In a nightmare of déjŗ vu, a young adult inflicts a paroxysm of violence upon society. In this latest example in suburban Denver, a 24-year-old man kills 12 people and shoots dozens more, leaving behind a booby-trapped apartment in an effort to create additional victims. Compounding the senselessness of the tragedy is our realization that the suspect was once a high-functioning graduate student of neuroscience with a world of promise ahead of him.
In the week that followed the July 20 shooting, specialists with the Mood Disorders Center at the University of Cincinnati Neuroscience Institute, a component of UC Health, provided media interviews to help the public grapple with questions about how such a tragedy could occur and how future tragedies might be prevented. Here, Melissa DelBello, MD, professor of psychiatry and pediatrics and co-director of the Division of Bipolar Disorders Research in UCís Department of Psychiatry and Behavioral Neuroscience, discusses recognition and prevention of serious mental illness.
Question: Many of the perpetrators of mass violence are young individuals who seemed normal earlier in their lives. What has happened in these cases?
Dr. DelBello: Late adolescence and early adulthood is the most common period of onset of psychiatric disorders, specifically psychotic and mood disorders. There are multiple stressors that exist in life during this period, including going off to college and making important career and personal life decisions. These are all big stressors. There is also the potential for substance use, since this is the most common period for exposure to alcohol and drugs. Finally, genetics and neurodevelopment are biological aspects that contribute to the onset of these illnesses. We think that you have to have the "rightĒ genes, in combination with these stressors, to develop these brain-based illnesses.
Question: What specifically is happening during adolescence that makes the brain vulnerable to psychosis and other mood disorders?
Dr. DelBello: From puberty up to age 25, there is rapid development in the prefrontal cortex, the large and newest part of human brain that lies just behind the forehead and is responsible for cognitive analysis, abstract thought and regulation of emotion. The prefrontal cortex is establishing connections with other areas of the brain and then fine-tuning and developing them into the important connections. This process continues throughout late adolescence and early adulthood. An abnormal environment, or stressor, or the wrong genetics, or a combination of those factors can contribute to abnormal brain development and eventually the onset of these disorders.
Question: Should we be paying more careful attention to young people during this critical phase of their lives?
Dr. DelBello: This is a time for people to be watching. This includes family, friends, co-workers, roommates. Signs to look for are a change in behavior, sleep patterns, appetite or interests; an inability to perform as well as the person previously did; signs of functional impairment or impaired logic or thinking; evidence that a person is starting to use drugs or alcohol; signs that the person is withdrawing or isolating himself from friends. Those are all warning signs that an individual is not functioning as well as he or she used to.
Question: How well can the system intervene if someone is deteriorating?
Dr. DelBello: Many times people will hide the information from their families, particularly if theyíre not living with their family and are away at school, where people donít know them that well. We obviously donít know the specifics about what happened in Colorado, but obviously there is some speculation that there was a new interest in weapons and guns. And I donít know whether that pre-existed. New interests or different interests should raise red flags. But sometimes people hide the symptoms well.
Question: Does the brain actually deteriorate during mental illness? Are cells dying?
Dr. DelBello: "There are two different processes in the brain: neuro-development and neuro-degeneration. We think that these disorders develop because of a neurodevelopmental abnormality, so initially the brain doesnít develop as most developing brains do. This is followed by a secondary phase: a progression of abnormalities in different brain regions. Whether this is a result of the illness itself or confounding factors such as medications, drugs, alcohol, stressors, other illnesses that develop, we donít really know.
Question: Is there anything you personally took away from the latest tragedy? A wish that society could do something that is not currently doing?
Dr. DelBello: What happened is incredibly tragic. I donít know that all of the preventive strategies in the world would have stopped it. But if I had a wish it would be that more research is devoted to preventing these illnesses so that we could understand exactly how the combination of these risk factors and the interaction of genetics and abnormal brain development unfold. Being able to somehow intervene and slow down or prevent the onset of mental illness would be the ultimate goal.
Question: Some if this research is ongoing right now at UC and Cincinnati Childrenís Hospital Medical Center.
Dr. DelBello: We are doing high-risk studies in children of parents with bipolar disorder, trying to look at the longitudinal course of these children in order to identify whether there are biological or clinical factors that predict who is going to go on to develop a mood disorder. This is part of a center grant from the National Institutes of Health. Iím involved in the high-risk study where we recruit young children, 8-20, who have at least one parent with bipolar disorder. They participate in a neuroimaging study, and then over time we ask them about their mood and function. Once they start developing symptoms, we follow them very closely and perform another neuroimaging scan to identify brain changes predictive of and associated with illness development.
In another research study, we are treating children who develop early depressive symptoms with omega 3 fatty acids. The earlier in the childís development the symptoms appear, the more benign the treatment has to be. If they havenít developed a full-blown illness, itís hard to use medications that treat bipolar disorder, which have potentially significant side effects. So you have to intervene with something more benign, such as therapy or nutriceuticals. Weíve been looking at omega 3 fatty acids because thereís some evidence that one of the factors that contribute to the onset of bipolar disorder may be low omega 3 levels.
Question: Are these studies still enrolling?
Dr. DelBello: Yes. Our goal, ultimately, is to figure out what combination of biological, environmental and genetic risk factors contribute to the onset of bipolar disorder. We want to learn how to predict when we should intervene and at what time point, before the full-blown illness has developed. And once an individual has developed the full-blown illness, we want to know how to treat them most effectively to prevent the illnessís recurrence and associated co-occurring illnesses, such as substance use disorders.