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Thomas Insel: Toward a new understanding of mental illness

January 18, 2013

Today, thanks to better early detection, there are 63% fewer deaths from heart disease than there were just a few decades ago. Thomas Insel, 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.” (Filmed at TEDxCaltech.)

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. Full bio

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Double-click the English subtitles below to play the video.
So let's start with some good news,
00:12
and the good news has to do with what do we know
00:15
based on biomedical research
00:17
that actually has changed the outcomes
00:19
for many very serious diseases?
00:23
Let's start with leukemia,
00:26
acute lymphoblastic leukemia, ALL,
00:28
the most common cancer of children.
00:31
When I was a student,
00:33
the mortality rate was about 95 percent.
00:35
Today, some 25, 30 years later, we're talking about
00:39
a mortality rate that's reduced by 85 percent.
00:42
Six thousand children each year
00:46
who would have previously died of this disease are cured.
00:48
If you want the really big numbers,
00:53
look at these numbers for heart disease.
00:54
Heart disease used to be the biggest killer,
00:57
particularly for men in their 40s.
00:59
Today, we've seen a 63-percent reduction in mortality
01:00
from heart disease --
01:04
remarkably, 1.1 million deaths averted every year.
01:06
AIDS, incredibly, has just been named,
01:11
in the past month, a chronic disease,
01:14
meaning that a 20-year-old who becomes infected with HIV
01:16
is expected not to live weeks, months, or a couple of years,
01:19
as we said only a decade ago,
01:23
but is thought to live decades,
01:25
probably to die in his '60s or '70s from other causes altogether.
01:28
These are just remarkable, remarkable changes
01:32
in the outlook for some of the biggest killers.
01:35
And one in particular
01:38
that you probably wouldn't know about, stroke,
01:40
which has been, along with heart disease,
01:42
one of the biggest killers in this country,
01:43
is a disease in which now we know
01:46
that if you can get people into the emergency room
01:47
within three hours of the onset,
01:50
some 30 percent of them will be able to leave the hospital
01:52
without any disability whatsoever.
01:55
Remarkable stories,
01:58
good-news stories,
02:00
all of which boil down to understanding
02:02
something about the diseases that has allowed us
02:06
to detect early and intervene early.
02:09
Early detection, early intervention,
02:12
that's the story for these successes.
02:14
Unfortunately, the news is not all good.
02:17
Let's talk about one other story
02:20
which has to do with suicide.
02:23
Now this is, of course, not a disease, per se.
02:24
It's a condition, or it's a situation
02:27
that leads to mortality.
02:30
What you may not realize is just how prevalent it is.
02:32
There are 38,000 suicides each year in the United States.
02:35
That means one about every 15 minutes.
02:39
Third most common cause of death amongst people
02:42
between the ages of 15 and 25.
02:45
It's kind of an extraordinary story when you realize
02:47
that this is twice as common as homicide
02:50
and actually more common as a source of death
02:52
than traffic fatalities in this country.
02:55
Now, when we talk about suicide,
02:58
there is also a medical contribution here,
03:01
because 90 percent of suicides
03:04
are related to a mental illness:
03:06
depression, bipolar disorder, schizophrenia,
03:08
anorexia, borderline personality. There's a long list
03:11
of disorders that contribute,
03:14
and as I mentioned before, often early in life.
03:16
But it's not just the mortality from these disorders.
03:20
It's also morbidity.
03:23
If you look at disability,
03:25
as measured by the World Health Organization
03:27
with something they call the Disability Adjusted Life Years,
03:30
it's kind of a metric that nobody would think of
03:33
except an economist,
03:35
except it's one way of trying to capture what is lost
03:36
in terms of disability from medical causes,
03:40
and as you can see, virtually 30 percent
03:43
of all disability from all medical causes
03:46
can be attributed to mental disorders,
03:48
neuropsychiatric syndromes.
03:51
You're probably thinking that doesn't make any sense.
03:53
I mean, cancer seems far more serious.
03:55
Heart disease seems far more serious.
03:58
But you can see actually they are further down this list,
04:01
and that's because we're talking here about disability.
04:04
What drives the disability for these disorders
04:06
like schizophrenia and bipolar and depression?
04:09
Why are they number one here?
04:13
Well, there are probably three reasons.
04:16
One is that they're highly prevalent.
04:18
About one in five people will suffer from one of these disorders
04:20
in the course of their lifetime.
04:23
A second, of course, is that, for some people,
04:25
these become truly disabling,
04:28
and it's about four to five percent, perhaps one in 20.
04:29
But what really drives these numbers, this high morbidity,
04:32
and to some extent the high mortality,
04:37
is the fact that these start very early in life.
04:39
Fifty percent will have onset by age 14,
04:43
75 percent by age 24,
04:46
a picture that is very different than what one would see
04:49
if you're talking about cancer or heart disease,
04:53
diabetes, hypertension -- most of the major illnesses
04:55
that we think about as being sources of morbidity and mortality.
04:58
These are, indeed, the chronic disorders of young people.
05:03
Now, I started by telling you that there were some good-news stories.
05:09
This is obviously not one of them.
05:12
This is the part of it that is perhaps most difficult,
05:13
and in a sense this is a kind of confession for me.
05:16
My job is to actually make sure that we make progress
05:19
on all of these disorders.
05:24
I work for the federal government.
05:26
Actually, I work for you. You pay my salary.
05:28
And maybe at this point, when you know what I do,
05:30
or maybe what I've failed to do,
05:32
you'll think that I probably ought to be fired,
05:35
and I could certainly understand that.
05:37
But what I want to suggest, and the reason I'm here
05:39
is to tell you that I think we're about to be
05:41
in a very different world as we think about these illnesses.
05:44
What I've been talking to you about so far is mental disorders,
05:49
diseases of the mind.
05:52
That's actually becoming a rather unpopular term these days,
05:54
and people feel that, for whatever reason,
05:57
it's politically better to use the term behavioral disorders
06:00
and to talk about these as disorders of behavior.
06:03
Fair enough. They are disorders of behavior,
06:07
and they are disorders of the mind.
06:09
But what I want to suggest to you
06:11
is that both of those terms,
06:14
which have been in play for a century or more,
06:15
are actually now impediments to progress,
06:18
that what we need conceptually to make progress here
06:21
is to rethink these disorders as brain disorders.
06:25
Now, for some of you, you're going to say,
06:31
"Oh my goodness, here we go again.
06:33
We're going to hear about a biochemical imbalance
06:35
or we're going to hear about drugs
06:37
or we're going to hear about some very simplistic notion
06:39
that will take our subjective experience
06:44
and turn it into molecules, or maybe into some sort of
06:47
very flat, unidimensional understanding
06:53
of what it is to have depression or schizophrenia.
06:56
When we talk about the brain, it is anything but
07:00
unidimensional or simplistic or reductionistic.
07:05
It depends, of course, on what scale
07:08
or what scope you want to think about,
07:11
but this is an organ of surreal complexity,
07:13
and we are just beginning to understand
07:20
how to even study it, whether you're thinking about
07:23
the 100 billion neurons that are in the cortex
07:25
or the 100 trillion synapses
07:28
that make up all the connections.
07:30
We have just begun to try to figure out
07:32
how do we take this very complex machine
07:36
that does extraordinary kinds of information processing
07:39
and use our own minds to understand
07:42
this very complex brain that supports our own minds.
07:45
It's actually a kind of cruel trick of evolution
07:48
that we simply don't have a brain
07:51
that seems to be wired well enough to understand itself.
07:55
In a sense, it actually makes you feel that
07:58
when you're in the safe zone of studying behavior or cognition,
08:00
something you can observe,
08:03
that in a way feels more simplistic and reductionistic
08:04
than trying to engage this very complex, mysterious organ
08:07
that we're beginning to try to understand.
08:12
Now, already in the case of the brain disorders
08:15
that I've been talking to you about,
08:18
depression, obsessive compulsive disorder,
08:20
post-traumatic stress disorder,
08:22
while we don't have an in-depth understanding
08:24
of how they are abnormally processed
08:27
or what the brain is doing in these illnesses,
08:31
we have been able to already identify
08:33
some of the connectional differences, or some of the ways
08:36
in which the circuitry is different
08:39
for people who have these disorders.
08:41
We call this the human connectome,
08:43
and you can think about the connectome
08:45
sort of as the wiring diagram of the brain.
08:47
You'll hear more about this in a few minutes.
08:49
The important piece here is that as you begin to look
08:51
at people who have these disorders, the one in five of us
08:54
who struggle in some way,
08:58
you find that there's a lot of variation
09:00
in the way that the brain is wired,
09:02
but there are some predictable patterns, and those patterns
09:05
are risk factors for developing one of these disorders.
09:08
It's a little different than the way we think about brain disorders
09:12
like Huntington's or Parkinson's or Alzheimer's disease
09:15
where you have a bombed-out part of your cortex.
09:18
Here we're talking about traffic jams, or sometimes detours,
09:20
or sometimes problems with just the way that things are connected
09:23
and the way that the brain functions.
09:26
You could, if you want, compare this to,
09:27
on the one hand, a myocardial infarction, a heart attack,
09:30
where you have dead tissue in the heart,
09:33
versus an arrhythmia, where the organ simply isn't functioning
09:35
because of the communication problems within it.
09:39
Either one would kill you; in only one of them
09:41
will you find a major lesion.
09:43
As we think about this, probably it's better to actually go
09:46
a little deeper into one particular disorder, and that would be schizophrenia,
09:49
because I think that's a good case
09:52
for helping to understand why thinking of this as a brain disorder matters.
09:54
These are scans from Judy Rapoport and her colleagues
09:57
at the National Institute of Mental Health
10:01
in which they studied children with very early onset schizophrenia,
10:03
and you can see already in the top
10:07
there's areas that are red or orange, yellow,
10:09
are places where there's less gray matter,
10:11
and as they followed them over five years,
10:13
comparing them to age match controls,
10:15
you can see that, particularly in areas like
10:17
the dorsolateral prefrontal cortex
10:19
or the superior temporal gyrus, there's a profound loss of gray matter.
10:21
And it's important, if you try to model this,
10:26
you can think about normal development
10:27
as a loss of cortical mass, loss of cortical gray matter,
10:29
and what's happening in schizophrenia is that you overshoot that mark,
10:32
and at some point, when you overshoot,
10:36
you cross a threshold, and it's that threshold
10:38
where we say, this is a person who has this disease,
10:41
because they have the behavioral symptoms
10:44
of hallucinations and delusions.
10:46
That's something we can observe.
10:49
But look at this closely and you can see that actually they've crossed a different threshold.
10:50
They've crossed a brain threshold much earlier,
10:56
that perhaps not at age 22 or 20,
10:59
but even by age 15 or 16 you can begin to see
11:02
the trajectory for development is quite different
11:05
at the level of the brain, not at the level of behavior.
11:07
Why does this matter? Well first because,
11:10
for brain disorders, behavior is the last thing to change.
11:13
We know that for Alzheimer's, for Parkinson's, for Huntington's.
11:16
There are changes in the brain a decade or more
11:19
before you see the first signs of a behavioral change.
11:21
The tools that we have now allow us to detect
11:26
these brain changes much earlier, long before the symptoms emerge.
11:29
But most important, go back to where we started.
11:33
The good-news stories in medicine
11:37
are early detection, early intervention.
11:40
If we waited until the heart attack,
11:43
we would be sacrificing 1.1 million lives
11:47
every year in this country to heart disease.
11:51
That is precisely what we do today
11:53
when we decide that everybody with one of these brain disorders,
11:55
brain circuit disorders, has a behavioral disorder.
12:00
We wait until the behavior becomes manifest.
12:03
That's not early detection. That's not early intervention.
12:06
Now to be clear, we're not quite ready to do this.
12:11
We don't have all the facts. We don't actually even know
12:13
what the tools will be,
12:16
nor what to precisely look for in every case to be able
12:18
to get there before the behavior emerges as different.
12:23
But this tells us how we need to think about it,
12:27
and where we need to go.
12:30
Are we going to be there soon?
12:31
I think that this is something that will happen
12:32
over the course of the next few years, but I'd like to finish
12:35
with a quote about trying to predict how this will happen
12:38
by somebody who's thought a lot about changes
12:40
in concepts and changes in technology.
12:43
"We always overestimate the change that will occur
12:45
in the next two years and underestimate
12:47
the change that will occur in the next 10." -- Bill Gates.
12:50
Thanks very much.
12:54
(Applause)
12:55
Translator:Joseph Geni
Reviewer:Thu-Huong Ha

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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. 

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