ECNP Congress programme spotlight
Early emergence of mental illness

Professor Deanna Barch is the chair of the Department of Psychological and Brain Sciences and the Gregory B. Couch Professor of Psychiatry at Washington University in St. Louis. In addition, she is deputy editor at Biological Psychiatry and editor-in-chief of Biological Psychiatry: Global Open Science. At the 36th ECNP Congress in Barcelona, she will give a plenary lecture entitled ‘Early emergence of mental illness, from brain imaging to emotion regulation’. She recently spoke about her work to ECNP press officer, Tom Parkhill.

TP: Professor Barch, you are based at Washington University in St. Louis. How long have you worked there?
DB: I was born and raised in St. Louis. I went away when I was younger, but I came back because I had a good job offer. I’ve been here 25 years now. My husband and I were on the job market together, and we got job offers here at the same time and now co-run a lab together.

The imaging aspect is interesting, and I see that you are also a professor of radiology. How did this happen?
I’m a professor of psychological and brain Sciences, psychology and radiology. One of the attractive things about working at WashU is that it has long been one of the major centres for human brain imaging, starting in the early days of positron emission tomography, then moving into the tools that we use more frequently – these tools are now less invasive and more ‘do-able’ with kids. Here we’re talking MRI, EEG, and high-density optical tomography, which is another non-invasive measure of brain function. Our radiology department has always embraced people who are undertaking innovations in the application and analysis of imaging data. So I don’t consider myself a radiologist in the sense that I’m not studying brain tumours and so on. But I do use neuroimaging as a tool to try to understand the causes and treatments of major mental illness, starting early in childhood. MRI is a technique which is non-invasive to use and safe and as early as the first days of life. So that makes it a very useful tool for understanding the developmental course of risk of mental health challenges.

And of course, the more you know about the tools you are using, the better it is. For lots of people MRI is just a black box.
Yes, and it’s used for everything. If you get hit on the head you use it, if you break an arm or a leg you use it – cardiac imaging, kidney imaging. It’s very useful tool.

You mostly work with kids?
No, I really have two lines of research, one mostly in adults, one mostly in kids. Around half of my work is focused on development and both the antecedents of risk for mental health challenges, and also the long-term outcomes of experiencing early mental health challenges. I have another line of research which is more aimed at adults with serious mental illnesses – schizophrenia, depression, bipolar disorder. And there are certainly relationships between these two lines of research, but they are different in terms of focus and approach.

At the ECNP Congress in October you’ll be talking on ‘Early emergence of mental illness, from brain imaging to emotion regulation’.
I’m going to focus on depression. I’m going to be presenting on a growing body of work – both our own and from others – that are asking questions about the extent to which the psychological and neural mechanisms associated with either experiencing depression very early in life, or being at risk for early-onset depression, are similar or different to depression which starts in adolescence or early adulthood.

We are asking to what extent are these risk factors for the development of depression, to what extent are they ‘scars’, and to what extent can they change as a function of treatment? We’ve done a lot of work with kids who have very early-onset depression, for example with pre-school kids. We also work with younger kids who are at risk for depression. Over many studies, we see these kids show many of the same disruptions in emotion regulation and reward processing that we see in adults who have depression.

It seems to be that the earlier the onset of the depression, the worse this is – which makes a lot of sense. But we are also seeing positive evidence that treatments which are designed to target depression in little kids can have an effect. This is true particularly true of treatments where the child is not just treated in isolation; whenever you are working with kids you need to think about their caretaking context, their parents, their carers.

We’re developing treatments that are focused on helping the child/carer dyad to develop more effective emotion-regulation skills in the child. We’re asking how does that improve depression, and does it also change some of the psychological and neural disruptions we see associated with emotional dysregulation and reward processing. And we do see evidence that these things improve over the course of treatment. So I’ll really focus on the understanding that there seem to be some common mechanisms that cross the lifespan in terms of risk factors and disruptions associated with depression, and that these are amenable to early treatment. My tendency is to say that the earlier we can intervene, the better it is for the child. Living their lives experiencing depression probably creates its own set of problems because they are not having the set of developmental experiences that they might have otherwise, which might be important for healthy brain and behavioural development. The earlier you can tip kids back on a healthy developmental trajectory the more you can help them take advantage of the positive developmental experiences they should be having. Hopefully this helps them develop more resilience to later episodes of depression.

I imagine that in treating kids for mental problems, you are more often than not treating not just the child, but the child alongside the family or carers. And a lot of people are resistant to treating mental health in children.
I think that it depends on the type of treatment we are talking about. There is much resistance – much appropriate resistance – to the idea of medication treatments for young children. There certainly are circumstances where medications may be necessary, but we never think of that as the first line treatment. Often we don’t know too much about these medications, and especially for kids, and in their family or caring context, there are often behavioural interventions which can be helpful. We don’t see much resistance in the US to the idea that behavioural interventions might be useful, particularly when they are targeting the family unit.

It mostly doesn’t make sense at that age to think about individual child treatment, although there are some cases where it is appropriate, for example kids who have experienced trauma, especially within the family. In these cases, you need to focus on the child because the family may have been part of the problem. In general, with the things which tend to arise early in kids, things such as anxiety, depression, disruptive behaviour disorders, there is always a role for the family in helping shape the child’s behaviour. Historically we don’t have enough resources to provide the level of treatment which would be helpful, but that’s an issue in Europe too. Where the model is one-on-one treatment with a therapist, there are just not enough therapists in the world to treat everyone who needs help.

My colleague Joan Luby, who is a child psychiatrist, has been working on more non-traditional models of intervention: what can we do in schools, can we have much shorter interventions, single-session interventions, can we think about utilising lay therapists to help? There’s much work to be done.

I see that you have been heavily involved in the ABCD study. What’s the background to this, and will you be talking about this?
Yes, I will be talking about this. The Adolescent Brain Cognitive DevelopmentSM (ABCD) Study, is the largest long-term study of brain development and child health ever conducted in the United States. How many years ago did it start – I can still remember the very first planning meeting – I think it was in 2015. We recruited 11,875 nine- and ten-year-old kids across the country, at 21 different sites. We have been following these children longitudinally into early adulthood. We are funded to follow them until they are 21 years old, although obviously we hope to go beyond that stage. We do annual, in-person assessments with the kids (although some were done remotely due to Covid). Every other year we do brain imaging studies, where we look at brain structure and function.

It’s a study designed to study normal development, what is typical brain development: what are typical relations to emotions, cognition, sports involvement, hobbies, screen time, friendships, culture, everything under the sun really. We’re trying to understand how all these factors relate to brain development in kids. We’re also looking at mental health, and the development of mental health challenges, and what factors influence this, for example substance use. The project is now much broader than the original conception. It’s a great dataset to look at kids who may be at risk for depression, for example either thorough a family history of depression or through the life experiences they have had, or genetic factors, and how this may relate to such things as pubertal development. We know that the onset of puberty is when we see a pretty dramatic increase in the risk of depression in both boys and girls. And that is the period where gender differences in rates of depression change. There are no significant differences in rates of depression prior to puberty, but when you hit puberty you see rates go up for both, but they go up more for girls than they do for boys.

We’re trying to understand what happens in that pubertal period in terms of hormonal changes, but also in terms of peer relationships, and shifts in the socio-emotional context, and how that might be associated with increased risk for depression. As I say, in all of our young pre-school and school age pre-pubertal studies we see pretty low rates of depression. But puberty changes that, with the increase more noted for girls than boys.

Pre-school onset depression is a real thing, despite what many think. We have a lot of opportunities to think about early intervention and early prevention opportunities that we might not previously have appreciated. And these might be really important in developing resilience to depression later in life. People are not used to thinking about this, but if we let it go it becomes a huge risk factor for lots of other things. I think people need to recognise the validity and importance of early depression, and how similar it is to later depression, in terms of neural and psychological associations and risk factors. Clinicians, schools, carers, families, all need to recognise this. We have opportunities for early intervention and prevention.

Deanna Barch, USA, will speak on Sunday 8 October 2023 at 16.35-17.20 CEST (Central European Summer Time).
PL02 — Early emergence of mental illness: from brain imaging to emotion regulation

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