Professor Robert Howard MD MRCPsych
Professor of Old Age Psychiatry and Psychopathology
Consultant Old Age Psychiatrist, South London and Maudsley NHS Foundation Trust
Dean, The Royal College of Psychiatrists
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Institute of Psychiatry
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After undergraduate education at Cambridge and St Bartholomews Hospital and a couple of years in general medicine, Robert Howard came to the Maudsley Hospital as an SHO in 1988 and has never been able to work out how to leave. He is Chief Investigator on the MRC CALM-AD and DOMINO trials and works to provide an independent evidence base to support the use of effective treatments in people with dementia, depression or psychosis. Clinically, Robert Howard is an inpatient consultant in the Southwark Mental Health for Older Adults Service within SLAM and has an interest in forensic and other medicolegal issues in old age. As Dean of the Royal College of Psychiatrists he leads on the setting and raising of professional and training standards for psychiatry in the UK.
activities and interests
Very late-onset schizophrenia-like psychosis. Psychosis that has onset after the age of 60 years is surprisingly common and our work has shown that this cannot be attributed to focal brain pathology or increased morbid risk among relatives but that increasing age, membership of a migrant group and difficulties with mentalisation can be added to the established risk factors of female gender and sensory impairment. We are continuing to explore how activity within the dopaminergic system changes with increasing age in females and investigating the utility of mentalising therapy, using film clips to train patients to understand social situations within which deception is involved. We are also about to begin recruitment to ATLAS (Antipsychotic treatment in very late-onset schizophrenia-like psychosis) which will be the first RCT to examine treatment in this group.
Brain imaging in dementia and psychosis. We were among the first groups to use functional brain imaging to locate activity associated with auditory and visual hallucinations and to investigate the substrate of visual imagery and motion perception and were the first to show that purely visual stimulation could activate auditory cortex and that hallucinatory activity was restricted to those brain areas whose activity supports perception. These findings have been used to explore the use of functional brain imaging to distinguish different dementia pathologies. Our main imaging approach to dementia has been to develop a paired associate learning stimulation paradigm which can be delivered to subjects during scanning at a number of different difficulty levels so that we can control for the confounds of performance success, relative and absolute difficulty. With this we have shown that young and old healthy subjects and patients with early Alzheimers disease all use the same brain areas to perform paired associate learning and that patients doing an easy task use the same brain regions that a healthy person would only have to use at a more difficult task level. These findings are currently being exploited to try and develop a robust biomarker of disease course progression in Alzheimers disease. To carry out more difficult levels of task, both patients and healthy comparison subjects recruit medial frontal regions - patients at easier levels than comparison subjects. We are currently investigating the sensitivity and reliability of just how early this frontal activation occurs and how it increases with increasing task difficulty in patients and healthy subjects scanned at 2 intervals separated by 6 months.
Independent large-scale randomised controlled trials. The evidence base used to support the use of most drug treatments in old age psychiatry is either modest or has been controlled by the pharmaceutical industry. Our work aims to change this situation through the identification of areas of genuine clinical uncertainty that can be tested through conduct of a trial. Some of the trials are still ongoing, but here is a sample with the questions that they hope to answer:
Is delirium preventable through training of general hospital staff to recognise and take steps to avoid emergence of symptoms? We carried out a trial of a staff education package within wards at Kings College Hospital and were able to halve the number of incident cases of delirium seen.
Is it possible to reduce the large proportion of nursing home residents with dementia who are routinely prescribed antipsychotic drugs? The FITS trial showed that provision of support to nursing homes in the form of 1 day per week of additional training reduced the proportion of residents prescribed antipsychotic drugs by 50%.
Do cholinesterase inhibitors have efficacy in the treatment of clinically significant agitated behaviour in people with Alzheimers disease? The CALM-AD trial showed unequivocally in 270 patients that these drugs were no better than placebo in the treatment of agitation although they did have a small positive effect on cognitive function.
Are the current NICE stopping rules for cholinesterase inhibitors correct? Should patients continue with their drugs once they have moderate to severe Alzheimers disease and do they benefit from adding memantine? The DOMINO trial begins recruitment in February 2008. To learn more about this trial visit http://neuroscience.iop.kcl.ac.uk/domino/
Are antipsychotic drugs superior to placebo in the treatment of patients with very late-onset schizophrenia-like psychosis? The ATLAS trial which commences recruitment in late 2010 will examine the effects of double-blind short-term (12 weeks) and longer term (26 weeks) treatment with amisulpride 100mg and placebo.
Can cognitive training improve cognition and slow down the rate of cognitive decline in mild Alzheimer’s disease? Together with Adrian Owen and colleagues in Cambridge we are developing an internet-deliverable cognitive training package based on the Cambridge Brain Gym (http://www.cambridgebraingym.com/tests.htm) which will be subject to a major RCT in the near future.
Can immunotherapy prevent or delay the appearance of Alzheimer’s disease in people with Downs Syndrome? Together with Tony Holland in Cambridge we are interested in investigating whether one of the current amyloid-based immunotherapy treatments can delay onset of symptomatic AD in this very high risk group.
Training and Standards in Psychiatry
As Dean of the Royal College of Psychiatrists (2008-13) I am the profession’s elected lead on training and professional standards. Within the College, I Chair the Education, Training and Standards Committee and the Heads of Schools Committee. Together with four Associate Deans, I have responsibility for the Curriculum, MRCPsych Examination and other assessments, Continuing Professional Development and Revalidation. As part of raising and maintaining standards in Psychiatry, I want us to attract the very brightest and best of trainees from all over the World to join us. In recent years, careers in Psychiatry have not been popular with UK medical school graduates. Changing undergraduate and foundation trainee perceptions about Psychiatry is an important ambition for the College and you can find out more about how we are doing this by visiting the College website.
Howard R, Juszczak E, Ballard C, Bentham P, Brown RG, Bullock R, Burns A, Holmes C, Jacoby R, Johnson T, Knapp M, Lindesay J, O’Brien J, Wilcock G, Katona C, Jones R, DeCesare J, Rodger M on behalf of the CALM-AD Trial Group (2007) Donepezil for agitation in Alzheimers disease: a randomized placebo-controlled trial (The CALM-AD Trial). New England Journal of Medicine 357 1382-1392.
Reeves S, Brown R, Howard R, Grasby P (2009) Increased striatal dopamine (D2/D3) receptor availability and delusions in Alzheimer’s disease. Neurology 72 528-534.
Bentall RP, Rowse G, Shryane N, Kinderman P, Howard R, Blackwood N, Moore R, Corcoran R (2009) The phenomenology and cognitive structure of paranoid delusions: A transdiagnostic investigation of patients with schizophrenia spectrum disorders and depression. Archives of General Psychiatry 66 236-247.
Bishara D, Taylor D, Howard R, Abdel-Tawab R (2009) Expert opinion on the management of behavioural and psychological symptoms of dementia (BPSD) and investigation into prescribing practices in the UK. International Journal of Geriatric Psychiatry 24 944-954.
Ballard C, Brown R, Fossey J, Douglas S, Bradley P, Hancock J, James I, Juszczak E, Bentham P, Burns A, Lindesay J, Jacoby R, O’Brien J, Bullock R, Johnson T, Holmes C, Howard R (2009) Brief psychosocial therapy for the treatment of agitation in Alzheimer disease (The CALM-AD Trial). American Journal of Geriatric Psychiatry 17 726-733.
Jones R, Sheehand B, Phillips P, Juszsczak E, Adams J, Baldwin A, Ballard C, Banerjee S, Barber B, Bentham P, Brown R, Burns A, Dening T, Findlay D, Gray R, Griffin M, Holmes C, Hughes A, Jacoby R, Johnson T, Jones R, Knapp M, Lindesay J, McKeith IG, McShane R, Macharoutou A, O’Brien J, Onions C, Passmore P, Raftery J, Ritchie C, Howard R (2009) DOMINO-AD protocol: donepezil and memantine in moderate to severe Alzheimer’s disease. Trials 10 57
Tabet N, Howard R (2009) Pharmacological treatment for the prevention of delirium: review of current evidence. International Journal of Geriatric Psychiatry 24 1037-1044.
Reeves S, Brown R, Matthews D, Howard R, Grasby R (2010) No effect of donepezil on striatal dopamine release in mild to moderate Alzheimer’s disease. Journal of Neurology, Neurosurgery and Psychiatry 81 119-121.
Reeves S, Mehta M, Howard R, Grasby P, Brown R (2010) The dopaminergic basis of cognitive and motor performance in Alzheimer’s disease. Neurobiology of Disease 37 477-482.
Owen AM, Hampshire A, Grahn JA, Stenton R, Dajani S, Burns AS, Howard R, Ballard C (2010) Putting brain training to the test. Nature 465 775-778.
last updated: Monday, June 28, 2010