IConS PlenaryRegister here
Topic: Shifting Sands: Trends in Our Understandings of Psychoses
In the past 25 years, our understandings of the nature, aetiology, and outcome of psychoses have transformed. In 1997, the broad consensus was that schizophrenia occurred at a similar rate around the world and was relatively rare (with a lifetime prevalence of ~ 0.5 to 1.0%); that it was a neurodevelopmental disorder, determined by a combination of genes and early neurological insults, the effects of which unfolded during the course of development, leading to onset in late adolescence / early adulthood; and that it was a chronic, deteriorating disorder, with generally poor long-term outcomes. In the time since, several developments in research have challenged these core characterisations of schizophrenia and psychoses more broadly. I will review some of these developments, focusing on select examples from our own research programmes, i.e., on variations in incidence, in phenomenology, in risks, and in course and outcome, concluding that – contrary to what was previously assumed – psychoses occur at widely varying rates worldwide and are common (or more common than assumed); that psychoses are determined by a wide array of risks, including social risks; and that outcomes vary widely, with recovery common. These shifting sands in our understandings of the very nature of psychoses has implications for research and, more importantly, for how we respond – that is, for services, for communities, and so on.
Chittaranjan Andrade, M.D., National Institute of Mental Health and Neurosciences, Bangalore
Dr Suhas Satish, Assistant Professor of Psychiatry, NIMHANS
Topic: Reinventing the neurobiology of schizophrenia
Chittaranjan Andrade, MD, is a Senior Professor in Clinical Psychopharmacology and Neurotoxicology at the National Institute of Mental Health and Neurosciences, Bangalore, India. His principal expertise lies in psychopharmacology, electroconvulsive therapy, ketamine therapy, research methodology, and statistics. He has been writing a monthly column on Psychopharmacology in the Journal of Clinical Psychiatry since 2012. In 2020, he was listed among the world’s top 2% scientists in psychiatry, and the top-ranked in India. His extracurricular interests and activities include classical music, classical poetry, freelance journalism, close up and stage magic, middle-distance athletics, rock-climbing, and high-altitude mountaineering.
Schizophrenia (Sz) is a major mental illness about which a great deal is known. Problematically, a great deal remains unknown, ranging from an understanding of etiopathogenesis to prognostications about course and outcome. This presentation attempts to construct a framework for a reconceptualization of the neurobiology of Sz, from etiopathogenesis to outcome, with a view to bring disruptive ideas into the field.
The presentation is organized into the following sections:
- The importance of heterogeneity in Sz
- The importance of risk factors in the origins of Sz
- Neurodevelopmental abnormalities in Sz: static or dynamic?
- Where in the brain do the abnormalities of Sz lie?
- Tipping point mechanisms and the origins of psychosis
- Origins of negative symptoms and cognitive dysfunction
- Challenging the dopamine hypothesis
- A neurocognitive hypothesis for psychosis
- How do antipsychotics really work?
- Reexamining the role of glutamate
- Prognostication: course and outcome
- Bits and bobs
Henry A. Nasrallah, MD, University of Cincinnati College of Medicine, Ohio, USA.
Topic: 10 devastating consequences of psychotic relapses
Dr. Henry Nasrallah is a widely recognized neuropsychiatrist, educator and researcher. Following his psychiatric residency at the University of Rochester and neuroscience fellowship at the NIH, he served for 12 years as chair of psychiatry at The Ohio State University and 6 years as chair of Neurology and Psychiatry at Saint Louis University. He also served as Associate Dean for Faculty Mentorship at the University of Cincinnati College of medicine for 4 years. He is currently Vice-Chair for Faculty Development and Mentorship, Professor of Psychiatry, Neurology and Neuroscience, Medical Director of Neuropsychiatry Program and Director of the Schizophrenia Program in the Department of Psychiatry and Behavioral Neuroscience at the University of Cincinnati College of Medicine.
Dr. Nasrallah’s research focuses on the neurobiology and psychopharmacology of schizophrenia and psychotic mood disorders. He has published 450 scientific publications, 580 abstracts, 175 editorials, and 13 books. He is the Editor-In-Chief of 3 journals (CURRENT PSYCHIATRY, SCHIZOPHRENIA RESEARCH AND BIOMARKERS IN NEUROPSYCHIATRY) and is the co-founder of the Schizophrenia International Research Society (SIRS).
He is a Distinguished Fellow of the American Psychiatric Association and served as president of the Ohio Psychiatric Physicians Foundation, President of the American Academy of Clinical Psychiatrists, President of the Missouri Psychiatric Association and the Scientific Director of the CURESZ Charitable Foundation which he established with a former patient who recovered completely from schizophrenia after 5 years of homelessness as well as visual and auditory hallucinations. He has received over 95 research grants and has been elected annually for 25 years to the list of “Best Doctors in America”.
Matcheri S Keshavan MD., Stanley R Cobb Professor and Vice-Chair of Psychiatry, Beth Israel Deaconess Medical Center & Massachusetts Mental Health Center, Harvard Medical School, Boston, USA.
Topic: Is the schizophrenia construct in need of a revision?
The concept that schizophrenia is a disease entity distinct from affective disorders has lasted in its current form for over a century. However, while current symptom-based nosology of psychotic disorders has improved reliability and some utility, but continues to have limited validity. As an alternative to symptom-based classification, biologically based subtypes (biotypes) can be reconstructed based on objective biomarkers. Our ongoing studies have shown replicability, stability and concurrent validity.
In our current understanding, schizophrenia may be better thought of as a spectrum of disorders characterized by cognitive, conative and reality distortion symptoms. A better conceptualization of this group of disorders can help redefine what we call this entity, which may be more acceptable for multiple stake-holders, and reduce stigma. More research is needed to identify biologically homogenous categories within this construct that may enable a better understanding of pathophysiology, etiology, treatment and will help in better outcome prediction and targeted treatments.
Dr. Keshavan is Stanley Cobb Professor of Psychiatry at the Beth Israel Deaconess Medical Center; Harvard Medical School, a position he assumed in April 2008. He is also Vice-Chair for the department’s Public Psychiatry division, and a senior psychiatric advisor for the Massachusetts Mental Health Center. Dr. Keshavan received his medical training in Mysore, India (where he graduated at the top of his University), and his psychiatric training in Bangalore (India), Vienna, London, and Detroit. In 1986, Dr. Keshavan joined the faculty at Western Psychiatric Institute and Clinic, Pittsburgh, PA. He was appointed full tenured Professor in 1998. Between 2004 and 2008, he served as Tenured Professor and Associate Chair of the Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI.
Dr. Keshavan is closely involved in research in neurobiology of psychosis, especially as it pertains to first episode psychotic disorders. His research has resulted in over 450 publications to date, including over 350 peer-reviewed papers, 4 books, and 100 reviews/ book chapters. He has received several awards including the Gaskell Gold Medal of the Royal College of Psychiatrists (1985); Nancy Roschke Certificate for Teaching Excellence of the American Psychiatric Association in 1993; Teaching awards at the Departments of Psychiatry in Pittsburgh (1992, 1994, and 2004), Wayne State University (2008) and at
Harvard (2011); the Research Scientist Development Award from NIMH (National Institute of Mental Health); the 2003 NAMI (National Alliance for the Mentally Ill) of Pennsylvania Psychiatrist of the Year Award and the 2013 Gerard Hogarty Award for Research from the University of Pittsburgh. He is a distinguished Fellow of the American Psychiatric Association; a Fellow of the Royal College of Physicians, Canada; and a Fellow of the Royal College of Psychiatrists, UK.
Dr. Keshavan is the Editor-in-Chief of the Asian Journal of Psychiatry (Elsevier) and serves on the editorial board for journals such as Acta Neuropsychiatrica, and Schizophrenia Research. In addition, Dr. Keshavan is often invited to speak at national and international conferences. He has several funded grants. His main areas of research include the neurodevelopmental basis of schizophrenia, neuroimaging, and early intervention. He sees patients in the Southard Clinic at MMHC, of which he is the Medical Director.
Dr. Venkatasubramanian Ganesan MD, PhD, FAMS, FNASc., National Institute of Mental Health and Neurosciences, Bangalore.
Topic: Understanding Schizophrenia as a Disorder of “Bayesian” Brain: Theoretical & Translational Implications
“We see what We expect” and “We expect what We see”
The term “Bayesian” refers to assigning probabilities based on prior knowledge when interpreting data. The Bayesian approach, which hypothesizes the brain as a “hierarchical predictive machine,” has transformed our perspectives on the brain in health & disorder. Such a “predictive” paradigm has immensely influenced contemporary formulations of schizophrenia. An imbalance in “predictive processing” can lead to faulty inferences with resultant false beliefs (delusions) and false perceptions (hallucinations). Deranged predictive processing can explain disorganized thought processes and communication disturbances in schizophrenia. The negative symptoms of schizophrenia may be explained by aberrations in social predictive circuits. Critically, the neural circuit and neurotransmitter aberrations in schizophrenia align with the neurobiology of the “predictive processing framework” of the “Bayesian Brain”. Thus, neuroscientific approaches cast in the “Bayesian” paradigm can offer overarching explanations for schizophrenia ranging from pathogenesis to clinical manifestation. Significantly, this has provided “informed avenues” to apply neuromodulatory techniques to unravel the neurobiological aberrations and treat the debilitating symptoms of schizophrenia.
Swaran Preet Singh MBBS, MD, DM, FRCPsych., University of Warwick, UK.
Topic: The Future of Early Intervention: where next?
In High Income countries (HIC), the most significant reform in mental health care since deinstitutionalisation has been early intervention in psychosis (EIP) services, shown to be clinically and cost-effective in enhancing symptomatic and functional recovery. The development and implementation of EIP is a salutary lesson in policy making based on ‘best available’ rather than ‘best possible’ evidence. EIP models have been developed and tested in HICs but the bulk of untreated or inadequately treated patients with psychosis live in Low- and Middle-Income Countries (LMICs), where resources are scant and the scale of the challenge overwhelming. It is neither feasible nor entirely appropriate to simply ‘transport’ such HIC models of EIP - with their well-resourced specialist teams providing community-based packages of care - to LMIC settings. This lecture will summarise how EIP came to be developed in HICs, describe the different forms of EIP and the underlying evidence that support these, and elucidate what we now know about early intervention, and more importantly, what we still don’t know. Data from the recent UK NIHR funded Warwick India Canada (WIC) collaboration will be presented to show that some forms of early intervention are feasible and effective in LMICs, and hence early intervention in LMIC is an opportunity waiting to be grasped.
Professor Swaran Preet Singh (MBBS, MD, DM, FRCPsych) initially trained as a surgeon in New Delhi, changing to psychiatry after witnessing the impact of 1984 killings on Sikh children. He has been a clinical academic in UK for thirty years, pioneering reform of youth mental health care across UK, Europe, Australia and Canada. He was a Commissioner for Equality & Human Rights Commission (2013-19), mandated by the UK Parliament. His current research involves improving mental health care for young people in the Indian subcontinent and sub-Saharan Africa. He also leads the Independent Investigation into discrimination (including Islamophobia) within the British Conservative Party.
His eternal struggle is between being focussed and productive and wasting time on idle speculation and meaningless meandering. When he can, he enjoys literature, poetry, theatre, blues, jazz, cricket, cooking, gardening and fishing. One day he will write a book on the meaning of life and create the perfect Sushi platter.
Graham Thornicroft, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK
Topic: Exploring links between research and interventions in psychoses: the role of stigma
Graham Thornicroft is Professor of Community Psychiatry at the Centre for Global Mental Health and the Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College London. He is also a Consultant Psychiatrist at South London & Maudsley NHS Foundation Trust, working in a community mental health team in Lambeth. He is a Fellow of the Academy of Medical Sciences, is a National Institute of Health Research Senior Investigator Emeritus, and is a Fellow of the Royal Society of Arts, Honorary Fellow of King’s College London and the Honorary Fellow of the Royal College of Psychiatrists.
Graham took his undergraduate degree at Cambridge in Social and Political Sciences, studied Medicine at Guy’s Hospital, London and then trained in Psychiatry at the Maudsley and Johns Hopkins Hospitals. He gained an MSc in Epidemiology at the London School of Hygiene and Tropical Medicine, and a PhD at the University of London.
Graham has made significant contributions to the development of mental health policy in England, including chairing the External Reference Group for the National Service Framework for Mental Health, the national mental health plan for England for 1999-2009.
He is also active in global mental health, for example, he chaired the World Health Organisation Guideline Development Group for the Mental Health Gap Action Programme (mhGAP) Intervention Guide (1st, 2nd and 3rd editions), a practical support for primary care staff to treat people with mental, neurological and substance use disorders in low and lower middle-income countries, which is now used in over 100 countries worldwide. He chaired the External Reference Group for the WHO guidelines on the Management of Physical Health Conditions in adults with severe mental disorders. He has recently chaired the Guideline Development Group for the WHO guidelines on Mental Health at Work.
He is a Board Trustee of United for Global Mental Health, a Board Member for Mental Health and Human Rights, and he chairs the Board of Implemental. His areas of research expertise include: reduction of stigma and discrimination, evaluation of mental health services, and global mental health. Graham has written over 640 peer-reviewed papers in PubMed, and authored or edited over 32 books of which 7 are award winning. In 2020 and 2021 he was named as among the most Highly Cited Researchers in the world by Clarivate. Graham has appeared in the media including BBC 1, BBC World Service, BBC Today radio programme, and The Economist. Graham received a Knighthood in the Queen’s Birthday Honours Awards in 2017.
Smita Neelkanth Deshpande MD, DPM, CCST (UK), St John’s National Academy of Health Sciences, Bengaluru.
Topic: Capacity Building in Mental Health Research in India
Dr Deshpande served as the Head, Dept. of Psychiatry, ABVIMS-DR RML Hospital, New Delhi from July 2004 to September 2018. Beginning with systems research in 1988, she led over 38 research projects in autism, schizophrenia genetics, clinical trials, psychosocial aspects of mental health, disability and rehabilitation, tobacco cessation, de-addiction, yoga for cognitive enhancement in schizophrenia and Implementation research for agencies such as the NIH, WHO, ICMR, DST and DBT, with more than 250 publications and innumerable presentations. As national Coordinator, she mentored 21 Principal Investigators in 12 research projects focussed on Priority Areas of the National Mental Health programme of India (NMHP) based on Implementation Research from 2016-2022.
She is India Principal Director PRIIIA (Psychiatric Research Infrastructure for Intervention and Implementation in India) which partnered with the Indian Council of Medical Research in August 2022 to mentor 32 research projects.
She participated in developing the Indian Scale for Assessment of Autism (ISAA) recognized by the Government of India for certifying disability for autism.
She was a co-author in Tobacco Cessation Guidelines for Government of India. She is an international WHO trainer for Tobacco Cessation and has visited several countries to train their trainers. She was a member in the sub-committee for developing ICMR Human Research Guidelines for Vulnerable Groups in 2017.
She is on the board of several national and international journals.
She is Co-Chair, World Psychiatric Association Section on Genetics.