Post by Former NIMH Director Thomas Insel: Making the Connection
In recent months, there has been a growing global interest in brain science. The President called attention to the effort to map the human brain in his State of the Union address, the European Union recently announced its largest scientific award (1 billion euros) for the Human Brain Project, and private foundations such as the Allen Brain Institute and the Kavli Foundation have announced new bold efforts to map the brain.1
At the same time, there has been an unprecedented national conversation about what role mental illness plays in gun violence. In communities and legislatures, the debates have focused on finding the right balance on several complex issues: gun control versus gun rights, commitment laws versus protecting the rights of people with serious mental illness, and public safety versus personal freedom. A survey published in the New England Journal of Medicine this week reveals little consensus on these issues, and a deep public ambivalence about mental illness. Almost half of the respondents believed that people with serious mental illness are more dangerous than the general population.2
What’s the connection between the global interest in neuroscience and the national conversation about mental illness? One may be the key to unlock the other: brain science may ultimately answer our questions about how to eliminate untreated mental illness as a contributor to violence.
If this seems like a stretch, consider two inconvenient truths. First, while most violence has no relationship to mental illness, we must accept that some people with serious mental illness who are not treated can be violent, most often against themselves but also against others. Denial of a link between untreated serious mental illness and violence against self or others serves neither those with mental illness nor our larger society. Recognizing the link reminds us of the importance of early treatment for protecting people with illness, their families, and their communities. Second, we must recognize that although treatment is essential, for too many people, today’s treatments are not good enough. These serious mental illnesses are brain disorders requiring the kind of commitment to science-based discovery and care that we have developed for cancer and heart disease. To find better treatments for serious mental illness, we need neuroscience.
Earlier this week, the Congressional Neuroscience Caucus in the U.S. House of Representatives, chaired by members of Congress Earl Blumenauer (D-OR) and Cathy McMorris-Rodgers (R-WA) held a briefing to hear about the connection between the brain, serious mental illness, and violence. Dr. Elizabeth Childs, a child psychiatrist from Brookline, Massachusetts, gave a riveting account of two children she treated, one who later killed his parents before killing himself and another who has mostly recovered and is now in college. Exploring the difference in outcomes in adolescents afflicted with the same illness, Dr. Childs noted that persistent isolation is often the difference between tragedy and recovery. Engagement is essential for recovery.
“The best opportunity to help families access mental health services is to meet crisis with engagement. Engagement is the singular most difficult task when the patient, family, and community are in denial. We have seen success when mental health programs…assure immediate access to patients in crisis and have capacity to provide outreach and actively engage youth and families confronted with the onset of serious mental illnesses. This type of outreach can and does work, but is only happening in isolated pockets across the nation.”
Dr. Raquel Gur, a scientist and psychiatrist from the University of Pennsylvania, described what this engagement might look like in the near future based on recent research. Dr. Gur has found that adolescents who are at high risk show an altered pattern of brain and cognitive development long before the onset of psychosis. Her conclusion: the best way to reduce the risk of violent behavior by people with untreated mental illness is to detect these changes in the brain early and engage families in the process of treatment, preempting psychosis with its complications. As Dr. Gur reminds us, treating a serious mental illness after one or more psychotic episodes is like intervening only after a person has had a heart attack.
Developmental Trajectories: Multiple indices of brain function show age-related maturation and should provide early clues on vulnerability to psychosis.
Source: T. Satterthwaite and R. Gur, University of Pennsylvania
As we continue the national conversation about mental illness, we need to remember that better outcomes will require not only better engagement, better access, and better care, but also better diagnostics and better treatments. In the worlds of cancer, heart disease, and diabetes, where we have already seen greater reductions in morbidity and mortality than in the world of mental illness, there are major initiatives to improve both diagnostics and therapeutics.
For serious mental illness, neuroscience is the key to new diagnostics and new therapeutics. That is why the global surge in brain research should be a hopeful sign for individuals and families affected by mental illness. Indeed, neuroscience should change the national conversation on mental illness to focus our attention on paths to preemption and recovery and not the risk of violence and disability.
1 Alivisatos AP et al. The brain activity map. Science. 2013 14 Mar;339(6125):1284-5. doi: 10.1126/science.1236939.
2 Barry CL et al. After Newtown — public opinion on gun policy and mental illness. N Engl J Med. 2013 Mar 21;368(12):1077-81. doi: 10.1056/NEJMp1300512.