces estimates for 359 diseases and injuries and 84 risk factors.

Zhou and co-authors found stroke and ischemic heart disease replaced lower respiratory infections and neonatal disorders as the leading causes of disease burden between 1990 and 2017.

In addition to stroke, ischemic heart disease, and lung cancer, the top five causes of premature death include chronic obstructive pulmonary disease (COPD) and liver cancer.

Compared to countries with similar levels of development, such as Russia, China has unusually high levels of stroke, COPD, lung cancer, liver cancer, neck pain, and stomach cancer. All provinces had higher-than-expected cases of liver cancer, with rates of disability-adjusted life years (DALYs) between two and seven times higher than would be expected based on their level of development.

The analysis demonstrates considerable variation in health problems at the provincial level, confirming that one's health depends on where one lives. People in urban, coastal, and wealthier provinces in eastern China generally are healthier than those in rural and poorer areas in the west.

"We are committed to achieving the goals of the Healthy China 2030 Plan," said Dr. Xiaofeng Liang, Deputy Director at the Chinese Center for Disease Control and Prevention, referring to an initiative announced in 2016 to improve health, control risk factors, and improve and enlarge the nation's health care system. "These detailed provincial findings will help us tailor evidence-based policies to the health needs of local communities."

Liver cancer ranked among the top five causes of DALYs in seven provinces, but in 11 provinces it did not rank in the top 10. The rank order for road injuries ranged from third to 20th leading cause of DALYs across all provinces; whereas hypertensive heart disease saw variation in rank order from seventh to 56th leading cause.

Nationally, smoking is the top risk factor in 21 provinces, and is ranked the second- or third-leading risk in all remaining provinces. Exposure to some risk factors is rising, particularly high blood sugar, high blood pressure, high body mass index (BMI), and, in many provinces, outdoor air pollution.

Additional findings include:

• The suicide rate for females fell from 21.5 deaths per 100,000 people in 1990 to 7.5 deaths in 2017. This trend is partly explained by urbanization and development as well as improved opportunities for women and young people. Males also saw a decline, but to a lesser degree, dropping from 17.0 deaths per 100,000 to 10.7 deaths over the same time period.
• After 2000, rates of diabetes increased more rapidly due to changing lifestyles, including increased consumption of red meat and decreased levels of physical activity. National diabetes rates increased by more than 50%, from 4,206 prevalent cases per 100,000 in 2000 to 6,336 prevalent cases in 2017.
• The maternal mortality ratio declined by 86% during the study period, falling from 95 to 14 maternal deaths per 100,000 live births. At the same time, the under-5 mortality rate decreased by 76%, from 50 to 12 child deaths per 1,000 live births.
• The top three disabling conditions in 1990 and 2017 were musculoskeletal disorders, mental disorders, and sense organ diseases (e.g., vision loss, hearing loss).
• High blood pressure accounted for 2.5 million Chinese deaths in 2017, with nearly all (96%) resulting from cardiovascular diseases (CVD).
• Beijing had significantly lower rates of premature death (age-adjusted) than the national average across all top 20 causes.
• Ten provinces in mainland China had DALYs rates (age-adjusted) at least 30% lower than would be expected given their level of development. They include Chongqing (37%), Anhui (35%), Zhejiang (34%), Fujian (33%), Shanghai (33%), Guizhou (32%), Ningxia (31%), Jiangsu (30%), Hainan (30%), and Beijing (30%).

The study is entitled "Mortality, morbidity, and risk factors in China and its provinces, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017."

Journal information: The Lancet 

Provided by Institute for Health Metrics and Evaluation

Gut bacteria associated with chronic pain for first time

by McGill University Health Centre

Human gut microbiome composition shows an enormous richness. Each circle represents a bacterial species, while the different colours mark different bacterial phyla. Credit: Dr. Amir Minerbi

Scientists have found a correlation between a disease involving chronic pain and alterations in the gut microbiome.

23 jun 2019--Fibromyalgia affects 2-4 percent of the population and has no known cure. Symptoms include fatigue, impaired sleep and cognitive difficulties, but the disease is most clearly characterized by widespread chronic pain. In a paper published today in the journal Pain, a Montreal-based research team has shown, for the first time, that there are alterations in the bacteria in the gastrointestinal tracts of people with fibromyalgia. Approximately 20 different species of bacteria were found in either greater or are lesser quantities in the microbiomes of participants suffering from the disease than in the healthy control group.

Greater presence or absence of certain species of bacteria

"We used a range of techniques, including Artificial Intelligence, to confirm that the changes we saw in the microbiomes of fibromyalgia patients were not caused by factors such as diet, medication, physical activity, age, and so on, which are known to affect the microbiome," says Dr. Amir Minerbi, from the Alan Edwards Pain Management Unit at the McGill University Health Centre (MUHC), and first author on the paper. The team also included researchers from McGill University and Université de Montréal as well as others from the Research Institute of the MUHC.

Dr. Minerbi adds, "We found that fibromyalgia and the symptoms of fibromyalgia—pain, fatigue and cognitive difficulties—contribute more than any of the other factors to the variations we see in the microbiomes of those with the disease. We also saw that the severity of a patient's symptoms was directly correlated with an increased presence or a more pronounced absence of certain bacteria—something which has never been reported before."

Are bacteria simply the markers of the disease?

At this point, it's not clear whether the changes in gut bacteria seen in patients with fibromyalgia are simply markers of the disease or whether they play a role in causing it. Because the disease involves a cluster of symptoms, and not simply pain, the next step in the research will be to investigate whether there are similar changes in the gut microbiome in other conditions involving chronic pain, such as lower back pain, headaches and neuropathic pain.

Bacterial species which were found in greater quantities in individuals with fibromyalgia (left) versus species which were found in greater quantities in healthy individuals (right). Credit: Dr. Amir Minerbi

The researchers are also interested in exploring whether bacteria play a causal role in the development of pain and fibromyalgia. And whether their presence could, eventually, help in finding a cure, as well as speed up the process of diagnosis.

Confirming a diagnosis and next steps towards finding a cure

Fibromyalgia is a disease that has proved difficult to diagnose. Patients can wait as long as 4 to 5 years to get a final diagnosis. But this may be about to change.

"We sorted through large amounts of data, identifying 19 species that were either increased or decreased in individuals with fibromyalgia," says Emmanuel Gonzalez, from the Canadian Center for Computational Genomics and the Department of Human Genetics at McGill University. "By using machine learning, our computer was able to make a diagnosis of fibromyalgia, based only on the composition of the microbiome, with an accuracy of 87 per cent. As we build on this first discovery with more research, we hope to improve upon this accuracy, potentially creating a step-change in diagnosis."

"People with fibromyalgia suffer not only from the symptoms of their disease but also from the difficulty of family, friends and medical teams to comprehend their symptoms," says Yoram Shir, the senior author on the paper who is the Director of the Alan Edwards Pain Management Unit at the MUHC and an Associate Investigator from the BRaiN Program of the RI-MUHC. "As pain physicians, we are frustrated by our inability to help, and this frustration is a good fuel for research. This is the first evidence, at least in humans, that the microbiome could have an effect on diffuse pain, and we really need new ways to look at chronic pain."

How the research was done

The research was based on a cohort of 156 individuals in the Montreal area, 77 of whom suffer from fibromyalgia. Participants in the study were interviewed and gave stool, blood, saliva and urine samples, which were then compared with those of healthy control subjects, some of whom lived in the same house as the fibromyalgia patients or were their parents, offspring or siblings.

The researchers' next steps will be to see whether they get similar results in another cohort, perhaps in a different part of the world, and to do studies in animals to discover whether changes in bacteria play a role in the development of the disease.

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More information: Amir Minerbi et al, Altered microbiome composition in individuals with fibromyalgia, PAIN (2019). DOI: 10.1097/j.pain.0000000000001640

Journal information: Pain 

Provided by McGill University Health Centre 

We know contact with nature makes you feel better. Can virtual contact do the same?

by Navjot Bhullar, The Conversation

There is a link between exposure to natural settings and better psychological well-being. Credit: Shutterstock

You might have noticed that being in nature can improve your mood. Whether it's walking in a beautiful rainforest, swimming in the ocean or a moment of wonder at the plants and animals around you, nature offers a respite from daily routines and demands.

22 jun 2019--In 1984, the sociobiologist Edward O. Wilson described this innate desire to connect with natural environments—and the positive experienceswe derive from this connection—as the "biophilia hypothesis":

"Biophilia, if it exists, and I believe it exists, is the innately emotional affiliation of human beings to other living organisms."

There is evidence to back up the link between exposure to natural settings and better psychological well-being.

And my own research suggests that virtual exposure to nature via film (videos) or virtual reality can mimic this effect.

Why being in nature makes us feel better

Studies on the psychological benefits of exposure to nature show spending time in natural settings can result in:

• reductions in stress, as measured by cortisol levels
• reductions in anger and fatigue
• increases in happiness
• reductions in symptoms of attention-deficit and hyperactivity disorder (ADHD) in children
• fewer symptoms of depression in adulthood.

Two major theories help us understand how exposure to nature increases mood and psychological well-being.

First, Attention Restoration Theory is the idea that natural environments restore attention. We can only focus our attention for a certain period of time before feeling mentally fatigued. A short break in natural environments helps restore it.

This sense of "restorativeness" improves our sense of well-being, and breaks the routine of our every day life. Restorativeness explains some of the association between nature experience and psychological well-being.

Then there is Stress Reduction Theory. This suggests that natural environments promote recovery from stress, which is different from attention fatigue.

Non-threatening, natural environments would have increased the chances of survival for our ancestors because they provided opportunities for reproduction, food and shelter. As a result, we've evolved to respond positively to such settings.

Emotional responses to aesthetically pleasing stimuli, such as green spaces, also tend to decrease physiological arousal, thus making us feel relaxed.

Virtual contact with nature mimics this effect

In a meta-analysis of 32 studies, researchers compared the effects of exposure to both natural and urban environments. Results showed that exposure to natural environments showed a moderate association with higher positive mood.

This exposure doesn't have to take place in-person. Research I conducted with my colleagues at the University of New England's Applied Psychology Lab showed that while people got the most psychological benefit from physical exposure to nature, exposure to simulated natural environments—such as film or virtual reality—had a comparable effect.

One study showed that taking part in a virtual reality experience of a natural environment resulted in higher levels of positive affect and greater attention restoration compared to a virtual reality experience of an urban environment.

Psychological benefits seem to be dependent on the type of nature experience. Another study found that a virtual experience of wild nature (defined as natural settings, such as wilderness with little human interference) improved positive mood. By contrast, a virtual experience of urban nature (such as parks in urbanised areas) exerted its beneficial effect by reducing negative mood.

The studies also showed that simulated natural environments providing realistic representations of nature, such as interactive virtual reality, resulted in greater psychological benefits than less immersive mediums such as photographs of natural settings.

Increasing our daily contact with nature

In a modern world increasingly characterised by built environments, it's not always possible to spend time in nature every day. Promoting exposure to virtual natural environmentsseems like an effective way of improving psychological well-being.

Simulated representations of nature can help improve urban and indoor environments where access to nature is limited, such as hospitals, urban offices, apartments, and inner city schools.

That might mean displaying photographs and moving videos of natural colours and patterns, installing living green walls, or placing potted plants in areas people move through everyday.

Provided by The Conversation 

Want to be healthy and happy? Choose a ⁠c⁠o⁠n⁠s⁠c⁠i⁠e⁠n⁠t⁠i⁠o⁠u⁠s⁠ ⁠p⁠a⁠r⁠t⁠n⁠e⁠r⁠

by Lynn Williams, The Conversation

Credit: Rawpixel.com/Shutterstock

Y⁠o⁠u⁠r⁠ ⁠p⁠a⁠r⁠t⁠n⁠e⁠r⁠'⁠s⁠ ⁠p⁠e⁠r⁠s⁠o⁠n⁠a⁠l⁠i⁠t⁠y⁠ ⁠c⁠a⁠n⁠ ⁠i⁠n⁠f⁠l⁠u⁠e⁠n⁠c⁠e⁠ ⁠y⁠o⁠u⁠r⁠ ⁠l⁠i⁠f⁠e⁠ ⁠i⁠n⁠ ⁠a⁠l⁠l⁠ ⁠s⁠o⁠r⁠t⁠s⁠ ⁠o⁠f⁠ ⁠w⁠a⁠y⁠s⁠. For example, studies have shown that a conscientious partner i⁠s⁠ ⁠g⁠o⁠o⁠d⁠ ⁠f⁠o⁠r⁠ ⁠y⁠o⁠u⁠r⁠ ⁠h⁠e⁠a⁠l⁠t⁠h. Our latest study shows that they are also good for your quality of life.

21 jun 2019--Personality reflects a person's characteristic way of thinking, feeling and behaving. Psychologists tend to examine personality across five key traits: extroversion, openness to experiences, conscientiousness, emotional stability and agreeableness. Typically, these traits are measured using questionnaires that help psychologists build up a profile of a person's personality.

Personality characteristics can have a strong impact on health, even influencing how long you live. Research shows that the more conscientious a person is, the longer they live. Conscientiousness is defined by high levels of self-discipline. Because conscientious people are more organised and careful they are more likely to lead healthier lives than their less conscientious peers. For instance, they may be more likely to follow their doctor's advice, eat more healthily and do more exercise.

It's not just your own personality that can strongly influence your health, though—your partner's can too. A US study examined the relationship between partner conscientiousness and health ratings in 2,203 older couples. They found that husbands' conscientiousness influenced wives' health, and wives' conscientiousness influenced husbands' health. The same findings were also replicated in a more recent study.

These results showed something particularly interesting: conscientiousness had a compensatory effect, meaning that having a more conscientious spouse predicted better health, even after taking into account a participant's own conscientiousness. A finding that the researchers described as "compensatory conscientiousness".

A better quality of life

We recently carried out a study to see if we could find similar effects in younger adults. We also wanted to see if a person's conscientiousness influenced their partner's quality of life. The term "quality of life" reflects a person's satisfaction with their life, including physical health, psychological state and social relationships.

We talked to 182 romantically involved couples, asking each person to complete a questionnaire. The participants were aged from 18 to 78, with an average age of 36. To qualify to take part, couples had to have been in a relationship for at least six months. Just under half the sample was married and most couples lived together. On average, the couples had been together for just over ten years.

Each person completed the questionnaire separately from their partner so that they could not discuss their answers. The survey questions let us measure their personality, using the ten-item personality inventory and ask them questions about their quality of life using questions developed by the World Health Organisation.

Our analysis showed that an individual's own level of conscientiousness was related to their quality of life, with participants who had higher levels of conscientiousness reporting a better quality of life. We also found that people who had partners with higher levels of conscientiousness also reported having a better quality of life. This finding was true for both men and women.

Our findings raise the question of how a person's conscientiousness influences their partner's health. It is likely that partners high in conscientiousness help to create an environment that leads to greater health. For instance, a conscientious partner likes to plan and be organized and so they may provide their partners with useful health reminders, such as to take medication or attend a doctor's appointment. Conscientious partners are also dependable and so are likely to be good providers of social support for their partner.

These findings show that our partner's personality is important for our health, so choose your life partner carefully.

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Provided by The Conversation 

Those with elevated risk of Alzheimer's may show memory changes up to 40 years before onset

by Steve Yozwiak, Translational Genomics Research Institute

Credit: CC0 Public Domain

Results from a study of nearly 60,000 individuals suggest those at higher risk of developing Alzheimer's disease due to family history may demonstrate changes in memory performance as early as their 20s.

20 jun 2019--Researchers from the Translational Genomics Research Institute (TGen), an affiliate of City of Hope, and the University of Arizona gathered the data through an online word-pair memory test called MindCrowd, one of the world's largest scientific assessments of how healthy brains function.

Published today in the scientific journal eLife, study datasuggests that those with a family history of Alzheimer's disease, and who are younger than 65, on average do not perform as well as their peers who do not have a family history of Alzheimer's, the most common form of dementia.

The study results suggest that the family history effect is particularly pronounced among men, as well as those with lower educational attainment, diabetes, and carriers of a common genetic change in APOE, a gene long associated with Alzheimer's disease risk.

While family history has previously been associated with the risk of Alzheimer's, this is the first study of its kind, and in these numbers, that indicates this risk can be detected up to four decades before the typical age of onset. The study looked at 59,571 MindCrowd participants aged 18-85, and the effect of family history was shown across every age group, up until age 65.

"In this study we show that family history is associated with reduced paired-associate learning performance as many as four decades before the typical onset of Alzheimer's disease," said Dr. Matt Huentelman, TGen Professor of Neurogenomics, and the study's senior author

Because there is no cure or proven way of slowing progressive memory-loss among those with Alzheimer's, early indicators of the disease can help those at risk to focus on ways to help stave off dementia.

"Risk reduction for Alzheimer's disease is now more critical than ever due to the continued lack of a cure or effective disease-slowing treatment," said Dr. Joshua S. Talboom, a Postdoctoral Fellow in TGen's Neurogenomics Division, and a member of Dr. Huentelman's lab.

"This study supports recommendations underscoring the importance of living a healthy lifestyle and properly treating disease states such as diabetes," said Dr. Talboom, the study's lead author. "Our findings specifically highlight the positive effects of such interventions for those with a family history risk of Alzheimer's, opening the door to the development of more targeted risk-reduction approaches to combat the disease."

In addition, this study underscores the utility of web-based participant recruitment to research studies like MindCrowd, facilitating large sample sizes in a cost- and time-effective fashion, said Dr. Lee Ryan, a University of Arizona Alzheimer's researcher, who along with the UA's Dr. Betty Glisky, helped Dr. Huentelman develop MindCrowd. Drs. Ryan and Glisky were contributing authors to the study.

"It should be acknowledged that that web-based studies are not without concerns. However, we propose that the advantage of considerably larger sample sizes and enriched participant diversity in online research mostly diminishes the potential disadvantages," Dr. Ryan said.

The MindCrowd study (www.mindcrowd.org) began in 2013. By August 2018, it had nearly 60,000 qualified participants, whose performance is reflected in the study. Today, more than 115,000 people, aged 18-95—from all 50 states and 150 nations around the world—have completed the MindCrowd assessment.

MindCrowd cannot tell you if you have Alzheimer's. What it does give researchers is a set of data baselines about how people not suffering from the disease perform at different ages; among men and women, among those with quick and slow physical responses, among those who smoke and those who don't, and among many other demographic, lifestyle and health factors.

Establishing these baselines will help researchers to more properly evaluate Alzheimer's patients and usher in a new era of what the MindCrowd developers describe as Precision Aging.

Alzheimer's is a progressive neurological disorder that typically presents clinically as deficits in memory and thinking. It is estimated that more than 5 million Americans are living with Alzheimer's, and that by 2050 that number will nearly triple to almost 14 million.

The Arizona Alzheimer's Consortium, the Norwegian University of Science and Technology, and the University of Miami also contributed to the study.

The study is titled "Family history of Alzheimer's disease alters cognition and is modified by medical and genetic factors."

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More information: Joshua S Talboom et al. Family history of Alzheimer's disease alters cognition and is modified by medical and genetic factors, eLife (2019). DOI: 10.7554/eLife.46179

Journal information: eLife 

Provided by Translational Genomics Research Institute 

Antidepressants can lead to reductions in behavioral and neural responses to pain empathy

by University of Vienna

Credit: Pietro Jeng/pexels.com

Depression is a disorder that often comes along with strong impairments of social functioning. Until recently, researchers assumed that acute episodes of depression also impair empathy, an essential skill for successful social interactions and understanding others. However, previous research had been mostly carried out in groups of patients who were on antidepressant medication. Novel insights of an interdisciplinary collaboration involving social neuroscientists, neuroimaging experts, and psychiatrists from the University of Vienna and the Medical University of Vienna show that antidepressant treatment can lead to impaired empathy regarding perception of pain, and not just the state of depression itself. The results of this study have been published in the scientific journal Translational Psychiatry.

20 jun 2019--An interdisciplinary research team set out to disentangle effects of acute depressive episodes and antidepressant treatment on empathy. The researchers recruited unmedicated patients with acute depression, and tested their empathic responses to the pain of others twice: first, during an acute depressive episode, i.e., before they had received any medication. Second, after three months of psychopharmacological treatment with antidepressants (mostly selective serotonin reuptake inhibitors).

In both sessions, patients underwent functional magnetic resonance imaging while watching videos of people undergoing painful medical procedures. Their brain activity and self-reported empathy were compared to those of a group of healthy controls. Before treatment, patients and controls responded in a comparable way. After three months of antidepressant treatment, the research revealed relevant differences: patients reported their level of empathy to be lower, and brain activation was reduced in areas previously associated with empathy.

First author Markus Rütgen says that reduced empathic responses were not caused by a general dampening of negative emotions: "The lowered emotional impact of negative events in a social context possibly allows patients to recover more easily. Nevertheless, the actual impact of reduced empathy on patients' social behavior remains to be explored."

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More information: Markus Rütgen et al. Antidepressant treatment, not depression, leads to reductions in behavioral and neural responses to pain empathy, Translational Psychiatry (2019). DOI: 10.1038/s41398-019-0496-4

Journal information: Translational Psychiatry 

Provided by University of Vienna 

Study shows 70% of patients lack advance directives before elective surgery

by Regenstrief Institute

Only 30% of pre-op patients reported having some form of Advance Directive documenting their wishes regarding emergency medical care. Only 16% had one on file in their electronic medical record (EMR) where a clinician could access it at the time of surgery. When there is no record of care preferences, families must decide what kind of emergency care their loved one receives. Credit: Regenstrief Institute

The majority of people visiting preoperative testing clinics before an elective surgery do not have an advance directive (AD) in case of surgical complications. This can lead to situations where patients' families are forced to make tough decisions about their loved one's care.

18 jun 2019--A study from researchers at the Regenstrief Institute, Indiana University Health and Indiana University School of Medicine found that only 30% of the patients in the study reported having some form of AD documenting their wishes regarding emergency medical care. However, only 16% had one on file in their electronic medical record (EMR) where a clinician could access it at the time of surgery. When there is no record of care preferences, families must decide what kind of emergency care their loved one receives.

An advance directive is a legal document stating the patient's wishes for care if he or she is incapacitated. These preferences can include whether or not the person wants to receive CPR or intubation or who is in charge of making care decisions on their behalf. If there is no AD, doctors turn to a priority list of people, reaching out to them, in order of priority, to make the decision.

The lead author of the study, Shilpee Sinha, M.D., is the service line lead for the Adult Academic Health Center for Palliative Care at IU Health in Indianapolis. She sees patients every day who are at an increased risk of surgical complications. "When a crisis does occur," Dr. Sinha said, "family members tend to project their own emotions into what they think is best for the patient, but their choices may not be what the patient actually wants."

Dr. Sinha and her colleagues looked at EMRs of 400 patients who underwent preoperative evaluation. They found only 16% of those people had some form of AD on file.

Dr. Sinha performed this research as part of The Advanced Scholars Program for Internists in Research and Education (ASPIRE). ASPIRE is a one-year program through the Division of General Internal Medicine and Geriatrics at IU School of Medicine and the Regenstrief Institute that provides physicians in clinical practicewith a chance to hone their skills in research.

"One of my goals for doing this study is to drive clinical change," said Dr. Sinha. "The discussion of advance care planning is not part of the established routine. I think we've achieved buy-in on the idea of having these conversations. Now we need actual logistical application."

Regenstrief researcher Alexia Torke, M.D., M.S., was Dr. Sinha's mentor through the ASPIRE program, and senior author of this paper. She has conducted extensive research in surrogate decision making.

"When an AD is not available in cases of emergency, it creates a complex situation for the care providers and surrogate decision makers. Emotions are often high, and family members may have difficulty navigating those emotions to make the best decision for their loved ones," said Dr. Torke. "Work like Dr. Sinha's is very important. These findings suggest there is a significant opportunity for improvement in advanced care planning in the clinical setting."

"Advance Care Planning in A Preoperative Clinic: A Retrospective Chart Review" was published in the Journal of General Internal Medicine. The study was funded through the ASPIRE program. Dr. Torke was supported by a Midcareer Investigator Award in Patient-Oriented Research (K24 AG053794) from the National Institute on Aging.

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More information: Shilpee Sinha et al, Advance Care Planning in A Preoperative Clinic: A Retrospective Chart Review, Journal of General Internal Medicine (2019). DOI: 10.1007/s11606-018-4744-8

Journal information: Journal of General Internal Medicine 

Provided by Regenstrief Institute