As many as 8 percent of adolescents attempt suicide today. Completed suicides have increased by 300% over the last 30 years. (Girls make more attempts at suicide, but boys complete suicide four to five times as often as girls.) It is suspected that a significant number of children diag-nosed in the United States with attention-deficit dis-

order with hyperactivity (ADHD) have early-onset bipolar disorder instead. Up to 2.5% of children and up to 8.3% of adolescents in the United States suffer from clinical depression. This makes depression much less common than asthma or allergies, but many times more com-mon than, say, childhood diabetes or cancer. Depression in children is recurrent. About 35% will again meet the criteria for major depression within a year from recovering. By two years, half of the children who

recovered will have had a recurrence of their depression . About 75% of children will have a recurrence of their depres-

sion within four years of their first

BrainStormsW 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

For more in format ion on the Ch i ldhood and Ado lescen t Mood Disorders Cen te r , ca l l 404-727-3973 .

Childhood is defined by the joy of discovery and delight in the everyday. At least, it’s sup-posed to be. A depressed toddler or a manic preteen runs counter to the very notion of childhood. Indeed, as recently as 40 years ago, psychia-trists believed children were not cognitively capable of being clinically depressed.

Today, we know better. Children can and do suffer from mood disor-ders. Infants as young as one month

can show abnormalities in brain functioning that would indicate depression in older children and adults, while children as young as six years have been diagnosed with clinical depression. Young teens can suffer from bipolar disorder.

While researchers and clinicians have amassed a vast body of knowl-edge about depression and mood disorders in adults and seniors, very little is known about these conditions in children and adolescents. “This area lags far behind,” says Peter Ash, chief of child and adolescent psy-

chiatry in the Emory Department of Psychiatry and Behavioral Sciences. “There is little research on the most efficacious treatments for children, and there is a short-age of practicing child psychiatrists and treatment facilities.”

To fill this void, Emory has cre-ated the Childhood and Adolescent Mood Disorders Program. The brainchild of psychiatry depart-ment chair Charles Nemeroff, the center is one of four programs under the umbrella of the newly established multidisciplinary Comprehensive Neurosciences Center (CNC). The other pro-grams target Alzheimer’s disease, Parkinson’s disease, and stroke.

Like those programs, the Childhood and Adolescent Mood Disorders Program draws on Emory’s wide areas of exper-tise—including neuroscience, brain imaging, and genetics—to marry biomedical research and clinical care. “Our ultimate goal is to develop a world-class specialty program in childhood and adoles-cent mood disorders that would include components in research,

training, and treatment,” says Ash. “Our department already has a world-wide reputation in adult mood disorders, and we know the need for similar research and treatment for children is great.”

Indeed, the need has never been greater. Suicide is the third leading cause of death for American children and adolescents. About 8.5% of

Continued on page 3

Young and sad:Understanding childhood mood disorders

B y M a r t h a N o l a n M c K e n z i e

As many as 8 percent of adolescents attempt suicide today. Completed suicides have increased by 300% over the last 30 years. (Girls make more attempts at suicide, but boys complete suicide four to five times as often as girls.) It is suspected that a significant number of children diagnosed in the United States with attention-deficit disorder with hyperactivity (ADHD) have early-onset bipo-lar disorder instead. Up to 2.5% of children and up to 8.3% of adolescents in the United States suffer from clinical depression. This makes depression much less common than asthma or allergies, but many times more common than, say, childhood diabetes or cancer. Depression in children is recurrent. About 35% will again meet the criteria for major depression within a year from recovering. By two years, half of the children who recovered will have had a recur-rence of their depression . About 75% of children will have a recurrence of their depression within four years of their first episode. Each time depres-sion recurs, it makes it that much more likely that it will recur again . Bipolar disorder appears to affect children and adolescents more severely than adults. Children and adolescents may have longer symptomatic stages and more frequent cycling

The Facts n Up to 2.5% of children and

up to 8.3% of adolescents in the

United States suffer from clinical

depression. This makes depres-

sion much less common than

asthma or allergies, but many

times more common than, say,

childhood diabetes or cancer. Continued on page 3

News from the Department of Psychiatry and Behavioral Sciences at Emory UniversityFall 2006

© 2004 Brian Stauffer

As many as 8 percent of adolescents attempt suicide today. Completed suicides have increased by 300% over the last 30 years. (Girls make more attempts at suicide, but boys complete suicide four to five times as often as girls.) It is suspected that a significant number of children diagnosed in the United States with attention-deficit disorder with hyperactivity (ADHD) have early-onset bipolar disorder instead. Up to 2.5% of children and up to 8.3% of adoles-cents in the United States suffer from clinical depression. This makes depression much less common than asthma or allergies, but many times more common than, say, childhood diabetes or cancer. Depression in children is recurrent. About 35% will again meet the criteria for major depression within a year from recovering. By two years, half of the children who recovered will have had a recurrence of their depression . About 75% of children will have a recurrence of their depression within four years of their first episode. Each time depression recurs, it makes it that much more likely that it will recur again . Bipolar disorder appears to affect children and adolescents more severely than adults.

all high school students have attempted suicide in the past year, according to the Centers for Disease Control and Prevention. Rates of mood disorders seem to be increasing.

“Ten to 20 years ago, you had about a 17% probability of suffering from clinical depres-sion during your lifetime,” says Ed Craighead, director of the Childhood and Adolescent Mood Disorders Center. “Now you have a 17% proba-bility of depression by the time you are 18 years old. We’re also seeing rates of bipolar disorder in adolescents approaching those in adults.”

The numbers are staggering, especially considering that it wasn’t until the 1970s that psychiatrists accepted the idea that children were capable of becoming clinically depressed. “In the 1950s and 1960s, psychiatry residents were taught that children’s cognitive thinking was not mature enough to make depression possible,” says Ash. “I remember hearing a nationally rec-ognized expert in the 1970s who said bipolar disorder could not appear before the age of 14. Now it’s sometimes diagnosed as early as age 7 and suspected even before that.”

Despite greater understanding of the prevalence of mood disorders in children, treat-ment for kids lags far behind that for adults. According to a 2001 report from the Surgeon General’s Conference on Children’s Mental Health, fewer than 20% of American children and adolescents with mental illness, including mood disorders, receive treatment.

Part of the problem lies in diagnostic diffi-culty. “Kids don’t go around telling you they are sad in the way adults do,” says Emory psychologist Nadine Kaslow. “They present in different ways. Symptoms such as moodiness and anger may be mistaken for typical

adolescent behavior.”When a child or teen is diagnosed, finding

appropriate treatment becomes the next hurdle. “If a pediatrician or general practitioner believes a child has a mood disorder, there often isn’t a place to send him to get a full evaluation and treatment recommendation,” says Craighead. “There is also very limited research—just a hand-ful of studies, really—on the types of treatments that are the most beneficial for this cohort. We know that adolescents have a weaker response rate with SSRIs (selective serotonin reuptake inhibitors) than adults do, and in some cases SSRIs can cause suicidal thinking. So treatment for children and adolescents is more complicated, and we need to find other kinds of interventions.”

The Emory Childhood and Adolescent Mood Disorders Program will address these shortfalls. Initially, the center is offering treatment only on an outpatient basis, but it plans to open an inpa-tient short-stay unit within 18 months. The cen-ter will serve as a training ground for future child and adolescent psychiatrists. And it will conduct research using neurobiology, brain imaging, and genetics to create novel prevention and treatment strategies for childhood and adolescent mood disorders.

“The scope of what we are doing makes this program unique,” says Ash. “There are some pro-grams that do drug studies. There are programs that work with bipolar disorder. But they all tend to be centered around one key investigator, and one person can’t do everything.

“We are bringing together a large, cross-disciplinary group of experts in child and adolescent psychiatry to cover all its domains and build a state-of-the-art program.” •

�

FROM THE CHAIR

As you will read in this issue of Brainstorms, we recently launched our Childhood and Adolescent Mood Disorders Program to address the dearth of research and available facilities in this field. When this center is fully staffed and operational, it will be a world-class program for both biomedical research and clinical care. To head the center, we have recruited W. Edward Craighead (see story at right) while his wife Linda Craighead will bring her nationally

recognized expertise in eating disorders to Emory’s psychology department and the student mental health center.

Many other new faculty joined us this fall with specialties ranging from functional brain imaging research to trauma care, and they will share their talents across the Emory family of facilities, includ-ing Emory University Hospital, The Emory Clinic, student health, and our partners, Grady Hospital and the VA Medical Center. In addition, we have wel-comed new residents in adult and child psychiatry

and new geriatric, addiction, forensic, and research fellowsI am proud of our faculty and staff accomplishments. Our psychiatry ser-

vice at Emory University Hospital ranked #15 in the nation in the recent U.S. News & World Reports, and we climbed to #17 in National Institutes of Health funding. We recently received more than $10 million in an NIH Center for Intervention Development and Applied Research grant to study predictors of antidepressant response in treatment naive patients. This pioneering research will help us identify subtypes of depression, each of which will be defined with genomic markers, neuroendocrine measures, and brain imaging studies. These studies will help us identify which of the available treatments for depression is best for each patient.

Our department vice chair for research, Clinton Kilts, was recently named the Dr. Paul Janssen Chair of Neuropsychopharmacology (see story page 4). This prestigious honor is in recognition of his contributions in the field of addition research. Indeed, my colleague’s studies may eventually allow us to prevent addiction before it starts.

I am certain that the articles in this issue of Brainstorms will convey to you the remarkable energy, excellence, and excitement that exemplify Emory psychiatry. We will continue to improve our ranking of excellence in clinical service and research, and we intend to expand our clinical services to provide much needed consultation to the community in Atlanta, the Southeast, and the nation. We are also enthusiastic about Emory medical school’s new curriculum and the role our faculty will play in its implementation. With a favorable finan-cial outlook and a growing faculty that is increasingly nationally renowned, the future indeed looks bright.

Charles B. Nemeroff, MD, PhDReunette W. Harris Professor and Chair

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

Charles B. Nemeroff, MD, PhD Reunette W. Harris Professor and Chairman Department of Psychiatry and Behavioral Sciences

Marlene Goldman Editor Martha McKenzie Writer Peta Westmaas Designer Jack Kearse Photographer

Comments or questions? Contact Phil Hills, vice president for health sciences development, at 404.727.5711 or phil.hills@emory.edu

Change is in the air in the Department of Psychiatry and Behavioral Sciences at Emory University

Young and sad continued

The newsletter of the Department of Psychiatry and Behavioral Sciences at Emory UniversityBr a i n S t o r m s FA L L 2 0 0 6�

Emory’s new Childhood and Adolescent Mood Disorders Center would still be just

a dream if not for the generosity of J. Rex Fuqua. A longtime sup-porter of Emory’s psychiatry department, Fuqua donated $2 million to establish the new program’s chair.

“Not only did Rex Fuqua’s gift allow us to suc-cessfully recruit

Ed Craighead to direct this exciting new program, but his willingness to chair our department’s board of external advisors

has helped attract other business and com-munity leaders to support our clinical, train-ing, and research programs,” says Charles Nemeroff, department chair.

Fuqua has a longstanding interest in psychology and mental health. He earned a master’s in clinical psychology from the California School of Professional Psychology in Berkeley, where he was a doctoral candidate. His father, the late J.B. Fuqua, endowed Emory’s Fuqua Center for Late-Life Depression in 1999. The legend-ary businessman and philanthropist took his support to a more personal level a few years later when he went public with his 50-year battle with depression in an effort to help de-stigmatize the disorder.

“We now know that mood disorders are disorders of the life span,” says Fuqua. “But while we do know a significant percentage

of children have mood disorders, there is a tremendous gap in our knowledge about what causes these various disorders and the most effective treatments for children and adolescents.

“Emory has a national reputation as a top clinical and research center for adult and late-life mood disorders,” he continues, “so my wife Duvall and I thought the need and timing seemed right to create a cen-ter of excellence for child and adolescent mood disorders at Emory. We are particu-larly pleased that Ed Craighead will be directing this new initiative.”

Fuqua is president and CEO of Atlanta-based Fuqua Capital Corporation, a pri-vate investment firm. Among his many board affiliations, he chairs the Emory Department of Psychiatry Advisory Board. Fuqua and his family live in Atlanta. •

Craighead leads new center

When Charles Nemeroff went searching for someone to head Emory’s new Childhood and Adolescent Mood Disorders Program, he knew just where to look: Colorado.

Nemeroff, chair of Emory’s Department of Psychiatry and Behavioral Sciences, set out to woo Edward Craighead, chair of the

psychology department at the University of Colorado, and Linda Craighead, director of clinical training at Colorado. The Craigheads worked with Nemeroff when he was chief of biological psychiatry at Duke.

“Ever since I accepted the chair posi-tion here at Emory, I have tried to convince Edward and Linda Craighead to join our department,” says Nemeroff. “Their stature in the field, their passion for research, teach-ing, and clinical service of these underserved patient populations render them invaluable additions to our faculty.”

For his part, Craighead was driven to accept the Emory post by three factors. “First, I found the opportunity to help build a national program for child and adolescent mood disorders too important to pass up,” he says. “Second, I’ll also have the chance to work on a new initiative at Emory that will look at the neurobiological mechanisms of change in cognitive behavioral therapy, which is much of my background. And third, Emory offered a great opportunity for my

wife. They really recruited us as a couple.”Linda Craighead wrote The Appetite Awareness Workbook and is an

internationally recognized expert on eating disorders. She will serve as a professor in the psychology department and a psychologist in the student mental health center. Her clinical work and research will be conducted within the Department of Psychiatry and Behavioral Sciences, where she will establish a center for eating disorders.

With a PhD in psychology from the University of Illinois in Urbana-Champaign, Edward Craighead brings an extensive clinical and administrative background to his new post in the Childhood and Adolescent Mood Disorders Center. Before joining the University of Colorado, he taught, treated patients, and conducted research at Duke in the departments of psychology and psychiatry.

For the past several years, Craighead has co-directed a clinical research program in Reykjavik, Iceland, designed to prevent initial episodes of depression among adolescents. Administered in schools by school psychologists, the program has cut the rate of first episodes of depression by more than half among 14- to 16-year-old Icelandic youth. He also has served as co-director of the Sutherland Center, a treatment center for bipolar disorder at the University of Colorado.

Edward Craighead will have a joint appointment in psychology, help train clinical psychology doctoral students, and teach Emory undergraduates.

Also joining the new program is Margaret Shugart, a child, adoles-cent, and adult psychiatrist from East Tennessee State University. Until her recent appointment at Emory, Shugart served on the Tennessee Child and Adolescent Psychiatry Treatment Guidelines Committee, and she has a rich background in childhood mood disorders research.

Shugart was lured to the new Emory program primarily by the opportunity to work with Nemeroff. “I knew him when we were at Duke, and he is a brilliant researcher,” she says. “And he is so commit-ted to advancing the knowledge and treatment of childhood mood disorders. Everyone knows there is a huge need in this area, but he was able to actually find donors and start this new program. That’s real commitment.” •

The Facts continued

n Depression in children is recurrent. About

35% will again meet the criteria for major

depression within a year from recovering. By

two years, half of the children who recovered

will have had a recurrence of their depression.

About 75% of children will have a recurrence of

their depression within four years of their first

episode. Each recurrence of depression increas-

es the likelihood that it will recur again.

n As many as 8% of adolescents attempt sui-

cide today. Completed suicides have increased

by 300% over the last 30 years. (Girls make

more attempts at suicide, but boys complete

suicide four to five times as often as girls.)

n A significant number of children diagnosed in

the United States with attention-deficit disorder

with hyperactivity (ADHD) may have early-onset

bipolar disorder instead.

n Bipolar disorder appears to affect children

and adolescents more severely than adults.

Children and adolescents may have longer

symptomatic stages and more frequent cycling

(changing from one mood to another).

J. Rex Fuqua

Fuqua endows C&A Mood Disorders Chair

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

esteemed pharmacological researchers in the world for more than 20 years,” says Charles Nemeroff, department chair. “Dr. Kilts has already completed work of national impor-tance in his field using functional brain imag-ing to study the brain at work. This is exciting, uncharted territory, at the intersection of mind and brain, where motivation, emotion, and

addiction arise. The more we know about the actual physical working of the brain, the closer we are to developing new and more effective interventions for diseases.”

The endowed chair, named after pioneering Belgian pharmacologist Paul Janssen, will pro-vide Kilts with unencumbered financial support for his research, most of which focuses on addic-tion. “All along, we have felt we would be better served to study the causes of addiction rather than the consequences,” says Kilts. “Specifically, we are using fMRI and PET scans to explore the brain correlates of the hallmarks of addiction—the pathological motivation to use the drug and the inability to stop. It’s essentially the problem of too much gas and too little brakes.”

In his most recent research, Kilts and his research team are trying to understand how behavioral therapy for addiction works. After years at its mercy, some addicts escape their addiction through a behavioral therapy regimen

such as outpatient 12-step programs or inpatient treatment centers.

“These are some of the oldest forms of ther-apies in medicine,” says Kilts. “AA just marked its 70th anniversary. But we have no idea, on a brain level, how they work.”

To find out, Kilts teamed with a group of investigators at the Atlanta VA Medical Center

to study cocaine-dependent men before and after an intensive four-week behav-ior therapy program. At the beginning and end of treatment, subjects from each group were asked to perform a simple task—pressing a button whenever they saw a visual stimulus in the form of alphabetical letters—while in an fMRI scanner. They also were instructed not to press the button if they saw the let-ters but heard a subsequent tone. This task demands the engagement of “response inhibition,” a highly evolved behavioral control process that is degraded in drug addiction.

Kilts found that before treatment, the subjects were unable to resist pushing the button when they saw the letters, even when they heard the subsequent tone. The frontal cortical network (the part of brain involved in executive function) was markedly less respon-sive—or not lighting up on the fMRI scan—during the task. By contrast, that

region of a non-addict’s brain lit up as the sub-ject successfully inhibited the motor response. In other words, they were able to resist pressing the button when seeing a letter and then hearing a tone.

“It was a straight-forward demand to control a behavioral impulse that had noth-ing to do with addic-tion, but the addicts were unable to mount a normal neural response,” says Kilts. “That ties in with a cardinal feature of addiction: When an addict has an urge to use, he or she is completely unable to control that urge.”

After completing the four-week treatment, the men performed the same task in the scanner.

This time, Kilts divided the cocaine-addicted subjects into one group that successfully com-pleted the program and one group that resumed drug use before the treatment ended. He found that the men who relapsed had a far more profound neural response deficit (their frontal cortical network showed less activity during the impulse-control task). “This suggests that a key element of your ability to respond to treatment may be how profoundly disabled your impulse control mechanism is,” says Kilts.

Brains of the men who successfully com-pleted the program actually changed during the course of treatment. Activity increased in the ventral medial prefrontal cortex, an area of the brain recently linked with the ability to stop a habitual behavior. This area appears to be involved in the new learning and memory that inhibits prior learned associations.

“This gave us some very interesting insights,” says Kilts. “The neural responses to addiction are not normalized by treatment, but treatment does cause reorganization in the brain. This reorganization, which activates new sections of the brain, allows the treatment to get traction.”

Currently, Kilts is planning a clinical trial to see if combining the use of behavioral therapy with a drug known to facilitate extinction can improve treatment outcomes. “If it works, we may be able to prevent relapse, which is a huge problem,” says Kilts. “Very few cocaine addicts in treatment make it beyond six months without using again.”

Going forward, Kilts and his team will study both environmental and genetic causes of addic-tion. On the nurture side, he just received fund-ing from the National Institute on Drug Abuse to study the impact of early childhood trauma on the neurobiology of drug addicts. On the nature side, Kilts has begun to genotype addicts and non-addicts to search for specific genetic variants that might be related to impulsivity. Already his researchers have found that a subtle genetic mutation seems to cause large differ-ences in the brain regarding addiction-related behavior. “In other words, a very small genetic glitch can make a big, big difference in brain

function, which sur-prised us,” says Kilts.

The overarching goal of all this research is stopping addiction before it starts. “By knowing a person’s genetic makeup and early trauma history, we may be able to identify those at greatest risk for addic-tion and intervene before they begin using drugs,”

says Kilts. “We are moving toward a model in which we are preventing the illness before we have to treat it, much like they can do in cardiol-ogy. It’s an enticing possibility.” •

Br a i n S t o r m s FA L L 2 0 0 6�

About 34 million Americans age 12 and older

have tried it at least once. More than 5%

of all high school seniors have used

it within the past year.

One in ten workers

say they know

someone

who uses it

on the job.

I t ’ s coca Ine .

“Cocaine use is a public health epidemic in this country,” says Clinton Kilts, vice chair for research in the Department of Psychiatry and Behavioral Sciences at Emory University School of Medicine. “Up to 10% of people who try cocaine will become addicted to it, and it is associated with a culture of violence and aggression.”

Kilts has been at the forefront of addiction research,

using sophisticated imaging technologies to understand the neural mechanisms at work in cocaine addiction, treatment, and relapse. His contributions to the field recently were recognized when he was named the Dr. Paul Janssen Chair of Neuropsychopharmacology.

“The Paul Janssen Chair is a wonderful tribute to a man who has been one of the most productive and

DDRRUUGGSSDDRRUUGGSSDDRRUUGGSSdrugs

B y M a r t h a N o l a n M c K e n z i e

DRUGS your brain on

DRUGS

The overarching goal

of this Emory research

is to stop addiction

before it starts

Vice Chair for Research Clinton Kilts found that treatment does not normalize the neural responses to addiction, but it does activate new sections of the brain, allowing the treatment to gain traction.

�

Jay Weiss hopes for accidents. “We depend on accidents in order to discover anything,” says Weiss, clinical and experimental psycholo-gist, Jenny Adams Professor of Psychology, and recipient of the MacArthur Fellowship (often called the “genius grant”). “If we didn’t have accidents, we would be stuck with what we can figure out.”

Indeed, it was an accident—several, really—that led Weiss to discover what could turn out to be the first viable animal models of

depression and bipolar disorder. His current success was built upon

a succession of failures. First he tried to breed a line of “super-depressed” rats by selectively mating males and females that responded most to stress tests. However, “after five years and a huge number of rats,” Weiss recog-nized defeat. For one thing, the family of symptoms necessary for a diagno-sis of depression broke apart as the generations progressed. And even

more problematic, the rats simply stopped reproducing after a while. “If you make these animals vulnerable enough, evolutionary dynam-ics causes them to self-eliminate from the population.”

Weiss then lowered his sights and set about breeding rats for high and low activity in swim tests. When put in a container of water, the high-activity rats swam vigorously for a long time before giving up. He reasoned the low-activity rats might be susceptible to antidepressants. Many generations

later, it turned out that the low-activity rats and normal rats showed the same level of response to antidepressants. Again, failure.

While working on the failed experiment, he noticed a group of hyperactive rats born of the same mother. He bred them to produce a line of hyperactive rats and subjected later generations to stress. The results were totally unexpected.

“On the fourth or fifth day after the stress, these rats blasted into hyperspace, literally running laps around their cages,” Weiss says. “Basically, they had a manic episode. There are no good animal models for bipolar disorder, and we think this might be an animal model for mania.”

Weiss got equally unexpected results when he stressed 10-month-old hyperactive rats—much older than rats he usually test-ed—and found they sank into sustained depression afterward. “The big problem with animals models of depression is the animals must be continually stressed to sustain the depressed state,” he says. “But in humans, the hallmark of depression is people stay there without anything happening in their environment. With these older hyperac-tive rats, we found a group we could expose to a single stress ses-sion and they would stay depressed for weeks.”

The implications could be far-reaching. Researchers can study the brains of these rats to determine the physiological neurological defect that produces the disorders. They can test new drug thera-pies. “If you’ve got viable animal models, you can test a host of drugs that you may not have ever considered to be useful,” Weiss

says. “That’s how antidepressants were discovered. That’s how lithium was discovered. It all comes back to accidents.” •

M e e t o u r fa c u l t y :

Sad rats and manic mice

Marianne Celano has dedicated her career to working with low-income populations. She also has asthma, a condition she developed after moving to Atlanta 17 years ago. It seemed only natural to the Emory psy-chologist to combine the two.

“I had to take multiple daily medications, which was challenging, and I thought it must be extremely difficult for families living in poverty, who face many more daily challenges than I do, ” she says. Indeed,

low-income chil-dren have a higher incidence of asthma than their more affluent counter-parts. They also face greater morbidity and mortality.

Celano began to study low-income children (ages 6 to

12) with persistent asthma, focusing on family fac-tors that influence self-management. She discovered that asthma medication adherence is poor among low-income patients. For example, the mean daily adherence to Flovent (an anti-inflammatory medica-tion delivered by inhaler) over a 14-day period was 56% at the first data collection visit and 48% one year later. “So these kids are taking on average one-

half of what is prescribed,” Celano says. Daily adherence to Singulair, which one-third to

one-half of children with persistent asthma take, was higher, at 75%. Singulair is a pill taken only once a day, which is easier than using an inhaler.

Caregivers of children with poor adherence to Singulair were more likely to show signs of depres-sion. More important, parental warmth toward the child (based on observational ratings) resulted in higher Flovent adherence. “So the warmer the parent, the more the kid takes Flovent,” she says. “That’s big, since anti-inflammatory agents such as Flovent are critical in asthma control.”

Celano and the American Lung Association are now targeting low-income, African-American chil-dren in Atlanta who have poor asthma control and a caregiver under stress. Many of the latter are women and many suffer from depression. Caregiver depres-sion and stress complicate pediatric asthma manage-ment, so Celano’s challenge is to help families cope with stress so they can better manage the condition.

“My goal is to provide individually tailored, cul-turally acceptable interventions to low-income fami-lies of children with severe persistent asthma,” she says. “Hopefully, these interventions will improve asthma self-management, lower asthma morbidity, and help the family and child feel more confident in managing asthma.” •

Helping poor children breathe easier

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

THE WRONG MANTHE MADMAN’S TALEH A R T ’ S WA RTHE ANALYST

When celebrated author John Katzenbach took the lectern to address grand rounds of Emory’s Department of Psychiatry and Behavioral Sciences, he admitted a slight bewilderment. “When Charlie [Nemeroff] asked me to come to grand rounds, I naive-ly assumed he was going to give me a white jacket and let me walk around and diagnose people,” Katzenbach said. “So I apologize if my talk is a little disjointed, but there was some confusion on my part.”

The confusion may well have been shared. Whoever heard of inviting a best-selling novelist to address the faculty and students of a university psychiatry depart-ment? It made perfect sense to department chair Nemeroff, who met Katzenbach when the author was accepting an award from the National Alliance for the Mentally Ill. “I have read many of his novels and find his writings extraordinarily psychiatric,” Nemeroff says. “It is remarkable how accurate he is about the subject matter that we deal with every day.”

Indeed, mental illness is a constant theme in Katzenbach’s work. In The Madman’s Tale, the narrator is a schizophrenic—off his medication and rapidly unraveling—who scribbles a tale of murder on his apartment walls. In The Analyst, a psychoanalyst is forced into the role of detective as he scrambles to determine the identity of a former patient intent on killing him. And in his newest novel due out this fall, The Wrong Man, divorced parents search for a way extricate their 22-year-old daughter from a relentless stalker.

“All of my books are basically the same,” Katzenbach told the attend-ees. “They are about ordinary people who get caught up in great psycho-logical and moral dilemmas which they solve with a volley of gunfire.”

Self-deprecation aside, Katchenbach has an uncanny ability to get inside mental illness and the criminal mind. Consider the opening of The Madman’s Tale, narrated by Francis Petrel, a 41-year-old schizophrenic recalling a series of murders that happened 20 years earlier in a mental institution where he was a patient:

I can no longer hear my voices, so I am a little lost. My suspicion is they would know far better how to tell this story. At least they would have opinions and suggestions and definite ideas as to what should go first and what should go last and what should go in the middle. They would inform me when to add detail, when to omit extraneous information, what was important and what was trivial. ... And sometimes I’m unsure that incidents I clearly remember actually did happen. A memory that seems one instant to be as solid as stone, the next seems as vaporous as a mist above the river. That’s one of the major problems with being crazy: you’re just naturally uncertain about things.

So how does a self-described “reasonable guy” portray mental illness so accurately? For starters, Katzenbach draws from family members. His mother, a Freudian psychoanalyst, ignited his fascination with human behavior. “Analysts live in worlds defined by their patients and their troubles,” Katzenbach writes on his website. “Ideas about truth, veracity, and honesty are all redefined in the analytic setting. I once asked my mother if she was ever concerned that a patient had lied to her, and her response was what I recalled when I set out to write The Analyst: ‘A lie often speaks as loudly about someone as the truth.’”

Katzenbach’s late brother-in-law, Ray, was a schizo-phrenic who spent time in a mental institution. The author used his brother-in-law’s description of life inside the institution to create the hauntingly realistic setting for The Madman’s Tale. And though he didn’t fashion Francis Petrel in the image of Ray, he did try to capture Ray’s voice. “Ray told me once that what frightened him

the most about being crazy was that things were forever unraveling around him, and he felt helpless to prevent them from unraveling.”

The author also relies on experience he gained from years as a crimi-nal court reporter, during which he covered grisly murders, interviewed psychotic killers, and walked the corridors of jails and mental hospitals.

But in the end, most of Katzenbach’s characters and their precarious mental states spring from his imagination. “In all novels, you have to be very cautious about research,” he said. “You want to be accurate, but you don’t want to over-research it so it becomes clinical.”

Hand-in-hand with mental illness come those who treat it. Indeed, Katzenbach’s novels are filled with psychiatrists and psychoanalysts. “It’s really easy to write about detectives detecting and police policing,” he said. “It’s far more interesting to take people who are in professions in which they are not expected to have great knowledge about detecting and put them in situations where they have to find those resources within them-selves. Psychiatrists and psychoanalysts, in particular, make for good char-acters because really good detectives lurk within them.”

So does Katzenbach foresee a novel set within the psychiatry depart-ment of a prestigious Southern university? “I didn’t before, but now, who knows?” he quipped.

Katzenbach ended his talk with an observation: “In your own professional lives, when you look across the room at a patient, there is a mystery there. Everyone is, in a sense, a story that needs to be told. It’s all the stuff of fiction, and it’s all the stuff of reality. And that’s what makes life interesting.” •

“One of my claims to fame

is that one of my books,

The Traveler, was found in

the possession of three real

serial killers when they were

arrested. They had actually

underlined certain sections

of the books.”

B y M a r t h a N o l a n M c K e n z i e

Inside the criminal mind with Katzenbach

AccoladesIn recognition of his long commitment to postgraduate education in neuroscience and psychiatry, Charles Nemeroff, chairman of Emory’s Depart-ment of Psychiatry and Behav-ioral Sciences, received the first Research Mentorship Award, sponsored by the American Psychiatric Association (APA) and the American Association of Chairs of Departments of Psy-chiatry. He also was selected by the APA Council on Medical Education and Lifelong Learning to receive the 2006 Vestermark Award for outstanding contribu-tions to undergraduate, gradu-ate, or postgraduate education and career development in psychiatry. This fall, Nemeroff delivered the Vestermark Award Lecture at the APA Institute of Psychiatric Services meeting in New York City.

Marianne Celano: managing asthma and depression

Br a i n S t o r m s FA L L 2 0 0 6

Jay Weiss is studying viable animal models of depression and bipolar disorder.

what’s insideYoung and sad: Understanding childhood mood disorders cover story Little is known about depression and mood disorders in children.

Emory’s new Childhood and Adolescent Mood Disorders Center means

to change that.

Your brain on drugs page four Using fMRIs and PET scans, an Emory researcher maps the neurobiol-

ogy of cocaine addiction, treatment, and relapse in an effort to stop

addition before it starts.

Inside the criminal mind with John Katzenbach page six Psychiatrists and psychoanalysts make for good characters because really

good detectives lurk within them, says the author of psychological thrill-

ers The Madman’s Tale and The Analyst.

Sad rats, manic mice page seven MacArthur Fellow Jay Weiss develops what could be the first viable ani-

mal models for bipolar disorder and depression.

Helping poor children breathe easier page seven A study looks at the role parental psychological health plays in asthma

medication adherence in inner-city children.

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

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“Ray told me once that what frightened him the most

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BrainStorms

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BrainStormsA newsletter from the Department of Psychiatry and Behavioral SciencesEmory University School of Medicine1440 Clifton Road, Suite 112Atlanta, GA 30322

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