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Science to Service: Mental Health Care After the Decade of the Brain

Science to Service: Mental Health Care After the Decade of the Brain. Thomas R. Insel, M.D. Director, NIMH SSWR Annual Meeting January 16, 2004. Data for United States and Canada all ages. WHO World Health Report 2002. Which medical disorder causes greatest disability?.

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Science to Service: Mental Health Care After the Decade of the Brain

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  1. Science to Service: Mental Health CareAfter the Decade of the Brain Thomas R. Insel, M.D. Director, NIMH SSWR Annual Meeting January 16, 2004

  2. Data for United States and Canadaall ages WHO World Health Report 2002 Which medical disorder causes greatest disability?

  3. Causes of Disability by Illness CategoryUnited States and Canada15-44 years old WHO World Health Report 2002

  4. Causes of Disability by Specific IllnessUnited States and Canada15-44 years old WHO World Health Report 2002

  5. 18 16 14 12 10 Suicide Deaths per 100,000 Homicide 8 6 4 2 0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 IOM, 2002 Year What is greater source of mortality: suicide or homicide?

  6. Burden is mortality as well as disability • 30,000 deaths from suicide per year in the United States (90% with mental illness) • 0.8 million deaths per year worldwide • Third leading cause of death in adolescence

  7. Largest institution for people with mental disorders? Answer: L.A. County Jail Cost for psychotropic meds in 2001: $10M Approx 13 million people jailed every year (3X increase in past 20 years), 7% have serious mental illness, suicide rate 9X general population.

  8. Where are the people with mental disorders? Answer: Criminal justice – 15% of youth with MDD Nursing homes – mood disorders, suicide Schools –ADHD, eating disorders, suicide Homeless –47% of 2 mill. homeless report SMI Primary care – 3x incr. in care of MDD since 1990 Rural - 85% of 1669 federally designated shortage areas are rural

  9. What is the economic cost of mental illness? $71 Billion direct for treatment Antipsychotics represent >50% of all prescriptions within Medicaid, at a cost of >$2.7 Bill in 2001. Cost increasing 20-35% per year past 3 years. $79 Billion indirect (social services) SSI – Mental disorders are largest dx group (35%) SSDI – 28% have mental disorders Total investment in MH research = $1.3 Billion PCMH, 2003

  10. How Should Mental Health Services be Coordinated? SAMHSA-CMHS Federal level SMHA State level Local level CMHC Case Mgt. M.H. Care Housing Coordinated Care Job Support Consumer M.D. Meds Income Support

  11. “Coordination” of Mental Health Services in Reality Medicare Medicaid CMHS HUD Education SSA SMHA State Medicaid Agency V.R. CMHC PHA Case Mgt. M.H. Care Housing Job Support Patient M.D. Meds Income Support

  12. Recovery is the goal.

  13. President’s New Freedom Commission on Mental Health The Goals of a Transformed System Goal 1Americans Understand that Mental Health Is Essential to Overall Health Goal 2 Mental Health Care Is Consumer and Family Driven Goal 3 Disparities in Mental Health Services Are Eliminated Goal 4 Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice Goal 5 Excellent Mental Health Care Is Delivered and Research Is Accelerated Goal 6 Technology Is Used to Access Mental Health Care and Information

  14. Combining Medication and Family Education in Schizophrenia: Relapse Rates % of Patients

  15. VOCATIONAL STUDIES % Working

  16. CONTROLLED ACT RESEARCH 25 Studies

  17. Family Psycho-education for Schizophrenia ACT CBT for Anxiety CBT for Depression Integrated Dual Diagnosis SMI Treatment 6. Multidimensional Foster Care 7. “Incredible years” 8. IPT for Depression 9. Nurse-Family Partnership 10. Place and Support Vocational Rehab Empirically Based Psychosocial Treatments

  18. The U. S. Psychotherapy Workforce 200,000 192,814 180,000 160,000 140,000 120,000 100,000 80,000 73,014 60,000 40,000 33,486 20,000 17,318 0 Clinical Social Psychologists Psychiatrists Psychiatric Nurses Workers SAMHSA 1998

  19. Research for Recovery –What do we need? • Providing the evidence base and implementing what we know • Biomarkers for diagnosis, risk, and prevention • New treatments that are truly effective, safe, accessible, and targeted to individual needs • Going for the cure.

  20. Research for Recovery –How are we going to get there? • Decade of the Brain 1990 – 2000 • Decade of Discovery 1998 - 2008 • Decade of Translation 2005 - 2015

  21. Neuroimaging: Inside the “Black box” Structure Function Chemistry Connectivity

  22. Decade of the Brain Neurons are born and connections change throughout life; Synaptic density begins to drop after age 3 Information processing is modular; The brain organizes perceptions by categories Individual differences are enormous; There are many paths to the same endpoint

  23. > > p = 10 -40 0.05 0.05 10 -40 Category-Related Activity: Naming animals and tools N = 7 Chao et al., Cerebral Cortex, 2002 Medial fusiform Lateral fusiform R MTG z = - 8 > >

  24. Decade of Discovery: 1998 - 2008 Human Genome - Completed 4/14/03 Total Genes: 30,000 (about 1.5% of genome) Genes in the brain: 16,000 Brain specific genes: 6,000 Total proteins: ???? Genes with known function: less than 1% Protein targets for current medications < 500

  25. Schizophrenia susceptibility genes Whole genome linkage 1q,2p,5q,6p,6q,8p,10p,11q,13q,15q,22q Finer mapping SNP association dysbindin (6p) (five)*# neuregulin (8p) (four)*# g72 (13q) (three)* mrds1(6p) (three)*# Expression profiling RGS4 (1q) (four)* Chromosomal translocation DISC1 (1q) (three)*# Functional candidates COMT (22q) (eight)*# GRM3 (7q) (five)*# GAD 67 (2q) (three)*# calcineurin(8p) (two)* CNRNA7 (15q) (one)* * Number of positive samples worldwide # Positive in CBDB

  26. Are genes the answer? NO – genes will not give us the “cause”. All mental disorders appear to involve both genetic and environmental contributions. But genetic variation can identify susceptibility, biomarkers, molecular pathophysiology, and subtypes of illness including who will respond best to a specific treatment.

  27. Science, 302: 386-388, 2003

  28. Decade of Translation: 2005 - 2015 Mood Disorders Schizophrenia Anxiety Disorders Autism Cells: multiple subtle abnormalities Genes: multiple susceptibility alleles each of small effect Systems: abnormal information processing Behavior: complex functional interactions and emergent phenomena

  29. Translation – From Discovery to Recovery Time lag from discovery (evidence) to widespread use: Most of medicine: 17 years Mental disorders: forever General aviation: 48 hours

  30. Intervention “evidence” is only one piece of the picture Family Access and Engagement Organization Structure and Climate Tx “Evidence” External Environment (stigma, financing) Provider knowledge and behavior

  31. After the Decade of the Brain The need for bridging science and service is urgent. We must ensure that “what we know is what we do”; that science informs practice. Current treatments are often not sufficient. The promise of research has never been greater – science will yield new strategies for prevention, recovery, and possibly cures for mental disorders.

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