As modern pressures take their toll doctors preach relaxation
"Rule No. 1 is, don't sweat the small stuff. Rule No. 2 is, it's all small stuff. And if you can't fight and you can't flee, flow."
—University of Nebraska Cardiologist Robert Eliot, on how to cope with stress
It is the dawn of human history, and Homo sapiens steps out from his cave to watch the rising sun paint the horizon. Suddenly he hears a rustling in the forest. His muscles tense, his heart pounds, his breath comes rapidly as he locks eyes with a saber-toothed tiger. Should he fight or run for his life? He reaches down, picks up a sharp rock and hurls it. The animal snarls but disappears into the trees. The man feels his body go limp, his breathing ease. He returns to his darkened den to rest.
It is the start of another working day, and Homo sapiens steps out of his apartment building into the roar of rush hour. He picks his way through the traffic and arrives at the corner just in time to watch his bus pull away. Late for work, he opens his office door and finds the boss pacing inside. His report was due an hour ago, he is told; the client is furious. If he values his job, he had better have a good explanation. And, by the way, he can forget about taking a vacation this summer. The man eyes a paperweight on his desk and longs to throw it at his oppressor. Instead, he sits down, his stomach churning, his back muscles knotting, his blood pressure climbing. He reaches for a Maalox and an aspirin and has a sudden yearning for a dry martini, straight up.
The saber-toothed tiger is long gone, but the modern jungle is no less perilous. The sense of panic over a deadline, a tight plane connection, a reckless driver on one's tail are the new beasts that can set the heart racing, the teeth on edge, the sweat streaming. These responses may have served our ancestors well; that extra burst of adrenaline got their muscles primed, their attention focused and their nerves ready for a sudden "fight or flight." But try doing either one in today's traffic jams or boardrooms. "The fight-or-flight emergency response is inappropriate to today's social stresses," says Harvard Cardiologist Herbert Benson, an expert on the subject. It is also dangerous. Says Psychiatrist Peter Knapp of Boston University: "When you get a Wall Street broker using the responses a cave man used to fight the elements, you've got a problem."
Indeed we have. In the past 30 years, doctors and health officials have come to realize how heavy a toll stress is taking on the nation's well being. According to the American Academy of Family Physicians, two-thirds of office visits to family doctors are prompted by stress-related symptoms. At the same time, leaders of industry have become alarmed by the huge cost of such symptoms in absenteeism, company medical expenses and lost productivity. Based on national samples, these costs have been estimated at $50 billion to $75 billion a year, more than $750 for every U.S. worker. Stress is now known to be a major contributor, either directly or indirectly, to coronary heart disease, cancer, lung ailments, accidental injuries, cirrhosis of the liver and suicide—six of the leading causes of death in the U.S. Stress also plays a role in aggravating such diverse conditions as multiple
Studying such kids for more than a decade, the researchers discovered that those who became schizophrenic were most often from families that, when first interviewed, displayed "communication deviance" (unclear, unintelligible or fragmented speech) and highly critical and intrusive parenting. These weren't merely families that argued with difficult sons and daughters; they were families that had lost all ability to cope.
McFarlane and others began working with some of the families to address their interactions and teach them how to communicate better — more slowly, with less anger and intrusion. Even after they are on medication, people with schizophrenia have a difficult time tracking rapid, highly emotional speech, yet that's the kind they often hear from frustrated family members. These patients would improve in hospitals but relapse once they got home, even when they continued to take antipsychotics.
For several years, McFarlane developed and tested the Multi-Family Group approach, which brought several families together at a time to learn from one another how they sounded to outsiders. In twice-monthly sessions, the families modeled greater clarity and compassion and troubleshot daily-living problems like kids' marijuana use or sexual activity. It was a simple intervention that, when combined with antipsychotic drugs, worked to reduce schizophrenic relapse rates significantly more than the drugs alone.
McFarlane wondered if the treatment could work even earlier, to help prevent the illness in largely asymptomatic kids who were at risk for schizophrenia. Such prediagnosis would not be easy, but McFarlane knew that once a patient's perception of reality has cracked for the first time, it becomes exceedingly hard to walk back to normality. Indeed, a major study just published in the journal Neuropsychology shows that the signature cognitive problems of schizophrenia — deficits in verbal learning and memory along with processing speed — actually begin days or weeks before a first psychotic episode, making the earliest possible detection all the more urgent.
And so in the 1980s, McFarlane began canvassing schools in the New York City area to try to get the staffs excited about preventing schizophrenia among their students. A number of the superintendents "practically threw us out the window," he says. "They just kept saying, 'We don't have mental illness in our high school.'" It was dispiriting: based on the epidemiological data, McFarlane knew that each year about 12 in 10,000 young people suffered a first episode of psychosis. Some of the kids were clearly in those schools, but if he couldn't get through the door to screen them, he couldn't prevent any illness.
A Theory Goes WideEven as McFarlane was exploring his schizophrenia-prevention idea, other researchers were having similar what-if moments with respect to other, more routine conditions. Suppose irritable infants who become fearful toddlers who become shy children somehow could be stopped from becoming adults with anxiety disorders. Suppose men and women who go to war or become cops in inner cities could be helped before developing posttraumatic stress disorder. Could you, similarly, identify the children of depressed parents early and give them skills to prevent their own first depressive episode?
In any given year, approximately 17% of Americans under 25 have a mental, emotional or behavioral disorder. (Over our lifetime, 46% of us will receive such a diagnosis.) If we reduce the proportion of young people who become mentally ill by even one-quarter, that would mean about 3.8 million saved each year from what can turn into a lifelong struggle.
But if most mental illnesses have a genetic origin, isn't even that modest 25%-reduction goal unlikely? The science can get tricky here, but the simple answer is that genes aren't destiny. You can't do anything to change your genome, but your environment and experiences have powerful effects on the way those genes are expressed. A susceptibility to cancer may remain just a susceptibility — until you start smoking and kick the disease process into motion. Similarly, change a child's emotional experiences for the worse and you can trigger mental illness; change them for the better and you may hush the problem genes. One concrete example of this: in 2003, a study in Science found that the larger the number of copies an individual carries of a serotonin-transporter gene called 5-HTTLPR the greater the risk of developing major depressive disorder and suicidality — but only if the individual suffers stressful early-life experiences like abuse.
How long is the window between first symptoms and actual diagnosis? The National Academies report says that across several mental illnesses — including obsessive-compulsive disorder, depression and substance dependence — we have about two to three years to intervene and keep short-term symptoms from becoming long-term afflictions.
Depression offers particularly good evidence of this idea at work. Currently, about 5% of adolescents experience an episode of clinical depression in any given year. Rates of depression are three to four times as high among the children of depressed parents as among those whose parents aren't depressed. Dr. William Beardslee of Children's Hospital Boston, one of the authors of the National Academies report, has spent more than 25 years studying how some kids of depressed parents avoid the illness, and he has found that resilience is key. The kids who don't develop depression are "activists and doers," Beardslee says. Even growing up in the darkness of a depressed home, they muster the capacity to engage deeply in relationships. They also are likelier than other kids to understand that they aren't to blame for their parents' disorder — and that they are free to chart their own course.
How do you foster resilience in order to prevent depression? Over the past 17 years, Beardslee's team has developed an early intervention that targets kids from families in which at least one parent is depressed. Like McFarlane, he uses a family-based approach because a bad home environment tends to be more predictive of adolescent mental illness than dysfunctional peer relationships are. Beardslee's Family Talk Intervention includes both separate meetings with parents and kids as well as family meetings with social workers or psychologists that focus in part on demystifying depression — explaining that it is a treatable illness, not a beast that will necessarily crush a family. In a randomized trial, Beardslee found that just seven sessions of this intervention decreased predepression symptoms among the kids and improved the parents' behavior and attitudes. All this makes kids more resilient.
Tackling SchizophreniaMcFarlane hadn't gotten far with the New York City schools in the 1980s, and his prevention work waned for a few years as he taught at Columbia University and wrote articles on his Multi-Family Group approach to treating psychosis. Eventually, he moved to Portland, Maine, where he had been offered the chairmanship of Maine Medical Center's psychiatry department. There, he settled into quieter, less paradigm-changing work.
It wasn't until 1996 that his prevention work resumed. That year, a team of researchers in Norway — one that included Dr. Thomas McGlashan of Yale — approached McFarlane about training therapists to use the Multi-Family Group approach with patients who had just suffered a first psychotic episode. These patients already had the illness, so it was too late for prevention. But the Norwegians had succeeded where McFarlane had failed in New York: they had connected with schools and other local institutions to identify the first signs of psychosis and refer patients to the team immediately.
In October 1998, the picture grew still more promising when NATO sponsored a major psychotic-disorders conference in Prague, where McFarlane learned that several groups around the world, including one in Australia, had also been trying to prevent first episodes of psychosis. He returned from Prague and tried again to set up an early-detection system with schools, this time in Portland. By now, the stigma against mental illness had eased a bit; schools had seen a dramatic rise in emotional and behavioral problems during the '90s. Unlike their New York counterparts, Portland school superintendents welcomed McFarlane.
At about the same time, McGlashan's team at Yale was working on a screening interview that might distinguish kids who would become psychotic from those who wouldn't. McGlashan tested his questions at various sites in North America, including with teens who sought treatment in McFarlane's department in Portland. By 2001, McGlashan and his team had completed their "Structured Interview for Prodromal [pre-disease] Symptoms" (SIPS) — a two-hour assessment involving various oral tests and a family history. Those who meet SIPS criteria for risk are about 30 times as likely as the general population to develop a diagnosable psychotic disorder. SIPS allows for the careful scoring of warning signs, some of which are obvious (hearing mumbling that isn't there) and some of which are less so (changing your behavior because of a superstition).
McFarlane and his team connected with most of Portland's principals and pediatricians. The message was simple: If you encounter kids who seem slightly off — prone to jumbled thoughts, maybe even hearing voices — send them our way. Among those referred to him, McFarlane found that 80% of those who met SIPS criteria for prodromal psychosis would receive a diagnosis of schizophrenia within 30 months. He put kids who met a certain SIPS threshold into Multi-Family Group psychoeducation. At first, he intended not to use drugs with these prediagnosis kids, particularly since the meds can cause side effects like weight gain, acne and uncontrollably shaky legs. But McFarlane found that once symptoms like auditory hallucinations started, he couldn't correct them with only psychosocial interventions. (Today, virtually everyone enrolled in his Portland Identification and Early Referral prevention program is prescribed psychiatric medication.)
The combination of the family approach and drug support seems to be working well. The National Institute of Mental Health is funding a trial of McFarlane's work, and while he is still writing up his data for publication, his anecdotal results are promising: most of the kids are so far avoiding a first psychotic episode. Even those who have heard voices and nearly dropped out of high school are going to college and getting jobs.
But this approach doesn't come cheap. The kids who are enrolled are bombarded with care: social workers help them at school or work; therapists guide them and their families in individual and group sessions; a psychiatrist or nurse practitioner carefully calibrates their medication based on response rates and side effects.
When members of McFarlane's clinical team gather each day to discuss cases, they know virtually everything about their kids: they know about boyfriends, girlfriends and summer plans. They know the kids' grades in English class, how much pot they smoke, what they did on a recent trip to Disneyland. They know whether Dad just lost his job and if Mom's grandmother killed herself. This is what prevention of mental illness looks like: unwavering, sweeping, complicated. But it works.
One Family at a TimeThe Robert Wood Johnson foundation is so impressed with McFarlane's program that it has devoted $15 million to its national expansion. It is the foundation's single largest mental-health initiative. McFarlane's approach costs about $3,500 per patient per year, but compare that with the $150,000 a year to care for a hospitalized schizophrenic or severely bipolar patient.
Still, not all the kids McFarlane sees can be helped. Patti White is a plainspoken 47-year-old Mainer who works for McFarlane as an administrative coordinator. She has a son who began experiencing psychotic symptoms a few years ago, and he might have seemed like a perfect fit for her boss's program. He wasn't; prevention isn't that easy. Instead, White's son Tyler, who turns 20 this month, was too far along in his illness — eventually diagnosed as schizoaffective disorder, a relative of schizophrenia — to benefit from prevention therapy. A social worker on McFarlane's team helped Tyler get into treatment, and he is doing better and holding down a job in food service.
But White has another son, Jacob, who causes her to worry. A few months ago, Jacob, 10, started to withdraw. He was getting paranoid. At school, he started seeing complicated machinations where none existed. And even though White works for one of the world's leading prevention experts, she at first resisted having Jacob take the SIPS test. "If his brother had had diabetes, I wouldn't have thought twice about having Jacob screened for diabetes," she says. "But I just couldn't deal with the idea that another one of my kids would have" — she pauses — "this enormous thing."
Three weeks ago, Jacob took SIPS. The good news: he showed no red flags for psychosis. He does have depressive symptoms and is now taking a low dose of Prozac to help prevent a full-blown depression. But for Jacob — and millions of other Americans with all manner of mental ills — intervention can now come in time
