W o r k i n g t o g e t h e r t o s o lv e t h e p u z z l e s o f t h e m i n d S um m er 20 08

News from the Department of Psychiatry and Behavioral Sciences

Forever in fear

Unraveling the mysteries of PTSD By

M a rt ha Nol a n Mc Ke n z i e

Half of all women and 60% of all men will experience a traumatic event in their lifetimes. They will be raped, abused as children, assaulted, involved in a serious accident or witness a murder or attack. If they happen to serve in active military duty or live in an impoverished inner city, their odds of suffering such horrors go way up. Most of these trauma victims will find a way to cope. They’ll weep. They’ll rage. They’ll think about the event obsessively. And finally, they will put the tragedy behind them, not forgotten but relegated to a dark corner of their mind. For a small portion, however, the event will live on, forever current. They will struggle in the grip of nightmares, flashbacks and ceaseless anxiety, unable to distinguish between safe and dangerous situations. Their world will shrink as they try to Why do some people, after avoid anything that might surviving a traumatic event, evoke painful memories. These victims suffer from develop PTSD while others do Post Traumatic Stress not? That’s the question that Disorder (PTSD). “Some people who Emory researchers are trying have experienced a very severe trauma find that to answer through a multitude their life has changed of studies and clinical trials. forever after that,” says Kerry Ressler, an Emory assistant professor of psychiatry and a researcher at the Yerkes National Primate Research Center. “It’s not simply a matter of having a bad experience and they grieve, but it seems to change the way the emotional part of their brain responds to the world so that they are not able to ever feel safe again.” Why do some people, after surviving a traumatic event, develop PTSD while others do not? That’s the question that Emory researchers are trying to answer through a multitude of studies and clinical trials. From developing rat models of PTSD to treating returning Iraqi vets using virtual reality therapy, and from examining genetic, biological and psychosocial data from inner-city trauma victims to attempting to ward

They will struggle in the grip of nightmares, flashbacks and ceaseless anxiety, unable to distinguish between safe and dangerous situations. Their world will shrink as they try to avoid anything that might evoke painful memories. These victims suffer from Post Traumatic Stress Disorder (PTSD).

off the development of PTSD through immediate post-trauma intervention, Emory scientists from various disciplines are trying to unlock the mysteries of the disorder that will conservatively strike 10% of the general population. “Our goal is to use the understanding – on a neuroscience level - of how we reduce these fears – a process known as ‘extinction’ - to develop new treatments that specifically target this memory process,” says Ressler, Continued on page 3

For more information about the Emory Department of Psychiatry and Behavioral Sciences, call Jack Redmond, 404.727.8253

F rom t h e c hair

The department continues to thrive! In this short note, I want to highlight a few major developments. First, as described in detail in this issue of BrainStorms, we continue to make claim to being the No. 1 department in the country in the area of trauma and post-traumatic stress disorder – our faculty are pioneers in understanding the prevalence, genetics and neurobiological consequences of trauma, as well as being on the forefront of novel treatments. I could not be prouder of the accomplishments of Kerry Ressler, Rebekah Bradley, Barbara Rothbaum, Mike Davis, Doug Bremner, Elizabeth Binder, Ann Schwartz, Rickey Gillespie and others who have in the past year reported paradigm-shifting original observations – published in the best journals in the field. For example, see the outstanding article in the Journal of the American Medical Association (299:1291-1305, 2008) on a genetic polymorphism (FKBPS) that mediates risk It is my hope that all faculty, past and present, all alumni, medical students and residents, and friends

for PTSD in victims of child abuse. Second, we have all breathed a big sigh of relief with the announcement that Grady Memorial Hospital, a vital clinical training and research site for the department and an essential facility for

of the department,

providing care for thousands of patients

will make some

in Atlanta, will remain open under new

contribution to

leadership, all possible by a wonderful

our campaign.

$200 million gift from the Woodruff

Tom Johnson: Emory psych fan When Charles Nemeroff asked former CNN CEO Tom Johnson to join the newly created Psychiatry and Behavioral Sciences External Advisory Board, Johnson jumped at the chance. “I want to do anything I can to help Charlie Nemeroff with this future programs,” says Johnson. “I became significantly better, if not almost completely better, as result of being a patient of his.” Johnson had secretly struggled with depression for years before his wife forced him to seek treatment after being ousted as publisher of the Los Angeles Times. Though he did begin seeing a psychiatrist and taking an antidepressant, he didn’t find relief until he moved to Atlanta to accept the post at CNN and began seeing Nemeroff. “He recommended a different medication – Effexor – and a treatment plan, and for me, it was a miracle,” says Johnson. From that acquaintance, Johnson became interested in the work of Nemeroff and his Emory team, particularly in the area of childhood psychiatry. “In Atlanta, we have an excellent program for seniors at the Fuqua Center for Late-Life Depression at Wesley Woods (which is a component of Emory’s psychiatry department) and an excellent center for adults at Skyland Trail (an Emory affiliate),” says Johnson. “But we badly need a center that can handle inpatient treatment of children. It is a gaping hole.” Toward that end, Johnson and other advisory board members are working to spread Nemeroff’s vision of the center. Says Johnson, “We are determined to help him raise the funds that can help him make the department the best in the U.S.”

nation, moving up three slots from the previ-

Virtual Iraq

of the Emory Capital Campaign and the important role of this campaign in allowing our department to continue to grow – in training, clinical research and clinical service delivery. It is my hope that all faculty, past and present, all alumni, medical students and residents, and friends of the department, will make some contribution to our campaign. My wife Gayle and I have kicked off the campaign with a $100,000 gift as evidence of our commitment. I have little doubt that ranking as one of the top 5 departments of psychiatry in the United States is clearly within our grasp – currently we are ranked No. 9 in the nation in NIH funding and No. 12 in clinical service delivery by US News and World Report. We are clearly on a trajectory to realize our collective goals. As always, I am

Movin’ on up! The 2007 US News & World Report survey of hospital-based psychiatry programs ranked

Reunette W. Harris Professor and Chairman

Forever in fear

the Emory Psychiatry Department 12th in the

Third is the formal announcement

Charles B. Nemeroff, MD, PhD

who was recently named a Howard Hughes Medical Institute Investigator (see “Hughes Investigator,” page 4). “Instead of using a drug that just treats the symptoms, we want to find ways to combine new medications with the learning process that goes on with behavior exposure therapy to make a much more effective treatment.”

Despite the debilitating effects of PTSD, relatively little is known about the disorder. By definition, it follows a traumatic event – a terrifying experience during which the victim may think his or another’s life is in danger. Symptoms, which can emerge months after the event include: n Re-experience. A cue will remind the victim of the event and he will suddenly be reliving it in a flashback or nightmare. n Avoidance and numbing. Victims avoid places and things that can remind them of the event. An often repeated example is a woman who was raped by a man whose hands smelled of oranges. Afterward, the taste of oranges made her nauseous. Then she found just seeing oranges in the produce section upset her, so she started avoiding that area of the grocery. Finally, she stopped going to the grocery altogether. Victims also experience a general numbing of emotions. “Feeling dead” is a common description. n Sympathetic arousal. Victims tend to feel forever jumpy and on edge. They are constantly awash in adrenaline, trapped in a state of fightor-flight. Exaggerated startle is one of the cardinal symptoms of PTSD. “PTSD is something that haunts victims day and night,” says Barbara Rothbaum, an Emory psychiatry professor and director of the Trauma and Anxiety Recovery Program. “They don’t feel safe in their beds. They don’t feel safe anywhere.” The primary treatment for PTSD is a combination of medications and talk therapy. All of the medications, however, merely target the symptoms. Victims are typically given antidepressants to combat depression, hypertensive drugs to ward off nightmares and/or anti-anxiety drugs to help calm them. “At this point, all the drugs we have for PTSD are just Bandaids,” says Ressler. “This is clearly a disorder of the memory, yet none of these drugs can target that.” Talk therapy, on the other hand, can treat the root of the problem, not just the symptoms. “The Institute of Medicine recently reviewed all the studies of PTSD treatments – all the medications, all the forms of therapy – and it said the only treatment that had enough evidence to support it is exposure therapy,” says Rothbaum. In imaginal exposure therapy, the therapist asks the victim to close his eyes and call up the memory of the trauma over and over again. “The idea is to only take people as far as they can go in a session, but to have them go to the point where they are quite upset and then keep talking, stay at that level of anxiety, fear At this point, all of the drugs we and upset until it habituates down to a more have for PTSD are just Bandnormal level that they aids. This is clearly a disorder of can handle,” says Ressler. “Then you can take the memory, yet none of these them to the next step. drugs can target that. By repeatedly exposing themselves to emotions that are very difficult and that they typically avoid, they learn both cognitively and emotionally that they can, in fact, habituate to those emotions. When people habituate to those memories, then the strength those memories have over the rest of their lives diminishes.”

Foundation.

grateful to you for your support.

Forever in fear continued

ous year.

To understand PTSD, scientists first have to understand how fear memories are formed and how they are extinguished. For that, Emory researchers turned to rats. A team led by Michael Davis, a professor of psychiatry,

and Ressler, conditioned rats to fear a cue – a light – by pairing it with a small shock. Then they tried to extinguish that fear by repeatedly exposing the rat to the light cue without the shock. “This is not actually an end to the fear or an erasure of that fear memory,” says Davis. “Rather, it’s a new form of learning that actively suppresses the fear. This process is called extinction.” Davis and his colleagues identified a particular protein in the amygdala –the fear center of the brain – that was critical to the extinction process. When he inactivated that protein – called NMDA receptor – he could present the light without the shock over and over again, but the rat never got over its fear of the cue. Davis combined this discovery with the findings of other researchers that a tuberculosis drug called D-cycloserine (DCS) enhances NMDA receptor functioning to fashion his next experiment. “Since NMDA is critical for extinction, and DCS makes it work better, we reasoned that if we could give DCS when we were doing fear extinction training, perhaps the animal would get over its fear more quickly,” says Davis. And that is what, in fact, happened. Davis injected DCS either systemically or directly into the rats’ amygdala immediately before extinction training, and they learned to inhibit their fear much more quickly. For

Michael Davis Davis is trying to find out if a drug developed to treat tuberculosis can enhance the fear extinction process in rat models of PTSD.

example, in one experiment rats extinguished more than three times as rapidly as the rats that got the placebo. The next step was to take these findings out of the lab and into a clinical study. “That’s the great thing about being at Emory,” says Davis. “Barbara Rothbaum pioneered the use of virtual reality in exposure therapy back in the early ‘90s. For me, it’s a perfect test procedure to use because everyone gets exactly the same treatment.” Davis, Ressler, Rothbaum and other colleagues first paired DCS with virtual reality exposure therapy to treat patients with fear of heights and then retested them in the virtual environment either one week or three months later. The people given DCS got better about four times faster than the usual course of therapy. Their results were so encouraging that other researchers began studying the combination to treat other anxiety disorders, and positive results have already been shown from others at Harvard, Yale, and in Australia with social phobia and obsessive compulsive disorder. Additional, ongoing studies are combining DCS with a range of disorders from fear of public speaking (virtual audience) to addiction (virtual crack house). At Emory, Rothbaum is using a combination of DCS and a virtual Iraq setting to study PTSD in returning Iraq and Afghanistan veterans. “It’s very likely to change the way we think about providing therapy,” says Dr. Farris Tuma, chief of the Traumatic Stress Disorders Program at the National Institute of Mental Health (NIMH), which is funding the Virtual Iraq study. “It’s setting the stage for dramatically more effective treatment.” Continued on page 4

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The newsletter of the Department of Psychiatry and Behavioral Sciences at Emory University

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Forever in fear continued

Forever in fear continued

at roughly the same rate as combat vets. Indeed, a pilot study of outpatients at Atlanta’s Grady Memorial Hospital showed that over 80% of this population has suffered a significant trauma and about 30% have PTSD. “This population has experienced incredibly high rates of trauma,” says Ressler. “Something like two-thirds of the men have been attacked with a weapon and over one-third of the women have been sexually assaulted. More than half have known someone personally who has been murdered.” Over the course of five years, Ressler, Rebekah Bradley, an assistant professor of psychiatry at Emory, and others will collect data on up to 4,000 subjects at Grady, having already interviewed over 1,500 subjects. Researchers conduct extensive interviews to gather information about any history of child abuse or trauma, demographic data, adult depression and PTSD symptoms. They also collect saliva and blood samples to gather genetic and biological data, along with measurements of startle response and heart rate. “The overarching goal is to gather a large amount of psychological, biological and genetic data on people with civilian trauma and look at risk and resilience factors for predicting PTSD and depression,” says Bradley. “There’s a whole lot of resilient people out there, and we’d like to know what factors contribute to that resilience.” Researchers already know there is a strong genetic component. The risk of PTSD given a severe trauma has been shown to have the same genetic heritability as depression and schizophrenia – on the order of 30%-40%. Researchers also have known that a history of child abuse or trauma puts a person at higher risk for developing PTSD as an adult, but they haven’t been sure why. “Our data suggests that, just as there is a critical period of development for sensory systems, there seems to be a critical period of development for emotional memory systems”, says Ressler. “So presumably stress during this time of emotional development alters the sensitivity of genes involved in the stress response, leading to an Kerry Ressler altered stress sensitivity for the rest of the Ressler’s group found that low-income inner city residents person’s life.” Hughes Investigator suffer from PTSD at roughly the same rate as combat vets. To further probe Kerry Ressler, an Emory neuoscientist at this, Bradley is beginthe Yerkes National Primate Research Center, ning to study inner was named one of 15 new Howard Hughes Medical Institute (HHMI) device (IED) exploding nearby, a roadside city mothers and chilInvestigators. He is the first practicing physician to be appointed an HHMI ambush or a comrade gunned down. “The dren, following them investigator. goal is for them to have one foot there and over time. “Almost all HHMI, a nonprofit research organization, has been selecting investigators one foot here,” says Gerardi. “With the head of the world’s literature through national competitions since the 1990s. Rather than awarding mask, they are seeing and hearing it. The on the effects of child research grants, HHMI selects highly creative, productive scientists and platform they are sitting on vibrates, imitating abuse and PTSD are funds them. “The goal of HHMI is to increase the freedom of investigathe feel of driving in a Humvee, and I can add retrospective studies,” tors to study the questions that they think are the most exciting,” says smells. In many ways, they really are back in says Bradley. “In this Ressler. “The area of research that I highlighted was the translational Iraq, but I am talking to them the whole time, study, I’ll gather psyasking them what they are thinking and feelchological and, hoperesearch between understanding fear in animals and treating fear in ing, getting them to rate their anxiety level. fully, imaging data humans. This will allow us to strengthen the integration between the aniThey are able to process their feelings in a on the children and mal studies and the human pre-clinical studies.” safe and controlled place.” mothers over time. While nine to twelve sessions of imaginal That way we’ll have a exposure are generally needed to effectively treat PTSD, Rothbaum and chance to look at children before they are exposed to trauma, and follow her colleagues are hoping the combination of DCS and virtual therapy their development afterward.” Ressler’s hope for these studies is nothing less than breaking the can cut that time in half, making therapy much more appealing to potenvicious cycle of inner city violence, “It makes intuitive sense that if you tial patients. grow up in a violent atmosphere, you are more likely to be violent as Stress in the city an adult,” says Ressler, “But our hope is that by having a more medical Ressler and his colleagues are studying very different PTSD population model of understanding of how the intergenerational process works, we in an effort to determine the genetic and environmental risk factors for may be able to offer new policy and treatment options. I see that as critideveloping the disorder. While many people equate PTSD with combat cal, since our current social policy has left us with really no improvement trauma, Ressler’s group found that low-income inner city residents suffer in inner city rates of poverty and cycles of violence.”

In blink of an eye

In the Virtual Iraq study, participants are randomized into three groups – one receives DCS, one a placebo and one an anti-anxiety medication. “Many clinicians who do exposure therapy don’t want their patients on anti-anxiety drugs because they think it will interfere with the therapy,” says Rothbaum. “The patient has to become sufficiently anxious to begin to learn to overcome the fear. However, there is very little scientific data on this, so this will be one of the first studies to look at the use of anti-anxiety drugs and exposure therapy in a scientific way.” All of the participants will receive the same therapy regimen – one introductory session and five session of virtual reality exposure therapy. “In the first session, we explain PTSD and the rationale for exposure therapy, since it’s counterintuitive to many people,” says Maryrose Gerardi, assistant professor of psychiatry. “They think, ‘This is so painful, why would I want to think about it?’ But that is exactly what they need to do in order to process it and move on.” Gerardi also gets as many details as she can about the vet’s particular trauma so she can customize the virtual reality experience. She has two basic scenarios from which to choose – riding in a Humvee on a desert road or walking in a crowded street in Baghdad. From there, however, she can add cues specific to the vet’s story – a improvised explosive

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In another area of study, Emory researchers are trying to develop a reliable measure of the degree of PTSD for use in diagnosis and development of more effective treatments. Clinicians have typically assessed PTSD suffered based on their accounts of their symptoms. Erica Duncan, assistant professor of psychiatry at Emory, is looking at eye blinks as a means of objectively measuring the extent of the victim’s fear control impairment. Duncan divided combat vets at the Atlanta Veterans Affairs Medical

J. Douglas Bremner Bremner is combining mindfulness meditation and yoga in an attemtp to ground returning Iraqi vets in the present and to give them more control over their thoughts and memories. Center into two groups – those with high-symptom PTSD and those with low-symptom. Both groups were trained to fear a particular visual stimuli – two lights appearing together, called for the sake of the study A and X. Anytime the subjects saw that combination, they got an unpleasant blast of air to their throat. Then the subjects were shown another visual stimuli – two lights, called B and X –with no air blast. Finally, the subjects were shown a novel combination of lights – A and B – with no airblast. By measuring the startle response in each of the settings, Duncan could determine the subject’s degree of reaction to the danger signal, the degree to which he was able to inhibit that reaction to the safety signal and his ability to transfer his knowledge of safety to a novel situation. “The importance of this work is that it will allow us to measure the ability of an individual subject to inhibit fear to certain safety signals,” says Duncan. “We’re exploring whether we can use it as a test paradigm to do pharmacologic challenge studies to test medications that are being developed to treat fear symptoms in PTSD before all the hard work and expense of a large clinical trial. We’re also looking at whether it will predict who will get better and who will not get better with treatment.”

Nipping it in the bud All the studies mentioned so far have focused on patients once they developed PTSD. Emory researchers also want to know if there is a way to prevent PTSD from developing in the first place. Once again, they turned to rats. “We have found that both the formation of a memory and the extinction of it seem to require new synapses to be formed,” says Ressler. “A peptide – brain-derived neurotrophic factor (BDNF) – has long been studied with learning and memory. We found BDNF was increased after fear learning and after extinction learning, so it seems to be a neuroplasticity factor that is changed with both kinds of learning.” No drugs exist that specifically target BDNF receptors, so Ressler and his team created a genetically altered virus that would block BDNF in the rat brain. They injected the virus into the rat’s amygdala either before the rat learned to be afraid of a stimulus or before it learned to extinguish that fear. If the rats were already afraid, and then the virus was put in, they could express the fear just fine. But if the virus was put in before they learned to be afraid, they could not learn a new fear memory. Also,

if they were already afraid and the virus was put in, they would not learn to extinguish the fear. “This suggests the BDNF is required both to form fear memories and to inhibit them,” says Ressler. “So new drugs that block BDNF function might be useful after a trauma to prevent the normal consolidation of that fear memory.” Emory scientists are also looking at the potential effectiveness of a therapeutic intervention immediately following a trauma in preventing PTSD from developing. “Dr. Davis and his group found that if you do extinction training almost immediately after you condition the fear, it nearly erases the rats’ fear,” says Rothbaum. “That suggests that while the memory is fresh, before it gets consolidated, it is malleable. So maybe if we can do an intervention right away, it won’t be stored as a traumatic memory.” To test this theory, Debra Houry, an emergency room physician at Grady and director for the Center for Injury Control at Emory, is conducting a pilot study on ER patients at Grady. Houry and her colleagues will divide patients into two groups. One group will be guided through imaginal exposure therapy within 24 hours of their trauma, and the other group will merely get an assessment. Researchers will follow up with both groups up to 12 weeks afterward to see if they develop PTSD symptoms. “I am not a psychiatrist,” says Houry. “Dr. Rothbaum trained me and other non-psychiatric ER staff how to go through imaginal exposure therapy with a patient. If it is effective just using regular medical personnel, then it could be used in disaster settings and other ER departments more readily.” J. Douglas Bremner, director of mental health research at the Atlanta VA Medical Center and professor of psychiatry at Emory, is conducting a similar study with returning Iraqi vets. However, Bremner and his colleagues are using a technique called “mindful based stress reduction” rather than imaginal exposure. The technique combines mindfulness meditation with yoga to center the person in the present. “The emphasis is on being in the here-and-now and not dwelling on things that happened in the past or might happen in the future,” says Bremner. “But while we don’t focus on the war trauma, the technique helps them deal with the trauma because it helps them have more control over their thoughts and memory.” Bremner and his colleagues are imaging the subjects’ brains and measuring hormone response to stress before and after the study to detect any changes caused by the intervention. Bremner and his team were the first to apply brain imaging to the study of PTSD, finding alterations in victims’ brain circuits and systems. Studies suggest that while a “This moved PTSD memory is fresh, it is malleable. from being viewed as a psychological disorder That could mean an immediate to a brain-based disorintervention might keep an event der,” says Bremner. Emory scientists from being stored as a traumatic hope discoveries such memory. as these will solve the mysteries of PTSD. “I hope eventually that the biology of PTSD will lead to both increased predictability of who is at risk and more targeted drug therapeutics and psychotherapy approaches,” says Ressler. “That would allow us, in the immediate aftermath of a trauma, to prevent the development of PTSD or help those with PTSD recover more quickly. From a social perspective, I hope these approaches can be taken in impoverished and traumatized communities and help decrease the cycle of violence that seems to be ongoing intergenerationally.”

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The newsletter of the Department of Psychiatry and Behavioral Sciences at Emory University

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Mind-Life Program

Expanding the heart to cure the mind By

M a rt ha Nol a n Mc Ke n z i e

Western scientists are looking to Eastern meditation practices in an effort to solve one of the most universal problems in psychiatry – the effective treatment of depression. Indeed, researchers are finding that Buddhist meditation techniques – specifically mindfulness meditation and compassion meditation –can alter brain functioning and help lift the cloud of depression. In October, Emory researchers presented these findings and more to the Dalai Lama the 15th Mind and Life Conference: Mindfulness, Compassion and the Treatment of Depression. The day-long event drew cognitive scientists, researchers and Buddhist scholars together to discuss the role mindfulbased therapies and techniques to enhance compassion could play in the treatment of depression and other mental disorders. “We are beginning to understand what happens to persons’ brains when they are depressed,” says Charles Raison, assistant professor of psychiatry. “The contemplative traditions of Buddhism tell us about ways to address these problems, and they offer techniques we can borrow to reduce suffering and have happier lives.” The Mind and Life Institute was founded 20 years ago by the Dalai Lama, a neuroscientist and an entrepreneur. When it began, the Dalai Lama had a request: “First investigate the positive effects of meditation. If you find it successful, please teach it to your society in a purely secular manner in order to benefit everyone.” The Institute has grown dramatically since that time, capturing the interest of the Western scientific community and encouraging countless studies. Emory is on the leading edge of this interest. One of the leading institutions for medication research in the country, Emory has long crossed disciplinary boundaries, merging research and investigation of psychiatry, psychology and spirituality through its Mind-Body program and its Collaborative for Contemplative Studies. At the conference, researchers from Emory and other institutions presented to His Holiness some of the latest findings on depression. Charles Nemeroff, chairman of the Emory Department of Psychiatry and Behavioral Sciences, discussed his work in identifying early life factors in depression. Animal and human studies have revealed that abuse or neglect early in life can actually alter brain chemistry. Those changes, which persist into adulthood, result in a hypersensitivity to stress, which in turn increases the individual’s risk of mood disorders. Nemeroff and his team were also able to identify a gene that impacts a child’s vulnerability to those brain changes, suggesting children could be tested for this factor at birth to predict who is vulnerable and who is protected against child abuse.

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Says Nemeroff, “It would be practicing preventative psychiatry.” Emory researchers Lobsang Tenzin Negi and Raison presented their findings of another potential form of preventive psychiatry – one closely aligned with the conference theme. The scientists are looking at meditation to help protect against more than depression, but also against the emotional and medical diseases that arise from stress. A body of scientific evidence shows the same systems the body uses to assess dangerous situations as to fight infections. “The immune molecules that are released are very helpful in allowing you to survive a bacterial infection, but these same molecules are harmful when released in response to psychological stress,” says Raison. “They increase the risk of heart disease, diabetes and maybe dementia.” Conversely, things that make people feel safe and secure have been shown to dampen the body’s response to stress. “People who have good social connections make fewer of these harmful chemicals,” says Raison. “So the boss may yell at them and they’ll get a bit stressed, but their body doesn’t react as if they were being attacked by a tiger.” So Raison and Negi decided to study compassion medication – a more than 1,000-year-old practice which sets as its goal a reformulation of a person’s social connectedness in a more positive way. The team recruited 100 college freshmen and divided them into two groups – one was given health instruction for six weeks but did not meditate. Negi taught the other group compassion medication. The technique uses basic meditation practices such as regulating one’s attention and posture, but it uses them to help people reformulate their beliefs and feelings about other people. “The goal is to develop a spontaneous sense of empathy and compassion for all people. We think this could increase a person’s feeling of social connectedness, which, in turn, could protect them from the harmful effects of stress.” To test the theory, Raison and Negi put the students through a widely used lab stress test and measured the levels of inflammation indicators in the blood. While Raison declines to discuss the results of the study pending publication, Sally Mengel found the practice helpful. Now a junior at Emory, Mengel participated in the study during her freshman year. “It was difficult for me to learn, and I don’t think I ever truly mastered it, but it definitely helped me stay calmer in stressful situations,” says Mengel. “I’ve found the breathing helps me concentrate and relax. The philosophy behind it has changed how I act in confrontations – now I try to give compassion back to the other person and try to understand their perspective.”

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Meet our faculty:

From Baghdad to Bedlam When Col. Emile Risby left Iraq last August, he probably thought his biggest battles were behind him. After all, he had spent a harrowing year traversing the war-torn country overseeing the combat stress control teams, counseling command staff and dealing with the conflict-related deaths of three colleagues. For Risby, the return to Atlanta, where he was an associate professor of psychiatry at Emory University and medical director of one of the in-patient psychiatry units at Grady Memorial Hospital, could not come soon enough. However, when the Army reservist came home, he entered another war zone, of sorts. Risby was asked to take the helm as clinical director for Georgia Regional Hospital/ Atlanta. One of Georgia’s seven state psychiatric hospitals, Georgia Regional had just been under scrutiny after several newspaper reports revealed serious patient care issues at the facility, including the high-profile death of a Col. Emile Risby went from oversee14-year-old girl. Risby’s marching mental health personnel in Iraq to ing orders – transform the taking the helm of Georgia Regional ailing facility into a center of Hospital/Atlanta. excellence. The biggest problem Risby faces is recruiting and keeping staff. “The majority of the patients are here involuntarily, so they can be very difficult to work with,” says Risby. “They have severe psychiatric conditions, often have co-morbid medical conditions, and difficult social problems. In addition, we run above 100% census 98% of the time, so everyone works long hours seeing more patients than the facility is funded and staffed to treat. The result is burn out.”

One of his first efforts to improve working conditions and morale involves establishing working collaborations between Georgia Regional and Emory and Morehouse Schools of Medicine. “If we build that relationship, where we are bringing bright, energetic people with academic credentials and skills to this hospital, we can change the culture and public perception of Georgia Regional,” says Risby. Military experience may prove Risby’s ally, since he is certainly used to working in adverse circumstances. He had been deployed to Kuwait and Afghanistan prior to his most recent tour to Iraq, where he served with the 3rd Medical Command as the theater mental health consultant. In that post, he traveled throughout Iraq, providing technical oversight and operational guidance to the combat stress control teams and all the mental health personnel in the combat support hospitals. The experience was sobering. “It was the first time I’ve ever felt imminently in danger,” he says. “There is really no safe place in Iraq. Even our secured compounds received rocket attacks.” Three of Risby’s colleagues were killed while he was stationed there, including one of the interpreters he worked with, who was kidnapped, along with her son, and killed for “collaborating with the infidels.” In this dangerous, pressurized environment, Risby was charged with commanding the mental health troops who treated the soldiers. “I think the people in our combat stress control units had one of the hardest jobs in the war zone,” says Risby. “They were the ones interacting every day with soldiers who were dealing with all sorts of deployment related problems such as grief, acute stress, anxiety and depression. In addition, they helped soldiers deal with home-front problems.” The Iraq experience puts the challenge he faces at Atlanta Regional in perspective. “The issues at Atlanta Regional are fixable,” he says. “We are already making progress and I’d say 99% of what we do meets the community standard of care, I’d just like to crank it up to 99% of what we do exceeds the community standard of care.”

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Depression in May and December rats Depression at any age is problematic, but particularly so in adolescence and in latelife. A depressive episode during adolescence puts the patient at high risk for subsequent episodes later in life, and depression in late-life is typically more treatment resistant than it is in the 25 to 50 set. In an effort to understand the underlying neurobiology of the disease at both ends of the age spectrum, Gretchen Neigh is developing rat models of adolescent and geriatric depression. In the former study, Neigh, an assistant professor of psychiatry at Emory, induces depression by exposing a rat at puberty to stressors and then measures their anxiety-like and depressive-like behaviors. She is particularly interested in the cerebral-vascular changes caused by adolescent stress and subsequent behavioral changes. Specifically, she is investigating the effect of vascular endothelial growth factor (VEGF), which stimulates blood vessel

growth and has recently been found to be critical in neurogenesis. “Neurons function more efficiently with more connections,” says Neigh. “We know stress leads to a lot of pruning of connections. I would like to find out if keeping blood vessels healthy results in keeping neurons healthy and functioning properly. I’ll be using VEGF to boost the health of blood vessels. If I can demonstrate a connection between blood vessel health and neuron health, that could eventually lead to novel therapies for adolescent depression.” In another study, Neigh is looking at depression in older rats. “Geriatric depression seems to be an organically different disorder than earlierin-life depression,” she says. “People with lateonset depression commonly have small cerebral pin strokes – little spots that show up on MRI tests that indicate the person had a mini-stroke, and probably didn’t even know it. What we don’t know is if this is a cause and effect relationship

between the pin strokes and depression.” So Neigh developed an animal model of same type of pathology by injecting microbeads into the rat’s carotid artery, Gretchen Neigh is working which induces to develop animal models a series of very of adolescent and geriatric small strokes. depression. After the injection, the rats exhibited depressive behavior, indicating a viable animal model of late-life depression. From there, Neigh is going on to test the efficacy of antidepressants and to look at novel treatments.

The newsletter of the Department of Psychiatry and Behavioral Sciences at Emory University

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what’s inside

News from the Department of Psychiatry and Behavioral Sciences at Emory University

Forever in fear cover story Through a host of studies and clinical trials, Emory researchers attempt to unravel the mysteries of Post Traumatic Stress Disorder (PTSD). Expanding the heart to cure the mind page 6 The Dalai Lama attended the 15th Mind and Life conference at Emory, which delved into the link between Buddhist meditation techniques and mental health.

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suffering and have happier lives.” BrainStorms is published

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Charles B. Nemeroff, MD, PhD

Reunette W. Harris Professor and Chairman Department of Psychiatry and Behavioral Sciences

Martha McKenzie Writer Peta Westmaas Designer Jack Kearse Photographer

Comments or questions? Contact Jack Redmond, director of development, at 404.727.8253 or [email protected]

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A newsletter from the Department of Psychiatry and Behavioral Sciences Emory University School of Medicine 1440 Clifton Road, Suite 112 Atlanta, GA 30322

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biannually for patients, families, staff, and friends of the Department of Psychiatry and Behavioral Sciences at Emory University.

Depression in May and December rats page 7 Gretchen Neigh is developing animal models of adolescent and geriatric depression.

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“The contemplative traditions of Buddhism tell us about ways to address these problems, and they offer techniques we can borrow to reduce

From Baghdad to Bedlam page 7 Col. Emile Risby left one war zone in Iraq for another in Atlanta when he took the reins at Georgia Regional Hospital/Atlanta.

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