James Potash, M.D., M.P.H.
Posted January 5, 2009
James Potash, M.D., M.P.H., is a graduate of Yale. Following graduation he served in the Peace Corps in West Africa, and there decided to become a physician. He first completed a master's degree in public health at John Hopkins, and then attended Hopkins medical school as well. He went on to do residency training at Hopkins, and was selected as chief resident in his fourth year. In 1998 he joined the faculty as an Instructor and has since been promoted to Associate Professor, Arlene and Robert Kogod Chair, and Director of Research Programs for the Johns Hopkins Mood Disorders Center in the Department of Psychiatry and Behavioral Sciences.
The primary focus of Dr. Potash's work has been on research regarding the genetic basis of mood disorders. This work has resulted in more than 60 publications. He has also collaborated on a revision of the leading textbook in the field, Manic-Depressive Illness. Dr. Potash is the principal investigator on three major grants from the National Institute of Mental Health aimed at studying the genetics of bipolar disorder, the genetics of major depression, and the epigenetics of major depression, respectively. His two areas of research specialty have been the genetic basis of the psychotic form of bipolar disorder and the epigenetics of mood disorders. He has published a series of papers showing that the vulnerability to the psychotic form of bipolar disorder is genetically distinctive, and that it overlaps with the vulnerability to schizophrenia. The importance of this body of results was recognized with the Robins/Guze Award for research excellence given by the American Psychopathological Association in 2003.
In his work on the epigenetics of mood disorder, Dr. Potash has collaborated closely with Dr. Andrew Feinberg, Director of the Epigenetics Center of the Institute for Basic Biomedical Science at Johns Hopkins, and a world leader in epigenetics. Dr. Potash is studying epigenetic variation in the brains of people with major depression and bipolar disorder, and in the brain generally. He showed that DNA methylation signatures across over 800 genes distinguish brain regions and may help account for region-specific functional specialization. In addition to doing outstanding research, Dr. Potash is also a gifted clinician.
1) How long have you been helping people with bipolar disorder?
Dr. Potash: I have been in psychiatry since 1995, and I became a mood disorders specialist in 1998. My clinical work includes taking care of patients on a mood disorders speciality inpatient hospital service and seeing patients for second opinions in a mood disorders speciality consultation clinic. Similarly, the outpatients I see all have depression or bipolar disorder.
2) What advice do you have for a person recently diagnosed with bipolar disorder?
Dr. Potash: On the one hand, it is important to understand that this is a disease of the brain, and to a large extent, people have to accept that they did not bring it on themselves, and that they cannot control the fact that they have an illness. This is important given some patients' tendency to blame themselves. On the other hand, there are some things patients can do to help themselves manage the illness. These include: a) not drinking alcohol or using illicit drugs. People who cannot avoid this problem have, on average, more severe problems with their bipolar disorder; b) keeping a regular sleep schedule and don't stay up too late. The stability of this pattern helps counteract the instability inherent in the illness; c) taking medications regularly and reliably. These medications can be very effective but only when used as directed; d) seeing a psychiatrist regularly (and possibly therapist) and making decisions jointly with him/her. A good working relationship can go a long way in smoothing the path towards wellness.
3) What advice do you have for the family and friends of someone recently diagnosed with bipolar disorder?
Dr. Potash: Learn as much as you can about the illness. The better informed you are the better prepared you'll be to serve as a support. When you can recognize early signs and symptoms, you'll be in a position to get the patient help quickly, before the situation deteriorates. Being well informed also allows you to better appreciate when the patient should be pushed and when s/he should be left alone. Also, well informed family and friends are in a good position to participate in the treatment by going with the patient to doctor's visits. They can help the doctor to better understand where things stand, whether a treatment is helping, and when it is time to try the next treatment.
4) What is the most common mistake that you see a person with bipolar disorder make after receiving initial or prolonged treatment (e.g. coming off medication, drug/alcohol use, etc.)?
Dr. Potash: One major mistake is making unilateral decisions about coming off of medication. While there are times when it may make sense to stop medication, these decisions are best made by the doctor and patient weighing the pros and cons together and coming up with a plan by consensus. Another major mistake is for a young person with bipolar disorder to think that s/he can continue drinking or using illicit drugs in moderation, and that this will not interfere with the illness. The problem is that moderation is hard to achieve when one's mood swings wildly up and down.
5) In your experience, do you think it is possible for a person diagnosed with bipolar disorder to live a relatively stable and productive life once they are receiving proper treatment?
Dr. Potash: There is no doubt that a large group of people with bipolar disorder live stable and productive lives with proper treatment. I have taken care of young people who have had to drop out of college because of their illness, but once they got proper treatment, they returned to school, finished their degrees, and were back on track. Many patients have had great success taking lithium, including our Johns Hopkins faculty member, Kay Jamison, author of An Unquiet Mind and Touched With Fire. It is sometimes astonishing to realize how many highly successful people have had bipolar disorder. Dr. Jamison has documented this in her books and in some of the speeches she has given, for example, at our annual Johns Hopkins Mood Disorders Symposium.
6) In your opinion, how has the mental health field changed over the past 10 years? Better or worse?
Dr. Potash: I think things have gotten better for people with bipolar disorder insofar as the recognition of the illness as a brain disease has become steadily more entrenched. Ten years ago there were still vestiges of the psychodynamic era in which the signs and symptoms of the illness were thought of as psychological weaknesses rooted in the patient's faulty psychosexual development and in their aberrant relationships to their parents. This could sometimes lead to dangerous forms of treatment, for example, blaming parents, who are often the most critical support for a sick patient, or suggesting that an acutely suicidal patient needed to shore up their coping skills, rather than making sure s/he was emergently treated for a worsening of an illness.
7) Can you briefly explain genetics?
Dr. Potash: Genetics refers to the DNA that is passed down from parent to child. This DNA contains 20,000-25,000 genes, spelled out by chemical letters. We all have the same genes, and they are more than 99% the same, but the small fraction of variation in the way the genes are spelled out, can influence a person's likelihood of developing bipolar disorder.
8) Is there strong evidence that bipolar disorder is inherited and passed on genetically?
Dr. Potash: Yes, there is. And it has been accumulating since the 1920s. Family studies shows the illness runs in families. That's the first important point. But does this mean that what is shared is in the DNA or in the environment? Twin and adoption studies can help sort this out. Twin studies show that identical twins, who share 100% of their DNA are more likely to be similar in whether or not they have the illness than fraternal twins who share only half of their DNA. And adoption studies show that people who have been adopted and have bipolar disorder are more likely to also have the illness in their biological parents, than in their adoptive parents. Both of these types of studies demonstrate the importance of genetics in the familial sharing of bipolar disorder.
9) Are we close to understanding what genes are involved in bipolar disorder and if so, what does this mean?
Dr. Potash: We are getting closer. The prospects for making ground-breaking discoveries have never been better, because technological developments have given us tools we have never had before. One such tool is the microchip. We think of computers when we think of chips, but the same technology that allows huge numbers of transistors to be put on a chip has been applied to allow huge numbers of DNA experiments to be put on a chip. A second tool derives from the development of a comprehensive catalogue of human DNA variation that now numbers more than 10 million variants and is accessible within seconds over the Web to researchers worldwide. Progress in these areas provides us the opportunity to do an experiment where we test 900,000 DNA variations, in one fell swoop on a chip. This kind of experiment can now be done on several thousand people's DNA in the same amount of time it would have taken to study a single DNA variation 20 years ago. These experiments have the potential to bring us closer to a fundamental understanding of the way bipolar disorder unfolds in the brain, and to having the ability to interrupt the disease process more effectively.
10) Does the future of genetic research into bipolar disorder look promising based on what you have seen so far?
Dr. Potash: It does. If we can figure out which of our genes are the critical players then better treatment options should follow. First, having genes in hand might allow us to tailor current treatments based on a patient's genetic profile. For example, this would be possible if bipolar patients with one DNA variant were more likely to respond to lithium while those with another were more likely to respond to Depakote. This knowledge would enable us to get the right drug to the right patient right away, allowing us to avoid the painful process of trying to find the medication that will work best for a given person. The second way genes might help us is that they might lead us to new and better medications than we have now. Genes will take us inside of brain cells where illness is generated. Within these cells genes will lead us to biochemical pathways. Identifying the key pathway through which the disease unfolds will be the key to the design of new medications. Blocking the pathway may allow us to block the disease.
11) Anything else that you would like to add?
Dr. Potash: We at Johns Hopkins are hard at work trying to uncover the genetic causes of bipolar disorder. Our current studies should bring us closer to a fundamental understanding of the way bipolar disorder unfolds in the brain, and to having the ability to interrupt the disease process more effectively. We are very excited about the prospects for new discovery and particularly about the potential for using what we find to make a difference for people who suffer with bipolar disorder. If you would like to hear more about participating in our research, please call us at 1-877-MOODSJH (1-877-666-9754) or 410-614-1017 or e-mail moods@jhu.edu.
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