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Professor Barbara Sahakian in interview with Kate McAllister

Barbara Sahakian is Professor of Clinical Neuropsychology at the Department of Psychiatry and Fellow of the Academy of Medical Sciences. Barbara has a prolific publication record in cognition, psychopharmacology, neuroscience and mental health and is currently President of the British Association for Psychopharmacology (BAP) as well as being a member of the Women in Science, Engineering and Technology Initiative (WiSETI) Steering Committee at the University of Cambridge. Her new book on decision making, Bad Moves, has recently been published and was discussed at the Hay Festival of Literature and Arts, the Times Cheltenham Science Festival and a recent MRC Café Scientifique. Professor Sahakian took some time out from her work to speak to us about decision making in the real world, in business and in mental health, as well as her thoughts on the future of mental health research and the role of women in science.

Is ‘Bad Moves’ aimed at a general audience?

Yes, very much so. It helps to have a little bit of scientific knowledge but really I’ve talked about the book at Hay Festival and at Cheltenham to very general audiences. I think the science and concepts are clear and there are pictures in the book to help explain very clearly about the different areas ofthe brain and decision making in general. I worked with my co-writer Jamie Nicole Labuzetta to make it very understandable to the general public because I did want it to be something that people who were interested in science, the brain, and society, could read and understand. I’ve had some comments from people who have said that it is really clear so I’m really pleased about that.

Could you give us a snapshot of what Bad Moves is about?

I was very excited to write the book, because decision making is such an important topic. We make decisions all the time and some of them are relatively trivial and we don’t really think about them at all. Sometimes though we make very important decisions and it’s key that we make good quality decisions, e.g. ‘am I going to marry this person?’, ‘do I want to go to this university?’, because these are life forming decisions and you want to make good quality ones. In my research I work with patients who have psychiatric disorders and sometimes the quality of their decisions is very poor. Sometimes they may make impulsive or risky decisions, or have difficulty coming to a decision at all.

 I separate out two types of decisions: hot and cold. Cold decisions are non emotional decisions, such as planning today, what you’re going to do first, how you’re going to organise things. We also make hot decisions. I ask my students to suppose they have an exam tomorrow and friends invite them for drinks and this girl/boy that they’re interested in is also going. You’ve got a conflict between knowing that you should stay in and study, get a good night’s sleep and knowing your friends are going to have a really good time. There’s a lot to gain- a reward- but you know there’s also punishment if you stay out too late. That’s a hot decision.

In business, a business plan is a cold decision, deciding the cost of marketing, or the sale price for example. The hot decision might be Dragons’ Den style venture capitalism deciding between risk and reward in a short time frame. Hot decisions are often time limited, so frequently these decisions have to be made rather rapidly.

Under conditions where your emotions take over, sometimes these hot decisions can be made very badly, so for instance in mania, people might max out a credit card. We’ve shown on tests of hot decision making that people in the manic state make very poor quality decisions and that’s related to the severity of their mania. 

 In work that we’ve done with people with depression we’ve shown that sometimes it takes a lot longer to make a decision and that can be problematic because sometimes our decisions are time limited.  Ideally in life we have a good balance between these types of decision, so we try to make sure that our emotions are regulated well and we watch ourselves so for example, we don’t get in the car and start driving when we’re angry because being in overly emotional state can cause you to make poor quality decisions and do something quite dangerous.

How is decision making affected by neurodegenerative conditions like dementia?

We’ve studied patients with neurodegenerative conditions like frontotemporal dementia (FTD) and it’s quite different from patients with Alzheimer’s disease (AD). In AD we see poor memory and it starts with what we call poor episodic memory, but usually personality stays quite intact and behaviour stays quite intact until the moderate to severe stages of AD. FTD affects the front part of the brain which is very important for our decision making, for instance an area that’s very important for our hot decision making is the orbitofrontal cortex, and an area that’s very important for the cold decision making is the dorsolateral prefrontal cortex. The orbitofrontal cortex gets affected quite early on in FTD and frequently results in behaviour changes and in strange decision making. One person we studied for example jammed his fork into a neighbour’s steak and took the steak and put it on his plate at a dinner party because it looked bigger. That is an example of the type of problems that these FTD patients experience.

We used a hot decision making task in the laboratory and looked to improve or reduce the risky behaviour and decision making in these patients with the drug methylphenidate, or Ritalin, a treatment for ADHD, and we found that we were able to reduce these

What is the neuroscience behind this, and what pathways is Ritalin working on in this instance?

We use these drugs to investigate the brain, but unfortunately our tools are not as specific as we would like so we know Ritalin boosts dopamine and noradrenaline in the brain. There is a newer treatment for ADHD called atomoxetine which relatively specifically works on noradrenalin and is very good at reducing overly impulsive behaviour. This has led us to suggest that increasing noradrenaline is important in reducing impulsivity. At present, we’re doing further studies to see whether we can help reduce unduly risky behaviour using atomoxetine.

We know that with manic patients if we could only help to improve their quality of their decision making and risky behaviour, there wouldn’t be so many consequences to their actions during manic state. That links to the second part of the book where I take up the idea that as these drugs that can improve our cognitive functioning, healthy people have started to use them to improve their cognition as well. The final part of the book talks about this increase in lifestyle use of ‘smart drugs’. I discuss how that might affect society in the future and why people are doing this and try to look at the pros and cons. One drug that’s frequently being used in universities is Ritalin and that’s being used by students often in exam situations or cramming for exams at the end of the academic year.

Modafinil is an interesting drug because it has many actions, for example, on dopamine, on noradrenaline, but also on glutamatergic function, so we’re not really sure how it exerts its cognitive enhancing effects but it does seem to indeed reduce apathy and promote task related motivation. In one of our recent studies with Ulrich Muller we were able to show that people found tasks much more pleasurable when they were on Modafinil compared to placebo. Drugs like Modafinil seem to improve the motivation and the pleasure of doing tasks which perhaps might not be enjoyable, such  as, studying for exams or completing a tax return.

Are smart drugs widely used?

There is an increasing lifestyle use of these ‘smart drugs’ by healthy people. It seems to me to be a growing market, but a lot of the buying is Internet buying so you don’t have any accurate record of it. Internet buying of course is a very dangerous way to get prescription only drugs, and I’m certainly very concerned about that aspect that young people are buying drugs that way.

I co-wrote a paper for Nature called Professor’s Little Helper about academics who were using the drugs and then they followed it up with a survey which had 1400 respondents showing that a fifth of respondents were using a cognitive enhancer, mainly stimulants and Modafinil.

We conducted a study in collaboration with Professor Lord Ara Darzi and we were interested in Modafinil and how it might be beneficial to keeping surgeons and other medical doctors awake and alert and how it might perhaps help them also train faster. In surgery, operations are often long and very delicate and so require focused attention for very long periods of time. Usually the way that doctors try to stay awake and alert is by taking coffee, caffeine, but side effects of caffeine includes heart palpitations and tremor, and so we were interested in perhaps trying to find an alerting, wake promoting agent that did not have such side effects at the dose required for cognitive enhancement.

We studied sleep deprived doctors on Modafinil and we found that it improved their cognitive flexibility (insert hyperlink) and it also reduced their impulsivity, so that seemed a very good thing. We can imagine that there are certain circumstances where certain groups of people who might want to use those sorts of drugs. The military have for some time used stimulants to keep themselves awake for long periods to make sure that they and their colleagues are safer under conflict or war situations.

What effect might smart drugs have on society?

I think as a society we have to consider and discuss this important question. We have an aging population. We know that with age there is a decline in cognition and of course it’s much exaggerated in mild cognitive impairment or AD, but it may be that if people have to work for longer and have to stay awake, alert, and function in the work environment, that we will be using more of these drugs in the future.

I was involved in the joint academies report recently on Human Enhancement and the Future of Work. The Royal Society, the Academy of Medical Sciences, the British Academy, and the Royal Academy of Engineering all came together to look at how human enhancement in the future might change the work environment and one thing that was raised was cognitive enhancing drugs. Perhaps bus drivers who are driving children back at night should be using these drugs because we know that there have been a few tragic accidents where bus drivers have fallen asleep and if they’d been on Modafinil and been alert this sort of thing might not have happened.

We have to consider how the lifestyle use of these ‘smart drugs’ will change society. One thing we don’t want to do is accelerate into a 24/7 society where we have no work/life balance and everybody just works all the time. Students when they’re using these ‘smart drugs’ frequently take another as it wears off and then of course they can’t sleep at night. We know that we consolidate our memories in our sleep and sleep is very restorative and it’s counterproductive not to be able to sleep. We want to boost our cognition and enhance our wellbeing through other means like education and new learning or exercise, and we don’t want our society to be transformed into a group of people who just pop pills and work all the time.

What about smart drug safety?

We don’t have long-term safety studies yet in healthy people and that’s one of the big problems, we don’t know whether over time using these drugs is a safe practice. It may be the government could get together with the pharmaceutical companies to conduct some of these drug safety trials. If they’re found to be safe and effective, perhaps they could be marketed through chemists and you could go to your doctor and find out whether it’s suitable for you, because another concern is when people are buying drugs over the internet they don’t know whether the drug is safe for them to use. For example, the person may have a pre-existing medical condition or be on other pharmaceutical treatments which might preclude the use of a particular cognitive enhancing drug.

It is very important that we have these cognitive enhancing drugs because people with neuropsychiatric disorders and brain injury need them so badly. People with depression frequently have to come off work because they can’t concentrate or make decisions. It would be great if these cognitive enhancing drugs could improve their ability to function at work and at home or at school or university and their ability to have a better quality of life.

You are very passionate about mental health research, what do you think are the next big areas that we need to tackle?

Mental health costs more than any of the other disorders, cancer, heart disease, and yet we don’t have enough research money. We really need to understand good brain health and what goes wrong when somebody gets a mental health disorder. The Department of Health issued a document in 2011 called ‘No Health Without Mental Health’ emphasized the key point that mental health is every bit as important as physical health.

I was involved in the Foresight Mental Capital and Wellbeing project with the UK government and there we took a life-course approach. The Foresight project was set up to try to address two major problems that the government had. One was the ageing population and with age increased risk of dementia. The other issue was financial loss to businesses due to days lost at work due to depression. I think that we need to start thinking very early on about our brain health in the same way we think about physical health and what we should be doing is detecting mental health problems early and treating them early. We know that 75% of mental health disorders start before the age of 24 years, so we really should be trying to stop them becoming life-course problems, life-long problems, because we know depression for instance can be chronic and relapsing and it is so debilitating for people.

We really want to make sure we can treat people effectively very early on so that they have a good quality of life. That’s not only good for the individual but it’s great for society because the cost of these disorders is very large. Hopefully we would be able to prevent mental health disorders from developing, but certainly we would reduce the cost and the debilitating effect of disorders like depression in the future through early detection and early effective treatment.

What do you think will help to destigmatise mental health conditions?

I do think celebrities like Ruby Wax and Stephen Fry talking about mental health is extremely helpful. When you think about it, 16% of us have a common mental disorder at any one time, and with the stresses of modern living, anxiety and depression are common disorders, so really there shouldn’t be much stigma attached to them because they’re so common.

You are a strong advocate of women in science. How do you think we can convince young female scientists to stay in research?

One of the things that keeps me most excited about my work is training young PhD students and I’d love to have more women come up through the ranks. I give a talk on leadership and women in science and I think most of what I have to say is equally useful for men as it is for women. I think some female students don’t have the level of confidence that their male counterparts have. It’s so important that you do have confidence in yourself.

I would also emphasise resilience, because in any field you get knocked back no matter how senior you get, you don’t get everything you want all the time. Sometimes papers get rejected, sometimes grants get rejected and you just have to try to learn from the experience, try to learn from the constructive comments that have been made and just try again. Try somewhere else, try the next journal and just move on. Try to take the criticism constructively, and be resilient, get back in there and if somebody tells you that you can’t do it, just be more determined to do it. Fortunately, we now have the Athena Swan Initiative, which is meant to help women get to the very top levels.

Why don’t women always advance to the highest levels in science?

I think the answer to this question is a complicated mix of reasons. Frequently, there are about equal numbers of women and men as undergraduates but as you get up towards the top there’re very few women. In part, it’s the combination of needing to be very resilient and needing to have confidence in yourself which is required to get to those very top levels. It makes it more difficult I think if you do have children to get to those very top levels, because science moves on so rapidly. So for women who take career breaks when having children, it is particularly difficult to reach the very top level. Networking is crucial for career development in science and I think it is a problem if it is difficult to travel to international meetings and network due to the responsibilities of looking after young children. What I would say to young women scientists is: keep your future goals in mind, be optimistic and be positive, because generally, if you’re optimistic, if you’re positive and you work hard, you will achieve your goals. Also, keep learning and developing throughout life.

Training young neuroscientists and contributing to improving the functionality and quality of life of patients is a very rewarding life goal so I very much hope you young female neuroscientists reading this will join me in translational research that will impact on good brain health for all members of society.

Bad Moves is now available to purchase and Professor Sahakian is pleased to sign copies for anyone who wishes. You can listen to her recent Radio 4 ‘Life Scientific’ here, coverage of her recent Café Scientifique event here and a podcast about women in science here.

Adapted from interview with Kate McAllister for Department of Psychiatry News


Posted on 19/07/2013

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