General Update
Outreach Partnership Program 2005 Annual Meeting
Friday, April 1, 2005
Richard Nakamura, Ph.D., Deputy Director
National Institute of Mental Health
Dr. Nakamura presented an update on the following: (1) important events and trends in mental health and at NIMH, and (2) some important scientific discoveries and their significance in advancing the understanding of mental illness and mental health.
In any era of real progress and real advances, problems arise. During the past year, there have been questions about the role of the pharmaceutical industry in mental health treatment development and about how medications are tested. Some antidepressants now carry a “black-box” warning for particular populations, stating that these medications should be prescribed with great care and caution, and that individuals taking antidepressants should be monitored closely for signs of possible agitation, suicidal ideation, and suicide attempts. Although adjustments need to be made in prescribing treatments, we have effective treatments that benefit most people; choices are available; and more and better treatments are being developed.
Several other issues are worth noting. NIMH and NIH as a whole are experiencing a slower rate of growth in the budget, and because of long-term commitments it is currently much harder to fund new research proposals.
The mission of NIMH is to reduce the burden of mental illness and behavioral disorders through research on the mind, brain, and behavior. The tremendous burden (morbidity and mortality) of mental illness and behavioral disorders across all ages and among people in developed countries is comparable to that of cardiovascular disease and cancer. Furthermore, mental illnesses account for nearly 40 percent of disability experienced by people between the ages of 15 and 44. Mental illness is uniquely different from other disorders in its ability to cause pain and suffering: approximately 90 percent of suicides occur in people with a mental disorder.1
We are now at the point where there have been many advances in understanding mental illnesses and behavioral disorders through basic research. Dr. Thomas Insel, who became director of NIMH just three years ago, changed the focus of the Institute to emphasize using that understanding to develop better treatments - and even to think in terms of cures for mental illness. Our research emphases are based on three principles: relevance (to the understanding and treatment of mental illnesses and behavioral disorders), traction (identifying the research that will yield what is needed to understand and treat these disorders), and innovation (fundamentally new ideas and approaches) equals impact. The overarching goal is to increase the impact of NIMH on understanding, diagnosing, preventing, and treating mental illnesses. Dr. Insel wants to allocate resources strategically to focus on research priorities; identify and adopt best practices; and develop standards for improved operation of the Institute.
NIMH has reorganized its divisions to reflect its emphasis on translational research. Translation from “bench to bedside” and back to bench entails two-way movement between two pillars: (1) basic neuroscience and behavioral sciences, and (2) clinical trials and services research. Basic research focuses on understanding the causes and course of disease, developing diagnostic tests or biomarkers for a disease, and developing new treatments. New treatments are tested in clinical trial networks and in practical trials, and services research yields information that clinicians and service providers can use in their practices, hospitals, and communities. The information gained from services research needs to be fed back to basic science in the form of new questions that can lead to solutions to clinical problems. Dissemination of new ideas about science and treatment is critical, and the NIMH Outreach Partnership Program is a major dissemination avenue.
NIMH has a long history of supporting mental health parity. Some important points that support parity are as follows: (1) science has demonstrated that mental illnesses are real, thus there is no medical reason to discriminate against people with mental illnesses; and (2) a number of effective treatments are available that allow most individuals with mental disorders to improve strikingly or recover their lives.
There are other strong arguments for providing treatment to people with mental illnesses and for funding interventions that address risk factors for mental illness in the same way that high blood pressure is checked as a risk factor for cardiac disease. An Australian study by Gavin Andrews demonstrated that mental health expenditures for depression and anxiety disorders are in fact health “best buys”. Using current usual treatments and service delivery systems (despite limitations) society recovers more for treating depression and anxiety then the cost of treatment. If optimal treatment is provided, even though it costs more, the individuals improve more and the gains are greater. Currently used treatments for alcohol disorders are not cost-effective. However, treatment becomes cost-effective if optimal treatments are used. The burden of schizophrenia, however, remains high regardless of whether individuals receive optimal or suboptimal treatments.
One of the goals of the President's New Freedom Commission on Mental Health was to accelerate research with the goal of promoting recovery and ultimately curing and preventing mental illnesses. NIMH is taking that charge very seriously. In looking at the various disorders we study, we can rank them in terms of whether we now possess interventions that have been demonstrated to reduce risk and/or treatments that can be used to manage symptoms to the point of full remission. To a large degree, the more difficult to treat diseases are those strongly influenced by genetics.
There are very effective interventions for “externalizing” disorders such as conduct disorder, aggression, and violence. A successful strategy for children and adolescents with these disorders includes first identifying biological predispositions and factors in the sociocultural environment, and then using interventions. Conducting home visits to bolster parenting skills, changing the individual's peer group, building social skills, and providing tutoring are all useful interventions. Evidence suggests that prevention interventions would be effective in suicide and depression. Striking differences in suicide rates among various ethnic groups in the United States indicate that there are social and cultural factors which might be influenced by public health interventions.2
Discoveries in neuroscience suggest ways of preventing disorders with a strong genetic component. We now understand that the brain and behavior (nature and nurture) are inseparable. Genes start the brain on a path that can include vulnerability to mental illness, and the brain changes through behavior and interactions with the environment. We are rapidly learning more about how changes in the brain, called neuroplasticity, occur. Neurogenesis, the growth of new neurons in the brain, can be affected negatively by stress and environment, and positively by physical activity and learning new things. Epigenetics is the study of how genes can be turned on and off through environmental interactions. Animal studies have shown the powerful differences in social behavior that are governed by only one gene, and have demonstrated how environment, stress or maternal behavior can change gene activity, and thus modify behavior for life.3 In some cases those changes can last through generations.4 Scientists are also developing ways to modify synapses, the sites where neurons communicate with one other.
We are learning that the brain is modular: specific parts of the brain are important for moods and emotions. New understanding of brain circuitry is not only revealing how we can develop new treatments and approaches to mental illnesses, but is making us optimistic that we can develop ways of determining whether medications or behavioral interventions are helping or are worsening symptoms. Here is a speculation: our systems are more receptive to responding to behavioral change than to medications. In fact, the body has a natural resistance to manipulation by medications. Behavioral interventions offer hope for more targeted and effective treatments.
Brain imaging is helping us to understand fear-based behaviors. The frontal cortex interacts with a structure called the amygdala to produce and control fear, and we have evidence that individuals who cannot control fear cannot turn on a specific portion of their anterior frontal lobes, called the medial frontal cortex. This has been demonstrated in studies of veterans who suffered trauma during the Vietnam War, as well as women rape survivors.5 In both groups, the medial frontal cortex was not activated in those who developed post-traumatic stress disorder (PTSD). It was activated in those who did not have PTSD.
In conclusion, we need to communicate these messages: mental illnesses are real and diagnosable, and their secrets are being revealed through brain and behavioral research. Treatments are effective for most affected individuals, and recovery for most is possible, although managing expectations is important.
Questions and Answers
In response to a question about suicide, Dr. Nakamura said that the relationship between ideation, attempts, and completed suicide is unclear, and NIMH is examining that question in new clinical trials. The caution about suicide in the new 'black-box' warning for antidepressants was based on studies in which there were reports of ideation and attempts, but no completed suicides.
One Outreach Partner urged NIMH to expand research on pedophilia, which is classified as a mental illness in the DSM-IV. NIMH does support some research in this area, but it is difficult to attract investigators because they encounter community resistance and find it hard to recruit research volunteers.
Another participant asked how advocates can assure that service systems are using optimal or effective interventions. Dr. Nakamura alerted the group to new studies coming out by Dr. Ronald Kessler (see http://www.hcp.med.harvard.edu/ncs/publications.php), which will provide a status report on all mental illnesses (except schizophrenia) in the United States, and will assess the adequacy of services. The NIMH is working collaboratively with the Substance Abuse and Mental Health Service Administration's (SAMHSA) Center for Mental Health Services (CMHS), to increase effective dissemination and implementation of mental health treatments and services. For example, NIMH will be funding studies designed to pinpoint the effective methods for disseminating and implementing evidence-based treatments and services while SAMHSA recently developed practice implementation resource kits designed to encourage the use of evidence-based practices in mental health. The SAMHSA Web site has more information on these kits.
A participant proposed an analysis of the impact of proposed Medicaid cuts on the entire fabric of the public mental health system. NIMH has just funded a research application on the effects of changes in the Medicare/Medicaid system. NIMH has strengthened collaborations with CMHS and SAMHSA, and with the state mental health program directors. In four regional meetings, staff from NIMH and CMHS will meet with state mental health groups to discuss how to improve and measure services through research.
One participant voiced concern about the need to carefully communicate research that shows how the brain changes in response to the environment, so that families are not once again blamed for causing mental illness. Dr. Nakamura advocates a nuanced perspective, drawing a distinction between saying that families cause mental illness, which is untrue: yet recognizing that families can mitigate or influence the course of disease by helping the affected person get treatment and follow treatment guidelines: just as families can help improve outcomes for infectious diseases or heart disorders.
References
1. WHO Report 2002.
2. Suicide in the U.S.: Statistics and Prevention.
3. Francis DD, Szegda K, Campbell G, Martin WD, Insel TR. Epigenetic sources of behavioral differences in mice. Nature Neuroscience May 2003; 6:445-6.
4. Weaver IC, Cervoni N, Champagne FA, D'Alessio AC, Sharma S, Seckl JR, Dymov S, Szyf M, Meaney MJ. Epigenetic programming by maternal behavior. Nature Neuroscience August 2004; 7:847-54.
5. Shin L, Whalen P, Pitman R, Bush G, Macklin M, Lasko N, et al. An fMRI study of anterior cingulate function in posttraumatic stress disorder. Biological Psychiatry December 2001; 12:932-42.
