By SHERRY LEVY-REINER
On July 3, 1946, President Harry S. Truman signed the National Mental Health Act. In addition to its broad purpose of improving "the mental health of the people of the United States," the act enabled the founding, three years later, of the National Institute of Mental Health (NIMH), now part of the National Institutes of Health.
To mark this 50th anniversary, policymakers, scientists and the public gathered at the Library of Congress this spring and summer for six programs focusing on "Fifty Years of Progress in Understanding and Treating Mental Illness."
Eighty to 100 audience members at each session heard researchers and clinicians from NIMH and other institutions report on cutting-edge research and therapies for depressive illnesses, schizophrenia, developmental and learning disorders, Alzheimer's disease and anxiety disorders.
The series was the seventh program since 1991, when the Library and NIMH signed an interagency agreement establishing the Project on the Decade of the Brain. The collaborative initiative advances the goals of a proclamation by President George Bush designating the 1990s as the Decade of the Brain.
While earlier programs focused on understanding brain functions on a molecular level, according to Prosser Gifford, director of the Library's Office of Scholarly Programs, this year's series reported on progress in treating some of the most common and debilitating brain disorders.
Steven Hyman, M.D., the new director of NIMH, praised the collaborative effort for increasing NIMH's effectiveness in "getting treatments to real people in real settings." Unlocking the secrets of the brain, noted Dr. Hyman, is "the most difficult scientific undertaking" because the brain includes "100 billion different nerve cells, each making 10,000 different connections with other nerve cells"; nevertheless, he is "absolutely optimistic" about success because of "profoundly dedicated people of talent and commitment [who are making] scientific advances."
Organic Origins of Brain Disorders
The most significant change in viewing brain disorders, according to the speakers, is the recognition of their identifiable biological origins. At the same time, they are disorders that "involve disturbances in the very characteristics which make us most human: our complex capacity to think, to feel, to create, and to act," noted Rex Cowdry, M.D.
Dr. Cowdry was a panelist in the first program, on May 2, "Overcoming Obstacles to Treatment" with Robert Boorstin and Laurie Flynn, who focused their presentations on the need to remove the stigma attached to mental illness and eliminate financial barriers to treating it.
The series coincided with increased public and congressional interest in extending insurance coverage for mental disorders to achieve parity with coverage of physical illnesses. "We can't afford not to provide coverage," explained Ms. Flynn, "because the benefits include increased productivity, savings in Medicaid and expenditures on our correctional system, and simply helping people return to work and get on with their lives."
Sens. Domenici and Wellstone Among Speakers
Sens. Pete V. Domenici (R-N.M.) and Paul D. Wellstone (D-Minn.) both have family members affected by brain disorders, and they support legislation that would mandate equity of insurance coverage. Sen. Wellstone made opening remarks at a session on May 9 on depressive illnesses; Sen. Domenici on May 14 introduced the session on schizophrenia.
The enormous personal costs of brain disorders as well as the economic costs to the nation were described by a number of participants. Kathy Cronkite characterized her major depression as "an ongoing sense of hopelessness" but said she now derives hope from knowing she has a treatable medical condition. Between 80 and 90 percent of those who seek care for depression can be treated successfully; unfortunately, noted both Mr. Boorstin and Ms. Cronkite, only one-third of those who need help seek it.
Agreeing that "a little hopelessness goes a long way," Raymond DePaulo, M.D., identified the diagnosis of depression as the first and most important therapeutic step. In addition to working with patients, Dr. DePaulo pursues research on possible genetic causes of depression.
Thomas Wehr, M.D., emphasized the multiple aspects of depression on which NIMH researchers work, including Seasonal Affective Disorder (SAD) and biological interventions that may modify the brain's metabolism. Dr. Wehr also highlighted NIMH's D/ART (Depression/Awareness, Recognition and Treatment) program, which educates the public and the professional community on brain disorders.
Calling schizophrenia the "cancer" of mental illness, Daniel Weinberger, M.D., described his discoveries linking schizophrenia to abnormal brain development. Referring to the moving account given by panelist Mary Ellen Moran of coping with her mother's and her son's schizophrenia, Dr. Weinberger noted that research is now focusing on genes that confer a risk for schizophrenia.
Research Anchored in Patients
Joseph Coyle and Albert Galaburda on May 31 presented different perspectives on developmental and learning disabilities. Dr. Galaburda, whose work focuses on developmental dyslexia, explained that the brain is organized in stages and pathways of processes, widely distributed in the nervous system. Particular areas are incapable of extracting all types of information from stimuli, so the information must be processed by several areas; learning disabilities result when, for a variety of reasons, the connections among processes break down. Research demonstrates, however, that the brain is capable of changing physically, adapting and correcting or compensating.
Joseph Coyle, M.D., drew on his clinical experience in child psychiatry and his research background in neurotoxicology and brain development to propose that "toxic environments play a major role in limiting children's optimal development and fostering social dysfunction, and that these adverse circumstances create self-perpetuating and transgenera-tional dysfunction." Noting the disproportionate number of inner- city children who suffer developmental disorders, Dr. Coyle named three environmental risk factors that impair brain development and cognitive function: cocaine, alcohol and lead. He cited action to remove lead from gasoline and paint as an example of how policy can be influenced by science.
Dementia describes brain failure over time as a result of one of any number of causes, including Alzheimer's disease. Alzheimer's, because it has been demonstrated to shrink the brain's "gray matter" by as much as 40 percent, is one brain disorder that society generally accepts as physical. As Trey Sunderland, M.D., pointed out on June 6, research is now focusing on diagnosing Alzheimer's earlier and delaying the point at which it becomes debilitating. Researchers, suspecting that people begin early in life to have a "cascade" of events leading to Alzheimer's, are looking for ways to interrupt and retard that chain of occurrences.
The price of Alzheimer's is enormous, Dr. Sunderland pointed out, because it "steals away the person that we love"; it is expensive to families rarely reimbursed by insurance for the costs of caring for the patient, and it is also expensive to society. Eve Lubalin described her feelings about taking care of her father and her ultimate recognition that she could improve the quality of his life but could not influence the course of his disease.
Ms. Lubalin's account showed how Alzheimer's is a "systems illness," in the words of Pierre Tariot, M.D. Alzheimer's affects an entire system of care givers, so Dr. Tariot believes that supporting and bettering the system is the best way to help individual patients. He described nursing homes as "petri dishes for understanding the key issues we are faced with as a society: how do you care - in an ethical, humane and cost-effective way - for someone who is impaired?"
'It's All in Your Head'
Victims of a panic attack frequently are told, "It's all in your head," said Jerilyn Ross at the final program, on June 12, on anxiety disorders, "as if your head isn't part of your body." In fact, panic disorder is a real, serious and treatable disorder that costs the nation about $47 billion each year.
Thomas Uhde, M.D., reported on his research on sleep- panic attacks. Dr. Uhde explained that movement disorders such as Parkinson's disease provide the best models for psychiatric disorders because they demonstrate how one's mind, body and psychological makeup are inextricably linked.
Focusing on her work with obsessive-compulsive disorder (OCD) in children, Susan Swedo, M.D., emphasized that OCD is not caused by punitive discipline but most likely by a brain dysfunction triggered by some environmental factor such as bacteria or viruses. For example, Dr. Swedo and her research team have identified a kind of OCD that affects some children who have had strep throat.
Although the participants have focused their research on different forms of mental illness, they all agreed that enlightened public policy will promote progress.
For more information about the Library of Congress/National Institute of Mental Health Project on the Decade of the Brain, contact Project Coordinator Sherry Levy-Reiner at (202) 707-1513 (slevyrei@mail.loc.gov).