Can we prevent psychosis? It’s more hopeful than NIMH Director Insel thinks

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Morning Zen Guest blogger ~ Dennis D. Embry, Ph.D. 

The Director of the National Institute of Mental Health, Dr. Thomas Insel wrote on November 20, 2014:

Well, Dr. Insel, you are in luck and so are the 500,000 people and their families per year, because the news is a lot better than you first thought. Just a few days before Dr. Insel’s blog was published, scientists reported about the long-term prevention psychosis using omega-3, something Dr. Insel mentioned as hopeful in his blog but did not know at the time. The results were reported at International Early Psychosis Conference in Tokyo, Japan (Nov 17-19, 2014), see http://bit.ly/psychosisN3

I knew about the earlier report in the Archives of General Psychiatry in 2010 [1], and I loudly talked about it in Tucson where people I know were killed or injured by Jared Loughner on January 8, 2011, when he had a first episode psychosis. The one-year results were amazing, and now the long-term results seven years later are stunning—shown below. I knew about the 2010 study long before the terrible events in Tucson, because of my involvement with colleagues at the National Institutes of Health who were studying how omega-3 could avert or reduce many forms of mental illness [2-6]. The long-term follow up showing the promise of high-quality omega-3 (fish oil) for averting psychosis are remarkable. 

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What might these results mean? The most optimistic extrapolation of these results from the Archives of General Psychiatry might mean that out of 500,000 prodromal people for psychosis each year—cited by Dr. Insel’s blog—suggests that potentially 30% fewer of those troubled individuals (about 150,000) might develop full blown psychosis years later. Even if subsequent studies show it’s only a 5% difference, it’s still 25,000 people saved.

Ah, perhaps you are wondering, “Does Dr. Embry have financial interests in fish oil?”  The answer is no, and nobody pays me to talk about it. I do so because omega-3 has terrifically good science that could save huge amounts of pain and suffering. So are there other strategies that might help avert, prevent or reduce the risk of psychosis? Yes, and those strategies have many other benefits for averting or reducing multiple mental, emotional, and behavioral disorders. Those other strategies can be implemented as a public health model, with many diverse prevention effects—that might happen well before young people are prodromal for psychosis.

Consider the well-known link of exposure to traumatic events and psychosis? Can such exposure be prevented scientifically? Yes. For example, exposure to child maltreatment is a significant risk, and a CDC sponsored study shows that it is possible to reduce population-level measures of child maltreatment in two years for about $15 per child ages 0-8 in communities [7], and even potential preventive effects are possible from a prime-time show modeling how parents successfully handle problematic children [8-10]. Averting early child-maltreatment could have many positive effects on not only averting psychosis but also many other mental, emotional, behavioral and related disorders. One needs to recall that the Adverse Childhood Experiences (ACE’s) literature—as exemplified by the Kaiser Permanente study [11-13]—happened in middle-class families, not just among children living in bad areas. Thus a public-health approach to averting child maltreatment, and not just case-finding mode for abused children is needed to reduce the prevalence rates of maltreatment and related lifetime sequelae mental and physical disorders.  

What about averting or reducing the early trajectory of mental illness (emotional problems, ADHD, conduct problems, peer problems etc.) among young children that foreshadows elevated risk of psychosis later as young adult? Could such protection be implemented as a universal model to reduce mental health morbidity and mortality? The answer is yes, and the strategy was specifically noted in the 2009 IOM report [14-17]. Because of the powerful prevention effects and cost-effectiveness [18], the Substance Abuse and Mental Health Services Administration (SAMSHA) funded real-world expansion of the strategy in scores of sites across America, which my colleagues and I support as the PAX Good Behavior Game (http://bit.ly/NREPP). It’s the most widely used practical version of my colleagues’ prevention studies at Johns Hopkins (about 8,000 classrooms), and we’ve been able to show that the expected effects are replicable in the real world for averting or reducing the trajectory of mental, emotional, and behavioral disorders [19].

Please note, I have all sorts of conflicts of interest with PAX Good Behavior Game in terms of income, which doesn’t negate its proven benefits. This strategy is not about classroom management. Rather, it is a simple behavioral vaccine [20, 21] in first-grade classrooms that teaches self-regulation that, in turn, reduces multiple lifetime mental health symptoms that elevate risk of lifetime serious mental illness, addictions, violence, early risk sex, and even suicide for less than the cost of a measles, mumps, varicella and rubella vaccination. Behavioral vaccines are simple daily practices that reduce morbidity, mortality and improve wellbeing. Seatbelts and hand washing are real-world examples of behavioral vaccines. And for the big boat rocker about your genes being destiny for mental illness is that equipping parents and teachers with simple behavioral vaccines cause protective expression of Brain Derived Neurotropic Factor (BDNF) genes [22], which regulate many outcomes of mental disorders. There is considerable evidence that nurturing environments versus toxic environments [23] cause expression or suppression of genes associated with mental, emotional, and behavioral disorders disorders [24-28]. Most people over age 30, unless they are students or scientists of epigenetic factors, don't know that the social environment changes gene expression in humans.

I suspect that there are novel behavioral vaccines that have not been mobilized to prevent the terrifying emergence of psychosis. Consider two examples. We’ve known both scientifically and practically that heavy marijuana use elevates the risk of psychosis [29, 30]. We’ve also known that sleep deprivation can trigger psychosis [31-34], something that I have witnessed of the admissions unit of psych hospitals. Sleep problems are now epidemic among American young people, and almost every case of the mass shooters (like Jared Loughner in Tucson where I live) had major sleep problems. We know now, too, thanks to an elegant epidemiological study that sleep problems among teens is “contagious” across social networks and that then increases the risk of marijuana use and abuse [35]. There are practical strategies and policy options that reduce both causes of psychosis.

Can these proven and possible preventive strategies for lifetime risk of mental illnesses be deployed across America to protect the coming generations of young people? Yes, absolutely. Consider our past ingenuity in this country.

When the polio epidemic struck hard in America in the 1950s, people frantically called for more post-infection care—iron lungs, braces, crutches, wheelchairs and physical therapy. In a way, we are like the 1950s when it comes serious mental illnesses, stuck in the notion of treating the disease until the publication about Salk Vaccine triggering polio antibodies [36]. Right after the theoretical proof of the Salk Vaccine, Thomas Francis and colleagues lead mobilization to prove we could actually prevent polio among 1.8 million children [37], and the Salk Vaccine actually prevented polio—paving the way to universal protection of children against polio. In just five years after the national mobilization to assure all children were protected against polio with either the Salk or Sabine vaccine, we had only 168 cases of polio in 1963 from a high of 60,000 cases in the early 1950s.

Today, we have as good or better science for preventing mental illness than we did with Jonas Salk’s polio vaccine in 1954.  His study only showed reduction in antibodies for a few thousand of kids. Today, we have scores, if not hundreds, of studies showing we can actually avert, reduce or even prevent mental illnesses —and not by just one method.

Now why have we NOT acted? That’s a good question, and I can only opine about that. Here are some reflections on my part.

Unlike polio, mental, emotional, and behavioral disorders have been consigned to faulty genes and biochemistry. It’s the fault of your stars, if you will. There is a damn serious problem with that homage to genetic or chemical determinism: 1) the same 2009 IOM Report [38] and cited references show that mental, emotional, and behavioral disorders are increasing almost every two years in longitudinal cohort studies [39, 40]; 2) the Wall Street Journal found that 40.4 million out-of-75 million young people in 2009 had at least one prescription for psychotropic medications [41]; and 3) a other studies show historic rises in mental, emotional, and behavioral disorders in America that cannot be attributed to “over-diagnoses” [42]. 

Something is wrong in our social and cultural environment, triggering gene expression and adverse biochemistries. I made this point very real in my December 3, 2014, Congressional Briefing in very simple way. I asked all the 30-somethings to raise their hands, which was about half of the room. Then, I asked all the 50 and over people to raise their hands, which was about a third of the room. Next, I asked how many of the 30-somethings to raise their hand, if a high school or college friend of theirs had committed suicide. Almost all of them raise a hand.  Finally, I asked the question of the 50-something people, and only three raised their hand. A gasp occurred in the room, with the point made. Suicide is the terminal end of mental, emotional, and behavioral disorders, which is not easily dismissed as “over-diagnoses.”

Suicidality today is massively more epidemic that polio was when I was a kid.  Corrected for population today, the 1950s polio epidemic would have killed 6,000 kids and young adults and infected 120,000 people.  And suicide? CDC reports that 38,000 people killed themselves, and 706, 000 people showed up emergency rooms with self-inflicted injuries—excluding single car crashes and drug overdoses.  That many people were born with defective genes that cause them to try suicide?

The faulty gene and biochemistry story has also given rise to the massive marketing of psychotropic medications in the U.S. No other rich country has this influence. The massive marketing supports the notion that these problems are genetic and biochemical, immune from the scientific forces of prevention using a pubic-heath model. Instead of marketing medications, rich European countries, Canada, Australia and New Zealand have been far more likely to invest dollars into population-level approaches to averting, preventing or reducing mental emotional and behavioral disorders. Interestingly, those other countries have lower morbidity from mental, emotional, and behavioral disorders—reported in another recent IOM report [43]. It’s more probably that the prevention and practices lowered the prevalence rates, than the citizens of those countries have better genes.

All of the above has oddly stilled any public outcry for preventive action, unlike the constant drum by the March of Dimes and media to find a way to prevent polio 60 years ago. Thus, I’m asking the people and organizations like Children’s Mental Health Network, Mental Health America, and the Federation of Families for Children’s Mental Health to help foster a true, national public-health approach to prevent mental, emotional, and behavioral disorders. We’ve got pretty damn fine science to do it. So ask your elected representatives—from a federal to local level if they will step up and support the equivalent of the 1950s campaign that ended polio. I’ll bet virtually every elected official in America has young family members who’ve been harmed by the present, preventable epidemic.

What can be next steps to kick off a movement to begin protecting all our kids from the scourge of lifetime mental, emotional and behavioral disorders? Here you go:

And one other thing, write a check or whip out your credit card to support the Children’s Mental Health Network that published this. It’s the only web presence that makes this kind of action possible. I just gave them a $1,000.00. Together, we can save all our kids.

PS. Of course we won’t be able to avert every case, but it will be a way better world…#saveallkids

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enbry

Dennis Embry, President/Senior Scientist at PAXIS Institute – Dennis D. Embry is a prominent prevention scientist in the United States and Canada, trained as clinician and developmental and child psychologist. He is president/senior scientist at PAXIS Institute in Tucson and co-investigator at Johns Hopkins University and the Manitoba Centre for Health Policy. His work and that of colleaguesiscited in 2009 the Institute of Medicine Report on The Prevention of Mental, Emotional, and Behavioral Disorders Among Young People. Clinically his work has focused on children and adults with serious mental illnesses. He was responsible for drafting of the letter signed by  23 scientists, who collectively represent scores of randomized prevention trials of mental illnesses published in leading scientific journals. In March 2014, his work and the work of several signatories was featured in a Prime-TV special on the Canadian Broadcast Corporation on the prevention of mental illnesses among children—which have become epidemic in North America. Dr. Embry serves on the Children's Mental Health Network Advisory Council.  

References Cited

1. Amminger GP, Schafer MR, Papageorgiou K, Klier CM, Cotton SM, Harrigan SM, Mackinnon A, McGorry PD, Berger GE: Long-Chain {omega}-3 Fatty Acids for Indicated Prevention of Psychotic Disorders: A Randomized, Placebo-Controlled Trial. Arch Gen Psychiatry 2010, 67(2):146-154.
2. Blasbalg TL, Hibbeln JR, Ramsden CE, Majchrzak SF, Rawlings RR: Changes in consumption of omega-3 and omega-6 fatty acids in the United States during the 20th century. Am J Clin Nutr 2011, 93(5):950-962.
3. Lewis MD, Hibbeln JR, Johnson JE, Lin YH, Hyun DY, Loewke JD: Suicide deaths of active-duty US military and omega-3 fatty-acid status: a case-control comparison. J Clin Psychiatry 2011, 72(12):1585-1590.
4. Freeman MP, Hibbeln JR, Silver M, Hirschberg AM, Wang B, Yule AM, Petrillo LF, Pascuillo E, Economou NI, Joffe H et al: Omega-3 fatty acids for major depressive disorder associated with the menopausal transition: a preliminary open trial. Menopause 2011, 18(3):279-284.
5. Sublette ME, Hibbeln JR, Galfalvy H, Oquendo MA, Mann JJ: Omega-3 polyunsaturated essential fatty acid status as a predictor of future suicide risk. American Journal of Psychiatry 2006, 163(6):1100-1102.
6. Hibbeln JR, Nieminen LR, Blasbalg TL, Riggs JA, Lands WE: Healthy intakes of n-3 and n-6 fatty acids: estimations considering worldwide diversity. American Journal of Clinical Nutrition 2006, 83(6 Suppl):1483S-1493S.
7. Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR: Population-based prevention of child maltreatment:  The U.S. Triple P System Population Trial. Prevention Science 2009, 10(March):1-13.
8. Sanders M, Calam R, Durand M, Liversidge T, Carmont SA: Does self-directed and web-based support for parents enhance the effects of viewing a reality television series based on the Triple P-Positive Parenting Programme?J Child Psychol Psychiatry 2008, 49(9):924-932.
9. Sanders MR, Turner KMT: The role of the media and primary care in the dissemination of evidence-based parenting and family support interventions.Behavior Therapist 2002, 25(9):156-166.
10. Sanders MR, Montgomery DT, Brechman-Toussaint ML: The mass media and the prevention of child behavior problems: The evaluation of a television series to promote positive outcome for parents and their children.Journal of Child Psychology & Psychiatry 2000, 41(7):939-948.
11. Anda RF, Brown DW, Felitti VJ, Bremner JD, Dube SR, Giles WH: Adverse childhood experiences and prescribed psychotropic medications in adults. Am J Prev Med 2007, 32(5):389-394.
12. Anda RF, Brown DW, Felitti VJ, Dube SR, Giles WH: Adverse childhood experiences and prescription drug use in a cohort study of adult HMO patients. BMC public health 2008, 8:198.
13. Anda RF, Felitti VJ, Bremner JD, Walker JD, Whitfield C, Perry BD, Dube SR, Giles WH: The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. European archives of psychiatry and clinical neuroscience 2006, 256(3):174-186.
14. Wilcox HC, Kellam S, Brown CH, Poduska J, Ialongo N, Wang W, Anthony J: The impact of two universal randomized first- and second-grade classroom interventions on young adult suicide ideation and attempts. Drug & Alcohol Dependence 2008(Special Issue):14.
15. Kellam S, Brown CH, Poduska J, Ialongo N, Wang W, Toyinbo P, Petras H, Ford C, Windham A, Wilcox HC: Effects of a universal classroom behavior management program in first and second grades on young adult behavioral, psychiatric, and social outcomes,. Drug & Alcohol Dependence 2008(Special Issue):24.
16. Furr-Holden CD, Ialongo NS, Anthony JC, Petras H, Kellam SG: Developmentally inspired drug prevention: middle school outcomes in a school-based randomized prevention trial. Drug & Alcohol Dependence 2004, 73(2):149-158.
17. Bradshaw CP, Zmuda JH, Kellam S, Ialongo N: Longitudinal Impact of Two Universal Preventive Interventions in First Grade on Educational Outcomes in High School. Journal of Educational Psychology 2009, 101(4):926-937.
18. Aos S, Lee S, Drake E, Pennucci A, Klima T, Miller M, Anderson L, Mayfield J, Burley M: Good Behavior Game, Return on Investment: Evidence-Based Options to Improve Statewide Outcomes. In. Olympia, WA: Washington State Institute for Public Policy; 2013: 8.
19. Wilson DS, Hayes SC, Biglan A, Embry DD: Evolving the Future: Toward a Science of Intentional Change. Brain and Behavioral Sciences 2014, 37(4):395-416.
20. Embry DD: The Good Behavior Game: A Best Practice Candidate as a Universal Behavioral Vaccine.Clinical Child & Family Psychology Review 2002, 5(4):273-297.
21. Embry DD: Behavioral Vaccines and Evidence-Based Kernels: Nonpharmaceutical Approaches for the Prevention of Mental, Emotional, and Behavioral Disorders. Psychiatric Clinics of North America 2011, 34(March):1-34.
22. Musci RJ, Bradshaw CP, Maher B, Uhl GR, Kellam SG, Ialongo NS: Reducing aggression and impulsivity through school-based prevention programs: A gene by intervention interaction. Prevention Science 2013:No Pagination Specified.
23. Biglan A, Flay BR, Embry DD, Sandler IN: The critical role of nurturing environments for promoting human well-being. American Psychologist 2012, 67(4):257-271.
24. Belsky J, Beaver KM: Cumulative-genetic plasticity, parenting and adolescent self-regulation. Journal of child psychology and psychiatry, and allied disciplines 2011, 52(5):619-626.
25. Gervai J: Environmental and genetic influences on early attachment. Child and adolescent psychiatry and mental health 2009, 3(1):25.
26. Golding J, Gregory S, Iles-Caven Y, Lingam R, Davis JM, Emmett P, Steer CD, Hibbeln JR: Parental, prenatal, and neonatal associations with ball skills at age 8 using an exposome approach. Journal of child neurology 2014, 29(10):1390-1398.
27. Leen-Feldner EW, Feldner MT, Knapp A, Bunaciu L, Blumenthal H, Amstadter AB: Offspring psychological and biological correlates of parental posttraumatic stress: review of the literature and research agenda. Clinical psychology review 2013, 33(8):1106-1133.
28. Rutten BP, Mill J: Epigenetic mediation of environmental influences in major psychotic disorders. Schizophrenia bulletin 2009, 35(6):1045-1056.
29. Jonsson AJ, Birgisdottir H, Sigurdsson E: [Does the use of cannabis increase the risk for psychosis and the development of schizophrenia?]. Laeknabladid 2014, 100(9):443-451.
30. Le Bec PY, Fatseas M, Denis C, Lavie E, Auriacombe M: [Cannabis and psychosis: search of a causal link through a critical and systematic review]. L'Encephale 2009, 35(4):377-385.
31. Hippius H, Ruther E: [Sleep problems and their treatment in psychosis (author's transl)]. Wiener klinische Wochenschrift Supplementum 1979, 106:6-10.
32. Kahn-Greene ET, Killgore DB, Kamimori GH, Balkin TJ, Killgore WD: The effects of sleep deprivation on symptoms of psychopathology in healthy adults. Sleep medicine 2007, 8(3):215-221.
33. Petrovsky N, Ettinger U, Hill A, Frenzel L, Meyhofer I, Wagner M, Backhaus J, Kumari V: Sleep deprivation disrupts prepulse inhibition and induces psychosis-like symptoms in healthy humans. The Journal of neuroscience : the official journal of the Society for Neuroscience 2014, 34(27):9134-9140.
34. Wright JB: Mania following sleep deprivation. The British journal of psychiatry : the journal of mental science 1993, 163:679-680.
35. Mednick SC, Christakis NA, Fowler JH: The spread of sleep loss influences drug use in adolescent social networks. PloS one 2010, 5(3):e9775.
36. Salk JE, Bazeley PL, Bennett BL, Krech U, Lewis LJ, Ward EN, Youngner JS: Studies in human subjects on active immunization against poliomyelitis. II. A practical means for inducing and maintaining antibody formation. American journal of public health and the nation's health 1954, 44(8):994-1009.
37. Francis T, Jr., Korns RF, Voight RB, Boisen M, Hemphill FM, Napier JA, Tolchinsky E: An evaluation of the 1954 poliomyelitis vaccine trials. American journal of public health and the nation's health 1955, 45(5 Pt 2):1-63.
38. O'Connell ME, Boat T, Warner KE (eds.): Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington, DC: Institute of Medicine; National Research Council; 2009.
39. Merikangas KR, He JP, Brody D, Fisher PW, Bourdon K, Koretz DS: Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES. Pediatrics 2010, 125(1):75-81.
40. Merikangas KR, He JP, Burstein M, Swendsen J, Avenevoli S, Case B, Georgiades K, Heaton L, Swanson S, Olfson M: Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 2011, 50(1):32-45.
41. Mathews AW: So Young and So Many Pills: More than 25% of Kids and Teens in the U.S. Take Prescriptions on a Regular Basis. In: Wall Street Journal. New York: The News Corporation; 2010.
42. Twenge JM, Gentile B, DeWall CN, Ma D, Lacefield K, Schurtz DR: Birth cohort increases in psychopathology among young Americans, 1938-2007: A cross-temporal meta-analysis of the MMPI. Clin Psychol Rev 2010, 30(2):145-154.
43. Woolf SH, Aron L: U.S. Health in International Perspective: Shorter Lives, Poorer Health. In: Board on Population Health and Public Health Practice, Division of Behavioral and Social Sciences and Education. Edited by Martinez RM. Washington, DC: The National Research Council and Institute of Medicine; 2013.

Comments

  1. Dennis Embry's avatar
    Dennis Embry
    | Permalink
    Thanks Captain Jack for the info and kudos. The consensus statement by a special panel of the American Psychiatric Association (See http://www.ncbi.nlm.nih.gov/pubmed/17194275) is that folks with a DSM-IV diagnoses need at least 2 full grams of EPA/DHA, with EPA being equal to or more than DHA for mental health benefits. Again, I wish to make it clear that neither I nor PAXIS Institute receive funding from any vendor or association involved with the manufacture or sales of any omega-3 product. I am reporting this as a measure of good science.
  2. Captain Jack's avatar
    Captain Jack
    | Permalink
    Ignore the recommended dose on the bottle: "one pill a day." N3=EPA DHA, not the amount of fish oil. Most fish oil only has 300 mg of N3 in a 1000mg pill. Children need >1000mg a day so 3 to 4 low quality pills. Double that for adults. High quality oil with say 900 mg of EPA DHA would be one or two or three pills depending on your weight. And don't buy combination Omega 3-6-9. It is the Omega 6 overload we get from things like high fructose corn oil that is actually causing many problems. Thank you Dr. Embry, I read your links.
  3. Richard Seitz's avatar
    Richard Seitz
    | Permalink
    I have read the research Dr. Embry cites and have seen schools with the Pax Good Behavior Game being used and can affirm the tremendous changes even in the first year of use. Schools see an immediate decrease in students being sent to the principal's office for discipline.
  4. Dennis Embry's avatar
    Dennis Embry
    | Permalink
    Dear Anne, this is a great question. Sorry I didn't see this earlier. There is no auto prompt that someone has posted. I saw this yesterday. In general, the answer is that n3 after diagnoses for mental illness is helpful. It value can come from reducing selected symptoms and improving health. There is still a lot of research going on about this. I've give you (and others) a hyperlink for the National Library of Medicine (searching omega-3 AND psychiatric). http://www.ncbi.nlm.nih.gov/pubmed/?term=omega 3 AND psychiatric

    There are other searches you can do to pinpoint concerns.

    One of the things that is clearly beneficial is that n3 helps improve the overall health of patients taking psychiatric medications that have a variety of adverse effects. Hope this helps. One thing n3 is increasingly show to affect is: aggression, suicidality and PTSD.
  5. Anne's avatar
    Anne
    | Permalink
    Is there any proof that Omega-3's could help after a diagnosis? My brother was diagnosed with Paranoid Schizophrenia two years ago. Do Omega-3's help after the full blown psychosis has taken place?
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