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February 22, 2016

The new debate over mental health treatment

Daily Briefing

    New advances in neurology and imaging are challenging traditional approaches in psychiatry, a field that has long emphasized treating symptoms over finding biological causes, Amy Ellis Nutt reports for the Washington Post.

    Looking for answers

    Scientists know there is a relationship between biological processes in the brain and certain mental health issues, but there are still striking gaps in knowledge. For instance, selective serotonin reuptake inhibitors are one of the most popular treatments for depression, and they work by boosting levels of serotonin. "But it's not known whether that corrects an imbalance [in the brain]," Nutt writes, "because there's no way to directly measure a person's neurochemical levels."

    Such limitations are one reason psychiatry has historically focused on treating symptoms rather than discovering underlying biological causes. For instance, the Diagnostic and Statistical Manual of Mental Disorders (DSM) categorizes various mental health issues based almost entirely on symptoms reported by clinicians and patients.

    But critics have increasingly made the case in recent years that a symptoms-based approach is flawed. "Cancer treatment doesn't treat the symptoms of cancer," notes Kenneth Kaitin, director of the Tufts University Center for the Study of Drug Development. "But that's what we're doing in psychiatry."

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    A new approach

    The year 2013 marked a major shift in approach, when Thomas Insel, then director of the National Institute of Mental Health, announced that federal funding would no longer support research based solely on the DSM. Instead, the government would focus on research guided by the principle that "mental disorders are biological disorders involving brain circuits," Insel said.

    The idea, experts say, is to use advanced imaging and other techniques to search for so-called biomarkers of mental illnesses. For instance, researchers in the field of optogenetics modify cells to be sensitive to light—a method that has been used in mice to study the biological basis of aggression. Optogenetics is too intrusive for human use, but some researchers are employing magnets and nanotechnology to study the effects of turning cells on and off in humans.

    In addition, some clinicians are looking to electrical activity in the brain for clues on treating patients.

    Psychiatrist Hasan Asif uses a quantitative electroencephalogram (qEEG) to monitor patients' brain activity. The qEEG compares patients' electric activity with "a digital database of hundreds of EEGs of healthy subjects," Nutt reports.

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    Asif says his approach helps him get a granular understanding how his patients' brains are affecting their mental states. "The brain is almost screaming out loud: 'Read me! I'm showing you everything!'" he says. Asif uses that information to inform traditional treatments like psychotherapy and medication.

    He also uses the data to improve less traditional treatments, such as:

    • Neurofeedback, which is designed to train patients to modify their brain activity and, when used with real-time brain imaging in a Yale study, was found to significantly reduce depression and anxiety; and
    • Transcranial magnetic stimulation, a method of directly stimulating certain parts of the brain that has been approved by FDA to treat depression.

    Is it overhyped?

    But some critics still worry that such approaches—and the broader shift toward treating the biological basis of mental health issues—are ill-advised. Allen Frances, a professor emeritus at the Duke University School of Medicine, says the search for biomarkers is overhyped. "There's been an intense search for biomarkers for the last 40 years," he notes, "and so far we've come up empty."

    Even Insel, who announced the federal shift away from funding DSM-based research, cautions that biological models of psychiatric treatment have a long way to go. "Rigorous studies are required to establish evidence" for biological tests of mental health issues, he explains.

    And Richard Shulman, a clinical psychologist and one of the founders of a not-for-profit that provides traditional talk therapy, warns that the biological approach can distract clinicians from identifying what really afflicts their patients. "You look at things through [a patient's] eyes and say, yes, this person has gone through the wringer," he explains (Nutt, Washington Post, 2/19).

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