Psychological Implications of the Connecticut School Shooting

A lone gunman killed 20 children and 6 adults including himself at a Connecticut) School He used guns registered to his mother. The emergence of ASD and PTSD Acute Stress Disorder and/ Post Traumatic Stress Disorder) were identified as happening after a major incident such as this one. The symptoms that can be present in this situation were reviewed as well as some possible long term effects. The grieving process was also discussed. In the aftermath of such situations, attention is often focused on people with mental illness who might have the potential do do violence and/or commit a copycat crime even though in retrospect this is very small proportion of the population.The gun control issue and related psychological factors were also discussed.

I am writing this blog one day after the horrific massacre at a school in Newtown, Connecticut. Thus far it is known that a 24 year old man shot and killed his mother and then took three weapons including automatic assault rifle, dressed in combat gear and  appeared at the school where his mother taught. He was recognized as the son of a teacher and was buzzed in. He then killed 4 adults including the principle who had recently  instigated stricter security measures at the school and 20 students between the ages of 6 and 10 as well as himself. There was one report that he had some kind of argument at the school the day before the shooting. There are also descriptions that he was a troubled kid in school who had no friends and was very shy. He was said to be very bright in math. It was suggested that  he may have had Asperger’s Syndrome and was on the Autism Spectrum. Another report said that he spoke of demons and therefore suggesting he may have been paranoid with schizophrenia. His parents were divorced after 17 years of marriage and his mother was reported as very protective. He has a brother at college.

I have no idea of his diagnosis and would not make any attempt to speculate on on the nature of his mental condition.

Psychological Trauma 

Common wisdom and research in this area tell us  that the closer a person is to the traumatic event,  the more likely and the more severe the psychological trauma will be. This however is a complicated issue. Certainly the adults and children who witnessed the shooting (including of course anyone wounded ) would be directly effected.  This would include anyone in the school  who heard sounds and participated in the terror of hiding and escaping from danger.

The two conditions that will emerge from such an incident  are  Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder(PTSD) . According to the Diagnostic Manual of the American Psychiatric Association (DSM IV), the necessary requirement for both of these conditions must include the following :

The person has been exposed to a traumatic event in which both of the following were present.

1-The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others.

2- The person’s response involved intense fear, helplessness, or horror (in children, this may be expressed instead by disorganized or agitated behavior.)

In addition for us to make a diagnosis of ASD there needs to be three or more  symptoms such as  numbing, detachment, absence of emotional responsiveness or reduction in awareness of his or her surroundings (being in a daze) or derealization ( things don’t seem real) or depersonalization ( you don’t feel like yourself) , a tendency to re-experience the event by flashbacks, an avoidance phenomena related to recollection of the traumatic event, impairment of social and other areas of functioning, increased  anxiety and arousal with sleep and concentration problems and a duration of these symptoms  2 to 4 weeks.

In order for us to make diagnosis of PTSD  there needs to be similar symptoms as ASD with one or more symptoms of recurrent and intrusive recollections (manifested in young children by repetitive play), recurrent dreams, re-experiencing the traumatic event with illusions , hallucinations and flashbacks , physiological reactions, , persistent avoidance of stimuli associated with the trauma, numbing , efforts to avoid thoughts and feelings related to trauma, decreased interest or estrangement, inability to have loving feelings, insomnia, outbursts of anger , exaggerated startle response  impairment in social functions, with a t least one of these symptoms lasting more than one month.

For more detailed and exact definitions see the DSM IV (or the new DSM V which may be somewhat revised )

Trauma Not Limited to Immediate Geographic  Area

The development of these symptoms is not limited to people in the immediate vicinity.

Classmates who didn’t attend school that day can have symptoms as can people all over the world who are traumatized by accounts in the media which vividly reconstruct the events and allow others to identify with the victims. There will be very few school age children in the U.S. who will not have heard about the details of this event

I recall at the time of the Challenger disaster, we saw school children all over the country effected by seeing this spacecraft carrying the astronauts and some teachers disintegrate before their eyes on television . Similar situations have happened in other tragedies, which are covered, on TV.

Long Term Effects

It should be recognized that the acute and  long term psychological  effects of this trauma  goes beyond the two disorders described above The experience also  becomes woven in the psychological makeup of people who are impacted by it whether near or far where it happened . For some, the innocence of childhood is taken away . The sense of security is changed forever. Long after the acute symptoms are gone, the effects of this event will have changed the individuals who experienced it. In some cases it will be a determining factor in how they will mold their future lives. Perhaps they will always be a cautious person, looking for unexpected danger. In other ways, the trauma can motivate persons to become doctors, nurses, police, researchers or influence the way they view their own lives for better or worse.

The Need for Immediate Psychological Intervention;

There has immediately been an outpouring of offers of psychological help.

I am sure the school system ,local and state agencies  will bring in counselors and therapists. Local mental health professionals  will ofter their help. I know the Committee on Disasters of the American Psychiatric Association ( of which I have been a member ) has offered the local Psychiatric Society materials and information that can be useful . There has been offers from International Groups that have experience  with these situations as well as from the Red Cross and from the nearby Yale Child Study Group. There will be individual and group meeting with the teachers and counselors as well with parents and of course with the children. The teachers will be trained how to be sensitive to the reactions of the children. It is important that all involved be aware of the various symptoms that can develop after events like this (some of which were described above) Danger signals need to be picked up. I am sure a wide variety of techniques will be used for one to one therapy  as well as in groups. Talking in groups can be useful for many but for others individual sessions can be very helpful  or a combination can  be used. For some of the children, the comfort of discussions and interactions with their parents will be  most important. Some parents will know how to handle this, other parents will benefit by discussion or counseling. I don’t believe there is one method which needs to be applied. The techniques used in individual and group treatment can cover a wide range from catharsis which involves expressing  one’s experience and feelings, Cognitive Behaviors Therapy ( CBT) which uses correcting misconceptions  and directly dealing with ideas and behavior and  psychodynamic therapy  where underlying meaning is explored and interpreted. In some acute situations medication (anti-anxiety or other stronger tranquilizers  can be used and when conditions  such as major depression is identified, antidepressants may be prescribed.  Other techniques and combinations of approaches will be used especially the human support and caring offered by people near and far and by such groups as the Red Cross which will be quite useful and meaningful.

Grieving the Loss of Life.

As most of us know grieving is a very intense process. Kubler-Ross described five stages of grief ; denial,, bargaining , anger , depression and acceptance. However, when there is unexpected death, traumatic death especially by murder and death of children, the grief takes on a different pattern which has been labeled Complicated Grief. We can expect the anger and depression to be greatly intensified and the duration of the intense emotions to be much more prolonged especially when there is the loss of a young child. Ultimately various types of memorials to the lost child which can give significances to the lost out life can be helpful

Concern About Other Disturbed Individuals Including Copycat Incidents

It is only natural that there will be concern on all levels that disturbed individuals who might do anything like this incident should be identified , receive help and be safely  in a place where they can not harm anyone. This problem is accentuated at the time of such an incident and in the immediate aftermath since we know that sometimes in the mind of a severely mentally disturbed person, media reports of this event have  the possibility of precipitating a copycat pattern of behavior in another disturbed person. The presence of mental illness is usually identified by family , friends and teachers at an relative early point in life. While there has been great progress in providing mental health care in the United States since the 1960s , there are still people who do not get the care that they need because of finances and the unavailability of services. Quality health care should be available to everyone and this includes those with mental illness.

The Overwhelming Majority of People with Mental Illness are Not Dangerous

Only a very small percentage of people with mental illness are a serious danger to other people. An incident such as this school shooting invariably unfairly intensifies the stigma towards people with mental illness. This can hinder recovery and adaptation to this condition. We need continued research in identifying people who could be dangerous and we also need to understand and educate the public about mental illness.

The Gun Control Issue and The Psychological Implications.

We don’t yet know the history and the story why the Connecticut shooter’s mother   had registered guns in the house. I would guess that most probably if there were not these guns in the house ( which included automatic weapons ) that untold psychological trauma would not have occurred. The young man may have done something terrible but if guns were not available to him, the   chances are,  not as many people would have been killed.

I also wonder about the psychological effect of his growing up in a household where such guns were owned , kept and valued. I understand the argument that most gun owners may teach their children about gun safety. However when there are guns present, there may very well be the underlying message to a disturbed child, that when you are angry this is the way that you can act.

 

One in Five American Suffer From Mental Disorders

Everyone has occasional feelings of anger, frustration sadness, fear of inadequacy and worries about the future. Often just talking about such feelings with friends or loved ones is enough to get you through a difficult period. But sometimes the problems don’t go away, resulting in sleep problems and added difficulty in working or socializing.  Anyone can develop an emotional problem. At any given time between 30 million and 45 million Americans-nearly one in five- have a mental disorder that can involve a degree of incapacity, interfering with employment, attendance at school or daily activities. There is a very strong likelihood that  mental problems  have touched  you or your love one in a very personal way.  Consider the following:

8-14 million Americans suffer from depression each year. As many as two out of ten Americans will have at least one episode of major depression during their life times.

20% of ailments for which Americans seek a doctor’s care are related to anxiety disorders such as panic attack, that interfere with their ability to live normal lives.

About 12-15  million children under the age of 18 suffer from mental disorders such as autism, depression and hyperactivity.

In all 1.5 million Americans suffer from schizophrenia disorders and 300,000 new cases occur each year

13 million Americans suffer from alcohol abuse or dependency and another 12.6 million suffer form drug abuse or dependence.

It is substantially worse when a person is suffering a drug addiction combined with a mental disorder, a medical condition described as a dual diagnosis.

Nearly 1/4 of the elderly who are labeled senile actually suffer some form of mental illness that can be effectively  treated.

The cost of work related mental health problems to businesses is very high. Almost 3  billion dollars and an estimated 50 million working days are lost each year.

What are implications of these and other similar statistics to your life? What are implications to our health care system? What is the meaning to the mental health professions?

 

Nazi Extermination of Mental Illness

IIn 1922 Alfred Hoche a German psychiatrist co-authored a document demanding the extermination of persons he believed were a burden to society. In 1933 Adolph Hitler followed up on this by introducing obligatory sterilization of people with diseases he believed to be inheritable including mental retardation, schizophrenia, affective psychosis, and alcoholism. In July 1939 a plan was developed with the assistance of leading psychiatrists for the extermination of this group of people. Torrey and Yolken in their analysis of the literature believe that the entire population of people with schizophrenia (between 220,000 and 295,000 people) living in Germany at the time were either sterilized or killed. After the invasion of Poland the systematic murders of patients in various psychiatric hospitals were carried out. There are reports of only two psychiatrists who chose to stay with their patients and both perished. This plan to eliminate schizophrenia did not succeed probably because it is not entirely a genetic disease. We should never forget those whose lives were taken during this time and how and why they they were killed.

Year End Reflection on Those Taken From Us

There are certain times of the year such as religious holidays, anniversaries and the New Year where I find myself reflecting on those people who are no longer with us. As we come to a new year and the end of the first decade of the 21st century that is one of those times. As a son, I think about my parents which leads me to remember other relatives and dear friends who have died and whom I miss. As a Jew I think of the Holocaust and the extermination of millions of people who were murdered because they were  born Jewish. I know history is filled with other similar events which have occurred even in the recent past and may approach the evil nature and magnitude of Hitler’s work.

E. Torrey Fuller
E. Torrey Fuller

People with Schizophrenia Also Targeted by Hitler

As as a psychiatrist,  I also find myself  reflecting at these times on the systematic murder by the Nazi’s  of people because they had a mental illness! This addition to my personal memorial list is relatively new to me since I only recently became aware of the details of Hitler’s systematic singling out mental disease,  especially schizophrenia due to recent writing of E. Fuller Torrey, Robert Yolken and others. Yes,  I had  known how the Nazi’s in their attempt at racial purity were targeting other groups in addition to the Jews but I did not appreciate how people with Schizophrenia were being especially chosen. I was originally alerted to this piece of history by an article in Psychiatric News by Mark Moran in November of this year which also referred to an article by Torrey and Yolken in the September 2009 issue of the Schizophrenic Bulletin

Psychiatrist May Have Given  Birth to this Plan

Alfred Hoche
Alfred Hoche

Some further review turned up  additional information which suggested that Hitler’s thought process on this may have had it’s roots in events that occurred in 1922. At this time the psychiatrist Alfred Hoche and the lawyer, Karl Binding, published a document titled “Extermination of Life Unworthy Creatures” , using that ominous term for the first time and demanding extermination of persons who constituted “a burden” to the society, ravaged by World War I. They argued, in this document, that excessive humanitarian ideas be abandoned in the interest of what they called  “the higher state morality” implying that the existence of an individual is worthless if unfitting to the interest of society.  Shortly after Adolf Hitler took power in 1933, an act was passed, translated as Act on Preventing an Inheritable Burdened Progeny” The act introduced the obligatory sterilization of persons suffering from inheritable diseases, including, among others, mental retardation, schizophrenia, affective psychoses, epilepsy, and alcoholism. Implementation of the act, associated with the sterilization of approximately 350,000 persons in Germany, induced a wide discussion during which only the Catholic Church expressed a negative attitude toward the act.

Physicians Including Psychiatrists Participate in Extermination Plan

The next stage was the elimination of these people as well as the Jews. The approach to the Jews is well documented. However how Hitler utilized physicians including psychiatrists to approach the eliminations of psychiatric patients was not as well understood at least by myself. In July of 1939, an agreement between Hitler, the Reich Chancellory head, Lammers and the leader of the Reich’s physicians, Dr. Leonardo Conti, resulted in the formation of a strictly secret commission for the extermination of patients, directed by Philip BouhIer and called T4 (according to its official address at Tiergartenstrasse 4, in Berlin). The commission included, among others, recognized professors of psychiatry and neurology: Carl Schneider from Heidelberg, Paul Nitsche from Halle, Werner Heyde from Wurzburg. The commission was to choose methods of extermination (at the beginning carbon monoxide was used) and provide opinions on the lists of patients submitted for extermination by psychiatric hospitals, using official questionnaires. This occurred two months before the invasion of Poland. Apparently gold fillings were removied from the teeth of the deceased and used to partially pay for this program. Torrey and Yolken in their analysis of the data estimate that between 220,000 and 295,000 people with schizophrenia were either sterilized or killed which according to them represented all of those people with schizophrenia living in Germany at the time.

Extermination Plan Continued After the Invasion of Poland

After attacking Poland in September, 1939, the Germans began in the very same month a systematic murder of patients in Polish psychiatric hospitals that were situated in the captured parts of the country. The action of murdering these patients  took a similar course in all psychiatric hospitals.HItler The schedule was typical of Nazi mass crimes, followed a specific plan, and was performed scrupulously. After taking control of a hospital under a German director, no patient could be released from the hospital under threat of the death penalty. All the patients were counted and transported out in lorries to an unknown destination. Each transport was accompanied by armed soldiers from special SS detachments, who returned without the patients after a few hours. The patients were said to be transferred to another hospital, but circumstances showed that they had been killed.

In October, 1939, approximately 1,000 patients (children and adults) of the psychiatric hospital in Owinska, near Poznan, began to be transported out in an unknown direction. At the same time, a chapel and a rich, 100-year old medical library were destroyed. The hospital was turned into SS barracks and burned at the end of war. Extermination of patients from the hospital in Owinska requires special attention since on that occasion for the first time new methods for the mass killing of people were implemented. Investigations conducted after the war by the Commission for Examination of Nazi Crimes demonstrated that the special Gestapo unit  took care of the patient evacuation. The patients, dressed only in worn clothes, were transported out in lorries, each lorry accommodating 25 patients and some armed SS men. Distressed and protesting patients were quieted with injections of narcotics. According to witnesses, the lorries drove first toward Poznan where the patients were crowded into an old fort.  Each of the bunkers accommodated approximately 50 persons. The gates were sealed up with clay, and carbon monoxide was fed into each bunker, killing the patients within 10-20 minutes. Corpses of the murdered patients were dragged out by a group of prisoners of the fort, and other prisoners transported them and buried them in a forest close to Oborniki.

On December 7, 1939, approximately 1,200 patients were transported out of the neighboring psychiatric hospital in Dziekanka, near Gniezno. Selection of the patients for the transport was made personally by the hospital director, Ratka, who had just changed his citizenship to German and put on an SA uniform. Later on, the hospital kept providing psychiatric services for patients of German nationality and also served other, peculiar aims. On orders from Berlin, the hospital was disguised to represent a place of burial of the exterminated patients even if most of them had never visited the hospital. Families of the patients were falsely informed that the patients being searched for were buried at the hospital cemetery, and the families were even charged for the care for these graves. After the war, it was found that the psychiatric hospital in Pruszkow near Warsaw played a similar role. Families of the murdered patients were referred to the hospital and told that their relatives had been brought to the hospital, but died natural causes.

The sanatorium in Koscian for neurological and psychiatric patients lost approximately, 500 patients who were murdered and the institution then appropriated for other purposes. Patients in psychiatric hospitals in Warta (approximately 580 patients), Gostynin (approximately 100 patients), and Choroszcz (564 patients) were shot in the neighboring forests while patients of Kochanowka hospital (approximately 540 patients), Nazi loading on trainnear Lodz were killed in the sealed lorries using engine exhaust. In the psychiatric hospital of Lubliniec, 194 children were killed with high doses of luminal. The existence of the psychiatric hospital in Kobierzyn, near Cracow ended on June 23, 1942. The hospital was surrounded by soldiers in helmets and SS uniforms, the patients were loaded into lorries and cattle trucks, and the patients were transported to Auschwitz to gas chambers. Severely ill patients were transported to the hospital cemetery and shot there. A total of 566 patients died in that action.

The above data that originated from individual hospitals do not unfor­tunately create a complete image of the extermination of patients. It is difficult to estimate, e.g., how many of the psychiatric patients in the hospitals died due to drastically lowered food rations. Systematic starvation increased the mortality of patients several fold. It should be mentioned that this statistic does not pertain to patients of German origin who were fed better. The numbers of known victims also fail to include crimes which have not been documented. At the end of the war, the Nazi authorities destroyed evidence of their own crimes, as they pulled back from the captured territories. In most cases, extermination of patients was executed with no preliminary formalities (in the Reich it was preceded by filling in of questionnaires) and unexpectedly. The data quoted above originated from hospital registers that escaped destruction or from secretly prepared lists of those patients who were transported out of the hospitals.

Most Psychiatrists Don’t Protest but Two Psychiatrists Chose to Stay with Their Patients

I apologize for somewhat wordy unpleasant detail of this blog but I felt the story had to retold. My source for much of the above detail which I have shortened comes from the previously mentioned reference  Project Inposterum.

Torrey made the  point of emphasizing how while psychiatrists played a leading role in these horrendous events, he is not aware of any protests against the policy from organized German psychiatry. He notes “if you wanted a bright future in Nazi Germany you would not be enhancing your prospects by saying “we shouldn’t be doing this.” However the above link  gives two instances in Poland where psychiatrists chose the path of staying with their patients. Dr. Józef Bednarz, (see date of 1932 in this link ) Director of the Psychiatric Hospital  in Swiecie in Wisla, who rejected the chance to escape, did not want to leave his patients, and was shot with them in November of 1939.

Grave of Dr. Halina Jankowska
Grave of Dr. Halina Jankowska

Dr. Halina Jankowska, the eminent psychiatrist, and her nurses on  August 23, 1944, during the Warsaw Uprising rejected the chance to leave their patients in the Hospital of Saint John of God and died with them in the ruins of the bombed hospital

How Did This  Extermination Effect the Future of Schizophrenia ?

Torrey and Yolken also make the point that the Nazi reasoning  for killing patients with schizophrenia was also founded on an erroneous notion that the disease was entirely genetic. In fact the number of existing cases or the prevalence of the disease after the war was low as expected, because of the killings.  However the incidence or number of new cases was high suggesting that factors other than genes played an important role in schizophrenia. Studies have  found that the incidence rate in Germany 20 years after the last patient was sterilized or killed were 2 to 3 times the rates in the US and England . It was postulated that the most likely explanation is that social conditions after the war produced environmental factor such as famine, illnesses  and poverty which led to an increase in new cases of schizophrenia

Of course what ever we can glean from the results of this horrible “experiment “ will never provide any justification for what was done. I do that believe that we are obligated to use  any data that emerges from this event to better help people in the future just as we can use the data from other unspeakable Nazi experiments on helpless victims  to make people’s lives better in the future. In doing so we need to never  forget those whose lives were taken including  why  and how they were killed.

May This Be A Good Year for All of You

While I chose to write the last blog of the year on a somber topic, I do want to also end with an optimistic greeting to all of you.  I appreciate the interest and encouragement that many of you have given me as I have undertaken this weekly blog . I know that there are many people who share my interest and concern about educating the public about all aspects of  mental illness.

I wish everyone of you a most Happy New Year.

Comments Are Always Welcome

The Genome and Psychiatric Care

This blog discusses how the understanding of the human genome and the construction of the human chromosome may be able to influence psychiatric care. Psychiatrists have previously relied on history ( including family history ) with a mental status evaluation to make a diagnosis and develop a treatment plan. Unless the patient had an identical twin with similar symptoms, family history only has a limited value in providing assistance in making the diagnosis or in predicting response to medication. The author originally hoped that this would radically change with the breaking of the genetic code and the human genome project. However thus far the research has limited value in the application to current psychiatric care. There is some promising research in regard to schizophrenia and genetics as well as some recent work concerning bipolar disorder and post partum depression, which is reviewed. The use of biomarkers particularly in brain imaging and the use of the EEG for the prediction of effectiveness for antidepressants are discussed. Several ethical considerations related to this type of research are also raised.

How Understanding the Human Genome Can Influence the

Practice of Psychiatry

The Human Genetic Sequencing Project

In April 2003 the human genetic sequencing project was completed.  This meant that the 25,000 genes  (which are made up of 3 billion chemical bases) in the human DNA were defined and stored in computers. dna_530I am far from being a biochemist and am in no way an expert in this area. In fact I didn’t even understand that it would take another three years until we understood the  construction of the first  human chromosome. However that did not stop me from imagining what the future of psychiatry and all medicine would be like after this great accomplishment.

The Decision Process Before The Genetic Code Was Broken

When a patient comes to me I take a detailed history and do a mental status examination (the psychiatrist equivalent of the physical examination except it is by talking). I inquire about the patient’s family history including medications used by the patient and any medications  used by close family members who have the same illness. I make a diagnosis of the patient’s condition and then I  may suggest psychotherapy or medication or a combination of both.

Let us say that the patient has a major depression and required an antidepressant medication. I would have many choices from which to choice. I would base my decision on the latest research. Job+InterviewI may be influenced in my choice of which medication to use if the patient were highly anxious or had insomnia since some medications are more activating than others and some are more sedating.  I would inquire about the patient’s sexual functioning since many of these medications can have sexual side effects. Some medications might help various types of pain or obsessive symptoms which could  influence my first choice of a medication. I may have to take into account the patient’s financial status in regard to a choice of a less expensive generic medication or if there were a list of medications, which are less expensive in regard to their insurance coverage. All these factors need to be considered  not only with the first choice of medication but very often a medication may be changed or a second one is added and these factors would all be reconsidered.

Very rarely would genetic factors be taken into account in deciding on which medication should be used. (Family history would be helpful in making the diagnosis.) If the patient should be an identical twin with the exact same genetic make up than I would pay exquisite attention in considering a similar diagnosis and choosing the same medication. This occurs only once in every 250 births. If such a person needed a medication I could be pretty sure that their side effects and efficacy probably would be identical or nearly the same as their twin. Of course even identical twins  can have different life experiences  and therefore their total psychological make up and environmental exposure would not be the same. If a sibling, parent or child  had a good or a bad experience with a particular medication that might influence my decision but it would have no where near the significance to me as the situation where  the patient would be an identical twin.

How I Imagined the Decision Process Would Be  After the Genetic Code was Broken

I had this vision which I told my residents and students  how, in the future,  patients would come to doctors and would have a card in their wallet with their entire human genetic makeup encoded . Elecom-Magnetic-Card-ReaderThe physician would put the card  into a device on his or her desk, which would  read it and provide information as to any illnesses for which  the individual had a clear genetic propensity. It would also tell us the exact medications, which would target and cure these illnesses. In fact it would be possible to construct viruses ( which are DNA particles ), which could alter genetic structure and eliminate the diseases or even the propensity for them. Not only would cancer be cured or prevented but also so would the major mental illnesses  I had read about these possibilities in he past and now that the secret of the human genome had been unlocked , I thought that it was just a matter of time before this became a reality.

How Things Now Stand

I am sorry to report that my fantasy has not yet become a reality.  The journals and scientific meetings are filled with various pieces of research that might contribute to the puzzle . There are new companies, which offer saliva or blood tests, which will examine DNA. However,  there are no genetic research  tests, which have substantially changed clinical practice in the past several years.

I would like to give you a sample of some the latest genetic research so you can get a glimpse of where we might be heading with the expansion of our understanding of the genome.

Schizophrenia

Even before the genome was completely mapped there were many connections to various regions of the  chromosomal structure that suggested linkage to schizophrenia.chromsome

More recently the International Schizophrenia Consortium pooled genomic data from various data bases and analyzed 8000 schizophrenic patients and 19,000 healthy controls. They found differences in a region on Chromosome 6 between schizophrenics and the controls. This chromosome area is related to the immune system response to infections and autoimmune diseases.

Bipolar

Research by the same group demonstrated that  there were genetic similarities in the genome of schizophrenic and bipolar patients that were not shared by nonpsychiatric diseases such as coronary artery disease and rheumatoid arthritis which suggests that these genetic variations are specific to psychiatric disturbances.

Post Partum Symptoms

In still another  study, published in the  American Journal of Psychiatry November, 2009,  showed that genetic variation on specific chromosomes may increase the susceptibility to post partum mood symptoms.

The researchers were able to show some  polymorphisms or  variations of Chromosome 1, 2, 9 and 14 which could indicate susceptibility to postpartum  symptoms . There is a wide range of postpartum symptoms as I outlined in a previous blog. It is essential that evaluation of such symptoms  be a part of the pre and post natal care of all women. It may be that the these findings will be helpful in the future for diagnosing and treatment of this condition.

Effectiveness of Antidepressant Medication

There  has been some preliminary research to suggest that people with certain alleles related to the serotonin transport system had positive or negative responses to SSRI antidepressant medication . However  the latest research which I could find in regard to whether genes and chromosomes will allow us to predict the effectiveness of particular antidepressant therapy was far from conclusive and suggested that there would most probably be multiple interacting genetic factors.

As promising as all this research seems to be, it has not yet changed the way psychiatric diagnosis is made or how treatment is plans are developed. I hope that this will happen in the next few years. Down the road  researchers may also be able to design drugs to correct the chromosomal variations that are  due to dysfunctional protein arrangements.

Biomarkers May Have to Do if We Don’t Have Complete knowledge of Genetic Makeup

Research has also been moving forward ( perhaps even faster than genetic research)  in the area of biomarkers.  We have known for a long time that an elevated serum  cortisol level, could indicateEEG an emotional state such as anxiety and/or depression . This is not specific enough to be of great help in making a diagnosis which we could make without these tests. However more specific biochemical tests might be helpful in making the diagnosis even though we don’t have the specific genetic markers.

Similarly, if we can use brain imaging to see changes in the brain structure with various psychiatric conditions such as schizophrenia, this may help make the diagnosis.

We may be able to  even use various tracing devices to follow the uptake distribution and utilization of various medications in the brain, which should be able to help us in our decision making processes. Even a non evasive procedure such as an EEG may tell us if an antidepressant is working.

The research described above is just a small sample of the explosion of work that is being done .

Ethical Considerations in Utilization of Genetic Research

Even before the sequencing of the human genome , questions have been raised about  the ethical considerations that sophisticated knowledge of genetics as well as advanced biomarkers  will bring up.

For example with genetic engineering, not only might physical and mental illnesses be avoided but also so might psychological traits where genetic links were discovered. Could this create adverse impact on future generations?

There are also important questions as to how genetic information will be acquired and used. Will individuals be giving full informed consent for this testing and use of their genetic material ?  Will there be mandatory genetic testing? Will all newborns have to undergo genetic testing for various conditions?

Also will the knowledge that one has an illness which hasn’t shown it self yet  or the propensity to have an illness create problems for people? This may be especially true if there is not an adequate treatment for an illness. For example, not everyone would choose to be tested to determine if they are likely to get Alzheimer’s Disease especially if there were nothing to do to prevent it.

What will happen if the insurance industry gets hold of  genetic testing results?

Fortunately the new healthcare legislation is supposed to prevent any discrimination on the basis of preexisting conditions . I assume this will also apply to preexisting genetic variations, which are expected to  create various physical and mental conditions.

It looks as if we have a long road to go before physicians will have  a genetic code reader on their desk  and there may be some important ethical questions along the way.

I welcome your comments of this topic.