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IN THE NEWS 2018

2018 DEPARTMENT HONORS Ranked #5 in the U.S. for psychiatry graduate/professional programs U.S. News & World Report Ranked #8 in the U.S. for psychiatry residency programs Doximity Residency Navigator Survey Ranked #11 in the U.S. for adult psychiatric care U.S. News & World Report

2018 INDIVIDUAL HONORS Nancy E. Adler, PhD • Clarivate Analytics Most Highly Cited Researcher Tom Benson, MT-BC • American Music Therapy Association Betty Isern Howery Award Jeremy Biane, PhD • NARSAD Young Investigator Renée L. Binder, MD • APA/AAPL Isaac Ray Award W. Thomas Boyce, MD • Simms/Mann Institute Whole Child Award Jennifer E. Boyd, PhD • VA Mental Health Lived Experience Community of Practice Award John Chamberlain, MD • American Psychiatric Association Distinguished Fellow Elissa Epel, PhD • President-Elect, Academy of Behavioral Medicine Research Stephen P. Hinshaw, PhD • American Book Fest Best Book Award Fumiko Hoeft, MD, PhD • Society for Neuroscience Science Educator Award William Hua, PhD • James Besyner Early Career Award for Distinguished Contributions to VA Psychology Alison Hwong, MD, PhD • American Association for Geriatric Psychiatry Honor Scholar Alicia Lieberman, PhD • Generations Award in Leadership Ruchi Malik, PhD • NARSAD Young Investigator John R. McQuaid, PhD • Federal Employee of the Year, SFVAHCS Tomasz Nowakowski, PhD • NARSAD Young Investigator Aoife O’Donovan, PhD • International Society for Traumatic Stress Studies Chaim and Bela Danieli Young Professional Award Aric A. Prather, PhD • American Psychosomatic Society Herbert E. Weiner Early Career Award Stephan J. Sanders, PhD, BMBS • Clarivate Analytics Most Highly Cited Researcher Katherine Scangos, MD, PhD • NARSAD Young Investigator Matthew W. State, MD, PhD • Clarivate Analytics Most Highly Cited Researcher Samuel Wan, PhD • President-Elect, Association of VA Psychologist Leaders Kristine Yaffe, MD • Clarivate Analytics Most Highly Cited Researcher

CONTENTS Message From the Chair / New Faculty Members

Alzheimerâ€™s, Dementia and Cognitive Aging

Attention-Deficit Hyperactivity Disorder (ADHD)

Autism and Neurodevelopmental Disorders

Depression, Anxiety and Mood Disorders

Eating Disorders and Nutrition

Learning and Development

Neuroscience

Public Mental Health and Interdisciplinary Studies

Substance Use Disorder and Addiction

Trauma and PTSD

Other Topics

FROM THE CHAIR

It’s hard to believe, but 2018 marked the five-year anniversary of my tenure as a UCSF faculty member and department chair. It has been a tremendously exciting and productive time for our department and mental health broadly at UCSF, thanks to the dedication and talent of our faculty, staff, trainees, and government/community partners, the generosity of our donors, the commitment to our mission by UCSF senior leadership, and the remarkable spirit of collaboration shared by our colleagues at UCSF and UC Berkeley. The breadth and depth of our mental health enterprise is amazing, encompassing Zuckerberg San Francisco General, the San Francisco VA Health Care System, Langley Porter Psychiatric Hospital and Clinics, UCSF Benioff Children’s Hospitals in San Francisco and Oakland, UCSF Health, our campuses at Laurel Heights and Mission Bay, as well as our remarkable community-based programs, such as Citywide Focus, Alliance Health Project and the Trauma Recovery Center. This past year has underscored both the multitude of challenges we face and the tremendous opportunities before us. In 2018, UCSF contributed important new insights into the root causes of autism, schizophrenia, and mood disorders, and taken important strides in developing novel interventions for conditions ranging from ADHD and eating disorders to PTSD and depression. At the same time, we were on the front lines of addressing the heartbreaking reality of homelessness, the tragedy of the thousands of mentally ill and substance-dependent individuals on our city streets, the skyrocketing rates of substance use disorders and suicide, and the continued marginalization, stigmatization, and criminalization of our most seriously ill patients. I could not be more gratified or proud of the daily commitment shown by our people to providing outstanding and compassionate care, training the next generation of leaders, advancing science, and advocating for the most vulnerable in society.

In the pages that follow, you’ll find dozens of articles highlighting some of our most notable discoveries and initiatives from 2018, as documented by news and media outlets. It is a testament to the incredible work being done here and still only represents a fraction of what has been achieved just in the past 12 months. As remarkable as this past year has been, I am even more excited about what the future has in store. Our continuing expansion of clinical, research and educational programs and community engagement efforts has UCSF poised to play a transformative role in behavioral neuroscience and mental health care in the Bay Area and beyond. Our future clinical and research facilities at the new Child, Teen and Family Center/Department of Psychiatry Building and Weill Institute for Neurosciences Building—both slated to open in 2020—will set a new standard in patient- and family-centered care, and provide state-of-the-art resources for our faculty, staff and trainees. They are a tangible symbol of the central role the Department of Psychiatry continues to play in the unparalleled neuroscience and health care communities at UCSF.

Matthew W. State, MD, PhD

Oberndorf Family Distinguished Professor in Psychiatry Chair, Department of Psychiatry Executive Director, UCSF Child, Teen and Family Center Director, Langley Porter Psychiatric Institute President, Langley Porter Psychiatric Hospital and Clinics

NEW FACULTY MEMBERS

Michael Burnias, PsyD

Ashley Maliken, PhD

Health Sciences Assistant Clinical Professor

Alexandra Crosswell, PhD

Payal Mapara, PsyD

Assistant Adjunct Professor

Health Sciences Assistant Clinical Professor

Carly Demopoulous, PhD

Rachel Nosheny, PhD

Assistant Adjunct Professor

James Duffy, MD

Margo Pumar, MD

Professor of Clinical Psychiatry

Health Sciences Assistant Clinical Professor

Nathan Ewigman, PhD, MPH

Loren Roth, MD

Health Sciences Assistant Clinical Professor

Health Sciences Associate Clinical Professor

Tova Fuller, MD, PhD

Ramotse Saunders, MD

Health Sciences Assistant Clinical Professor

Health Sciences Clinical Instructor

Regina Graham, MD

Katherine Scangos, MD, PhD

Health Sciences Associate Clinical Professor

Assistant Professor of Clinical Psychiatry

Lisa Hail, PhD, MA

Esme Shaller, PhD

Health Sciences Assistant Clinical Professor

Health Sciences Associate Clinical Professor

Joan Jou Santacreu, PhD

Erin Watson, PsyD

Health Sciences Assistant Clinical Professor

Chuan-Mei Lee, MD, MA

Christine Zalecki, PhD

Health Sciences Assistant Clinical Professor

Jacy Leonardo, PhD, MA

Health Sciences Associate Clinical Professor

ALZHEIMER’S, DEMENTIA AND COGNITIVE AGING

Can older vets with TBIs benefit from mobile game apps? MIKE RICHMAN APRIL 18, 2018

These veterans aren’t playing video games to shoot down asteroids, take part in World War II battles, or follow criminals and their efforts to commit heists. They are, however, striving to improve their mental sharpness. That’s what Dr. Allison Kaup, a neuropsychologist at the San Francisco VA Medical Center, has in mind. She’s leading a pilot study on whether two types of video-game-like apps—a multitasking game and a word-puzzle game—can help improve cognitive health in older veterans with traumatic brain injury (TBI). The games are considered investigational therapeutic software. The study is called the “Brain Aging in Veterans (BRAVE) Training” program. It involves vets ages 60 to 85 who have a history of repetitive mild TBI, also known as a concussion, or at least one moderate TBI. The veterans in the study have disclosed cognitive complaints, such as trouble concentrating, getting organized, and remembering things they need to do. Evidence suggests that involvement in mentally stimulating activities like crossword puzzles and reading may help keep the brain healthy as people age. But whether computer games are the best way to accomplish this is unclear, Kaup says. “Some studies of ‘brain games’ have shown promising effects, but others haven’t,” says Kaup, who is also an assistant professor at the University of California, San Francisco (UCSF). “A common finding in past studies that have tested such games is that people may get better at playing the game itself. But that may not necessarily translate into improvements in other cognitive skills or to meaningful benefits in everyday life. We need more research to understand this and to inform whether there may be a type of game that is most likely to help.” Kaup’s research focuses on understanding cognitive decline in older adults. She wants to help increase the knowledge of how to promote healthy brain aging in veterans and prevent older vets from developing cognitive decline and dementia. She’s part of a group called the Center for Population Brain Health, which includes researchers from the San Francisco VA and UCSF. Recently, she authored a study that aimed to capture the neuropsychological impact of lifetime TBI. She studied a group of about 90 veterans, average age 79. Through neuropsychological tests, she found that the vets with TBI—compared with those without—were worse off in mental processing speed and complex thinking skills, such as those related to planning, organizing, and completing tasks. The two groups performed similarly in attention, memory, and language skills. The study appeared in the Journal of the International Neuropsychological Society in January 2017. It stemmed from the original BRAVE study, a project that compared older veterans with and without TBI on a series of measures, including cognitive ability, mood, sleep, and physical and motor functioning. Dr. Kristine Yaffe, the chief of neuropsychiatry at the San Francisco VA and the director of the Center for Population Brain Health, led the original BRAVE study. Kaup’s pilot study is building on Yaffe’s project and is still in the research phase. Kaup and her colleagues are hoping to enroll 90 older veterans with TBI in the trial by the end of 2018. About 60 have signed up thus far.

Those selected are randomized evenly into three groups for four-week periods. In two of the groups, the vets play a video game on an iPad for about 30 minutes a day at least five days a week. In the multitasking game, a veteran has to steer down a course and tap the iPad screen when certain objects appear. The game calls for reacting quickly and doing two things at once. The main goal in the word-puzzle game is for the player to create as many words as possible by connecting letters on a puzzle board. The game involves visual searching and word knowledge. Participants in the third group simply go about their regular activities over the four-week period. This group is key to the study, Kaup says, because it helps the researchers understand whether the two other groups are benefiting from the video games. All three groups complete cognitive tests and questionnaires at baseline, at the end of the four-week period, and at a three-month follow-up visit. Preliminary results say most participants are enjoying the video games and are finding them easy to use, supporting part of the researchers’ hypothesis. But it’s too early to know if the vets in the video game groups are improving cognitively. In the future, Kaup hopes more research by her group and others clears up how TBI influences brain health as people age. There’s not enough research yet, for example, to pinpoint whether having just one mild TBI influences dementia risk, she says. That question is a focus of an ongoing project led by Yaffe that is investigating the long-term effects of mild TBI in veterans. Kaup notes that the risk of dementia may depend on how severe the injury is and on how many TBIs a person has had over his or her lifetime. “TBI is a relatively common injury experienced by veterans,” she says. “Some studies, including ones led by others in our group, have suggested that people who have had traumatic brain injuries may be at higher risk for dementia in aging, compared with people who have not. Although more research is needed to understand this, such findings suggest older veterans who have had a TBI are an important group among whom to try to improve cognitive and brain health.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A01

Certain female veterans may face higher dementia risk MAUREEN SALAMON DECEMBER 12, 2018

The toll of U.S. military service can be steep for female veterans, with depression, post-traumatic stress disorder and brain injury each significantly raising the odds of later dementia, new research suggests. The study, of more than 100,000 older women veterans, spotlights the risk factors stemming from military service that can lead to thinking and memory problems down the road, said study author Dr. Kristine Yaffe. "It's really the first time anybody in the world has tried to understand women veterans and their risks for dementia," said Yaffe, a professor of psychiatry, neurology and epidemiology at the University of California, San Francisco. "Nothing was known about these older women, yet more and more women are going into the military and more younger women are in combat," she added. Yaffe is also a physician at the San Francisco VA Medical Center. She said her prior research showed similar effects in male veterans. While traumatic brain injury (TBI), depression and post-traumatic stress disorder (PTSD) aren't unique to those in the military, veterans are between two and five times more likely to experience these conditions, according to study documents.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A02

ALZHEIMER’S, DEMENTIA AND COGNITIVE AGING

UCSF Psychiatry researchers surveyed the medical records of more than 350,000 Americans who served during the wars in Iraq and Afghanistan to study a potential link between traumatic brain injury and developing dementia later in life.

In veterans, even a mild case of traumatic brain injury is linked to an increased risk of dementia KAREN KAPLAN MAY 7, 2018

Mild traumatic brain injury may sound like an oxymoron, along the lines of "jumbo shrimp" or "random order." But a new study shows that mild TBIs can have serious consequences for military veterans by raising their risk of dementia. Researchers who examined the medical records of more than 350,000 Americans who served during the wars in Iraq and Afghanistan found that men and women who experienced at least one mild TBI were more than twice as likely as their uninjured peers to develop dementia after they retired from the military. The finding was published Monday in the journal JAMA Neurology. Experts already knew that moderate and severe traumatic brain injuries were linked with an increased risk of dementia and Alzheimer's disease, as well as an earlier onset of these conditions. But whether mild TBIs pose risks as well has been unclear. The question is important because 15–20 percent of veterans who participated in Operation Enduring Freedom and Operation Iraqi Freedom had at least one mild TBI, typically through exposure to a shock wave that follows an explosion. Suffering multiple mild TBIs was not uncommon. A team led by Deborah Barnes, PhD, a researcher with the San Francisco Veterans Affairs Health Care System and UC San Francisco, hoped to gain some insight by casting a very wide net. The team members scoured two large government databases to identify every patient treated by the Veterans Health Administration who was diagnosed with any kind of TBI during a 13-year period between 2001 and 2014. They found 178,779 such patients. For 10 percent of these veterans, the most severe instance of traumatic brain injury was a mild TBI without any loss of consciousness. Another 13 percent had a mild TBI that did cause them to lose consciousness for no more than 30 minutes. In addition, nearly 31 percent of the veterans were diagnosed with mild TBI, but their medical records did not say whether they had lost consciousness as a result. The remaining 46 percent of veterans had a TBI that was classified as moderate or severe. All of these patients were matched with another veteran who was treated by the VHA but did not have a TBI. These 178,779 patients served as controls. In the control group, 2.6 percent of veterans went on to be diagnosed with dementia. So were 6.1 percent of the veterans with a history of TBI.

The more serious a veteran's brain injury, the greater the risk that he or she would subsequently develop dementia. After accounting for factors like age, medical history and psychiatric conditions that could affect the results, the researchers found that those who experienced a mild TBI without losing consciousness were 2.36 times more likely to develop dementia during the study period than those in the control group. The risk of dementia was 2.51 times greater for veterans with mild TBI who did lose consciousness for a short period of time, and it was 3.19 times greater for veterans with mild TBI whose records didn't indicate whether they had lost consciousness or not. Barnes and her team also calculated that veterans with moderate or severe TBI were nearly four times more likely than their uninjured peers to develop dementia during the study period. That was consistent with previous studies, they wrote. On average, the time between entering the study and being diagnosed with dementia was 3.6 years for those who had suffered a TBI, compared with 4.8 years for those who hadn't. It's not entirely clear why the damage caused by a traumatic brain injury would make someone more susceptible to dementia, the study authors noted. Perhaps the inflammation and loss of white matter that follow a TBI create a more fertile environment for the amyloid beta plaques and neurofibrillary tangles associated with dementia, they wrote. The researchers cautioned that their findings might not apply to the public at large, since their study was based solely on military veterans who had served since 2001. Even so, they wrote, the results strengthen the case that mild TBIs can have serious consequences. A pair of neurologists agreed in an editorial that accompanied the study. "This study provides the best information to date that military veterans are at risk for dementia as a consequence of injuries sustained during their service to the United States," wrote Dr. Kimbra Kenney of the U.S. Uniformed Services University and Dr. Ramon Diaz-Arrastia of the University of Pennsylvania's Traumatic Brain Injury Clinical Research Center.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A03

ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

Why are so many more children being diagnosed with ADHD today? CAROLYN L. TODD SEPTEMBER 24, 2018

ADHD, or attention-deficit/hyperactivity disorder, is one of the most common mental health conditions among children in the U.S. And the diagnosis rate of this brain disorder—characterized by a difficulty focusing attention, restlessness, and impulsive behaviors—appears to have increased over the past 20 years, according to a new study published in JAMA. The study is based on data collected by the National Center for Health Statistics at the Centers for Disease Control and Prevention (CDC) annually from 1997 to 2016. Researchers found that the prevalence of ADHD diagnoses in adolescents (ages 4 to 17) rose from 6.1 percent in 1997–1998 to 10.2 percent in 2015–2016. That's about a 67 percent increase. An increase was seen across the board, regardless of sex, race, ethnicity, family income, and geographic location, although it varied a bit among these subgroups. This uptick in ADHD diagnoses isn’t exactly out of the blue, though. Previous research shows it’s part of a continuing trend. For example, the National Survey of Children’s Health found a 42 percent increase in diagnoses of 4- to 17-year-olds between 2003 and 2011. So why are so many children reportedly diagnosed with ADHD today? Increased awareness of the disorder and access to medical care could be a factor. “It may not be so much that ADHD itself has increased, but that the diagnosis of it has increased,” clinical psychologist Faye Dixon, PhD, clinic director at the UC Davis MIND Institute ADHD Clinic, tells SELF. Experts point to a number of possible reasons for this increase, including an increase in health care access. The study authors credit the Affordable Care Act with widening access to care, especially among minority and lower-income communities. “Kids who were being underserved medically before may now have access to resources they didn’t,” Dixon says, including things like ADHD screenings and referrals for clinical evaluations. Researchers also believe we’ve simply become better at understanding the condition. “Almost definitely, increased awareness and decreased stigma are major factors,” John Leikauf, MD, a child and adolescent psychiatrist at Stanford, tells SELF. “There’s been greater public awareness—more good information out there that both parents and teachers are paying attention to,” Dixon adds. In addition to a general increase in knowledge about ADHD, we’ve come to better understand how the condition manifests in girls in particular. The stereotypical presentation of a child with ADHD used to involve a hyperactive boy running around and disrupting class. And while boys are still diagnosed with ADHD more than twice as often as girls, the rate at which girls are diagnosed has doubled in the last 20 years from 3.1 percent to 6.3 percent (the rate in boys increased from 9 percent to 14 percent). Some experts are worried that this study reflects overdiagnosis. Because there is no simple blood test or brain scan to detect ADHD, a proper diagnosis requires a comprehensive evaluation using a number of collaborative sources, Dixon says. This includes interviews with both the child and the parent (and potentially the teacher), symptom rating scales, observation by a doctor, and cognitive or academic assessments. “Performing a valid diagnostic appraisal takes real time,” Stephen P. Hinshaw, PhD, psychology professor at UC Berkeley, and psychiatry professor and vice chair in the Department of Psychiatry at the UCSF Weill Institute for Neurosciences, tells SELF. But it's possible that sometimes doctors may make a diagnosis too quickly or based on incomplete information. “Many non-specialists—pediatricians for kids [and] general practitioners for adults—are confronted with parents [and] individuals seeking an ADHD diagnosis,” Hinshaw says. “Within a 10 to 12 minute evaluation, and especially given the increased recognition of ADHD these days, it's quite possible that ADHD is a convenient diagnosis for individuals with a variety of conditions,” such as depression or anxiety. It should also be noted that the data in this study could contain some "false positives" due to the way it was conducted, which relied solely on parent interviews rather than medical records or clinical evaluations, Dixon says. So some parents may have responded “yes” even if their child never got a formal diagnosis.

If more kids are actually experiencing ADHD today than they were before, then the question becomes why that is. What we know is that ADHD is caused by a mix of genetic and environmental factors and interactions between those things. “The best estimates we have right now indicate that most of the risk for ADHD is genetic, about 70 to 80 percent,” says Dr. Leikauf. (A review published in Molecular Psychiatry this year analyzed 37 twin studies and found a mean heritability of 74 percent.) The genetics are complicated, though, because each different gene contributes only a small amount of risk. Then there is the environmental component, which is even less well understood. “Only about 20 to 30 percent of the risk seems to come from the environment,” Dr. Leikauf says. Although genetics account for the majority of the risk, if we are seeing a true rise in ADHD, it seems likely that environmental factors play a role in the recent rise, “because genetics don’t change that quickly,” he says, i.e. over the course of 20 years. There hasn’t been as much research into the environmental component as there has been into the genetic one, although a number of lines of inquiry have been opened. The evidence we do have is not strong, because it’s difficult to single out any one factor as having a direct influence on a child's risk of developing ADHD. There are several environmental risk factors that research has associated with an increased risk of developing ADHD, though nothing has been shown to be a definitive cause. The environmental risk factor with the strongest evidence may be preterm birth and low birth weight. Hinshaw calls very low birth weight “a clear risk factor for ADHD.” A rigorous meta-analysis published in Pediatrics in 2017, which pooled data from 12 studies and 1,787 infants, found that babies born “very” and “extremely” preterm or at very and extremely low birth weights were about three times more likely to develop ADHD than children born full term at normal weight. (As Hinshaw points out, improvements in neonatal intensive care in the past couple decades means that more children born at extremely low birth weights are surviving.) Other studies have suggested that exposure to toxins (like lead or smoking during pregnancy and traumatic brain injuries may play a role. It's also possible that some of these environmental factors may interact with genetics to increase a child’s risk, Hinshaw says. For example, “It may also be the case that increasing numbers of toxins in the environment—some of which interact with genetic risk for ADHD in certain cases—are leading to greater numbers of cases.” One thing all ADHD experts can agree upon is that we need more research to figure out exactly what’s going on. In light of data like this newest report, a clear understanding of ADHD may be more important than ever. We need to get better at figuring out why people develop ADHD and how to properly diagnose it while also making sure we’re not misdiagnosing or overdiagnosing it. In addition to better diagnostic tools and more treatment options, learning more about the role of environmental factors could lead to possible preventions— especially for children who may be genetically predisposed to the condition.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A04

ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

Why ADHD drug overdoses are rising among U.S. children SY MUKHERJEE MAY 22, 2018

The opioid crisis ravaging America has understandably become the biggest public health story of the past few years. But the specter of potential overmedication, and the consequences thereof, isn’t limited to painkillers—as suggested by a new study noting a significant increase in hospitalizations and overdoses related to ADHD medications. Researchers examined data from U.S. poison control centers between 2000 and 2014. During this timeframe, there were more than 156,000 reported cases related to ADHD, or attention deficit/hyperactivity disorder, drug exposure (such as to popular brands like Adderall, Ritalin, and Vyvanse). And while exposures to the treatments, which can be deadly if misused or abused, dropped slightly between 2011 and 2014, the rate of incidents ballooned nearly 72 percent from 2000 to 2011. Admittedly, many of these exposures (nearly 42 percent) were attributable to simple medication error (although that in and of itself is also concerning from a public safety perspective). But suicide attempts and abuse of ADHD drugs accounted for more than half of the exposures for teenagers aged 13 to 19, according to the study, and one in four of all exposures involved children 12 years old and younger. More than 9,300 of these incidents required medical treatment and several children died. So what’s driving this increase? The researchers have some theories. “The increasing number and rate of reported ADHD medication exposures during the study period is consistent with increasing trends in ADHD diagnosis and medication prescribing. Exposures associated with suspected suicide or medication abuse and/or misuse among adolescents are of particular concern,” wrote the study authors. Indeed, ADHD diagnoses have skyrocketed over the past few decades, according to the Centers for Disease Control (CDC). About 6.1 million children aged two to 17 had been diagnosed with the condition as of 2016, with steady rises between the beginning of the millennium and 2012. Part of that may be attributable to better screening and diagnosis of a behavioral condition that afflicts millions of American children (and adults).

Over the past 20 years, percentage of children with ADHD nearly doubles RACHEL BLUTH AUGUST 31, 2018

The number of children diagnosed with attention deficit hyperactivity disorder has reached more than 10 percent, a significant increase during the past 20 years, according to a study released Friday. The rise was most pronounced in minority groups, suggesting that better access to health insurance and mental health treatment through the Affordable Care Act might have played some role in the increase. The rate of diagnosis during that time period doubled in girls, although it was still much lower than in boys. But the researchers say they found no evidence confirming frequent complaints that the condition is overdiagnosed or misdiagnosed. The U.S. has significantly more instances of ADHD than other developed countries, which researchers said has led some to think Americans are overdiagnosing children. Dr. Wei Bao, the lead author of the study, said in an interview that a review of studies around the world doesn't support that. "I don't think overdiagnosis is the main issue," he said. Nonetheless, those doubts persist. Dr. Stephen Hinshaw, who co-authored a 2014 book called "The ADHD Explosion: Myths, Medication, Money, and Today's Push for Performance," compared ADHD to depression. He said in an interview that neither condition has unequivocal biological markers, so it makes it hard to determine if a patient truly has the condition without lengthy psychological evaluations. Symptoms of ADHD can include inattention, fidgety behavior and impulsivity. "It's probably not a true epidemic of ADHD," said Hinshaw, a professor of psychology at the University of California, Berkeley and a professor of psychiatry at UC San Francisco. "It might be an epidemic of diagnosing it." In interpreting their results, however, the study's authors tied the higher numbers to better understanding of the condition by doctors and the public, new standards for diagnosis and an increase in access to health insurance through the ACA.

But some caution may also be warranted, especially when it comes to dispensing and monitoring addictive drugs.

Advances in medical technology also may have contributed to the increase. Twenty years ago, preterm or low-weight babies had a harder time surviving. Those factors increase the risk of being diagnosed with ADHD.

“The hard part is that ADHD is just like depression, just like autism, just like schizophrenia in that it’s a symptom-based mental disorder,” University of California psychologist and ADHD expert Dr. Stephen Hinshaw said in one interview with the American Psychological Association.

7.2 percent of non-Hispanic white children, 4.7 percent of non-Hispanic black children and 3.6 of Hispanic children were diagnosed with ADHD in the late 1990s, according to the study. By 2016, it was 12 percent of white kids, 12.8 percent of blacks and 6.1 percent of Hispanics.

“We don’t have a blood test or a brain scan yet that’s definitive. I believe that ADHD is a real condition, but it’s on a spectrum, just the way that high blood pressure and autism are. It’s always a bit arbitrary as to who is actually above the cut and who is below because we don’t know exactly where the cut is.”

Over the past several decades, Hinshaw said, there's been an expanded view of who can develop ADHD. It's no longer viewed as a disease that affects only white middle-class boys, as eating disorders are no longer seen as afflicting only white middle-class girls.

 READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A05

Still, he cautioned against overdiagnosing ADHD in communities where behavioral issues could be the result of social or environmental factors such as overcrowded classrooms.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A06

Diagnoses of ADHD have mushroomed over the past few decades, but it remains unclear whether or not the increase can be attributed to an actual rise in the number of cases.

AUTISM SPECTRUM DISORDER AND NEURODEVELOPMENTAL DISORDERS

Analysis of sequences pegs 99 top autism genes JESSICA WRIGHT MAY 10, 2018

The number of top autism genes has risen from 65 to 99, based on an analysis of nearly 35,000 sequences. And researchers are seeing the first hints of autism risk variants in the regions between genes. The new findings are the payoff from increasingly sophisticated analyses of a growing number of sequences from people with autism and their families. Researchers presented the unpublished results today at the 2018 International Society for Autism Research annual meeting in Rotterdam, the Netherlands. “Large-scale collaborations which integrate data have the potential to give context to the results we’re seeing,” says co-lead investigator Stephan Sanders, assistant professor of psychiatry at the University of California, San Francisco. The analysis is based on sequences of exomes—the protein-coding regions of genomes—pulled from multiple datasets. In a 2015 study, Sanders and his colleagues assembled 15,000 sequences and pinpointed 65 genes with strong ties to autism. (This analysis also included genes within large deletions or duplications linked to autism.) For their new work, the team added 20,000 sequences. This alone raised the number of genes from 65 to 79, says Brooke Sheppard, a postdoctoral associate in Sanders’ lab who presented the findings. The team then applied an updated version of their statistical method, called TADA, which indicates whether a variant in a gene is likely to be harmful. The statistics reboot raised the number of significant genes to 99. It also boosted the significance of many genes previously included in the list of 65. For example, FOXP1 is now a leading autism gene and SYNGAP1 is nearly as significant as the top two contenders, CHD8 and SCN2A. Just building a list of genes will not be enough to understand autism, however, says Thomas Bourgeron, professor of genetics at the Institut Pasteur in Paris, who was not involved in the study. Researchers from various disciplines need to work together to tease apart all aspects of the condition, he says. Sanders says he plans to make the list of genes freely available prior to publication, so that scientists can work together to understand how the candidates contribute to autism. Another study presented at the same session explored risk variants in the 99 percent of the genome that does not code for genes. The researchers found evidence that variants in so-called ‘noncoding regions’ may increase autism risk. Sanders and his colleagues first looked at noncoding regions in 2,076 whole genomes. They used a stringent statistical method that corrects for chance findings and did not tie variants in any type of noncoding region to autism. They reported those findings 26 April in Nature Genetics. They then repeated this analysis with more than 7,000 whole genomes. This number is still too low to link any one type of noncoding region to autism with statistical significance, according to Joon An, a postdoctoral associate in Sanders’ lab who presented the results. The team then tried a different approach: They applied a machine-learning method to the first set of sequences to determine what aspects of the genome predict whether someone has autism. They then tested this prediction on another 5,532 sequences. This analysis suggests that people with autism carry an excess of variants in regions that extend 1,500 base pairs before genes and control the genes’ expression, if those regions are also conserved during evolution. “It shows the way forward,” Sanders says. “We can show that there is something in the noncoding genome; it’s just going to take large sample sizes to find it.” Researchers may need more than 24,000 whole genomes to pinpoint the most relevant noncoding regions, Sanders says. And they will need thousands more before they should even attempt to identify individual variants in those regions.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A07

Ask me first: What self-assessments can tell us about autism DAISY YUHAS APRIL 8, 2018

Self-insight is a nettlesome concept. Most people think they know themselves the best, despite the fact that psychology has repeatedly demonstrated the limits of human intuition. Some individuals on the spectrum expect other people to know them better than they know themselves—and that is not always the case, either. Early observers viewed children with autism—a word derived from autos, the Greek word for self—as wrapped up in their own private world. But by the 1980s and 1990s, opinions had swung in a different direction. Some experts argued that autism involves poor introspection, not self-absorption. They noted that people on the spectrum have higher rates of alexithymia, or difficulty recognizing their own feelings, and a limited ability to imagine the minds of others. They guessed this might also extend to having limited self-insight. Over the past decade, many studies have suggested that the truth falls somewhere in between self-absorption and zero introspection. Autism does not always preclude awareness of one’s own or another’s feelings, and if people with autism lack self-insight, those shortcomings may manifest only in their interactions with others. Self-report questionnaires support this picture. One 2014 analysis compared how young people with and without autism evaluate their own personality traits. The researchers reviewed 100 self-reports—half from teens or children with autism and half from those without—plus parent reports for each child. For the most part, the descriptions from parents and children matched well, indicating similar levels of self-awareness. But the young people with autism actually had slightly greater awareness of their own neuroticism, or emotionality, than the typical children. And they agreed less often with their parents on their level of ‘extraversion,’ a measure that calls for insight into social performance and how other people see you. People with autism don’t always lack self-insight, even in social settings. A study last year found that, like typical people, those on the spectrum answer questions about themselves differently depending on context. For example, they reported having more features of autism when they thought about their own behavior compared with that of typical individuals, and fewer autism features compared with others on the spectrum. That sensitivity, the researchers argue, is in itself a sign of strong self-awareness. Even when people protect themselves and provide inaccurate self-reports, that perspective is valuable. For instance, self-reports have shown that teens with autism may not realize or acknowledge when they are being bullied or teased by their peers. “In some ways, that’s really protective, if you don’t think other people are picking on you,” says Somer Bishop of the University of California, San Francisco. “But it can also make you really vulnerable.” Those vulnerabilities are important for a clinician to know about.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A08

AUTISM SPECTRUM DISORDER AND NEURODEVELOPMENT DISORDERS

Autism, developmental delay can have distinct genetic origins JESSICA WRIGHT MAY 11, 2018

Mutations in certain genes contribute specifically to autism, and others only to developmental delay. This finding suggests that, despite overlap between the two conditions, they can be distinct in origin.

Unearthing autism’s genetic basis by manipulating frog brains UCSF FOUNDATION DECEMBER 1, 2018

Researchers presented the unpublished results yesterday at the 2018 International Society for Autism Research annual meeting in Rotterdam, the Netherlands.

If you give frogs the human pregnancy hormone known as human chorionic gonadotropin (hCG), they mate like crazy, producing thousands of embryos at once. Then—if you’re Helen Willsey, PhD—you can take each frog embryo and, at the stage when it’s only two cells, mutate genes in one of those cells. As the embryo grows, the mutated cell will develop into one half of the frog, while the unchanged cell develops into its other half.

“We know there’s a strong relationship between developmental delay and autism, and I think we were worried that we were only capturing the developmental delay component of autism,” says Stephan Sanders, assistant professor of psychiatry at the University of California, San Francisco. “These results refute that and suggest that there is genuine social-impairment risk coming from some of these genes.”

In this way, Willsey says, “you can alter the genes of half of the frog’s brain, leaving the other side untouched.” That’s important if you want to understand how gene mutations affect the brain during development. “By comparing the altered half of the brain to the other, fully functional half, you can pick up subtle differences,” she explains.

The researchers looked at two large sets of sequences of exomes. They analyzed sequences from 12,327 people with autism and 12,879 people with developmental delay, plus their unaffected parents.

Specifically, Willsey wants to know how certain mutations might cause symptoms of autism. Many of these mutations were discovered by Matthew State, MD, PhD, chair of the UCSF Department of Psychiatry and the Oberndorf Family Distinguished Professor, whose work inspired Willsey to join his lab in 2016 as a postdoctoral fellow.

Other teams have analyzed each of these sets to find spontaneous, or de novo, harmful mutations associated with either condition. But this is the first analysis of both sets together, says Bert Klei, a research scientist in Bernie Devlin’s lab at the University of Pittsburgh. The researchers used an updated version of a statistical method called TADA. They found that, overall, de novo harmful mutations are 3.7 times more common in individuals with developmental delay than in people with autism. This finding supports the theory that much of autism risk stems from mild inherited variants, Klei says. However, the sequencing technology in the developmental delay analysis may have been more thorough and so may have detected more variants in that group.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A09

‘Outmoded’ mouse models of autism may still yield new advances NICHOLETTE ZELIADT MARCH 21, 2018

In 2000, two of the most popular mouse models of autism were environmental ones: mice that had been exposed in the womb to a maternal immune response or to valproic acid, a seizure drug. Seven years later, a third set, an inbred strain of mice called BTBR, attracted followers after two teams reported unusual, autism-like features in the mice.

In revealing autism’s underlying biology, Willsey and State’s unique collaboration— which combines clinical genetics with developmental biology—could usher in new approaches to treatment. Their pioneering work is also part of the broader Psychiatric Cell Map Initiative, a partnership between UCSF, UC Berkeley, and UC San Diego to understand mental health on a molecular level. To mutate her frogs’ genes, Willsey uses the revolutionary CRISPR-Cas9 DNA-editing tool. “This is powerful technology,” she says. “It enables us to study many genes at once—whereas historically, you could only study one at a time—and in a very costeffective way.” Willsey has found that the gene mutations she imposes on her frogs start to have an effect early in development. “Six days into development—the equivalent of about 25 weeks for a human—we see differences in the size of the frogs’ forebrains,” she says. The forebrain is responsible for social intelligence and higher-order thinking and learning – areas where people with autism tend to struggle. Willsey hopes to illuminate how each gene functions within a cell and how the mutations that State has helped identify lead to autism. “This is the essential step required to really understand what’s going on in autism and eventually find drugs to reverse it,” she says.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A12

These three models remained the mainstay of autism research until about six years ago, when researchers began linking dozens of genes to autism. Since then, they have put many of the mutated genes into mice to try to understand the condition’s origins. They have learned, for example, that mutations in certain genes can cause subtypes of autism. These days, the early environmental models seem quaint and imprecise compared with the genetic ones. And many autism researchers now eschew some of the older models. And yet some researchers still see promise in the mice. For instance, in a study published in November, researchers matched mice exposed to valproic acid in utero with two genetic mouse models of autism and identified a faulty brain circuit linked to social difficulties. “My view is always not to put too many bets on any one model,” says lead researcher Vikaas Sohal, associate professor of psychiatry at the University of California, San Francisco. “But when you find things that seem to be shared across models, then that seems really important to me.” It’s too soon to tell whether these latest efforts to redeem the older models will prove fruitful. But finding new uses for old models might be wiser than discarding them.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A10  READ AN ACCOMPANYING EDITORIAL ARTICLE BY DR. SOHAL AT PSYCH.UCSF.EDU/A11

Are embryonic frogs the key to unlocking the secrets of autism? UCSF Psychiatry researchers are using them to cost-effectively explore the disorder’s clinical genetic and developmental biology underpinnings.

AUTISM SPECTRUM DISORDER AND NEURODEVELOPMENTAL DISORDERS

Tourette disorder risk genes emerge from expanded analysis STAFF REPORT SEPTEMBER 25, 2018

A recent analysis of an expanded sequencing dataset underscores the role that de novo variants and structural changes play in Tourette disorder. An international team led by investigators at the University of California, San Francisco and Purdue University performed exome sequencing on 291 affected children and their parents, adding to data for Tourette-affected parent-child trios assessed by exome sequencing in the past. Along with an overall uptick in de novo variation in affected children, the researchers found recurrent changes involving the CELSR3 gene and representatives from cell polarity pathways. "You might expect that mutations in these cell polarity genes would affect things like neurons getting to the right place in the brain, or forming the right connections, with the appropriate directionality," co-senior author Jeremy Willsey, a psychiatry and neurodegenerative diseases researcher at UCSF, said in a statement. "Our group has already started experiments modeling the effect of mutations in these cell polarity genes during early brain development." In particular, the de novo alterations appeared to be linked to Tourette syndrome in families with just one affected child and in Tourette cases that affected female children. The study, published online today in Cell Reports, also highlighted overlap between the de novo alterations implicated in Tourette disorder and those described in previous studies of obsessive compulsive disorder (OCD) or autism spectrum disorder (ASD). "While tics are the defining feature of [Tourette disorder], there are many other symptoms that tend to go along with the disorder, like attention problems, learning difficulties, OCD, depression, and anxiety," co-senior author Matthew State, chair of the UCSF psychiatry department, said in a statement.

"If we knew exactly what was going wrong and could target this more specifically, not only could we do a better job of decreasing tics, but we could potentially simultaneously address multiple symptoms that accompany [Tourette disorder]," State said, "and that in many children are more debilitating than the tics themselves." For the new analysis, researchers from the Tourette International Collaborative Genetics Study and other consortia brought together new exome sequencing data for 873 members of 291 Tourette-affected trios—generated with Nimblegen or Agilent capture arrays and Illumina HiSeq 4000 instruments—and data for 511 affected children and their parents who were included in a study published in Neuron last spring that highlighted four potential risk genes. The team's analyses of all 802 trios (representing more than 2,400 individuals), along with 1,184 unaffected controls and 582 sequenced trios from the Simons Simplex Collection, pointed to recurrent de novo alterations in the same four genes—WWC1, FN1, CELSR2, and NIPBL—and led to two more genes with potential ties to Tourette disorder, OPA1 and FBN2. It also confirmed another feature reported in last's year study: an overrepresentation of de novo changes in the individuals with Tourette disorder. The researchers found that the de novo damaging variants identified in Tourette disorder were shared with OCD, even after taking into account cases in which individuals were affected by both conditions. And along with a general uptick in potentially damaging de novo copy number changes, they reported, the Tourette cases tended to involve de novo CNVs that have also been reported in ASD trios from the Simons Simplex Collection and in conditions such as schizophrenia and epilepsy.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A13

Lab-grown neurons showcase effects of autism mutations EMILY ANTHES JANUARY 15, 2018

Neurons derived from people with mutations linked to autism display diverse abnormalities that may help explain the origins of these individuals’ unique features, according to three new studies. In all three studies, researchers reprogrammed skin cells from individuals with one of these mutations into stem cells that can mature into any cell type. They then turned these induced pluripotent stem (iPS) cells into neurons. In one study, Lauren Weiss and her colleagues crafted neurons from people who have a mutation in a region of chromosome 16 associated with autism. These neurons display abnormalities in size, shape and function that correspond with features seen in people with the mutations, the team reported. Researchers also reprogrammed skin cells from people with cardiofaciocutaneous syndrome (CFC), a condition often accompanied by intellectual disability and autism. They found problems in the cultures that suggest an imbalance of brain cell types in people with the condition. Another team generated neurons from people with a deletion or duplication of a region of chromosome 15 linked to autism, epilepsy and related conditions. These neurons show abnormalities that could disrupt their signaling, the team found. Together, the studies provide new insight into the cellular consequences of genetic variants associated with autism and related conditions. “The [researchers] found different mechanisms for how the genes had their effects,” says Anthony Wynshaw-Boris, a professor of genetics at Case Western Reserve University in Cleveland, Ohio, who was not involved in any of the studies. “It underscores the heterogeneity of autism.” The studies also illustrate the promise of the iPS cell approach for understanding how genetic mutations lead to functional impairments, says Alysson Muotri, professor of pediatrics and of cellular and molecular medicine at the University of California, San Diego, who was not involved in the study. “This is a nice representation of the type of work that’s possible,” he says.

Weiss and her colleagues derived neurons from the skin cells of three people with deletions and three with duplications of the 16p11.2 chromosomal region; both types of mutations are associated with autism. The researchers also generated neurons from four typical individuals. Neurons derived from people with a 16p11.2 deletion have unusually large cell bodies and unusually long dendrites, or signal-receiving branches. By contrast, those from people with a duplication in this region are atypically small and have truncated dendrites. The results jibe with the observation that people with a 16p11.2 deletion tend to have macrocephaly, or abnormally large heads, whereas those with an extra copy of the region are likely to have microcephaly, or small heads. Neurons with either type of mutation have fewer synapses, the junctions between neurons, than do those from controls, the researchers found. The findings help explain certain features in people with a 16p11.2 variant. They also suggest that different genes within the region underlie the disparate features seen in people with a mutation in the region. (The region contains 29 genes.) “The mechanism for cell size, which we think is likely to be related to macrocephaly and microcephaly, did appear to be distinct from that of synapse density, which seems more likely to be related to behavioral features,” says Weiss, associate professor of psychiatry at the University of California, San Francisco. The study appeared December 5 in Cell Reports. The next stage is to find specific genes that cause each cellular abnormality, Weiss says. “I think this is definitely a step forward,” Muotri says. “Each one of these cells comes from a specific individual with a different genetic background, so I think this makes the data very robust.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A14

AUTISM SPECTRUM DISORDER AND NEURODEVELOPMENT DISORDERS

Analysis spotlights mutations in the ‘dark’ regions of the genome JESSICA WRIGHT DECEMBER 14, 2018

Spontaneous mutations in stretches of DNA between genes contribute to autism, a robust new analysis of nearly 8,000 whole genomes suggests. These mutations are present in promoters, the segments that abut genes and control their expression. Researchers published the findings today in Science. Scientists have typically hunted for autism mutations within genes, but the vast majority of human DNA lies between genes. This DNA was once dismissed as unimportant, but over the past five years, researchers have begun to search through it for mutations linked to various conditions, including autism. Figuring out which mutations in these regions are harmful and why is a big challenge, says lead researcher Stephan Sanders, assistant professor of psychiatry at the University of California, San Francisco. This is because it is difficult to find a relevant variant among the hordes present across the whole genome. Sanders’ team devised a multistep computational approach to clear this hurdle. “The big message is that this is a tractable problem with current technology,” he says. This new analysis linked 163 types of noncoding variants from the 519 families to autism. Of the 163 categories, 45 include promoters—defined as the 2,000 base pairs closest to the beginning of a gene. Promoters appeared in the categories more than twice as often as would be expected by chance.

Top autism gene may rewire brain by altering expression of other genes ALLA KATSNELSON NOVEMBER 15, 2018

The autism gene TBR1 controls the expression of several other candidate genes that govern the architecture of the cerebral cortex, the brain’s outer section, a new study suggests. TBR1 is among a select set of genes with strong ties to autism. The new findings explain that connection: Mutations in TBR1 may disrupt gene expression in a way that alters brain circuits. When the gene is disabled in layer 6—the deepest layer—of the cerebral cortex of mice at birth, the neurons there do not wire up the way they typically do. They also have unusual gene-expression patterns. “When major neurons like this are confused in terms of the information they are gathering and sending, that’s a huge problem for normal circuits,” says lead investigator John Rubenstein, professor of psychiatry at the University of California, San Francisco. Restoring the expression of WNT7b, one of the genes under TBR1’s control, reverses some of the problems with the circuits, providing a clue to a therapy.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A17

A noncoding variant in one of these promoters predicted autism in the remaining 1,383 families. (The team presented some of this work in May at the 2018 International Society for Autism Research annual meeting in Rotterdam.) The researchers then looked at which of these promoter regions are mutated more often in the children with autism than in their siblings. They found that promoter regions that are preserved across species—that is, conserved throughout evolution —show more mutations among the autistic children.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A15

Researchers gaming the search for new autism treatments SARAH DEWEERDT JUNE 20, 2018

Over the past year, several small pilot studies have produced promising results for games designed to help children with autism, showing that they may improve a range of abilities—including balance, attention and gaze control. The creators of those games are working to prove that those gains persist and translate into real-life benefits. In gaming lingo, they are trying to ‘level up.’ If they succeed, it would be a welcome change to the current state of play. A directory compiled by the advocacy organization Autism Speaks lists more than 700 apps, games and other digital resources intended for people with autism or their families, but only around 5 percent of those have scientific data backing their effectiveness. The scientists designing video games for autism need to walk a fine line: Make the games compelling, but not too compelling. Every 20 minutes a child spends playing a game is 20 minutes spent not engaging in social interactions. The temptation to stay in the virtual world may be particularly intense for people with autism. Akili Interactive, a software company based in Boston, is trying to mitigate this by framing their product, called “Project: EVO,” as a training program rather than a game. “It’s designed to feel like it and to have the graphics at the level of a video game,” says Elysa Marco, a pediatric neurologist at the University of California, San Francisco, who has worked with Akili to validate the program. “But it’s not timed and rewarded in that way.” The pace of play and the timing of the rewards are carefully calibrated to keep children engaged but not addicted, Marco says. “Project: EVO”—based on technology licensed from neuroscientist Adam Gazzaley’s lab at the University of California, San Francisco—aims to improve various aspects of attention, especially cognitive control, or the ability to juggle different tasks and ignore irrelevant information. This ability is often impaired in children with autism or attention deficit hyperactivity disorder (ADHD).  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A16

Optimism and skepticism greet investors’ sudden interest in autism therapy HANNAH FURFARO JULY 9, 2018

In the past five years, more than a dozen private equity firms have injected hundreds of millions of dollars into companies that offer autism treatment. Only one such deal was struck in 2009, but about a dozen were made in 2016, and there were 19 more in 2017. Changes to U.S. federal and state laws now compel insurance companies to reimburse autism treatments—and have made the field attractive to investors. A dearth of major treatment centers for autism has also enticed investors. Many researchers are cautiously optimistic—because the investments may give more families access to care they need. But some experts are worried about this influx, saying a focus on profit might increase costs for families and lower the quality of the treatment offered. “It’s not that I think the companies are inherently bad or that they’re inherently flawed, but it’s all in the execution,” says Bennett Leventhal, professor of child and adolescent psychiatry at the University of California, San Francisco. (Leventhal has provided informal, unpaid consulting to some companies.) “If one looks at how venture capitalists have executed other things, it rarely reduces costs and rarely increases quality,” he says.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A18

AUTISM SPECTRUM DISORDER AND NEURODEVELOPMENTAL DISORDERS

The unbearable sensation of being CLAIRE CONWAY JUNE 28, 2018

Cindy was cradling her son, Elias, against her chest when she and a room full of family simultaneously yelled “Surprise!” to an unsuspecting aunt on her birthday. The outburst shot like a bolt of electricity through Elias. He cried for an hour. Xander, while growing up in the perpetual sensory assault of Manhattan, had to get off the train any time someone with a guitar entered his subway car to play for small change. Cal had a more enigmatic reaction to stimuli. His mother, Jennifer, points to the floor-to-ceiling windows in her hilltop living room. Rooftops, forests, and the San Francisco Bay spool out for miles. Cal was 2 when they moved here from a small, contained apartment. “We got here and Cal was always running away from me,” recalls Jennifer. “He suddenly had all this space and stimulation. He was in sensory overload.”

Beyond nails-on-a-chalkboard Elias, Xander, and Cal all experience extreme reactivity to tactile, auditory, or visual stimulation—a condition known as sensory processing disorder (SPD). Tactile triggers that torment kids with SPD include tags in shirts, wooly sweaters, socks, or an accidental shoulder brush during preschool circle time. Auditory offenses include coffee grinders, the birthday song—surprise or not—and noisy, erratically moving toys. Visual provocations that can set kids off include IMAX movies, crowded stadiums, parking lots, even bikes and tents hanging from the ceiling of a camping store. Whether seen, heard, or felt, what all these sensory inputs have in common is their sudden onset and unpredictability. For an SPD kid, these experiences are beyond a nails-on-a-chalkboard annoyance. “As soon as these kids can move themselves, they will run screaming from the room when these stimuli reach their world,” says Elysa Marco, MD, a cognitive and behavioral pediatric neurologist at UCSF Benioff Children’s Hospital San Francisco and a member of the UCSF Weill Institute for Neurosciences. Take Xander, who is now 14. He would rather be kicked in his hapkido martial arts class than receive a friendly hug. “It physically hurts when people hug me,” he says. This makes his mom, Judy, who is a hugger, think twice before reflexively going in for a hug. And Elias, at age 2, would hold his breath and sit at the bottom of the pool— the silence and water pressure his only solace. Living in a state of perpetual flight, fight, or freeze in reaction to stimuli—or in constant fear of those reactions’ onset—takes a toll on SPD children and their parents alike. The disorder can be profoundly disruptive on every level. As a parent, how do you diaper a child who feels abraded by even a cloth diaper? And if you can’t diaper a child, how do you leave the house, much less go to work? As a preschool teacher, how do you manage a student who falls apart every time a block falls or a tambourine is tapped? And as that student, how do you connect with your classmates when you feel compelled to dart under a table to save yourself from that tumbling block or terrifying tambourine? But as life-altering as SPD is for the children and families affected by it, the disorder isn’t included in the Diagnostic and Statistical Manual (DSM), clinicians’ touchstone for diagnosing psychiatric conditions. Marco’s professional quest is to build a better understanding of the genetics and the neural underpinnings of sensory-processing differences. It’s clear that sensory overresponsivity is shared by many children with genetic or psychological conditions like autism and attention-deficit/hyperactivity disorder (ADHD). Indeed, kids with SPD often struggle with more than hypersensitivity: Some 40 percent of kids with an SPD diagnosis also have dysgraphia, meaning they have such poor fine-motor coordination that they have difficulty writing, and 40 percent also have ADHD (these are not necessarily the same 40 percent). While Marco isn’t hung up on labels, she is committed to achieving better understanding and better therapeutic support for children with sensory-based challenges. She’s encouraged by signs that the field is moving past the DSM debate to a more genetic and symptom-based approach to caring for such kids—in their homes, schools, and communities. According to Marco, who is also an associate professor of neurology, pediatrics, and psychiatry at UCSF, many SPD kids acquire an autism label along the way, which helps with insurance coverage. And there is overlap in the disorders. Nearly 90 percent of kids with autism also have sensory processing differences—some underresponsivity and some overresponsivity. However, kids with SPD do not usually exhibit the fixated interests, repetitive motions, and social indifference that are hallmarks of autism. “Kids with SPD are wanting to socially engage, they just can’t tolerate it,” explains Marco.

For children with sensory processing disorder, everyday sights, sounds, and touches can be profoundly disruptive.

Diagnostic debate Early in her practice, Marco kept seeing kids with what were described as developmental delays; they often had autism diagnoses, too. “I would want to ask these parents about seizures, walking, and language development, but they wanted to know how they were supposed to wash their kids’ hair when they couldn’t touch their head, or how they could just get them clothed and out the door,” recalls Marco. A distinct SPD diagnosis is not without controversy. Some neurologists and pediatricians think SPD is listed exactly where it should be—under autism. Others argue that the condition doesn’t exist at all; for years, clinicians attributed SPD to inadequate parenting. Indeed, every parent of an SPD child has stories of being judged for their parenting by clinicians, loved ones, and strangers alike. “I take Cal to places like a restaurant or party where the volume rises. He just loses it—both imploding and exploding. Or in parking lots, he’ll just sit down,” says Jennifer. “In these scenarios, we always get comments basically indicating that we are obviously not doing this whole parenting thing very well and that with more discipline and authority, his behavior would change. Honestly, I thought that initially, too. And my confidence as a parent went way downhill.” Instead, Marco believes, sensory differences should be regarded as a function of brain structure and brain activity that’s guided by both genetic and environmental influences.

Indisputable evidence Marco’s practice is now spilling over with SPD kids like Elias, Xander, and Cal. She also has a significant social media presence on a Facebook page devoted to sensory processing disorders. Her contributions there resonate with the page’s 85,000 members, who are desperate for answers about their children’s seemingly bizarre reactivity. And in her lab, she is scientifically validating the life experience of SPD patients by identifying their brains’ unique structure and function and their distinct genetic profiles. Marco and her team have done so with great success by leveraging leaps in imaging technology and cross-disciplinary partnerships. Her lab’s first research breakthroughs were back-to-back papers, published in 2013 and 2014 with UCSF radiologist Pratik Mukherjee, MD, PhD. In the first one, Marco and Mukherjee performed brain-imaging studies on kids with SPD, primarily boys, and compared them against typically developing boys. In the SPD kids, they found abnormal tracts in their white matter, a part of the brain that’s essential for perceiving, thinking, and learning. These tracts connect the auditory, visual, and tactile systems involved in sensory processing. It was the first time researchers had identified a biological basis for SPD. In the second study, they compared structural communications in the brains of boys with SPD and boys with autism. They visualized connections among neurons by tracking water moving through the brain’s white matter. When water molecules move in the same direction, connections are thought to be directional and strong, while water going against the flow is a sign of faulty connections.

AUTISM SPECTRUM DISORDER AND NEURODEVELOPMENT DISORDERS “The data was so clear. Kids with sensory processing differences just have different degrees of connection efficiency, particularly in the back part of the brain,” says Marco. This study was the first to show that kids with SPD have quantifiable and distinct differences in brain function. Marco’s research and social media outreach is now arming parents, teachers, and clinicians all over the country—many of whom had never heard of SPD before— with the tools to diagnose and deliver help to kids earlier. The papers are also a wake-up call for neurologists, pediatricians, family, and friends who have questioned the disorder’s existence—a bittersweet validation of what parents of SPD kids already knew. A diagnosis that stands on hard scientific ground gives parents authority to explain rather than apologize for their kids’ behavior. But more importantly, it gives them license to forgive themselves—to say “I am not crazy,” as Elias’s mom, Cindy, puts it. “And this is not my fault.”

A four-part framework That scientific confirmation has shifted the conversation to finding viable treatments. Marco has developed a four-part framework for building a safe, positive world in which SPD kids can thrive. The first two elements—controlling kids’ environment and arousal—help parents figure out how best to structure their children’s physical and emotional surroundings. The third helps kids master healthier reactivity behaviors through brain training. The last helps kids achieve calmness through medications that soften the blows of overstimulation. “First, I encourage parents to get an occupational therapist,” recommends Marco, “to help them figure out both at home and at school what environmental changes need to be done to make their lives quiet and consistent. Because it’s the novel stuff that unseats them.” At home, that can be as simple as organizing their room. At school, it can mean putting tennis balls on the legs of chairs so they don’t make sudden sounds as kindergarteners squirm.

“These kids are not breaking down in school because their parents are doing a bad job or because they are bad kids. Their brains are wired differently.” - ELYSA MARCO, MD

Some schools are more accommodating than others, and parents may find that out the hard way. Kids might be asked to leave a school, or parents might pull them out. “About 25 percent of the kids in my clinic end up in independent schools,” says Marco. Cal is in a small and very structured early intervention program, offered through the public school system, that has been incredibly effective in helping him understand the expectations of a school environment. Other SPD kids, like Xander and Elias, are schooled at home, either online or by teachers who come to them. Marco’s biggest takeaway on school choice is this: You don’t want your child to have post-traumatic stress from a school environment that can’t accommodate them. “Whether your kid is 3, 12, or 18, you need their self-esteem intact,” she says. Her treatment plan also calls for a healthy diet free of simple sugars and simple carbs, a regular bedtime, and consistent exercise, all of which help control the arousal levels of kids—and parents. “If parents are out of control, their kids will be. As a simple start, I suggest they take 10 deep breaths if their kids start to escalate.”

Brain training Typically, kids with SPD have weekly occupational therapy sessions that focus on gross motor skills, as well as fine motor skills for those with dysgraphia. “It is amazing to me to see how really smart kids with terrible handwriting get crushed by school,” says Marco. “On a short-answer test you may know volumes but fail because writing a single sentence is torture.” Programs that work on cognitive control or attention are also critical for SPD kids who have ADHD in addition. Marco has partnered on this front with Joaquin Anguera, PhD, director of the clinical program at Neuroscape, UCSF’s translational neuroscience center. They are addressing cognitive control deficiencies with a new video gaming platform called Project EVO (developed by Akili Interactive Labs, a UCSF startup). On EVO, kids navigate a character along a winding path, avoiding obstacles and responding to variously colored targets. It’s designed to strengthen the brain’s ability to process and prioritize thoughts and external stimuli, and the game gets harder as a player gets better at it.

“Playing EVO actually made a difference in issues of inattention that we measured in the lab and that were reported by parents,” says Anguera, who is also an assistant professor of neurology and psychiatry. “We showed a significant change in the kids’ neural activity. These changes were really deep, and they persisted for nine months beyond the eight-week intervention.” Though medication is the therapy of last resort, it can be crucial. Marco prescribes beta blockers, which dampen kids’ reactivity, particularly to touch. It’s been a game-changer for Xander. “It has really helped,” he says. “I don’t feel nearly as much pain if someone hugs me. But I’ll still never be a huggy person.” Judy is thrilled. “I remember Xander saying when he was little, ‘I wish I could get a jacket, like a bubble jacket, because then I could just walk around and people could hug or brush up against me and it wouldn’t hurt.’ Well, with this drug, he’s finally found that layer of protection.”

New therapeutic targets Anguera and Marco are currently doing a feasibility study of Neuroscape’s Body-Brain Trainer (BBT), a video game for kids with ADHD, some of whom also have SPD. To play BBT, kids are hooked up to a heart monitor and put in front of a large-screen TV. They’re then directed to touch an image that flashes onto the screen. “We designed BBT to see if cognitive and physical training lead to synergistic effects on cognition, so that one plus one equals seven with respect to cognitive control abilities,” explains Anguera. They hope this will be the case for kids who struggle with attention issues. Marco is also poised to publish a study with Elliott Sherr, MD, PhD, a fellow pediatric neurologist. This study looked at whether the genes involved in SPD are the same as or different from those involved in autism; neurogeneticists have uncovered 76 genes that contribute to autism. Marco and Sherr found that kids in Marco’s clinic have an enhanced number of changes in these genes. “And so do their parents,” adds Marco, who was initially uncomfortable sharing that finding with the parents. But it turned out that few were surprised, given their own life experiences or observations of their spouses’. “We’ve also found that 18 percent of our kids have an identifiable genetic difference that is distinct from autism,” she says. Knowing SPD’s structural, functional, and genetic underpinnings provides Marco and her team with both new therapeutic targets and new ways to measure the success of their therapies. Her goal is to understand the relationship between the differences in SPD kids’ brains and their autonomic nervous systems—the part of the nervous system that controls respiration, digestion, the heartbeat, and the fight-or-flight response, which, in SPD kids, can feel like their resting state. “We’ve already shown that just eight weeks of training with EVO can change the ring of neurons in the brain,” says Marco. “These kids’ brains are continually changing through the course of their childhood. If we can keep them in positive environments and train their brains to change in positive ways, we can help them adapt.” With a combination of medication, online schooling, and a deep sensitivity to Xander’s needs, Judy has helped him strike a balance between controlling his environment and integrating with society. He is educated at home, at a pace and in a space tailored to his needs, but he interacts with like-minded kids at large, organized meet-ups. He is now gearing up to apply to MIT. Jennifer and Cindy—also exquisitely attuned to their sons’ sensitivities—are still in the thick of it, and their paths forward are less clear. Elias, like Xander, has found great relief from medication that calms his reactivity. He, too, is being taught at home, by teachers who come to him. He still seeks physical solace through near-perpetual motion. “One morning he woke up in a terrible mood,” says Cindy. Knowing he needed motion, she handed him a pogo stick and started counting. It took 413 jumps to calm him. Her advice to other parents is this: “The only way you are going to get through is to find other families—I say women, because for me it has been moms—who are going through the same thing. Because there is nothing like having a friendship with somebody who gets it.” Cal is just three and a half and goes to two different schools—one very structured, the other a Montessori school and more experiential. The Montessori kids all know Cal’s name, but he doesn’t know theirs. They run toward him and he runs away, pretending he’s king. He plays surrounded by other kids, but is essentially alone. “We are stuck in the heartbreak of what to expect and what to let go of,” says Jennifer. “Will he make friends? Does he want to? Will he be happy?”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A19

DEPRESSION, ANXIETY AND MOOD DISORDERS

Since 2014, Dagmar Dolby (right) and her son David have given more than $60 million to fund research and clinical treatment for mood disorders in the Bay Area.

UCSF receives $20 million from Dolby family for new mood disorders center and research LISA M. KRIEGER SEPTEMBER 18, 2018

Could depression be eased by fixing the brain’s flawed electrical circuitry? A $20 million gift from the family of audio pioneer Ray Dolby to UC San Francisco will help find an answer, through research at the new Dolby Family Center for Mood Disorders. Drugs and other therapies can help many of the millions of Americans who live with depression. But some people struggle with severe symptoms that are beyond the reach of current remedies. The gift, announced Tuesday, builds on the Dolby family’s 2015 investment in mood disorders research at UCSF. Ray Dolby’s wife Dagmar and son David also have donated $21 million for Alzheimer’s disease support at the California Pacific Medical Center, where Ray Dolby received care in his final days. Dolby grew up in Redwood City and graduated in 1951 from Sequoia High School, where he was the student projectionist. He worked at Ampex Corp. while earning his bachelor’s degree in electrical engineering at Stanford University. He went on to invent the Dolby sound system and helped develop the video tape recorder, founding San Francisco-based Dolby Laboratories in 1976. His influence also extended to film. “This is an extremely generous gift that really is a game-changer for research on mood disorders,” said Dr. Andrew Krystal, vice chair of research in UCSF’s Department of Psychiatry. “Depression is a problem that affects people’s lives in a pervasive way,” he said. “When severe, it leaves people essentially nonfunctional.” The research will be conducted at the new Dolby Family Center for Mood Disorders, which “will build on our exceptionally strong basic neuroscience program by expanding cutting-edge research, growing our clinical and training efforts, and promoting innovative and collaborative science,” said UCSF Chancellor Sam Hawgood. The goal of the new research is to develop a new personalized approach to treatment that involves identifying the circuitry dysfunction in the brain, and then targeting treatment directly, said Krystal.

There has been much recent research into the use of functional magnetic resonance imaging (fMRI) and electroencephalograms (EEG) to identify regions of the brain that seem involved in regulation of mood. UCSF wants to start a first-of-its-kind clinical trial in early 2019 that studies the circuits connecting regions of the brain which seem important in central processing—and are thought to play a role in depression. An intricate network of electrodes will be surgically implanted on the surface of the patients’ brains, allowing Krystal and his team to determine which circuits are involved in mood and whether electrical stimulation of these circuits could lift spirits. Other teams have reported that stimulation can improve symptoms for disorders like epilepsy and obsessive compulsive disorder, with some success. During treatment, patients’ moods improved. That led to testing brain stimulation for depression. “It’s unique, because you measure something and then treat it by specifically targeting a dysfunctional circuitry when you need to, rather than treating everything all the time,” said Krystal. It’s a novel approach and very expensive, because different regions of the brain may be involved in different people. The team also aims to identify specific brain biomarkers—reflecting the activity of inflammatory, neurotransmitter, neurotrophic, neuroendocrine and metabolic systems—to aid diagnosis and treatment of depression, anxiety, and other mood disorders. Over the past two years, support from the Dolby family has enabled Krystal to build a research program focused on testing the hypotheses that mood disorders can be the first manifestation of dementia—and that the particular features of a patient’s mood disorder are specific to the type of dementia he or she may ultimately develop, according to UCSF. This work has the potential to improve care and also boost understanding of the changes in brain circuit function that seem linked to mood disorders.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A20

DEPRESSION, ANXIETY AND MOOD DISORDERS

Scientists uncover a circuit for sadness in the human brain JON HAMILTON NOVEMBER 8, 2018

Scientists may have caught a glimpse of what sadness looks like in the brain.

Even so, Sohal says the finding may bring comfort to people with depression.

A study of 21 people found that for most, feeling down was associated with greater communication between brain areas involved in emotion and memory, a team from the University of California, San Francisco reported Thursday in the journal Cell.

"As a psychiatrist, it's incredibly powerful to just be able to say to patients, 'Hey, I know there's something happening in your brain when you're feeling down.' "

"There was one network that over and over would tell us whether they were feeling happy or sad," says Vikaas Sohal, an associate professor of psychiatry at UCSF. The finding could lead to a better understanding of mood disorders, and perhaps new ways of treating them. Previous research had established that sadness and other emotions involve the amygdala, an almond-shaped mass found in each side of the brain. And there also was evidence that the hippocampus, which is associated with memory, can play a role in emotion. But Sohal and the other researchers were curious about precisely what these and other brain areas are doing when someone's mood shifts. "We really wanted to get at, you know, when you're feeling down or feeling happy, what exactly is happening in the brain at those moments," Sohal says. You can't get that information from brain scans, which don't capture changes that happen in fractions of a second. So the team studied 21 people who were in the hospital awaiting brain surgery for severe epilepsy. Before the surgery, doctors insert tiny wires into the brain and monitor its electrical activity for up to a week. Sohal says the team hoped those recordings would help answer a basic question: "When patients are sitting there, or watching TV or talking with their family or waiting or being anxious, which regions of the brain are talking to each other?"

In one sense, the new study merely confirms the results of early research on animals, says Dr. Joshua Gordon, who directs the National Institute of Mental Health. "It's finding a circuit, a piece of the brain that we kind of already knew was involved in mood—that's the less-than-wow part," he says. "The wow part is that it's in human beings." The study also provides a detailed map of what's going on in the human brain, which is what doctors and scientists need to look for better treatments for patients with mood disorders. "It's really important that we find the circuits underlying mood so we can learn more about them and treat them with tools we are developing that are aimed at circuits." Those tools include transcranial magnetic stimulation, which uses pulses of energy delivered through the skull to change the activity of brain circuits. The study also shows the value of the BRAIN Initiative, which was launched by then-President Obama in 2013, Gordon says. "The goals of the BRAIN Initiative are to develop tools we can use to get unprecedented access to, and understanding of, the brain," Gordon says. "This study does both." The research team's funding came in part from the Defense Advanced Research Projects Agency, a major supporter of the BRAIN Initiative.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A22

The patients agreed to keep a running log of their mood. And the team looked to see whether certain moods coincided with communication within specific networks in the brain. The researchers thought they might find networks that were similar in a couple of people. But they were "really surprised" to learn that 13 of the 21 patients shared the same network, Sohal says. Still, he says, it makes sense that communication between areas involved in memory and emotion would be associated with sadness. "Maybe you're feeling down and so you start remembering times in your life when bad things have happened, or you are starting to remember those experiences and that is what is making you feel down," he says. The study couldn't confirm that. It also couldn't show whether the increase in communication was the result of a mood change or the cause of one.

Anxiety, multitasking, and video games as medicine REBECCA C. WALDER SEPTEMBER 27, 2018

Adam Gazzaley is an MD and a PhD, meaning he's a neurologist and a neuroscientist. If your first thought is "Wow, that must have been a lot of school"—you're not alone. He has studied the brain for decades, specifically researching the connection between technology and anxiety, depression, ADHD, and dementia. His book, The Distracted Mind, and his viral article, "The Cognition Crisis," explore how technology can both cause the problem and be a solution. In this episode of the mbg podcast, we sat down with Dr. Gazzaley to talk about just how vulnerable the human brain—especially a young human brain—is to distraction, multitasking, and "interference." We have a crisis on our hands in the form of technology changing how we think and feel, and Dr. Gazzaley believes that until we tackle this challenge, we won't be able to tackle other major challenges facing our world, like climate change.  LISTEN TO THE PODCAST EPISODE AT PSYCH.UCSF.EDU/A21

Vikaas Sohal, MD, PhD

DEPRESSION, ANXIETY AND MOOD DISORDERS

Divorcing after 50: How ‘gray divorce’ affects your health HEIDI GODMAN SEPTEMBER 21, 2018

Divorce can be tough on health, no matter your age. Legal uncoupling is listed as the No. 2 stressor on the Holmes-Rahe Stress Inventory, a scale that predicts which life events are likely to cause a stress-induced health breakdown within two years. And for people age 50 or older, whose divorce rates have doubled since 1990, divorce may be even harder on their health. "What I see among older patients is that divorce can have myriad psychological and physical consequences, especially for those with already existing medical problems," says Dr. Andreea Seritan, a geriatric psychiatrist and professor of clinical psychiatry at the University of California, San Francisco. Divorce rates for people younger than age 50 are higher (about double) than they are for seniors. But younger couples' divorce rates aren't seeing dramatic increases. For 40-somethings, divorce rates are only slightly higher than they were in 1990. For people younger than 40, divorce rates have actually fallen. The sudden jump in older age divorce rates is a phenomenon commonly called gray divorce. It was uncovered by Bowling Green State University researchers Susan Brown and I-Fen Lin in a landmark 2012 study. Brown says the data were the same as recently as 2016. "Older adults are at the forefront of family change," explains Brown, a distinguished professor and chair of the sociology department. "Most divorces among older adults are happening in the 50- to 64-year-old age range." Some of Brown's ongoing research suggests that gray divorce is associated with elevated depressive symptoms.

Seritan isn't surprised. She frequently sees newly divorced seniors who've developed depression, chronic stress or anxiety. She says gray divorcees may also experience post-traumatic stress symptoms such as nightmares and flashbacks of unhappy events (especially for people who've been in abusive relationships). Psychological conditions on their own are linked to physical problems. Depression is associated with heart disease, Parkinson's disease and Type 2 diabetes. Untreated chronic stress increases the risk for developing high blood pressure, insomnia, heart disease, obesity and a weakened immune system. And it can worsen symptoms of existing health problems. Seritan says even the symptoms of psychological distress—fatigue, lack of focus, poor memory, muscle aches, hopelessness, mood swings, changes in appetite and sleep or a loss of interest in activities that once brought pleasure—are enough to hurt health, especially when a combination of symptoms is at play. Divorce may also affect older adults when it comes to caregiving and finances Divorcing may mean a senior loses his or her closest caregiver. "The spouse is the one who knows the health issues best and makes sure someone takes medications or has groceries or a ride to a doctor's appointment," Seritan points out.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A23

How anxiety lies to our girls—and what you can do about it SARA ISRAELSEN-HARTLEY & ERICA EVANS AUGUST 15, 2018

The first day of seventh grade found Katherine huddled on the floor of her bathroom, clutching the toilet. When she wasn’t throwing up she was crying, doubled over in pain.

Needing to be competitive, nurturing and flawless is what Hinshaw refers to as the “triple bind”—a trio of unhealthy, stereotypical expectations that are “physically and psychologically impossible."

By eighth grade, her stomach cramps and vomiting were more frequent and worse.

Yet when girls try and fail, they blame themselves, he says, not the unrealistic expectations.

Finally, after Katherine had missed nearly three weeks of school, and completed a battery of medical tests, she and her mom realized what was going on—this was anxiety. For Katherine, a high-achieving middle-school student, the pressures to live up to a growing set of expectations were wreaking havoc. “I need to be perfect,” says the now 15-year-old who agreed to speak on condition of just using her first name. “I need to be good, I need to be smart, and pretty and everything. I need to be all of it.” In her mind, society expects nothing less than perfection from her. From all girls. Since the women's liberation movement of the 1960s, society has tried to break through glass ceilings and level the playing field between boys and girls, says Stephen Hinshaw, a professor of psychology at the University of California, Berkeley and vice chair for psychology at the University of California, San Francisco, listing policies like Title IX, college admission changes and increasing STEM involvement among girls through things like all-girl coding camps. And girls have stepped up. They’re outperforming boys in elementary school, out-graduating young men in high school, out-enrolling men in college and out-achieving men in advanced degrees. For the first time, more than half of all medical school students in 2017 were women, and as of 2016, 11.2 percent of women ages 25 to 29 had a master’s degree or higher, compared to 7.2 percent of men. On the outside, young women are excelling. But on the inside, many feel like they’re imploding. Nearly 38 percent of teen girls have an anxiety disorder, compared to 26 percent of boys, according to the National Institute of Mental Health. More than two-thirds of antidepressants prescribed for teens are for girls, and girls comprise more than 90 percent of hospital admissions for eating disorders.

Experts don’t know whether these expectations are creating anxiety in teens, or simply fueling pre-existing insecurities and triggering genetic predispositions.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A24

Can you ever stop taking antidepressants? REBECCA C. WALDER SEPTEMBER 27, 2018

When a life event triggers the use of antidepressants, the question that inevitably follows is “How soon can I stop taking these?” While there is no one size fits all answer, the clear consensus from those on the other side of the prescription pad is to proceed with caution. Apart from paying attention to your own eating, exercise, and sleep patterns, there are self-assessment tools you can use prior to broaching the conversation with your doctor. “Antidepressants are not a medication you can just stop,” says Renee Binder, MD, a past president of the American Psychiatric Association and Professor of Psychiatry, University of California, San Francisco School of Medicine. “Whether and how you get off antidepressants is a decision best made between you and your doctor. Depression is a biological brain disorder. It has nothing to do with a weakness of character.” “Depression has a habit of recurring,” Dr. Binder points out. “If this is a patient’s only episode of depression, there is still a 50 percent chance of recurrence.” “When the patient begins to feel better, it’s an ideal time to start that conversation,” Dr. Binder says. One key is to plan the process when you there are no major life changes on the horizon, she warns. “If you are anticipating a new job, getting married, or experiencing an otherwise stressful life event (even good stress!), it’s wise to wait until a less stressful time.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A25

DEPRESSION, ANXIETY AND MOOD DISORDERS

Depression and anxiety linked to higher risk of other major health conditions DAVID DISALVO DECEMBER 17, 2018

People suffering from anxiety and depression may be at higher risk for developing other major health conditions like heart disease, suggests new research, perhaps at levels comparable to smoking and obesity—though the "perhaps" in this case is significant. The study analyzed health data for more than 15,000 adults over a four-year period from the Health and Retirement study, a large U.S. population-based study of older adults. Among that group, 16 percent suffered from high levels of anxiety and depression, 31 percent were obese, and 14 percent were smokers. The researchers found that compared to those without anxiety and depression, participants suffering from those conditions were at 65 percent increased risk of a heart condition, 64 percent for stroke, and 50 percent for high blood pressure. Risk was especially high for arthritis at 87 percent. “These increased odds are similar to those of participants who are smokers or are obese,” said senior study author Aoife O’Donovan, PhD, of the UCSF Department of Psychiatry. “However, for arthritis, high anxiety and depression seem to confer higher risks than smoking and obesity.” The research team also found strong correlative links between depression and anxiety with more common symptoms such as headache, back pain, upset stomach, and shortness of breath. Headache occurrence was 161 percent higher among depression and anxiety patients, compared with no increase among smokers and obese participants. The study didn’t find a correlation between depression, anxiety and higher risk of cancer. “Our findings are in line with a lot of other studies showing that psychological distress is not a strong predictor of many types of cancer,” O’Donovan said. “On top of highlighting that mental health matters for a whole host of medical illnesses, it is important that we promote these null findings. We need to stop attributing cancer diagnoses to histories of stress, depression and anxiety.” The researchers who conducted the latest study emphasized the importance of health care professionals paying more attention to depression and anxiety as predictors of other major health conditions. The results of the study underscore the “long-term costs of untreated depression and anxiety,” added O’Donovan.

Study finds primary doctors can do a better job of depression screening ALLEN CONE SEPTEMBER 12, 2018

Primary care physicians rarely package depression assessments with patient screenings for hazardous alcohol use, according to a study. In research published this week in the Journal of the American Board of Family Medicine, scientists found screenings identify symptoms of depression that doctors may not otherwise notice. Primary care settings are an "untapped resource" to treat depression, according to first author Dr. Matthew Hirschtritt, a forensic psychiatry fellow at University of California San Francisco. "Our study provides evidence that, with a simple questionnaire, primary care doctors have a big opportunity to better spot depressive symptoms in at-risk patients and help improve their lives through treatment," Hirschtritt said in a press release. "Depressive symptoms are extremely common, but we know many people don't make it to specialty psychiatric treatment," said Dr. Stacy Sterling of the Kaiser Permanente Northern California Division of Research. "Many people do already have a strong relationship with their primary care provider, so it may actually be the perfect environment for behavioral health intervention." Studied were more than 2.8 million Kaiser Permanente Northern California primary care patients who had been screened for hazardous alcohol use. Patients were asked how many days they typically drank per week, and the number of drinks per day. "The finding that I found most concerning is that individuals who self-identified as white were more likely to receive screening than were historically marginalized ethnic groups," Hirschtritt said. Although non-white patients were less likely to be screened for depression than white ones, they were more likely to report clinically significant depressive symptoms, the authors found. "It's unclear why non-white individuals weren't screened at a higher rate," Hirschtritt said. "These patients may face multiple stressors that put them at a higher risk for depression, in addition to hazardous alcohol use." Approximately 8.1 percent of U.S. adults have exhibited significant depressive symptoms in the past two weeks and 21.6 percent have had some depressive symptoms at some point, Hirschtritt said.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A27

 READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A26

Hospitals struggle with postpartum depression cases APRIL DEMBOSKY JANUARY 28, 2018

With her first daughter, everything was fine. But four months after having her second, Jessica Porten started feeling really irritable. Little things would annoy her, like her glider chair.

When patients reference violent thoughts, it forces doctors to think about things in a different way, said Melanie Thomas, MD, a psychiatrist at UC San Francisco and Zuckerberg San Francisco General Hospital.

She read that this could be a symptom of post-partum depression—a condition that affects up to one in five women in California during or after pregnancy. The rates have spurred state lawmakers to introduce a package of bills to improve mental health screening and treatment for new moms.

California law allows doctors to involuntarily confine a person with a mental disorder if they are a danger to themselves or others. But Thomas says what constitutes imminent danger can be vague.

She went to Capital OB/GYN, a women’s clinic in Sacramento that takes her Medi-Cal coverage, to talk about medication options and therapy. She admitted to the nurse that she was having some violent thoughts. The nurse called the police. The police escorted Porten and her baby to the Sutter Emergency Room. Hospital staff made her change into a gown and took her purse, but they let her keep her diaper bag for the baby. They put them both in a room, under constant watch. Finally, at midnight, 10 hours after she first got to the doctors’ office, a social worker sent her home. She wrote on Facebook that the whole thing made her feel like a criminal. “It was all legality,” Porten said. “Everybody was protecting their own liability instead of thinking of me.”

“You can imagine a provider, a social worker, any number of people might interpret that phrase in different ways, about what is necessary to report and what isn’t,” she said. The laws and medical protocols don’t always line up, Thomas said. There have been times she felt asked to put legal reasoning over her clinical judgment. “The fragmented aspects of our system of care make it difficult to get women the help that they really want,” she said. That’s one reason lawmakers in Sacramento are now introducing a package of bills to address maternal mental health. Assemblyman Brian Maienschein, R-San Diego, is backing two of them. One would require doctors to screen new moms for depression —under current law, it’s voluntary.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A28

DEPRESSION, ANXIETY AND MOOD DISORDERS

In a first, Veterans Affairs centers use genetic testing to treat depression CATHERINE HO MARCH 17, 2018

Kewchang Lee, a psychiatrist who oversees mental health consultations at the San Francisco Veterans Affairs Medical Center, is not used to being studied. But in recent weeks, Lee signed up to be part of a first-of-its-kind experiment that is playing out in 21 VA health centers around the country, including San Francisco and Palo Alto. For the first time since he began practicing medicine in 1992, Lee is asking a small number of his patients to take a cheek swab for a genetic test analyzing their ability to metabolize commonly prescribed antidepressants. Lee uses the information to help decide which and how much of an antidepressant to prescribe. And he’s allowing other psychiatrists to observe, during the course of the two-year VA study, whether his knowledge of the genetic information will ultimately lead to better recovery and remission rates among his patients with major depressive disorder. It is the first study in the VA health system to examine whether doctors gaining knowledge of their patients’ genomic composition can help shape more precise treatment plans for depression. “Different people for genetic reasons metabolize things differently,” said Lee, who is also a clinical professor of psychiatry at UCSF. “With fast metabolizers, I might not necessarily change the antidepressant, but might target a higher dose. If a patient is a slow metabolizer, I might consider changing the antidepressant itself depending on the side-effect profile of that drug.” Depression, post-traumatic stress disorder and other mental health disorders are prevalent among combat veterans. Up to 25 percent of returning troops experience depression — compared to 8 percent among the U.S. adult population. In one recent survey of 700 San Francisco veterans, 58 percent had probable depression, based on their answers to a health questionnaire, according to a 2017 report by the USC Center for Innovation and Research on Veterans & Military Families, part of the university’s Suzanne Dworak-Peck School of Social Work. The recent tragedy at Yountville’s Pathway Home, where Army infantryman Albert Wong fatally shot two Pathway staff members, a VA clinical psychologist and himself, highlights the need to advance research to improve mental health treatment. Wong had been undergoing PTSD treatment at Pathway, a treatment center for troubled veterans of the post-Sept. 11 wars, and had been asked to leave the program two weeks before the shooting. “When things like this happen, we all think about ways that we can improve mental health care and access to mental health care,” Lee said. “It does speak to the need for funding for research and studies to improve the treatment of conditions like PTSD and depression.” The VA depression study, funded by $12 million from the Department of Veterans Affairs, seeks to enroll 2,000 pairs of doctors and veterans who have not responded well to previous treatment for depression. Patients will take a test that analyzes 12 genes associated with the body’s and brain’s ability to metabolize and process 55 commonly prescribed antidepressants and mood stabilizers, including Zoloft, Prozac and Wellbutrin. The test uses an algorithm to produce a report matching each patient with the antidepressants that are most likely to work well, moderately well and not well. The test is provided by Myriad Genetics, a Salt Lake City company, at no cost to the patient. Lee is the first doctor to join the study at the San Francisco VA. So far, four of his patients have agreed to participate. The information gleaned from the tests so far has been “potentially useful,” Lee said. “It’s something I would consider using if it were readily available and inexpensive.” Researchers have been making great strides over the past decade in better understanding the role genetics plays in psychiatric syndromes including depression, bipolar disorder and schizophrenia. But the use of genetic testing in routine psychiatric care is still in the early stages of adoption. Some psychiatrists in private practice order genetic tests, some of which are covered partially or entirely by commercial insurers, but the practice is not commonplace in the VA or other public health systems.

Kewchang Lee, MD, is chief of the San Francisco VA Medical Center’s psychiatric consultation unit, as well as the director of the UCSF Consultation-Liaison Psychiatry Fellowship.

This is in part because there are few independent, large studies that have determined whether having a patient’s genetic information before prescribing medication makes a difference in their treatment outcome, said Dr. Steven Batki, the study’s co-principal investigator for the San Francisco VA site. “Without genetic testing...psychiatric medication uses a little bit of guesswork,” Batki said. “If you’re seeing 10 different people with depression, you might start them all out on Prozac but maybe only a third will respond. Up until now, psychiatrists are using their best clinical judgment without clear scientific reasons for picking one antidepressant over another, other than different side effects. That’s what this study is trying to help.” In half of the study’s participants, the veterans’ physicians will have immediate access to their test results, and can prescribe a medication based on that information. In the other half, physicians will wait six months before seeing the test results, and in the meantime will prescribe a medication based on their own medical judgment before having seen the test results. The VA health system is often a testing ground for new medical research because many of its medical centers are affiliated with leading research institutions, such as UCSF and Stanford in the Bay Area. But the study opens the door for future studies that could help doctors incorporates genetics in psychiatric care into health systems beyond the VA, experts said. “The VA system can take emerging data and begin to help define what personalized medicine is in psychiatric illnesses,” said Matt State, chair of the Department of Psychiatry at UCSF, who is not involved in the study but oversees doctors at the San Francisco VA who treat patients for psychiatric disorders. “It is a path forward to being much more personalized about understanding a patient’s prognosis.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A29

EATING DISORDERS AND NUTRITION

Study finds obese young adults are prone to purging, binging ROBERT PREIDT JUNE 12, 2018

Brain cell ‘antenna’ may be key to understanding obesity NICHOLAS WEILER JANUARY 8, 2018

Overweight and obese young adults are twice as likely as those who are thinner to try to control their weight through binging and purging, using laxatives or diuretics, or forcing themselves to vomit, a new study finds.

UC San Francisco researchers have discovered that the brain's ability to regulate body weight depends on a novel form of signaling in the brain's "hunger circuit" via antenna-like structures on neurons called primary cilia.

The University of California, San Francisco (UCSF) researchers noted that these unhealthy weight-control methods increase the risk of depression, alcohol and tobacco use, poor nutrition and even significant weight gain.

Primary cilia are distinct from motile cilia, the finger-like projections that act as a sort of cellular conveyer belt, with functions such as removing debris from the lungs and windpipe. Immotile primary cilia were once thought to be vestigial, like a cellular appendix, but in the past decade, research at UCSF and elsewhere has revealed that these structures play a key role in many forms of hormonal signaling in the body.

For the study, the research team analyzed data from more than 14,000 young adults, aged 18 to 24, across the United States. The findings showed that rates of unhealthy weight-control methods were: 29 percent among obese and overweight women; 16 percent among underweight or normal-weight women; 15 percent among obese and overweight men; and 7.5 percent among underweight or normal-weight men. Diagnoses of eating disorders, such as anorexia and bulimia, were twice as high among those who were normal weight or underweight. But this finding may be due to under-recognition that these conditions occur in overweight and obese young adults, according to study first author Dr. Jason Nagata. Nagata is a fellow in the Eating Disorders Program at UCSF Benioff Children's Hospitals and UCSF Langley Porter Psychiatric Hospital and Clinics. "Clinicians and parents should be aware that eating disorders occur in people who are overweight and obese. They should ask if and how young people are trying to lose weight and discourage unsafe practices, which can lead to severe illness and hospitalization," Nagata said. According to the study's senior author, Dr. Kirsten Bibbins-Domingo, "Young adulthood is a critical developmental period that is distinct from adolescence and older adulthood but, unfortunately, this period has not received sufficient attention within clinical or research circles." "Although they are usually assumed to be healthy, young adults often have poor patterns of health behaviors and are less likely to be engaged in medical care," she added. The study was published June 12 in the Journal of General Internal Medicine.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A30

Anorexia more stubborn to treat than previously believed, study shows STUART MURRAY AUGUST 30, 2018

Anorexia nervosa is a psychiatric illness that primarily effects young people during their adolescence. While anorexia is relatively uncommon, affecting about 1 percent of the population, it can be lethal. Indeed, despite its relatively early onset, anorexia can last for several decades for more than half of those afflicted. It can lead to many associated psychiatric and medical risk factors, which in part explains why anorexia has the highest mortality rates of any psychiatric disorder. Those who suffer with anorexia have a powerful fear of weight gain and a cruelly distorted self-perception. As a result, some restrict caloric consumption to fewer than 400 calories per day, which is less than a quarter of what is typically recommended for adolescents. Those with anorexia may quickly become emaciated and lose more than 25 percent of their typical body weight. This rapid weight loss causes cardiac abnormalities, structural and functional brain alterations, irreparable bone disease, and in some instances, sudden death. I have specialized in the treatment of anorexia nervosa for 10 years, and my National Institute of Mental Health-funded program of research is exclusively focused on understanding the mechanisms of anorexia nervosa, with a view to informing precise treatment approaches. Colleagues and I recently completed the largest meta- analysis ever undertaken of outcomes for existing treatments for anorexia. Our analysis revealed major flaws in the way people are currently treated for this illness.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A31

Now the new UCSF study—published January 8, 2018 in Nature Genetics—shows that primary cilia also play a crucial role in signaling within the brain. Neuroscientists are accustomed to thinking of brain signaling in terms of direct chemical or electrical communication among neurons at sites called synapses, but the new findings reveal that chemical signaling at primary cilia may also play an important, and previously overlooked role. In addition, the findings suggest potential new therapeutic approaches to the growing global obesity epidemic, the researchers say. The modern epidemic of obesity is driven largely by environmental factors, including access to essentially unlimited sources of ready calories paired with increasingly sedentary lifestyles. But not everyone exposed to the same unhealthy conditions becomes overweight. Studies have estimated that genetics contribute between 40 and 70 percent to people's inclination towards unhealthy weight gain. Since the 1990s, geneticists have shown that most of the genetic alterations that contribute to severe obesity in humans appear to disrupt a network of neurons within the brain's hypothalamus. This "hunger circuit" monitors levels of leptin, a hormone secreted by fat cells, and uses this information to adjust appetite and energy expenditure to maintain a stable weight. People (and mice) with mutations in the leptin gene itself, or in neural genes involved in detecting and responding to leptin, cannot detect when their body has already got plenty of fat, and constantly eat as if they were starving. The system works like this: fat cells throughout your body secrete leptin, which travels to your brain and is detected by neurons in a part of the hypothalamus called the arcuate nucleus. These neurons then relay information about leptin levels to a group of neurons in another part of the hypothalamus, called the paraventricular nucleus (PVN), which determine if leptin levels are too high (indicating excess body fat) or too low (indicating dangerously depleted energy reserves). The PVN neurons then send out instructions to the rest of the brain to adjust your appetite and energy level appropriately. In the new study, team lead by Christian Vaisse, MD, PhD, a professor in the Diabetes Center at UCSF and a member of the UCSF Institute for Human Genetics, collaborated with Jeremy Reiter, MD, PhD, professor and chair of the Department of Biochemistry at UCSF, as well as neuroscientist Mark von Zastrow, MD, PhD, a professor of psychiatry at UCSF, to study whether there might be a link between how MC4R mutations and cilia defects drive obesity. They began by fluorescently tagging the MC4R protein in the brains of laboratory mice. When the researchers examined the newly visible MC4R-expressing neurons, they found that the MC4R protein was uniquely concentrated in the cells' primary cilia, suggesting that its key appetite-regulating function may occur there. Indeed, when the researchers caused mice to express the mutated versions of the human MC4R gene seen in patients with extreme obesity, they found that the MC4R protein failed to reach the cilia. These imaging studies also examined a protein called adenylyl cyclase 3 (ADCY3), which, like MC4R, localizes to primary cilia and has been recently associated with obesity. This protein is known to mediate signaling through proteins like MC4R, so to test whether these two proteins interact in the primary cilia of MC4R-expressing neurons in the PVN, the researchers blocked ADCY3 function in these cells in mice, and found that the animals significantly increased their food consumption and began to exhibit signs of obesity. The researchers conclude that ADCY3 and MC4R must come together in the primary cilia of PVN neurons to allow these cells to detect signals from the arcuate nucleus indicating high body-fat levels and to respond appropriately by reducing appetite. This suggests that if genetic mutations prevent MC4R from getting to the cilia, or if other genetic defects damage the primary cilium itself, the brain has no way to pull the emergency brake on weight gain.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A32

EATING DISORDERS AND NUTRITION

‘Get shredded in six weeks!’: The problem with extreme male body transformations SIRIN KALE JUNE 27, 2018

In 2004, Men’s Health journalist Dan Rookwood walked into his editor’s office in a funk. The topless beefcakes who appeared on their covers were unrealistic, he had decided. No one actually looked like that—not least the staff of what was then the UK’s third-biggest-selling men’s magazine. His editor smiled. He felt a feature coming on. Just over a year later, a smirking Rookwood appeared on the March 2006 cover of Men’s Health. His biceps were huge, his six-pack extraordinarily well defined. “From fat to flat!” read the cover line, alongside a picture of a mournful-looking Rookwood, pre-transformation, his belly soft and rounded. It became the biggest-selling Men’s Health issue of all time. The transformation genre of men’s magazine cover stories was born. Since then, they have become the bread and butter (or steamed spinach and chicken breast) of these publications. Pick up a copy of Men’s Health every six months or so and you will see a topless staffer grinning for the camera, next to the words “Get shredded in six weeks!” or “From scrawny to brawny!” In difficult times for print publishing, Men’s Health and its competitors hit upon a monetisable formula. Across the country, podgy dads and harried office workers dreamed of having the perfect physique. Makeover transformations promised the body they longed for—typically within eight to 12 weeks.

A cottage industry whirred into action. You can join the Men’s Health Transform Club or purchase a copy of the Men’s Fitness 12 Week Body Plan. The message is clear: ditch the carbs, start deadlifting and you too can upgrade your dad bod to the crisply defined torso of a Hollywood hunk. The Men’s Health team did more than shift magazines: they ushered in a protein-blasted physical aesthetic. In this new paradigm of masculine excellence, anyone can achieve physical perfection if they put in the hours. It is an aspirational narrative, accompanied by a specific vernacular. Men are hench, wammo or tonk. A good swolder never forgets leg day. Our physical ideals change according to the times in which we live. The 80s masculine ideal was typified by action heros such as Arnold Schwarzenegger and Sylvester Stallone, while scrawny, beer-drinking lads dominated the 90s. “The idealised body image is highly muscular right now,” says Dr. Stuart Murray, a psychologist at the University of California, San Francisco who specialises in muscle dysmorphia in men. As eating disorder services tend to be designed for women, male sufferers can be overlooked. Only one in 10 patients who seek help for eating disorders are men, despite the fact that men are as likely as women to suffer. Clinicians are trained to look for emaciation, despite the fact that many sufferers are not underweight, particularly if they are packing on muscle at the gym. “Another complication is that these guys are coming from gyms where there is a ‘no pain, no gain’ ethos, which means they’re socialised into thinking it’s OK to forgo important parts of their lives in the service of this muscularity,” says Murray. “They don’t see it as a problem.” Murray says that men work out to elevate their standing among other men, not women. “A compliment from a man is worth more than a compliment from a woman, because males have more credibility in affirming other males.” Although Murray does not believe the media causes eating disorders, he says it creates the powerful social comparisons that many sufferers have experienced. “Exposure to these images gives positive connotations of what it means to be highly muscular for males,” he says. “This almost always induces a profound body dissatisfaction that results in compensatory efforts to try and increase one’s muscularity.” Individuals can end up in a dangerous cycle of overexercising and restricted eating. Murray says: “You generate this wonderful physique and get lots of compliments and then the fear of not maintaining this physique becomes powerful. It becomes your primary identity. That leads to some of the extreme lengths these guys go to.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A33

Doctors should send obese patients to diet counseling, but many don’t ERIN BLAKEMORE SEPTEMBER 18, 2018

A visit to your primary care physician may focus on your headaches or that achy back. But if your body mass index is over 30, a panel of national experts says, it should also include a referral to an intensive weight-loss program. That's the latest recommendation of an independent panel of national experts in disease and public health that advises primary care physicians on best practices. The group published the recommendation in the Journal of the American Medical Association on Tuesday. The group's main recommendation: If patients are obese, physicians should refer them to behavior-based weight loss programs or offer their own. The Affordable Care Act requires insurance providers to cover all recommended preventive services.

But "the evidence suggests that primary care doctors are not talking to their patients about obesity and not offering them the services that could be helpful in losing weight and maintaining physical fitness," says Chyke Doubeni, a University of Pennsylvania primary care physician and professor of family medicine and community health. Ashley Mason, a behavioral psychologist at UC San Francisco's Biology and Experience of Eating Lab, says the reason might be time. "Those 14-minute visits with your [primary care physician] aren't enough time for everything," she says. And whenever a patient leaves their doctor's office without a plan for addressing obesity, they remain at risk for developing negative health outcomes like diabetes and hypertension.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A34

LEARNING AND DEVELOPMENT

Chartwell and UCSF partnering to gain a deeper understanding of dyslexia HANNAH HAGEMAN NOVEMBER 17, 2018

What if schools created curriculum so precise lessons were personalized to each student’s brain? That’s one long-term goal of a new partnership forged between the UC San Francisco Dyslexia Center and Chartwell School in Seaside. Chartwell is the second school to partner with UCSF on the project, which seeks to understand where dyslexia originates in the brain and the variety of symptoms it causes. UCSF is finding distinct dyslexia groupings, or phenotypes, throughout the population. Marilu Gorno Tempini, co-director of the UCSF Dyslexia Center, says the study aims to holistically investigate dyslexia, “Thinking of the brain made from different muscles. You want to see the strengths and weaknesses in all the different muscles, to understand where the reading problem is coming from.” Since 1983 Chartwell, a private school, has served students with a variety of language-based learning differences. Eighty percent of their students have dyslexia. The school groups students in classes based on assessments, not age, in grades first through 12th, and uses multi-sensory and individualized teaching techniques.

Thirty-six Chartwell students are participating in the study this year and six students are undergoing assessments with the UCSF team now. For each child, the data from these assessments will illuminate which parts of their brain are most affected by dyslexia, and how that translates to their academic and social life. The next component of the study relies on parents and teachers to incorporate the team’s findings into specific lesson and life strategies for the student, and report to UCSF on the progress the student is making through a computer database. Armed with details on how dyslexia affects the student individually, the hope is that by implementing targeted changes in the classroom, and at home, the student will experience more academic and personal success. Chartwell anticipates incorporating the results of the study into their curriculum by spring of 2019. “This is the early work, the research, the data collection…so that it changes education for everybody in the country,” said Chartwell’s Kate Mulligan.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A35

Chartwell student participants will spend roughly two days undergoing assessments for a “whole brain” evaluation. At the UCSF Dyslexia center, the children undergo an MRI, completing various cognitive tasks while researchers image and analyze what the brains look like during these tasks. Children also give a saliva sample to the researchers so they can explore the genetic aspect of dyslexia. The second component of the evaluation puts the children in various virtual environments to explore other social, emotional, and cognitive traits involved in dyslexia, explained UCSF’s Gorno Tempini. Through tracking the children’s performance on video games and emotional reactions to video clips, the team can uncover each brain’s strengths and challenges. One of the emotional assessments involves the children watching video clips, while the researchers observe their facial expressions, and measure heart rate, and respiration. Gorno Tempini says the emotional and social aspect of the evaluation is especially innovative, “Typically in psychiatry people give questionnaires and they ask parents ‘Is your child anxious, is your child distressed, is your child depressed?’ And here we’re trying to measure in an objective way so we could better, for instance, decide if and what medication a child might need.”

Why ‘resilient dyslexics’ have good reading comprehension BRIAN BLUM JULY 29, 2018

Some dyslexics may improve their reading comprehension by baking cakes and playing strategy games rather than more traditional techniques such as learning the sounds of letters and phonological awareness. That’s one surprising conclusion from a new published study on “resilient dyslexics” conducted by researchers at Tel Aviv University (TAU) and the University of California, San Francisco (UCSF). Dyslexia is a reading disorder characterized by a difficulty in “decoding”—that is, navigating between the visual form and sounds of a written language. But a subset of dyslexic people—so-called resilient dyslexics—exhibit remarkably high levels of reading comprehension despite their difficulties decoding. To find out what made these resilient dyslexics different the researchers peered into their brains. The team examined 55 English-speaking children aged 10-16 with a wide variety of reading disabilities. Half the children had been previously diagnosed with dyslexia. The researchers created a simple formula to calculate the difference between reading abilities and decoding skills. The participants were then scanned in an MRI. Comparing the mapped images of the participants’ brains with their reading skills, the scientists discovered that the left frontal part of the brain known as the “left DLPFC” was directly related to this discrepancy.

DLPFC stands for “dorsolateral prefrontal cortex” and is kind of a traffic controller for the brain’s executive functions and cognitive controls. The resilient dyslexics had an enlarged DLPFC with more gray matter—that’s the darker tissue of the brain and spinal cord. It consists mainly of nerve cell bodies and branching dendrites. The researchers’ discovery about the role of the DLPFC posed a classic chicken-or-egg question. “Do resilient dyslexics have distinct brain structures that allow for better resiliency,” asked TAU communications disorders researcher Dr. Smadar Patael, “or is their success in reading a result of compensation strategies that actually altered the density of neurons in a specific region of the brain?” Researchers scanned 43 kindergarteners and then three years later tested the children’s reading abilities. The result: the density of neurons in the DLPFC predated mature reading ability. That’s a big deal because it allows physicians to predict who will be a resilient dyslexic, regardless of the child’s initial reading ability. And it allows psychologists to develop exercises for these children that emphasize “working memory” that may improve their abilities to comprehend texts. “If your child is entering first grade, practicing the alphabet may not be enough,” says Patael, who led the study with Prof. Fumiko Hoeft of UCSF.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A36

LEARNING AND DEVELOPMENT

Why toddlers deserve more respect: Young kids might be smarter and more empathetic than adults think ISABEL FATTAL DECEMBER 17, 2017

In The Emotional Life of the Toddler, the child-psychology and psychotherapy expert Alicia F. Lieberman details the dramatic triumphs and tribulations of kids ages 1 to 3. Some of her anecdotes make the most commonplace of experiences feel like they should be backed by a cinematic instrumental track. Take Lieberman’s example of what a toddler feels while walking across the living room:

Isabel Fattal: In the years since you last published this book, technology became a dominant part of parents’ and toddlers’ lives. You argue in the book that people are always afraid that social changes will have a negative effect on toddlers, but that often, with time, this fear is proven unfounded. Do you think this will happen with current concerns about technology?

“When Johnny can walk from one end of the living room to the other without falling even once, he feels invincible. When his older brother intercepts him and pushes him to the floor, he feels he has collapsed in shame and wants to bite his attacker (if only he could catch up with him!) When Johnny’s father rescues him, scolds the brother, and helps Johnny on his way, hope and triumph rise up again in Johnny’s heart; everything he wants seems within reach. When the exhaustion overwhelms him a few minutes later, he worries that he will never again be able to go that far and bursts into tears.”

Alicia Lieberman: I do. I think that any pressure, any new source of stress, adds to the difficulty that parents and children have in negotiating [family] relationships and negotiating the world. For example, the data shows that when working mothers are committed to their work, and find meaning and satisfaction in their work, and have working conditions that enable them to balance their work life and their family life, working is not a risk factor for children. When mothers are feeling that the work conditions are so demanding, so oppressive, that it comes at the expense of their ability to pay attention to their children...then it does have a negative impact.

“If adults experienced and enacted the full range of feelings available to an average toddler in the course of a day,” Lieberman writes, “they would collapse from emotional exhaustion.” But Lieberman doesn’t view this range of emotions as the toddler’s downside. She sees toddlers as complex, compassionate human beings, and she has dedicated her life’s research to helping adults understand the feelings and the logic behind the most seemingly ridiculous or wild toddler behaviors.

Divorce [is another] example. When the most major researcher in divorce, Mavis Hetherington, began studying divorce in the 1970s, she thought it was cause and effect: Parents get divorced, [which has a negative effect on] children. Thirty years later, she realized that it depends on: What are the mediating factors, moderating factors, social circumstances? How do the parents get along after divorce, how do they talk about each other to the child? All kinds of emotionally charged conditions that are much more predictive than the single factor of divorce. The same thing will happen with screen time and media.

Lieberman first published The Emotional Life of the Toddler in 1993, and it has since become known as a seminal guide to life with young kids. The book’s publishers asked her if she wanted to celebrate the book’s 25th anniversary with a second edition. They asked if she had anything to add, and after following new developments in both parenthood and toddlerhood over the past few decades, she did. Lieberman recently spoke with me about the second edition of her book, out this week. She discussed what’s changed in the past 25 years—including revelations in child psychology, growing societal acceptance of gay parents, and the omnipresence of technology—and what’s stayed the same. The interview has been edited for length and clarity.

Fattal: How have shifts in public mental-health discourse over the past 25 years affected toddlers? Lieberman: There is an increasing understanding of how out-of-control behaviors or withdrawn behaviors—intense separation anxiety, persistent sleeping problems, inconsolable tantrums, aggression, emotional or social withdrawal—can be traced to stress and trauma that nobody has asked about. There are studies showing that when one goes to community behavioral-health clinics and looks at the diagnoses given to children in the 2-to-5 age range, the predominant diagnoses are ADHD and behavioral problems. But when one asks the parents, ‘What happened to your child?’ and one is asking systematically about accidents, frightening separations, violence in the community, violence in the home, [many] of those children have been exposed to traumatic circumstances that very clearly can be connected to symptoms. There is a group of people that is carrying that knowledge, and we are doing our best to disseminate it. We’ve come a long way, but it is by no means incorporated yet in all the systems of care that need to know about this frame. Fattal: What impact has the growing normalization of same-sex parenting had? Lieberman: I think there has been a very important and timely humanization of gay parents. [When I first wrote the book, society was] not even giving gay people permission to be parents. It was like, why would you want to be a parent? I’m a consultant for child-protective services. I was in court several times to uphold the fact that gay parents that wanted to adopt a child had all the strength that heterosexual parents had. They were giving them the love, the understanding, the socialization. That giving a child for adoption to a gay couple did not endanger the child in terms of their mental health...I think gay parents really led the way in creating communities for themselves that were able to show the world that they were healthy, loving, joyful families. Twenty-five years ago that was by no means something that was understood or accepted. Fattal: Is 25 years a long time in the world of child-psychology research? What has changed about our knowledge of toddlers? Lieberman: Twenty-five years ago, when I was giving talks about the book, I always started with addressing the question of the “terrible twos.” I was talking about the not-so-terrible twos; [now] I don’t even use the term. I think the more we move away from that term, the better off we are. And I think that my audience did not miss my talking about the “terrible twos.” There is a new understanding that tantrums, oppositionalism, [and] negativism are not a sign that the child is terrible or that the child’s age is terrible. It’s a sign that the ability of the child to think through a situation has collapsed because of overwhelming feelings of fear and frustration that dysregulates their emotional composure. There is more of an awareness that when we say the “terrible twos” we’re really talking about the adult experience rather than the child’s.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A37

NEUROSCIENCE

Mapping the brain’s genetic landscape BENEDICT CAREY DECEMBER 13, 2018

For over two decades, scientists have been exploring the genetics of schizophrenia, autism and other brain disorders, looking for a path toward causation. If the biological roots of such ailments could be identified, treatments might follow, or at least tests that could reveal a person’s risk level. In the 1990s, researchers focused on genes that might possibly be responsible for mental distress, but then hit a wall. Choosing so-called candidate genes up front proved to be fruitless. In the 2000s, using new techniques to sample the entire genome, scientists hit many walls: Hundreds of common gene variants seemed to contribute some risk, but no subset stood out. Even considered together, all of those potential contributing genes—some 360 have been identified for schizophrenia—offered nothing close to a test for added risk. The inherited predisposition was real; but the intricate mechanisms by which all those genes somehow led to symptoms such as psychosis or mania were a complete mystery. Now, using more advanced tools, brain scientists have begun to fill out the picture. In a series of 11 papers, published in Science and related journals, a consortium of researchers has produced the most richly detailed model of the brain’s genetic landscape to date, one that incorporates not only genes but also gene regulators, cellular data and developmental information across the human life span. The work is a testament to how far brain biology has come, and how much further it has to go, toward producing anything of practical value to doctors or patients, experts said.

“I see it as foundational work, and an investment that will pay off in giving us a far richer context to develop new hypotheses and study these disorders.” - MATTHEW STATE, MD, PHD

The $50 million project, initiated in 2015 and financed by the National Institute of Mental Health, involves more than a dozen research centers and scores of specialists in cell biology, genetics and bioinformatics, the application of advanced computer learning to huge data sets. It is an all-hands, brute-force effort, coordinating top brain banks and brain scientists at major research centers, led by Yale, Mount Sinai, UCLA and the University of California, San Francisco. The new model was based in part on analyses of nearly 2,000 human brains, from people with and without diagnoses, collected over decades. In one of the papers, a research team led by Mark Gerstein, a professor of bioinformatics at Yale University School of Medicine, began by combining all those genes, as a group, and calculating the combined added risk they impart into a single coefficient. That calculation on its own barely beats a random guess in assessing added risk.

Dr. Gerstein and his team then integrated those implicated genetic locations with other biological data: Patterns of gene expression from single cells. The varying ratios of different cell types, in different individuals. The activity of transcribing and regulating molecules, which moderate the expression of genes—the conversion into functioning proteins—over time. This combined analysis improved predictive power to about 25 percent over random guessing, from 4 percent in previous models. “One of the things that’s really interesting about psychiatric disease is that it’s more heritable than many other diseases,” Dr. Gerstein said. “But people don’t have any clue about mechanisms between the underlying gene variants” and the symptoms, for disorders such as schizophrenia or autism. “Now, we’re starting to fill that in.” In another report, investigators delivered a clearer picture of brain development over the human lifetime. The brain is continually adapting, or “rewiring,” itself through life, particularly in utero and through adolescence, generating an ever-transforming genetic and cellular landscape that had defied the tools of modern science. A research team led by Nenad Sestan, another brain scientist at Yale, analyzed cells from tissue samples from 16 locations in the brains of dozens of people of all ages. The brains were collected post-mortem, and about half were from people who had been diagnosed with a disorder. The 16 brain regions correspond to areas, such as the prefrontal cortex, thought to be affected by problems like schizophrenia or bipolar disorder. The team tracked changes in the activity of genes and other molecular processes in those cells, looking for patterns that correlated with schizophrenia, bipolar disorder or autism. It identified a network of genes active in specific cell types—genes that were apparently communicating with one another—at about the stage in life when disorders begin to surface. Working backward, the researchers could trace the network pattern to specific cell types, biological activity and timing, as if reconstructing the how and when of a crime scene. The result from all this work is a computer model for brain genomics that scientists can search—a database akin to Google Earth that charts specific genetic addresses in the brain and reveals which genetic and biological processes are active there, and at what point during maturation. Dr. Matthew State, chair of the department of psychiatry at the University of California, San Francisco, and a co-author on two of the papers, said: “Essentially what these papers do is lay out cellular and molecular landscape at a resolution that’s never existed before. I see it as foundational work, and an investment that will pay off in giving us a far richer context to develop new hypotheses and study these disorders.” For the time being, those hypotheses are unformed. And, for all the coordination and dazzling science on display, there is a long way to go before any practical payoff arrives, some experts said. “We know that if you put 100 schizophrenic people in an MRI scanner, you might be looking at 100 different genetic conditions,” Dr. Mitchell said. “The same is true for analyzing gene expression in their brains.” The genetic and molecular origins are so diverse, he said, that studying the brain at this level may not, in the end, prove fruitful for understanding these disorders. Time, and more science, will tell.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A38

NEUROSCIENCE

Researchers in the lab of UCSF neuroscientst Mazen Kheirbek, PhD (center) are focused on the circuits that are disrupted in mood and anxiety-related disorders.

Researchers discover ‘anxiety cells’ in the brain JON HAMILTON JANUARY 31, 2018

Scientists have found specialized brain cells in mice that appear to control anxiety levels.

"And what we found is that these cells became more active whenever the animal went into an area that elicits anxiety," Kheirbek says.

The finding, reported Wednesday in the journal Neuron, could eventually lead to better treatments for anxiety disorders, which affect nearly 1 in 5 adults in the U.S.

This activity didn't prove the cells were causing anxious behavior, though. So the team found a way to control the activity of these cells using a technique called optogenetics.

"The therapies we have now have significant drawbacks," says Mazen Kheirbek, an assistant professor at the University of California, San Francisco and an author of the study. "This is another target that we can try to move the field forward for finding new therapies." But the research is at an early stage and lab findings in animals don't always pan out in humans. The discovery of anxiety cells is just the latest example of the "tremendous progress" scientists have made toward understanding how anxiety works in the brain, says Joshua Gordon, director of the National Institute of Mental Health, which helped fund the research. "If we can learn enough, we can develop the tools to turn on and off the key players that regulate anxiety in people," Gordon says. Anxiety disorders involve excessive worry that doesn't go away. These disorders include generalized anxiety disorder, panic disorder and social anxiety disorder. Kheirbek and a team including several researchers from Columbia University discovered the cells in the hippocampus, an area of the brain known to be involved in anxiety as well as navigation and memory. They did it by studying some anxious mice, Kheirbek says. "Mice tend to be afraid of open places," he says. So the team put mice in a maze in which some pathways led to open areas. Then the researchers monitored the activity of brain cells at the very bottom of the hippocampus.

The team set out to answer a simple question, Kheirbek says: "If we turn down this activity, will the animals become less anxious? And what we found was that they did become less anxious. They actually tended to want to explore the open arms of the maze even more." When the researchers dialed up the cells' activity, the mice got more anxious and didn't want to explore at all. But there's a lot more to anxiety than just these cells in the hippocampus, Kheirbek says. "These cells are probably just one part of an extended circuit by which the animal learns about anxiety-related information." For example, the cells in the hippocampus communicate with another brain area called the hypothalamus that tells mice when to avoid something dangerous. Kheirbek says other parts of the anxiety circuit might detect dangerous odors or sounds. "You can think of this paper as one brick in a big wall," Gordon says. In recent years, he says, scientists have been finding and assembling other bricks at rapid pace. And they need to because anxiety disorders are "incredibly prevalent," Gordon says. "They hit us in the prime working years of life, and our treatments are, at best, partially efficacious."  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A39

NEUROSCIENCE

Can’t put down the phone? How smartphones are changing our brains LYNNE PEEPLES DECEMBER 14, 2018

Science explains why the mother-daughter bond is so powerful JULIE SCAGELL DECEMBER 17, 2018

Until a year and a half ago, Samuel Veissiere's smartphone was the last thing he saw before he fell asleep and the first thing that greeted him when he woke up. During the day, the device bombarded him with constant notifications—from four different email accounts as well as Instagram, Facebook, WhatsApp, Reddit and Twitter. "It was abominable," said Veissiere, co-director of the Culture, Mind and Brain Program at McGill University in Montreal. It's also a daily storyline familiar to many of us. In the U.S., at least three of every four people now own a smartphone. And one estimate suggests that Americans touch their mobile devices more than 2,600 times a day on average. But what do all those pings and buzzes, scrolls and swipes actually add up to? Is it worrisome—or not so much? After all, Socrates once warned that writing would "introduce forgetfulness" and make people "difficult to get along with." Initial data from a $300-million study by the National Institutes of Health, for example, now provides evidence that a child's brain may indeed develop differently with heavy use of digital devices. Those of us whose brains matured before the first iPhone came to market in 2007 may also be vulnerable to mental changes. The more tethered we are to our phones, studies show, the harder it is to think deeply, attentively and conceptually—not to mention remember basic information. It's harder now to get lost, but easier to find a date and keep up with friends, kids and the news. And in some ways, a greater diversity of people is at our fingertips. Apps such as Tinder allow people to easily connect with others outside their typical social networks. "The crux of the problem is figuring out how to get all these amazing benefits of this globally interconnected world without abandoning the things that make us most human," said Adam Gazzaley, a neuroscientist at the University of California, San Francisco. For him, that means taking back control over how we use the technology. He is co-developing technology—for smartphones—that aims to improve how our brains function. His video game is in the final stages of FDA approval and would be the first non-drug treatment for ADHD.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A40

If you have a daughter, you know the mother-daughter bond is one of the strongest connections two people can share. According to science, there’s a reason for that— and it comes down to how our brains process emotion. According to a study published in the Journal of Neuroscience, the part of the brain that regulates emotion is more similar between mothers and daughters than any other intergenerational pairing (mother-son, father-daughter, father-son). The current study suggests that the “corticolimbic circuitry, which has been implicated in mood regulation, shows a matrilineal-specific transmission patterns.” And those of us who have daughters know that can be both a blessing, and a curse. Of course there are a number of environmental factors that can impact how a bond develops between mother and child, but it seems according to science, those transmission patterns play a major role in how mothers and daughters process emotions and react to each other’s as well. This explains why I’m constantly saying, “Ugh, she just knows how to get under my skin.” It also could be that she’s 15 years old and that’s sort of her job at that age. What’s more, the study also found this corticolimbic circuitry could go a long way in understanding the genetics around mental health conditions. Lead author Fumiko Hoeft, an associate professor of psychiatry at the University of California, San Francisco, explained that, among other things, the corticolimbic system is strongly tied to depression. Although additional research is warranted, “these matrilineal associations may be tightly linked to greater vulnerability for daughters but not sons in developing depression when their mothers have depression,” the study said. That means the mental health of a mother could be a strong indicator for daughters down the road. While there can be a lot of guilt associated with this from a mom’s perspective, it could also be used to help identify the symptoms more quickly and possibly seek treatment years earlier than one typically would, which could have a tremendous positive impact on those who suffer. This study was the first of its kind to use intergenerational MRIs to study brain patterns, and Hoeft hopes future research will explore the possible link to other mental health conditions. In a press release, she said, “Anxiety, autism, addition, schizophrenia, dyslexia, you name it—brain patterns inherited from both mothers and fathers have an impact on just about all of them.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A41

Teaching new birds old tweets can reveal more about human genetic traits JENNIFER LEMAN FEBRUARY 12, 2018

A flurry of live tweets may hold the secret to understanding some of genetics’ most confounding mysteries. Researchers at UCSF have found that if a songbird is exposed early to singing lessons from a foster father, they adopt the songs of that bird rather than their true parent. Studying these finches can tell us how genetic traits are passed down in humans. “You can override, and essentially eliminate the influence of genetics,” said Michael Brainard, a neuroscientist at UCSF’s Center for Integrative Neuroscience. This new research shifts our understanding of the relationship between nature and nurture. While some studies involving twins who were separated at birth show a strong genetic basis for traits like sense of humor, reading comprehension, and even fashion sense infer that these traits are fixed, Brainard’s research suggests they might be strongly influenced by a person’s environment after all. For example, the vocal cues babies pick up from their parents shape the way they will speak. Bengalese finches learn their songs in a similar way. Even from within the egg, young male finches are absorbing the sounds their fathers make, picking up nuances in tempo and even dialect. While “other species of bird sing the exact same pattern over and over again, Bengalese finches sing a variety of songs,” said Brainard. This makes them particularly useful as a model for study.

Initially intrigued by the amount of variation in the birds’ musical repertoire, David Mets, a postdoctoral researcher in Brainard’s lab, decided to conduct an experiment to find out what drives that diversity of songs. The results were intriguing. Synthetic birdsongs were less catchy to the chicks that heard them. When creating their own tunes, they developed songs that were more similar to the songs of their biological fathers—showing a clear bias towards their own genetic makeup over computer learned songs. The birds that were given live instruction by another bird showed a preference towards the tune sung by their foster father than for the songs genetically imprinted on them by their biological father. The chirps of these birds also provide insight on what’s happening inside the classroom. As the influence of technology in schools increases, Mets and Brainard agree that this work reaffirms the importance of personalized learning. Children who, at an early age, struggle with, say, reading comprehension will have a better chance of getting ahead if they’re tutored by a live instructor, who is invested in their success. To Brainard, it’s simple: “better instruction drives stronger learning.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A42

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

UCSF Benioff Children’s Hospital Oakland is known internationally for its basic and clinical research and is at the forefront of translating research into clinical mental health services for the children of the East Bay and beyond.

$15 million gift from Marc and Lynne Benioff expands children’s mental health services in the East Bay KATE VIDINSKY DECEMBER 18, 2018

UCSF Benioff Children’s Hospital Oakland has received a $15 million gift from Lynne and Marc Benioff to address the acute shortage of mental health services for children and adolescents in Oakland and the East Bay, which reflects a nationwide shortage. The $15 million gift—the final investment in a $50 million commitment made by the Benioffs to UCSF Benioff Children’s Hospital Oakland in 2014—is intended to enable the Oakland hospital to increase its mental health services, while also serving as a catalyst to raise awareness and spur additional philanthropy into pediatric and adolescent mental health in the Bay Area. “Children are suffering from an extraordinary amount of stress and mental illness, and we must rise to the challenge of meeting this need in what is truly a public health crisis,” said Michael Anderson, MD, president of UCSF Benioff Children’s Hospitals, which has campuses in San Francisco and Oakland. “UCSF Benioff Children’s Hospital Oakland stands as a beacon of hope for kids, and thanks to the generous foresight of Lynne and Marc Benioff, we can lay the groundwork to become an international leader in pediatric mental health care.” The funds will be put to immediate use to strengthen and enhance the current mental health programs at the Oakland hospital, including by increasing the number of providers on staff, which will allow an additional 5,000 psychiatric visits per year, doubling current capacity. It also will allow for new early intervention approaches, including an access portal to support training of primary care physicians in the community, as well as a patient referral process so that children get the care they need sooner. The Benioffs have a long history of support for children’s health care. Since 2005, the couple has donated more than $327 million to UCSF, including $200 million in support of the Benioff Children’s Hospitals in San Francisco and Oakland, and $50 million to launch the UCSF Benioff Children’s Hospitals Preterm Birth Initiative, in partnership with the Bill and Melinda Gates Foundation. “Cities across the nation are facing a tremendous need for mental health care for our children and teens. This is an issue that cuts across all races, all cultures and all socioeconomic levels,” said Oakland Mayor Libby Schaaf. “This generous gift from Marc and Lynne Benioff is a key step in enabling our beloved UCSF Benioff Children’s Hospital here in Oakland to care for all of our children, not only in Oakland but throughout the East Bay.”

The Benioffs’ support for mental health comes as the prevalence of mental illness has skyrocketed nationwide. Today, one in five youth under the age of 18 suffers from some type of diagnosable mental illness, the most common of which include anxiety, depression, eating disorders and attention deficit-hyperactivity disorder. At the same time, the number of providers has remained flat, leading to a major shortage of mental health services for children and adolescents. The pervasiveness of mental illness has done little to abate the widespread stigma surrounding mental disorders, largely due to a lack of knowledge about their underlying biology and root causes, explained Bryan King, MD, Lisa and John Pritzker Family Distinguished Professor in Child Psychiatry, co-director of the UCSF Child Teen and Family Center, and vice president for child behavioral health services at UCSF Benioff Children’s Hospitals. “This is a crisis that demands our immediate attention,” King said. “This gift will put us on the right trajectory to not only do a better job caring for our population, but also elevate the discourse in a way that will positively impact the stigma that has surrounded mental illness for too long,” he said. Efforts are already underway to recruit six new child psychiatrists as a result of these initial funds, as well as two psychologists and one social worker. The hospital hopes to continue that growth further. In addition to bolstering its mental health team, the hospital will add two new child psychiatry training positions designed to attract top talent and encourage trainees to remain in the East Bay to practice medicine long-term. Finally, the funds will be used to establish a new Child Psychiatry Access Portal, a model King successfully implemented during his tenure at Seattle Children’s Hospital. The portal program is designed to train primary care physicians in the community—particularly those in more rural areas—to serve as the front line for early stage mental health care management, with the support of a psychiatric hotline, referral management and continuing medical education. By utilizing the primary care setting to manage common mental health conditions, patients are more likely to get the care they need early on, improving the likelihood of successfully managing their illness.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A43

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

For mentally ill homeless patients, new center offers beds and a dose of hope KEVIN FAGAN MARCH 5, 2018

City officials plan to announce a major step toward rescuing San Francisco’s severely mentally ill homeless people from their afflictions—the opening this month of 54 new lockdown psychiatric beds at St. Mary’s Medical Center. This will more than double the current number of beds in the city for mental patients who have been ordered by a judge into conservatorship, meaning they must involuntarily accept round-the-clock treatment because they are too ill to live on their own. Mental health policy experts and city leaders including the late Mayor Ed Lee and current Mayor Mark Farrell have been pushing for the expansion for years. The new facility, called the San Francisco Healing Center, will be for anyone under conservatorship. Though city officials promise this won’t bring a sudden roundup of mentally ill homeless people, a big goal of the center will be to help them. The most obvious candidates for cops, street counselors and others who deal with the most chronic homeless people will be the city’s 40 or so “frequent fliers”—those who often use medical services and still wind up back on the street with serious behavioral health problems. Not all are the type who scream at telephone poles. Some just suffer in silence, hiding or rocking in place. Either way, their plight—and sight—is heartbreaking, and as Farrell walked through the soon-to-be opened center last week, he said the new beds could be transformative. “This has the promise of making a massive difference on our streets,” Farrell said, standing in the middle of the Healing Center. “This is addressing one of our biggest issues in the city, and getting the most visible homeless people on our streets into a healthier place like this will be better for everyone.” The $3 million-plus reconstruction of the previously unused floor was expected to take two years, but it’s been completed in less than one, with funding by the city, Dignity Health, and UC San Francisco.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A44

Ex-ER psychiatrist: More inpatient treatment needed in San Francisco HEATHER KNIGHT OCTOBER 9, 2018

A five-minute stroll around downtown San Francisco makes it obvious the city has a huge number of people with mental health problems. And it’s not unusual to see homeless people who appear mentally ill wearing hospital gowns or identification bracelets, signaling they’ve just been released from the hospital and are back on the streets. What’s going on? I sat down with Dr. Paul Linde, a UCSF professor who worked in the psychiatric emergency room at San Francisco General Hospital for a quarter-century before leaving to work part-time as a primary care psychiatrist. He described San Francisco’s revolving door for mentally ill homeless people, the shortage of treatment beds, and how California’s newly passed law strengthening the conservatorship program might help.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A45

Why San Francisco should open a supervised drug-injection facility JACOB IZENBERG JANUARY 15, 2018

Jacob Izenberg is a resident physician in psychiatry at UCSF and a drug-use researcher, with his most current research focused on gentrification and health in California. Just under a decade ago, Philippe Bourgeois published Righteous Dopefiend, his chronicle of homeless, heroin-injecting San Franciscans making their lives on the city’s streets. The book’s publication turned out to be chillingly well-timed: Since 2010, opioid-related deaths have skyrocketed, tearing apart communities and leading, for the first time in decades, to declining life expectancy across swaths of the American population. Those featured in Righteous Dopefiend often encountered heroin in the hard-living years of the 1970s and 1980s. By contrast, the current epidemic largely started with prescription painkillers. But, efforts to crack down on pills are leading a new generation to turn to heroin, and with it, the needle. Drug injection, an efficient way to get high, is also a dangerous one. Dosing can be hard to control, increasing overdose risk. Equipment sharing can lead to HIV, hepatitis C, and other serious chronic illnesses. Bacterial infections of the skin, heart or central nervous system can send people to the hospital for days or weeks. When I worked as a medical intern at Zuckerberg San Francisco General Hospital, these sorts of infections were among the most common reasons for admission to our service. As more people turn to injection, all these complications will become more common. The costs, both human and economic, will be high. If there’s any good news, it’s this: Effective addiction treatments exist for opioid use disorders, and many of injection’s most serious harms are preventable. Treatments include methadone and buprenorphine, the mainstays of opioid replacement therapy. Naltrexone, a medication that blocks opioid receptors, is a promising option as well. Psychiatric medication, therapy, and group programs can all play important roles. Then there are critically important harm-reduction programs, which often take the form of needle and syringe exchange, where people who inject can get clean supplies. More recently, the distribution of naloxone, an effective overdose antidote, has gained widespread popularity. Now, San Francisco is debating an approach that, though not new, is still viewed by many as radical: the supervised injection facility, a place where people who inject drugs can drop in—with their own supply—and use. An on-site needle exchange allows easy access to clean equipment. Clients then go to a clean location—be it a booth or a lounge chair, where they can inject. All the while, staff trained to respond quickly to overdose or other emergencies stand at the ready. These facilities offer people who inject drugs safety, support and dignity, worthy goals in and of themselves. Furthermore, they offer a one-stop point of connection to detox, treatment, counseling services and other resources, gaining the trust of people who may have more than a little well-earned skepticism of government and public health authorities.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A46

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

Helping patients in minority communities cope with serious mental illness DAVID LEVINE OCTOBER 26, 2018

Mental illness is race-blind and colorblind. According to the American Psychiatric Association, most racial and ethnic minority groups have similar rates of mental disorders than whites. However, minority populations face numerous barriers to treatment that make them less likely to get the care they need and, as a result, the consequences of mental illness in minorities may be long lasting. Depression in blacks and Hispanics is likely to be more persistent, for example, and ethnic and racial minorities often bear a disproportionately high burden of disability resulting from mental disorders, the APA says. An APA fact sheet published last year lists the following daunting statistics: 

In 2015, among adults with any mental illness, 48 percent of whites received mental health services, compared with 31 percent of blacks and Hispanics and 22 percent of Asians.

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Compared with non-Hispanic whites, African Americans with any mental illness have lower rates of any mental health service use, including outpatient services and prescription medications, but higher use of inpatient services at hospitals.

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Compared with whites, African Americans are less frequently included in research, less likely to receive guideline-consistent care, and are likely to use emergency rooms or primary care rather than mental health specialists.

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People who identify as being two or more races (24.9 percent) are more likely to report any mental illness within the past year than any other race/ethnic group, followed by American Indian/Alaska Natives (22.7 percent), white (19 percent) and black (16.8 percent).

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American Indians/Alaskan Natives report higher rates of post-traumatic stress disorder and alcohol dependence than any other ethic/racial group.

These facts are not lost on those who pledge to help. Many groups, including police departments, social services organizations, faith-based groups and mental health professionals, are working to reduce or eliminate the barriers that prevent minority patients from getting the treatments they need and deserve. “What I think is exciting is that people are starting to think out of the box,” says Dr. Christina Mangurian, professor of psychiatry and vice chair for diversity and health equity in the department of psychiatry at the University of California, San Francisco Weill Institute for Neurosciences. Despite recent efforts to improve mental health services for African Americans and other minority groups, barriers remain regarding access to and quality of care. These barriers, the APA says, include the stigma associated with mental illness, distrust of the health care system, lack of providers from diverse racial/ethnic backgrounds, lack of culturally competent providers, language barriers, and lack of insurance or underinsurance. Other factors also prevent minority patients from getting proper care. African Americans are less likely to be offered either evidence-based medication therapy or psychotherapy. Compared with whites with the same symptoms, African Americans are more frequently diagnosed with schizophrenia and less frequently diagnosed with mood disorders, perhaps because of differences in how African Americans express symptoms of emotional distress, the APA says. And physicians often communicate with African Americans and whites differently. In fact, the APA reports that one study found that physicians were 23 percent more verbally dominant and engaged in 33 percent less patient-centered communication with African American patients than with white patients. Mangurian, who is also chair of the APA’s Council on Minority Mental Health and Health Disparities, adds that, “So many structural things impede delivery and access to care, people often end up in inappropriate settings. Black people, especially those with schizophrenia or bipolar disorder, are more likely to be incarcerated instead of where they should be, in a hospital.” Breaking down the stigma of mental illness is perhaps most important, and groups like the National Alliance on Mental Illness and the APA and celebrities like Serena Williams and Jay Z are working to normalize mental illness by talking openly about their struggles. “If you can be a rapper and admit to mental health problems, it’s role modeling for people,” says Ruth White.

NAMI is offering fellowships to minorities doing research as well as practicing in mental health, says White, a clinical associate professor at the University of Southern California's Suzanne Dworak-Peck School of Social Work. “When training practitioners, we are paying more attention to cultural competencies, developing skills to practice with people of color and other marginalized communities.” She says she has seen tremendous growth in the number of licensed practitioners who are African American. “I am part of a group called Black Therapists Rock, and there are about 20,000 people on our webpage,” she says. Along with this growing professional cadre, there are more resources within those networks for professionals to access. “I have seen a huge shift. It’s much easier now (to find minority practitioners), but still mostly in big cities,” she says. “It’s not true in other areas.” Police departments and other government agencies throughout the country are creating teams to address the aftermath of trauma like police shootings, which research has shown is taking a toll on the mental health of minority communities. “They are trained to handle these cases better,” Mangurian says. “They are particularly useful in communities that are traumatized, so instead of using drugs to deal with their feelings, they have an opportunity to talk about it, get help and change that cycle.” More schools are teaching students about mental health—in New York, in fact, it is now mandated. “Especially with populations of public schools, which are overwhelmingly minority, this will normalize the conversation for the next generation, give them more tools and a better understanding of what mental health and mental illness are,” White says. “I think it is revolutionary.” The work is far from over, of course. “Right now in our political climate, there is a lot of implicit and explicit discrimination against women, race, gender, sexual orientation,” Mangurian says, mentioning the confirmation hearings of Justice Brett Kavanaugh, the separation of families at the U.S. border, the Trump administration’s attacks on religious freedom and gender identity and the fraught relations between law enforcement and minorities as factors adding to the stress and anxiety many nonwhite, nonmale, non-Christian people are under. “People in those groups are seeking care, and it is the responsibility of providers to appreciate how that discrimination and the events happening in public are impacting these patients. We need to recognize it and deliver trauma-informed care.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A47

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

Even America’s top doctors aren’t getting the parental leave that doctors recommend REBECCA GREENFIELD FEBRUARY 13, 2018

Doctors recommend that new parents get 12 weeks off work, but even the top doctors teaching their future peers at America’s best medical schools are getting leave far short of their own profession’s guidelines. Policies for faculty at 12 top U.S. medical schools vary widely in terms of who gets paid time off and how much, a new review has found—but on average, birth mothers get about two months of paid leave, about a month short of what the American Academy of Pediatrics recommends. The schools’ broader policies, covering more than just birth mothers, were even wider-ranging and often used more ambiguous language. Some policies applied only to “primary caregivers”; others specifically mentioned fathers. Many ultimately left decisions up to a professor’s supervisor. The study, conducted by researchers at the University of California, San Francisco, looked at the top 10 medical schools in the U.S. News & World Report academic rankings, as well as the 10 that receive the most NIH funding. Its findings are published in a new paper in the Journal of the American Medical Association. “What surprised me was how difficult it was to interpret the leave policies,” said Dr. Christina Mangurian, one of the study’s authors and a psychiatrist and professor at University of California, San Francisco School of Medicine. “How many MDs and PhDs does it take to understand what a leave policy is trying to say?” Of the almost 1 million licensed physicians in the U.S., just under 200,000 work as faculty at medical schools. But even as more women than ever enter academic medicine, men still dominate at its highest echelons. Women hold fewer than a quarter of full-professor positions, thanks in part to what researchers have called the “leaky pipeline” phenomenon, with many women leaving academia when they’re still assistant professors, Mangurian said. “It does coincide with childbearing years,” she added. “Our retention of women is poor up to senior leadership roles.” That’s already a problem in medicine, and at a point well before doctors become professors. All practicing physicians start their careers as medical residents training at academic institutions, and their leave policies are all over the place, with most programs making it impossible for residents to take 12 weeks off for a new child. Mangurian and her colleagues did find a hopeful spot in their survey, though: While they worked on it, three of the institutions they looked at bumped up the amount of leave they offer faculty. “I don’t think they’re doing it out of the kindness of their hearts,” she added. “They’re just like, ‘If we do this, we can retain and recruit better talent.’”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A48

Psychologist Hinshaw wins American Book Fest Award for memoir RON SHOLKOFF DECEMBER 13, 2018

When UC Berkeley and UC San Francisco professor Stephen Hinshaw’s father was 16, he jumped off the roof of his Pasadena home because he thought he could fly. While he survived the fall, he spent the next six months in the wards of a county hospital. Hinshaw’s memoir about his father’s struggle with mental illness and its impact on his upbringing, Another Kind of Madness: A Journey Through the Stigma and Hope of Mental Illness, won the American Book Fest 2018’s award for best memoir or autobiography. “I had dedicated my life to being trained as a clinical psychologist and doing research and teaching and I felt over the years, that it wasn’t complete unless we were open and honest about our own family’s experience,” Hinshaw said.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A49

One of America’s most at-risk populations frequently gets unwelcoming care at psychiatric facilities JOSH ISRAEL & DANIELLE MCLEAN MAY 21, 2018

The estimated 1.4 million-plus Americans who identify as transgender and/or gender non-conforming struggle with mental health at much higher rates than their cisgender peers. Trans Lifeline and the National LGBTQ Task Force surveyed 8,574 people in 2017, almost all of whom self-identify as transgender and are U.S. citizens. Eighty-eight percent said they have considered ending their own life. Over half have attempted suicide at one point. Those suicide attempt rates are far above the national averages for people of all genders (about 0.5 percent of adults). But with overtaxed psychiatric care facilities that frequently lack the training and expertise to competently treat transgender patients, the American health-care system frequently fails those who need psychiatric hospitalization.

Dan Karasic is a clinical professor of psychiatry at the University of California, San Francisco, and a World Professional Association for Transgender Health (WPATH) board member. He said that WPATH offers trainings and certification for providers who want to learn how to competently care for trans patients—a service that has been provided to more than 2,000 people. But, he explained, that the training often misses the people who need it the most. “My guess is that some of the people who most could benefit are choosing not to get that training because they don’t feel it’s as important as other things,” said Karasic. Trans competency “needs to be incorporated into psychiatric medical training, med school training, and training in other disciplines so there is some basic knowledge everyone has.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A50

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

People with mental health difficulties remain among the most stigmatized groups DAVID B. FELDMAN AUGUST 10, 2018

In the mid 1950’s, when Stephen Hinshaw was five, his father mysteriously vanished. “Dad was a professor of philosophy at Ohio State University, Mom became an instructor of English...From outside appearances, it was an idyllic Midwestern family,” the now-UC Berkely and UC San Francisco professor of psychology told me during an interview on Radio KPFA’s About Health. “But Dad would disappear—for three months, six months, at one point when I was in third grade, twelve months at a time—as though someone had abducted him.” In fact, over the next decade of Hinshaw’s childhood, his kind, soft-spoken father would vanish half a dozen more times. “No one ever talked about it before, during, or after,” he recalled. “I didn’t know if he was dead or alive. And then he would be back one day, as though nothing had happened” Hinshaw’s father suffered from a severe form of bipolar disorder, a condition often characterized by alternating episodes of depression and mania. Unlike many people with milder forms of the disorder, however, he experienced psychotic symptoms during his manic phases. Once, when Hinshaw’s father was himself a boy, he developed the delusional belief that only his behavior could stop Hitler and the fascists from taking over the world. He believed that, if he extended his arms, they would become wings, and his flight would inspire the leaders of the free world to take action. When he jumped off the trellis of their family home, the flight ended in his first six-month hospitalization. About half of people in the United States are estimated to have a diagnosable mental illness at some point in their lives. Whether we’re talking about major depressive disorder, bipolar disorder, OCD, schizophrenia, or a host of other mental health conditions, this accounts for more than 160 million people in this nation alone. These are people like you and me. They’re people we encounter everyday—those who teach our children, fix our plumbing, bus our tables, pilot the aircraft we ride on, and write the books we read. In fact, we may actually be talking about ourselves.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A51

Mentors help psychiatry resident achieve her dream REBECCA GREENBERG APRIL 3, 2018

Stefana Morgan, M.D., a fourth-year psychiatry resident at the University of California, San Francisco (UCSF), studies how personality affects psychological outcomes in cancer patients. Her work at UCSF fulfills a lifelong ambition.

Stefana Morgan, MD

She was admitted to the University of Michigan Medical School. It was there that she met Michelle Riba, MD, MS, a past APA president. Riba said she was captivated by Morgan’s background and enthusiasm. “She came here on her own. She had to fend for herself without family or friends while coping with the language issue,” she said. “She is an example of how we need to think about some of our international students and the hardships they face.” Meanwhile, Morgan’s family had immigrated to the United States and was living in San Francisco. When her grandfather was diagnosed with terminal lung cancer in her third year of medical school, she began a research fellowship at UCSF, where she was also able to complete her medical degree.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A52

SUZANNE GORDON MARCH 6, 2018

As Congress moves ahead with plans to outsource more and more veteran health care to the private sector, three high-profile studies should urge lawmakers to pump the brakes. The studies, published in recent weeks by RAND Corporation, Federal Practitioner, and the National Academies of Science, Engineering and Medicine, spotlight serious flaws in private-sector veterans’ care compared with the VHA, from suicide prevention to overall health care. In so doing, the reports underscore a critical fact: Despite their best intentions, few private-sector physicians, hospitals, mental health, and other health-care professionals have the knowledge, experience, and skill to provide the level of care veterans need and deserve. Perhaps the most damning of those studies comes from the RAND Corporation. In a report entitled “Ready or Not?” researchers examined whether private-sector health professionals in New York state had the “capacity” and “readiness” to deal with that state’s 800,000 veterans in need of care. Such patients, the study noted, are on average older, sicker, poorer, and far more complex than the ordinary civilian-sector patient. The conclusion? Only 2 percent of New York state providers met RAND’s “final definition as ready to provide timely and quality care to veterans in the community.” While the majority of providers said they had room for new patients, less than 20 percent of them ever asked their patients if they were veterans. Fewer than half used appropriate clinical practice guidelines to treat their patients, and 75 percent didn’t use the kind of screening tools commonly deployed in the VHA to detect critical problems like PTSD, depression, and risk of suicide. Most providers had no understanding of military culture and less than one-half said they were interested in filling such knowledge gaps. Mirroring a similar study conducted by the VA and Medical University of South Carolina in 2011, RAND found that New York state providers had little understanding of the high quality of VHA care. Informed by media reports rather than medical journals, they had a negative view of the VHA and would be unlikely to refer eligible veterans to the VHA for needed care in programs in which the VHA actually excels. Echoing the RAND study, another report by VA psychologist and UCSF faculty member Russell Lemle in the Federal Practitioner warns that in the private sector, the quality of integrated mental health care for veterans lags significantly behind the VHA. Every VHA medical center, Lemle reports, has at least one trained suicide prevention coordinator who directs care for veterans at high risk for suicide.

Born in 1981, Morgan witnessed Bulgaria’s democratic transition as a teenager, which she said inspired her interest in human behavior. In high school she decided she wanted to train to become a psychiatrist in the United States. When she first arrived in this country, Morgan struggled to gain her footing. The upside was that being on her own for the first time made her realize the importance of networking—or, as she said, “essentially building my own family or community.”

Studies show private-sector providers are not ready to care for veterans

The VHA has also developed an algorithm to identify the veterans who are at the very highest risk of suicide and notifies their provider of the risk assessment, enabling preemptive intervention and expansion of services to the veteran. This and other programs explains why the rate of suicide of veterans not using the VHA increased by 38 percent between 2001 and 2014 while only 5 percent for those using the VHA. For veterans who had a “mental health or substance use diagnosis, the rate decreased by 25 percent.” Finally, for veterans returning from the Iraq and Afghanistan conflicts, a prestigious National Academies of Science, Engineering and Medicine report released just four weeks ago found VHA mental health care to be “comparable or superior to that in the private sector.” The majority of veterans who accessed the system had “positive experiences” and appreciated VHA staff’s “respect toward patients.” This was despite serious shortages of mental health staff, as well as clinical and exam space, and confusion about how to access care—all of which could, and should, be improved. When veterans were asked whether needed services were provided in the VHA, 64 percent said they were. When they were asked about services they’d received in the private sector, only 20 percent said they got needed services.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A53

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

States set aside millions for crime victims, but some gun violence survivors don’t get the funds they desperately need ELIZABETH VAN BROCKLIN FEBRUARY 12, 2018

Hours after a gunman killed 58 people and injured hundreds more in Las Vegas last October, donations for victims and their families began pouring in. A GoFundMe campaign launched by local leaders would raise $11 million in three weeks. Uber gave free rides to blood-donation sites and hotels offered complimentary rooms for relatives. One group of hospitals treated 71 victims, then promised to waive all of their medical bills. Yet mass shootings, despite the attention they receive, are not the norm. Each year, tens of thousands of people are wounded in incidents of gun violence that have become almost routine. The injured are disproportionately young black men, who have few services specifically geared to support them in the jarring wake of violence. Some victims require extensive therapy to relearn how to write, speak, or walk. There may be follow-up surgeries to remove bullet fragments, treatment for pain and infections, and counseling for stress, anxiety, and depression. Some miss work because of their injuries, or can’t work at all. Roughly one-third of hospitalized gunshot patients are uninsured. A resource does exist to help vulnerable crime victims, including gunshot survivors, though many never tap into it. Victim compensation programs in every state reimburse victims and their families for expenses like medical bills, mental health counseling, lost wages, and funeral costs. Revenue for the state-run programs comes from offender fees and fines, along with federal grants under the Victims of Crime Act, or VOCA. In 2016, compensation programs paid more than 250,000 claims totaling more than $348 million, according to federal data.

Victim advocates, anti-violence activists, and social workers interviewed by The Trace said that victims of violent crime face numerous hurdles in applying for the funds. They say that for traumatized victims, the eligibility criteria can be daunting, the applications toilsome, and processing times long. Even the most basic requirements to receive compensation, like reporting the crime to law enforcement, can deter victims, especially those from neighborhoods where distrust of the criminal justice system runs high. Most vexing, advocates say, is that state laws that govern compensation programs can ultimately exclude people at the highest risk of being shot. While black men disproportionately experience violence, they are also more likely than whites to have been convicted of a felony, which in some states can disqualify people from receiving funds. Victim compensation “is set up to really help victims, and yet it’s ironic, because it often really adds to the pain that they are going through,” said Alicia Boccellari, a clinical psychologist and founder of the University of California, San Francisco’s Trauma Recovery Center, which provides mental health services and case management for violent crime survivors. “It puts a lot of expectations on them, when they really have so few inner resources to deal with all this. Sometimes the victim ends up feeling further victimized.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A54

Doctors who are mothers face ‘insidious, persistent’ discrimination, study finds JOANNE FINNEGAN DECEMBER 13, 2018

It’s not always easy being a mom. Try being a mother and a physician. A new study, published in the BMJ, finds “insidious, persistent and sometimes blatant” discrimination experienced by physicians based specifically on their status as mothers. That conclusion was drawn from an analysis of 947 responses to an online survey of female doctors who are part of the Physicians Moms Facebook group. In their own words, the survey participants provided numberous vivid descriptions of maternal discrimination. How so? The team of U.S. researchers found several themes. The physicians reported varying expectations of job performance (both higher and lower), financial inequities (including lower pay than equally qualified colleagues and more unpaid work), fewer opportunities for career advancement, lack of support during pregnancy and after giving birth and difficulties achieving life-work balance. While some of the recorded experiences are consistent with those reported by women in other professions, the researchers said there are unique aspects of medical training and the profession that make maternal discrimination worse.

The researchers called for structural changes that address pregnancy, parental leave and childcare to mitigate the impacts of maternal discrimination in medicine. That becomes more crucial since the majority of medical students are now women and it is estimated that 80 percent of female physicians are or will become mothers. A recent study published in JAMA highlighted parental stresses for medical residents, who are in their prime childbearing years. Of 15 top teaching hospitals, eight had an institutional policy providing paid childbearing or family leave for residents. The average maternity leave was 6.6 weeks. For same-sex couples, adoptive parents or fathers, paid leave policies averaged 3.9 weeks. "In my opinion, there is an urgent need for medical schools to create more generous family leave policies for all of their trainees," said co-senior study author Christina Mangurian, MD, professor of psychiatry and vice chair for diversity and health equity at the University of California, San Francisco. "Regarding birth-mothers specifically, I believe that expanding childbearing leave will not only benefit the mental and physical health of these mothers and their babies, but will also support our long-term goal to have women thrive in medicine by providing support when they need it most," she said.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A55

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

Mental health experts discuss importance of early intervention for youth amid rising suicide rates AMBER LEE DECEMBER 20, 2018

Mental health experts are sounding the alarm about a rising suicide rate across the U.S. It was announced earlier this week that Salesforce CEO Marc Benioff put $15 million behind increased mental health services for children and adolescents at UCSF Benioff Children's Hospital. One young woman coping with mental illness says more services will save lives. At 23 years old, Megan Alvarado, of San Francisco, is on what she describes as a continuous journey to recovery. "When I was 13, I began having symptoms of depression and anxiety," said Alvarado. She says her personality changed from outgoing to anti-social. Alvarado says her mother tried to get her psychiatric help, but there was a six-month long wait to get an appointment. "When you are in crisis, when you are desperate for treatment and help, that's too long. That's a ridiculous amount of time," said Alvarado. She ended up being treated by her pediatrician who was not a mental health expert. "I just felt really alone in the struggle," said Alvarado, "I was suicidal. I self-injured. I stopped eating. It was the worst-case scenario." Alvarado is far from being alone in her struggle. "The suicide rate among girls have doubled in the last ten years and that's absolutely something we need to be alarmed about," said Dr. Bryan King, head of psychiatry at UCSF Benioff Children's Hospital. He blames the shortage of pediatric psychiatrists and long waits for appointments. Dr. King says the $15 million gift from Salesforce CEO Marc Benioff will be used to double the number of pediatric psychiatrists and to start a consultation program to help pediatricians treat mentally ill patients. "Mental disorders can be dealt with early and outside of the long lines that these families will otherwise have to wait in to get care," said Dr. King. Alvarado said after years of trying to calm the chaos in her head, she finally got the help of a psychiatrist, enabling her to live a full life. She now works as a program coordinator for the National Alliance on mental illness, helping others in the same struggle. "Recovery is certainly a journey. It takes a lot of work," said Alvarado, but she's undaunted.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A56

The complexities of suicide risk RONA RENNER AUGUST 27, 2018

What leads to suicide? A new report is challenging assumptions JUSTIN PRICE JUNE 8, 2018

Suicide is the tenth leading cause of death in the nation, yet experts say efforts to curb the problem fail to keep up as social stigmas persist and inadequate funding restricts further research. Family problems, poor physical health, shaky finances or legal stress all contribute to suicide, according to a federal report released Thursday that challenges commonly held assumptions that mental illness is the driving factor of death by suicide. The report from the Centers for Disease Control and Prevention, published the same week as the high profile deaths by suicide of fashion icon Kate Spade and celebrity chef Anthony Bourdain, jibes with assertions by mental health experts that no single factor can explain the reason behind a person's suicide. Efforts to curb suicide still fall short due to persistent social stigma, experts say.

Suicide is a major public health concern. Over 40,000 people die by suicide each year in the United States; it is the 10th leading cause of death overall. Suicide is complicated and tragic, but it is often preventable. Knowing the warning signs for suicide and how to get help can help save lives.

"The public face of mental illness is violent school shooters," said Dr. Stephen Hinshaw, a researcher of developmental psychopathology at the University of California at Berkeley and UC San Francisco, referring to misconceptions about people with mental health conditions and violence propensity.

Suicide does not discriminate. People of all genders, ages, and ethnicities can be at risk. Suicidal behavior is complex and there is no single cause. In fact, many different factors contribute to someone making a suicide attempt.

"We don't invest in mental health research and treatment to the same extent we do for so-called physical health conditions, like cancer,'' Hinshaw said. "And I think the stigma attached to mental health issues is part of the clear reason for that."

UCSF psychologist Esme Shaller and private practice psychiatrist Eli Merritt join KPFA’s Rona Renner to discuss the warning signs of possible suicidal behavior and what you can do to help.

The federal report shows suicide rates have risen by more than 30 percent since 1999 in half of all states, and that more than half of the 45,000 people who died by suicide in 2016 had no mental health condition.

 LISTEN TO THE PODCAST EPISODE AT PSYCH.UCSF.EDU/A57

 READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A58

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

Build a better neighborhood to boost kids’ health KATELYN NEWMAN MAY 9, 2018

Being poor can be hazardous to your health, but a new study shows building a better neighborhood may help blunt poverty's ill effects. According to the study by researchers at the University of California, San Francisco, low-income children were found to have less stress and be in better physical health if they lived in higher-opportunity neighborhoods. Researchers examined the impact of neighborhood quality and a family's socioeconomic status on the health of a group of kindergartners in the Bay Area. To do so, they analyzed existing data showing levels of the stress hormone cortisol in 338 kindergartners from varying economic backgrounds, as well as assessments of the children's health by parents and teachers. In predicting the children's health outcomes at the beginning and end of a school year, the researchers also assessed the quality of the neighborhoods where students lived through an index that takes into account factors such as access to parks and healthy food. "When these children from lower economic-status families were living in more resourced neighborhoods that are quality neighborhoods—those with greater access and supportive services—they had those lower levels of cortisol and fewer health problems than the lower socioeconomic children living in poor-quality neighborhoods," says Danielle Roubinov, an assistant professor of psychiatry at UCSF and first author of the study. Childhood experiences—good or bad—can play a large role in a person's health behaviors and conditions later in life, according to the Centers for Disease Control and Prevention. And while poverty has been linked to poor health many times over, Roubinov says the higher quality of a neighborhood where a child grows up is a factor that can protect against the negative health consequences associated with growing up in a poorer household.

"Being reared in conditions of economic deprivation, living in a low socioeconomic environment, can absolutely be a source of adversity and is often captured within those measures of adverse childhood experiences—not being able to make ends meet, not having enough food to put on the table," Roubinov says. "But I think...they’re not completely deterministic—it's not the case that if you have one or two of these adverse childhood experiences that you’re destined to develop poor health outcomes." "There are these protective, buffering factors that can be identified in the environment to lessen the negative impact of those adverse childhood experiences," Roubinov says. “One of the biggest things I think this speaks to is the importance of early intervention—the fact that we are seeing the effects this early suggests the need to really intervene now, if not earlier, to help put children on a healthier developmental trajectory." The research results fall in line with those of a 2011 U.S. Department of Housing and Urban Development study that identified improvements in the mental and physical health of low-income people—exhibited by decreases in rates of extreme obesity, diabetes, psychological distress and major depression—when they moved to wealthier neighborhoods through a voucher housing initiative. While improving family incomes is important, Roubinov says her study's results also reflect the importance of improving children's environments outside of their homes. "Parks and green spaces and healthy food and quality of early education—those are these broader, more expansive interventions that by nature are administered at a community level, so they naturally have the possibility of reaching more people just in their design than trying to help individuals make more money on a family-byfamily basis," Roubinov says.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A59

Does mental illness raise diabetes risk? ROBERT PREIDT JUNE 20, 2018

Americans with severe mental illness are more than twice as likely to develop type 2 diabetes, and the increased risk is highest among minorities, a new study suggests. Researchers looked at more than 15,000 patients with severe mental illness and found that 28 percent had type 2 diabetes. The rate in the general population is 12 percent. Among people with severe mental illness, rates of type 2 diabetes were 37 percent for Hispanics, 36 percent for blacks, 31 percent for Asians, and 25 percent for whites. It's important to point out, though, that the study only found an association between mental health and diabetes, not a cause-and-effect connection. "Antipsychotic medications prescribed for conditions like schizophrenia and bipolar disorder may cause weight gain and impact cholesterol levels and insulin resistance," said study leader Dr. Christina Mangurian. She's vice chair for diversity and health equity at the University of California, San Francisco's department of psychiatry. "Additionally, people with severe mental illness have more tenuous life circumstances, including food insecurity, low income and unstable housing situations, which all increase their risk of diabetes," Mangurian said. "Stressors such as structural racism compound these problems in minorities."

The researchers also found nearly half of people with severe mental illness had prediabetes, compared with about one-third of the general population. Rates of prediabetes (elevated blood sugar levels) were highest among blacks, Hispanics and Asians with severe mental illness, and the condition tended to appear as young as age 20. The findings were published recently in the journal Diabetes Care. "The results of the study indicate that we should be screening all patients with severe mental illness for diabetes," Mangurian said. "I view this as an opportunity to change how doctors think about health screening and to help prevent diabetes," she said. "By diagnosing prediabetes early, we can help patients make lifestyle modifications or start medicine so that they don't develop diabetes." Previous research by Mangurian found that severe mental illness was associated with low rates of diabetes testing, HIV testing and cervical cancer screening.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A60

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

Is there a link between mass shootings and mental illness? RACHEL NUWER MAY 10, 2018

When it comes to mental illness and violence, the public, media and policy-makers often have difficulty discerning fact from fantasy. Opinion polls consistently reveal that the majority of adults in the U.S. believe that people with mental illnesses are more likely to be violent than those without. That assumption is further reinforced each time a new mass shooting takes place, inevitably followed by calls for mental healthcare reform. But what does the evidence say about the relationship between mass shooters and mental illness? Are these acts of violence really a mental health problem?

“...We need to be careful with our definitions, because while something is clearly wrong with [mass shooters], it’s often not a serious mental illness.”

- RENÉE BINDER, MD

If social media and sensationalist headlines are a guide, the fear of extreme violence from the mentally ill is common. “The idea of losing the capacity to control one’s thoughts or behaviours is scary and alien, which translates into fear of mental illness—particularly in its more severe manifestations,” says Paul Appelbaum, a psychiatrist at Columbia University . “We also have a tendency as human beings to pay particular attention to unusual events in our environment, so when acts of violence are committed by people with mental illness, they may be particularly salient in our minds.” Senseless tragedies like mass shootings also provoke and demand answers— preferably ones that are also accompanied by easy fixes, says Jeffrey Swanson, a professor of psychiatry and behavioural sciences at Duke University. “We want life to be safe and predictable and to make sense,” he says. “The normal reaction is to want an oversimplified master explanation so you can put it in this box and say, ‘Ah, it’s mental illness’...” That knee-jerk conclusion is problematic, he continues, because it encourages even more stigmatisation of people who have a mental illness, many of whom already have extremely difficult lives and already face discrimination in several areas, namely housing, jobs, and relationships. Individuals suffering from mental illnesses are actually three times more likely than the average person to be victims of violence, as they are more vulnerable. In fact, few mass killers actually suffer from a diagnosable, serious mental illness such as schizophrenia, bipolar disorder and psychotic spectrum disorders. A 2004 analysis of more than 60 mass murders in North America, for example, found that just 6% were psychotic at the time of the killings. And when it comes to mass shootings, those with mental illness account for “less than 1 percent of all yearly gun-related homicides”, a 2016 study found. Other studies indicate that people with mental disorders account for just 3-5 percent of overall violence in the U.S., (much lower than the prevalence of mental illness in the general population—up to 18 percent). “If you remove additional risk factors and look at mental illness alone, it’s almost unrelated to violence,” Swanson says. “There’s consensus in the field that the unique contribution of psychopathology to violence in the population is very small.” In the wake of an incomprehensible tragedy, however, the implications of that conclusion can be difficult for many to process. “When one of these horrible mass shootings occurs, people say, ‘Anyone who would do such a thing must be mentally ill,’” says Renée Binder, a professor and director of the psychiatry and law program at the University of California San Francisco School of Medicine. “But we need to be careful with our definitions because, while something is clearly wrong with them, it’s often not a serious mental illness.” Making this inaccurate link can also shift the focus of policy debates in the U.S. In debates over limiting access to firearms, some people start talking about fixing the mental healthcare system instead. “Suddenly you hear the gun lobby—which is very powerful in this country and has a vested interest in not having guns be regulated—become an advocate for better mental health care in America,” Swanson says. “It’s a distraction so we don’t talk about guns.” It’s difficult to psychologically profile mass shooters because they often commit suicide or are killed during their attack. But what doctors and scientists do know is that the perpetrators of such events are frequently angry young men, who feel they have been mistreated by society and therefore seek to extract revenge. The problem, however, is that tens of thousands of individuals fit that description— yet the vast majority do not commit a mass shooting.

Predicting who could turn into a mass killer is virtually impossible, Swanson says. Some mass killers had even visited psychiatrists for behavioural problems prior to their attacks, but had no diagnosis of a specific mental illness. “Most of the people who commit mass shootings don’t want treatment and don’t meet the criteria for treatment,” Binder points out. Nor can individuals be committed to a mental hospital just for being angry. This means that bolstering treatment for mentally ill people would not actually solve the gun violence problem in the U.S., Swanson argues. The majority of perpetrators would still slip through the system. So, in debates over how to reduce mass shootings, the evidence suggests that framing these events as caused by mental illness is unlikely to help prevent further attacks—and may only serve to perpetuate an ungrounded fear of the mentally unwell that is rooted more in fiction than fact.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A61

Blaming mass shootings on serious mental illness has harmful effects APA PSYCHIATRIC NEWS FEBRUARY 28, 2018

In an article published in JAMA Psychiatry, American Psychiatric Association past president Renée Binder, MD, and Matthew Hirschtritt, MD, MPH, both of UC San Francisco, wrote that while political rhetoric focusing the blame for mass shootings on individuals with serious mental illness may be “politically expedient,” such an approach “stigmatizes an already vulnerable and marginalized population, fails to identify individuals at the highest risk for committing violence with firearms, and distracts public attention from policy changes that are most likely to reduce the risk of gun violence.” Multiple factors other than serious mental illness contribute to violence risk, Binder and Hirschtritt wrote, including being male, young, having a history of perpetrating violence or being a victim of violence, and unlawful use of firearms. Certain triggers, including intoxication and severe stress, have also been shown to increase the risk of gun violence in people with and without mental illness. “Addressing the risk of future mass shootings requires addressing a wide range of individual, community-level, and national and state policy factors, including decreasing access to guns, especially during periods of heightened violence risk,” they wrote. “Likewise, identifying and assisting those with serious mental illness requires the investment of resources and coordination of services, including supportive case managers, law enforcement and emergency personnel, and mental health clinicians.” Psychiatrists should work to counter the perception that mental illness is the primary cause of gun violence, Binder said. “I believe that psychiatrists have a role in advocacy and education. We have a responsibility in terms of educating people that guns are very dangerous, should be safely stored, and should be taken away from dangerous people,” she said. “Most people with mental illness will never commit a mass shooting, and this rhetoric leads to increased shame, societal reduction, stigmatization, and problems in gaining stable employment and housing.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A62

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

UCSF resident physician Colin Buzza, MD, MPH, is part of a new street medicine program in which psychiatrists visit homeless encampments specifically to provide treatment for opioid addiction and mental illness.

The crisis in our city: Tackling San Francisco’s dire homelessness problem KATHERINE CONRAD MAY 31, 2018

Matthew State, MD, PhD, chair of UCSF’s Department of Psychiatry, is playing a key role in an ambitious effort to tackle San Francisco’s dire homelessness problem. He answers some tough questions about the challenge. In recent years, homelessness has moved from the periphery to seemingly every street corner. Despite determined efforts by many to fix the crisis, it only seems to worsen. Is it an intractable problem? No, I don’t believe it is. It’s a persistent problem, but this is a city that has taken on enormous problems before. During the worst days of the AIDS crisis, academia, philanthropy, the nonprofit community, and government came together to attack what seemed to be an insurmountable challenge. This is the model we are following now in our effort to solve homelessness. We have a committed and diverse community willing and ready to get to work together, and I am proud the psychiatry department and UCSF are contributing to this effort. You’re a renowned expert on the genetics of autism. Why are you focusing on homelessness? I’m the chair of the psychiatry department at a leading public institution. We take care of people with psychiatric illnesses and substance use disorders. These are individuals who unfortunately are dramatically overrepresented among the homeless. The homeless population in San Francisco numbers more than 10,000 people, and conservatively between 30 percent and 40 percent suffer from mental illness and/or substance abuse. There is an essential connection between mental health and homelessness, and that makes addressing it a central part of our mission. You came to UCSF in 2013 after having worked at Yale. Did you know solving homelessness was part of the job description here? One of the reasons I came to UCSF was that this place is committed to bringing together world-class science and the public mission. It’s in our DNA. We staff the psychiatry services at Zuckerberg San Francisco General, our safety net hospital. This is ground zero, where the sickest and most vulnerable people in the city come for care and also happen to be overrepresented among the chronically homeless. What role does the stigma of mental illness play? The reality is we don’t fully understand what causes mental illness and substance abuse yet, so there’s still a pervading belief that “it’s a choice, it’s a moral failing.” It’s a fundamental misunderstanding of mental illness when people say that “it’s just part of the normal spectrum of human behavior” as opposed to “it’s a brain disease.” In fact, we know these are brain disorders not unlike Alzheimer’s disease. But from the standpoint of public policy and the health care system, in many ways it’s worse to have schizophrenia than it is to have Alzheimer’s. Few people would say someone suffering from severe dementia has a human right to wander the streets.

How can these attitudes change? We need to keep up our efforts at advocacy and education. And attitudes will change as we understand the biology of mental illness and substance use disorder better. For instance, real progress in discovering the molecular basis of autism has made a big difference in how society views that condition. We’ve made tremendous advances in understanding a disorder that once was blamed on “refrigerator mothers.” How is the Department of Psychiatry at UCSF attacking homelessness? Through our public psychiatry programs, including training residents and fellows. Through services that care for severely mentally ill and addicted patients, and patients in supportive housing and the criminal justice system. In addition to psychiatric care, we offer vocational rehab, staff mental health court, consult with public schools and the San Francisco jail, and provide services for teenagers in the criminal justice system. That’s just a small sample of the services we provide. And through basic science. Some people see the basic science side as dissociated from some of these big societal problems. I don’t see it that way at all. I think science is going to transform our ability to take care of folks. If we had more effective treatments, many people would not end up sleeping on the streets. That’s the beautiful thing about being here at UCSF. We have an opportunity as one of the world’s great medical institutions to attack homelessness at all levels. How have donors responded? In many parts of the country, donors might think twice about having their name associated with drug abuse or mental illness. It’s clearly not that way in San Francisco. We have had remarkable support for a broad range of psychiatric issues since I arrived here five years ago. This institution and our community of supporters recognize homelessness and mental illness as the crisis of our time. That’s why health equity is a central theme of UCSF: The Campaign. Do you know how unusual that is? I’ve never experienced any other place like UCSF. What will success look like to you? When I don’t have to say, “We don’t have that service right now. We can’t get you a bed. There’s not an opening in that rehab program. I don’t have a doc available for a month or a social worker who can manage that.” That’s what we live with right now. Both my head and my heart tell me we have no choice but to get up every day determined to do better. There should be no place better than San Francisco for taking care of people who are homeless, mentally ill, or suffering from substance use disorders.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A63

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

LGBT+ youth face tougher time as first offenders, study shows STEPHANIE SOPHIE LEE AUGUST 1, 2018

Teens who get in trouble with the law have high rates of substance abuse and mental health issues, but the problems are even worse for lesbian, gay, bisexual, transgender and queer adolescents who are first-time offenders, researchers say in a study published today in the Journal of Adolescent Health. “We already know that adolescents involved in the justice system are at higher risk for drug and alcohol use, risky sexual behaviors and HIV, and more severe mental health issues,” Dr. Matt Hirschtritt, lead author of the study and a forensic psychiatry fellow at University of California, San Francisco (UCSF), told ABC News. “There’s far fewer data [on] those that are not detained, who are court-involved but not incarcerated," Hirschtritt said. "And adolescents who are sexual minorities—in behavior, orientation or gender expression—are also at risk for a lot of these same behaviors. So when you combine these two vulnerabilities, does this confer greater individual risk [of health problems]?” To answer the question, a team led by Dr. Marina Tolou-Shams, an associate professor in the Department of Psychiatry at UCSF, used more than one strategy to find teens who identified as a sexual minority, including those who chose “other” for gender, reported same-sex sexual behavior and reported victimization based on sexual orientation or gender expression.

Among 423 first-time offending, non-incarcerated youth, about one-third could be classified as a sexual minority, which was “one of the biggest things we found that jumped out to us,” said Hirschtritt. “Sexual minorities are over-represented, and this number is also found in detained adolescents [those who end up in a locked facility].” Other findings of the study include higher rates of behavioral and mental health symptoms in first-time offending, (non-jailed) sexual minority youth, including unhealthy internalizing of problems, inattention/hyperactivity, emotional symptoms and personal adjustment issues. “Our suspicions were confirmed that mental health indicators as measured by self-report of various domains in psychological functioning were more severe for sexual minority youth compared to non-sexual minority youth,” said Hirschtritt. Also notable is that the rate of self-harm is four times higher in sexual minorities than in their heterosexual peers, higher rates of substance abuse and a 60 percent higher rate of being intoxicated during sexual activity. “What was interesting was what wasn’t different between groups—self-reported history of delinquent acts and sensation-seeking,” Hirschtritt adds. “Sexual minority youth are at higher risk for risky drug use and sexual behavior and/or more severe psychological distress, but they’re not necessarily more likely to have engaged in delinquent acts or drawn to behavior that would generate a delinquent effect with sensation-seeking.” Instead, trouble with the law is “more a product of their marginalization,” he believes. “We’re seeing a dually vulnerable group that’s subjected to stressors of court but also have historically marginalized identity.” In fact, these court-involved LGBT+ youth reported more post-traumatic symptoms in the past seven days than their heterosexual peers. These findings aren’t surprising to Dr. Alex S. Keuroghlian, director of the National LGBT Health Education Center and a clinical psychiatrist at Massachusetts General Hospital and Fenway Health, a large LGBT-focused health center in Boston. “We call this the minority stress model,” Keuroghlian told ABC News. “External stigma-related stress like everyday victimization, violent victimization, can lead to internalized stigma-related stress regarding sexual orientation and gender identity, such as internalized homophobia and transphobia. This can be associated with higher prevalence of mental health problems and decreased self-care, and higher prevalence of physical health problems down the road.” And when it comes to LGBT+ youth and getting in trouble with the law, he’s quick to clarify, “There's nothing inherently more criminal about this population. It’s due to life circumstances, due to stigma and discrimination.” In his experience, Keuroghlian said “LGBTQ youth are much more likely to have strained relationships with family, to be ostracized from peers. And all this can predispose someone to needing to survive by means other people may not need to, getting into problems with the law.” This points to the importance of identifying sexual attraction preferences and helping those individuals deal with the stressors of living in a society that assumes everyone is straight until told otherwise. Keuroghlian’s advice? Reframe the conversation. “Young people will attribute challenges in their lives to personal failings, and focus on maladaptive cognitive structures, like 'it’ll never get better, no one will ever love me.' It’s important to correctly attribute challenges in their life to external stigma. It can be liberating not to blame yourself and not feel like a failure.” The most important thing is helping LGBT+ youth recognize there is a community out there for support. “It’s a tremendous source of empowerment [knowing] what people have accomplished in the last few decades,” Keuroghlian advised, because LGBT+ people are "more integrated into the mainstream fabric of American society than ever before."  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A64

PUBLIC MENTAL HEALTH AND INTERDISCIPLINARY STUDIES

Collaboration and integration key to addressing global mental health inequities SAVANNAH DEMKO APRIL 3, 2018

Global mental health interventions that emphasize community collaboration in delivering mental health care and integrate mental health care into primary care settings are key to addressing health disparities between lower- and higher-income countries, according to research published in Psychiatric Annals. “Early research conducted by cultural psychiatrists had limited public health and clinical application in international settings due to lack of economic and political support and was mainly used to develop interventions for refugees living in high-income countries,” Anna Fiskin, MD, MSc, assistant clinical professor in the Department of Psychiatry at University of California San Francisco, and colleagues wrote. Although representatives of the U.N. signed the Millennium Development Goals to fight disease, cut child mortality and improve maternal health by 2015, mental health was not prioritized. Therefore, global strategies and interventions to improve the mental health of people living in underserved and lower-income places around the world are needed. “This lack of inclusion has been highly criticized, as mental illness has been found to disproportionately affect the poor and marginalized and have a profound effect on maternal well-being and childhood failure to thrive,” Fiskin and colleagues wrote. “Global mental health advocates have argued that stigma against mental illness among all levels of society has been a major barrier to implementing mental health policy to improve overall health outcomes for both developing and developed countries.” Interventions that use an integrated collaborative care delivery model—in which a stepped-care approach is delivered in community and primary care settings—offer the most effective way to bridge the treatment gap, according to the authors. Sharing tasks with nonspecialists, such as nurses and primary care providers, increases affordability and accessibility to mental health care. Robust evidence has shown that community health workers in low- to middle-income countries can deliver good mental health interventions for depressive and anxiety disorders, schizophrenia and dementia. “An important component of integrated collaborative care is that the majority of care should be delivered outside of specialty mental health care settings and focus on homes, schools, work, or primary care centers,” the authors explained. “Additionally, interventions should actively involve patients and families in their design and implementation, and mental health care should be integrated with social and economic interventions.” In addition, strategies developed to improve health in low- to middle-income countries may help serve the mental health needs in marginalized populations living in higher income countries, according to the researchers. Underserved communities can be positively impacted by approaches that support community-based organizations, leadership within the community, use technology to improve access, link clinical care with public health and social services, and join health with economic development. “Repeated funding cuts for community mental health efforts in the U.S. have resulted in a fragmented mental health system in which a large proportion of care has been transferred from asylums to other institutions, such as residential facilities and prisons,” Fiskin and colleagues explained. Using existing methods developed by global mental health supporters can improve mental health care for vulnerable people living in the United States, according to the authors. Methods that highlight collaboration on the local level within the community can help fix social and economic factors that impact mental health. Psychiatrists and other mental health professionals should continue to research effective task-sharing approaches that consider the needs of those at the local level, they wrote. “The lessons learned from global mental health efforts in [low- and middle-income countries] are highly relevant to addressing health disparities and improving care for vulnerable populations in [high-income countries],” the authors wrote. “These interventions stress community collaboration in designing and delivering mental health care, integration of mental health into primary care settings, and engagement of trained and supervised nonspecialist health workers in care delivery.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A65

Despite a rise in mental health ER visits, urgent care for non-suicidal patients is rare SUZANNE ZUPPELLO DECEMBER 14, 2018

The 2010 Patient Protection and Affordable Care Act reaffirmed and promised to expand on the Mental Health Parity Act of 1998, which states that insurers must offer mental health care comparable to medical and surgical benefits. But insurers still skirt the law or simply do not cover an adequate number of providers. Another source of distress is that many dedicated mental health facilities are closing or are understaffed because of funding issues. The facilities are beholden to state and federal funds, as well as grants from other institutions and wealthy benefactors and mental health funding is low priority for most of these agencies. When patients exhaust their options for affordable care within a reasonable distance, they turn to emergency departments. These have become places of “overflow” for mental and behavioral health patients who cannot access care elsewhere, according to Anne Zink, the emergency department medical director of Mat-Su Regional Medical Center in Palmer, Alaska. Unfortunately for these patients, emergency medicine physicians only receive basic psychiatric training. “Most people are worried that they can’t afford it. Some people think they can handle the problem without any treatment,” Zink stated. “Most people don’t know where to actually go for services. People feel like they don’t have time for treatment. Maybe they feel like they don’t really need treatment.” Physicians, therapists, crisis hotlines, and even family members and friends refer people to the ER too frequently without realizing most patients who visit will not be admitted on the basis of psychiatric need. And there’s limited follow-up for the patients who visit or are turned away. With lack of access to the appropriate level of care and the exorbitant cost of it looming over an already-stigmatized community, cities and states are looking to alternative methods of care. One low-cost, high-impact change that could vastly improve mental-health care is for patients to have strong relationships with their primary health-care providers. According to a study published earlier this year in the Journal of the American Board of Family Medicine, depression screenings performed by primary-care physicians are an untapped resource in a very dry field. UC San Francisco's Matthew Hirschtritt, one of the study’s authors, says “with a simple questionnaire, primary care doctors have a big opportunity to better spot depressive symptoms in at-risk patients and help improve their lives through treatment”; yet only 1.4 percent of all adult primary care visits involve a mental-health screening. Zink also emphasized the importance of telemedicine, through which patients, ED, and primary care physicians can consult with psychiatrists no matter how far apart they are.  LISTEN TO THE PODCAST EPISODE AT PSYCH.UCSF.EDU/A66

Fresno County addresses psychiatry shortage with new training program KERRY KLEIN FEBRUARY 20, 2018

A study published last week by UC San Francisco argues the San Joaquin Valley has some of the lowest ratios of behavioral health providers like psychiatrists and licensed clinical social workers in the state. The study also predicts that if nothing changes, California is on its way to a statewide behavioral health worker shortage. One of the authors’ recommendations, however, is a medical training program that began three years ago at the University of California and just recently gained funding from Fresno County. Listen to the audio for an interview with Dr. Shawn Hersevoort, a psychiatrist at UCSF Fresno and an associate director of the program, called the Train New Trainers Primary Care Psychiatry Fellowship.  LISTEN TO THE PODCAST EPISODE AT PSYCH.UCSF.EDU/A67

SUBSTANCE USE DISORDER AND ADDICTION

Can Facebook help you quit smoking? Study indicates yes CATHERINE HO MAY 24, 2018

Facebook may be able to help you quit smoking, according to a new UCSF study. The study used the world’s most popular social media site to recruit 500 smokers ages 18 to 25. It exposed them to messages about quitting and counseling about quitting, all through Facebook. The upshot: the Facebook users were 2½ times more likely to stop smoking than young adults who were exposed to more traditional online quitting programs—in this case, the National Cancer Institute’s smokefree.gov website. The study, conducted between 2014 and 2016, is one of the first by a U.S. research institution to examine whether social media can help young adult smokers to quit. A 2016 Canadian study had similar findings—that young adult smokers who were targeted by a social media campaign were more likely to stop than those who used a telephone hotline.

Someone who didn’t smoke for seven consecutive days was considered to have successfully abstained. For verification, participants took a saliva test that detects cotinine, an indicator of nicotine exposure. Researchers were particularly interested in targeting young adults because that age group does not use traditional quitting programs as often as older adults, even though the programs are accessible online and through texting services.

The UCSF study’s participants joined a private Facebook group in which they could communicate with a trained counselor through a weekly live counseling session, similar to a Reddit-style question-and-answer exchange.

“In our intervention, people were much more engaged and active,” said Danielle Ramo, the study’s lead author and director of the research on addiction and digital interventions lab at the UCSF Department of Psychiatry.

Researchers also created daily posts tailored to the participants’ level of interest in quitting—some expressed a desire to quit immediately, some indicated they wished to quit in the next six months, and others had no plans to quit. The study looked at whether people stopped smoking after three months, six months and 12 months of the Facebook intervention.

Ramo, an associate professor of psychiatry, is now looking into using Instagram to recruit participants for clinical trials to test the effectiveness of social media interventions for tobacco and alcohol for young adults and LGBT adults.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A68

Opioid drugs rush in where natural opioids fail to activate STAFF REPORT MAY 11, 2018

Opioid drugs and natural (or endogenous) opioids run along different paths inside neurons, which could explain why the “runner’s high” that results from exercise differs from the unnatural high produced by morphine, heroin, or synthetic opioids. Whereas opioid drugs and natural opioids both activate opioid receptors on the surface of neurons, opioid drugs take a detour after neurons internalize them.

“Peptide agonists produce a characteristic activation pattern initiated in the plasma membrane and propagating to endosomes after receptor internalization,” wrote the article’s authors. “Drugs produce a different activation pattern by additionally driving opioid receptor activation in the somatic Golgi apparatus and Golgi elements extending throughout the dendritic arbor.”

By tracking the path taken by opioid drugs, researchers based at the University of California, San Francisco (UCSF), hope to better understand opioid addiction. The researchers, led by Mark von Zastrow, MD, PhD, a professor of psychiatry at UCSF, also hope that their findings will lead to less addictive pain-killing drug designs.

Differences in the activation patterns of opioid drugs and endogenous opioids could help explain why the effects of opioid drugs are more rewarding than those produced by endogenous opioids. Now that these differences are being uncovered, old assumptions about opioid signaling may need to be revised.

“There has been no evidence so far that opioid drugs do anything other than what natural opioids do, so it's been hard to reconcile the experiences that drug users describe—that opioid drugs are more intensely pleasurable than any naturally rewarding experience that they've ever had,” said Dr. Von Zastrow. “The possibility that these opioid drugs cause effects that natural opioids cannot is very intriguing because it seems to parallel this extremely rewarding effect that users describe.”

It had generally been thought that all opioid molecules, natural or synthetic, impart their signal only from receptors on the surface of the cell. Opioid-bound receptors are then taken inside the cell to compartments called endosomes, but receptors were thought not to signal from this location.

Dr. Von Zastrow and colleagues essentially found a way to track opioid drugs and endogenous opioids, and what they discovered came as a surprise. Opioid drugs achieve opioid receptor activation in the Golgi apparatus. Endogenous opioids do not. Details appeared May 10 in the journal Neuron, in an article entitled “A Genetically Encoded Biosensor Reveals Location Bias of Opioid Drug Action.” The article describes how the UCSF team created a biosensor that binds to opioid receptors along with opioid drugs or natural opioids. With their biosensor, the UCSF scientists uncovered a “real-time map of the spatiotemporal organization of opioid receptor activation in living neurons.”

Overturning this long-held view, the UCSF team discovered that receptors remain active in endosomes and they use the endosome to sustain the signal within cells. Even more intriguingly, the UCSF team discovered that morphine and synthetic opioids activate receptors in yet another internal location, the Golgi apparatus, where endogenous opioids are unable to produce any activation at all. Moreover, morphine and synthetic opioids crossed cell membranes without binding receptors or entering endosomes. They traveled directly to the Golgi apparatus, reaching their target much more quickly than endogenous opioids got into endosomes, taking only 20 seconds compared to over a minute. This time difference could be important in the development of addiction, the researchers said, because typically the faster a drug takes effect, the higher its addictive potential. The scientists hope to apply their findings to create new types of opioid-based pain medications that have a lower risk for addiction. They also plan to screen other existing medications to see if they act more like natural or synthetic opioids. “We're very excited about the possibility of leveraging these principles to develop better or more selective drugs that have the ability to get into the brain, but then differ in their activities at internal locations within individual neurons,” said Dr. Von Zastrow, who is the senior author of the Neuron article. “This is an area that hasn't been explored in drug development because people haven't been thinking about it, but the potential is there.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A69

SUBSTANCE USE DISORDER AND ADDICTION

How legalized weed is changing the way schools talk to kids about drugs ASHLEY ABRAMSON JULY 19, 2018

When California legalized recreational marijuana on January 1, 2018, the state changed their drug education messaging from “Just Say No” to “Delay,” using research about adolescent substance use to encourage lifelong health and prevent abuse. California is the eighth US state faced with the challenge of modernizing its approach to drug education alongside the legalization of marijuana. While there’s minimal research on how legalizing weed for adults impacts teens’ attitudes toward, and use of, marijuana,studies consistently demonstrate that early, persistent use of cannabis has detrimental effects on cognitive development. That’s why states are considering their responsibility in preventing drug abuse among youth, starting in schools. The state’s Proposition 64, which both legalizes weed for adults over 21 and creates a tax on cannabis sales, will eventually also funnel some of the tax money into schools to promote drug education. But since the taxation structure is not yet fully developed, substance use prevention and education varies from school to school. Currently, more than 20 San Francisco-area schools use a drug education curriculum called Being Adept, a research-based and science-backed program that encourages students to make healthy decisions about substance use. Studies link early use of drugs and alcohol to substance abuse later on in life, so the program’s goal is to empower kids to make their own informed choices about drugs and alcohol—based on facts about the impact of early, frequent drug use rather than the traditional scare tactics involved with outdated (and generally ineffective) anti-drug campaigns. Danielle Ramo-Larios, who directs research on adolescent drug use at the University of California, San Francisco, says programs like Being Adept were created to adapt to the changing attitudes adolescents have toward marijuana. “Teens are less and less inclined to believe that cannabis use causes problems, so telling them not to use at all, ever, is just not a realistic message that they will take seriously,” she tells Brit + Co.

So rather than scaring teens out of drug use altogether, programs like Being Adept focus on empowering them to make healthy, thoughtful decisions for themselves. Lesson topics like the science of addiction, “brain basics,” stress management, and even “two-minute yoga” both help students to understand how drug use could affect them and give them tools to deal with stress, a known risk factor for drug and alcohol use among youth. “Good drug prevention programs should also focus on why making healthier decisions in the face of stress (like choosing to exercise rather than drink or use drugs, for example) will support lifelong behavior patterns that will make teens happier adults later on,” Ramo-Larios says. Since school drug education programs will likely continue to develop as cannabis taxation does, and more states will likely follow suit in legalization in the near future, Ramo-Larios says families play a significant role in delaying drug and alcohol use and preventing abuse—regardless of a given state’s marijuana legislation. Parents play a large role in setting the tone for adolescents’ attitudes toward drugs and alcohol, which is a responsibility they should take seriously. “Parents should be aware of the risk factors for problem drug use, talk to their kids early and often about what they have heard about drug use, and set clear limits around use and stick to them,” she says. “They should also not glamorize their own use, and [they should] generally take a stance that use in adolescence is not the same as use later on.”

Rather than a fear-based approach—like the D.A.R.E. and “Just Say No” programs of the 1980s and 1990s—Ramo-Larios says a more modern, realistic approach that aligns with scientific research could be more effective long-term. “We know that the ‘Just Say No’-type programs really did nothing to prevent the onset of drug use in teens. The modern approach to prevention should be realistic about the research with cannabis, which shows that using early and often in adolescence is not good for the brain or body,” she says. “Focusing the message on delaying use until the brain is fully developed—and until decisions to use will not impede on important life goals, from school to extracurriculars—is ideal.” Rather than scaring teens out of drug use altogether, programs like Being Adept focus on empowering them to make healthy decisions for themselves. Lesson topics like the science of addiction, “brain basics,” stress management, and even yoga both help students to understand how drug use could affect them and give them tools to deal with stress, a known risk factor for drug and alcohol use among youth.

Use of ‘smart drugs’ on the rise ARRAN FROOD JULY 5, 2018

The use of drugs by people hoping to boost mental performance is rising worldwide, finds the largest ever study of the trend. In a survey of tens of thousands of people, 14 percent reported using stimulants at least once in 2017, up from 5 percent in 2015. The non-medical use of substances—often dubbed smart drugs—to increase memory or concentration is known as pharmacological cognitive enhancement (PCE), and it rose in all 15 nations included in the survey. The study looked at prescription medications such as Adderall and Ritalin—prescribed medically to treat attention deficit hyperactivity disorder (ADHD)— as well as the sleep-disorder medication modafinil and illegal stimulants such as cocaine.

The work, published in the International Journal of Drug Policy in June, is based on the Global Drug Survey, an annual, anonymous online questionnaire about drug use worldwide.

Cultural factors, the prevalence of ADHD diagnoses and availability all influence which drugs are used for PCE and the rate of use, says study leader Larissa Maier, a psychologist at UC San Francisco.

U.S. respondents reported the highest rate of use: in 2017, nearly 30 percent said they had used drugs for PCE at least once in the preceding 12 months, up from 20 percent in 2015.

In the United States, where ADHD diagnoses are high and medication is a common treatment, 22 percent of respondents said they had used amphetamine combination drugs such as Adderall for PCE. The study suggests that the spread of U.S.-style practices in ADHD treatment is driving the trend and making drugs more available: countries with higher rates of ADHD diagnoses have higher rates of non-medical prescription-drug use for cognitive enhancement.

But the largest increases were in Europe: use in France rose from 3 to 16 percent, and from 5 to 23 percent in the United Kingdom. An informal reader survey by Nature in 2008 found that one in five respondents had used drugs to boost concentration or memory.

 READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A70

TRAUMA AND PTSD

The wounds of the drone warrior EYAL PRESS JUNE 13, 2018

It has been almost 16 years since a missile fired from a drone struck a Toyota Land Cruiser in northwest Yemen, killing all six of its passengers and inaugurating a new era in American warfare. Today, targeted killings by drones have become the centerpiece of U.S. counterterrorism policy. Although the drone program is swathed in secrecy—the CIA and the military share responsibility for it—American drones have been used to carry out airstrikes in at least eight different countries, analysts believe. Over the past decade, they have also provided reconnaissance for foreign military forces in half a dozen other countries. According to the Bureau of Investigative Journalism, a London-based organization that has been tracking drone killings since 2010, U.S. drone strikes have killed between 7,584 and 10,918 people, including 751 to 1,555 civilians, in Pakistan, Afghanistan, Yemen and Somalia. Drones have fostered the alluring prospect that terrorism can be eliminated with the push of a button, a function performed by “joystick warriors” engaged in an activity as carefree and impersonal as a video game. Critics of the drone program have sometimes reinforced this impression. In 2010, Philip Alston, the United Nations special rapporteur on extrajudicial executions, warned that remotely piloted aircraft could create a “PlayStation mentality to killing” that shears war of its moral gravity. But the more we have learned about the experiences of actual drone fighters, the more this idea has been revealed as a fantasy. In one recent survey, researchers found that far from exhibiting a sense of carefree detachment, three-fourths of intelligence analysts and officers involved in remote combat operations reported feeling grief, remorse and sadness. Many experienced these “negative, disruptive emotions” for a month or more. According to another recent study conducted by the Air Force, drone analysts in the “kill chain” are exposed to more graphic violence—seeing “destroyed homes and villages,” witnessing “dead bodies or human remains”—than most Special Forces on the ground. Because the drone program is kept hidden from view, the American public rarely hears about the psychic and emotional impact of seeing such footage on a regular basis, day after day, shift after shift. Compared with soldiers who have endured blasts from roadside bombs—a common cause of brain injuries and PTSD among veterans of the wars in Iraq and Afghanistan—the wounds of drone pilots may not seem consequential. But in recent years, a growing number of researchers have argued that the focus on brain injuries has obscured other kinds of combat trauma that may be harder to detect but can be no less crippling. Drone warfare hasn’t eliminated these hidden wounds. If anything, it has made them more acute and pervasive among a generation of virtual warriors whose ostensibly diminished stress is belied by the high rate of burnout in the drone program.

A redefined terminology The term “moral injury” is not new. It appeared in the 1994 book Achilles in Vietnam, by the psychiatrist Jonathan Shay, who drew on Homer’s epic war poem The Iliad to probe the nature of the wounds afflicting veterans of the Vietnam War. Shay read The Iliad as “the story of the undoing of Achilles’ character,” which, he argued, unravels when his commander, Agamemnon, betrays his sense of “what’s right,” triggering disillusionment and the desire “to do things that he himself regarded as bad.” “I shall argue what I’ve come to strongly believe through my work with Vietnam veterans: that moral injury is an essential part of any combat trauma,” he wrote. “Veterans can usually recover from horror, fear and grief once they return to civilian life, so long as ‘what’s right’ has not also been violated.” Fifteen years later, the term “moral injury” began to appear more frequently in the literature on the psychic wounds of war, but with a slightly different meaning. Where Shay emphasized the betrayal by authority figures, a new group of researchers expanded the focus to include the anguish that resulted from “perpetrating, failing to prevent or bearing witness to acts that transgress deeply held moral beliefs,” as a 2009 article in the journal Clinical Psychology Review proposed. In other words, they defined it as a wound sustained when soldiers wading through the fog of war betrayed themselves, through harmful acts they perpetrated or watched unfold. This definition took shape against the backdrop of the wars in Iraq and Afghanistan, chaotic conflicts in which it was difficult to distinguish between civilians and insurgents, and in which the rules of engagement were fluid and gray. One author of the Clinical Psychology Review article was Shira Maguen, a researcher who began to think about the moral burdens of warfare while counseling veterans at a PTSD clinic in Boston. Like most VA psychologists, Maguen was trained to focus on the aftershocks of fear-based trauma—IED blasts that ripped through soldiers’ Humvees, skirmishes that killed members of their unit.

The link between PTSD and such “life-threat” events was firmly established. Yet in many of the cases she observed, the source of distress seemed to lie elsewhere: not in attacks by the enemy that veterans had survived, but in acts they had committed that crossed their own ethical lines. “I was hearing about experiences where people killed and they thought they were making the right decision,” Maguen told me recently, “and then they found out there was a family in the car.” To find out how heavy the burden of killing actually was, Maguen, who is now a staff psychologist at the VA Medical Center in San Francisco and a faculty member at the University of California, San Francisco, began combing through databases in which veterans of conflicts dating back to the Vietnam War were asked if they had killed someone while in uniform. In some cases, the veterans were also asked whom they killed—combatants, prisoners, civilians. Maguen wanted to see if there might be a relationship between taking another life and debilitating consequences like alcohol abuse, relationship problems, outbursts of violence, PTSD. The results were striking: Even when controlling for different experiences in combat, she found, killing was a “significant, independent predictor of multiple mental health symptoms” and of social dysfunction. In San Francisco, Maguen convened groups where veterans came together and talked about the killing they had done. In the VA no less than in the military, this was a taboo subject, so much so that clinicians often refer to it euphemistically, if at all. The veterans in Maguen’s groups didn’t speak much about fear and hyperarousal, emotions linked to PTSD. Mostly, they expressed guilt and self-condemnation. “You feel ashamed of what you did,” one said. Others described feeling unworthy of forgiveness and love. The passage of time did little to diminish these moral wounds, Maguen found. Geographic distance didn’t lessen them much either. She recounted the story of a pilot who was haunted by the bombs he had dropped on victims far below. What troubled him was, in fact, precisely his distance from them —that instead of squaring off against the enemy in a fair fight, he had killed in a way that lacked valor. Obviously not all pilots felt this way. But the story underscored the significance of something Maguen has come to regard as more important than proximity or distance in shaping moral injury—namely, how veterans made sense of what they had done. “How you conceptualize what you did and what happened makes such a big difference,” she said. “It makes all the difference.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A71

TRAUMA AND PTSD

Veterans with both PTSD and depression face much higher risk of suicidal thoughts ERIC W. DOLAN MAY 28, 2018

New research suggests that military veterans suffering from both PTSD and depression are at substantially increased risk of having suicidal thoughts. The study, published in Psychiatry Research, is the first to report tremendously high rates of suicidal ideation among those with co-occurring PTSD and depression.

VA uses ketamine to treat PTSD effectively JULIE SCAGELL DECEMBER 17, 2018

The San Francisco Veterans Affairs Medical Center is administering ketamine to veterans with post-traumatic stress disorder and depression. Tobias Marton, the director of the ketamine infusion program at the center and a faculty member at the University of Californa, San Francisco, said that since the program first launched two years ago, they have treated about 40 patients who had virtually exhausted all other options.

“It has been well-established that veterans are at increased risk for developing PTSD and depression, and that those suffering from these conditions are more likely to think about, attempt, and complete suicide. As such, it is critical that researchers and care-providers identify anything we can use to target and treat them,” said study author Melanie B. Arenson of the San Francisco VA Medical Center and University of California.

“They’ve done everything we’ve asked them to do and they remain with very severe symptoms and with a poor or impaired quality of life,” he said. “Despite [past treatments], there remains a high risk of suicide [with some veterans].”

For their study, the researchers evaluated 746 veterans at two Department of Veterans Affairs sites in the San Francisco Bay Area. A little more than half of the participants served in the Vietnam era. The study also included veterans who served during World War II, the Korean War, the Gulf War, the Iraq War, and the War in Afghanistan.

Marton said that in general, about a third of people diagnosed with depression don’t respond to first, second and third lines of treatment. In contrast, ketamine infusion has yielded “impressive outcomes.”

“In this study, nearly 50 percent of veterans who had PTSD and depression at the same time endorsed thoughts that they would be better off dead or hurting themselves in some way within the previous two weeks, regardless of when they served, which means their trauma could be decades old,” Arenson said. “These rates are in comparison to 34 percent of those with depression alone, 11 percent of those with PTSD alone, and only 2 percent of those with neither disorder, suggesting that the effects of PTSD and depression on suicidal ideation are additive. These veterans represent a high risk group that can benefit from suicide prevention efforts.” The study controlled for potentially confounding variables like demographic factors, symptom severity, anger, hostility, anxiety, alcohol use, optimism and social support. But the study—like all research—has some limitations. “Perhaps the most substantial one being that our data was all cross-sectional (e.g. collected at the same time), so we cannot show what is leading to what: PTSD could lead to depression which could lead to suicidal thoughts, but it’s also possible that depression increases the risk of developing PTSD, and those together lead to suicidal thoughts,” Arenson explained. “More research is needed to tease causal links apart. Additionally, this project purposefully over-recruited veterans who had PTSD, and therefore the rates of PTSD and depression we report are likely not representative of veterans overall.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A72

While it was not clear where the 40 patients are from, the option is something that is available to Humboldt County veterans who are suffering from PTSD or depression.

Many people know of ketamine as a party drug, often referred to as Special K, but it is mainly used medically for anesthesia or pain treatment. “We know ketamine has rapid and powerful anti-suicide properties,” he said. “To have another tool, a potentially powerful tool to have an impact on suicide rates is really exciting.” While Marton is proceeding with “cautious optimism,” Boris Nikolov, the CEO of Neurosciences Medical Clinic in Miami, Florida, which has a ketamine clinic, believes the application might be a medical breakthrough. Nikolov’s clinic has treated 120 patients with ketamine, including his wife who has PTSD as a result of severe child abuse. Nikolov said most medicines that treat depression take from two to four weeks to start working. Ketamine begins working within hours after it is administered, a process which usually involves an IV infusion over the course of about an hour. “What’s most important is the strong and fast effect of ketamine in patients who are very seriously depressed, or want to hurt themselves,” he said. “When they finish treatment, they’re totally different people. There is no other medication that does that.” Brad Burge, the director of strategic communication at the Multidisciplinary Association for Psychedelic Studies, or MAPS, said there has been “an explosion of treatment that’s outpaced research.” “It means that people are going to have another option,” he explaned, “an alternative to conventional medications.” According to Burge, MAPS believes the best form of ketamine infusion involves pairing with other forms of psychotherapy such as group or individual counseling. While ketamine is an FDA-approved drug which has been used as an anesthetic as well as a pain reliever, it isn’t officially sanctioned by the FDA to be used for treating mental health disorders. However, Marton said that ketamine has been administered in this fashion for over 18 years now. A company is currently in the process of trying to get an intranasal product approved by the FDA which would administer ketamine through the nasal passage, according to Marton. He expects the FDA’s decision to be announced sometime around March 2019. If the product is approved, he said, VA clinics in rural communities like the one in Eureka would likely be able to start offering ketamine treatments as well. For now, only the location in San Francisco is able to offer the treatment, but Marton said anyone within their service realm, which includes Humboldt County, is invited to consult with the VA about seeking treatment. “We want to be as thoughtful as we can,” he said. “As we understand more about it … (we) might be able to start helping people who we haven’t been able to help despite throwing everything we have at them.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A73

TRAUMA AND PTSD

Temper tantrums, post-traumatic stress, depression: How family separation devastates migrant kids SOPHIE MURGUIA JUNE 20, 2018

A host of doctors and psychologists have condemned the separation of migrant families at the border, citing the potential health and mental health risks for children. Even as President Donald Trump plans to sign an executive action ending the policy, more than 2,000 children have already been affected by the separations. In an interview with CNN, the president of the American Academy of Pediatrics described the family separations as “child abuse.” The American College of Physicians, the American Psychological Association and the American Psychiatric Association have also denounced the policy. In a call with reporters last week, child welfare experts pointed to studies showing that children separated from their parents can experience symptoms such as anxiety, depression, changes in sleeping or eating habits, aggression, and other behavioral problems. To better understand the psychological effects of family separation on children, I spoke with Chandra Ghosh Ippen, the associate director of the Child Trauma Research Program at the University of California, San Francisco.

“Depressed, anxious, fearful that it may happen again–those are the symptoms we’re likely to see.” - CHANDRA GHOSH IPPEN, PHD

What psychological symptoms these kids might experience in the long term? It’s super complex, because it depends on the kids’ neurobiology, their genetic tendencies. We see different patterns in stress related to different people. Some of your common patterns are what you might call fight or flight. If you think about that from a symptom picture, fight is aggression, anger—those sort of symptoms that cluster together. Flight might be depression, anxiety, slowing down of developmental momentum, developmental delays. We also see freeze responses, so when things are really bad and there is no help, we might see kids who tend to dissociate more. And then we see a clinging pattern, kids who have a lot of separation anxiety, who worry. Kids can display all of these symptoms, or based on the way they’re wired—their genetics, their neurobiology, their experiences, the way their caregivers have responded—they may tend to adopt more of one pattern. How might being in a shelter affect these kids? Again, what’s going to matter is their age, their experiences, how long they’re going to stay in the shelter, and the quality of their care. So again, it’s hard to comment on anyone, but we know that the research suggests that institutional care is not good for children. We have a lot of people who were part of the Bucharest orphanage study that happened in Romania, where they went in and we had kids who were in orphanages really suffering. What they found was that if you could get those children into high-quality foster care as soon and as early as possible, they did much better. But even as we’re suggesting this, we may not need high-quality foster care. We may have loving parents that they should never have been taken away from in the first place. This a problem that we’ve created, and rather than finding solutions in foster care or in institutionalization, we should find solutions in terms of how quickly can we reunite them with loved ones.

What would you expect the short-term psychological effects to be for these children who are being separated from their parents? The short-term psychological effects are going to depend a lot based on their age and also on their previous history. We’re going to see a range of responses from the children. Some of the children have probably experienced a fair amount of other traumas, and that’s why they’re fleeing the situation that they’re in…We might expect to see sleep problems, we might expect to see nightmares from sleep problems. We’re gonna see kids who fall apart more—temper tantrums, more angry outbursts. All of us would be angry—we call them symptoms, but they’re also normal reactions. We might see more relationship problems, because how can [they] trust people if this can happen? You might even see anger at parents, so relationship disconnections even after they’re reunited. You may see problems in concentration and attention, you may see increased activity levels in some kids. You may see withdrawal and numbing and shutting down in other kids. Some kids may dissociate. Some kids in an effort self-soothe may shut down. You also might end up seeing health problems. What kinds of health problems? When you’re under tremendous stress, your body puts out stress hormones, cortisol and adrenaline. Those hormones, in high doses, are going to affect your immune system, making you more susceptible in the short term to illness. I think we’ve all had that experience, where when we’re stressed we catch everything. These kids, if they’re super stressed, their bodies and their immune systems may be more susceptible. What might be the long-term effects of these separations? It really depends. It depends on whether or not we can reunite them quickly with loved ones who can calm them down, and whether or not they can get services…Otherwise, what we’ll see is heightened post-traumatic stress symptoms. Children who are jumpy in the longer term, children who may constantly live in fear that their parent could leave them. This will make it difficult for them to explore, to learn. Even when they raise their own kids, they may fear separation. That age when they were separated may become a trigger if they aren’t given help to make meaning and to carry this in a certain way. Longer term, you may see increased levels of depression. Depressed, anxious, fearful that it might happen again—those are really common symptoms we’re likely to see.

Talking to children traumatized by the Pittsburgh shooting BEN HARRIS DECEMBER 18, 2018

While children and adolescents directly connected to the Pittsburgh shooting may have suffered trauma most acutely, even children farther removed from the massacre may be traumatized, experts say. Part of the professional response to a mass event like Pittsburgh is to reassure people that their feelings will subside in time. For young children especially, voices of adult reassurance are crucial because kids often pick up subtle messages from the media or close relations and ascribe meaning to those messages. “Whether or not we talk to young children, young children try to give meaning to what they hear,” said Alicia Lieberman, a psychiatry professor at the University of California, San Francisco and an expert in treating trauma in children. “And so it’s better for us to tell them, for example, ‘Mommy and daddy are upset because a very bad man hurt people and he shouldn’t have done that. And we are doing lots of things to keep everybody safe.’”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A74

TRAUMA AND PTSD

Children separated from parents could be traumatized for life, experts say BRENDAN COLE JUNE 20, 2018

Study: A quarter of college students could develop PTSD because of the 2016 election ISAAC STANLEY-BECKER OCTOBER 24, 2018

Babies and young children who are forcibly separated from their parents at the U.S.-Mexico border could face emotional problems for the rest of their lives, according to child experts.

Are college students “snowflakes”—triggered, traumatized and all together too delicate for the real world? Or are they apathetic—so unconcerned that they can’t be bothered to purchase stamps to send in their absentee ballots?

President Donald Trump's administration officials have been sending babies and young children to three “tender age” shelters in South Texas, the Associated Press reported. They are located in Combes, Raymondville and Brownsville. A fourth shelter is planned for Houston.

The two characterizations of young Americans are in conflict, observed Melissa Hagan, a psychologist with faculty appointments at the University of California, San Francisco and San Francisco State University. Her research has led her to believe that neither captures what’s going on in the minds of young people. Their intense reaction to political events runs contrary to the charge of apathy, she said, while the emotional trauma they report should not be dismissed as hypersensitivity.

The playrooms of the facilities in Rio Grande are full of crying preschoolers as authorities struggle to implement the Trump administration zero tolerance policy to prosecute anyone who crossed the border illegally. This has led to more than 2,300 children being taken from their parents in five weeks. South Texas pediatrician Marsha Griffin said the standards in the facilities were fine, but the children were hysterical and could not cope with the trauma. Alicia Lieberman, who runs the Early Trauma Treatment Network at University of California, San Francisco, told the AP, “Children are biologically programed to grow best in the care of a parent figure.” “When that bond is broken through long and unexpected separations with no set timeline for reunion, children respond at the deepest physiological and emotional levels,” she said. “Their fear triggers a flood of stress hormones that disrupt neural circuits in the brain, create high levels of anxiety, make them more susceptible to physical and emotional illness, and damage their capacity to manage their emotions, trust people, and focus their attention on age-appropriate activities.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A75

How to stay updated on the news without losing your mind LINDSAY HOLMES JANAURY 12, 2018

Who’s ready to chuck their phone into the sea and never read another media alert again? That solution may be a bit dramatic, but news fatigue is real—and it’s likely wrecking your well-being. Research shows constant exposure to negative news can affect your mental health over time. Data published in 2016 found a majority of Americans are stressed over the future of the nation. Gyms are even banning cable news because it’s taking a toll on people. However, as nice as avoiding the news until the end of time sounds, it’s also incredibly unrealistic. It’s smart to stay in touch with what’s happening. Plus, people are personally living out news stories in their daily lives as they face racism, terrorism, health care issues and weather-related disasters. It’s a good idea to read different news sources to get a well-rounded picture of the world. However, that could mean multiple news alerts on your phone. The barrage of notifications not only can get overwhelming, it’s essentially setting you up for on-demand stress. “When it comes to stress, it’s important to determine what is in your personal control and what is not within your control, and what action needs to be taken and what the appropriate action is,” said Dr. Renée Binder, past president of the American Psychiatric Association and a psychiatry professor at the University of California, San Francisco, School of Medicine. In some cases, taking action might mean limiting what you expose yourself to on a regular basis. Consider doing a cleanup of your notifications by enabling only what you feel is necessary. Binder told HuffPost that turning to other resources—like enabling local county alerts rather than national news alerts—may also be a good workaround.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A76

With a team of researchers, she surveyed 769 introductory psychology students at Arizona State University in January and February 2017, asking about their satisfaction with the 2016 election, whether they were upset about the outcome and whether the results of the race had affected their close relationships. The results were published in the Journal of American College Health, a bimonthly, peer-reviewed public health journal. The article finds that 25 percent of students had “clinically significant event-related distress,” which it argues can predict future distress as well as diagnoses of PTSD, commonly associated with veterans and defined by the Mayo Clinic as “a mental health condition that’s triggered by a terrifying event—either experiencing it or witnessing it.” The research speaks to the personal toll of partisan battles, and it offers insight into the perspective of young Americans coming to political consciousness in the era of President Trump. Her students were “visibly upset,” she recalled in an interview. “Some were even crying.” They told her that they were scared and anxious about policies that had been discussed on the campaign trail, she said, as well as about the elevation of “a candidate who had an audio recording of him describing sexual assault.” The analysis reveals that women, racial minorities, people from working and lower-middle social classes, Democrats, non-Christians and sexual minorities reported significantly more election-related distress. Accounting for connections among various factors, the most useful predictors of stress were sex, political party, religion and perceived impact of the election on close relationships—more so than race and social class. Controlling for party affiliation, other demographic factors still influenced stress symptoms. In other words, Hagan said, it wasn’t just a case of sore losers. The 2016 election itself was not a trauma, Hagan said. The term implies the threat or actual experience of personal injury, and usually applies to events such as mass shootings or armed conflict. “But what’s underneath that is helplessness and fear,” she said. “We can think about the election campaign—with discussions of deportation and how women are treated, for instance, and the extreme language used by both candidates—as driving these experiences of intrusion,” Hagan said. “Young people can’t stop thinking about it. It interferes with their concentration." “Or else,” she added, "there’s avoidance, where they don’t want to talk about it.” Most notable, Hagan said, was “the extent of the clinical impairment”—the proportion of students whose symptoms rose to the level that could entail risk of subsequent PTSD. At the same time, she said, the accounts of individual survey subjects demonstrate why this would be the case. One of the students, Hagan said, was fearful that her parents were going to be deported. Hagan rejected the notion that distress was a sign of emotional weakness, even when political events don’t reach young people directly. The fear can still be real, she said, pointing to the more recent example of the dramatic accounts of children being separated from their parents at the country’s southern border. The data does not spell out the long-term consequences for mental or physical health of election-induced distress. Nor does it establish the cause of the trauma-like symptoms. But the researchers speculated that "issues of identity and social inequality prominent in election-related rhetoric” played a role, as they wrote. “Repeated exposure to visual stimuli and words relevant to one’s identity, when perceived to be threatening or priming negative stereotypes regarding social group membership, can negatively impact psychological well-being.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A77

TRAUMA AND PTSD

What happens when #MeToo stories reignite old trauma LESLIE MCCLURG JANUARY 23, 2018

For victims of sexual violence, the flood of #MeToo sexual harassment stories may stir a mix of emotions. In many ways it can be validating to know you’re not alone. But the stories can also spark old memories and uncomfortable physical reactions. “What’s happening right now has been a big trigger," says San Francisco resident Jane Johnstone. The many tales of male sexual misconduct have ended careers in numerous workplaces, including NPR. Johnstone was relieved to see a national conversation unfolding about a subject painfully close to her heart, but it wasn't long before all the headlines sent her into a tailspin. "I just felt all of the things that I hadn't felt in so long," Johnstone, says. She's also been hit by waves of pain and sadness. "There's still so much shame." So much shame, for something that happened nearly 50 years in the past. When Johnstone was about eight years old, she was sexually abused by her best friend’s father. At first she was too young to fully understand his actions as wrong. But experts say her brain instinctively knew. Johnstone endured the abuse silently for several years. As an adult, she remained emotionally withdrawn. “I couldn’t get close to people," she says. "I was afraid to open up and have really intimate relationships.” That response makes complete sense to Laurie Richer, a psychiatrist at UC San Francisco and the director of the Trauma Recovery Center. “So right away she developed a sense that not everybody's safe," Richer says. "In general, especially when we're talking about sexual harassment, sexual assault, or sexual abuse, individuals tend to feel less safe in all relationships and especially in intimate relationships." Women are more than twice as likely as men to develop PTSD, and survivors of sexual violence are particularly at risk. Richer says a traumatic experience can literally rewire the nervous system and alter the body’s coping mechanisms. Victims who develop PTSD may struggle with symptoms, such as hyperarousal, for their entire lives. The visceral nature of flashbacks is a unique symptom. In most people, a memory lights up the thinking part of the brain. In people with PTSD, a memory lights up the sensory area, so that the past is not just recalled, but rather relived.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A78

A sign your workplace is toxic: You can’t bring yourself to disclose the mental health issues you’re experiencing JENN SINRICH JULY 9, 2018

Your work environment can make a huge impact on your health, which is why it’s so important to ensure that you’re not only happy with the work, but you’re happy and comfortable with the people, too. Under the Americans with Disabilities Act, people with physical or mental disabilities cannot be discriminated against on the job. The tricky part, however, is that you have to disclose your issues in order to get reasonable accommodations, explains Stephen P. Hinshaw, PhD, professor of psychology at UC Berkeley, and professor of psychiatry with UC San Francisco. He recommends talking with your human resources counselor to avoid a toxic work environment. “Know your rights and rehearse your disclosures until you feel comfortable making them.”  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A79

TRAUMA AND PTSD

When female veterans return home JIM RENDON OCTOBER 29, 2018

By 2020, the U.S. Department of Veterans Affairs (VA) estimates there will be nearly two million female veterans. And many of them will contend with mental health issues. According to a 2013 study from researchers at the National Center for PTSD in Boston, 21 percent of women and 23 percent of men deployed to Iraq and Afghanistan were likely to report symptoms of probable PTSD. Though those rates are similar, more women report depression, in part because they are more likely to experience it as a symptom of PTSD than men. While civilian and military men commit suicide at higher rates than their female counterparts, according to a 2016 VA report, in 2014, the difference between soldiers and civilians was greater for women in all age groups. For young women it is particularly alarming: In 2014, female veterans between 18 and 29 years old killed themselves at six times the rate of civilian women of the same age. Researchers don’t know exactly why so many female veterans are committing suicide, but they have found that survivors of military sexual trauma have a higher rate of suicide than others, and about 20 percent of female soldiers have been victims of such abuse, according to the VA. The study also found that female veterans were more likely than civilians to kill themselves using a firearm—the most lethal method of suicide. Navy Captain Michael Colston, a psychiatrist and director of mental health programs for the Office of the Assistant Secretary of Defense for Health Affairs, says the military has been focused on PTSD, spending more than $330 million on the disorder over the last decade. Treatments such as prolonged-exposure therapy, in which patients repeatedly recount their traumatic experiences to desensitize them, and cognitive-processing therapy, in which the trauma is also revisited, are the norm, as is prescribing medication, including the antidepressants Prozac, Paxil, and Zoloft. Most therapy lasts two or three months, with follow-up over six to 12 months for medication management, he says.

While these therapies have decades of studies to validate them, many soldiers fail to complete them because of the effort they require and the need to revisit the trauma, Colston acknowledges. “It can be unsettling for some,” he says. Up to 80 percent of veterans drop out of these therapies at VA centers, according to a 2015 study led by a researcher at the Veterans Affairs Boston Healthcare System. Those who complete treatment do benefit, but not always enough. One review of decades of studies by VA researchers shows that while the therapies reduce PTSD symptoms, more than 70 percent of patients still meet the criteria for PTSD when the therapy ends. Shira Maguen, a psychologist with the San Francisco Veterans Administration Medical Center and a professor at UCSF Medical School who works with and studies female veterans, says that some VA centers have begun offering a few complementary and integrative treatments for PTSD in addition to the evidence-based psychotherapies. “We know that we need a multipronged approach,” says Maguen. “Veterans need alternatives.” Studies show that absence of support makes PTSD more likely, and Maguen’s research on veterans of the first Gulf War shows strong social support predicts post-traumatic growth. Female soldiers are more likely than men to experience isolation, as women make up only 16 percent of the armed forces. Many women in the military avoid fraternizing with men because they worry others will think they are sexually involved. Female soldiers often struggle to find anyone they trust, and that isolation can prime them for PTSD, Maguen says. The military’s high rates of sexual assault and harassment can further alienate women, she adds, making them more vulnerable to mental health problems.  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A80

Study: Friends can help kids cope with bad parents ALEXA LARDIERI NOVEMBER 21, 2018

Friendships that children make during their early years in school can offset bad behaviors they develop as a result from harsh parenting, according to a new study. A study published this week in Development and Psychopathology discovered a link between friendships in kindergarten and an improvement in the behavior of a child who has experienced punitive parenting. Researchers from the University of California, San Francisco studied 338 kindergarteners in six different public schools. They found that 10 percent of children had oppositional defiant disorder. The disorder usually develops during the preschool years, and children who experience it exhibit angry and irritable moods, lose their temper easily, are frequently and easily annoyed by others and exhibit argumentative and defiant behavior, especially toward adults and authority figures. The disorder in young children is linked to an increased risk in antisocial behavior, anxiety, depression, substance abuse, criminal offenses and incarcerations in adolescence and adulthood. Among the 10 percent of children who met the criteria for oppositional defiant disorder, 71 percent had been exposed to high levels of harsh parenting. Twenty-nine percent had been exposed to lower levels of harsh parenting. However, researchers found that when the children who had been raised with punitive parenting were liked and accepted by the classmates, they displayed fewer combative behavioral traits. Among these students, 64 percent had fewer symptoms of the disorder than the children who were not liked or accepted. Author of the study and assistant professor in the UCSF Department of Psychiatry, Danielle Roubinov said in a press release that "acceptance within one's peer group creates opportunity for socialization and a sense of belonging that acts as a buffer against the impact of harsh parenting." "Healthy peer relationships may have an attenuating influence by modelling or providing children with feedback about the inappropriate nature of oppositional behaviors acquired from harsh interactions with parents," Roubinov said.

In addition to having healthy relationships with classmates. A warm, supportive child-teacher relationship "may improve children's self-regulation, positive emotionality and responsiveness to warnings about oppositional behavior." Based on these results, researchers believe that it may be beneficial to treat oppositional defiant disorder outside of the house and away from the family environment. "There is a significant proportion of families for whom parent training is minimally effective," Nicki Bush, author and professor in the UCSF Departments of Psychiatry and Pediatrics said. "Teacher programs that focus on managing difficult classrooms and providing support for at-risk children may be optimally timed to interrupt the developmental processes that lead to long-term poor outcomes and more severe psychopathology when ODD symptoms are left untreated."  READ THE FULL ARTICLE AT PSYCH.UCSF.EDU/A81