Neurology Center

According to a major new report from Australia, social and family factors associated with autism are associated with a lower risk of intellectual disability - and vice versa. But why?


The paper is from Leonard et al and it's published in PLoS ONE, so it's open access if you want to take a peek. The authors used a database system in the state of Western Australia which allowed them to find out what happened to all of the babies born between 1984 and 1999 who were still alive as of 2005. There were 400,000 of them.

The records included information on children diagnosed with either an autism spectrum disorder (ASD), intellectual disability aka mental retardation (ID), or both. They decided to only look at singleton births i.e. not twins or triplets.

In total, 1,179 of the kids had a diagnosis of ASD. That's 0.3% or about 1 in 350, much lower than more recent estimates, but these more recent studies used very different methods. Just over 60% of these also had ID, which corresponds well to previous estimates.

There were about 4,500 cases of ID without ASD in the sample, a rate of just over 1%; the great majority of these (90%) had mild-to-moderate ID. They excluded an additional 800 kids with ID associated with a "known biomedical condition" like Down's Syndrome.

So what did they find? Well, a whole bunch, and it's all interesting. Bullet point time.

• Between 1984 to 1999, rates of ID without ASD fell and rates of ASD rose, although there was a curious sudden fall in the rates of ASD without ID just before the end of the study. In 1984, "mild-moderate ID" without autism was by far the most common diagnosis, with 10 times the rate of anything else. By 1999, it was exactly level with ASD+ID, and ASD without ID was close behind. Here's the graph; note the logarithmic scale:
  

• Boys had a much higher rate of autism than girls, especially when it came to autism without ID. This has been known for a long time.
  
• Second- and third- born children had a higher rate of ID, and a lower rate of ASD, compared to firstborns.
  
• Older mothers had children with more autism - both autism with and without ID, but the trend was bigger for autism with ID. But they had less ID. For fathers, the trend was the same and the effect was even bigger. Older parents are more likely to have autistic children but less likely to have kids with ID.
  

• Richer parents had a strongly reduced liklihood of ID. Rates of ASD with ID were completely flat, but rates of ASD without ID were raised in the richer groups, though it was not linear (the middle groups were highest. - and effect was small.)
  

The blood-brain barrier is not a single barrier, but a composite of many systems that act to
control the entry of substances from the blood to the brain:
1. Capillary endothelial cells linked by tight junctions and expressing specialized uptake
systems for particular metabolic substrates (e.g., glucose, amino acids)
2. A prominent basement membrane between endothelia and adjacent cells
3. Pericapillary astrocytes with end-feet adjacent to capillaries
A similar system exists for the choroidal epithelium (blood-cerebrospinal fluid [CSF]
barrier).

1. Enhancement of diagnostic possibilities and treatment options
2. More appropriate selection of diagnostic tests and interpretation of test results
3. Prediction of drug side effects and interactions
4. Selection of optimal drug regimens
5. Aid to critical review of novel concepts and therapies
6. Understanding of the rationale for current clinical trials
7. Provision of a background for communicating information to patients and families

Here at Neuroskeptic we have closely followed the development of fMRI scanning on fish.


But a new study has taken it to the next level by scanning... some cheese.

OK, this is not quite true. The study used NMR spectroscopy to analyze the chemistry of some cheeses, in order to measure the effects of different kinds of probiotic bacteria on the composition of the cheese. NMR is the same technology as MRI, and indeed you can use an MRI scanner to gather NMR spectra.

In fact, NMR is Nuclear Magnetic Resonance and MRI is Magnetic Resonance Imaging; it was originally called NMRI, but they dropped the "N" because people didn't like the idea of being scanned by a "nuclear" machine. However, this study didn't actually involve putting cheese into an MRI scanner.

But the important point is that they could have done it by doing that. And if you did that, what with the salmon and now the cheese, you could get a nice MRI-based meal going. All we need is for someone to scan some vegetables, some herbs, and a slice of lemon, and we'd have a delicious dataset. Mmm.

How to cook it? Well, it's actually possible to heat stuff up with an MRI scanner. When scanning people, you set it up to make sure this doesn't happen, but the average fMRI experiment still causes mild heating. It's unavoidable.

I'm not sure what the maximum possible heating effect of an average MRI scanner would be. I doubt anyone has gone out of their way to try and maximize it, but maybe someone ought to look into it. Think of the possibilites.

You've just finished a hard day's scanning and you're really hungry, but the microwave at the MRI building is broken. Not to worry! Just pop your fillet of salmon in probiotic cheese sauce in the magnet, and scan it 'till it's done. You could inspect the images and the chemical composition of the meal before you eat it, to make sure it's just right.

Just make sure you don't use a steel saucepan...



Rodrigues D, Santos CH, Rocha-Santos TA, Gomes AM, Goodfellow BJ, & Freitas AC (2011). Metabolic Profiling of Potential Probiotic or Synbiotic Cheeses by Nuclear Magnetic Resonance (NMR) Spectroscopy. Journal of agricultural and food chemistry PMID: 21443163

According to the BBC, the British recession and spending cuts are making us all depressed.


They found that between 2006 and 2010, prescriptions for SSRI antidepressants rose by 43%. They attribute this to a rise in the rates of depression caused by the financial crisis. OK there are a few caveats, but this is the clear message of an article titled Money woes 'linked to rise in depression'. To get this data they used the Freedom of Information Act.

What they don't do is to provide any of the raw data. So we just have to take their word for it. Maybe someone ought to use the Freedom of Information Act to make them tell us? This is important, because while I'll take the BBC's word about the SSRI rise of 43%, they also say that rates of other antidepressants rose - but they don't say which ones, by how much, or anything else. They don't say how many fell, or stayed flat.

Given which it's impossible to know what to make of this. Here are some alternative explanations:

• This just represents the continuation of the well-known trend, seen in the USA and Europe as well as the UK, for increasing antidepressant use. This is my personal best guess and Ben Goldacre points out that rates rose 36% during the boom years of 2000-2005.
  
• Depression has not got more common, it's just that it's more likely to be treated. This overlaps with the first theory. Support for this comes from the fact that suicide rates haven't risen - at least not by anywhere near 40%.
  
• Mental illness is no more likely to be treated, but it's more likely to be treated with antidepressants, as opposed to other drugs. There was, and is, a move to get people off drugs like benzodiazepines, and onto antidepressants. However I suspect this process is largely complete now.
• Total antidepressant use isn't rising but SSRI use is because doctors increasingly prescribe SSRIs over opposed to other drugs. This was another Ben Goldacre suggestion and it is surely a factor although again, I suspect that this process was largely complete by 2007.
  
• People are more likely to be taking multiple different antidepressants, which would manifest as a rise in prescriptions, even if the total number of users stayed constant. Add-on treatment with mirtazapine and others is becoming more popular.
• People are staying on antidepressants for longer meaning more prescriptions. This might not even mean that they're staying ill for longer, it might just mean that doctors are getting better at convincing people to keep taking them by e.g. prescribing drugs with milder side effects, or by referring people for psychotherapy which could increase use by keeping people "in the system" and taking their medication. This is very likely. I previously blogged about a paper showing that in 1993 to 2005, antidepressant prescriptions rose although rates of depression fell, because of a small rise in the number of people taking them for very long periods.
  
• Mental illness rates are rising, but it's not depression: it's anxiety, or something else. Entirely plausible since we know that many people taking antidepressants, in the USA, have no diagnosable depression and even no diagnosable psychiatric disorder at all.
• People are relying on the NHS to prescribe them drugs, as opposed to private doctors, because they can't afford to go private. Private medicine in the UK is only a small sector so this is unlikely to account for much but it's the kind of thing you need to think about.
• Rates of depression have risen, but it's nothing to do with the economy, it's something else which happened between 2007 and 2010: the Premiership of Gordon Brown? The assassination of Benazir Bhutto? The discovery of a 2,100 year old Japanese melon?
  

Neurology and psychiatry are related fields - if for no other reason, because neurological disorders can often manifest as, and get misdiagnosed as, psychiatric ones.

But what's the borderline between neurology and psychiatry? What makes one disease "neurological" and another "mental"? Are some psychiatric disorders more "neurological" than others?

It's a rather philosophical question and you could discuss it for as long as you wanted. Rather than doing that I thought I'd have a look to see which disorders are, at the moment, considered to fall into each category.

To do this I did a quick search the archives of two journals, Neurology which the world's leading journal of... well, guess, and the American Journal of Psychiatry. I looked to see how many papers from the past 20 years had either a Title or an Abstract which referred to various different diseases. You can see the results above. Note that the total number of papers varied, obviously, and I've only plotted the proportion.

Some interesting results. Schizophrenia, which is probably considered "the most neurological" psychiatric disorder, is in fact the least talked about in Neurology. Depression is top amongst the "core" psychiatric ones.

Autism occupies a middle ground, discussed by psychiatrists at 70% and neurologists at 30%. That didn't surprise me, but what did was that ADHD is almost as neurological as autism. Mental retardation is also intermediate, though it's 30:70 in favour of neurology. Whether autism is really less neurological than mental retardation, is a good question.

Then out of the disorders with a known neuropathology, Alzheimer's disease, Huntington's disease and "dementia" (which overlaps with Alzheimer's) are a bit psychiatric while stuff like headache and epilepsy is almost 100% neurological. Why this is, is not entirely clear, since both dementia and epilepsy are caused by neurological damage, and they can both cause "psychiatric" symptoms.

I suspect the difference is that it's just much harder to treat Alzheimer's, Huntington's and dementia. With epilepsy or meningitis, neurologists have a very good chance of controlling the symptoms and few patients will be left with ongoing psychiatric problems. But with the neurodegenerative disorders, neurologists can't really do much, leaving a large pool of people for psychiatrists to study.

Someone once said that neurologists take all of the curable diseases and leave psychiatrists with the ones they can't help. These figures suggest that there may be some truth in this.

In This Is Spin̈al Tap, British heavy metal god Nigel Tufnel says, in reference to one of his band's less succesful creations:

It's such a fine line between stupid and...uh, clever.

Just wanted to let everyone know about a blog called 1 boring old man, which is a very poor name as it isn't boring at all.


I don't know if it's written by an old man or not, one can only assume so, but whoever writes it, it has got a lot of extremely good stuff about psychiatry and psychiatric drugs. Fans of Daniel Carlat's blog or even former readers of the now seemingly defuct Furious Seasons will find it extremely interesting.

It's actually been going since 2005, but for some reason I've only just found out about it (many thanks to regular Neuroskeptic commentator Bernard Carroll).