Sunday, August 17, 2008

Dangerous? It's Not That Simple.

The issues that surround mental health cross the boundaries of many disciplines and make up one of the most varied groups of stakeholders of any issue. It is impossible to examine mental health issues without crossing purposes with a number of different interest groups. It a way, the groups of stakeholders are representative of the complexity of the disorders themselves, defying simple labels and diagnoses. While other diseases are similarly complex and varied, none of them cover a range of social issues as broad as mental health.

Cancer, while seeming to be a unifying concept, touches diet and exercise, various organs, surgery, drugs and a host of causes, both environmental and lifestyle in nature. But unlike mental illness, it does not seem to cross into the realm of public safety and law enforcement.

Mental illness seems to be unique in that it touches not only the person affected by the disease, but often times people around the affected person. When the behavior of the person affected is involved, a whole new level of complexity of the issue is at stake. That seems to be why stigma has developed around disorders of the mind, the twin issues of complexity and potential for danger. Most often this is expressed legally as "danger to self or others."

The problem used in that legal expression is the threshold of the danger posed. Clearly this is a confounding problem and generates the most disagreement among those who take positions regarding how we as a society view the treatment and diagnosis of mental illness.

Philosophical worlds collide both before and after events which are judged both by what happened and what is thought to be the state of the mental condition of the person who is being judged. It is because of the potential for explosive and damning results that most positions are fixated based upon existing beliefs and viewpoints.

The collisions are very apparent in the dilemmas that state legislators are faced with in defining treatment plans for those who have been placed in the custody of the state who are "guilty except by reason of insanity." The dilemma is what to do with those who fall into this category.

Simplistic rules of morality might suggest that the best way to handle such a situation is "You do the crime, you serve the time." The problem with this manner in viewing the problem comes from two perspectives and creates some no-win scenarios. First of all, it is extremely difficult, if not impossible, to be certain of the state of a person's mind at the time of the crime. Secondly, some mental diseases result from not what might be classified as psychotic thought, but delusional thoughts.

A prime example of this situation is the case of Andrea Yates who drowned all five of her children in a bathtub. Mrs. Yates was arguably a person of substantial intelligence. She was valedictorian of her high school class. She was "aware" of her actions to the extent that she phoned police and was able to describe what she had done to the children. Given that information, some conclude that she was a cold-blooded killer. However; she was operating under assumptions of fear that her children were condemned to eternal suffering and she was "saving" them from her being an unfit mother.

Does the definition of insanity include distortions of logic and reality? Because the disorders are defined by DSM-IV behaviorally, the simple answer is yes. When does that depart from what society calls insane? Several times I have listened to people diagnosed as mentally ill tell their stories of "distorted" reality and "voices" driving their behavior. Are there really people who might suggest that Andrea Yates felt that she had something to gain by killing her children? For most people the thought of killing your own children is beyond their ability to conceive of such a vision of reality. In the case of Andrea Yates, not only was such action plausible, it was in her version of reality the only reasonable course of action to save her children.

Does that make Andrea Yates ill or a horrible murderer? The answer is a conflicting "both." She did in fact, kill her children. She did not, however, kill them for personal gain nor intentionally with malice, she killed them from application of a bizarre sense of beliefs and logic that almost anyone else would not accept. I would argue that distinction is where much of the controversy about mental illness lies within society today.

Society argues about propositions of "reality" every single day. There are those who argue that global warming is a reality. There are those who argue that it is a concept put forth by false science. The question becomes which reality is essentially "real?" To Ms. Yates, her reality as expressed by her behaviors was that her children were better off dead than subjected to her "perceived reality" of eternal suffering. Try and imagine the mental state of a person who would make such a choice and you may begin to understand how convinced she must have been to take the actions that she took.

In a similar fashion, people who take their own lives follow the same path of logic. Their decision is based upon a vision of their reality at that point in time that makes no sense to most people, yet research tells us that many people who take their lives experience a sense of relief after having made the decision to end their lives. At that point, the angst over the decision to take the suicidal action is replaced by a relief and the actions become a kind of surreal expression of of the fulfillment of a logical progression, flawed as it is. The result in the Yates case is the expression of a calmness and detachment over having fulfilled an action that resolved the situation. It is only later when a realization of the "other" reality sets in that the actions seem to impact the person. In the case of suicide, however, the "solution" is permanent and irreversible.

From a broader perspective, what is the function of the state in protecting people from potential harm, and where are the boundaries? In the Yates case, Andrea had received care for depressive episodes but her mental health benefits had been exhausted. Her mental health professional had suggested that she not have any more children as that would nearly certainly trigger another episode of severe depression. Her husband had vigorously suggested at the urging of a spiritual advisor that she procreate and bear all children that she could possibly bear. The mental health provider suggested that she was not to be left alone with the children as she could be dangerous, but her husband had thought it was advisable to give her short trial periods alone with the children to keep her from becoming too dependent upon him.

Like most stories, there are circumstances that go well beyond the initial headline that complicate the issues of the case. Some mental health and personal freedom advocates suggest that court systems strip away individual rights and force inhuman treatment. Some suggest people should be free to do as they will. Others, in defense of their perceived safety, want any person with mental health difficulties segregated and locked away.

Answers to these issues are being forced by legal and treatment systems in place. No answer in the extreme is helpful nor particularly effective. Neighborhoods are not necessarily safer because group rehabilitation homes are refused to be located there. There are, without question, predators that are yet to be identified that cannot be relocated away from schools and children. Even recent lawsuits surrounding the behavior of members of the clergy have suggested that dangers lurk in places previously presumed safe. Clearly, society needs to understand the problems better and find more comprehensive measures to treat people in crisis. To believe that there are perfect solutions available is foolish, but to believe that we can do no better than we are doing is equally lacking in wisdom.

One conclusion is certain. Not treating people and not discussing the problems surrounding the issue is not helpful.

Sunday, August 3, 2008

Bits and Genes

Recently, there have been some "breakthrough" articles regarding genetics and schizophrenia. But before I get to the details of that, a bit of background is in order.

My normal occupation is that of computer network technician. Part of my experience is with data storage which is not unlike some aspects of genetic coding. Computer information is made up of one's and zero's, lots of them to be a bit more precise. When they are stored on magnetic types of media. which is what hard disk drives are, or on things like CD-ROM's where they are little bits of reflective material, they are read by some type of reader device and reconstituted back into "reliable" strings of one's and zero's where the computer processes them according to a set of instructions contained in the computer. We see the the results on our screens and we are either happy with the results or infuriated with the lack of them.

If you have used a computer for any length of time, you have become frustrated when the bits of information get fouled up and things go wrong. I am often asked "What caused the problem?"

Far too often, there may not be a specific cause. The timing circuitry in a computer is extremely precise and the one's and zero's in the memory of the computer are represented by voltages which must be nearly constantly refreshed. If that process is subject to fallout of the proper voltages, errors can occur. There are error detection and correction systems that are used to correct for potential errors in the storage media and they have phenomenal measures of reliability. These sometimes are on the order of years of undetected and uncorrected errors. However, we must be careful to remember that if there were 300 million computers all running for one full day and we were looking at an error rate of one undetected and uncorrected error for every ten years of computing time, there would still be 82,192 undetected and uncorrected errors per day on our computers.

If you keep that number of errors in mind, consider the human genome and the billions of people on Earth and its process of replicating the genetic code. Also keep in mind that there are between 20 and 25 thousand genes in the human genome and roughly 3 billion chemical pairs that make up those genes, you can begin to see the potential for error. As a matter of fact, there are some type of errors that are of interest to researchers that have some very interesting characteristics.

As one might suspect, the potential for flaws in the genetic makeup of an individuals DNA is really quite substantial. It seems as though the genetic material is subject to errors, just like any other thing that is subject to a recreation or manufacturing process. In this process some of the genetic material can be missing and some of the material can be reproduced more than once. If some of these errors take place, they might determine either good or bad characteristics in the resulting person.

One of the first genes to be recognized as having multiple copies is the gene CCL3L1. It is of interest because " (CCL3L1), competes with HIV by binding to the protein the virus uses to enter the cell. They found HIV-positive subjects had fewer copies of CCL3L1 than HIV-negative subjects from the same geographical group: each additional copy of the CCL3L1 gene reduced the risk of HIV infection by 5-10%. Duplications of CCL3L1 not only reduced infection rates and also slowed disease progress once infected."

This explains why some people are lacking in their ability to get AIDS which is caused by HIV.

The current research as it applies to schizophrenia suggests that the number of copies of a particular gene (also known as Copy Number Variations or CNV's) had a significant impact on the presence of schizophrenia. In particular, several large scale deletions were associated with schizophrenia. Not only was this found in one study, but simultaneously in two separate independent studies. People who had these particular deletions were nearly 15 times more likely to develop schizophrenia than subjects who did not have the deletions.

This is important not in a particularly practical manner, but more so in finding a small portion of the reason why a small number of the people who suffer from the disease of schizophrenia develop the disease.

One of the problems with the application of basic research is the inability to draw generalization to wide ranges of patients who suffer from the diseases. I was present at a NAMI meeting where Dr. Aaron Janowsky of Oregon Health and Science University was describing research he was involved in that was looking at a sub-group of subjects diagnosed with schizophrenia that were split into groups that either had or did not have a reaction to Niacin. Most people diagnosed with schizophrenia do not have a Niacin reaction, which is characterized by a reddish flushing of the skin when exposed to Niacin. There is no particular conclusion to be made from this fact, other than observing that there is a strong association of a lack of Niacin reaction in those diagnosed with schizophrenia.

One of the devilish problems with research on schizophrenia is that the disease is diagnosed by behaviors and symptoms, not a specific chemical cause. In this case, there may be a disease or form of the disease which could be characterized by the lack of a Niacin reaction and a genetic deletion. But since people who do have Niacin reactions and do not have specific genetic deletions are also classified and diagnosed with schizophrenia, what are we to conclude?

The problem stems from the fact that we diagnose mental diseases in the manner in which we do, by a set of guidelines set up in the DSM-IV manual. While it is inadequate to fully describe the precise nature of mental disease, there is no other alternative to use to attempt to assess and research the aliments of mental disorders. Until then we will look toward each clue that will refine our understanding of what causes the behaviors that we outwardly observe.

Unfortunately, the disorder we call schizophrenia is most likely a series of problems with multiple causes, resulting in behaviors that have a similar outward characteristics. This would really explain why there is a wide range of effectiveness of drug treatments and such variability in the course of the disease(s). In the meantime, research continues and more and more clues are found that help explain the causes. Eventually science will gather more and more clues to this extremely complex set of disorders. Until then we will celebrate the accumulation of clues to the causes that will eventually lead to better treatment .