Sexual expressions and social expectations

Dr. Perri Klass writes eloquently about boys and girls and sex, and the importance of values, manners and gender equality.  As a child and youth psychiatrist I find much of what she recounts not only reasonable but reasoned.  There is however a developmental neurobiological reality that can help us put these sex and youth issues into a wider perspective.  Simply put, neurodevelopment prior to puberty has as its major goal the survival of the individual to the time of puberty so that species reproduction can take place.  As a result, the adolescent brain normatively develops its drive for sex and the associated dopamine driven nigro-striatal-cortical systems associated with craving (yes – the same system that allows for addictions to begin).  So there we have the phylogeny of the species.  So what now?

Every society develops social structures that serve to channel and direct sexual activities in youth.  And, because the brains of young people can be modified by the environment that they are in, by and large these social structures do modulate these behaviors, although sub-group and sub-cultural frameworks may not always conform to wider social norms and expectations.

So to be simple about it – young people will generally channel their sexual expressions within social expectations created by their environments.  Environment can be helpful or un-helpful in this regard.  However, while we may not be able to control the relentless process of pre-programmed neurodevelopment, we can provide behaviorally optimizing and socially enhancing environments for young people.  These begin within the family and include all aspects of values and behavioral expectations.  They extend outside the family and are taken up by our institutions and collective organizations.  They should extend to the media and the advertising industry.  The most interesting question for me is why they do not seem to.

~ Dr. Stan Kutcher

What we can learn from the tragedy of suicide

Carol Marquis has written a touching and highly personal story about her brother Donnie and his tragic suicide at age 27 years. While Carol’s personal journey led her to feel life more deeply, my professional journey is more focused on what we can do to prevent others, who like Donnie are living with a mental disorder (in his case bipolar illness), from death by suicide.

We know that unfortunately suicide is a mode of death for people who suffer from and live with mental illnesses; much like a heart attack is a mode of death for those who suffer from and live with heart disease. Thus, it is no surprise that in Canada, the highest rates of suicide are found in people who live with a major mental illness – in particular: major depression; bipolar disorder; schizophrenia. Study after study has demonstrated that these mental disorders are the greatest risk factors for suicide. Study after study has demonstrated that there are effective interventions for individuals living with mental illness that can decrease this risk for suicide.

Some of these interventions are: the continued application of effective treatments (medications and psychological interventions); easy access to emergency/crisis mental health care; unique programs that address a variety of factors that can lead to or trigger a suicide act. We know that the majority of individuals who die by suicide visit a health provider prior to the event.

The difficult questions we need to ask are as follows. Why is it that with so much knowledge about what can be helpful that so many people living with mental illness still die by suicide? Why is it that with so much knowledge about what we can do we still invest in programs and activities for which there is little or no evidence of effectiveness? Why is it that we do not widely distribute and ensure that evidence based standards of care for suicide prevention are available in every location where health care is provided? Why is it that we spend little or no time in educating the large legion of health providers to identify and intervene when their patients are or could be suicidal?

Are there many other areas in medicine where we know what to do to make things better and we still persist in doing things that we either know do not work or do not know if they work? If not, what is it about the field of mental health that encourages us to act this way?

~ Dr. Stan Kutcher

A Neuroimaging Revolution

Neuroimaging has indeed revolutionized and continues to revolutionize our understanding of mental disorders, because it is based on learning about how the brain grows, develops and functions.

This is so far removed from earlier ideas about how “society” or “the environment” or “culture” or “religion” or “monsters” created mental illness, that some people whose beliefs or other investments are in these explanations will have problems accepting its value. When linked to other new tools of understanding such as genetics and molecular biochemistry, we are beginning to learn how the brain functions in health, when it is challenged by the environment and in disease.

The recent article in the Globe and Mail by Elizabeth Scott brings to life the importance of this technologically enabled explosion in understanding. She shows us how valuable this harnessing of new methodologies can be as we pull away the shrouds of uncertainty and begin to lift the veil of confusion caused by centuries of invalidated explanations of why mental illness occurs.

The real challenge however will be in changing our perspective based on new knowledge.Simply put, old ideas die hard and the new understanding will be strongly resisted by those who either do not or will not wish to be informed. On the other hand, this new information will need to stand the rigorous and unfriendly critical scrutiny of science, as different researchers conduct different studies and argue about what their results mean. This is a messy business and science is not about “the truth”. It is merely about being less wrong, most of the time.

All of which brings me to an exciting study recently published in the Proceedings of the National Academy of Sciences which demonstrated an almost 1/3 reduction in the right cerebral cortex (the outer cell layer on the right side of the brain) in the brains of people who have a family history of depression. These changes were associated with a number of difficulties in thinking and when the left side showed thinning, these difficulties became part of the syndrome of what we call major depression.

To me, these findings suggest that depression (at least the type that runs in families) may be a degenerative brain disorder. That’s right, a degenerative disorder – much like Parkinson’s disease or Alzheimer’s disease. And the thinking problems that we have noticed in people with depression may not be the result of the mood problem but may actually be part of the same disease process that gives rise to the depressed mood. That is, our theories that negative thoughts cause depression are likely wrong. Both the mood problem and the thinking problems are due to the same disease process in the brain.

This finding supports observations that many researchers and clinicians have been making for years. And, this finding suggests that we may have to change how we search for better treatments for depression. Maybe we should be looking at medications that can arrest brain degeneration or maybe we should be looking at medications that can improve cognition.Whatever the outcomes, these findings are exciting, offer new hope for future research and challenge what we “believe” to be true. Stay tuned – the story will unfold as it should!

~ Dr. Stan Kutcher