Advocating on behalf of the power of prevention in psychiatry has been my life’s work. I ran a world-class community mental health center with a strong wellness component; have taught, researched, written, and spoken extensively about the importance of prevention; and have incorporated preventive ideas into my current clinical practice.
I would like to think that I have been one of the forces that helped start a new movement called “positive psychiatry,” the idea that mental health must encompass more than the reduction or elimination of psychiatric illness. In the new book edited by American Psychiatric Association Past-President Dilip V. Jeste, MD, and Barton W. Palmer, PhD, called “Positive Psychiatry” (Arlington, Va.: American Psychiatric Association Publishing, 2015), I contributed a chapter on the psychosocial factors tied to positive outcomes. In addition, I am part of a group of psychiatrists and researchers affiliated with the World Psychiatric Association who are starting an interest group focusing on positive psychiatry.
Recently, because of the prevalence of neurobehavioral disorder associated with prenatal alcohol exposure ( ND-PAE ) (the American Psychiatric Association’s DSM-5 version of fetal alcohol spectrum disorders) in my community, I have begun to tout this problem as a major public health issue. When we formulated the Institute of Medicine’s 2009 Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities report , we did not include the problem of fetal alcohol exposure – and this was an unfortunate oversight.
However, this area of interest had not yet fully developed, and nearly 8 years later, there have been some confluent developments regarding potential prevention of this problem. They both involve choline.
First, we know that when women drink while pregnant, the alcohol they consume rids their bodies of choline, a nutrient the fetus needs for proper cell construction, neurogenesis, and neurodevelopment. Accordingly, several scientists are exploring using choline both pre- and postnatally to see if the defects on ND-PAE can be ameliorated or prevented. All of the research in this area is new, but it looks very promising.
Recently, I had the good fortune to present an idea during the Andrea Delgado Memorial Lecture at the Black Psychiatrists of America transcultural conference in the Bahamas. I also spoke at a mini-plenary at the 32nd Annual Rosalynn Carter Mental Health Policy Symposium in Atlanta. The core of the presentations were not too deep (to paraphrase a line Morgan Freeman used on Jack Nicholson in the movie “The Bucket List” – ‘I have seen bathtubs that are deeper’), but I think it explicated an essential idea. Jessie Aujla, a 4th-year medical student, and I explored the content of choline in the 25 top prenatal vitamins and found none of them contained the 450-mg daily recommended dose of choline advised by the Institute of Medicine in 1998 . In fact, only two contain 50 mg; six others contain less than 30 mg; and the other 17 have no choline whatsoever (this study is in press at the Journal of Family Medicine and Prevention). So we are advocating that the prenatal vitamin manufacturers increase the choline content of their prenatal vitamins, because although women may be getting some choline from their food diets, we found one large study illustrating that 90% of pregnant women are choline deficient.
The other area of interest regarding choline as a preventive agent for mental illness is work published by researchers at the University of Colorado Denver. This research group is proposing that choline may prevent the development of autism, attention-deficit/hyperactivity disorder, and schizophrenia by an epigenetic mechanism involving a nicotinic acetylcholine receptor. This makes perfectly good sense clinically among those of us who are treating patients with ND-PAE. Some of us are starting to think of ND-PAE as a choline deficiency disorder and see symptoms that are extremely similar to autism, ADHD, and schizophrenia in such patients. Many patients with ND-PAE are misdiagnosed with these disorders. Accordingly, there appears to be some common ground between ideas aimed at preventing fetal alcohol exposure and those aimed at preventing autism, ADHD, and schizophrenia – specifically, ensuring that pregnant women get an adequate supply of choline.
There is certainly a great need to do more research to nail down these two potential preventive actions. But until that research is done, it seems to me that the least we can do is to advocate for a position that the manufacturers of prenatal vitamins at least include the daily recommended dose of choline (450 mg/day) pregnant women need per the findings of the Institute of Medicine’s Standing Committee on the Scientific Evaluation of Dietary Reference Intakes and its Panel on Folate, Other B Vitamins, and Choline, published in 1998.
Dr. Bell is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago; clinical psychiatrist emeritus, department of psychiatry, at the University of Illinois at Chicago; former president/CEO of Community Mental Health Council; and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.
