Dr. James Hudziak on The Balanced Mind Foundation's Flipswitch: the Bipolar and Depression Connection
"Recently in a paper...on the genetics of anxious depression, we have shown that you can consider that about 60% of the influence on whether a child has a mood disorder is due to genetic factors. This is as high as the genetic influences on disorders such as diabetes or asthma or many of the other complex medical conditions."
Flipswitch is a fast-paced, fact-filled weekly podcast tackling issues such as wellness, stigma, and creativity. Join co-hosts Chris, Ryan, Gopi, and Emily each week for upbeat and informative segments such as 'Quizzo', '20 Facts in 120 Seconds', 'The 'X' Affect', 'Mood Disorders in the News', as well as interviews with the experts.
Dr. Hudziak is coauthor of one of the largest genetic studies looking at risk factors in children and youth. His research efforts have involved the study of genetic factors including social behaviors, obsessive-compulsive, attention, and aggressive behavior in boys and girls.
He is a professor at the University of Vermont in the departments of Psychiatry, Medicine, and Pediatrics. He is Director of the Division of Child and Adolescent Psychiatry as well as the Behavioral Genetics Division. He is also an adjunct professor of psychiatry at Dartmouth Medical School, Hanover, New Hampshire and professor of genetics of childhood behavior problems at the Vrije University of the Netherlands. He is also chair of the Professional Advisory Committee of the The Balanced Mind Foundation as well as the head of the Vermont Center for Children, Youth, and Families.
The Balanced Mind Foundation: Jim, welcome to Flipswitch.
Dr. Jim Hudziak: It's good to be here.
The Balanced Mind Foundation: This week what we are talking about is the biological basis of mood disorders, the idea that this is actually a medical illness, not just some character flaw that you might have. I wonder, you being a clinician and a psychiatrist, you have seen so many cases and being the coauthor of one of the largest studies in the world on genetics of childhood dysregulation, if you could comment on any of your own work that looks at the genetics of a proposed marker for bipolar disorder and depression.
Dr. Jim Hudziak: Sure. First just talking about genetic and environmental contributions to emotional behavioral problems, whether they be mood disorders in children and adolescents, attention deficit hyperactivity disorder, obsessive-compulsive disorder, and markers for pediatric bipolar disorder, we use a variety of methods to study whether or not the conditions are influenced by genes, environment or an interaction of both. So, today, we have extensively studied these emotional behavioral problems in a large population of twins in the Netherlands. In fact, almost 70,000 twins that we followed since birth.
Because of the unique features of the twin population, we are able to determine what percentage of having an adolescent mood or anxious depression is due to genetic factors and what percentage of that influence is due to environment or the interaction. Recently in a paper published by Dr. Boomsma and our group on the genetics of anxious depression, we have shown that you can consider that about 60% of the influence on whether a child has a mood disorder is due to genetic factors. This is as high as the genetic influences on disorders such as diabetes or asthma or many of the other complex medical conditions.
So, we live in an era now where a child or an adolescent or teenager suffers from one of the so called psychiatric disorders that he or she should know that these are medical conditions rooted in the brain, influenced by genetic factors and that environment contributes as well in the path that these disorders will take.
The Balanced Mind Foundation: Now what do you mean when you say environment because a lot of people would say, “Environment? What do you mean? How cold it is, how warm it is”?
Dr. Jim Hudziak: It probably does make a difference, interestingly enough, whether you live in a cold or warm climate, but it turns out all kinds of environment makes a difference. With Dr. Boomsma and Dr. Bartels in the Netherlands, we study a number of common risk and protective factors. Whether or not a child smokes cigarettes can change his or her risk factors for having an emotional behavioral problem. Whether or not a child or an adolescent is on the sports team, believe it or not, can protect individuals from having more severe forms of emotional behavioral problems. Whether they are raised in a religious environment, whether or not their peers use drugs and alcohol, whether or not they are involved in music; these are all factors that we study in our work.
The Balanced Mind Foundation: What about the family in that context? It sounds like they could play a huge role, like another part of the environment in that sense.
Dr. Jim Hudziak: I think one of the really important things for families who struggle with emotional behavioral problems, whether it be bipolar disorder in an adolescent, mood disorders, anxiety or ADHD, is that the family can make a big contribution to the magnitude of how much of a struggle it is. And so, at the University of Vermont, where I direct the Vermont Center for Children, Youth and Families, we emphasize something called the “family based approach”, where we try to help moms and dads develop skills to help their adolescent and their children progress with this very difficult developmental period. In some instances that means that we help parents identify their own strengths and weaknesses. If the parent had a weakness that we could help with, we would do some family coaching, such as teaching them how to interact in a more healthy way with a volatile teenager who may respond in one way to one cue and then another way to another cue. We also offer treatment to mom or dad if one of them has an emotional behavioral problem. We operate under the principle that if it is good for the goose, it is good for the gander. Over the course my career I often note that teenagers suffering from a psychiatric condition are often forced to come to my office, it is often a hostage situation. Parents are almost dragging their teenager in and the teenager will look at me and say, "Okay, maybe I have all these problems, but so does my mom or so does my dad, how come I am the one who has to get treatment?" So, we use a family focus. We say the teenager is not the patient, the family is. We put blame nowhere and we just try to promote health and wellness.
The Balanced Mind Foundation: So, I guess in that context of the environment, bipolar disorder isn't just affecting you, it's kind of the whole family.
Dr. Jim Hudziak: It's your whole family, but it is also not just about taking the medicine. Where medicines are an important part of the treatment of certain conditions, they are not the only treatment. We practice health promotion, prevention, and intervention medicine. We prescribe exercise, reading, and sleep hygiene for instance. We teach parents and adolescents communication skills.
Although these approaches do not necessarily take the place of medicine, they certainly can make many things much better. So, a teenager who can get an hour's worth of exercise every day is going to be better off than one who doesn’t. A teenager who sleeps at least eight hours a night is going to be better off than one who doesn’t. A teenager who doesn’t smoke or use alcohol or cannabis is going to be better off than one who does. In correlation analysis, again using our Dutch twin sample, we’ve shown that the relation of all those variables to wellness is statistically strong. So, it is one thing to say you suffer from an emotional behavioral problem, here are the kinds of things that we can help you with, but it is another to go home and do all these things.
I think every teenager that we treat, we try to make the care about them and we try to have them control their care and we have them contract for their care so that it is not the parent saying, "You need to go get exercise. You need to get eight hours of sleep. You need to not smoke." It is the teenager saying, "Look, this is my illness. Here is the best way for me to get better."
The Balanced Mind Foundation: You mentioned sleep right there and we've talked on this show about the importance of sleep and how huge it is in mood disorders. I wonder if you could share some of your expertise of what your research has found on sleep?
Dr. Jim Hudziak: First of all, sleep is a great mystery, isn't it?
The Balanced Mind Foundation: Yeah.
Dr. Jim Hudziak: We really don’t have any idea where its recuperative powers are coming from, but we know they’re incredibly important and we know they are very protective.
One of the real phenomenon about working with adolescents, particularly adolescents who go to schools who require them to do four and five hours of homework after school, makes it almost impossible for them to get eight, eight-and-a-half hours of sleep. So, one of the things people have to do is to struggle to get their work done earlier in the day so that when they do go home, they can get some exercise and they can get fatigued, they can get tired, and they can fall asleep.
Now that is your goal to organize your life that way, and then you juxtapose alcohol or cannabis or nicotine or caffeine, you are not going to be able to get that recuperative sleep and you are more likely to not be refreshed and you are more likely to be more irritable and more moody as the day goes on and each one of these cues of course sets off another cascade of relational problems with teachers, with peers, and family.
So, I can't tell you in any way how I know why sleep is so important, but I can tell you I know it is very important and our data show that. I think one of the great frontiers of science and neuroscience in general is going to be understanding of sleep. But I do think there has been some other discoveries and I think of Xavier Castellanos, Judy Rapoport and her team at the National Institute of Mental Health looking at brain development that can help guide our health promotion strategies.
If I was a teenager, I think the healthiest thing for me would be to be educated about brain development, because the age period from 4 to 22 is marked with the most rapid and remarkable changes in brain architecture that a human being will go through, particularly from age 11 to about 19 or 20. Work by Judy, Xavier, and their colleague Paul Thompson show key areas of the brain such as the parietal lobe, the temporal lobe, the occipital lobe, the frontal lobe, the prefrontal lobe, all getting bigger and then plateauing and then starting to get smaller. The cerebellar lobe total brain mass peaks at around 14, 15, 16 years old and then starts to, through organizational neurobiology, diminish in total mass, a sign perhaps of the brain getting organized.
I think it parallels really nicely the tumult of being a teenager. When teenagers see these pictures and realize how many changes are going on throughout their brain, I usually encourage them to focus on the fact that these images show that around ages 20, 21, 22 things seem to quiet down a bit. I use these images to try to send that message that no matter how difficult adolescence might be, no matter how sad and hopeless, things do get easier.
I don’t feel like I am selling them a bill of goods because I am now unfortunately old enough that I have lived through most of these neurodevelopmental changes and have felt how much easier each developmental state is. I think we need to communicate, using neuroscience, some of these lessons a bit more clearly to our patients. More and more we are able to report that we understand the process of developmental neurobiology, and the process in which the cortical mantle develops, and from research to date, it appears that the period of adolescence is quite tumultuous. I try to communicate this to the young folks I work with by teaching them this mantra: “This is my brain and only I can protect it”.
The Balanced Mind Foundation: Now, one of the issues for any teen, especially one who is dealing with a mood disorder, is knowing when to seek treatment. Do you have any kind of guidelines or rule of thumb for when somebody should say, "This is not something I can snap out of, this is not something I can handle on my own. I need to seek help."
Dr. Jim Hudziak: That is another great question and I think just like sleep you are asking questions that I don’t have any firm evidence for. I can tell you that it is helpful if you have friends or family or someone that you can trust that when they say to you, "You know, I think it is getting bad again," that just some part of you can say, "Okay, I will go get help."
Truth be told and I may be wrong, I very rarely see a teenager in my office who wants to be there. I think if I put up a sign up sheet at the local mall and said, "If you want to go see a child psychiatrist, sign up here," I think it probably would be empty at the end of the week. So, most of kids I see are are brought in by their parents or because the schools say they have to go in or because they've been arrested and it is an option other than going to a juvenile facility. The good news is that with very few visits, the teenagers come back voluntarily often and most often religiously, if you respect them and their autonomy. If you build the treatment around them, if you let them make key decisions about what they want to do for their own wellness and what they don’t want to do.
I think empowering teenagers to learn about their illness, to educate them about the biology of their illness, to educate them about the signs and symptoms when things aren't going well, is probably going to lead to more wellness about saying, "Oh, boy, I am feeling it again, maybe I need some help." I think in the absence of that education and in the absence of a support system, it is very difficult, which brings up the heart breaking stories of young people who don’t have a support system and I think those folks we just really do have to reach out to and again like I said earlier for those folks, I am not sure I have a great answer.
The Balanced Mind Foundation: One thing I always like to do on this show is since we have an audience and you can talk directly to them, what would you say to somebody who has just been diagnosed with this disorder and is in high school?
Dr. Jim Hudziak: I tell them two things. One, I’d tell all teenagers to go home and tell their parents that you think it is important for your parents to know that no matter how hard they try, you will never think they are cool. If you do that your parents will be relieved of trying to be cool, trying to be hip, trying to fit in. Your parents… tell your parents, "I want to know exactly what you believe." Tell your parents to say, "Tell me I am not allowed to drink. Tell me I am not allowed to smoke. Tell me I am not allowed to take risks, because I want to know what you feel. I really do." Because one of the great problems in American families right now is a lot of parents try to be cool, try to be hip, and they are operating under an illusion that their teenager is going to think they are cool or hip and that is somehow going to help their child. It does not, and more often leads to problems. So, teenagers, you need to release us old people of this idea that we are ever going to be cool.
Now, at the same time I would ask teenagers to go home and say, "My parents are doing the best thing they can. My parents are doing the best thing they can and they are trying to help me even though they don’t completely understand me. So, the best way I can help my parents is I can help myself by taking responsibility for these choices I make". And those are the best outcomes I have ever seen is when you can convince parents, "Look, you just need to be a parent" and we convince a teenager, “you just need to be a teenager” and you guys should have a dialogue about how different those two things are and celebrate them. Having raised teenagers and having been educated that I am uncool. I can tell you that it has helped me as well.
The Balanced Mind Foundation: So, Dr. Hudziak, thanks so much.
Dr. Jim Hudziak: Thank you.