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So let's start with some good news.
And the good news has to do with what do we know based on biomedical research that actually has changed the outcomes for many very serious diseases.
Start with leukemia.
Acute lymphoblastic leukemia.
A.
L L most common cancer of Children.
When I was a student, the mortality rate was about 95%.
Today, some 25 30 years later, we're talking about a mortality rate that's reduced by 85%.
6000 Children each year who would have previously died of this disease are cured.
If you want the really big numbers.
Look at these numbers for heart disease.
Heart disease used to be the biggest killer, particularly for men in their forties.
Today, we've seen a 63% reduction in mortality from heart disease.
Remarkably, 1.1 million deaths averted every year.
AIDS, incredibly, has just been named in the past month.
A chronic disease meaning that a 20 year old it becomes infected with HIV is expected not to live weeks.
Months are a couple of years, as we said only a decade ago, but is thought to live decades, probably to die in his sixties or seventies from other causes.
Altogether.
These air just remarkable, remarkable changes in the outlook for some of the biggest killers, and one in particular that you probably wouldn't know about stroke, which has been along with heart disease.
One of the biggest killers in this country is a disease in which now we know that if you can get people into the emergency room within three hours of the onset, some 30% of them will be able to leave the hospital without any disability whatsoever.
Remarkable stories, good news stories, all of which boiled down to understanding something about the diseases that has allowed us to detect early and intervene early.
Early detection, early intervention.
That's the story for these successes.
Unfortunately, the news is not all good.
Let's talk about one other story, which has to do with suicide now.
This is, of course, not a disease per se.
It's a condition, or it's a situation that leads to mortality.
What you may not realize is just how prevalent it is.
There are 38,000 suicides each year in the United States.
That means one about every 15 minutes.
Third most common cause of death amongst people between the ages of 15 and 25.
It's kind of an extraordinary story when you realize that this is twice as common as homicide and actually more common as a source of death than traffic fatalities in this country.
Now, when we talk about suicide, there is also a medical contribution here because 90% of suicides are related to a mental illness, depression, bipolar disorder, schizophrenia, anorexia, borderline personality.
There's a long list of disorders that contribute, and as I mentioned before, often early in life, that it's not just the mortality from these disorders.
It's also morbidity.
If you look at disability as measured by the World Health Organization with something they call the disability adjusted life years, it's kind of a metric that nobody would think of accepting economists.
Except it's one way of trying to capture what is lost in terms of disability from medical causes.
And as you can see, virtually 30% of all disability from all medical causes can be attributed to mental disorders, neuropsychiatric syndromes.
You're probably thinking that doesn't make any sense.
I mean, cancer seems far more serious.
Heart disease seems far more serious, but you can see actually there further down this list, And that's because we're talking here about disability.
What drives the disability for these disorders, like schizophrenia and bipolar and depression?
Why are they number one here?
Well, they're probably three reasons.
One is that they're highly prevalent.
About one in five people will suffer from one of these disorders in the course of their lifetime.
A second, of course, is that for some people these become truly disabling, and it's about 4 to 5% reps of one and 20.
But what really drives these numbers this high morbidity?
And to some extent, the high mortality is the fact that these start very early in life.
50% will have on set by age 14 75% by age 24 a picture that is very different than what one would see if you're talking about cancer or heart disease, diabetes, hypertension, most of the major illnesses that we think about as being sources of morbidity and mortality.
These are indeed the chronic disorders of young people.
Now, I started by telling you that there was some good news stories.
This is obviously not one of them.
This is the part of it.
That is perhaps most difficult and in a sense, this is a kind of confession for me.
My job is to actually make sure that we make progress on all of these disorders.
I work for the federal government, actually work for you.
You pay my salary and and maybe at this point, when you know what I do, or maybe what I failed to do, you'll think that I probably ought to be fired, and I could certainly understand that.
But what I want to suggest and the reason I'm here is to tell you that I think we're about to being a very different world as we think about these these illnesses.
What I've been talking to you about so far is mental disorders, diseases of the mind that's actually becoming a rather unpopular term these days.
And people feel that for whatever reason, it's politically better to use the term behavioral disorders and to talk about these as disorders of behavior.
Fair enough.
They are disorders of behavior and they are disorders of the mind.
But what I want to suggest to you is that both of those terms which have been in play for a century or more are actually now impediments to progress that what we need conceptually to make progress here is to rethink thes disorders as brain disorders.
Now, for some of you, you're going to say, Oh my goodness, here we go again.
We're going to hear about a biochemical imbalance.
So we're going to hear about drugs, or we're going to hear about some very simplistic notion that will take our subjective experience and turn it into molecules, or maybe into some sort of no very flat, unit dimensional understanding of what it is to have depression or schizophrenia.
When we talk about the brain, it is anything but uni dimensional or simplistic, a reductionist IQ.
It depends, of course, what scale or what scope you want to think about.
But this his an organ of surreal complexity, and we are just beginning to understand.
How do we even study it?
Whether you're thinking about the 100 billion neurons that are in the cortex, or the 100 trillion synapses that make up all the connections, we have just begun to try to figure out how do we take this very complex machine that does extraordinary kinds of information processing and and use our own minds to understand this very complex brain that supports it supports our own minds.
It's it.
It's actually a kind of cruel trick of evolution that we simply don't have a brain that seems to be wired well enough to understand itself.
In a sense, it actually makes you feel that when you're in the safe zone of studying behavior or cognition something you can observe that in a way feels more simplistic and reductionist IQ than trying to engage this very complex, mysterious organ that we're beginning to try to understand now.
Already, in the case of the brain disorders that I've been talking to you about depression, obsessive compulsive disorder, post traumatic stress disorder, well, we don't have a an in depth understanding of how they are abnormally processed or what the brain is doing in these illnesses.
We have been able to already identify some of the connection all differences or some of the ways in which the circuitry is different for people who have these disorders.
We call this the human connect.
Um, and you can think about the connect.
Um, sort of is the wiring diagram of the brain.
You'll hear more about this in a few minutes.
The important piece here is that as you begin to look at people who have these disorders, the one in five of us who struggle in some way you find that there's a lot of variation in the way that the brain is wired.
But there are some predictable patterns, and those patterns are risk factors for developing one of these disorders.
It's a little different than the way we think about brain disorders like Huntington's or Parkinson's or Alzheimer's disease, where you have a bombed out part of your cortex.
Here we're talking about traffic jams.
Or sometimes detours are sometimes problems with just the way that things are connected and the way that the brain functions.
You could if you want, compare this to, on the one hand, a myocardial infarction, a heart attack where you have dead tissue in the heart versus name arrhythmia, where the Oregon simply isn't functioning because of the communication problems within it.
Either one would kill you, and only one of them will you find a major lesion.
As we think about this privy, it's better to actually go a little deeper into one particular disorder.
And that would be schizophrenia because I think that's a good case for helping to understand why.
Thinking of this as a brain disorder matters.
These air scans from Judy Rapoport and her colleagues at the National Institute of Mental Health, in which they studied Children with very early onset schizophrenia.
And you can see already in the top there's areas that are red or orange.
Yellow are places where there's less gray matter and as they follow them over five years, comparing them to age matched controls.
You can see that particularly in areas like the door, so lateral prefrontal cortex or the superior temporal gyrus.
There's a profound loss of gray matter.
It's important if you turn up model this.
You can think about normal development as a loss of cortical mass loss of cortical gray matter.
And what's happening in schizophrenia is that you overshoot that mark, and at some point when you overshoot, you cross a threshold, and it's that threshold where we taught.
We say this is a person who has this disease because they have the behavioral symptoms of hallucinations and delusions.
That's something we can observe.
But look at this closely and you can see that.
Actually, they've crossed a different threshold.
They've crossed a brain threshold much earlier that perhaps not at age 22 or 20.
But even by age 15 or 16 you can begin to see the trajectory for development is quite different at the level of the brain, not at the level of behavior.
Why does this matter?
Will first, Because for brain disorders, behavior is the last thing to change.
We know that for Alzheimer's, for Parkinson's, for Huntington's, there are changes in the brain a decade or more before you see the first signs of a behavioral change, the tools that we have now allow us to detect these brain changes much earlier, long before the symptoms emerge.
But most important, go back to where we started.
The good news stories in medicine are early detection, early intervention.
If we waited until the heart attack, we would be sacrificing 1.1 million lives every year in this country to heart disease.
That is precisely what we do today when we decide that everybody with one of these brain disorders, brain circuit disorders, has a behavioral disorder.
We wait until the behavior becomes manifest.
That's not early detection.
That's not early intervention.
Now, to be clear, we're not quite ready to do this.
We don't have all the facts.
We don't actually even know what the tools will be, nor what to precisely look for in every case to be able to get there before the behavior emerges as different.
But this tells us how we need to think about it and where we need to go.
Are we going to be there soon?
I think that this is something that will happen over the course of the next few years, But I'd like to finish with a quote about trying to predict how this will happen by somebody who's thought a lot about changes in concepts and changes in technology.
We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next 10.
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Toward a new understanding of mental illness - Thomas Insel

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林宜悉 2020 年 7 月 3 日 に公開

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