Articles, Blog

Mental Illness Across the Ages

December 28, 2019

Good evening everyone. My name is Mark Frankel, I am director of
the AAAS Scientific Responsibility, Human Rights and Law program under the [inaudible]
this series is held at AAAS. This is the third in our neuroscience and
society series in 2015, and tonight’s topic is mental illness through the ages from children,
to adolescence, to middle age and the elderly. We have an excellent series of speakers who
have accepted our invitation to address us on the topic. Before I go any further, I’d like to introduce
a relatively new staff addition to AAAS, but by no means someone who’s new to the community
of people who are concerned about the role of science and technology in society. He’s been with us less than a year and I believe
this is his first opportunity to attend one of our series events. So please welcome to AAAS our new chief executive
officer and former member of congress, Dr. Rush Holt who is in the back. Rush, we’re delighted to have you here and
look forward to your joining us for other events in this series as your schedule permits. This series, as some of you will know is a
partnership with the Dana Foundation. I want to acknowledge not only their financial
support but also their collaboration in planning these events. Every year at the end of the series for that
year we get together and brainstorm about topics, and we end up with a list of, I don’t
know, maybe nine or ten without repeating of course topics from previous years. This is by the way is the end of our fourth
year. We brainstorm about what will be topics, what’s
coming up, what’s emerging or what’s just plain interesting, at least would be interesting
to a public audience. I want to thank them for all of the contributions
that they make intellectually to the programs as well as financially. In planning for tonight’s topic I did a bit
of background research and was struck by some of the numbers associated with mental illness
in the United States. I have no doubt that our speakers will likely
introduce others, but here are some that stood out for me. Nearly 5 million children in the United States
have some type of serious mental illness with an estimated $247 billion spent each year
just on childhood mental disorders. Mental illness is linked to suicide which
is the second leading cause of death among adolescents between the ages of 12 and 17
years, and over 8% of adolescents suffer from depression that lasts a year or more, and
that depression is the leading cause of disability in the United States in people over five years
of age. As someone who does not work in this particular
field, I found those numbers quite striking, and I think it goes without saying and just
looking at the numbers, forgetting of course for a moment the personal price that people
pay. Just looking at the numbers suggest that we
have a topic of great social importance for all of us in the United States, and I suspect
you can get similar numbers from other parts of the world as well. Now to our program, after which we’ll end
around seven and there will be a reception just outside the auditorium, and you’re all
invited to join us and the speakers and informally converse about the topic of the day or whatever
else interests you. You have speaker bios in your program, this
is the program which I hope you picked up. So I’m not going to use a lot of time to go
through all of these biographical materials, they’re there for you to look at as you see
fit, but I will highlight a few things in my introducing each individual speaker. There will be no questions after each talk,
we’ll save those for a period that will follow the third speaker when all of them will come
up here, we’ll have a moderated discussion or a conversation, and then we’ll open it
up to the people in the audience. You’ll see mics on the aisles, microphones,
this is being videoed and recorded, it will be posted on the Dana Foundation website. Typically it’s a week to 10 days afterwards,
but we will also have a link to it from the AAAS website. One final announcement that I forgot that
I want to alert you to, and that’s our final event in the series for 2015, it’s going to
be on October 27th here, and has a working title of creativity and genius. Creativity and genius and we’re still fleshing
things out a bit at this moment, but put that on your calendar and you’ll hear from us when
we’re ready to go. Without further ado, let me introduce our
first speaker, Dr. Nelson Freimer. Dr. Freimer is the Maggie G. Gilbert Professor
in the department of psychiatry and human genetics in the David Geffen School of Medicine. Director of the Center for Neurobehavioral
Genetics, director of the Depression Grand Challenge, and Associate Director of the Semel
Institute for Neuroscience and Human Behavior all at UCLA. His research tends to focus on using the tools
of large scale genomic science to elucidate the genetic basis of common human disorders,
but he’s particularly interested in the number of those that fall under the rubric of mental
illness. He is going to focus on mental illness in
the midlife and elderly timeframe. Please join me in welcoming Dr. Freimer. Thank you for asking me to join this session
and it’s really a privilege to be involved in really such a valuable series, this is
really an incredible thing that AAAS and Dana do. As Mark said, I’m going to talk about mental
illness in mid and late life, and this is a pretty heavy charge for 20 minutes of talk. What I’m going to try to do is very briefly,
sort of give a summary of what the illnesses that we’re talking about are, a little bit
about their prevalence and impact, he’s already said a little bit about that. Then I’ll say something about treatment and
the issues of treatment for these disorders in mid and late life, and then finally I’ll
take a prerogative of just spending a couple of minutes talking about genetics and the
role of research in really hopefully developing better treatments which as you’ll hear is
something that we really need for these diseases. What we’re talking about when we talk about
the main mental disorders of midlife and late life, the adult mental disorders can really
be broken down into these categories. Disorders of thought by which we mainly mean
schizophrenia which consists of mainly psychotic symptoms like delusions, hallucinations, disorganization
of speech and behavior, and the so-called negative symptoms, loss of volution, loss
of affect and so forth. Disorders of mood by which we mean major depression
and bipolar disorder, where both major depression bipolar disorder are characterized by episodes
of depression which people are mostly familiar with which involve depressed mood, loss of
pleasure, alterations in sleep and weight, either up and down, slowed speech, loss of
energy and concentration, feelings of worthlessness and its most extreme form, suicidality which
Mark also mentioned. Bipolar disorder also involves episodes of
mania which, simplistic terms are essentially the opposite of depression, elevated mood,
pursuit of pleasurable activities usually ones that are risky and could have catastrophic
consequences with a decreased need for sleep, pressured speech, flight of ideas and grandiosity. Both depression and bipolar disorder may have
psychotic symptoms. Anxiety disorders which may be the most common
of all of these disorders for example, panic disorder, social phobia, some people would
include post-traumatic stress in this category. I’m not going to talk about it anymore in
the interest of time. The neurocognitive disorders which, again,
some people may not consider a mental disorders, but I think that they do go with the other
disorders that we’re talking about. What really differentiates these disorders
from the other ones we’re talking about is that whereas the other ones are diagnosed
and really recognized entirely on the basis of symptoms and subjective manifestations. The neurocognitive disorders such as Alzheimer’s
disease, frontotemporal dementia, vascular dementia are diseases for which we actually
understand something about the underlying biology, we understand the pathology which
is different in all of these types of disorders. In many cases, we actually have identified
the genetic contributions of these diseases which has really led to the sort of the start
of gaining traction on more specific treatments. One thing I want to mention though is that
all of these disorders are very prevalent, schizophrenia the least at 1%, but as you
can see with depression in about 7-10%, bipolar disorder is 3-4%, anxiety disorder is as high
as 20%, and these neurocognitive disorders as high as 5-6%. These are among the most common disorders
that face our society. As Mark mentioned, these disorders have an
incredible impact on society. So, if one looks at the burden of disease
by which we usually mean the premature loss of life or mortality and disability, mental
disorders throughout the adult age ranges are the leading contributors to the burden
of disease until the very, very last years of life when cancer and heart disease overtake
it. For most of these period of mid and late life,
it’s really the mental disorders that are the biggest impact diseases in the society. Depression as he also mentioned is the leading
one of all. Depression is the disease that is the leading
contributor of global disease burden and even more so in North America. This is really a very significant health problem. However, the funding for these diseases is
really not commensurate with the burdens that they represent. Now, I think that one should not just equate
the amount of funding that the disease, the research in the disease gets with its burden
of disease. I mean clearly, AIDS research has been enormously
important not only for the United States but for the world, but I do just want to really
emphasize the fact that considering the burden that it represents, depression in particular
has been enormously underfunded at the federal level and also in terms of philanthropy. It’s one of the reasons why we still understand
so little about this disorder, and again, this is something that characterizes really
all of these adult psychiatric disorders. While we talk about all of these disorders
as being adult mental disorders, they all have different periods of the life span in
which they’re particularly important. This is actually a slide which shows the impact
of disease that is the impact on the burden of disease of different disorders at different
points in a lifetime. I won’t talk about the childhood, adolescent
disorders that you’ll hear about in the next talk, but to talk about the adult disorders
at the beginning of adulthood disorders such as schizophrenia, drug and alcohol abuse play
a particularly large role. As you can see, in large part because of the
excess mortality that affects people that have these disorders, for example, people
with schizophrenia, it’s estimated something like a 10 to 15-year lower life expectancy
than the rest of the population, and so by end of life, these disorders play a much smaller
role. In contrast, depression which is shown here
in this light purple horizontal bar represents the largest prevalence and impact disorder
really throughout the adult range. Bipolar and anxiety disorders again are fairly
constant throughout the adult lifespan. It’s important though to interpret these kinds
of statistics cautiously and I’m just going to give an example of this with respect to
depression. This is from what’s called the National Comorbidity
study, a very large epidemiology study in the US. If you look at this you would think that prevalence
follows this very neat process where it remains about the same prevalence, and then it’s much
less prevalent among the elderly. However, if one dissects this further, what
you can actually see is that what really is determining this apparent decrease in prevalence
among the elderly is really that depression is characterized by a cohort effect whereby
each cohort, as in each younger cohort has a higher prevalence of depression at an earlier
onset so that those who are now in early adulthood will, by the time they are in late life, having
much higher prevalence of depression than the individuals who are now over 60. This is something that’s actually, again,
a very important point because it speaks to what will be and it really an epidemic of
depression in mid and late life over the next several decades. To talk about treatment, the first point I
want to make is that in some ways treatment has come in enormously long way over the past
couple of hundred years. This is a painting by Goya called the Madhouse
from about 200 years ago, and it sort of conforms to what you might imagine was the treatment
of severe mental illness in the middle ages where people who were suffering from these
disorders were essentially thrown in to what essentially amounted to prisons and not offered
any treatment. While we’ve gotten a lot better, it’s also
really important to recognize the incredible deficit of treatment that we have for these
disorders and our society, and this is something that particularly I think affects the United
States. One very important point is that psychiatric
inpatient treatment is almost completely disappearing. In fact, we have about the same number of
psychiatric inpatient beds now that we had in 1850 when what you might consider the humane
treatment was just starting. That’s really had the effects that mental
illness is now seen primarily in places like the criminal justice system where rating from
about 40% of the population of federal prisons, to about 60% of the population of local jails
are affected with major mental illness to the point where … not as facetious comment,
it’s stated that the Los Angeles Jail is the largest psychiatric hospital in the world. I’ve heard similar things about the Cooke
County Jail and I think it just speaks to the overall problem. The other place where mental illness is found
to be an incredibly high degree is on the streets where among the homeless, at least
30% of the population also suffers from major mental illness. However, it’s not just in these settings where
treatment is really insufficient. If you look at the population as a whole,
less than 40% of all adults who have mental illness received any kind of treatment in
the past year. There’s a major problem with ethnic disparities
here where, as you might expect that certainly not a great percentage of the white population
receives care for mental illness, but you can see that it’s much greater than among
Hispanic, black and asian populations. Really, the major point about the treatment
of adult mental illness is that it’s just not being done. I mean we can talk about the inadequacies
of our treatments which I will in a moment, but really the major point that I want to
get at of this entire talk is that we really are doing very little to treat what is an
enormous problem. We know that the failure to treat has really
devastating effects both for the society and for the individuals affected, and this is
particularly true in the mid and late life. For example, taking depression, the failure
to treat depression is associated with functional decline and increased disability throughout
the mid and late life period. It’s associated with increased use of regular
health services that is non-mental health services, and this has become an enormous
economic issue. It’s also associated with increased mortality
among individuals over the 50 months after being diagnosed with depression, there’s a
four times higher rate of mortality. I’m just going to mention briefly suicide
and cardiac deaths. While teen suicide is something that obviously
gets a lot of attention and it’s been an obvious tragedy, the highest both in rate and in number
of suicides are among individuals in mid life. What I think people maybe really surprised
by is that the rate remains incredibly high even among the elderly, so that again, next
to the group that’s in the age range of 45 to 54, those over the age of 75 have the second
highest rate of suicide of any age range. For cardiac disease similarly, mortality is
an incredible consequence of depression. This slide just shows over the months after
myocardial infarction, the mortality rate among individuals who were not depressed compared
to individuals who are depressed. You don’t really need any kind of statistics
to see that this is really an incredibly powerful effect that depression has on death after
myocardial infarction. Just to talk very briefly about the treatments
that we have for these major disorders of adult life, and again, this is something that
could be an hour long discussion in its own right. The major categories of treatments include
psychotherapy which includes both a whole range of what might be called traditional
psychotherapies, more recently has been particularly were called evidence-based therapies such
as cognitive and behavioral therapy, drug therapy including anti-psychotic treatments,
mood stabilizing treatments which are primarily used in bipolar disorder, and anti-depressants
which are used in really all of the different categories of adult mental illness. Neuromodulation treatment is a category that’s
gotten a lot of attention in the last few years. In particular, for depression the sort of
initiation of methods such as transcranial magnetic stimulation or even deep brain stimulation
which involves implantation of electrodes to stimulate particular areas of the brain. I also want to really emphasize that sort
of the oldest of all of these forms of treatment in some ways is electroconvulsive therapy
or ECT which of all the treatments for depression is actually the most effective, and actually
because of that fact is increasingly being used. Really, all of our current treatments are
unsatisfactory and that’s what’s going to drive my talk about research in the last few
minutes. For example, anti-psychotic drugs have really
serious side effects. For schizophrenia they mostly target the so-called
positive symptoms like hallucinations and delusions, they really don’t at all target
the negative symptoms which are really the ones that maybe the most disabling, which
really are the ones that prevent people from say, going to school or going to work. We really have no treatments for bipolar depression
that are very effective, and this is really the major source of disability for bipolar
disorder is the inability to treat the depressive phase. We’re actually pretty good at treating and
preventing the manic phase with stabilizing drugs. Depression treatments are really incredibly
unsatisfactory, they take too long to work, they usually take months to begin to show
an effect, they’re very, very modestly effective. Perhaps 50% of the people who were treated
with either psychotherapy or drugs get only at best a very partial effect. They are completely non-specific, although
depression is probably a very heterogeneous disorder, when we go to treat depression it’s
like throwing a dart while we’re blindfolded, we really have absolutely no targeting at
this point. I just want to mention that are special issues
in the treatment of mental illness in late life. Neurocognitive disorders, we essentially have
no treatments which really do anything to slow, much less to stop the decline in cognition
from these disorders. The treatments that we use for other disorders
may in fact worsen cognition, so drugs that we use to treat say psychosis or depression. Because of the fact that people in the elderly
having a lot of other medical problem, there’s an increased problem with side effects and
drug-drug interactions. Again, throughout the entire range of these
disorders, we have really no good treatments at this point that we should feel very satisfied
with. The last point that I want to make is that
to improve treatments we must understand causation. Our current diagnostic system in psychiatry,
in particular that that describe these adult disorders is based on observation and self-report. As I mentioned, the neurocognitive disorders
are based on pathology, or at this point even based on molecular understanding. For disorders like depression, schizophrenia,
bipolar disorder, they really all are still diagnosed according to the system developed
by Emil Kraepelin who is a German psychiatrist. At the turn of the last century, based on
his observations, because people stayed in mental hospitals at that time for years, he
was able to make observations over years in most of his patients. On the basis of course of illnesses he separated
the mood disorders, depression, bipolar disorder from thought disorders like schizophrenia. He really made these categorizations based
on the observation that people with schizophrenia had a, what he considered a chronic and unrelenting
course, whereas these disorders had an episodic course. Of course, this doesn’t really conform to
the complete clinical reality, and so, if one actually looks at these disorders which
he treated as completely separate, one can see that at the level of the clinical manifestations,
if not, the disease course, that it’s the clinical manifestations that are the targets
for treatment. Things like hallucinations, like suicidality,
like delusions, that there’s an incredible overlap between these disorders. One can see this when one looks at the results
of genetics studies. Recent studies have really emphasized this
overlap has a genetic basis. For example, if we look at the whole range
of studies that had been undertaken comparing bipolar disorders with schizophrenia, depression
with schizophrenia, depression with bipolar disorder, one can see that these disorders
at the genetic level are really quite correlated with each other. That is to really get to the causation involves
trying to study them together, and it’s really the only way that we’re going to get to new
treatments in my opinion. Now in the last couple of slides, this slide
actually summarizes the history of genetic research for these disorders. Without go through it in detail, this takes
the whole range of the psychiatric disorders, and we’ve already talked about how highly
prevalent they are, they all have a very strong genetic basis, they all have a very high degree
of heritability in families. We are now just beginning to get success from
doing genetic studies, so studies looking at common genetic variation, we now have for
example for schizophrenia, over 110 different genes that are now conclusively associated
with schizophrenia which is in my mind a truly remarkable accomplishment. However, the results have been much less good
for some of the other disorders, and I’ll particularly mention depression which as I
have been emphasizing is the most prevalent and the one that has the largest impact where
we’ve really at this point had almost no success for genetic studies. That’s really because in order to elucidate
the genetic contribution to disease like depression which is so heterogeneous and complex, is
going to take very, very large studies. This is a quote from Steve Hyman who’s a former
director of the National Institute of Mental Health which is saying that to understand
the molecular and mechanisms of depression, we’re going to need to collect data from more
than 100,000 people. The last thing I want to talk about is the
endeavor that I’m most involved with which is called the depression grand challenge and
has the goal of ultimately eliminating the burden of depression. Sort of taking Steve Hyman’s challenge and
its word were now embarked on the study of 100,000 with depression to try to identify
the genetic contributions to depression risk which will lead to new molecular targets for
treatment, to identify markers for depression course of treatment response. So that unlike throwing a dark at the dart
board blindfolded, we’ll have more specific treatment, and this really is what people
nowadays are calling precision medicine and it’s gotten a lot of publicity recently. Ultimately from the results of these studies,
we will hopefully be able to implement new treatments and preventive interventions. This is something that I’ve been mentioning
here for depression, but really it’s the same process that we hope will occur for all of
these disorders. Thank you. I told you they’d be on the numbers, they
were all very discouraging unfortunately. So our next speaker, thank you Dr. Freimer,
our next speaker is Dr. Ann Marie Albano. She is a professor of clinical psychology
and psychiatry at the Columbia University Medical Center, and founder and director of
the Columbia University Clinic for Anxiety and related disorders. She’s board certified in clinical child and
adolescent psychology, and is the inaugural editor of evidence-based practice in child
and adolescent mental health. Evidence-based practice is a phrase that really
resonates here at AAAS. I’m delighted she’s able to join us, and you
might imagine, she’s going to be discussing mental illness among children and adolescents. Please join me in welcoming her. Thank you. My turn to mess up here. In this talk, what I want to go over today
is a bit of discussion of the rates of mental illnesses in kids, children and adolescent,
you saw a little bit of it in the previous talk but we’ll talk more in-depth. What we know about treatment, what we know
about treatment based on the science but what we know also about what’s going on in the
community. I want to focus on two neglected age groups,
the very young children and those who are emerging into adulthood, and then what we’re
going to be looking at going forward. First, let’s just take a quick look at the
scope of the problem. This is a slide from the study of the National
Comorbidity Survey of adolescents conducted by Kathleen Merikangas in addition to Ron
Kessler and others. What I want you to focus on here is bearing
in mind when do these disorders start and what are these disorders that wreak havoc
in the lives of children. So here’s the age in years, and this is cumulative
percent in terms of prevalence. Starting at age four you see the onset of
anxiety disorders, this continue a steep and steady rise throughout adolescents through
age 18, and as we saw previously, throughout the lifespan. Anxiety disorders in childhood predict every
mental illness you can name in adulthood. In the old days, parents would be told about
their child’s fear of the dark, fear of separating, don’t worry they’ll grow out of it, it’s a
phase. What this data and others have shown is they
are not phases, in fact, anxiety disorders are the gateway disorders for every mental
health condition that comes next. We have to keep that in mind, these are not
being conditions. Next, the age of onset around six to seven
years of age, eight, are the disruptive behavior disorders. We’re talking here about ADHD and oppositional
defiant disorder, and then when we hit the adolescent years you’re looking at conduct
disorder. What might be precursors to then antisocial
personality. These are the next disorders of onset. You see here then, adolescent depression. Depression sometimes will occur earlier in
childhood but mostly girls 13 to 14 years or age are at higher risk, and then for boys
it’s a little later, 15 to 16 years of age. But depression is typically preceded by anxiety,
so remember that. Finally, the last disorders of onset per say
are the substance used conditions, so 16, 17 years of age. A lot of times use of substances is in response
to self-medication of anxiety or depression, or in reaction to acting out that you get
from the externalizing disorders. These disorders add to one another, and it’s
very rare in any of our studies that we have conducted to find only one or two conditions
in a youth of any given age, they are usually multiply comorbid with three, four, five or
more conditions in one child. Just so we also look at this, these are rates
for now autism spectrum diagnosis. You could see from 2000 going to 2010, what
we look at is an increased prevalence but actually this may be more of a better characterization
and classification of youth who have the spectrum, or on the spectrum in one way. If I talk to colleagues like Cathy Lord who’s
an expert in this … If I talk to colleagues like Cathy Lord, who’s
an expert in this area, she will say that we are really categorizing kids more. Whether there are kids who are false positives
here? It depends. There’s a wide range of variation on who gets
diagnosed with these disorders. But the bottom line is that children are suffering. They’re suffering early and they’re suffering
from all the conditions that you heard talked about in adults, they’re just coming on earlier
time. So what do we do about this? Because one of the things we know is for any
given mental health problem, it interferes with the child’s functioning. It interferes with their ability to progress
in school. It interferes with their ability to make and
keep friends and become socially adept. It interferes with family functioning, and
then the vegetative aspects of it. They don’t know how to sooth themselves. They get into great distress. There’s a lot of somatization and such, so
kid’s are really suffering in a big way. Now the good news is that we do have effective
treatments. And just to give some of the examples of some
of the key studies in child and adolescent mental health funded by the national institutes
of mental heath. One is the child anxiety mulitmodal study,
where we had 488 children between the ages of seven to 17 randomly assigned to combination
treatment of cognitive-behavioral therapy, or SSRI of sertraline, cognitive-behavioral
therapy alone, sertraline, or pill placebo. The good news from the acute outcomes are
that three different treatments are affective for the anxiety disorders. This is separation, social, and generalized
anxiety disorder. What you find is the combination treatment
is the most effective, significantly better than all others. But the two monotherapies are just as effective
as one another, and they too are significantly better than pill placebo. Effective treatments. Let’s keep that in mind. The outcomes for this holdout over six months
in terms of keeping the children after we broke the blind, we kept the kids who were
responders on maintenance therapy, and they continued to hold their outcomes over six
more months. If you look at the other large trials that
were conducted, the multimodal treatment of ADHD study, this was the largest study ever
funded for the treatment of youth. Again, I think they were closer to seven to
14 years of age with ADHD. Here what we find is methylphenidate or the
stimulant medication is equally effective by itself to combination of methylphenidate
with behavioral interventions. The behavioral interventions involve classroom
training, parent training, and some self controlled training for the youth. By itself, behavioral interventions were not
significantly different from just whatever you can get in the community that wasn’t an
evidence-based treatment. However, over the longer, longer terms, the
behavioral interventions caught up with the kids who were treated with combination or
methylphenidate. It just might be that for these behavioral
treatments, they take a little longer. In the treatments for adolescents with depression
study, of which I was a principal investigator there too, combination therapy for adolescents
between the ages of 12 and 17 is the most effective treatment. There what we saw is cognitive- behavioral
therapy with Prozac. In fact, also, when you have the combination
you have fewer incidents of suicidality or self-halm. Okay? But then fluoxetine, or Prozac, by itself
was effective and better than CBT, which did not separate from placebo after 12 weeks. Again, if you go out to 16 weeks CBT is doing
well. We likewise know that interpersonal therapy
also, again, doesn’t come on as quickly in terms of the effects of the medication, but
then also is an effective therapy evidence based for adolescent depression. Finally the pediatric OCD treatment study,
combination treatment, was superior to all the others but CBT was superior to the medication
only. The medication actually was just beating placebo
here. The bottom line, what we know, is we do have
effective treatments in pharmacotherapy and also in evidence based cognitive-behavioral,
behavioral interventions, and interpersonal therapy. This is just a follow up of the TAD study,
the Treatments for Adolescent Depression study. Again, you find this where the psychosocial
intervention by itself tends to pick up over time in comparison to the medication conditions. With that in mind, what’s happening in the
community? What actually are kids getting when they seek
care in the community from providers? Well, one thing to know, again, this is from
the National Comorbidity Survey, the community prevalence of any disorder that you see here
is not at all being touched by the prevalence of treatment for that disorder in the community. So where we have an 11.7% prevalence of mood
disorder, you’re only seeing about 4.6% of those kids receiving treatment. If you look at disorders with high levels
of prevalence, specific phobia, which are not, as I said, benign conditions. 1.4% are receiving treatment. Social phobia, which is one of the most prevalent
anxiety disorders in adulthood, that is just gonna stick with these kids, again 1.4%. So we’re pretty bad at getting kids into treatment
at a time when they most need it. I want you to also bear in mind something. When children develop a mental illness, as
you saw in the first slide, it starts early. As soon as they develop a mental illness,
they become very different from their peers. They are taken off the developmental trajectory
of just normal development. They are not socializing the way the other
kids are. They are not accessing and learning from their
teachers and in the environment of school the way others are. They are more disrupted in terms of their
mood and regulating their emotions than others. They’re not learning social problem solving
skills. They’re not becoming independent. For whatever reason, maybe because they’re
suffering, maybe because the parents are anxious about how behind they are, this is where what
the laypeople call “helicopter parenting,” we call parental overprotection occurs. Parents swoop in to help. What happens is kids fall behind developmentally
and they don’t learn to struggle and deal with things and the skills that the other
kids have, so they chronically fall behind others. So, what we need to do is deliver effective
interventions, but here’s something for us to think about. Where is the gap between having developed
effective interventions in studies and transporting them and delivering them into the community? Well, one of the things that we know is that
what we call a research to practice gap, for any kind of intervention, is whether the intervention
is provided or not provided based on evidence. There’s different types of evidence. We could have evidence of a positive effect,
like you see for some of the slides I show for depression, anxiety, and so forth. If that treatment from the TAD study, the
MTA, any of them, if they’re delivered in the community, there’s no practice gap, things
are fine. But if a child, let’s say, is referred for
an anxiety disorder and they are not given one of the evidence based interventions, they’re
maybe sent to playing solitaire therapy or something, that is a failure to translate
the evidence. That child then doesn’t get help with getting
back on track of managing the emotions, and then also developmentally on track. We also know about treatments in the community
that actually have evidence of a harmful effect. When that intervention is provided, that causes
harm. Okay? So that’s a gap that can be harmful. There may be evidence of no effect, that is,
there’s no evidence that this treatment works. It’s kinda like giving out placebos. This is opportunity costs. When kids and parents spend time and resources
in a therapy that’s going nowhere and the child is not referred to an evidence based
treatment. Then, finally, we just have some treatments
that do not have studies behind them yet, but they’re out there. We could talk about traditional psychotherapies
where we need to study these interventions and understand what’s happening. Just to understand what is delivered in the
community, many kids get sent for disruptive behavior disorders to bootcamp type settings. There is, in fact, evidence that these programs
do harm. So kids should not be sent there. They actually should be sent to more of the
fast track or multisystemic therapy, or dialectical behavioral therapy approaches, which have
evidence behind them. We also know dolphin and equine therapy. It’s equine therapy in the north. It’s dolphin therapy in Florida. Lot’s of kids with disruptive behavior disorders,
anxiety, depression, you name it, there absolutely, there’s not evidence thus far that these treatments
work. So what happens, and these are costly treatments
for families, opportunity is lost. Because again, the child is in a program that’s
not changing their mental illness issue, not putting them back developmentally where they
need to be. The families are sinking money. They’re losing hope, and the child is losing
time. Let’s remember, you only have 18 years, roughly,
until you are supposedly out in the world. Some of the more severe problems that we’ve
seen, these rage reduction holding therapies, where you wrap a child in a blanket or various
ways, children have actually died from this. Again, it does harm. We’ve heard a lot in the news recently about
conversion or reparative therapies for sexual orientation. Again, these do harm, thank goodness. This is where we see kids committing suicide. These are prominent in the news. A number of cases because of families trying
to get them converted to being straight. Thank goodness, these therapies are being
outlawed in certain states. So again, there’s different problems with
the translation of the evidence based to the community and that is also being served by
the fact that, in training programs for mental health practitioners, psychiatry, psychology,
PsyD’s, and masters of social work, for example. We really don’t train and compel the programs
to offer evidence based treatments. Psychiatry has come online. They’re doing a better job. But even in my beloved psychology, we are
not compelling training programs. We’re not making accreditation based on whether
they train in evidence based treatments. They offer some courses, but they don’t require
them. They don’t require competency. The other thing to bear in mind, is like I
said, besides the fact that all kids suffer, what we also know is that in the community,
if you are between the ages of three and seven and you have a mental health disorder, you
are now more likely to be prescribed an antipsychotic than not. This data comes from a wonderful researcher
by the name of Mark Olfson, who I happen to be married to, and his colleagues. The sad thing that’s illustrated here, first
of all, especially if you’re a boy between the ages of two or three, but also girls,
you are not, in these data these kids did not have a mental health visit in the year
prior to getting prescribed this medication. There’s no evidence, randomized controlled
trials, for anxiety, ADHD, and other diagnoses, except in the area of autism spectrum. So, we have to do something, because, in fact,
there are evidence based parenting programs, parent-child interaction therapy and others
that are highly effective for turning around kids in this age group. We also need to look at our emerging adults,
what Jeffrey Arnett, the developmentalist, calls the age of in between. The problem with our emerging adults, 18 to
29, is there are no services specializing in the transition. Child and adolescent psychiatrists say goodbye. Adult psychiatrists say, “Eh, come around
when you’re 30, 35.” These kids, though, are struggling. There’s no coordination between services for
them and a very low rate of referrals amongst this age group. So again, with this cohort, and this is from
the national comorbidity survey, you see high rates of disorder in terms of prevalence in
lifetime for the various conditions of anxiety. I’m just picking at anxiety, but mood disorders
and others too. Then when you look at who’s getting care,
this is a slide that shows in children 13 to 18, and then after age 18, use of services
drop significantly when you hit the young adulthood, or emerging adulthood, years. So, conditional service use means that they
used any services in the three months prior to the occasion of a mental condition. When they’re under their parents’ roof, they’re
getting it. But as soon as they can say no, this doesn’t
mean they get out from under the parents, they stay home. They’re refusing services because they can. From a public health perspective, and I’m
gonna hand this over in a second here on that, but just bear in mind, in the state of working
with children and adolescents there are concerns that we have because we have high prevalence
of these diagnoses that take kids off their developmental trajectory, which double whammy’s
them. These conditions build upon one another. Anxiety leads to depression, to substance
abuse, and so forth. What happens is, although we have effective
treatments, many children do not receive them. And when they are receiving treatments in
the community, they may not be evidence based treatments. In fact, they may be treatments that can do
much harm. So, we need to find ways of beefing up and
really disseminating effective treatments, but engaging kids and their families. One of the things that we have to do, too,
is given that we have effective treatments, we still have to answer the main question
that parents come into centers like mine with. “What do we start with for my kid? How long do they have to be in that therapy? What’s gonna happen when it stops?” Now, I’m of the opinion, having worked for
many years with children and adolescents, that kids should be kids. They shouldn’t be on somebody’s couch or in
my empty chair for the time of their development. They should be in when they need it, but they
need skills and evidence based treatments so they can get back into their world. What we need to do then is to continue to
develop our treatments and make use of what we’re learning in neuroscience, in genetics,
and in other areas of medicine and psychiatry, where we can target various risk factors and
various mechanisms. There’s a lot that needs to go on to look
at what happens within families, what kind of risk factors, such as behavioral inhibition
and others, that put kids at risk for certain disorders, and see how to tailor treatments
to meet these needs. We need to disseminate our effective treatments
for youth who are early in development, such as parent management training, and address
something that is not often studied when we study child treatments, and that is what about
the parents? Just late breaking news in the last week,
Golda Ginsburg, from the University of Connecticut, formerly from Hopkins, just published the
results of her study that looked at group of families that were randomly assigned to
just getting psychoeducation, information, and being monitored. These are families who had children with anxiety
disorders. Versus families who were randomly assigned
to receive for the parents a program that addressed their anxiety and the way that they
parented their anxious child. What was found in this study, then, is that
the kids who go the coping program, the families with the coping program, were delayed and
had much less occurrence of a new anxiety disorder. Whereas those kids whose parents had problems
themselves and were assigned to the education program, they did develop anxiety disorders. What we have to do is focus on the parents
in a way that we haven’t before. In addition, we have to increase access to
care. I think a big thing is changing the standards
by which programs operate for training clinicians and states operate for licensing clinicians. That’s something that has to happen. Also, require our clinicians to deliver evidence
based treatments. I think the Affordable Care Act is helping
with that in many ways because it is much more outcomes based. Just so we take a look here, in terms of young
adults who now have health insurance, they are now seeking treatment for mental health
care, and are making use of being on their insurance policies of their parents much longer,
which will hopefully keep them engaged in treatments so that they can get access to
care over the longer term and not just tune out once they turn 18. So, I’ll just summarize. These disorders start early in childhood. They run a chronic course. They build upon one another. We have effective treatments but they’re not
readily as accessible. Even though they are there in a lot of places,
kids don’t often receive care. It’s critical for us to understand how to
address what kids need for how long, and then also how to deal with taking them off treatments
when the time comes. Okay? I will leave it at that. Thank you Doctor [inaudible]. Well, we’ve sort of looked at the spectrum,
if you will, along age categories. Now our final speaker is gonna sort of look
at a bigger picture. Sort of the social and policy perspective. She is Doctor Colleen Barry, who is associate
professor and associate chair for research and practice in the department of health policy
and management at Johns Hopkins Bloomberg School of Public Health. Her research is focused on the impact of policies
on such things as to broaden access to mental health and substance use disorder treatment
through insurance expansions. Other issues: equalizing insurance coverage
for those services comparable to other medical benefits, and alter financing to improve integration
of behavioral and medical care. I think to a certain extent, we’re going to
hear about the access issue in this presentation that we heard about from our previous speakers. That even if there is treatment out there,
a lot of the people who need it are not getting it. There are probably a lot of reasons, from
the personal to the societal for that. I expect that we’re going to hear about some
of those from Dr. Barry. So please join me in welcoming her to make
her presentation. Thank you to the AAAS and to the Dana Foundation
for inviting me to be here to speak today. I’m gonna orient my talk in the following
way: I’m gonna first build on my colleagues’ presentations by thinking about the population
with mental illness, in particular in the context of how healthcare services are delivered,
and importantly, how they’re financed. I’m gonna briefly talk about some major federal
policy changes over the last few years that have aimed to address the treatment gap and
the evidence based care and quality gap that we’ve heard about. I’m gonna end by putting these issues in the
context of what we know, since part of the focus of this session is on society, what
we know about society’s attitude towards mental illness and the issue of stigma. To begin, I’m gonna skip over this slide,
because I think we’ve made the case so far that these conditions are highly prevalent
and they can be extremely debilitating for individuals with more severe disorders. Here in the U.S., we spend about $172 billion,
or about 7.4% of total healthcare spending, on mental illness and substance abuse. Most of this is related to mental illness. About 6.3% of total healthcare spending dollars. It’s important to note that the share of total
healthcare spending that’s going to mental health has actually been decreasing over time. This is, in large part, because of the rapid
increase in the denominator, the total healthcare spending dollar, over the last few years. You saw this in a somewhat different form
in the prior presentations, but if you look more closely at how the money is spent, you
see that about 14.5% of all adults 18 and older here, I’m focused on adults, receive
some mental health treatment during the year. But not all of those with a diagnosable mental
illness receive services. In fact, only about 41% receive some type
of treatment. The likelihood of receiving treatment is associated
with the severity of your condition. About 63% of those with a serious mental illness
receive treatment in a year, about half with a moderate mental illness, and about 30% with
a mild mental illness. Here I’ll also note, interestingly, that about
8.5% of those with no diagnosable illness receive treatment as well. This could represent a variety of things,
including people with no need for treatment getting treatment, but also individuals who
have been well maintained on treatment and are thus asymptomatic. Here, and I think that Venn diagrams are popular
in the panel today, but this version of the Venn diagram is trying to illustrate this
issue, where you can see the larger circle shows the number of people with a diagnosis
of mental illness. The second circle depicts those who receive
treatment. Clearly, some with a diagnosis don’t receive
treatment and some receive treatment but don’t have a formal diagnosis. The third circle depicts individuals with
serious impairment. And, again, some of this group falls outside
the treatment system. And some may have an impairment maybe because
of loss of a family member, but don’t meet diagnostic criteria. The largest portion of mental health spending
is clearly devoted to the intersection of these three circles. Those with a diagnosis receiving treatment
and with high levels of impairment. It’s important to note that the U.S. healthcare
system doesn’t always do a good job of matching mental health services to those with the greatest
need. Here, and this point was already made so I’m
not going to dwell on it, we’ve seen a huge decline in the number of beds available in
the U.S. for psychiatric treatment paralleling this shift away from inpatient care. We’ve heard a lot in the news and elsewhere
about overcrowding in emergency rooms due to psychiatric patients and what hospitals
report as emergency department boarding of patients with psychiatric illness. This is supported by recent survey of state
mental health authorities that found that the majority of states, a great majority of
states, reported substantial shortages in psychiatric beds. If you break down the spending on mental health
services, financed by government versus by private sector, for mental health compared
to the overall healthcare system, you can see they look somewhat different. We spend more public dollars on the mental
health sector, about 60% of total mental health spending compared to only about 50% when you
look at the overall health sector. This difference reflects a long history here
of government involvement in financing of care for individuals with mental illness. Here, this shows the distribution of spending
on mental health treatment by payer. You can see that Medicaid, this is the program
for low income individuals in the country, and the private health insurance system are
shouldering the bulk of this distribution of spending, each about a quarter. I wanna draw your attention to the 11% out
of pocket. This is individuals paying out of their own
pockets for services for themselves or for their families. I wanna emphasize the point here that this
represents a major shift. Financial protection from the costs of mental
health treatments has improved dramatically over the last 50 years. This, I’m gonna just take a quick departure
to tell a story about senator Paul Wellstone, who many of you may remember who, prior to
his death, had been very involved in advocacy issues and legislation in mental health. He described his motivation for being involved
in this issue as due to his experience, the experience of his brother who, during his
college years, had a breakdown, we called it a breakdown, left college, and was hospitalized
for a period. Paul Wellstone’s brother returned to college. He did well. He graduated, but it took his working class
parents over 20 years to pay off the accumulated medical expenses. So I don’t wanna, I would be remissed by not
noting what a difference has occurred over this time period in the out of pocket burden. Not to say that it has gone away. Here I show how mental health spending is
divided across different types of treatments. This also illustrates a shift over the past
several decades. The share of spending dedicated to inpatient
care has dropped dramatically. We’ve seen a substitution toward outpatient
treatment and psychotropic medication use as evidenced in the prior talks. The sheer mental health spending devoted to
prescription drugs has tripled over this time period, you can see, from 8% to 28%. You can also see that that share is flattening. Since the beginning of 2002, and continuing
into the present, many of the commonly used medications to treat depression, to treat
psychosis, have lost patent protection. The cost of these drugs have really decreased
as a result. The share of spending dedicated to drugs has
flattened and lowered, as a result, and will continue over the next few years. Here I wanna sort of make an even stronger
point related to the reliance on psychotropic medications. On this slide, you can really see this. By looking at the combination of the light
blue piece of the pie, the red pie, and the green pie, you can see that together 81% of
all individuals receiving mental health treatment receive psychiatric medication. So this is a large share of the treatment
we are currently providing. It’s worth emphasizing that blue slice that
shows that almost half of all individuals who receive any treatment are receiving only
a medication. The second generation medications are generally
somewhat easier to dose and prescribe, making it easier for primary care physicians to get
involved in the treatment of mental health conditions. We see, from this graph, that the vast majority
of spending on mental health treatment, almost three quarters, is still being spent in the
mental health specialty sector. However, access to specialty providers is
a real problem. In particular, within certain specialties,
child psychiatry for example, and within certain areas, in particular rural areas where it’s
really hard, often, to get access. In a recent study, about two thirds of primary
care physicians reported that they couldn’t get an outpatient mental health specialty
referral for their patients. This is a much higher rate than for other
specialties. Another issue that’s linked to this, and that
creates barriers to access, is that many psychiatrists don’t participate in either private or public
insurance. Psychiatrists are much less likely than other
types of specialty position groups to participate with only 55% accepting private insurance,
55% accepting Medicaid, and even less, about 45%. I’m sorry. 55% accepting Medicare and only about 45%
accepting Medicaid. With that I wanna, just in my limited time,
switch quickly to overview two of the major policy changes that have occurred in the last
few years that have aimed at both the access issue and some of the delivery system challenges
and financing challenges that I’ve talk about. Those policies are the Federal Mental Health
and Addiction Parity Law that was passed by congress in 2008, and the Affordable Care
Act. First I’m gonna just begin with parity. Historically, private health insurance has
been much more limited for mental health, and for substance abuse, than for general
medical care. Here I show you a benefit comparison for what
I would call a typical private employer sponsored plan circa 2007 or 2008. You can see that mental health benefits include
certain annual limits on the number of inpatient days and outpatient visits that aren’t paralleled
on the medical side as well. …paralleled on the medical side, as well
as higher levels of coinsurance, often we saw higher copays as well. And mental health advocates viewed these limits,
the differential insurance coverage, as evidence of discrimination and worked for years to
achieve so called purity, meaning equity in insurance coverage. And we’re able, after about 15 years, to pass
the Paul Wellstone and Pete Deomenici Mental Health Parity and Addiction Act in 2008. It was implemented in 2010. It was extended in some pretty important ways
in 2014. The law applies to both employer sponsored
plans with 50 or more employees, under the Affordable Care Act it’s extended to the individual
and small group market as well. As well as some government programs. It prohibits these special types of treatment
limits, it requires equity in financial requirements and it also requires equity in what’s called
in this sort of techy, nerdy way, non-financial treatment limits. Which basically means prior authorization,
utilization review, the adequacy of provider networks. All of these on the mental health and addiction
side need to, by law, be equivalent to what’s provided on the general medical, surgical
side. Quickly, there are a lot of pieces of this
large law, the Affordable Care Act, that have potential implications for individuals with
mental illness. First, it enacted a series of insurance market
reforms for example, prohibiting health plans from using pre-existing condition exclusions
or charging much higher premiums based on an individual’s health status. Clearly relevant to the population of individuals
with health insurance. Second, and perhaps most importantly, in the
states that have now counting 31, including the District, expanded Medicaid, which is
again the program for low income Americans there is much broader access to insurance
coverage for low income populations. We describe in health policy that the sort
of Medicaid expansion is carrying the lion’s share of the impact for individuals with mental
illness when you think about the Affordable Care Act as a whole, in the states that have
expanded. Also, the establishment of the new individual
and small group marketplaces within all 50 states, provides subsidies to lower income
individuals, many of which have diagnosable mental health conditions and aren’t part of
traditional employer based insurance. So this creates another route to accessing
care. It, as we heard from the prior slide, expands
coverage for young adults up to age 25, so they can get coverage through their parent’s
policy. This is particularly important given what
we know about age of onset of many of these conditions. And the ACA includes a whole set of different
delivery system and payment reforms that hold promise for changing the financing model in
a way that incentivizes both better integration, treating people sort of in a whole body sense,
mind and body in a more comprehensive integrated way. As well as strong financial incentives for
pushing evidence based care. And a lot of work force incentives as well. Why are efforts to broaden access to insurance
coverage under the ACA important for individuals with mental illness? Let me just sort of illustrate this very quickly
with this pre-ACA slide where you can see a much larger proportion of those with serious
mental illness and other mental health disorders were uninsured prior to the ACA compared to
the population without mental health disorders. And you see in particular those with severe
mental illness were much less likely than those without mental health disorders to have
had access to private insurance. To end, clearly there’s a lot more I could
say about those topics, but I wanna end my presentation by just saying a word or two
about societal attitudes. And these data that I’m going to present here
are from a study that we published in the New England Journal of Medicine in 2013. As you can see, nearly half of the American
public view people with mental illness as more dangerous than the general public. Only 29% of the public would be willing to
work closely on a job with a person with a severe mental illness. And only 33% expressed a willingness to have
a person with a serious mental illness as a neighbor. So you can see these high levels of perceived
dangerousness and desire for social distance have persisted over the years. And these attitudes are actually quite striking
when put alongside what’s been a really significant shift in public attitudes toward less severe
disorders. A higher level of comfort, there’s a, certainly
a cohort effect to it, but a higher level of comfort among the public with sharing that
someone’s on an anti-depressant or sharing that they’ve seen a counselor to deal with
some life issues. Yet we see these persistently high, negative
attitudes increasing even in some cases toward the more severely ill. So what explains the persistence of these
negative attitudes toward people with severe mental illness? It’s hard to know exactly, but changes in
media portrayals, and the sort of nature of media coverage and the changing sort of demographics
of how we as a society interact and view people with mental illness, I think probably have
something to do with it. We saw the slide related to rates of homelessness
among the mentally ill, rates of incarceration among the mentally ill. And these media portrayals can in turn influence
the design of public policy, including the passage of laws like the one in New York focused
on gun control measures. Specifically with regard to individuals with
mental illness even in the context of data showing that mental illness explains very
little of societal violence. And we conducted an experiment that we published
in the American Journal of Psychiatry, in which we randomized a nationally representative
group of adults to read a story of a mass shooting, or to be randomized to a control
arm. Those viewing the mass shooting story were,
unsurprisingly, much more likely to rate people with severe mental illness as dangerous, and
much more likely, about 14 percentage points. And I wanna end I think with a quote from
Steve [Sharfstein] whose run Sheppard Pratt Health System, which is right down the road
from my office at Hopkins. And he’s run this health system for almost
30 years now. He says, “Will we ever see an end to the stigma
that’s associated with mental illness? No, not as long as there are untreated, delusional,
disheveled, threatening, homeless individuals on our streets and in high profile media examples
of violence.” Thank you. Okay so thank you very much. We are now obviously inviting the three to
join me on stage, and this is the way we’re gonna work for the rest of the evening before
the reception, I’m going to ask one question of all three and then we’re gonna open it
up to the audience. So while they’re answering my question perhaps
some of you with questions can move to the microphones on either side of the room to
be prepared to ask your questions. We would like to know who you are and your
affiliation if you’re willing to share that with us. And we would like you to ask a succinct question. We don’t need another speaker to add to our
time frame. What we need is short, succinct questions
that they will be able to respond to hopefully in the same manner and be able to answer many
of those questions that arise. So, my first question, do you have the mics? You all ready to go? They’re on, excellent. So I have a hypothetical for you, at least
my question’s hypothetical, your answer I hope will be real. Let’s assume that the Dana Foundation called
you up and said, money is no object. Again it’s hypothetical. Money is no object, what would you propose? What would be the most important thing related
to the kinds of comments each of you made here today, tonight, as a research project? What would you want funded more than anything
else, money is not an object, in terms of a research project? Dr. [Freimer], can we start with you and then
just move down the row? Well, you know I think that answer is everything,
and particularly if money is no object. One of the things that I’ve increasingly come
to believe is that no piece of this in isolation can really make sufficient progress. I mentioned that I’m now involved in this
thing called the grand challenge in depression, and the reason I became involved in that is
because it became clear to me that I could, my colleagues could, find the causes of mental
illness ultimately, hopefully through genetic studies and other approaches. But that really wouldn’t do very much for
all the people that are suffering if that at the same time there weren’t efforts in
the areas that the other speakers talked about. To improve the access to treatment, to decrease
stigma, to get people to have a different view of mental illness. All of these things I think really have to
be done together. So really, I really believe that in comparison
with other areas of medicine and biomedical science, mental has suffered from a fracturing
and a disconnection of all these different components. And one of the things we could do with resources
is really bring all the strands together in a way that they never have been before. Thank you, Dr. [Alvanno]? Well, what he said. And I think what would do is examine the impact
of bringing services to the places where we find children. That is in the schools. And having mental health check ups and clinics
available in school systems across the board. Is your system on? Am I on? Can you hear me now? Okay. But that’s what I would do. In a way the Affordable Care Act I think is
trying to have practice teams that are multi-disciplinary in primary care settings, but I would want
to move those teams into the school setting. Okay. Again, money is no object, Dr. [Barry] what
would you propose? And while she’s answering, again, if you’d
like to go to the mics and be prepared to ask your questions, please do so. Please, go ahead. So I think it’s critical to have a robust
research agenda related to understanding whether these policies that we’re designing are achieving
the ultimate goal, which is to close the treatment gap. All of our presentations have touched on this
enormous treatment gap and quality of care gap. And so, for example, it’s not enough to just
give somebody an insurance card, it doesn’t make a difference in the receipt of care and
their receipt of high quality care. It’s not enough to create financial incentives
for different types of providers to work together better. Is it making a difference in the kinds of
care that people with mental illness get? We know that individuals with mental illness
die much earlier from preventable, chronic medical conditions. And so it’s critical to see whether these
policy interventions, and we’re in this incredibly interesting innovative moment in our country’s
history with regard to policy change related to health care and mental health and addiction
in particular. Is it making a difference? Well thank you all, I think Dr. [Gill] from
the Dana Foundation, we have a good portfolio for Dana to consider next year. Okay, so as promised let’s start here and
then we’ll go back and forth. Name, affiliation, and your question please
sir. Sure. Hi, my name is Dan [McHale] from George Mason
University. My question’s for Dr.Freimer and the other
panelists. You mentioned the global disease burden for
mental illness and the relative lack of funding for mental illness research, some of us are
part of a student group dedicated to trying to close that gap. Wondered if you had any advice for us and
the general public on increasing support for researchers? Well, it’s very gratifying to hear that students
are actually advocating for improvements in this area. You know, I think that it is largely going
to be the vocal involvement of young people in particular, saying how important this is
that’s gonna change this. It’s gonna change when congress and the other
bodies that are responsible for appropriating funds for research are consistently told how
important this is. I also think that we need to do a better job
of educating the public about the benefits of science based practice. And you know, words like evidence based treatment,
science, these are buzz words now that draw a lot of hot emotions on one side or the other
of pro or against these things. But the bottom line is that the evidence based
interventions save lives and somehow we have to get the broader population to understand
that, while working on the issue of stigma, and to lobby to put more funding, and allocate
more funds that we have in the public trust towards mental health and mental illness. Okay. Over here, please. Yes, hi. Jonathan [Drake] from triple AS. In the last presentation there was a very
fascinating time series graph showing the changes in treatment modalities; decline of
inpatient, dramatic rise of prescription drugs. And what I notice was that the take off in
prescription drug use occurred right around 1998, which seems to me to be about the time
I first saw television advertising for prescription drugs all over the place, saturating the air
waves. And so that led me to another question, which
is, to what extent, and is it even known to what extent, these changes in treatment modalities
are driven by changes in public policy versus changes in individual’s preferences, or how
they choose to be treated, versus the imperatives of the health care industry? Dr. Barry do you wanna-
I might turn to my colleagues to talk about this too but certainly there has been a big
increase in direct consumer advertising. There has been a large reliance in the mental
health field on detailing and free samples. And I think it’s sort of this part of the
marketplace. And so I think one key issue that we worry
about is conflict of interest and in part motivated by our students, the push in recent
years has been for medical schools, for residency programs, to put very strict conflict of interest
policies in place to make sure that that influence is not impairing prescribers and student’s
sense of sort of where the evidence is in prescribing and making treatment decisions
based on evidence. And making sure that we have an environment
that’s free of conflict of interest to the greatest extent possible. Any of the other panelists wanna quickly respond? Yeah, I mean I think there are couple of things
I’d just say in addition to that. I mean, in relationship to the point about
advertising, I think in part it relates to the fact, if you look at the first generation
of drugs that were used against mental illness, they were almost all discovered by accident,
and not by pharmaceutical companies. For example, lithium, which was the drug that
made, in some ways, the biggest difference for mood disorders, was discovered entirely
by accident by a practitioner in Australia. Similarly, first anti-psychotics were discovered
by accident as anesthetic agents and so forth. So in part I think it reflects the fact that
the pharmaceutical industry in the 70’s and 80’s was actually for the first time really
engaged in developing drugs for psychiatry. So I think in the 90’s is when you saw the
effect of that. And then the other point, which was also made
in one of the talks is that one of the trends in these medications was from agents that
really needed to be used by specialists, to agents, which were much safer and could be
used by primary care doctors with the SSRI anti-depressants being the best example of
that. They essentially became ubiquitous throughout
the healthcare system in the US and around the world. Thank you. Can I just add more one point, that might
not be a popular point, but especially what I see in families. Families who are burdened in many ways, both
parents are working, there’s a lot of stress, medications are often easier, because whether
you’re with your child taking them to therapy, or you yourself are struggling, therapy is
work. It’s a lot of hard work and so sometimes I
think that’s there. And I think, you know, the primary providers
of medication are typically primary care docs and such these days. And they’re not doing mental health assessments,
they don’t have the time to spend to learn about the patient and then refer to a therapist. They’re responding to what they’re hearing
in terms of sematic complaints and stress and stuff, sleep issues. It’s a lot easier for the patients, so they’re
going for it. So again, I think education of the public
is so important. Good, okay. Please, over there. Yes, I’m Deborah [Arucnle] triple AS. What is the current status of the arguments,
of the controversy over prescribing Prozac to teenagers? Do you wanna take this? You’re the psychiatrist on the panel. Yeah so the question relates to the controversy
of prescribing, I think it’s not just Prozac, but really the entire class of anti-depressant
drugs to teenagers. This relates to some evidence that suggests
that in contrast to adults who get these medications, that teenagers may be more likely to be sort
of, become prone to violence to themselves or others as a result of this treatment. I think it’s, to be honest, totally unclear
whether that’s so or not. These are so complicated, these relationships. Whether it’s that they really are doing something
specific that has this negative effect, or whether it’s a result of actually people beginning
to show a response, and whereas before they were apathetic and unable to leave their room,
and now suddenly they’re able to get out and do something. I think that remains unclear. What I’d like to do now, since we’re at seven
o’clock, what I’d like to … Honor those who were up to ask questions, if you would
go ahead starting here then back to there, then back to there, to please ask your questions
serially and then we’ll ask the panelists to respond to them. Good evening my name is Samantha [Dawson]
I recently graduated from Georgetown University. My question relates to the decrease in inpatient
treatment. Not only are there enough beds currently,
but there’s also been a decrease in CBT offered to inpatients. Evidence based treatments have proven that
combination treatment is the most effective in most cases and I wonder whether you have
any, anyone in the panel has any suggestions on how we can address this issue, either policy
wise, to ensure that people gain access to the care they need. Especially when in crisis in inpatient treatment. Okay, so please remember that question, think
about your response. Over there? Hi, my name is Lang [Wong] I’m a triple AS
science to technology policy fellow at the National Institute of Neurological Disorders
and Stroke. My question is for Dr. Alvanno, I was surprised
to see how low the treatment prevalence numbers you showed were in contrast, some would argue
that the diagnosis rates for some mental health disorders can be too high. So, for example, some people say that all
these kids nowadays don’t have ADHD, it’s that our idea of what is normal is what’s
shifting. So how do we reconcile those differences and
perspectives? Thank you. Thank you. And our final question. Yes, Jessica [Windham] from triple AS I have
two quick questions. My first for Dr. Barry, and that relates to
what you mentioned at the end about stigma. I was thinking in particular about the Lufthansa
tragedy in Europe. What do you consider to be the role and/or
the responsibility of the scientific community with regard to educating the media about how
they portray mental illness and people with mental illness in the context of such tragedies? And for our other two presenters, we know
about research that’s occurring as far as genetic heredity of depression, but I was
wondering the extent to which there’s research going on about the environmental heredity
for children growing up in families in which one or more family members have depression? Okay. I thought, very good series of questions. Dr. Barry do you wanna start? No one person has to answer all three. Okay. I’m gonna just quickly respond to the two
that I think pertain to my presentation and then I’ll turn it over to the experts here. First on inpatient treatment decline and inpatient
treatment. You know, our standard under [inaudible] is
that we provide treatment in the least restrictive environment and so I think part of the decrease
in inpatient treatment has been connected to the civil rights movement that has touched
the mental health field. And that is to provide individuals with the
most appropriate treatment in the least restrictive environment, and that led to the community
mental health movement, which of course was terrible underfunded. But I think that most folks will agree that
the answer is not to drive up inpatient treatment rates, but rather to make sure that we have
the right services for people at the right stage they are in their treatment needs. And in particular, we have a huge problem
with crisis intervention. And there are some really innovative programs
out there, New York has a great one to try to get people out of this waiting pattern
in emergency rooms and get them into real crisis intervention services. And for some individuals, some period of inpatient
care is gonna be appropriate, and for longer than is currently available. But I think there’s value in this idea of
least restrictive treatment environment that we need to build an effective community based
treatment system around. With regard to the point about the media and
the obligation of the media. The Carter Center has a wonderful program
that I want everybody to know about that’s related to journalism and mental illness. And they’ve had many cohorts of journalists
that have come and been part of this effort to try to provide journalists with information
both related to the nature of these diagnoses, but the impact of stigma on public support
for policy, individual’s willingness to seek treatment and to do their jobs as journalists
in a way that doesn’t further drive up stigmas. So this is, I think, a really important program. And one last thing I’ll say about news media
and messaging. I think it’s clear that we need stigma reducing
messages. And there’s a science here, and we do experiments
in the lab to try to understand how to communicate with the public better about mental illness. And one thing, we’ve learned a lot of important
information related to changing the way we communicate, and one is that if you can show
individuals, through the media or through other types of communication, stories of recovery,
stories of successful treatment, people that are successful in treatment, those stories
can change public attitudes. And I think the disservice that we do is only
showing through the news media these stories of people in distress, stories of people who
are homeless, stories of people that have done terrible things and we haven’t been aggressive
about showing the stories of treatment that works. Thank you. Dr. Alvanno, which questions? I’ll take the question on why is there such
a low rate of treatment in the community whereas the rates of the prevalence of these disorders
are so high. Some more recent analyses actually are showing
among kids who are being treated, part of the good news is that there’s been an increase
recently in children with more serious mental illnesses, or serious impairment in functioning,
are getting care. Not enough, but that has risen some. The question about, on the other hand, is
there are children who are being treated that aren’t necessarily … They’re more mildly
impaired. And why do they then have and make use of
treatment that they probably, or they might not need, we’re not sure. And this may be that some categorization for
those kids around learning disabilities or milder ADHD and such. But at least there’s been a shift that we
know of the more impaired kids, getting better access to care, so that’s good news. So we may be seeing a little bit of shift
in terms of treatment, but again, what we need to do is equip the work force to deliver
effective treatments and it is through effective treatments that we may engage more people,
more kids to stay in care where they need it. Thank you, Dr. Freimer? Okay. So I’m just gonna take one minute to … The
three of us have agreed on about 99% of everything that we’ve discussed, but I just wanted to
take issue with one comment. Which is, I actually disagree on the point
about hospitalization, I think as a result of trying to make less restrictive we’ve ended
up making more restrictive care because of the fact that treatment has gone from the
hospital to the criminal justice system. And so, anyway I just wanna make that point. But I’ll answer also the point about genetics
and the environment. And really what I believe is that the main
end result of genetics is not going to actually be the identification of the molecules, that
it’s really going to allow us to study the environment in a much more rigorous way than
we’ve ever been able to before. We’ve seen this throughout all other areas
of medicine as we’ve begun to understand genetics, we can really focus in on what are the, really
the relevant environmental exposures for disease, in a way that we were never able to before. And the environment is a huge space that encompasses
everything in our lives, and we’re never gonna be able to understand it, if we try to understand
our entire environment. So my view is that what genetics is gonna
do, is it’s gonna allow us to focus on what are the most specifically important aspects
of the environment that contribute to these diseases. Well thank you all and please join me in thanking
our speakers.

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