By Tom Insel, MD
For our last Roundup of 2021, we bring you some good news from the world of neuroscience and some not-so-good news from the front lines of mental health care. First the good news: A report from the largest, long-term study of child health and brain development shows big benefits to the brain from learning a second language. The not-so-good news: Frontline workers in the public mental health system are under serious stress from what is called financial precarity. Read on to get these stories and more.
Enjoy the holiday break. We’ll be back with more science stories in 2022. And if you enjoy this article, please sign up to receive our weekly Research Roundup newsletter.
Learning a Second Language is Good for Your Child’s Brain
Abundant evidence suggests that adverse childhood experiences can influence brain development, putting children at risk for behavioral problems as they grow up. What about positive childhood experiences? How do they influence brain development?
A new report from the Adolescent Brain Cognitive Development (ABCD) study compared multilingual and monolingual teens, gathering fMRI scans to look at brain connectivity and conducting tests to measure cognitive performance. The ABCD study is the largest long-term study of child health and brain development in the U.S., collecting data from over 10,000 children and youth across 21 sites. For this study, Young Hye Kwon and colleagues from the Korean Advanced Institute of Science and Technology focused on the data from 734 monolingual and 341 multilingual ABCD participants.
Not only were multilingual teens better at working memory, their brain connections or “connectomes” were significantly different. Because fMRI data are famously difficult to interpret at an individual level, imaging scientists generally report small group differences and usually find significant overlap between groups. The multilingual effect is notable because of the size and consistency of the difference. Indeed, Kwon and colleagues could accurately identify whether an individual was in the monolingual or multilingual group simply by looking at the brain scan results.
Is the connectome data related to the superior performance on working memory tests? Possibly. In the multilingual group, the team found a correlation between their enhanced connectomes and their working memory performance. No such correlation was evident in the monolingual group. Apparently, learning a second language, like learning to play a musical instrument, leads to lasting changes in brain connectivity and working memory. Because deficits in working memory are common in people with schizophrenia, could early mastery of a second language be protective? More research will need to examine that possibility, but these findings provide another powerful example of how experience shapes the developing brain.
Predicting multilingual effects on executive function and individual connectomes in children: An ABCD study. Proceedings of the National Academy of Sciences, Nov 29, 2021
Precision Psychiatry for Psychosis?
The concept of precision medicine has transformed the diagnosis and treatment of cancer. Genetic tools have identified subtypes of common cancers and these diagnostic biomarkers have led to targeted, effective treatments with better outcomes. So what about precision psychiatry? It is still a work in progress. Combining brain imaging (fMRI) or electroencephalograms (EEGs) with genetics, cognitive testing, and symptoms has yielded subtypes of depression and PTSD indexed to specific treatments, but for now these remain research findings, not clinical tools.
For psychotic disorders, a national study, the Bipolar and Schizophrenia Network on Intermediate Phenotypes (B-SNiP), has been searching for subtypes of psychotic illness for nearly a decade. Initial results published in 2016 found three different “biotypes” based on genetics, imaging, and cognitive testing. These biotypes, now replicated, did not map on to clusters of symptoms, suggesting that – as with cancer – the presenting clinical picture was not sufficient for a biologically precise diagnosis. People with biotypes 1 and 2 showed cognitive deficits, with biotype 1 showing blunted neural responses and biotype 2 showing hyperactive neural responses. People with biotype 3 showed few cognitive or neural abnormalities. In contrast to cancer, we do not know yet how these biotypes map on to treatment response or prognosis.
Now, in a new study, the B-SNiP team compared cognitive performance of 455 people with a psychotic diagnosis to 236 healthy controls. The team, led by Leah H. Rubin of Johns Hopkins University School of Medicine, looked at one aspect of social cognition: the ability to accurately identify emotion in videos of faces. Consistent with early research using still images, the people with psychosis were both less accurate and slower at identifying emotion in dynamic faces. But this difference was largely in biotypes 1 and 2. Patients in biotype 3 didn’t show a deficit in reading face emotion, consistent with earlier findings.
This new finding fits with earlier studies proposing three biotypes that are distinct biologically yet not captured by the current diagnostic categories of schizophrenia, bipolar disorder, and schizoaffective disorder. Now the task is to define the clinical utility of this effort. The value of precision medicine for cancer is better outcomes. We still do not know if precision psychiatry can improve clinical outcomes.
Real-time facial emotion recognition deficits across the psychosis spectrum: A B-SNIP Study Schizophrenia Research Dec 7, 2021
Looking for a Therapist Who’s a Psychiatrist? Good Luck
Remember when the prototypic picture of a psychiatrist was a beard-stroking, cardigan-wearing therapist who met with patients for 50 minutes twice a week? That image started – well, shrinking – in the 1980s and was already becoming infrequent by the mid-90s, when fewer than half of the visits to a psychiatrist involved psychotherapy.
In search of psychiatrists who are psychotherapists, Daniel Tadmon and Mark Olfson of Columbia University tracked the National Ambulatory Care Survey from 1996 to 2016. Whereas 44% of visits to a psychiatrist involved psychotherapy in 1996 to 1997, by 2015 to 2016 that proportion was down to 22%. For psychiatrists seeing people with a personality disorder diagnosis, the rate of psychotherapy dropped from 68% to 17%. By the 2010 to 2016 period, 53% of psychiatrists no longer provided psychotherapy. There was still a core group of 15% of psychiatrists who were full-time psychotherapists, but the rest had switched to only prescribing medication or only delivering psychotherapy as a small fraction of their practice.
During the 20 years of this study, both racial and geographic disparities grew. Older, white, self-paying, urban patients in the Northeast or West were the most likely to receive psychotherapy, and solo-practice psychiatrists were the most likely to provide it.
Why the shift? Reimbursement is higher for short medication visits relative to psychotherapy. And insurers generally prefer to pay non-physicians to deliver psychotherapy. These financial drivers are unfortunate since combined medical and psychological treatment may be the best option for many patients. Plus the growing evidence of the benefit of psychological treatments argues for greater use of these interventions.
Trends in Outpatient Psychotherapy Provision by U.S. Psychiatrists: 1996–2016 American Journal of Psychiatry, Dec 8, 2021
How Do We Value the Public Mental Health Workforce?
Nearly every effort to transform mental health care eventually runs into a workforce challenge. Recruiting – and keeping – enough people with the right training for vital mental health jobs has been challenging, and the pandemic has made things worse by increasing burnout and resignation. So how do we make sure the public mental health system has the people to deliver care?
For a new report, researchers surveyed 49 public mental health clinicians at 16 Philadelphia clinics serving youth experiencing trauma. Briana S. Last and her colleagues at the University of Pennsylvania describe a picture of “economic precarity” (being in a precarious financial state) and stress among these clinicians. More than a third were hired as contractors – although nearly half of them wanted a salaried position. Half of the respondents said they had taken a second job. Three-quarters had education debt, with more than a third reported owing more than $100,000. What’s more, 29% of clinicians said they weren’t receiving mental health care themselves because of the cost, and 22% met the criteria for experiencing secondary traumatic stress symptoms.
This exploratory study is limited by size (only 25% of invited clinicians completed the survey) and describes conditions in only a single system, but it deserves note. Much of the public mental health workforce is composed of social workers with master’s degrees. The Council on Social Work Education has reported that the average student debt of a social worker is $46,591, 50% higher than it was just 10 years ago. Mental health workers without graduate degrees are often paid minimum or near minimum wage. Yet they are being asked to address increasingly complicated problems and to work under increasingly difficult conditions. We’re not taking care of our caretakers.
Economic Precarity, Financial Strain, and Job-Related Stress Among Philadelphia’s Public Mental Health Clinicians Psychiatric Services Nov 29, 2021
Tom Insel, MD, is a psychiatrist, neuroscientist, and former director of the National Institute of Mental Health (NIMH). He is a donor to MindSite News and chair of its Editorial Advisory Board. Dr. Insel’s financial conflict of interest statement, which includes equity and advisory roles in several early-stage mental health technology companies, can be found here.