creating a culture of prevention and recovery

Developing a Culture of Prevention, Recovery & Wellness for Our Futures NOW!

Dennis D. Embry, Ph.D., President/Senior Scientist,PAXIS InstituteKeynote Presentation:Texas Behavioral Health Institute, Austin, TX, July 17, 2012

1Wednesday, July 18, 12

What good things do the people of Texas want to pack in the suitcase for life of their children?

What heavy things do the people of Texas NOT want to pack in the suitcase for life of their children?


How many of you know…

2x


35%

30%

25%

20%

15%

10%

5%

0%4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age in Years

Merikangas et al., 2010

Lifetime Prevalence of Disorders in US Adolescents (N=10,123)


35%

30%

25%

20%

15%

10%

5%

0%4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age in Years

Anxiety




35%

30%

25%

20%

15%

10%

5%

0%4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age in Years

Anxiety

Behavior




35%

30%

25%

20%

15%

10%

5%

0%4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age in Years

Anxiety

BehaviorMood




35%

30%

25%

20%

15%

10%

5%

0%4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Age in Years

Anxiety

SubstanceBehaviorMood




Nearly 3 out of 4 of United States 17- to 24-year-olds are ineligible for military service for based on national epidemiological data (not service entrance exams)

Medical/physical problems, 35 percent.

Illegal drug use, 18 percent.

Mental Category V (the lowest 10 percent of the population), 9 percent.

Too many dependents under age 18, 6 percent.

Criminal record, 5 percent.

Army Times, Nov 5, 2009 • www.missionreadiness.org/PAEE0609.pd


http://www.missionreadiness.org/PAEE0609.pd

http://www.missionreadiness.org/PAEE0609.pd

By 21 years of age, 61.1% of participants had met criteria for a well-specified psychiatric disorder.

An additional 21.4% had met criteria for a not otherwise specified disorder only, increasing the total cumulative prevalence for any disorder to 82.5%.

Cumulative prevalence of psychiatric disorders by young adulthood

a prospective cohort analysis from the Great Smoky Mountains Study.6Wednesday, July 18, 12

The US has 75 million children and teens.

40.4 million are on psychotropic medications Wall Street Journal, 12-28-2010


Depression Onset By Birth Cohort


Depression Onset By Birth CohortBorn 1986-1995?


Depression Onset By Birth CohortBorn 1986-1995?

Born 1996-2005?


Evolutionary bottleneck

1491 ADOriginalHumanMigrations to

North America 30,000,000Souls in

North America

300,000 Souls≈ ≈

Disease & War26,000 to 12,000 B.E. Extermination,Marginalization,& Suppression

The America’s First Peoples…

Residential Schools;

Western Diet



1491 ADOriginalHumanMigrations to

North America 30,000,000Souls in

North America

300,000 Souls≈ ≈

Today, Historic

Disparities

Disease & War26,000 to 12,000 B.E. Extermination,Marginalization,& Suppression

The America’s First Peoples…

Residential Schools;

Western Diet



Slavery1500’s to

1863Original Human

Populations in Africa

Capture

30% to 50% +

mortality

≈

MiddlePassage

Continuing Trauma

Institutionof Slavery

Separation,violence,

malnutrition

JimCrowAfrican Americans…

Exposureto Toxins

&Racism

The GreatMigration

North



Slavery1500’s to

1863Original Human

Populations in Africa

Capture

30% to 50% +

mortality

≈Today, historic

disparities

MiddlePassage

Continuing Trauma

Institutionof Slavery

Separation,violence,

malnutrition

JimCrowAfrican Americans…

Exposureto Toxins

&Racism

The GreatMigration

North


EpigenesisEpigenetics are heritable changes in gene expression caused by mechanisms other than changes in the underlying DNA sequence.

These changes can pass through multiple generations.

GenesisSocial Biological Environmental Inputs

Nurturing or Toxic Environments,

Disease, orThreats

Signali

ng

Morphogensis

PhosphorlyationAcetylation

Methylation

Histone RemodelingChromatin Stucture Changes

Development Immunity Stem Cell Changes Imprinting

ThreeGenerationE!ects

Parent, 1st Generation

Baby, 2nd Generation

Reproductive Cells,3rd Generation

These polygenes

can be “added”,

“subtracted”, “divided”, or “multiplied.”


http://en.wikipedia.org/wiki/Gene_expression

http://en.wikipedia.org/wiki/Gene_expression

http://en.wikipedia.org/wiki/DNA

http://en.wikipedia.org/wiki/DNA

Youthanasia


Humans are the only species with bi-directional wealth and wellbeing transfer across generations

OurChildren

Our Adults &Elders



OurChildren

Our Adults &Eldersadults and elders invest in children



OurChildren

Our Adults &Elders

Youth return the favor as adults

adults and elders invest in children


We are the first civilization to abandon what Mother Nature, Evolution & God gifted us…

5-Year Olds

65-Year Olds



5-Year Olds

65-Year Olds

Who are livinglonger though get

progressively sicker…



5-Year Olds

65-Year Olds



Requiring more wealth transfer



5-Year Olds

65-Year Olds

Who are lessand less able…






5-Year Olds

65-Year Olds

Who are lessand less able…




But elders voting to stop funds to kids



5-Year Olds

65-Year Olds



65-Year Olds


Our Own Future and Our Own Children’s Future


Our Own & Our Children’s Future Rests On Other’s Futures


Our Own & Our Children’s Future Rests On Other’s Futures

depression

bipolar

drugs

tobaccoalcohol

ADHD

aggression

learning disabilities

stealing

suicide

depression

crime

violence

dangerous acts

asthmaobesity cancer

heart-disease

diabetes

hi-blood pressure


Key facts that predict our futures in America…and, by the way, Texas…



Our children have the highest rates of mental, emotional, behavioral, and related physical disorders among the rich democracies.

Our children predicted to have a shorter lifespan and worse morbidity than their parents or grandparents.





Our current adults have the highest rates of mental, emotional, behavioral, and related physical disorders among the rich democracies.





Our bulge of retiring boomers have high rates of these same problems plus medical problems of aging.

Our current adults have the highest rates of mental, emotional, behavioral, and related physical disorders among the rich democracies.


What these trends this predict for small businesses in America & Texas?



What do these trends predict for US global economic competitiveness?



What do these trends predict for US global economic competitiveness?

What do these trends predict for US safety and security?


Who in Texas can act to protect our futures?

And how much could we reduce these problems?


Psychological flexibility is required…


Mental, Emotional and Behavior Disorders = MEBs24Wednesday, July 18, 12

Available at:www.slideshare.net/drdennisembry

The Critical Role of Nurturing Environments forPromoting Human Well-Being

Anthony Biglan Oregon Research InstituteBrian R. Flay Oregon State University

Dennis D. Embry PAXIS InstituteIrwin N. Sandler Arizona State University

The recent Institute of Medicine report on prevention (Na-tional Research Council & Institute of Medicine, 2009)noted the substantial interrelationship among mental, emo-tional, and behavioral disorders and pointed out that, to agreat extent, these problems stem from a set of commonconditions. However, despite the evidence, current re-search and practice continue to deal with the prevention ofmental, emotional, and behavioral disorders as if they areunrelated and each stems from different conditions. Thisarticle proposes a framework that could accelerate prog-ress in preventing these problems. Environments that fostersuccessful development and prevent the development ofpsychological and behavioral problems are usefully char-acterized as nurturing environments. First, these environ-ments minimize biologically and psychologically toxicevents. Second, they teach, promote, and richly reinforceprosocial behavior, including self-regulatory behaviorsand all of the skills needed to become productive adultmembers of society. Third, they monitor and limit oppor-tunities for problem behavior. Fourth, they foster psycho-logical flexibility—the ability to be mindful of one’sthoughts and feelings and to act in the service of one’svalues even when one’s thoughts and feelings discouragetaking valued action. We review evidence to support thissynthesis and describe the kind of public health movementthat could increase the prevalence of nurturing environ-ments and thereby contribute to the prevention of mostmental, emotional, and behavioral disorders. This article isone of three in a special section (see also Munoz Beardslee,& Leykin, 2012; Yoshikawa, Aber, & Beardslee, 2012)representing an elaboration on a theme for preventionscience developed by the 2009 report of the National Re-search Council and Institute of Medicine.

Keywords: prevention, nurturing environments, develop-ment, public health, problem behavior

The 2009 Institute of Medicine report on prevention(National Research Council & Institute of Medicine[NRC & IOM], 2009) documented the substantial

accumulation of knowledge on preventing the most com-mon and costly psychological and behavioral disorders.The report reviewed how and why psychological and be-havioral disorders develop and discussed numerous pro-grams, policies, and practices to prevent these problems.

The next big challenge is to translate this knowledge intosignificant reductions in the incidence and prevalence ofmultiple disorders.

Doing so requires us to accept two other conclusionsof the report: Psychological and behavioral disorders andrelated problems co-occur (e.g., Biglan, Brennan, Foster, &Holder, 2004; Donovan, Jessor, & Costa, 1993; Flay,2002), and these problems stem largely from the sameconditions (Biglan et al., 2004; Flay, Snyder, & Petraitis,

Editor’s note. This article is one of three in a special section presentedin this issue of the American Psychologist (May–June 2012) representingan elaboration on an important theme for prevention science developed bythe landmark report of the National Research Council and Institute ofMedicine (NRC & IOM, 2009). That report summarized the impressiveprogress in prevention research that has occurred over the past twodecades with children and youth. The report also presented recommenda-tions for the next generation of research and policy initiatives to translatethis progress into true improvements in the mental health of America’schildren and youth. One theme in the report concerns the power ofpositive aspects of the social environment to promote positive develop-ment and to prevent the development of disorder. The current articledevelops a coherent, empirically based, theoretical framework for con-ceptualizing the positive aspects of the social environment, which theauthors have labeled “nurturing environments.” The other articles in thisspecial section elaborate on two other themes in the NRC & IOM report,one of which concerns the salient role of poverty as a pervasive risk factor(Yoshikawa, Aber, & Beardslee, 2012) and the other of which concernsthe potential for preventing the incidence of depression, a major mentaldisorder (Munoz, Beardslee, & Leykin, 2012).

Authors’ note. Anthony Biglan, Promise Neighborhoods ResearchConsortium, Oregon Research Institute, Eugene, Oregon; Brian R. Flay,College of Public Health and Human Sciences, Oregon State University;Dennis D. Embry, PAXIS Institute, Tucson, Arizona; Irwin N. Sandler,Department of Psychology, Arizona State University.

Grants from the National Institute on Drug Abuse (DA028946,DA018760, and DA026874), the National Institute of Child Health andHuman Development (HD060922), and the National Institute of MentalHealth (P30 MH068685) supported the work on this article.

We thank Christine Cody for her editorial input and give specialthanks to Edward Maibach for his valuable feedback on earlier versions ofthis article.

Full disclosure of interests: Brian R. Flay’s spouse owns positiveAction, Inc. Dennis D. Embry receives salary, royalties, and training andconsulting fees related to the Good Behavior Game and evidence-basedkernels, through PAXIS Institute and Simple Gifts, Inc.

Correspondence concerning this article should be addressed to AnthonyBiglan, Oregon Research Institute, 1715 Franklin Boulevard, Eugene, OR97403-1983. E-mail: [email protected]

257May–June 2012 ! American Psychologist© 2012 American Psychological Association 0003-066X/12/$12.00Vol. 67, No. 4, 257–271 DOI: 10.1037/a0026796


http://www.slideshare.net/drdennisembry


Behavioral Vaccines andEvidence-Based Kernels:NonpharmaceuticalApproaches for thePrevention of Mental,Emotional, andBehavioral Disorders

Dennis D. Embry, PhD

KEYWORDS

! Evidence-based kernels ! Behavioral vaccines ! Prevention! Public health






Evidence-based Kernels: Fundamental Units of BehavioralInfluence

Dennis D. Embry Æ Anthony Biglan

! The Author(s) 2008. This article is published with open access at Springerlink.com

Abstract This paper describes evidence-based kernels,fundamental units of behavioral influence that appear to

underlie effective prevention and treatment for children,

adults, and families. A kernel is a behavior–influenceprocedure shown through experimental analysis to affect a

specific behavior and that is indivisible in the sense that

removing any of its components would render it inert.Existing evidence shows that a variety of kernels can

influence behavior in context, and some evidence suggests

that frequent use or sufficient use of some kernels mayproduce longer lasting behavioral shifts. The analysis of

kernels could contribute to an empirically based theory of

behavioral influence, augment existing prevention ortreatment efforts, facilitate the dissemination of effective

prevention and treatment practices, clarify the active

ingredients in existing interventions, and contribute toefficiently developing interventions that are more effective.

Kernels involve one or more of the following mechanisms

of behavior influence: reinforcement, altering antecedents,changing verbal relational responding, or changing physi-

ological states directly. The paper describes 52 of thesekernels, and details practical, theoretical, and research

implications, including calling for a national database of

kernels that influence human behavior.

Keywords Evidence-based kernels !Public-health benefits ! Prevention ! Treatment

This paper presents an analysis of fundamental units ofbehavioral influence that underlie effective prevention and

treatment. We call these units kernels. They have two

defining features. First, in experimental analysis,researchers have found them to have a reliable effect on

one or more specific behaviors. Second, they are funda-

mental units of behavior influence in the sense that deletingany component of a kernel would render it inert. Under-

standing kernels could contribute to an empirically based

theory of behavioral influence, facilitate dissemination ofeffective prevention and treatment practices, clarify the

active ingredients in existing interventions, and contribute

to developing interventions that are more efficient andeffective. Subsequent sections of this paper expand on the

two essential features of evidence-based kernels, as well as

the origins of the idea and terminology.The ultimate goals of treatment and prevention research

are a reduction of the prevalence of the most common and

costly problems of behavior and an increase in the preva-lence of wellbeing. Current thinking about how to

accomplish this assumes that we will identify empiricallysupported programs and, to a lesser extent, policies, and

will disseminate them widely and effectively. Although

substantial progress is occurring through this strategy, thereare at least four limitations to it that point to the value of

kernels as a complementary strategy.

First, it is difficult to implement a program’s efficacywidely with fidelity or effectiveness. Ringwalt et al. (2003)

surveyed a sample of 1,795 school staff members who were

in charge of teaching substance-use prevention programs.Nearly two-thirds reported teaching content that meta-

analyses showed was effective. However, only 17% used

effective delivery and only 14% used both effectivedelivery and content. In a second study, Ringwalt et al.

(2003) found that about one-fifth of teachers of substance-

D. D. Embry (&)PAXIS Institute, P.O. 31205, Tucson, AZ 85751, USAe-mail: [email protected]

A. BiglanOregon Research Institute, Eugene, OR, USAe-mail: [email protected]

123

Clin Child Fam Psychol Rev

DOI 10.1007/s10567-008-0036-x




Physiologicalinfluences triggeradverse biological

mechanisms

Reinforcementmore for anti-social

than prosocialbehaviors

Antecedentscue anti-social

acts and threats

Verbal Relationsoccasion perceivedthreats and related

reactions

Major Connected Ecologic Causes of the Adverse Trends Predicting MEBs & Related Illnesses

Multi-Inflammatory Brain & Body Response


MoodInstability Inattention Lo Reward

DelayLo ExecutiveFunction

Lo BehavioralCompetencies

PoorMotorSkills

Immune-Healing

Dysfunction


mechanisms




acts and threats


reactions


Multi-Inflammatory Brain & Body Response


MoodInstability Inattention Lo Reward

DelayLo ExecutiveFunction

Lo BehavioralCompetencies

PoorMotorSkills

Immune-Healing

Dysfunction


mechanisms




acts and threats


reactions


Mental Illness SubstanceAbuse Violence Work

ProblemsObesity,

etc CancerEarlySex

School Failure

STD’s SpecialEdMulti-Inflammatory Brain & Body Response


Rise in Depression

Rates

Rise in Aggression

Rates

Rise in ObesityRates

Change inGenes

IncreasedCancer

IncreasedAutism

IncreasedSchizo.

ATODAddictions

New cultural trends predict new challenges and risks 29Wednesday, July 18, 12

Rise in Depression

Rates

Rise in Aggression

Rates


Change inGenes

IncreasedCancer

IncreasedAutism

IncreasedSchizo.

ATODAddictionsOmega 3

Fatty AcidDeficiency

Vitamin DDeficiency

ReducedOutdoorActivities

Fear ofViolence &

Crime

IncreasedElectronicMedia Use


Rise in Depression

Rates

Rise in Aggression

Rates


Change inGenes

IncreasedCancer

IncreasedAutism

IncreasedSchizo.

ATODAddictionsOmega 3

Fatty AcidDeficiency

Vitamin DDeficiency

ReducedOutdoorActivities

Fear ofViolence &

Crime

IncreasedElectronicMedia Use

Lower Ratesof Positive

Reinforcement


Four Types of Kernels

AntecedentKernel

ReinforcementKernel

Relational FrameKernel

PhysiologicalKernel

Happens BEFORE the behavior

Happens AFTER the behavior

Creates verbal relations for the

behavior

Changes biochemistry of

behavior

Embry, D. D., & Biglan, A. (2008). Evidence-Based

Kernels: Fundamental Units of Behavioral Influence. Clinical Child & Family Psychology

Review, 39.


Physiologicalinfluences trigger

protective biologicalmechanisms

Reinforcementmore for prosocial

behaviors

Antecedentscue prosocial

behaviors

Verbal Relationsoccasion perceived

safety andaffiliation

Major Connected Ecologic Causes of the Positive Trends to Children, Youth and Adults

Multi Anti-Inflammatory Brain & Body Response


MoodStability

AttentionHi Reward

DelayHi Executive

FunctionHi Behavioral

Competencies

GoodMotorSkills

Immune-Healing

Efficiency




behaviors


behaviors




Multi Anti-Inflammatory Brain & Body Response


MoodStability

AttentionHi Reward

DelayHi Executive

FunctionHi Behavioral

Competencies

GoodMotorSkills

Immune-Healing

Efficiency




behaviors


behaviors




Mental health LowAddictions Prosociality Work

SuccessHeart Health

etcLow

CancerDelayedSex

Hi Sch.Grad

LowInjuries

HigherEdMulti Anti-Inflammatory Brain & Body Response


Kernels are building blocks of behavior change

Humans survive individually and collectively by influencing the behavior or other humans

The 2008 paper by Embry and Biglan identifies 52 evidence based kernels that can be used to design or or improve programs.


Table&2:&Examples&of&kernels&for&selected,&indicated&and&universal&prevention&

Kernel& Treatment& Intervention& Prevention/Protection&

Prize&Bowl/Mystery&Motivator&(reinforcement)&

Reduce/alcohol,/tobacco,/or/drug/use/to/Improve/engagement/in/treatment/goals./

Reduce/problem/behavior/in/high;risk/children/or/youth./

Improve/engaged/learning/and/reduce/disruptions/of/whole/class./

Goal/Node&Mapping&(relational/frame)&

Reduce/relapse/or/recidivism/rates/or/to/improve/recovery/

Prevent/ATOD/use/rates/of/improve/attainment/of/therapeutic/goals//

Increase/academic/success/or/cognitive/processes//

OmegaG3&fatty&acid&supplementation&(physiological)&

Treat/depression,/borderline,/and/or/bipolar/disorder./Reduce/autism/symptoms./

Prevent/emergence/of/psychotic/episodes/in/prodromal/adolescents./

Improve/children’s/cognitive/performance/and/prevent/behavioral/disorders./

Public&posting&(antecedent)/

Reduce/community/illegal/behaviors./

Improve/problematic/behavior/in/therapeutic/settings//

Reduce/impulsive/or/risky/behaviors/in/general/population//Promoting/participation/or/community/goods//

Kernels can be used across the lifespan…


Protecting our children right now


Muriel Saunders

PAX GBG: An Example Behavioral Vaccine

Read about multiple scientific studies on the “Good Behavior Game” at www.pubmed.gov35Wednesday, July 18, 12

http://www.pubmed.gov


AntecedentKernel

ReinforcementKernel


PhysiologicalKernel




behavior

Changes biochemistry & genes

of behavior


AntecedentKernel

ReinforcementKernel


PhysiologicalKernel




behavior


of behavior

Multiple non-verbal transition

cues


AntecedentKernel

ReinforcementKernel


PhysiologicalKernel




behavior


of behavior


cues

Mystery Motivator &

Premack Principle;

Group Rewards


AntecedentKernel

ReinforcementKernel


PhysiologicalKernel




behavior


of behavior


cues

Mystery Motivator &

Premack Principle;

Group Rewards

Motivational Interview &

Group Identity


Timeline of Life Time Benefits…


Timeline of Life Time Benefits…More time for

teaching and learning

First Month

Less stress for Staff & Students

Better Attendance

Better Academics

Less Illness

Fewer Service Needs

Fewer Referrals

First Year

Happier Families

Less Vandalism

2nd & 3rd Years

ADHD Averted

Oppositional Defiance Averted

Special Education Averted

5-15 Years

No Tobacco

Less Alcohol

Less Conduct Disorders

Delayed vaginal sex

Less Crime, Violence, Suicide

High School Grad & University


How much might PAX GBG save for Texans?To do PAX GBG will cost about $150 to protect our children for life from mental illnesses, behavioral problems, drug addictions, becoming a criminal, trying suicide, dying from tobacco or alcohol related illnesses. And, it increases their academic success—including university entry.PAX GBG pays back $4,636 to individuals, taxpayers, and others per student exposed in First Grade over 15 years. Assuming 40,000 First Graders each year, that saves $186 million every First Grade cohort.

CostSavings

Source: Aos, S., Lee, S., Drake, E., Pennucci, A., Klima, T., Miller, M., et al. (2011). Return on Investment: Evidence-Based Options to Improve Statewide Outcomes. (July), 8. Retrieved from http://www.wsipp.wa.gov/rptfiles/11-07-1201.pdf


http://www.wsipp.wa.gov/rptfiles/11-07-1201.pdf

http://www.wsipp.wa.gov/rptfiles/11-07-1201.pdf

First graders exposed to GBG for one year had these benefits at

age 21.

SOURCE: Kellam, S. G., Mackenzie, A. C., Brown, C. H., Poduska, J. M., Wang, W., Petras, H., & Wilcox, H. C. (2011). The good behavior game and the future of prevention and treatment. Addict Sci Clin Pract, 6(1), 73-84.

Read this and other studies about the Good Behavior Game at www.pubmed.gov

OUTCOMES STUDENT GROUPS GBG CLASSROOM STANDARD CLASSROOM

Drug abuse and All males 19 percent 38 percentdependence disorders

Highly aggressive males 29 percent 83 percent

Regular smoking All males 6 percent 19 percent

Highly aggressive males 0 percent 40 percent

Alcohol abuse and All males and females 13 percent 20 percent dependence disorders

Antisocial personality Highly aggressive males 40 percent 100 percent disorder (ASPD)

Violent and criminal Highly agressive males 34 percent 50 percent behavior (and ASPD)

Service use for All males 25 percent 42 percent problems with behavior, emotions, drugs, or alcohol

Suicidal thoughts All females 9 percent 19 percent

All males 11 percent 24 percent




Lifespan example of one kernel for prevention, intervention and

treatment

ReinforcementKernel


Available from Amazon.com for $45


Giggle Fest Giving Cuts in

Line

Mumble, Grumble

& Gowl

Play Hangman

Jokester Making Faces

Nerf Toss or

Nerf Basket

Paper Airplane

Toss

Pencil Tapping Penny or Poker

Chip Flipping

possible in the time set. You can’t help but giggle.

Suggested Time: 10 to 20 seconds

Winning teams can give cuts to a friend for one set time as determined by the teacher

Suggested Time: One lunch, or day only.

Suggested Time: 10 to 20 seconds

Winning teams get to mumble, grumble and growl as much as possible during the set time.

Winning teams are allowed to play a game of hang-man for a time set by the teacher.

Suggested Time: 1-2 minutes; more at day’s end

Suggested Time: 1-3 minutes, depending on joke book

A joke is read for each winning team. Teacher may read them or team captains can read the jokes. (Teach-er needs to have several joke books ready.)

Winning teams may make faces at each other or the teacher.

Suggested Time: 10-30 seconds.

Suggested Time: About 1-2 mins, based on nerf balls

Winning teams get to line up and toss a nerf ball into a box, bin or mini basketball hoop.

-ing them. (Nice at the end of the day prize)

Suggested Time: A few minutes to make, then toss

Suggested Time: 10 seconds or so.

cups or jars. You can make some containers smalller for more “points”.Suggested Time: A minute or so

PAX TIP: Please cut out and select prizes appropriate for you. Start and stop the prizes with PAX Quiet.

�

Using prize bowl or mystery motivator in prevention


Seine River Pilot DemonstrationApril, 2011 – Principals and key staff trained for two days for all 12 schools.

April, 2011 – First grade classrooms then trained that week

April through May – Each successive month other grades trained, including 8th grade 0

2

4

6

8

10

12

Before (Baseline)

After PAX GBG

Disruptions by All Seine River First Graders

Rate

Per

Hou

r Per

Chi

ld

40.8%Reduction

45%


An ancient inukshuk points the way

0%

6%

12%

18%

24%

30%

PsychosisOmega-3 Placeo

27.5%

4.9%

Per

cent

age

with

Psy

chos

is a

t 12

mon

ths

PhysiologicalKernel

Changes biochemistry of

behavior

Am J Psychiatry 160:1, January 2003 167http://ajp.psychiatryonline.org

Brief Report

Omega-3 Fatty Acid Treatment of WomenWith Borderline Personality Disorder:

A Double-Blind, Placebo-Controlled Pilot Study

Mary C. Zanarini, Ed.D.Frances R. Frankenburg, M.D.

Objective: The purpose of this study was to compare the effi-cacy of ethyl-eicosapentaenoic acid (E-EPA) and placebo in thetreatment of female subjects with borderline personality disorder.

Method: The authors conducted an 8-week, placebo-con-trolled, double-blind study of E-EPA in 30 female subjects meet-ing Revised Diagnostic Interview for Borderlines and DSM-IV cri-teria for borderline personality disorder.

Results: Twenty subjects were randomly assigned to 1 g of E-EPA; 10 subjects were given placebo. Ninety percent of those inboth groups completed all 8 weeks of the trial. Analyses thatused random-effects regression modeling and controlled forbaseline severity showed E-EPA to be superior to placebo indiminishing aggression as well as the severity of depressivesymptoms.

Conclusions: The results of this study suggest that E-EPA maybe a safe and effective form of monotherapy for women withmoderately severe borderline personality disorder.

(Am J Psychiatry 2003; 160:167–169)

Borderline personality disorder is marked by notablereactivity of mood and impulsive aggression. Because re-sponse to antidepressants and mood stabilizers has typi-cally been clinically modest in this patient group (1), theidentification of novel treatments is needed. Candidatesinclude omega-3 fatty acids, such as eicosapentaenoicacid and docosahexaenoic acid, which are commonlyfound in seafood and have beneficial effects and none ofthe adverse side effects commonly associated with phar-macotherapy. In cross-national studies, greater seafoodconsumption was associated with lower rates of bipolardisorder (30-fold range) and major depression (50-foldrange) (2). In placebo-controlled trials, a mixture of thesefatty acids was found to be an effective adjunctive agentfor patients suffering from bipolar disorder (3), and ethyl-eicosapentaenoic acid (E-EPA) was found to have a bene-ficial adjunctive effect for patients suffering from recur-rent depression (4). Because of the shared symptoms ofborderline personality disorder and these mood disorders,a double-blind, placebo-controlled trial of E-EPA seemedwarranted.

Method

Recruitment of women between the ages of 18 and 40 was ac-complished through advertisements in Boston newspapers.These ads asked, “Are you extremely moody? Do you often feel outof control? Are your relationships painful and difficult?” Subjectswere initially screened by telephone to assess whether they metDSM-IV criteria for borderline personality disorder by using theborderline module of the Diagnostic Interview for DSM-IV Per-sonality Disorders (5). A general medical and psychiatric historywas also taken at the time of first telephone contact. Potentialsubjects were excluded if they were medically ill, were currentlybeing prescribed any psychotropic medication, were taking E-EPA supplements or ate more than 1–2 servings of fatty fish per

week, were actively abusing alcohol or drugs, or were acutely sui-cidal.

Subjects were next invited to participate in face-to-face inter-views. At that time, the study procedures were fully explained,and written informed consent was obtained. Two semistructureddiagnostic interviews were then administered to each subject: theStructured Clinical Interview for DSM-IV Axis I Disorders (6) andthe Revised Diagnostic Interview for Borderlines (DIB-R) (7). Twoobserver-rated scales were also administered: the Modified OvertAggression Scale (8) and the Montgomery-Åsberg DepressionRating Scale (9).

Subjects were included if they met both DIB-R and DSM-IV cri-teria for borderline personality disorder. They were excluded ifthey met current or lifetime criteria for schizophrenia, schizoaf-fective disorder, or bipolar I or bipolar II disorder or were cur-rently in the midst of a major depressive episode.

Study duration was 8 weeks. Subjects were seen every week forthe first month and then biweekly for the next month. Both psy-chiatric rating scales were readministered at each subsequentvisit. Side effects were also assessed at these visits with a struc-tured questionnaire.

Subjects received two capsules per day (beginning the day aftertheir baseline assessment); each capsule contained either 500 mgof 97% E-EPA or a placebo (mineral oil). One gram was chosen asthe dose most likely to be effective on the basis of unpublishedstudies in depression (David Horrobin, personal communication,Feb. 1, 2001). Capsules were supplied by Laxdale Pharmaceuticals(Stirling, U.K.).

Between-group baseline demographic variables and clinicalhistory variables were analyzed by using chi-square analyses forcategorical variables and Student’s t test for continuous variables.Student’s t test was also used to analyze the between-group differ-ence on the baseline value of the mean Montgomery-Åsberg De-pression Rating Scale score (which was normally distributed).The nonparametric Wilcoxon rank sum test was used to analyzethe between-group difference on the mean Modified Overt Ag-gression Scale score because of the skewed distribution of thisvariable.

Random effects regression modeling methods were used to as-sess between-group differences on both outcome measures usingall available panel data. Baseline value (for each subject), treat-

Source: Archives of General PsychiatrySource: Am. Journal of Psychiatry


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UK maximum security prison -‐ 338 offences among 172 prisoners over 9 months treatment in a compared to 9 months baseline.

Gesch et al. Br J Psychiatry 2002, 181:22-‐28

Ac=ve -‐37.0% p ‹ 0.005

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PhysiologicalKernel


Why not reproduce the rapid results in the US to get a 37% reduction in jail violence?

It cost the Brits 19¢ per day or $69.35 per year.


Omega-3 Status and US Military Suicide Deaths

e1J Clin Psychiatry

Suicide Deaths of Active-Duty US Military and Omega-3 Fatty-Acid Status: A Case-Control ComparisonMichael D. Lewis, MD; Joseph R. Hibbeln, MD; Jeremiah E. Johnson, RD; Yu Hong Lin, PhD; Duk Y. Hyun, BS; and James D. Loewke, BS

ABSTRACTBackground: The recent escalation of US military suicide deaths to record numbers has been a sentinel for impaired force efficacy and has accelerated the search for reversible risk factors.Objective: To determine whether deficiencies of neuroactive, highly unsaturated omega-3 essential fatty acids (n-3 HUFAs), in particular docosahexaenoic acid (DHA), are associated with increased risk of suicide death among a large random sample of active-duty US military.Method: In this retrospective case-control study, serum fatty acids were quantified as a percentage of total fatty acids among US military suicide deaths (n = 800) and controls (n = 800) matched for age, date of collection of sera, sex, rank, and year of incident. Participants were active-duty US military personnel (2002–2008). For cases, age at death ranged from 17–59 years (mean = 27.3 years, SD = 7.3 years). Outcome measures included death by suicide, postdeployment health assessment questionnaire (Department of Defense Form 2796), and ICD-9 mental health diagnosis data.Results: Risk of suicide death was 14% higher per SD of lower DHA percentage (OR = 1.14; 95% CI, 1.02–1.27; P < .03) in adjusted logistic regressions. Among men, risk of suicide death was 62% greater with low serum DHA status (adjusted OR = 1.62; 95% CI, 1.12–2.34; P < .01, comparing DHA below 1.75% [n = 1,389] to DHA of 1.75% and above [n = 141]). Risk of suicide death was 52% greater in those who reported having seen wounded, dead, or killed coalition personnel (OR = 1.52; 95% CI, 1.11–2.09; P < .01).Conclusion: This US military population had a very low and narrow range of n-3 HUFA status. Although these data suggest that low serum DHA may be a risk factor for suicide, well-designed intervention trials are needed to evaluate causality.J Clin Psychiatry© Copyright 2011 Physicians Postgraduate Press, Inc.

Submitted: January 24, 2011; accepted March 9, 2011.Online ahead of print: August 23, 2011 (doi:10.4088/JCP.11m06879).Corresponding author: Joseph R. Hibbeln, MD, USPHS, Section of Nutritional Neurosciences, Laboratory of Membrane Biochemistry and Biophysics, National Institute on Alcoholism and Alcohol Abuse, National Institutes of Health, 5625 Fishers Lane, Rm 3N-07, MSC 9410, Bethesda, MD 20892 ([email protected]).

Suicide rates among active-duty US military have increased to re-cord numbers, doubling since the inception of Operation Enduring

Freedom (Afghanistan) and Operation Iraqi Freedom and rivaling the battlefield in toll on the US military.1 Army Vice–Chief of Staff General Peter W. Chiarelli described the record suicide rate as “horrible” and voiced frustration that “the Army has not yet been able to identify any causal links among the suicide cases.”2(pA2)

Deficiencies of nutrients critical for brain function may be a signifi-cant contributing risk factor for psychiatric pathology, especially suicide and stress-related psychiatric symptoms.3 Highly unsaturated omega-3 essential fatty acids (n-3 HUFAs), in particular docosahexaenoic acid (DHA), are selectively concentrated in neural tissues and are required for optimal neural function.4 These fatty acids cannot be made de novo but are available only from dietary sources, with seafood being the richest source. Nutritional deficiencies in n-3 HUFAs may increase vulnerabil-ity to combat deployment stress, manifesting as psychiatric symptoms including adjustment disorders, major depression, impulsive violence, and suicide.5 In civilian populations, observational studies indicate that low fish consumption is associated with increased risk of completed sui-cides6,7 and greater suicidal ideation.8 Low DHA status was associated with increased risk of past suicide attempts9 and future suicide attempts.10 In comparison to placebo, 2 grams per day of n-3 HUFA reduced suicidal thinking and depressive symptoms and reduced the perception of stress among subjects (n = 49) with deliberate self-harm.11

These findings suggest that low DHA levels may be a contributing factor for adverse psychiatric symptoms. In this study, we posited that low DHA status would be associated with increased risk of suicide death among military personnel. Prospectively collected serum and supporting data were available from the Armed Forces Health Surveillance Center (AFHSC) for a large number of active-duty suicide deaths (n = 800) and matched controls (n = 800). To our knowledge, this is the largest study of biological factors among suicide deaths.

METHOD

Study DesignThis case-control study compared total serum fatty-acid composi-

tions from among 800 randomly selected active-duty US military suicide deaths to 800 matched controls (2002–2008). The AFHSC is a repository of more than 40 million serum samples with matched health data from US military personnel. Data from service members’ postdeployment health assessment (Department of Defense [DD] Form 2796, obtained within 6 months of completion of last deployment) closest to the date of serum sample provided information regarding time and theater of deployment (if applicable), exposure to stresses during deployment, self-report of mental health status, and indication for referral to mental health services; demographic data and frozen serum samples were provided by the AFHSC. Mental health and substance abuse–related ICD-9-CM diagnosis data reports were similarly obtained.


REVIEW Open Access

Clearance of fear memory from the hippocampusthrough neurogenesis by omega-3 fatty acids:a novel preventive strategy for posttraumaticstress disorder?Yutaka Matsuoka1,2

AbstractNot only has accidental injury been shown to account for a significant health burden on all populations, regardlessof age, sex and geographic region, but patients with accidental injury frequently present with the psychiatriccondition of posttraumatic stress disorder (PTSD). Prevention of accident-related PTSD thus represents a potentiallyimportant goal. Physicians in the field of psychosomatic medicine and critical care medicine have the opportunityto see injured patients in the immediate aftermath of an accident. This article first briefly reviews the prevalenceand associated factors of accident-related PTSD, then focuses on a conceptual model of fear memory andproposes a new, rationally hypothesized translational preventive intervention for PTSD through promotinghippocampal neurogenesis by omega-3 fatty acid supplementation. The results of an open-label pilot trial ofinjured patients admitted to the intensive care unit suggest that omega-3 fatty acid supplementation immediatelyafter accidental injury can reduce subsequent PTSD symptoms.

Matsuoka BioPsychoSocial Medicine 2011, 5:3http://www.bpsmedicine.com/content/5/1/3

Clearance of fear memory from the hippocampusthrough neurogenesis by omega-3 fatty acids: a novelpreventive strategy for posttraumatic stress disorder?Matsuoka

Matsuoka BioPsychoSocial Medicine 2011, 5:3http://www.bpsmedicine.com/content/5/1/3 (8 February 2011)

Omega-3 for PTSD symptoms could be used routinely for the patients exposed to trauma

REVIEW Open Access

Clearance of fear memory from the hippocampusthrough neurogenesis by omega-3 fatty acids:a novel preventive strategy for posttraumaticstress disorder?Yutaka Matsuoka1,2

AbstractNot only has accidental injury been shown to account for a significant health burden on all populations, regardlessof age, sex and geographic region, but patients with accidental injury frequently present with the psychiatriccondition of posttraumatic stress disorder (PTSD). Prevention of accident-related PTSD thus represents a potentiallyimportant goal. Physicians in the field of psychosomatic medicine and critical care medicine have the opportunityto see injured patients in the immediate aftermath of an accident. This article first briefly reviews the prevalenceand associated factors of accident-related PTSD, then focuses on a conceptual model of fear memory andproposes a new, rationally hypothesized translational preventive intervention for PTSD through promotinghippocampal neurogenesis by omega-3 fatty acid supplementation. The results of an open-label pilot trial ofinjured patients admitted to the intensive care unit suggest that omega-3 fatty acid supplementation immediatelyafter accidental injury can reduce subsequent PTSD symptoms.

Matsuoka BioPsychoSocial Medicine 2011, 5:3http://www.bpsmedicine.com/content/5/1/3

Clearance of fear memory from the hippocampusthrough neurogenesis by omega-3 fatty acids: a novelpreventive strategy for posttraumatic stress disorder?Matsuoka

Matsuoka BioPsychoSocial Medicine 2011, 5:3http://www.bpsmedicine.com/content/5/1/3 (8 February 2011)


Omega-3 can improve school grades and success

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Omega 3 Placebo

These were gains in academics after 3

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Before Omega 3

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http://www.durhamtrial.org

http://www.durhamtrial.org

Hedelin et al. BMC Psychiatry 2010, 10:38http://www.biomedcentral.com/1471-244X/10/38

Open AccessR E S E A R C H A R T I C L E

© 2010 Hedelin et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

Research articleDietary intake of fish, omega-3, omega-6 polyunsaturated fatty acids and vitamin D and the prevalence of psychotic-like symptoms in a cohort of 33 000 women from the general populationMaria Hedelin*1,2, Marie Löf3, Marita Olsson3,4, Tommy Lewander1, Björn Nilsson1, Christina M Hultman1,3 and Elisabete Weiderpass2,3,5

AbstractBackground: Low intake of fish, polyunsaturated fatty acids (PUFA) and vitamin D deficiency has been suggested to play a role in the development of schizophrenia. Our aim was to evaluate the association between the intake of different fish species, PUFA and vitamin D and the prevalence of psychotic-like symptoms in a population-based study among Swedish women.

Methods: Dietary intake was estimated using a food frequency questionnaire among 33 623 women aged 30-49 years at enrolment (1991/92). Information on psychotic-like symptoms was derived from a follow-up questionnaire in the years 2002/03. Participants were classified into three predefined levels: low, middle and high frequency of symptoms. The association between diet and psychotic-like symptoms was summarized in terms of relative risks (RR) and corresponding 95% confidence intervals and was evaluated by energy-adjusted multinomial logistic regression.

Results: 18 411 women were classified as having a low level of psychotic-like symptoms, 14 395 as middle and 817 as having a high level. The risk of high level symptoms was 53% (95% CI, 30-69%) lower among women who ate fish 3-4 times per week compared to women who never ate fish. The risk was also lower for women with a high intake of omega-3 and omega-6 PUFA compared to women with a lower intake of these fatty acids. The effect was most pronounced for omega-6 PUFAs. The RR comparing the highest to the lowest quartile of omega-6 PUFAs intake was 0.78 (95% CI, 0.64-0.97). The associations were J-shaped with the strongest reduced risk for an intermediate intake of fish or PUFA. For fatty fish (herring/mackerel, salmon-type fish), the strongest inverse association was found for an intermediate intake (RR: 0.81, 95% CI, 0.66-0.98), whereas a high intake of fatty fish was associated with an increased risk of psychotic-like symptoms (RR: 1.90, 95% CI, 1.34-2.70). Women in the highest compared with the lowest quartile of vitamin D consumption experienced a 37% (95% CI, 22-50%) lower risk of psychotic-like symptoms.

Conclusion: Our findings raise a possibility that adult women with a high intake of fish, omega-3 or omega-6 PUFA and vitamin D have a lower rate of psychotic-like symptoms.

BackgroundEven though psychoses are relatively rare, between 5-15%of the general population has been estimated to reportsingle schizophrenia-like symptoms like delusions, magi-cal thinking, and hearing internal voices at some point in

their lifetime [1-3]. The biological mechanisms underly-ing the etiology of schizophrenia and psychotic symp-toms are largely unknown. Genetic constitution isimportant [4], but environmental factors like anunhealthy lifestyle with a poor diet may be involved [5,6].

Schizophrenia in adulthood is often preceded by mildersymptoms and delusions during adolescence. The typicalage of onset for schizophrenia is early adulthood (20-25years of age). Expression of psychotic symptoms in popu-

* Correspondence: [email protected] Department of Neuroscience, Psychiatry, Ulleråker, Uppsala University, Uppsala, SwedenFull list of author information is available at the end of the article

ENVIRONMENT AND SCHIZOPHRENIA

Developmental Vitamin D Deficiency and Risk of Schizophrenia: A 10-Year Update

John J. McGrath*,1,2,3, Thomas H. Burne1,2, Francxois Feron4, Allan Mackay-Sim5, and Darryl W. Eyles1,2

1Queensland Center for Mental Health Research, The Park Center for Mental Health, Wacol, Queensland 4076, Australia; 2QueenslandBrain Institute, University of Queensland, St Lucia, Queensland 4076 Australia; 3Department of Psychiatry, University of Queensland, StLucia,Queensland4076Australia; 4Neurobiologiedes InteractionsCellulaires etNeurophysiopathologie (CNRSUMR6184),Universite dela Mediterranee (Aix-Marseille II), Faculte de Medecine Nord, Institut Federatif de Recherche Jean Roche (IFR11), Marseille, France;5NationalCenter forAdultStemCellResearch,Eskitis Institute forCell andMolecularTherapies,GriffithUniversity,Brisbane,Queensland4111, Australia

*To whom correspondence should be addressed; tel: !61-7-3346-6372, fax: !61-7-3271-8698, e-mail: [email protected]

There is an urgent need to generate and test candidate riskfactors that may explain gradients in the incidence ofschizophrenia. Based on clues from epidemiology, we pro-posed that developmental vitamin D deficiency may con-tribute to the risk of developing schizophrenia. Thishypothesis may explain diverse epidemiological findings in-cluding season of birth, the latitude gradients in incidenceand prevalence, the increased risk in dark-skinned migrantsto certain countries, and the urban-rural gradient. Animalexperiments demonstrate that transient prenatal hypovita-minosis D is associated with persisting changes in brainstructure and function, including convergent evidence of al-tered dopaminergic function. A recent case-control studybased on neonatal blood samples identified a significant as-sociation between neonatal vitamin D status and risk ofschizophrenia. This article provides a concise summaryof the epidemiological and animal experimental researchthat has explored this hypothesis.

Key words: vitamin D/schizophrenia/epidemiology/animal models/neurodevelopment/prevention

Introduction

There is robust evidence demonstrating that the risk ofschizophrenia varies according to season of birth, placeof birth, and migrant status.1 We propose that develop-mental vitamin D (DVD) deficiency underlies thesegradients.2 Over the last decade, we have undertakena coordinated program of animal experiments, assaydevelopment, and analytic epidemiology in order to ex-plore this hypothesis. This article summarizes the currentresearch related to this hypothesis and makes recommen-

dations for future research. Key features of the evidenceare summarized in table 1.

Vitamin D—The Basics

Ultra Violet B (UVB) radiation on the epidermis convertsa cholesterol metabolite to vitamin D3 (cholecalciferol;a preprohormone). This is subsequently hydroxylatedto 25-hydroxyvitamin D3 (25OHD), a prehormone com-monly used to measure vitamin D status. A second hy-droxylation of this molecule converts 25OHD to theactive secosteroid hormone 1,25-dihydroxyvitamin D3

(1,25OHD). This hormone binds the vitamin D receptor(VDR), a member of the nuclear receptor superfamily.In concert with a range of binding partners and coactiva-tors (including the retinoid X receptor), this phylo-genetically ancient system influences the expressionof many genes in mammals. Vitamin D is a potentprodifferentiating and antiproliferative agent.Vitamin D deficiency (<25 nmol/l) and insufficiency

(25–50 nmo/l) are common in many nations.6–8 Hypovi-taminosis D is more prevalent in winter, in high latitudes,and in dark-skinned individuals. Migrants to Europeancountries are at higher risk of hypovitaminosis D com-pared with native-born.9 Compared with nonimmigrants,those from Africa have the highest adjusted ORs for vi-tamin D deficiency (about 7-fold), followed by migrantsfrom Arab-Islamic countries (about 6-fold) and Turkey(about 4-fold).10 Apart from darker skin color, variablesrelated to dress (eg, wearing a veil), behavior (eg, less out-door activities), and diet also contribute to an increasedrisk of deficiency in certain ethnic groups.11,12 Urban res-idence is associated with an increased risk of hypovitami-nosis, due to factors such as reduced outdoor activity andaccess to UVB radiation.13,14

Schizophrenia Bulletindoi:10.1093/schbul/sbq101

! The Author 2010. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.For permissions, please email: [email protected].

1

Schizophrenia Bulletin Advance Access published September 10, 2010

at UQ

Library on September 19, 2010

schizophreniabulletin.oxfordjournals.orgD

ownloaded from

Relation of Schizophrenia Prevalence to Latitude, Climate, Fish Consumption, InfantMortality, and Skin Color: A Role for Prenatal Vitamin DDeficiency and Infections?

Dennis K. Kinney1–3, Pamela Teixeira2, Diane Hsu2, SienaC. Napoleon2,4, David J. Crowley2, Andrea Miller2,William Hyman2, and Emerald Huang2

2Genetics Laboratory, McLean Hospital, Belmont, MA; 3De-partment of Psychiatry, Harvard Medical School, Boston, MA;4Wellesley College, Wellesley, MA

Previous surveys found a large (>10-fold) variation inschizophrenia prevalence at different geographic sitesand a tendency for prevalence to increase with latitude.We conducted meta-analyses of prevalence studies to inves-tigate whether these findings pointed to underlying etiologicfactors in schizophrenia or were the result of methodolog-ical artifacts or the confounding of sites’ latitude with levelof healthcare at those sites. We found that these patternswere still present after controlling for an index of health-care—infant mortality—and focusing on 49 studies thatused similar diagnostic and ascertainment methods. Thetendencies for schizophrenia prevalence to increase withboth latitude and colder climate were still large and signif-icant and present on several continents. The increase inprevalence with latitude was greater for groups with lowfish consumption, darker skin, and higher infant mortali-ty—consistent with a role of prenatal vitamin D deficiencyin schizophrenia. Previous research indicates that poor pre-natal healthcare and nutrition increase risk for schizophre-nia within the same region. These adverse conditions aremore prevalent in developing countries concentrated nearthe equator, but schizophrenia prevalence is lowest atsites near the equator. This suggests that schizophrenia-producing environmental factors associated with higher lat-itude may be so powerful they overwhelm protective effectsof better healthcare in industrialized countries. The ob-served patterns of correlations of risk factors with preva-lence are consistent with an etiologic role for prenatalvitamin D deficiency and exposure to certain infectious dis-eases. Research to elucidate environmental factors that un-

derlie variations in schizophrenia prevalence deserves highpriority.

Key words: epidemiology/etiology/immune function/prenatal/geography/risk factor

Introduction

Schizophrenia is an unusually burdensome disorder be-cause of the great economic costs of extensive care andloss of economic productivity, as well as the personal suf-fering and stigma, which often affect a patient and his orher family for most of the patient’s life. Moreover, formost patients there is still no cure or even an effectiveway of treating many of the most disabling, ‘‘negative’’symptoms of the disorder. Therefore, a key goal of schizo-phrenia research is elucidation of etiologic factors, partic-ularly environmental ones that could be readily avoidedand used in effective, inexpensive, and ethically sound pri-mary prevention programs.In a comprehensive survey of schizophrenia prevalence

studies around the world that were published in Englishover a period of 4 decades, Torrey1 noted 2 importantpatterns. First, prevalence rates varied widely at differentgeographic sites, with the highest rate being more than 10times greater than the lowest. Second, there was a strongtendency for schizophrenia prevalence to increase withincreasing latitude; ie, prevalence rates tended to bevery low near the equator and to increase as one movedtoward the poles. Both of Torrey’s conclusions were alsoreached in a survey and meta-analysis by Saha et al,2

which included more recent studies as well as ones pub-lished in languages other than English. Several other sur-veys have also concluded that schizophrenia rates vary atleast 10-fold around the world, including studies usingmeasures of point prevalence, lifetime prevalence, andincidence.1,3–10

A number of explanations have been proposed for thisvariability inprevalence.Severalcomplementary linesofre-search suggest that the tendency for schizophrenia preva-lence to increase with latitude and cold climate may bedue, at least inpart, to someunderlyingpre-orperinatal en-vironmental influences. For example, several studies have

1To whom correspondence should be addressed; Genetics Lab-oratory, McLean Hospital, NB-G-28 115 Mill Street, Belmont,MA 02478; tel: 617-855-3439, fax: 617-855-2348, e-mail:[email protected].

Schizophrenia Bulletin vol. 35 no. 3 pp. 582–595, 2009doi:10.1093/schbul/sbp023Advance Access publication on April 8, 2009

! The Author 2009. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.For permissions, please email: [email protected].

582

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Dennis D. Embry, [email protected]

Business cards availablefor follow up and copiesof papers & presentations


mailto:[email protected]

mailto:[email protected]

creating a culture of prevention and recovery

Health & Medicine

years of age

years merikangas

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