ABOUT THE SPEAKER
Thomas Insel - Neuroscientist and psychiatrist
The Director of the National Institute of Mental Health, Thomas Insel supports research that will help us understand, treat and even prevent mental disorders.

Why you should listen

Thomas Insel has seen many advances in the understanding of mental disorders since becoming the Director of the National Institute of Mental Health (NIMH) in 2002. During his tenure, major breakthroughs have been made in the areas of practical clinical trials, autism research and the role of genetics in mental illnesses.

Prior to his appointment at the NIMH, Insel was a professor of psychiatry at Emory University, studying the neurobiology of complex social behaviors. While there, he was the founding director of the NSF Center for Behavioral Neuroscience and director of the NIH-funded Center for Autism Research. He has published over 250 scientific articles and four books and has served on numerous academic, scientific, and professional committees and boards. He is a member of the Institute of Medicine, a fellow of the American College of Neuropsychopharmacology, and a recipient of the Outstanding Service Award from the U.S. Public Health Service and the 2010 La Fondation IPSEN Neuronal Plasticity Prize. 

More profile about the speaker
Thomas Insel | Speaker | TED.com
TEDxCaltech

Thomas Insel: Toward a new understanding of mental illness

Filmed:
1,412,184 views

Today, thanks to better early detection, there are 63% fewer deaths from heart disease than there were just a few decades ago. Thomas Insel, the director of the National Institute of Mental Health, wonders: Could we do the same for depression and schizophrenia? The first step in this new avenue of research, he says, is a crucial reframing: for us to stop thinking about "mental disorders" and start understanding them as "brain disorders."
- Neuroscientist and psychiatrist
The Director of the National Institute of Mental Health, Thomas Insel supports research that will help us understand, treat and even prevent mental disorders. Full bio

Double-click the English transcript below to play the video.

00:12
So let's start with some good news,
0
530
2961
00:15
and the good news has to do with what do we know
1
3491
2349
00:17
based on biomedical research
2
5840
2267
00:20
that actually has changed the outcomes
3
8107
3454
00:23
for many very serious diseases?
4
11561
3099
00:26
Let's start with leukemia,
5
14660
2247
00:28
acute lymphoblastic leukemia, ALL,
6
16907
2528
00:31
the most common cancer of children.
7
19435
2438
00:33
When I was a student,
8
21873
1962
00:35
the mortality rate was about 95 percent.
9
23835
3840
00:39
Today, some 25, 30 years later, we're talking about
10
27675
3133
00:42
a mortality rate that's reduced by 85 percent.
11
30808
3627
00:46
Six thousand children each year
12
34435
2616
00:49
who would have previously died of this disease are cured.
13
37051
4189
00:53
If you want the really big numbers,
14
41240
1791
00:55
look at these numbers for heart disease.
15
43031
2828
00:57
Heart disease used to be the biggest killer,
16
45859
1792
00:59
particularly for men in their 40s.
17
47651
1504
01:01
Today, we've seen a 63-percent reduction in mortality
18
49155
3494
01:04
from heart disease --
19
52649
2061
01:06
remarkably, 1.1 million deaths averted every year.
20
54710
4885
01:11
AIDS, incredibly, has just been named,
21
59595
2721
01:14
in the past month, a chronic disease,
22
62316
2281
01:16
meaning that a 20-year-old who becomes infected with HIV
23
64597
2915
01:19
is expected not to live weeks, months, or a couple of years,
24
67512
4071
01:23
as we said only a decade ago,
25
71583
2270
01:25
but is thought to live decades,
26
73853
2392
01:28
probably to die in his '60s or '70s from other causes altogether.
27
76245
4496
01:32
These are just remarkable, remarkable changes
28
80741
3025
01:35
in the outlook for some of the biggest killers.
29
83766
2589
01:38
And one in particular
30
86355
2079
01:40
that you probably wouldn't know about, stroke,
31
88434
2045
01:42
which has been, along with heart disease,
32
90479
1601
01:44
one of the biggest killers in this country,
33
92080
2178
01:46
is a disease in which now we know
34
94258
1791
01:48
that if you can get people into the emergency room
35
96049
2929
01:50
within three hours of the onset,
36
98978
2174
01:53
some 30 percent of them will be able to leave the hospital
37
101152
2605
01:55
without any disability whatsoever.
38
103757
3119
01:58
Remarkable stories,
39
106876
2257
02:01
good-news stories,
40
109133
2031
02:03
all of which boil down to understanding
41
111164
3065
02:06
something about the diseases that has allowed us
42
114229
3352
02:09
to detect early and intervene early.
43
117581
3323
02:12
Early detection, early intervention,
44
120904
2135
02:15
that's the story for these successes.
45
123039
3070
02:18
Unfortunately, the news is not all good.
46
126109
2736
02:20
Let's talk about one other story
47
128845
2349
02:23
which has to do with suicide.
48
131194
1691
02:24
Now this is, of course, not a disease, per se.
49
132885
2652
02:27
It's a condition, or it's a situation
50
135537
3088
02:30
that leads to mortality.
51
138625
1789
02:32
What you may not realize is just how prevalent it is.
52
140414
3080
02:35
There are 38,000 suicides each year in the United States.
53
143494
4209
02:39
That means one about every 15 minutes.
54
147703
2758
02:42
Third most common cause of death amongst people
55
150461
2776
02:45
between the ages of 15 and 25.
56
153237
2776
02:48
It's kind of an extraordinary story when you realize
57
156013
2248
02:50
that this is twice as common as homicide
58
158261
2512
02:52
and actually more common as a source of death
59
160773
2649
02:55
than traffic fatalities in this country.
60
163422
3335
02:58
Now, when we talk about suicide,
61
166757
2632
03:01
there is also a medical contribution here,
62
169389
3112
03:04
because 90 percent of suicides
63
172501
2432
03:06
are related to a mental illness:
64
174933
1770
03:08
depression, bipolar disorder, schizophrenia,
65
176703
3046
03:11
anorexia, borderline personality. There's a long list
66
179749
3058
03:14
of disorders that contribute,
67
182808
2109
03:16
and as I mentioned before, often early in life.
68
184917
4024
03:20
But it's not just the mortality from these disorders.
69
188941
3204
03:24
It's also morbidity.
70
192145
1642
03:25
If you look at disability,
71
193787
2261
03:28
as measured by the World Health Organization
72
196048
2152
03:30
with something they call the Disability Adjusted Life Years,
73
198200
3525
03:33
it's kind of a metric that nobody would think of
74
201725
2096
03:35
except an economist,
75
203821
1314
03:37
except it's one way of trying to capture what is lost
76
205135
3442
03:40
in terms of disability from medical causes,
77
208577
3183
03:43
and as you can see, virtually 30 percent
78
211760
2893
03:46
of all disability from all medical causes
79
214653
2264
03:48
can be attributed to mental disorders,
80
216917
2560
03:51
neuropsychiatric syndromes.
81
219477
2384
03:53
You're probably thinking that doesn't make any sense.
82
221861
2152
03:56
I mean, cancer seems far more serious.
83
224013
2672
03:58
Heart disease seems far more serious.
84
226685
3032
04:01
But you can see actually they are further down this list,
85
229717
3040
04:04
and that's because we're talking here about disability.
86
232757
2280
04:07
What drives the disability for these disorders
87
235037
2792
04:09
like schizophrenia and bipolar and depression?
88
237829
3904
04:13
Why are they number one here?
89
241733
2975
04:16
Well, there are probably three reasons.
90
244708
1509
04:18
One is that they're highly prevalent.
91
246217
1972
04:20
About one in five people will suffer from one of these disorders
92
248189
3295
04:23
in the course of their lifetime.
93
251484
2577
04:26
A second, of course, is that, for some people,
94
254061
2320
04:28
these become truly disabling,
95
256381
1584
04:29
and it's about four to five percent, perhaps one in 20.
96
257965
3128
04:33
But what really drives these numbers, this high morbidity,
97
261093
4264
04:37
and to some extent the high mortality,
98
265357
2429
04:39
is the fact that these start very early in life.
99
267786
3948
04:43
Fifty percent will have onset by age 14,
100
271734
3095
04:46
75 percent by age 24,
101
274829
3120
04:49
a picture that is very different than what one would see
102
277949
3465
04:53
if you're talking about cancer or heart disease,
103
281414
2271
04:55
diabetes, hypertension -- most of the major illnesses
104
283685
3400
04:59
that we think about as being sources of morbidity and mortality.
105
287085
4096
05:03
These are, indeed, the chronic disorders of young people.
106
291181
6310
05:09
Now, I started by telling you that there were some good-news stories.
107
297491
2867
05:12
This is obviously not one of them.
108
300358
1448
05:13
This is the part of it that is perhaps most difficult,
109
301806
2879
05:16
and in a sense this is a kind of confession for me.
110
304685
2584
05:19
My job is to actually make sure that we make progress
111
307269
5352
05:24
on all of these disorders.
112
312621
2352
05:26
I work for the federal government.
113
314973
1710
05:28
Actually, I work for you. You pay my salary.
114
316683
2018
05:30
And maybe at this point, when you know what I do,
115
318701
2384
05:33
or maybe what I've failed to do,
116
321085
2120
05:35
you'll think that I probably ought to be fired,
117
323205
2209
05:37
and I could certainly understand that.
118
325414
2155
05:39
But what I want to suggest, and the reason I'm here
119
327569
2332
05:41
is to tell you that I think we're about to be
120
329901
3255
05:45
in a very different world as we think about these illnesses.
121
333156
4663
05:49
What I've been talking to you about so far is mental disorders,
122
337819
3106
05:52
diseases of the mind.
123
340925
1716
05:54
That's actually becoming a rather unpopular term these days,
124
342641
3396
05:58
and people feel that, for whatever reason,
125
346037
2200
06:00
it's politically better to use the term behavioral disorders
126
348237
3377
06:03
and to talk about these as disorders of behavior.
127
351614
3911
06:07
Fair enough. They are disorders of behavior,
128
355525
2267
06:09
and they are disorders of the mind.
129
357792
2000
06:11
But what I want to suggest to you
130
359792
2405
06:14
is that both of those terms,
131
362197
1752
06:15
which have been in play for a century or more,
132
363949
3018
06:18
are actually now impediments to progress,
133
366967
2820
06:21
that what we need conceptually to make progress here
134
369787
4330
06:26
is to rethink these disorders as brain disorders.
135
374117
5208
06:31
Now, for some of you, you're going to say,
136
379325
1862
06:33
"Oh my goodness, here we go again.
137
381187
2219
06:35
We're going to hear about a biochemical imbalance
138
383406
2628
06:38
or we're going to hear about drugs
139
386034
1735
06:39
or we're going to hear about some very simplistic notion
140
387769
4826
06:44
that will take our subjective experience
141
392595
2940
06:47
and turn it into molecules, or maybe into some sort of
142
395535
6072
06:53
very flat, unidimensional understanding
143
401607
3218
06:56
of what it is to have depression or schizophrenia.
144
404825
4102
07:00
When we talk about the brain, it is anything but
145
408927
4498
07:05
unidimensional or simplistic or reductionistic.
146
413425
3263
07:08
It depends, of course, on what scale
147
416688
2959
07:11
or what scope you want to think about,
148
419647
2296
07:13
but this is an organ of surreal complexity,
149
421943
6280
07:20
and we are just beginning to understand
150
428223
3471
07:23
how to even study it, whether you're thinking about
151
431694
2173
07:25
the 100 billion neurons that are in the cortex
152
433867
2582
07:28
or the 100 trillion synapses
153
436449
2145
07:30
that make up all the connections.
154
438594
2359
07:32
We have just begun to try to figure out
155
440953
3576
07:36
how do we take this very complex machine
156
444529
3528
07:40
that does extraordinary kinds of information processing
157
448057
2744
07:42
and use our own minds to understand
158
450801
2717
07:45
this very complex brain that supports our own minds.
159
453518
3531
07:49
It's actually a kind of cruel trick of evolution
160
457049
2560
07:51
that we simply don't have a brain
161
459609
3830
07:55
that seems to be wired well enough to understand itself.
162
463439
2898
07:58
In a sense, it actually makes you feel that
163
466337
2314
08:00
when you're in the safe zone of studying behavior or cognition,
164
468651
2838
08:03
something you can observe,
165
471489
1323
08:04
that in a way feels more simplistic and reductionistic
166
472812
3005
08:07
than trying to engage this very complex, mysterious organ
167
475817
4968
08:12
that we're beginning to try to understand.
168
480785
2428
08:15
Now, already in the case of the brain disorders
169
483213
3656
08:18
that I've been talking to you about,
170
486869
1728
08:20
depression, obsessive compulsive disorder,
171
488597
2273
08:22
post-traumatic stress disorder,
172
490870
2162
08:25
while we don't have an in-depth understanding
173
493032
2942
08:27
of how they are abnormally processed
174
495974
3726
08:31
or what the brain is doing in these illnesses,
175
499700
2105
08:33
we have been able to already identify
176
501805
3055
08:36
some of the connectional differences, or some of the ways
177
504860
2576
08:39
in which the circuitry is different
178
507436
2504
08:41
for people who have these disorders.
179
509940
1816
08:43
We call this the human connectome,
180
511756
1758
08:45
and you can think about the connectome
181
513514
2381
08:47
sort of as the wiring diagram of the brain.
182
515895
1872
08:49
You'll hear more about this in a few minutes.
183
517767
2104
08:51
The important piece here is that as you begin to look
184
519871
2951
08:54
at people who have these disorders, the one in five of us
185
522822
3977
08:58
who struggle in some way,
186
526799
1828
09:00
you find that there's a lot of variation
187
528627
2288
09:02
in the way that the brain is wired,
188
530915
3216
09:06
but there are some predictable patterns, and those patterns
189
534131
2602
09:08
are risk factors for developing one of these disorders.
190
536733
3814
09:12
It's a little different than the way we think about brain disorders
191
540547
2992
09:15
like Huntington's or Parkinson's or Alzheimer's disease
192
543539
2768
09:18
where you have a bombed-out part of your cortex.
193
546307
2392
09:20
Here we're talking about traffic jams, or sometimes detours,
194
548699
3260
09:23
or sometimes problems with just the way that things are connected
195
551959
2747
09:26
and the way that the brain functions.
196
554706
1247
09:27
You could, if you want, compare this to,
197
555953
3170
09:31
on the one hand, a myocardial infarction, a heart attack,
198
559123
3049
09:34
where you have dead tissue in the heart,
199
562172
1823
09:35
versus an arrhythmia, where the organ simply isn't functioning
200
563995
3597
09:39
because of the communication problems within it.
201
567592
2251
09:41
Either one would kill you; in only one of them
202
569843
1969
09:43
will you find a major lesion.
203
571812
2600
09:46
As we think about this, probably it's better to actually go
204
574412
2832
09:49
a little deeper into one particular disorder, and that would be schizophrenia,
205
577244
3223
09:52
because I think that's a good case
206
580467
2136
09:54
for helping to understand why thinking of this as a brain disorder matters.
207
582603
3525
09:58
These are scans from Judy Rapoport and her colleagues
208
586128
3878
10:02
at the National Institute of Mental Health
209
590006
2172
10:04
in which they studied children with very early onset schizophrenia,
210
592178
3716
10:07
and you can see already in the top
211
595894
1470
10:09
there's areas that are red or orange, yellow,
212
597364
2537
10:11
are places where there's less gray matter,
213
599901
2138
10:14
and as they followed them over five years,
214
602039
1538
10:15
comparing them to age match controls,
215
603577
2238
10:17
you can see that, particularly in areas like
216
605815
1822
10:19
the dorsolateral prefrontal cortex
217
607637
2316
10:21
or the superior temporal gyrus, there's a profound loss of gray matter.
218
609953
4330
10:26
And it's important, if you try to model this,
219
614283
1543
10:27
you can think about normal development
220
615826
1956
10:29
as a loss of cortical mass, loss of cortical gray matter,
221
617782
3253
10:33
and what's happening in schizophrenia is that you overshoot that mark,
222
621035
3664
10:36
and at some point, when you overshoot,
223
624699
1569
10:38
you cross a threshold, and it's that threshold
224
626268
2991
10:41
where we say, this is a person who has this disease,
225
629259
3576
10:44
because they have the behavioral symptoms
226
632835
2288
10:47
of hallucinations and delusions.
227
635123
2121
10:49
That's something we can observe.
228
637244
1477
10:50
But look at this closely and you can see that actually they've crossed a different threshold.
229
638721
5642
10:56
They've crossed a brain threshold much earlier,
230
644363
2996
10:59
that perhaps not at age 22 or 20,
231
647359
3140
11:02
but even by age 15 or 16 you can begin to see
232
650499
2768
11:05
the trajectory for development is quite different
233
653267
2360
11:07
at the level of the brain, not at the level of behavior.
234
655627
3515
11:11
Why does this matter? Well first because,
235
659142
2095
11:13
for brain disorders, behavior is the last thing to change.
236
661237
3142
11:16
We know that for Alzheimer's, for Parkinson's, for Huntington's.
237
664379
2910
11:19
There are changes in the brain a decade or more
238
667289
2434
11:21
before you see the first signs of a behavioral change.
239
669723
5040
11:26
The tools that we have now allow us to detect
240
674763
2944
11:29
these brain changes much earlier, long before the symptoms emerge.
241
677707
4297
11:34
But most important, go back to where we started.
242
682004
3399
11:37
The good-news stories in medicine
243
685403
3216
11:40
are early detection, early intervention.
244
688619
2944
11:43
If we waited until the heart attack,
245
691563
3664
11:47
we would be sacrificing 1.1 million lives
246
695227
3975
11:51
every year in this country to heart disease.
247
699202
2409
11:53
That is precisely what we do today
248
701611
2408
11:56
when we decide that everybody with one of these brain disorders,
249
704019
4512
12:00
brain circuit disorders, has a behavioral disorder.
250
708531
3202
12:03
We wait until the behavior becomes manifest.
251
711733
3224
12:06
That's not early detection. That's not early intervention.
252
714957
4559
12:11
Now to be clear, we're not quite ready to do this.
253
719516
1805
12:13
We don't have all the facts. We don't actually even know
254
721321
3154
12:16
what the tools will be,
255
724475
2549
12:19
nor what to precisely look for in every case to be able
256
727024
4259
12:23
to get there before the behavior emerges as different.
257
731283
4205
12:27
But this tells us how we need to think about it,
258
735488
2937
12:30
and where we need to go.
259
738425
1489
12:31
Are we going to be there soon?
260
739914
1202
12:33
I think that this is something that will happen
261
741116
2678
12:35
over the course of the next few years, but I'd like to finish
262
743794
2831
12:38
with a quote about trying to predict how this will happen
263
746625
2535
12:41
by somebody who's thought a lot about changes
264
749160
2361
12:43
in concepts and changes in technology.
265
751521
2328
12:45
"We always overestimate the change that will occur
266
753849
2264
12:48
in the next two years and underestimate
267
756113
2223
12:50
the change that will occur in the next 10." -- Bill Gates.
268
758336
3876
12:54
Thanks very much.
269
762212
1363
12:55
(Applause)
270
763575
2683
Translated by Joseph Geni
Reviewed by Thu-Huong Ha

▲Back to top

ABOUT THE SPEAKER
Thomas Insel - Neuroscientist and psychiatrist
The Director of the National Institute of Mental Health, Thomas Insel supports research that will help us understand, treat and even prevent mental disorders.

Why you should listen

Thomas Insel has seen many advances in the understanding of mental disorders since becoming the Director of the National Institute of Mental Health (NIMH) in 2002. During his tenure, major breakthroughs have been made in the areas of practical clinical trials, autism research and the role of genetics in mental illnesses.

Prior to his appointment at the NIMH, Insel was a professor of psychiatry at Emory University, studying the neurobiology of complex social behaviors. While there, he was the founding director of the NSF Center for Behavioral Neuroscience and director of the NIH-funded Center for Autism Research. He has published over 250 scientific articles and four books and has served on numerous academic, scientific, and professional committees and boards. He is a member of the Institute of Medicine, a fellow of the American College of Neuropsychopharmacology, and a recipient of the Outstanding Service Award from the U.S. Public Health Service and the 2010 La Fondation IPSEN Neuronal Plasticity Prize. 

More profile about the speaker
Thomas Insel | Speaker | TED.com