National Family Caregivers Month

5 11 2013

November is the National family caregivers month in the United States.

According to the Caregivers Action Network, each year, more and more Americans are caring for a loved one with a chronic condition, disability, or the frailties of old age.  There are as many as 90 million family caregivers in the U.S. today. The current statistic indicates that:

  • Two out of every 5 adults are family caregivers.  39% of all adult Americans are caring for a loved one who is sick or disabled – up from 30% in 2010.
  • Alzheimer’s is driving the numbers up.  More than 15 million family caregivers are providing care to more than 5 million loved ones with Alzheimer’s disease.
  • But it’s not just the elderly who need caregiving.  The number of parents caring for children with special needs is increasing, too, due to the rise in cases of many childhood conditions.
  • Wounded veterans require family caregivers, too.  As many as 1 million Americans are caring in their homes for service members from the Iraq and Afghanistan wars who are suffering from traumatic brain injury, post-traumatic stress disorder, or other wounds and illnesses.
  • And it’s not just women doing the caregiving.  Men are now almost as likely to say they are family caregivers as women are (37% of men; 40% of women). And 36% of younger Americans between ages 18 and 29 are family caregivers as well, including 1 million young people who care for loved ones with Alzheimer’s.
  • Family caregiving is serious work.  Almost half of family caregivers perform complex medical/nursing tasks for their loved ones – such as managing multiple medications, providing wound care, and operating specialized medical equipment.
  • Family caregivers are the backbone of the Nation’s long-term care system. Family caregivers provide $450 billion worth of unpaid care each year.That’s more than total Medicaid funding, and twice as much as homecare and nursing home services combined.

While the  Caregiving awareness in the USA is rising (see Barak Obama’s proclamation below) in most of the world, including Israel, caregivers are transparent to the health, social, economical, and welfare systems; Caregivers have few tools, few support systems and receive minimal, if any, training that could have helped them simplify the caring responsibilities. As a result caregivers experience physical and emotional stress, which adversely impacting their overall health, well-being and quality of life. 

The good news is that there are some new initiatives in Israel that are aimed to increase public awareness to the caregiving phenomenon and its personal, social and national impacts while building an 1) engaged and powerful caregivers community in Israel, 2) promoting policies to support Israeli caregivers and 3) developing programs and services to help caregivers play their role effectively and efficiently. Since I am involved with one of these initiative I will be able to update you on our progress in due course.

Happy Caregivers Month, where-ever you are!

Here is the Presidential Proclamation for the 2013 National Family Caregivers Month:

“Across our country, more than 60 million Americans take up the selfless and unheralded work of delivering care to seniors or people with disabilities or illnesses. The role they play in our healthcare system is one we must recognize and support. During National Family Caregivers Month, we thank these tireless heroes for the long, challenging work they perform behind closed doors and without fanfare every day, and we recommit to ensuring the well-being of their loved ones and of the caregivers themselves.

Under the Affordable Care Act, patients and caregivers can benefit from a new Medicare pilot program that helps beneficiaries negotiate the transition from hospital to home. And through new Medicaid options, States can expand access to home and community-based services. With caregivers already balancing their own needs with those of their loved ones, and in many cases caring for both young children and aging parents, our Nation’s caregivers need and deserve our support. With this in mind, local agencies work to connect individuals with options including adult day care, respite care, training programs, and caregiver support groups — all shaped with the understanding that the generous women and men who take the health of their loved ones into their hands should not suffer from the toll caregiving can take.

There is no one to whom America owes more than our ill and injured service members and veterans, and while many offer kindness and assistance, it is the caregivers who truly sustain our wounded warriors as they work toward rehabilitation or recovery. In 2010, I was proud to sign the Caregivers and Veterans Omnibus Health Services Act, which provides the caregivers of our seriously injured post-9/11 veterans with training, counseling, supportive services, and living stipends. Under this law, injured veterans’ family caregivers also receive access to health care.

Just as our loved ones celebrate with us in our moments of triumph, American families strengthen the fabric of our Nation by lifting each other up in the face of life’s greatest challenges. And as Americans put their loved ones before themselves, we must offer our appreciation and flexibility, in our healthcare system, our workplaces, and our communities. This month, as we reflect on the generosity, grace, and strength of family caregivers, we renew our commitment to matching their dedication to the health and wellness of families across our country.

NOW, THEREFORE, I, BARACK OBAMA, President of the United States of America, by virtue of the authority vested in me by the Constitution and the laws of the United States, do hereby proclaim November 2013 as National Family Caregivers Month. I encourage all Americans to pay tribute to those who provide for the health and well-being of their family members, friends, and neighbors.

IN WITNESS WHEREOF, I have hereunto set my hand this thirty-first day of October, in the year of our Lord two thousand thirteen, and of the Independence of the United States of America the two hundred and thirty-eighth”.

Mental health knowledge and attitudes of general practitioners and pediatricians toward persons with psychiatric disorders prior to the integration of mental health into primary care – A research proposal

19 09 2013

Below please find is a research proposal entitled ‘mental health knowledge and attitudes of general practitioners and pediatricians toward persons with psychiatric disorders prior to the integration of mental health into primary care’. Since I think that this issue is very important and relevant to the Israeli health system and due to the fact that I do not have the time to promote it, I encourage you to use it and to study this highly important issue. Good luck!



Mental health knowledge and attitudes of general practitioners and pediatricians toward persons with psychiatric disorders prior to the integration of mental health into primary care


Scientific Background: Israel is currently promoting a reform aimed to improving the accessibility, availability, and efficiency of mental health services. As part of this reform, mental health integration into primary care will take place over the next couple of years.

Objectives: the main objective is to investigate whether, and to what extent, general practitioners and pediatricians, have the adequate knowledge and attitudes that are required to effectively assess, diagnose, treat, support and refer people with psychiatric disorders.  The findings of this proposed study may provide valuable information for policy makers concerning the current knowledge and attitudes of GPs and pediatricians in the mental health field while indicating whether there is a need to promote mental health training among these populations.

Working hypotheses: Overall, general practitioners and pediatricians do not have the adequate knowledge and attitudes to provide evidence based health services to children and adults with psychiatric disorders. Pre-service education and training in mental health, years of practice, participant’s country of origin country of medical studies and post graduate training, current workplace, familiarity with persons with psychiatric disorders, geographic location of the clinic and gender will impact the participant’s mental health knowledge and attitudes.

Methods of Data Collections: a cross-sectional quantitative research of general practitioner and pediatricians using case vignette questionnaires, demographic questionnaire and Level of Contact questionnaire

Methods of Data Analysis: Differences in socio-demographic characteristics across vignette groups will be analyzed using chi-square tests and one-way analysis of variance (ANOVA). The responses the questionnaires will be examined using one-way ANOVA tests, followed by posthoc Mann–Whitney U-tests for overall significance at the P < 0.05 level. ANOVAs followed by confirmatory ordinal logistic regressions will be used for interactions between the moderating variables and participants’ knowledge and attitudes towards the patients in the four vignettes.


  1. Scientific background:

About 450 million of people worldwide are affected by psychiatric disorders. The World Health Organization (WHO) estimates that 154 million people are affected by depression and 25 million people from schizophrenia; 91 million people are affected by alcohol use disorders and 15 million by drug use disorders (WHO, 2004, 2006). With regard to children, the literature indicates that approximately one in five children have a psychiatric disorder (WHO, 2005). Disorders regularly seen within this population include attention-deficit/hyperactivity disorder, conduct disorder, generalized anxiety disorder, depressive disorders, post traumatic stress disorder, and separation anxiety disorders (WHO, 2006; Korczak & Goldstein, 2009; Polanczyk, de Lima, Horta, Biederman and Rohde, 2007).


Psychiatric disorders are both prevalent and highly disabling conditions. Measured by years lived with disability and by premature death (DALYs), psychiatric and neurological conditions accounted for over 13% of the global disease burden in the year 2001 need more recent  (WHO, 2004). Among individuals age 15–44, unipolar depression is the second leading contributor of DALYs, with alcohol-related disorders, schizophrenia, and bipolar disorder among the top 10 disorders. Approximately, 33% of all years lived with disability (YLD) are imputed to psychiatric conditions. Of the 10 leading causes of YLD in the world among individuals of all ages, four are psychiatric conditions, with unipolar depression being the leading cause. These figures are rising. By 2030, in high-income countries, depression will become the single highest contributor to the overall disease burden (Mathers CD, Loncar, 2006). Psychiatric disorders also affect, and are affected by, chronic diseases such as cancer, cardiovascular diseases, diabetes and HIV/AIDS. Hence, when untreated, psychiatric disorders can contribute to unhealthy behavior, non-adherence to prescribed medical regimens, diminished immune functioning, poor prognosis and early dead (Miller, Paschall and Svendsen, 2006; Nakash, Shemesh, Nagar and Levav, 2012).


Despite the potential to successfully moderate the effect of psychiatric disorders, only a small minority of those in need receive adequate mental health care (World Health Organization and World Organization of Family Doctors (Wonca), 2008). The report of the US Surgeon General emphasized the critical role of stigma on the public’s willingness to seek help and to receiving mental health services (U.S. Department of Health and Human Services, 1999). Furthermore, it highlighted the fact that the separation of treatment care systems (i.e. mental health system – physical health system) increases the stigma of mental health disorders and care and decrease the accessibility to treatment, while maintaining the wide treatment gap.  As a result, many countries have recently sought to integrating mental health services into primary care to reduce the treatment gap while enhancing the access of mental health services (WHO & Wonca, 2008). In this process, those countries tried to assure that primary care workers hold the knowledge, which is required to effectively assess, diagnose, treat, support and refer to the specialized services people with mental disorders. Nonetheless, the professional literature indicates that in many parts of the world, primary care workers fail to detect psychiatric disorders, and for a range of reasons they also fail to provide evidence-based treatment to persons they do identify in need of care (Üstün & Sartorius, 1995).  While there are many reasons why psychiatric disorders are under-detected and undertreated in primary care (e.g., patient factors, health system factors, and societal and environmental factors) (WHO & Wonca, 2008), the role of the health care workers is crucial. Research suggests that many health workers do not receive adequate training on mental health issues or developed frank stigmatic attitudes. In most countries, primary care worker training ranges from a few hours to a maximum of one or two weeks. Misunderstandings about the nature of mental health problems, prejudice against people with mental disorders, and inadequate time to evaluate and treat psychiatric disorders in clinical settings are other contributing factors. For example, a recent study indicates that 98.5% general practitioners providing mental health services care in a primary care setting feel the need to be properly trained and oriented in the management of patients with psychiatric disorders to improve the overall quality of health care (Chaundhary & Mishra, 2012).  Furthermore, 79% of the primary care providers in their sample did not know any psychiatric illness diagnosis criteria neither have they any exposure to training to deal with psychiatric conditions. Hence, they treat their patients based on their “own intuitions” (Chaundhary & Mishra, 2012, p. 23).


While formal education in the mental health field can lead to better evidence based practice it may lead to positive attitudes toward persons with psychiatric illness. Research on health-related attitudes largely indicates that overall, one’s professional knowledge about psychiatric illness and disability, as well as one’s positive contacts and interactions with people who psychiatric disorders, positively affect the individual’s attitudes toward them, both in an absolute sense and in comparison to the views of the general public (Penny, Kasar, & Sinay, 2001; Whal & Aroesty-Cohen, 2010; Yamauchi Semba, Sudo, Takahashi, Nakamura, Yoshimura, Koyama et al, 2011). For example, in their recent review of the literature, Whal and Aroesty-Cohen (2010) found that 14 of the 19 studies investigated (published between the years 2004-2009) reported general positive attitudes among mental health professionals toward people with psychiatric illness, whereas only five showed predominantly negative attitudes. Nevertheless, students and professionals in the health field are not immune to the influence of negative attitudes and discrimination (e.g., Nordt, Rossler, & Lauber, 2006; Tervo & Palmer, 2004). In fact, the professional literature suggests that negative attitudes on the part of health professionals is most toxic, since their attitudes related to the prognosis, recovery and social inclusion of people with illnesses may have a crucial impact on the lives of their patients (Corrigan, 2007; Li, Comulada, Wu, Ding, & Zhu, 2011). For example, in a survey of 1073 mental health professionals and 1737 members of the general public, researchers found that psychiatrists held more negative attitudes toward people with psychiatric illness than the general public. Moreover, mental health professionals of all types were three times more likely to support restrictions for people with psychiatric illness than the general public (Nordt, Rossler, & Lauber, 2006). Another study found that general practitioners were less happy to have a patient with schizophrenia on their practice list and reported that patients with schizophrenia are more likely to be violent than most patients (Lawrie, Martin, McNeill, et al, 1998).

Israel is currently promoting a reform in its mental health system aimed to integrating mental health services into primary care settings. The main purposes of this reform are to (1) improving the link between mental and physical care by enhancing primary care physicians’ capacity to diagnose and treat psychiatric disorders; (2) strengthening the consultation and referral relationships between the primary care providers and mental health specialists; (3) and to improving availability and access of mental health services (Rosen,Nirel, Gross, Bramali and Ecker, 2008). Furthermore, the implementation of this reform is expected to facilitate help-seeking strategies, and improve early detection and intervention that that may increase the chances of quicker recovery and better long-term outcomes. Following the experiences of other countries (WHO and WONCA, 2008), one of the main factors that may determine the success of this reform is the degree to which primary care providers would have adequate knowledge and positive attitudes that would improve their practice, including their willingness to consult and be supervised by mental health experts. Hence, as will be elaborated in the next section, the main goal of this proposed research is to investigate the current diagnostic and treatment knowledge, attitudes and practices among general practitioners (GPs) and pediatricians.


  1. Objectives

General objective:

  1. To investigate mental health knowledge and attitudes of general practitioners and pediatricians (heretofore: participants), in primary care settings, in the pre integration era.
  2. To investigate mental health attitudes in general and attitudes toward persons with psychiatric disorders in particular among study participants.
  3. To investigate the association of participants’ age, gender,  country of origin, personal familiarity with persons with psychiatric disorders, country of medical studies and post graduate training,  current workplace (the health plan that the participate work with), mental health pre-service education; years of practice, geographic location of the site of current practice and, on mental health knowledge and attitudes.


  1. Working Hypotheses

Base on past research, we expect the following:

  • Overall, general practitioners and pediatricians do not have the adequate knowledge and attitudes to provide evidence based health services to children and adults with psychiatric disorders.
  • Pre-service education and training in mental health, years of practice, participant’s country of origin country of medical studies and post graduate training, current workplace, familiarity with persons with psychiatric disorders, geographic location of the clinic and gender will impact the participant’s mental health knowledge and attitudes. 


  1. Comprehensive description of study design and methodology:

This is a cross-sectional research of general practitioners and pediatricians using a case vignette questionnaire aimed to investigate 1) the degree to which the participants have the adequate knowledge on psychiatric diagnosis and treatments; 2) to explore the participants’ attitudes toward psychiatric disorders and patients with psychiatric disorders. Furthermore, the impact of pre-service education and training, country of medical studies and post graduate training, participants’ country of origin, years of practice, gender, geographic location of their clinic and personal familiarity with persons with psychiatric disorders, on their mental health knowledge and attitudes will be ascertained as well.

Participants: A convenient sample of 500 general practitioners and 200 pediatricians will be recruited for the present study. These figures were selected following a power analysis that was conducted using the G*Power 3 program (Faul, Erdfelder, Lang, & Buchner, 2007) to determine the sample size. With alpha set at 0.05 and power at 0.80 that a minimum sample of 180 participants was needed to detect a significant medium effect (f = 0.25) using one-way ANOVA with four [vignettes] groups.

Recruitment. This proposed research will approach all the registered GPs (around 5000) and pediatricians (around 2000) via an email message that will include a cover letter with the purposes and importance of the study followed by the research questionnaires. Furthermore, we will collaborate with the four Israeli health plans and will seek to promote collaborations with the Israel Ambulatory Pediatric Association and with the Israel Association of Family Physicians in order to increase participation.  The cover letter and questionnaires will also be published in websites and social media that are aimed for general practitioners and pediatricians. Finally, the research assistances will attend professional conferences where they will encourage GPs and pediatricians to fill the questionnaires on site.

Research tools:

The present research will be based on case vignettes that will be followed by mental health knowledge questionnaire concerning psychiatric diagnosis and treatment and attitudes measurements. The case vignettes that will be developed for GPs will include a description of adults who experience symptoms of schizophrenia, unipolar depression, diabetes or no illness (i.e. good health). The case vignettes that will be developed for pediatricians will include a description of children who experience symptoms of Attention deficit-hyperactivity disorder (ADHD), separation anxiety, Asthma or no illness.

These vignettes will be followed by a questionnaire that will be developed for this research aimed to assess the participants’ knowledge ability to diagnose and tailor a treatment (including referring the potential patient to a mental health expert) for the person described in the vignette. In addition, based on the study of Lawrie et al. (1998), which measured mental health attitudes among primary care providers, participants will be asked to report their level of agreement with 13 statements based on the vignette using a 7-point Likert scale (e.g., you would be happy to have this patient on your list, this person is likely to take up a lot of time, this patient is more likely to be violent than most patients, and this patient is unlikely to comply with advice or treatment given). In addition, a socio-demographic questionnaire will be distributed. In this questionnaire, participants will be also asked to report with what health plan they are working. Moreover, participants will be asked to answer a modified Level of Contact questionnaire (Holmes, Corrigan, Williams, et al, 1999) that include a lists 12 situations of varying degrees of intimacy that involve persons who have psychiatric illness and diabetes. The reason for asking of previous contact between the participants and persons with psychiatric illness and diabetes is based on the contact hypothesis (Allport, 1954) which demonstrated that contact under certain conditions is highly effective in alleviating negative attitudes and prejudice directed toward out-group members, including persons with psychiatric illness and other health conditions (Corrigan, Roe and Tsang, 2011; Wright, 2009). Finally, a questionnaire regarding the participants’ pre-service education will be developed. The aim of this questionnaire is to investigate to what extent, medical school, internship and residency programs impact the mental health knowledge, attitudes and practice of the participants.



Analyses will conduct using the Predictive Analytics SoftWare (PASW, Version 18.0). All data will be dual entered. Differences in socio-demographic characteristics across vignette groups will be analyzed using chi-square tests and one-way analysis of variance (ANOVA). The responses to the mental health knowledge and attitudes across the four groups will be examined using Kruskal–Wallis one-way ANOVA tests, followed by posthoc Mann–Whitney U-tests for overall significance at the P < 0.05 level. ANOVAs followed by confirmatory ordinal logistic regressions will be used for interactions between the following variables and participants’ knowledge, skills and attitudes towards the patients in the four vignettes:

1. Preserves medical education and training in the mental health field

2. Workplace (i.e. the health plan that the participant work with).

3. Years of practice

4. Country of origin and country of medical studies and post graduate training

5. Contact with persons with psychiatric disorders

6. Gender

7. Geographic location of the clinic



At the first stage the vignettes and questionnaires developed for this study will be reviewed by a panel of experts. The questionnaire will be distributed among 10 GP experts and 10 pediatric experts. They will be asked to provide feedback concerning the validity and clarity of the vignettes and the questions and their relevance to the research objectives. The panelists will not serve as study participates. After the validation phase, vignettes and the questionnaires will be uploaded to a research website. Then, study participant will be recruited by the research assistances (see the recruitment section). The vignettes will be then randomly allocated and a cover letter which describe the aim of the research and that states that all responses would be anonymous,  with a link to the website will then be sent to study participates. Moreover, they will be informed that their participation is entirely voluntary. A follow up reminder will be sent to participants will be sent a month after.


Possible biases and research limitations

The qualifications of the study are those characteristics of the design or methodology that set parameters on the application or interpretation of the results of the study, that is, the constraints on the generalizability and utility of the findings established by internal and external validity. With regard to external validity, the proposed research needs to be examined in light of several limitations. First, the fact that the proposed research relies on a convenience sample, rather than a representative sample, reduces the ability to draw inferential conclusions from the sample data about the general population. However, the findings of this proposed research may provide important information can lead to further research among a representative sample of GPs and pediatricians in Israel. A second limitation relates to response rates. In this project, the main problem is the difficulty to reach the participants who may be loaded with their daily work and not see the importance of filling in a questionnaire for research purposes. Therefore, multiple recruitment strategies will be employed in order to assure that most participants will indeed answer the questionnaires. Finally, social desirability is treated as a factor that can contaminate commonly used self-report measures and thus lower reliability and validity of the results. This is mostly relevant to attitudes questionnaires. The proposed study will be anonymous and that may significantly reduce the social desirability bias.

5. Significance of the Proposal:

Over the past two decades, the State of Israel is preparing to transfer legal responsibility for mental health care from the government to the country’s four, competing, non-profit health plans. This reform seeks to improve the health and well-being of the persons with psychiatric disorders by establishing a legal right to care, increasing the level of government funding for mental health care, and improving the accessibility, availability, and efficiency of services. Nowadays, where the mental health integration into primary care is about to come to realization, there is a need to assess whether primary care providers, which will serve as the main gatekeepers for mental health conditions, have the adequate mental health knowledge and attitudes. Learning from the experience of countries that conducted similar mental health reforms without ensuring that the primary care providers have the needed mental health knowledge and attitudes to provide adequate mental health services (WHO and Wonca, 2008), the present study seeks to provide information about the current mental health knowledge and attitudes of primary care providers; information that may assist to better implement this important reform.




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Miller B.J., Paschall C.B., 3rd, Svendsen D.P., (2006). Mortality and medical comorbidity among patients with serious mental illness. Psychiatric Services;57(10):1482-7.


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The BRAIN Initiative on The Charlie Rose Brain Series

22 07 2013

Please see the Charlie Rose Show Brain Series that discusses the greatest mysteries in science and one of the greatest challenges in medicine: The BRAIN. In this show you can see and hear the GREAT: Eric Kandel of Columbia University, Thomas Insel of the National Institute of Mental Health, Story Landis of the National Institute of Health, Cornelia Bargmann of Rockefeller University and William Newsome of Stanford University. ENJOY!





The Science of Mental Illness for Middle School Students

13 07 2013

If you are a teacher, check out this NIH Curriculum Supplement for Middle School students entitled: The Science of Mental Illness. In this supplement students gain insight into the biological basis of mental illnesses and how scientific evidence and research can help us understand its causes and lead to treatments and, ultimately, cures. As you can see below, it includes six interesting lessons.

Major Concept for Students
1. The Brain: Control Central The brain is the organ that controls feelings, behaviors, and thoughts, and changes in the brain’s activity result in long- or short-term changes to these.
2. What’s Wrong? Mental illnesses such as depression are diseases of the brain.
3. Mental Illness: Could It Happen to Me? Though everyone is at risk, factors such as genetics, environment, and social influences determine a person’s propensity to develop a mental illness.
4. Treatment Works! Medications and psychotherapies are among the effective treatments for most mental illnesses.
5. In Their Own Words Mental illnesses affect many aspects of a person’s life, but they can be treated so that the individual can function effectively.
6. You’re the Expert Now Learning the facts about mental illness can dispel misconceptions.

A New Job Board for Applicants with disabilities

10 07 2013

 Today I wish to briefly introduce a new Job board for applicants with disabilities. This unique job board was established by the Israel Ministry of Industry, Trade and Labor and is aimed to further enhance work inclusion of people with disabilities in Israel.  For more details (in Hebrew) see: or join the facebook page:

As part of this project, I had the privilege to write a guide for Job seekers with disabilities. In this guide, I sought to present relevant information about the job search process and to provide practical tools that will assist  job seekers in this complex journey. Furthermore, I discuss the disability disclosure issue, that is, whether, and when the person should disclose her/his disability (to read more on this issue see I will share this guide with you in the next few days. I will also share a review that I wrote about job boards to people with disabilities, worldwide.

“seeking treatment is a sign of strength”

6 06 2013

Following President Obama calls for end to mental illness stigma, here is an interesting post by Dr. Insel, NIMH director.

June 3 marked the first White House Conference on Mental Health in 14 years. President Obama opened the event by describing how many people “suffer in silence” rather than seeking help:

We see it in the veterans who come home from the battlefield with invisible wounds of war, but who feel like seeking treatment is somehow a sign of weakness – when, in fact, it’s a sign of strength.

We see it in the parents who would do anything for their kids, but who often fight their mental health battle alone – afraid that reaching out would invite judgment or reflect badly on them.

And we see it in tragedies that we have the power to prevent.

With these remarks, the President launched the National Dialogue on Mental Health, bringing together 200 mental health experts, a dozen members of Congress, and celebrities like Glenn Close and Bradley Cooper to start a national conversation about youth and mental health. The White House has also launched a website,, with its tag line “Let’s talk about it.”

Noting that less than 40 percent of people with mental disorders seek treatment, the President stressed the need to do a better job recognizing mental health issues, especially in children. Acknowledging that we must ensure that treatment is available, the President described how the Affordable Care Act will expand mental health care to 60 million more Americans, and he detailed new investments to increase the mental health workforce. He also noted how new investments in science, including the BRAIN initiative, should bring better treatments for those who need them.

It’s hard not to draw a parallel to the June 1999 White House conference, which was precipitated by the school shootings in Littleton, Colorado six weeks earlier. Hosted by Tipper Gore and President Clinton, the focus was on youth mental health and reducing stigma. Fourteen years later, the conversation leaders are different, but the issues are much the same. Again we are in the wake of a school shooting; again we turn our attention to mental health in youth; and again we are discussing how to overcome negative attitudes toward those with mental disorders. But this begs the question: why are we still having the same conversation about the same issues in mental health? How do we refocus this discussion?

First of all, much has changed in the past 14 years that should be enriching our dialogue: the era of genomics has transformed biomedical science; the revolution in mobile technology reaches countless adolescents and holds potential as an avenue to change behaviors; and the advent of health care reform will help more people get the treatment they need. All of these have the promise to transform mental health care and mental health research.

Second, we need not only a national dialogue but a national action plan. “Let’s talk about it” is a good place to start, but for a 19-year-old in the grip of a psychotic episode or a 16-year-old on the path to serious mental illness, we urgently need an action plan to alter the course of their illness. This year, the 100,000 young Americans who will have a first episode of psychosis will join over two million adults with schizophrenia. The majority of people with mental illness delay seeking care, which is especially serious for people with psychotic disorders. In the United States, individuals with psychosis go untreated for, on average, 110 weeks.1 Among other serious consequences, untreated psychosis poses an increased risk for substance use and suicide, both of which contribute to the elevated mortality associated with these disorders. Our best hope of reducing mortality from serious mental disorders will come from realizing that just like other medical illnesses, we need to diagnose and preempt the illness before the symptoms become manifest. At the White House conference, Vice President Biden spoke to this point directly, stressing that we must intervene earlier, as we do today for cancer and heart disease.

Recognizing this call to action, NIMH is preparing for a surge of research focused on predicting and preventing serious mental illness. New initiatives will seek to change the treatment paradigm from one of treating chronic illness to one of preempting the illness long before symptoms emerge. We have two landmark NIMH studies to build upon: The North American Prodrome Longitudinal Study (NAPLS) is a consortium of clinical research centers studying ways to identify individuals earlier who are at risk for an initial psychotic episode. Through NAPLS, we have the opportunity to create a toolkit to improve prediction of psychosis using biosignatures and neurocognitive testing. The Recovery After an Initial Schizophrenia Episode (RAISE) project is a large-scale research effort to explore whether using early and aggressive treatment will reduce the symptoms for individuals who have already had a psychotic episode and prevent the subsequent gradual deterioration of functioning. RAISE will be expanded with the aim to reduce the duration of untreated psychosis by linking community mental health care to primary care and school mental health resources.

We must make sure that the next White House conference on mental health is a celebration of progress. Science is the path on which progress is made. Investing in programs focused on early diagnosis are the best hope for creating more precise diagnostics and more effective preventive interventions to ensure better outcomes. Let’s start writing a new chapter in the chronicle on mental health. Our nation’s youth deserve to be part of a better story.


 1 Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T. Association between duration of untreated psychosis and outcome in cohorts of first-episode patientsArch Gen Psychiatry. 2005 Sep 62:975-983.

The Top Ten Research Advances of 2012 by NIMH Director‏

11 12 2012

Once again, here is a great post by By Thomas Insel, NIMH director. Enjoy!


“As in past years, once again I venture to suggest a “top 10” list for NIMH based on the most notable discoveries and events of the past 12 months. This year several of the major breakthroughs were not funded by NIMH and not directly focused on mental disorders, but they suggested new vistas for biology that will almost certainly change the way we understand serious mental illness and neurodevelopmental disorders. There is, of course, no way to do justice to the richness or the diversity of this year’s research by citing only 10 findings or events. But a list of 50 would be too long, and a list of 5 or fewer would be far too short.

10. Manipulating the epigenome to treat brain disorders
The epigenome – the collection of chemical compounds that transcribes our genome, telling it what, where, and when to do something – provides a link between nature and nurture. In previous years we have seen the effects of early stress or medication on the epigenome. This year marked some of the first studies manipulating the epigenome, revealing a new frontier for treating mental disorders. In an extraordinary study from Li-Huei Tsai’s laboratory, an increase in histone deacetylase 2 (HDAC2) – a protein that plays an important role in regulating the transcription of genes – was found to reduce memory in mice (and was associated with Alzheimer’s Disease in humans). Reducing HDAC2 improved memory in mice, suggesting a new target for developing treatments.1

9. The end of the AIDS epidemic?
The International AIDS meeting is an annual global event reporting on progress in behavioral and biomedical research on the epidemic. The meeting had not been held in the US since 1991 due to a ban on issuing visas to HIV-infected foreigners. With the lifting of this ban, the meeting was held in Washington DC in July 2012. Beyond the historic hosting of this meeting in the U.S., attendees heard for the first time a vision for an “AIDS free generation” with a combined prevention and treatment strategy that could end the epidemic.2

8. Neurodevelopmental genomics
The search for genetic variation associated with autism spectrum disorder, schizophrenia, and bipolar disorder seemed to move at light speed this year, with every month revealing new findings.3,4 The importance of de novo, or spontaneous mutations, often single base changes, became more apparent in 2012. And the role of paternal age, which shows a linear increase with de novo changes, demonstrated a mechanism by which environment and genes may interact.5 The current state of the field was summed up by State and Sestan as “one to many” (each genetic finding appears to be a risk factor for several different neurodevelopmental disorders) and “many to one” (disorders like autism appear to have scores, perhaps hundreds, of genetic factors contributing risk).4

7. Global mental health
If 2011 was the year to establish a vision for research in global mental health, 2012 was the year to initiate bold efforts to realize that vision. Grand Challenges Canada announced nearly $20 million in support of 15 innovative projects designed to improve mental health diagnosis and care in developing countries. The Centre for Global Mental Health, a collaboration based in London, increased its investment to over 30 projects across 20 countries. And NIMH launched the Collaborative Hubs for International Research in Mental Health in low- and middle-income countries – a network of 5 centers focused on research and research capacity-building in this field. The research agenda is designed not only to reduce the mental health treatment gap in low- and middle-income countries, but is actively learning and gaining insight from the innovations developed in these countries.

6. Optogenetics and oscillations in the brain
The holy grail of neuroscience has been finding the engram, the neural representation of memory (or thought or emotion). In 2012, we saw new evidence of the importance of synchronized waves of activity in the cortex – so called oscillations of coherent activity between distant regions – for supporting visual memory.6 Using optogenetics, which can turn activity on and off with light, scientists were able to manipulate gamma oscillations, the class of oscillations thought to be most relevant for schizophrenia 7,8 In one of the most remarkable demonstrations of the power of optogenetics, symptoms associated with depression in a mouse were turned on and off by regulating only the serotonergic input to the frontal cortex.9

5. Mapping the human brain at the molecular level
Ribonucleic acid (RNA) is a fascinating and frequently surprising family of molecules responsible for the coding, translation, expression, and regulation of genes. Building on the first maps of RNA expression of the developing human brain in 2011, this year saw the first comprehensive maps of RNA expression in adult humans, the first epigenomic map across human development and the first description of human specific patterns of gene expression.10,11,12,13,14

4. Mapping the human connectome
The wiring diagram of the human brain is extremely complex and traditionally has been considered too difficult to untangle in full. Using a new approach for visualizing white matter (the “cables” that connect brain regions), Wedeen and his colleagues at Massachusetts General Hospital discovered an inherent grid pattern in the human brain.15 While there is still discussion about the validity of this grid, the human connectome – the comprehensive map of all neural connections in the brain – promises to reveal important aspects of human variation, just as is the case with the human genome. Adding to this new picture of the structural connectome, brain imaging scientists from around the world have combined functional magnetic resonance imaging (fMRI) data to describe a functional connectome.16 Even at “rest,” distant brain areas appear highly active and synchronized, promising a new picture of individual differences in functional connectivity.

3. Unexpected variation
2012 may be considered as the year of genomic weirdness. Who knew that there would be genomic variation in the brain that was not apparent in blood cells? The possibility that somatic mutations – alterations that occur in DNA after conception – could contribute to neurodevelopmental disorders suggests that cancer may be a useful model for understanding autism or schizophrenia.17,18 Who knew that women could carry cells in their brains with DNA from their offspring? Microchimerism – in this case, the presence of male cells in a woman’s cortex – gives an entirely new meaning to the biology of motherhood.19 And who knew that microDNA segments could be transmitted independently of chromosomes? There appear to be thousands of short (200 – 400 bases long) circular DNA elements that function free of the well-known structured bundles of DNA called chromosomes in mammalian cells.20

But even our standard approaches to genetics revealed unexpected variation. The 1000 Genomes Project, an audacious project to sequence the genomes of 1000 typical humans, has forever put to bed the concept of “normal.” Based on data from the first 185 volunteers, the range of variation found has been, by any standards, stunning. Imagine that each of us has 100 genetic variants causing some loss of function, with 20 of these being variants that totally inactivate the gene. That means that each of us, on average, has a “knockout” of 20 genes. Overall, the team found more than 1000 different genes knocked out within the sample, apparently without consequences since all of their participants were selected because they were “healthy.”21 This suggests that a tremendous amount of unexpected redundancy is built into our genome. In another recent report, the 1000 Genomes Project demonstrates much of this variation is related to ancestry, with large differences observed across 14 different human populations.22

2. The human microbiome
This NIH Common Fund project delivered much of its payload in 2012 with some 17 papers published in June describing the findings from a consortium of 200 investigators mapping the microbial world of 18 different body sites.23 The results have altered how we think about what it means to be human, as our bodies are more of a complex ecosystem in which human cells represent a paltry 10% of the population. But beyond the sheer numbers, we now know about the profound diversity of this ecosystem and striking individual differences. How these differences in our microbial world influence the development of brain and behavior will be one of the great frontiers of clinical neuroscience in the next decade.

For sheer scientific shock value this year, nothing beat the prosaically-named ENCyclopedia Of DNA Elements (ENCODE) project. ENCODE, funded by the National Human Genome Research Institute, set out to map the active parts of the human genome where the prevailing belief had been that 2 percent was genes and 98 percent was “junk DNA” or, at best, the dark matter of the genome. In September, 30 papers in Nature, Science, and other journals reported that 80 percent, not 2 percent, of the genome was transcribed with over 20,000 non-coding RNA sequences serving as active biological elements of the genome.24 The biggest finding of the year is also the most humbling: we are still in the earliest stages of understanding the blueprints that make us human”.


 1 Gräff J, Rei D, Guan JS, Wang WY, et al. An epigenetic blockade of cognitive functions in the neurodegenerating brain. Nature. 2012 Feb 29;483(7388):222-6. PMID: 22388814

 2 More information about the conference is available at its website:

 3 Sanders SJ, Murtha MT, Gupta AR, et al. De novo mutations revealed by whole-exome sequencing are strongly associated with autism. Nature. 2012 Apr 4;485(7397):237-41. PMID: 22495306

 4 State MW, Šestan N. Neuroscience. The emerging biology of autism spectrum disorders. Science. 2012 Sep 14;337(6100):1301-3. PMID: 22984058

 5 Kong A, Frigge ML, Masson G, et al. Rate of de novo mutations and the importance of father’s age to disease risk. Nature. 2012 Aug 23;488(7412):471-5. PMID: 22914163

 6 Salazar RF, Dotson NM, Bressler SL, Gray CM. Content-specific fronto-parietal synchronization during visual working memory. Science. 2012 Nov 23;338(6110):1097-100. PMID: 23118014

 7 Deisseroth K. Optogenetics and psychiatry: applications, challenges, and opportunities. Biol Psychiatry. 2012 Jun 15;71(12):1030-2. PMID: 22503111

 8 Sohal VS. Insights into cortical oscillations arising from optogenetic studies. Biol Psychiatry. 2012 Jun 15;71(12):1039-45. PMID: 22381731

 9 Warden MR, Selimbeyoglu A, Mirzabekov JJ, et al. A prefrontal cortex-brainstem neuronal projection that controls response to behavioural challenge. Nature. 2012 Nov 18. Epub ahead of print. PMID: 23160494

 10 Hawrylycz MJ, Lein ES, Guillozet-Bongaarts AL, et al. An anatomically comprehensive atlas of the adult human brain transcriptome. Nature. 2012 Sep 20;489(7416):391-9. PMID: 22996553

 11 Zeng H, Shen EH, Hohmann JG, et al. Large-scale cellular-resolution gene profiling in human neocortex reveals species-specific molecular signatures. Cell. 2012 Apr 13;149(2):483-96. PMID: 22500809

 12 Numata S, Ye T, Hyde TM, et al. DNA methylation signatures in development and aging of the human prefrontal cortex. Am J Hum Genet. 2012 Feb 10;90(2):260-72. PMID: 22305529

 13 Shulha HP, Crisci JL, Reshetov D, et al. Human-specific histone methylation signatures at transcription start sites in prefrontal neurons. PLoS Biol. 2012 Nov;10(11): Epub ahead of print. PMID: 23185133

 14 Konopka G, Friedrich T, Davis-Turak J, et al. Human-specific transcriptional networks in the brain. Neuron. 2012 Aug 23;75(4):601-17. PMID: 22920253

 15 Wedeen, V. J., D. L. Rosene, et al. The geometric structure of the brain fiber pathways. Science. 2012; 335(6076): 1628-1634. PMID: 22461612

 16 Milham MP. Open neuroscience solutions for the connectome-wide association era. Neuron. 2012 Jan 26;73(2):214-8. PMID: 22284177

 17 Poduri A, Evrony GD, Cai X, et al. Somatic activation of AKT3 causes hemispheric developmental brain malformations. Neuron. 2012 Apr 12;74(1):41-8. PMID: 22500628

 18 Evrony GD, Cai X, Lee E, et al. Single-neuron sequencing analysis of l1 retrotransposition and somatic mutation in the human brain. Cell. 2012 Oct 26;151(3):483-96. PMID: 23101622

 19 Chan W.F, Gurnot C, Montine TJ, et al. Male microchimerism in the human female brain.
PloS One. 2012; 7(9): e45592. PMID: 23049819

 20 Shibata Y, Kumar P, Layer R, et al. Extrachromosomal microDNAs and chromosomal
microdeletions in normal tissues. Science. 2012; 336(6077): 82-86. PMID: 22403181

 21 MacArthur DG, Balasubramanian S, Frankish A, et al. A systematic survey of loss-of-function variants in human protein-coding genes. Science. 2012 Feb 17;335(6070):823-8. PMID: 22344438

 22 1000 Genomes Project Consortium, Abecasis GR, Auton A, et al. An integrated map of genetic variation from 1,092 human genomes. Nature. 2012 Nov 1;491(7422):56-65. PMID: 23128226

 23 More information on these and other articles in the journal PLoS may be accessed here:

 24 Additional information on ENCODE publications may be accessed here: