To find out, researchers are trying to fill in the blanks between the genetic blueprint (genotype) and psychiatric disorder (psychiatric phenotype). Phenotypes are a set of observable characteristics that result when a particular genotype interacts with its environment. The phenotype is the eventual outcome of a specific genotype.

But between genotype and psychiatric phenotype lie many measurable traits that together are called endophenotypes. This is an aspect of genetics that scientists are just starting to understand.

The National Institute of Mental Health has recently begun an initiative to push researchers to study endophenotypes with a program called Research Domain Criterion (RDoC), described as an effort to study basic dimensions of functioning that underlie human behavior.

So what exactly are endophenotypes, and how might they contribute to psychiatric illnesses?

Endophenotypes lie between genes and psychiatric phenotypes

An endophenotype can refer to anything from the size and shape of brain cells, to changes in brain structure, to impairments in working memory. The term can refer to a physical trait or a functional one.

An endophenotype must be associated with a specific psychiatric illness, such as schizophrenia, and it must be heritable. It must also be present even if the illness is not active. Within families, the endophenotype must be more common in ill family members than in healthy family members. But the endophenotype must be more common among nonaffected relatives of people with the associated illness than among the general population.

Certain endophenotypes are thought to precede behavioral symptoms. For instance, in several conditions, such as schizophrenia and Alzheimer’s disease, changes in brain structure have been found years before the onset of symptoms.

Currently doctors diagnose a psychiatric disorder based on the patient’s symptoms. The underlying neurobiology isn’t usually considered, because we lack the data to really use it.

In the future, endophenotypes might let us detect who is susceptible to psychiatric illness before clinical symptoms develop. That means we could try to combat, or at least appease, the symptoms of the disorder before they start. And knowing how endophenotypes contribute to these disorders could lead to precision medicine treatments.

How do you study endophenotypes?

One way to study the endophenotypes is to focus on a specific genetic alteration that is associated with a psychiatric disorder. This way we can get a sense of what brain changes the genetic change causes.

For instance, I study a genetic disorder called 22q11.2 Deletion Syndrome (also called 22q11DS). The syndrome is due to a deletion of up to 60 genes, many of which are linked to brain function. About 30 percent of individuals with 22q11DS will develop schizophrenia (the rate in the U.S. population overall is about one percent).

Studying 22q11DS lets us draw a line from a genetic alteration to a psychiatric phenotype, such as decreased neural function, brain structure changes or fewer neurons in certain parts of the brain, and to a psychiatric phenotype, such as schizophrenia.

Let’s go through some concrete examples of how this can be done.

22q11DS: a model syndrome to study endophenotypes

In one study researchers looked at a group of 70 children and adolescents with 22q11DS, and found deficits in executive function (which encompasses cognitive processes such as motivation, working memory and attention) in patients with 22q11DS.

In fact, researchers were actually able to predict subsequent development of psychotic symptoms in individuals with 22q11DS. This study shows that cognitive endophenotypes may underlie psychiatric phenotypes and demonstrates their predictive power. And, like all endophenotypes, it is invisible to the naked eye, but measurable in the lab.

Another study, using functional magnetic resonance imaging (fMRI), found reduced neural activity in patients with 22q11DS when they performed a working memory task compared to a group of healthy control subjects. What’s more, the magnitude of the decrease correlated with the severity of their psychotic symptoms. This suggests abnormalities in neural activity might underlie symptoms associated with schizophrenia.

Other studies have found an association between psychiatric illnesses such as schizophrenia and abnormalities in the size and shape of different brain regions. For instance, a recent study found that certain parts of the brain were thicker in patients with 22q11DS. What’s more, the degree of thickness was related to psychotic symptoms. Changes in brain structure have also been associated with psychiatric disorders, such as obsessive compulsive disorder.

In order to gain a more in-depth understanding of the underlying physiology in 22q11DS, researchers can breed mice with the deletion syndrome by “knocking out” genes in the mouse genome.

Researchers have found that mice with 22q11DS had fewer neurons in a part of the brain associated with cognition compared to unaffected mice.

The number of neurons correlated with how well the mice performed on tasks measuring executive function. These results suggest that individuals with psychiatric illnesses might actually have microscopic changes in their brain cells. This is a significant finding, because we can’t study these effects directly in humans.

These are just some examples of how we can experimentally determine endophenotypes that underlie schizophrenia in 22q11DS. And while 22q11DS is a risk factor for schizophrenia, what we learn from studying this syndrome could help us understand the endophenotypes behind other illnesses.

Of course defining endophenotypes for psychiatric illness is just the first step. After that, researchers and scientists need to find ways to use these results to inform diagnosis, treatment and prevention strategies.

This article first appeared on ‘The Conversation’ on 5 May 2016.

Australians are among the highest users of antidepressants anywhere in the world, but there has been a growing evidence questioning their effectiveness.

Experts from the National Centre of Excellence in Youth Mental Health and the University of Melbourne say while antidepressants have a role to play in treating depression, combining them with psychotherapy is more effective than using either alone.

“All patients should be offered psychotherapy where it is available, and medication should be considered if the depression is of at least moderate severity; psychotherapy is refused; or psychotherapy hasn’t been effective,” Dr Christopher Davey and Prof Andrew Chanen wrote in the Medical Journal of Australia.

They also recommend doctors encourage patients with depression to eat well and exercise.

Their calls are based on a review of studies examining the effectiveness of antidepressants and psychotherapy for treating adults and children with depression.

Ten per cent of Australian adults take antidepressants each day, with the usage rate having doubled since 2000.

Dr Davey and Prof Chanen said several studies have shown that antidepressants aren’t as effective as previously thought, with many suggesting that the “placebo response” can be a key factor as patients taking medication automatically expect they will get well.

Studies looking at psychotherapies, such as cognitive behavioural therapy, have also found a decline in effectiveness.

“The modest effect sizes for depression treatments … suggest that combining treatments might provide the best outcomes for patients,” Dr Davey and Prof Chanen wrote.

“In adults, the effect of combined treatment compared with placebo is about twice that of medication only compared with placebo.

“The effects of psychotherapy and medication appear to operate independently of each other, providing a good rationale for their combination.”

In high-income countries, HIV-related depression – the most common mental health problem in HIV-positive people – was recognised early in the AIDS epidemic as a factor that affects treatment outcomes. Yet it is only recently that the issue has drawn attention in sub-Saharan Africa, where research has found that one in three people living with HIV suffers from depression.

Addressing co-occuring mental health problems is a necessary step in controlling the HIV epidemic. But mental health care is not yet part of the HIV care package in the region.

There are efforts to change this. Our research shows how group psychotherapy interventions that give HIV-positive people emotional and social support, as well as positive coping and income-generating skills, can make a difference.

The link between mental health and HIV

There are biological, psychological and social factors that can cause mental health problems in HIV-positive people.

Depression is the natural grief response to being diagnosed with a terminal illness and to the chronic disability that may arise from it. It can also be linked to the stigma and discrimination associated with the illness. And new psychiatric symptoms and syndromes may occur as the virus affects the brain, or because of opportunistic diseases or treatment side-effects.

Mental health issues can, in turn, influence treatment outcomes. Co-morbid depression may affect motivation to seek HIV treatment or adhere to antiretroviral therapy.

It is also linked to behaviour that may facilitate HIV transmission. People commonly internalise negative stereotypes, expecting discrimination and devaluing themselves. This can interfere with their ability to choose sexual partners and negotiate safer sexual behaviour.

Depression is also associated with reduced coping capacity, poor HIV-related disease prognosis, diminished quality of life, greater social burden, increased health-care costs and higher mortality.

Our research focused on rural primary care settings in Uganda where we developed a group support psychotherapy model to treat depression. Group support psychotherapy treats depression by providing emotional and social support, and teaching positive coping and income-generating skills.

HIV-positive people suffering from depression met in eight weekly, gender-specific sessions. They were provided with information about depression and HIV. They were guided to share personal problems and taught problem-solving and coping skills. These included how to deal with anxiety and unhelpful ways of thinking, and basic livelihood skills.

High level of engagement

Unlike previous studies of group psychotherapy for depression in sub-Saharan Africa, the participants in our group support psychotherapy sessions were eager to engage in the process. More than 80% attended six or more sessions. Given the stigma attached to HIV and mental illness, this was surprising.

There are three possible explanations for the programme’s success.

First, the target community was involved in developing the model. Group support psychotherapy had also been piloted prior to the study and word had spread in the community about its benefits.

Second, trained mental health workers created a safe environment in which the participants could experience the therapeutic processes of group therapy. For example, facilitators reported that all participants had powerful cathartic experiences. Such catharsis has been shown to result in immediate and long-lasting change.

As sessions progressed, group members also began to provide feedback and support each other, during therapy and later, in their livelihood groups. The opportunity to help others, or altruism, has been shown to restore a sense of significance and increase self esteem.

Third, unlike other psychotherapeutic interventions, facilitators taught income-generating skills to mitigate poverty, which has been shown to be a potent risk factor for depression.

Addressing depression in resource-poor settings

Our study provides the first evidence of the success of this kind of group intervention in breaking the negative cycle of poverty and poor mental health in a resource-poor setting.

Six months after the programme ended, 80% of participants said the intervention had reduced their depression and motivated them to make positive changes in their lives.

Our findings also suggest that it is possible to roll out this kind of treatment in poorly resourced rural areas. Non-mental health professionals can be trained to deliver psychotherapeutic interventions in places where it is not possible to employ sufficient numbers of mental health providers.

The shifting of mental health-related tasks from health professionals to para-professionals or non-health professionals has been well-documented in non-HIV populations.

But less is known about the effectiveness of such a shift in HIV-positive populations. We now have evidence that specialists at tertiary institutions can train mid-level mental health workers to effectively deliver group support psychotherapy.

Looking ahead

We plan to expand capacity at primary health-care centres in three districts in northern Uganda. This will allow for depression diagnosis and treatment for those receiving HIV services at these centres.

Strategies include developing tailored training curricula to teach non-specialised health workers to recognise depression and employ group support psychotherapy in its treatment.

They will also be trained to teach lay health workers to deliver group support psychotherapy to HIV-positive people. This will make first-line treatments more widely accessible and sustainable

Etheldreda Nakimuli-Mpungu , Senior Lecturer and Psychiatric Epidemiologist, Makerere University

This article first appeared on ‘The Conversation’ on 11 May 2016.

Eating disorders are serious illnesses (someone with bulimia nervosa is around twice as likely to die young as someone without it; someone with anorexia nervosa about six times more likely), so this might make us worry about the effect of all-girls private or selective state schools on the mental health of young women – but should it?

In clinic, we do seem to see more girls with eating disorders from some schools than others – but no one had studied this before. We wanted to find out whether it really was the case. We also wanted to try to unpick whether any differences were because the schools themselves are different from each other, or because different types of individuals attend different schools.

Eating disorders are more common in the children of highly educated parents, so we would expect to find more eating disorders in a school with more children of university-educated parents. If the differences between schools are still there after we have taken account of each individual’s parental level of education (and other individual risk factors), then that suggests that the school environment itself might make a difference over and above this. The UK doesn’t collect the sort of data you need to answer these kinds of questions, so we worked with the Karolinska Institutet in Sweden, where everyone has a personal ID number and health and social care data is routinely collected.

We used data on 55000 girls from Stockholm County who left “Gymnasium” (school for 15-18 year olds) between 2002 and 2010, including information about who had been seen in an eating disorder clinic or diagnosed with an eating disorder, which school they attended, and individual characteristics like family history of an eating disorder and parental level of education.

We found that there were differences in rates of eating disorders between schools, even after taking into account the individual characteristics of the students within them, suggesting there may be something important about the school environment itself, not just different types of students attending different schools. A girl at a school with 50% girls and where 50% of the parents have university education has a 2.1% chance of developing an eating disorder, whereas at a school with 75% girls where 75% of the parents have university education, a similar girl with the same individual risk factors would have a 3.3% chance.

What we have found is an association – we don’t know if these types of schools actually cause eating disorders. Also, Sweden has strict gender equality laws, meaning that all-female schools do not exist there, so we don’t know how these findings would relate to all-girls schools in the UK. In the article, we speculate on possible reasons why eating disorders might be more common in some schools than others. One reason could be that eating disorders might spread within a school: if some students have eating disorders, that might make it more likely that others develop eating disorders too.

There is some evidence from other studies that extreme weight loss behaviours, body image concerns, and binge eating, all of which can be components of an eating disorder, spread within friendship groups. Another possible explanation is that very aspirational schools (with lots of highly educated parents) encourage their girls to try their best at all times. This might lead to some of them developing perfectionistic traits – which have been found to be linked with developing eating disorders.

Although large data sets like this one are really useful, they do have limitations. They rely on everyone with a health problem seeking help for it – people who don’t go to a clinic don’t get counted in the clinic numbers. Numbers receiving treatment are very low in the United States, for example, where only up to 28% of people with an eating disorder get help for it. We hope they are higher in Sweden, where there is a comprehensive, government-provided health service; but stigma, denial, and a lack of public awareness about eating disorders may still prevent people seeking the help they need. This means that a third possible explanation of our findings is that schools with high numbers of girls and high numbers of highly educated parents may seem to have more students with eating disorders because they are better at encouraging their students to seek treatment.

This leaves us in that common but frustrating position of concluding that we need more research before we know for certain where and how we might be able to intervene in schools to prevent eating disorders. Do we need to increase input into schools with lots of students with eating disorders? Or help those with fewer cases get better at identifying students in need of help? Either way, I think Child and Adolescent Mental Health Services (CAMHS) need to be working closely with school pastoral care teams to make sure that students get the help they need, as a recent initiative in Oxford Health has been doing. Nationally, this also means we need to address the chronic underfunding and cuts to CAMHS, and the fact that some areas have very long waiting times to get help, which leaves some schools trying to pick up the pieces, but that is another story.

Of course, eating disorders are complex illnesses, and what leads any one individual to become ill will probably involve genetic predisposition, personal characteristics and the environment and stressors they encounter. School environments are just one factor that may play a part. The more we can understand about each possible risk factor, the closer we can get to designing better interventions to try to prevent and treat them. And when you are working with illnesses this common, and this potentially serious, this is vital.

Dr Helen Bould is a Wellcome Doctoral Training Fellow at the Dept of Psychiatry, University of Oxford, and a registrar in Child and Adolescent Psychiatry. She tweets sporadically @drbould.

This article first appeared on ‘The Guardian’ on 29 April 2016.

I was distressed by these feelings, but they didn’t consume me. It wasn’t until my family moved from our home in Oman to the much colder climes of England that I began to feel ill at ease in my own head. The onset of puberty and all its raging hormones can’t have helped the confusion and displacement I was already feeling, but within a few short months I was battling Obsessive Compulsive Disorder, a form of chronic mental illness that invariably leaves its sufferers exhausted, scared and depressed.

Unfortunately, like many young girls, I was also extremely skilled at hiding it.

Perhaps unsurprisingly, it didn’t take long for my OCD (which had hitherto been expressed with typical tics like constant, obsessive hand washing, repetitive turning on and off of light switches, and repeated intrusive thoughts) to transpire as an eating disorder. My OCD tics were all about establishing some kind of control, and it stands to reason that controlling my body would become a part of that. I tracked my food intake religiously, allowing myself to consume no more than 800 calories a day. In less than three months, I lost 30 kilograms – but for a formerly chubby girl, this was a state of being that was treated by those around me like an accomplishment instead of a warning sign. Nor did anyone notice later when I began to purge the small amounts of food I allowed myself to eat.

Beyond Blue notes that women experience anxiety, depression and post-traumatic stress disorder at higher rates than men. Our susceptibility to mental illness is exacerbated by a range of factors, including pregnancy (up to 10 per cent of all pregnant women will experience depression or anxiety); early parenthood (1 in 7 women are likely to experience some form of postpartum depression); intimate partner or family violence and/or sexual assault; the burden of care and emotional labour that is left to women; and hormonal fluctuations (such as menopause). It is not unreasonable to suggest that the gender inequality that informs the society we live in is also responsible for provoking mental unrest in women, particularly in light of how it also teaches us to question our own interpretation of events and stay silent on issues like sexual harassment, assault and discrimination.

And yet, whenever discussions of mental health care are raised, they seem to predominantly deal with how mental illness affects men. This focus is necessary, of course – men are less likely to seek help for mental illness (because patriarchy instructs them to be stoic and resist ‘weakness’) and more likely to end their lives by suicide. Addressing this tragedy is essential, as is ensuring access to services for people predisposed to keep their pain secret.

But women are three times more likely than men to attempt to end their lives by suicide, and rarely is this discussed. Nor is there any understanding of the concept of ‘slow suicide’, such as the attempt to literally erase one’s existence that comes from starving yourself into invisibility or self-harming by use of methods such as secret cutting – both methods of self abuse that are predominantly practiced by women.

And while society is becoming much better at broaching the issues that influence poor mental health in men (for example, the devastating rate of suicide in young gay men marginalised by homophobia), it is still hesitant and even hostile at times in regard to discussing the range of abuses that tear away at the mental fabric of young women – like sexual violence, street harassment, the marketing of sexualisation, slut-shaming, body-shaming and sexual exploitation. Worryingly, attempts to discuss these issues are often retaliated against with accusations of ‘misandry’ and ‘feminazi agendas’, teaching young girls (once again) that it is their job to absorb the anger of everyone else (anger that is pathologised as deranged and unstable when expressed by women) and translate it into quiet, invisible suffering rather than upset the status quo.

Do people not notice or care about erratic mental illness in girls and women because we are so adept at hiding it, or do they not notice because our default state has always been dismissed as one prone to irrational hysteria?

As a young woman, I thought my history of mental illness marked me as different somehow. It took me a long time to realise that there were millions and millions of girls just like me who were slowly sinking beneath the currents of their own lives, simply because we have all been taught to let ourselves quietly drown while pretending to everyone else that we were simply waving.

This article first appeared on ‘Daily Life’ on 21 April 2016.

Author – Clemetine Ford

Specific therapies and medications can help relieve the burden of anxiety, yet only about a third of people suffering from this condition seek treatment. In my practice, part of what I discuss when explaining treatment options is the important role of diet in helping to manage anxiety.

In addition to healthy guidelines such as eating a balanced diet, drinking enough water to stay hydrated, and limiting or avoiding alcohol and caffeine, there are many other dietary considerations that can help relieve anxiety. For example, complex carbohydrates are metabolized more slowly and therefore help maintain a more even blood sugar level, which creates a calmer feeling.

A diet rich in whole grains, vegetables, and fruits is a healthier option than eating a lot of simple carbohydrates found in processed foods. When you eat is also important. Don’t skip meals. Doing so may result in drops in blood sugar that cause you to feel jittery, which may worsen underlying anxiety.

The gut-brain axis is also very important, since a large percentage (about 95%) of serotonin receptors are found in the lining of the gut. Research is examining the potential of probiotics for treating both anxiety and depression.

Foods that can help quell anxiety

You might be surprised to learn that specific foods have been shown to reduce anxiety.

• In mice, diets low in magnesium were found to increase anxiety-related behaviors. Foods naturally rich in magnesium may therefore help a person to feel calmer. Examples include leafy greens such as spinach and Swiss chard. Other sources include legumes, nuts, seeds, and whole grains.
• Foods rich in zinc such as oysters, cashews, liver, beef, and egg yolks have been linked to lowered anxiety.
• Other foods, including fatty fish like wild Alaskan salmon, contain omega-3 fatty acid. A study completed on medical students in 2011 was one of the first to show that omega-3s may help reduce anxiety. (This study used supplements containing omega-3 fatty acids). Prior to the study, omega-3 fatty acids had been linked to improving depression only.
• A recent study in the journal Psychiatry Research suggested a link between probiotic foods and a lowering of social anxiety. Eating probiotic-rich foods such as pickles, sauerkraut, and kefir was linked with fewer symptoms.
• Asparagus, known widely to be a healthy vegetable. Based on research, the Chinese government approved the use of an asparagus extract as a natural functional food and beverage ingredient due to its anti-anxiety properties.
• Foods rich in B vitamins such as avocado and almonds
• These “feel good” foods spur the release of neurotransmitters such as serotonin and dopamine. They are a safe and easy first step in managing anxiety.

Are antioxidants anti-anxiety?

Anxiety is thought to be correlated with a lowered total antioxidant state. It stands to reason, therefore, that enhancing your diet with foods rich in antioxidants may help ease the symptoms of anxiety disorders. A 2010 study reviewed the antioxidant content of 3,100 foods, spices, herbs, beverages, and supplements. Foods designated as high in antioxidants by the USDA include:

• Beans: Dried small red, Pinto, black, red kidney
• Fruits: Apples (Gala, Granny Smith, Red Delicious), prunes, sweet cherries, plums, black plums
• Berries: Blackberries, strawberries, cranberries, raspberries, blueberries
• Nuts: Walnuts, pecans
• Vegetables: Artichokes, kale, spinach, beets, broccoli
• Spices with both antioxidant and anti-anxiety properties include turmeric (containing the active ingredient curcumin) and ginger.

Achieving better mental health through diet

Be sure to talk to your doctor if your anxiety symptoms are severe or last more than two weeks. But even if your doctor recommends medication or therapy for anxiety, it is still worth asking whether you might also have some success by adjusting your diet. While nutritional psychiatry is not a substitute for other treatments, the relationship between food, mood, and anxiety is garnering more and more attention. There is a growing body of evidence, and more research is needed to fully understand the role of nutritional psychiatry, or as I prefer to call it, Psycho-Nutrition.

I will expand on these concepts and share research developments in future blog posts.

Dr Uma Naidoo, M.D. is an Instructor in Psychiatry at Harvard Medical School. She trained at the Harvard Longwood Psychiatry Residency Training Program and is currently on staff at Massachusetts General Hospital. She also graduated from the Cambridge School of Culinary Arts as a Professional Chef and was awarded the MFK Fisher award for Innovation. With her passion for food and psychiatry, she will share her perspectives on matters related to food, mental health and medicine.

This article first appeared in the ‘Harvard Health Blog’ on 13 April 2016.

A recent survey of headteachers reported a growing number of children self-harming as mental health problems among pupils rise. This has led to calls for improvements to children’s mental health care.

Last year, it was reported that heavy web use harms a child’s mental health, with each extra hour online compounding the problem. And research collated by Public Health England in 2014 reported that ChildLine now receives greater numbers of calls linked to internet-related problems such as cyberbullying.

What’s the implication here? That children are facing real and growing mental health problems? Or that parents, teachers and doctors are more aware of mental health problems among children?

Looking more closely at the suggestion that the internet is to blame, the headteacher survey didn’t track an increase in actual numbers over time, but rather asked head teachers if they perceived an increase – not exactly a rigorous standard of evidence.

I’d rely more on the representative national surveys of children conducted as part of the Good Childhood Report 2015, in which four waves of surveys from 2009 to 2013 revealed little change in the self-reported “subjective well-being” of British 10-17 year olds, neither for better nor worse.

Another, the Key Data on Adolescence report covering 1997-2015, agrees that “the majority of young people rate their well-being as good”, although there is older data that shows around 10% of five- to 16-year-olds suffer from a diagnosable mental health disorder. As they add, even though three quarters of mental health problems start before the early 20s, funding cuts mean that we lack up to date evidence on whether mental health problems are rising – or not.

It’s no surprise that critical sociologist Frank Furedi says that it’s time to stop getting anxious about the anxieties it’s claimed are found in children.

Guilt by correlation, not causation

The implication that the internet is responsible for these problems in children ignores the many alternative causes. The increased exam pressure, for example, or expectations for success weighing children down. We should also consider the debate over the reality of what internet or gaming “addiction” might really mean – the statistics are slight to say the least, and don’t really bear out the public’s concerns.

Blaming the internet for everything underplays the potential benefits, for mental health or otherwise, from internet use which may compensate for any drawbacks. The Children’s Commissioner for England reported that children are seeking mental health advice online in preference to asking their doctor or school nurse, for example. And ChildLine reported that most (82%) of their counselling sessions about suicide in 2013/14 were conducted through email or one-to-one online chat – a considerable increase.

ParentZone has just released some new research on the subject. There are some interesting findings in the report, but one point especially jumps out and helps make sense of my doubts about the “evidence” or otherwise regarding children and the internet.

The survey of students aged 13-20 and teachers is a small sample, but it suggests a great difference in perception between the two groups. Around a quarter (28%) of students felt that the internet is bad for young people’s mental health, while the perception that it was bad for children rose to around half (44%) among teachers. Around 45% of students said they would follow advice read online, but 86% of their teachers thought that their students would.

Asked about the biggest influences on young people’s mental health, teachers felt that family (49%) was a positive influence but saw the peer group (27%) and the internet (24%) as negative influences. Yet they rarely saw parents (9%) or family (8%) as negative influences, in stark contrast to the reasons children give for calling ChildLine, for instance, which are topped by family and school problems.

We cannot identify from this the true source of children’s difficulties. But it’s striking that teachers are more negative about the internet than their students are – and more negative about their students, too, thinking of them as gullible or uncritical about their use of the internet. Given this, it’s hardly surprising that headteachers blame the internet for the problems in children’s lives. And the space between these views makes it all the more important for more rigorous research to be carried out.

So I’m not arguing that the internet isn’t bad for children’s mental health. But I am arguing that we really don’t know either way – despite the overwhelming anxieties portrayed in the media. And given the amount of attention that continues to be devoted to this question, that’s a sorry state of affairs.

This article first appeared on ‘The Conversation’ on 18 March 2016.

Statistics now show that one in ten children have a clinically diagnosed mental health or behavioural problem and that half of lifetime mental illness starts by the age of 14. So the case for school-based activity in this area is mounting. This research is starting to feed through into education policy, as schools begin to understand their role in delivering a broad range of practice – beyond the focus on the cognitive side of education which has taken precedence in the past.

However, trials which have attempted to roll out well-being programmes in schools have demonstrated that supporting young people’s emotional health is a more complex task than first thought.

Mixed results

School-based programmes to support child emotional health range from targeted help for individual pupils with identified difficulties – such as cognitive behavioural therapy – to approaches that aim to improve social and emotional learning for all, such as the PATHS (Promoting Alternative Thinking Strategies) programme.

Various studies and some schools have reported promising results from these types of programmes yet, overall, school-based cognitive behavioural therapy trials and other similar interventions have failed to show sustained positive effects on symptoms of anxiety and depression among children.

Likewise, two recent trials of the highly acclaimed PATHS programme – which promotes emotional and social competencies and aims to reduce aggression and behaviour problems at the same time as enhancing educational progress in the classroom – have arrived at disappointing conclusions in large numbers of UK schools. One found no evidence of sustained effects on behaviour or well-being, while another showed a somewhat mixed pattern, sometimes in favour of PATHS schools but sometimes in favour of the control schools.

Given the current evidence, it appears there is no guarantee that introducing programmes such as these will generate positive and sustained impacts for children. But what then can be done to help our children grow into emotionally healthy adults? The answer lies in an integrated, embedded approach to learning.

A question of implementation

There are a range of factors that could influence when, and in what contexts, programmes to support emotional health are likely to be most successful. The main issue here seems to be implementation: to roll out and scale up even theoretically sound and well-researched programmes to large numbers of schools is already a challenge, and even more so in the face of the everyday constraints and pressures in education.

Our latest report into supporting the emotional health of children in primary schools highlights that while school programmes can sometimes be effective, school systems need to be strongly connected with each other in order to translate research evidence into sustained positive impacts. A large number of programmes are now available to schools, but the real-world success of intervention and prevention efforts cannot be attributed to any given programme per se – success is found in the way a programme is put into place within this integrated school systems approach.

To put it simply, emotional health needs to become a core part of all school matters, and not be just another competing priority.

This is easier said than done, however. At present, there is no established evidence base to inform practitioners and policy makers about how well-being programmes, the curriculum, staff and external professionals are coordinated to maximise the emotional health of primary school children. If efforts to support child well-being are connected with wider school visions then work on emotional health must be viewed as lying at the core of effective teaching and learning in the future.

Our report calls for exploratory work with small numbers of schools, working with expert support and national level support to test a framework that could inform activity across the school system as a whole. Only then can we really begin to address how to best support the emotional health of our children in schools.

This article first appeared on ‘The Conversation’ on 16 March 2016.

Aviation agencies around the world should draw up new rules requiring medical workers to warn authorities when a pilot’s mental health could threaten public safety, French investigators have recommended after a yearlong investigation into the Germanwings plane crash.

The French investigation found that Germanwings co-pilot Andreas Lubitz, who had been treated for depression in the past, had consulted dozens of doctors in the weeks before he deliberately crashed a jet into the French Alps on March 24, 2015, killing all 150 people on board.

But none of the doctors told authorities of any concerns about Lubitz’s mental health, France’s BEA air accident investigation agency said, including one who referred Lubitz to a psychiatric clinic just two weeks before the crash.

“Experts found that the symptoms (two weeks before the crash) could be compatible with a psychotic episode,” said Arnaud Desjardin, leader of the BEA investigation. This information “was not delivered to Germanwings”.

Because Lubitz didn’t inform anyone of his doctors’ warnings, the BEA said in a statement, “no action could have been taken by the authorities or his employer to prevent him from flying”.

The agency also said Lubitz was using antidepressants at the time of the crash. It said traces of anti-depressive medications Citalopram and Mirtazapine were found in Lubitz’s remains, as well as the sleeping medication Zopiclone.

The US National Library of Medicine notes on its entry for Citalopram that children and young adults who take the drug can become suicidal “especially at the beginning of your treatment and any time that your dose is increased or decreased”.

Lubitz was 27 when he crashed the plane.

Germanwings and its parent company Lufthansa have strongly denied any wrongdoing in the crash, insisting that Lubitz was certified fit to fly.

But relatives of those killed have pointed to a string of people they say could have raised the alarm and stopped Lubitz, going back to the days when he began training as a pilot in 2008.

The BEA investigation is separate from a manslaughter investigation by French prosecutors seeking to determine eventual criminal responsibility for the crash of Flight 9525 from Barcelona to Duesseldorf. The focus of the BEA report was recommendations to avoid such events in the future.

The agency found that the certification process failed to identify the risks presented by Lubitz. It said one factor leading to the crash might have been a “lack of clear guidelines in German regulations on when a threat to public safety outweighs” patient privacy.

Germany’s confidentiality laws prevent sensitive personal information from being widely shared, though doctors are allowed to suspend patient privacy if they believe there is a concrete danger to the person’s safety or that of others.

Desjardin described Germany’s privacy rules as being especially strict, and said doctors fear losing their jobs or potential prison terms if they unnecessarily report a problem to authorities. The doctors who treated Lubitz for depression and mental illness refused to speak with the BEA investigators, according to victims’ relatives who were briefed on the report.

“That’s why I think clearer rules are needed to preserve public security,” Desjardin told reporters at a press conference in Le Bourget, in the Paris suburbs.

But Johann Reuss of Germany’s air accident investigation agency told The Associated Press “there is no need to change the law”.

Reuss said “it might not be easy” to loosen the privacy rules and suggested that authorities instead focus on giving doctors checklists to prevent similar scenarios with pilots.

The new BEA safety recommendations also included peer support groups for aviation workers and other measures to reduce the stigma and fear of losing a job that many pilots face for mental health issues.

“The reluctance of pilots to declare their problems and seek medical assistance … needs to be addressed,” the BEA said.

Lufthansa pledged to back the new safety recommendations, saying in a brief statement on Sunday that it will “continue to co-operate with the relevant authorities and will support the possible implementation of concrete measures” based on the report.

Half an hour into the Germanwings flight, Captain Patrick Sondenheimer handed the controls to Lubitz and went to the restroom. When he returned, Sondenheimer found the cockpit locked from the inside. Lubitz, had disabled the safety code that would have allowed the pilot to open the door.

Shortly afterward, the Airbus A320 hit the ground near the French village of Le Vernet.

Lubitz had previously been treated for depression and suicidal tendencies, and documents seized by prosecutors show he partly hid his medical history from employers.

Lubitz had interrupted his Lufthansa training for several months due to psychological problems. He was allowed to return in 2009, having received the “all clear” from his doctors – though his aviation record now contained the note “SIC” meaning “specific regular examination”.

Lufthansa said after the crash that it was aware of Lubitz’s depressive episode, but Germanwings, which he joined in 2013, said it had no knowledge of his illness.

The French investigators decided that systematic, deep psychological tests every year for all pilots would be “neither effective nor beneficial,” Desjardin said.

Instead, the BEA recommended tougher monitoring of pilots who had mental health issues in the past.

The agency also said airplane cockpit security rules shouldn’t be changed, because it was still very important to protect the cockpit from outside attackers. Current cockpits are equipped with a code system to prevent the kind of hijackings that occurred on September 11, 2001, in the United States, where planes full of passengers were turned into weapons.

“A lockage system cannot be created to prevent threats coming from (both) outside and inside the cockpit,” Desjardin said.

After the Germanwings crash, some airlines and aviation regulators required that at least two people be in the cockpit at any given time to prevent such crashes.

This article first appeared on ‘The Australian’ on 14 March 2016.

Mates in Construction (MIC) has trained almost 100,000 people across Australia in suicide prevention.

The not-for-profit group visited the south-east of South Australia as part of the South Australian State Government’s drought response package.

MIC believes open dialogue about suicide and mental health is crucial in fighting the 2864 people who die each year in Australia from intentional self-harm.

Australian Bureau of Statistics data indicated there has been a 13.5 per cent increase in suicides from 2013-2014.

Field officer for MIC, Bob Clifford said directly asking someone if they have thought about taking their own life is much better than beating around the bush.

“Highly important to ask the question, how are you travelling and then listen carefully to what’s being said.”

Mr Clifford said non-judgemental listening was exceedingly important when communicating with someone you think might be struggling.

“We are not the professionals that are actually going to fix the problem,” he said.

“We are people who deeply care about our friends, our relatives.”

What do men in agriculture think about talking suicide?

Livestock agent trainee Hamish Jurgs said there was a drastic difference in how men and women dealt with their feelings.

He believed this could be why men were almost three times more likely to take their own life, compared with women.

“Through openness with their friends and family [women] can talk through things and work it out,” he said.

“Whereas, men tend to hold it close to their chest and not talk and just worry about other things, rather than themselves,”

Mr Jurgs said he was amazed at MIC’s advice to ask people straight out if they were thinking about suicide.

“That surprised me how they work toward that approach, rather than just saying ‘hey how you going?’,” he said.

An agribusiness consultant’s observations.

Naracoorte agribusiness consultant, Ken Solly said drought in the south-east of South Australia was weighing heavily on the mental health of the community.

“I’ve actually seen some cases of people I thought were extremely stable people,” he said.

“Having two poor years one on top of another, a lot of people don’t know how they will handle debt until they have actually taken it on.”

Mr Solly said people needed to realise the support that existed within the community.

“There are people in this society who care and are quite skilled in being able to help you through it,” he said.

This article first appeared on ‘ABC Rural’ on 9 March 2016.