In writing a book on mental illness (which is topping out, now, at 113K words), I find that although I haven't exactly written an anti-psychiatry screed, I've come about as close to that designation as you can come without sounding like a full-on psychiatry-bashing lunatic. Where's the dividing line? For one thing, I stop short of saying there's no such thing as mental illness; I believe that the utility of the illness model is (just barely) useful enough not to discard it completely. I also stop short of saying psychiatry has nothing to offer, or that drugs have nothing to offer, whereas many anti-psychiatry zealots are willing to go there. I can't go there unless that's where the evidence points. We know the evidence doesn't 100% point there, so let's not pretend it does.
On the other hand, psychiatry (not only psychopharmacology, but modern psychotherapy) deserves criticism on many fronts, and it's not hard to produce evidence on many of those points, so that's all fair game. My book is full of criticism. (And footnotes. Hundreds of footnotes.)
In medicine, there are many "31% solutions," which is to say therapeutic options that work for about 31% of people who try them. This includes placebos, antidepressants, antipsychotics, herbal cures, cures for alcoholism (the year-over-year retention rate for Alcoholics Anonymous is about 31%), various psychotherapies, low-dose electroconvulsive therapy, sham ECT, trans-cranial magnetic stimulation, and probably diets, exercise, and much else. Frankly, a 31% response rate, whether it's for a cancer treatment or a mental disorder, whether it involves "real medicine" or placebos or sham treatments, is not something you just walk away from. When people are desperate for relief, they'll try something that works 31% of the time. And well they should!
But we should be honest about response rates, remission likelihoods, etc., in treatment of mental illness, as in treatment of cancer or any other malady. And this is where the "mental health industry" (if you can call it that) has done a remarkably poor job. Patients are led to believe antidepressant drugs mostly work, when in fact they mostly do not. They've also been told ECT (electroconvulive therapy) mostly works, when in fact the benefits beyond the one-month point are essentially nil and there's no difference in long-term outcome between sham ECT (placebo) and real ECT, something I go into it the book (citing FDA's own internal literature review).
Also, CBT (cognitive behavioral therapy) has been so grossly oversold as a treatment modality, with claims of its superiority to other modalities, that I felt an obligation to counter some of the misleading claims made for CBT. So in the book, I devote a few pages to that. Again, not because CBT doesn't work for some people (it clearly does) or doesn't have any utility at all, but because it's been preposterously oversold. I'll devote a future blog post to that.
For more information about my upcoming book and how to get free sample chapters, please add your name to the mailing list (no updates have been sent out yet; I'm not interested in spamming anyone). And please check back here often. Thank you!
Showing posts with label mental illness. Show all posts
Showing posts with label mental illness. Show all posts
Saturday, January 17, 2015
Saturday, January 10, 2015
Where Are the Schizophrenia Genes?
Schizophrenia is another one of those conditions (like alcoholism) that we're constantly being told is highly heritable, based on the results of twin studies and various other findings (from studies that pre-date the DNA-sequencing era). Studies "proving" the heritability of schizophrenia are, in general, rarely questioned, or even reviewed critically, due to the fact that a genetic basis for schizophrenia makes so much intuitive sense and agrees so well with ordinary experience. Everybody knows someone who "has schizophrenia in their family," and it very much does seem to travel in families.
The fact that something travels in families is not automatically indicative of a genetic connection, but most people aren't ready to believe such a thing since it goes against common sense. Nevetheless, in the past few decades, a great deal of work (much of it quite compelling) has gone into the study of things like intergenerational trauma, with researchers finding, for example, that the course of PTSD in modern-day Israeli military veterans is much different for soldiers whose parents or grandparents were Holocaust survivors. (I talk about intergenerational trauma in Of Two Minds. In fact, there's a whole chapter on Trauma.)
Social workers and criminologists have known for years that childhood physical and sexual abuse tend to be intergenerational. Yet no one seriously suggests there's a "child abuse gene" or a "child molestation gene." A lot of things that aren't purely genetic are trans-generational; familial. Schizophrenia itself may be in this category. The links between childhood trauma and schizophrenia are quite strong and well known. Indeed, the literature shows that the associations between childhood trauma and schizophrenia are actually as strong as or stronger than the associations between childhood trauma and other disorders that we know have a high correspondence to childhood trauma (including depression, PTSD, anxiety disorders, dissociative disorders, eating disorders, personality disorders, substance abuse, and sexual dysfunction, among others).
Still, the search for "schizophrenia genes" goes on, and every so often we hear claims for this or that group of scientists having discovered some new genetic feature that confers high risk for schizophrenia. The latest of these reports comes from the Schizophrenia Working Group of the Psychiatric Genomics Consortium, which published a piece in Nature Letters in July 2014 called "Biological insights from 108 schizophrenia-associated genetic loci." The report trumpets the finding of "108 conservatively defined loci that meet genome-wide significance, 83 of which have not been previously reported." This is a genome-wide association study, subject to the usual GWAS caveats.
Of the 108 loci, 75% were associated with protein-coding genes, a very high number for a GWAS study, and quite a few genes involve physiologically relevant functions.
On the surface, it sounds promising.
Where things start to fall down is in determining how much heritability risk the 108 loci can account for. The authors said: "Assuming a liability-threshold model, a lifetime risk of 1%, independent SNP effects, and adjusting for case-control ascertainment, RPS" (risk profile scores) "now explain about 7% of variation on the liability scale to schizophrenia across the samples, about half of which (3.4%) is explained by genome-wide significant loci." To parse that: We know the lifetime risk of schizophrenia is 1%. If we total up the disease risk attributable to all of the 128 markers found in the study, we can explain 7% of schizophrenia risk. But if we limit ourselves to the 108 markers that met criteria for genome-wide significance (a stringent test intended to reduce the risk of false positives), we can explain only a little more than 3% of schizophrenia risk.
So once again, it's a mixed bag: a genome-wide association study (GWAS) that's filled with interesting findings (some of which may prove to be important), but that fails, quite miserably, to explain heritability.
Many people have commented on the possible reasons why genome-wide association studies have been hit-or-miss in their ability to explain heritability, why they so often find SNPs (single nucleotide polymorphisms) that don't map to genes, why the results often don't replicate well, etc. I think if we're honest, we have to admit that GWAS isn't always the right tool for the job. It's a great tool, but you have to remember how it works. GWAS attempts to match fairly common (i.e., occurring in 1% or more of the population) single nucleotide polymorphisms (which you can think of as point mutations) in databases that have been specially built to accommodate the most common polymorphisms. In a GWAS, you aren't doing deep sequencing of people's genes; you're looking for markers that cover a rather tiny percent of the genome. These markers occur commonly, which almost by definition prevents them from being very serious defects, because serious genetic defects are rendered rare by evolution (natural selection removes them from the gene pool over time). Therefore, in a technique that, by design, looks mainly at commonly occurring SNPs, which are overwhelmingly neutral (from an evolutionary standpoint), we should not be surprised to find that the markers that get spotted in GWAS (as genome-wide significant) are essentially neutral mutations without much phenotypic effect.
Unfortunately, we're at an awkward point in the history of science, because technology has given us some powerful DNA analysis tools (and the computers needed to crunch the data), but we're not quite yet at the point where detailed, deep genetic sequencing of whole human genomes is economically feasible for a study that includes, say, a thousand cases and a thousand controls. (Right now, it costs about $10,000 to do the necessary sequencing.) When a human genome can be reliably sequenced for under $2000, we'll have the tools to do really serious, deep genetic studies of hard-to-pin-down diseases. Whether we'll have the computer power needed to do the necessary statistical analysis on the scale of large (N > 1000) case-control studies is another matter; remember that in GWAS we're dealing with perhaps 500,000 data points per genome whereas in deep sequencing we're generating billions of data points per genome. It'll probably be doable using Amazon AWS/EC2 infrastructure (or Google's compute-cloud). Another reason to invest in Amazon, probably.
I'm in the process of writing a 100,000-word book on mental illness. It's evidence-based; part science, part memoir, with over 200 footnotes (so you can refer to the scientific literature yourself). To follow the progress of the book, check back here often, and also consider adding your name to our mailing list. Thanks!
The fact that something travels in families is not automatically indicative of a genetic connection, but most people aren't ready to believe such a thing since it goes against common sense. Nevetheless, in the past few decades, a great deal of work (much of it quite compelling) has gone into the study of things like intergenerational trauma, with researchers finding, for example, that the course of PTSD in modern-day Israeli military veterans is much different for soldiers whose parents or grandparents were Holocaust survivors. (I talk about intergenerational trauma in Of Two Minds. In fact, there's a whole chapter on Trauma.)
Social workers and criminologists have known for years that childhood physical and sexual abuse tend to be intergenerational. Yet no one seriously suggests there's a "child abuse gene" or a "child molestation gene." A lot of things that aren't purely genetic are trans-generational; familial. Schizophrenia itself may be in this category. The links between childhood trauma and schizophrenia are quite strong and well known. Indeed, the literature shows that the associations between childhood trauma and schizophrenia are actually as strong as or stronger than the associations between childhood trauma and other disorders that we know have a high correspondence to childhood trauma (including depression, PTSD, anxiety disorders, dissociative disorders, eating disorders, personality disorders, substance abuse, and sexual dysfunction, among others).
Still, the search for "schizophrenia genes" goes on, and every so often we hear claims for this or that group of scientists having discovered some new genetic feature that confers high risk for schizophrenia. The latest of these reports comes from the Schizophrenia Working Group of the Psychiatric Genomics Consortium, which published a piece in Nature Letters in July 2014 called "Biological insights from 108 schizophrenia-associated genetic loci." The report trumpets the finding of "108 conservatively defined loci that meet genome-wide significance, 83 of which have not been previously reported." This is a genome-wide association study, subject to the usual GWAS caveats.
Of the 108 loci, 75% were associated with protein-coding genes, a very high number for a GWAS study, and quite a few genes involve physiologically relevant functions.
On the surface, it sounds promising.
Where things start to fall down is in determining how much heritability risk the 108 loci can account for. The authors said: "Assuming a liability-threshold model, a lifetime risk of 1%, independent SNP effects, and adjusting for case-control ascertainment, RPS" (risk profile scores) "now explain about 7% of variation on the liability scale to schizophrenia across the samples, about half of which (3.4%) is explained by genome-wide significant loci." To parse that: We know the lifetime risk of schizophrenia is 1%. If we total up the disease risk attributable to all of the 128 markers found in the study, we can explain 7% of schizophrenia risk. But if we limit ourselves to the 108 markers that met criteria for genome-wide significance (a stringent test intended to reduce the risk of false positives), we can explain only a little more than 3% of schizophrenia risk.
So once again, it's a mixed bag: a genome-wide association study (GWAS) that's filled with interesting findings (some of which may prove to be important), but that fails, quite miserably, to explain heritability.
Many people have commented on the possible reasons why genome-wide association studies have been hit-or-miss in their ability to explain heritability, why they so often find SNPs (single nucleotide polymorphisms) that don't map to genes, why the results often don't replicate well, etc. I think if we're honest, we have to admit that GWAS isn't always the right tool for the job. It's a great tool, but you have to remember how it works. GWAS attempts to match fairly common (i.e., occurring in 1% or more of the population) single nucleotide polymorphisms (which you can think of as point mutations) in databases that have been specially built to accommodate the most common polymorphisms. In a GWAS, you aren't doing deep sequencing of people's genes; you're looking for markers that cover a rather tiny percent of the genome. These markers occur commonly, which almost by definition prevents them from being very serious defects, because serious genetic defects are rendered rare by evolution (natural selection removes them from the gene pool over time). Therefore, in a technique that, by design, looks mainly at commonly occurring SNPs, which are overwhelmingly neutral (from an evolutionary standpoint), we should not be surprised to find that the markers that get spotted in GWAS (as genome-wide significant) are essentially neutral mutations without much phenotypic effect.
Unfortunately, we're at an awkward point in the history of science, because technology has given us some powerful DNA analysis tools (and the computers needed to crunch the data), but we're not quite yet at the point where detailed, deep genetic sequencing of whole human genomes is economically feasible for a study that includes, say, a thousand cases and a thousand controls. (Right now, it costs about $10,000 to do the necessary sequencing.) When a human genome can be reliably sequenced for under $2000, we'll have the tools to do really serious, deep genetic studies of hard-to-pin-down diseases. Whether we'll have the computer power needed to do the necessary statistical analysis on the scale of large (N > 1000) case-control studies is another matter; remember that in GWAS we're dealing with perhaps 500,000 data points per genome whereas in deep sequencing we're generating billions of data points per genome. It'll probably be doable using Amazon AWS/EC2 infrastructure (or Google's compute-cloud). Another reason to invest in Amazon, probably.
I'm in the process of writing a 100,000-word book on mental illness. It's evidence-based; part science, part memoir, with over 200 footnotes (so you can refer to the scientific literature yourself). To follow the progress of the book, check back here often, and also consider adding your name to our mailing list. Thanks!
Tuesday, January 06, 2015
The Problem of "Missing Heritability"
When the human genome was sequenced in 2003, the expectation was that scientists, armed with a powerful array of new genetic techniques, would very quickly identify the genetic correlates of things like schizophrenia, depression, autism, and alcoholism, which we supposedly "know" have a large genetic component. Extremely large, well-funded genome-wide association studies (GWAS) were begun. (See this PLoS paper to learn how such studies are conducted.) Surprisingly, the studies failed, for the most part, to converge on genes, gene copy number variants, SNPs (single nucleotide polymorphisms), gene rearrangements, mutations, or other peculiarities of allelic architecture whose presence could predict important diseases. When genetic loci of interest were found, the findings often didn't replicate in followup studies; or if they did, the relative odds ratios (a measure of the ability of genetic features to predict the prevalence of a trait) fell far short of explaining the known magnitudes of various traits in target populations.
If things like schizophrenia and alcoholism truly do have a strong genetic basis (as we've been told), and if they were to involve tractable numbers of genes (say, dozens or scores of genes, rather than hundreds or thousands), DNA studies of the GWAS kind should produce immediate, strong, recognizable genetic signatures of disease. The results should leap off the page. But they don't. Time and again, the very few candidate alleles that are found are either found in low numbers, or have low "penetrance" (low capacity to predict disease), or both, and quite often the candidate alleles that are found are not confirmed by followup studies.
This has given rise to major crisis in genetics, summed up in a paper called "Finding the missing heritability of complex diseases" that appeared in Nature in 2009. Scientists are desperate to explain the "missing heratibility" of disorders we "know" are genetic.
It's assumed, by most scientists, that the failure of genome-wide association studies to find genetic explanations of complex diseases can be attributed to such studies' low power and resolution for genetic variations of modest effect. (So the quest has begun to increase the study size of future trials, in hopes of seeing more robust results.) In addition, there's a reasonable expectation that many complex diseases will doubtless be found to involve numerous genes, each contributing only a small effect to the total. It's also been suggested that some traits are dictated by extremely rare genetic features with high "penetrance." There's also an awareness that current laboratory techniques have low power to detect gene-gene interactions. What no scientist wants to say, however—and what none of the 24 co-authors of the Nature article (above) would say—is that maybe the genetic component(s) of schizophrenia, alcoholism, depression, etc. are simply vanishingly small to begin with. Yet that's exactly what the data are telling us. But we won't listen to the data because it doesn't fit our preconception of how the world should work.
We "know" that a person's height is largely controlled by genes. Studies going back almost a century have determined that body height is 80% to 90% heritable; no one seriously questions this fact. (Height is heritable—it "runs in families.") However, at least three large, modern genetic studies have been done to find "height genes"; the largest involved over 180,000 study subjects (and 291 co-authors). In all, some 180 genetic loci were identified that play a role in determining a person's height. But the 180 genomic features, put together, accounted for only 10% of observed variations in height. The rest appears to be environment.
Are we now supposed to enlarge our "study population" from 180,000 to several million, in order to find the genetic explanation for body height, just because we "know" one exists?
At some point, don't we have to just admit "the data's the data"?
Shouldn't we be willing (at least provisionally) to entertain the idea that maybe the twin studies and the data showing that certain things "run in families" (pre-GWAS-era data, mostly) are in need of reevaluation? Shouldn't we at least consider the idea that prior studies misjudged the importance of uncontrolled-for environmental variables? Now that we have powerful DNA-analytic techniques for investigating heritability, and the techniques aren't giving us the results we want, must we "increase the size of the microscopic" to make the results look bigger? Or shouldn't we just accept what the data are telling us (as painful as that may be)?
In a future post, I'll talk about some of the GWAS results for alcoholism. Stay tuned.
This post is, in part, derived from material for a forthcoming book on mental illness I'm writing. Please come back often to find out how to get free sample chapters.
If things like schizophrenia and alcoholism truly do have a strong genetic basis (as we've been told), and if they were to involve tractable numbers of genes (say, dozens or scores of genes, rather than hundreds or thousands), DNA studies of the GWAS kind should produce immediate, strong, recognizable genetic signatures of disease. The results should leap off the page. But they don't. Time and again, the very few candidate alleles that are found are either found in low numbers, or have low "penetrance" (low capacity to predict disease), or both, and quite often the candidate alleles that are found are not confirmed by followup studies.
This has given rise to major crisis in genetics, summed up in a paper called "Finding the missing heritability of complex diseases" that appeared in Nature in 2009. Scientists are desperate to explain the "missing heratibility" of disorders we "know" are genetic.
It's assumed, by most scientists, that the failure of genome-wide association studies to find genetic explanations of complex diseases can be attributed to such studies' low power and resolution for genetic variations of modest effect. (So the quest has begun to increase the study size of future trials, in hopes of seeing more robust results.) In addition, there's a reasonable expectation that many complex diseases will doubtless be found to involve numerous genes, each contributing only a small effect to the total. It's also been suggested that some traits are dictated by extremely rare genetic features with high "penetrance." There's also an awareness that current laboratory techniques have low power to detect gene-gene interactions. What no scientist wants to say, however—and what none of the 24 co-authors of the Nature article (above) would say—is that maybe the genetic component(s) of schizophrenia, alcoholism, depression, etc. are simply vanishingly small to begin with. Yet that's exactly what the data are telling us. But we won't listen to the data because it doesn't fit our preconception of how the world should work.
We "know" that a person's height is largely controlled by genes. Studies going back almost a century have determined that body height is 80% to 90% heritable; no one seriously questions this fact. (Height is heritable—it "runs in families.") However, at least three large, modern genetic studies have been done to find "height genes"; the largest involved over 180,000 study subjects (and 291 co-authors). In all, some 180 genetic loci were identified that play a role in determining a person's height. But the 180 genomic features, put together, accounted for only 10% of observed variations in height. The rest appears to be environment.
Are we now supposed to enlarge our "study population" from 180,000 to several million, in order to find the genetic explanation for body height, just because we "know" one exists?
At some point, don't we have to just admit "the data's the data"?
Shouldn't we be willing (at least provisionally) to entertain the idea that maybe the twin studies and the data showing that certain things "run in families" (pre-GWAS-era data, mostly) are in need of reevaluation? Shouldn't we at least consider the idea that prior studies misjudged the importance of uncontrolled-for environmental variables? Now that we have powerful DNA-analytic techniques for investigating heritability, and the techniques aren't giving us the results we want, must we "increase the size of the microscopic" to make the results look bigger? Or shouldn't we just accept what the data are telling us (as painful as that may be)?
In a future post, I'll talk about some of the GWAS results for alcoholism. Stay tuned.
This post is, in part, derived from material for a forthcoming book on mental illness I'm writing. Please come back often to find out how to get free sample chapters.
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