In order for mental health treatment to be front and center in our ongoing conversation about health, we need to engage those who are living with and through these conditions. While many people can maintain a quality life with treatment and support, living with a mental illness can be a painful experience and often a lonely one. The general lack of knowledge about mental illness stigmatizes the individual and deters many people from seeking treatment. We need to continue educating the public about mental disorders as illnesses requiring the same level of medical treatment, proactive patient involvement and compassionate care as any other illness.
There are a variety of effective treatments for many mental health conditions including psychotropic medications such as antidepressants, mood stabilizers, and anti-psychotics; psychotherapy approaches such as cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT); and, brain treatments including electroconvulsive therapy (ECT), trans-cranial magnetic stimulation (TMS), and vagus nerve stimulation.
Individualizing treatment is critical and continues to be challenging despite recent advances in neuroscience. This challenge is compounded by the fact that many individuals suffer from more than one mental health condition such as depression alongside an anxiety disorder, bipolar disorder and substance use, and schizophrenia coinciding with anxiety or depression---all common comorbidities. Additionally, many people with mental illness may find that treatments are partly effective, or work only for a period of time. Collaboration between patient and clinician, as well as patience and support, are needed through this process of finding the optimal treatment.
As with any health problem, access to excellent healthcare, the ability to sustain treatment for an appropriate span of time, and the individual’s commitment to managing one’s illness with the self-care basics of enough sleep and exercise, good nutrition, limited alcohol consumption, reducing stress, and maintaining healthy relationships all play an important part in treating mental health disorders.
We will continue to see promising treatments emerge in the field of mental health if we support the research necessary to further our understanding of the brain. Greater understanding of the mechanisms leading to mental illness will help eliminate the current stigma that surrounds these disorders and allow more people to receive the treatment they need to live full and satisfying lives.
Dr. Christine Moutier is the new AFSP Chief Medical Officer; she recently moved from San Diego to the NY/NJ area. Previously, she was at the University of California, San Diego (UCSD), School of Medicine, where she was professor of psychiatry and served as assistant dean for student affairs and medical education. She has always maintained an active clinical practice through the UCSD Medical Group and at UPAC (Union of Pan Asian Communities), a mental health clinic for the Asian refugee population.
Originally a classical pianist, Dr. Moutier studied piano performance at Vassar College prior to studying medicine. She received her medical degree from UCSD School of Medicine, where she also completed her residency in psychiatry and received additional training in women’s mental health and consultation-liaison psychiatry. She previously served as medical director of the Inpatient Psychiatric Unit at the VA Medical Center in La Jolla, associate director of the UCSD Outpatient Psychiatry Services Clinic, and attended the C-L Service and Neuropsychiatric and Behavioral Medicine Unit at UCSD Medical Center.
Dr. Moutier’s research interests include the arena of physician health and medical student mental health and professional development. She co-led a suicide prevention and depression awareness program for 2,300 health science faculty, residents and students, which utilizes AFSP’s Interactive Screening Program. Her research in medical education focuses on the associations between medical education, distress and burnout, and the development of traits important in the practice of medicine, such as empathy and resilience. Formerly, a co-investigator for the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) study, a large National Institute of Mental Health trial on the treatment of refractory depression, Dr. Moutier also worked with UCSD ophthalmology studying the co-occurrence of macular degeneration and depression. Her clinical focus has been in the areas of mood disorders and consultation-liaison psychiatry. Dr. Moutier developed and directed a comprehensive Fitness for Duty Assessment program for physicians and co-founded the San Diego chapter of AFSP.
Dr. Moutier has authored numerous articles and book chapters for publications such as JAMA (Journal of the American Medical Association), Academic Medicine, the American Journal of Psychiatry, the Journal of Clinical Psychiatry, and Academic Psychiatry.
We need a new generation of treatments for mental disorders. With current medications for schizophrenia, bipolar disorder, and depression, many people get better, but too few get well. And for many mental disorders, such as post traumatic stress disorder (PTSD), anorexia nervosa, and the core symptoms of autism, we lack effective medications altogether. The public health need is undeniable: neuropsychiatric disorders are the largest source of medical disability in the U.S. with onset before age 25 in 75% of affected people.
In the absence of predictably effective treatments, trial and error with current medications remains the standard of care. Since it takes several weeks for antidepressant and antipsychotic medications to reduce symptoms, trial and error often means weeks of needless suffering. In the absence of compelling evidence for choosing a specific treatment, polypharmacy, for better or worse, is now the norm for treating mental disorders. Unfortunately, multiple medications increase the risk for adverse events, and this approach has generally not been proven more effective than giving a single medication.
How can we do better in choosing treatments for mental disorders? Believing that the path to better therapeutics is better diagnostics, NIMH has proposed a new approach to nosology. Current diagnostic systems are based exclusively on observed signs and symptoms. Could imaging, physiology, genomics, and cognitive science give us a more precise diagnosis? What if autism and depression were symptom clusters, analogous to fever and body aches, with multiple underlying mechanisms requiring quite different treatments? The National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) project seeks to transform diagnosis through research that deconstructs the current diagnostic groups into more precise categories with biomarkers that could predict treatment response. As in other areas of medicine, for neuropsychiatric disorders we need better diagnostics if we are to get beyond trial and error.
But we also need better therapeutics. The recent progress in genomics (common variants found in schizophrenia and rare variants in autism) is beginning to define the biology of mental disorders. The discovery of rapidly acting antidepressants (treating depression in 6 hours instead of 6 weeks) reveals unexpected opportunities for treatment. And results from clinical trials with both psychosocial and neuromodulatory treatments demonstrate that psychiatric symptoms are, in fact, highly responsive to intervention, including interventions that tune specific brain circuits. The public health need is great and the opportunity for progress is clear. But it is equally clear that there will not be a magic bullet for schizophrenia or autism or anorexia nervosa. The future for treating mental disorders belongs to networked solutions that combine medications, technology, and psychosocial treatments.
Thomas R. Insel, M.D., is Director of the National Institute of Mental Health (NIMH), the component of the National Institute of Health (NIH) committed to research on mental disorders. Dr. Insel has served as Director of this $1.5B agency since 2002. During his tenure, Dr. Insel has focused on the genetics and neurobiology of mental disorders as well as transforming approaches to diagnosis and treatment. Prior to serving as NIMH Director, Dr. Insel was Professor of Psychiatry at Emory University where he was founding director of the Center for Behavioral Neuroscience and director of the Yerkes Regional Primate Center in Atlanta. Dr. Insel's research has examined the neural basis of complex social behaviors, including maternal care and attachment. A member of the Institute of Medicine, he has received numerous national and international awards and served in several leadership roles at NIH.
Mental illness can be debilitating and destructive not only for patients, but also their families and friends. The statistics themselves are jarring with the National Institute of Mental Health reporting 61.5 million Americans – one in four – have some form of mental illness. With such a large portion of the American population suffering why isn’t mental health more of a public priority? And specifically, why isn’t providing broad access to and awareness of treatments prioritized more?
As a psychiatrist, I know firsthand the value that effective treatment offers people suffering from mental illness. According to a 2012 National Survey on Drug Use and Health, approximately 60% of adults with any mental illness were untreated over the last year, leaving so many patients and families to suffer.
There are so many issues that contribute to the burden of mental illness – not the least of which is stigma, which impacts research, clinical trials, and diagnosis as patients are often embarrassed, ashamed, or unable to share their symptoms. Only when our society values the importance of treating mental health the way we do physical health, can we fully address patients’ needs. Beyond stigma, we face the sizable challenge of better understanding how the brain works. In my years of researching mood and anxiety disorders, it’s clear that given the nature and variety of mental illness, we also need more sophisticated diagnostics in place and a better understanding of the diseases we are looking to treat. It would be easy to suggest there’s a one size fits all approach to combatting mental illness but there simply isn’t. These are heterogeneous diseases, which makes it all the more important that patients get both the right diagnosis and then the appropriate treatment. That’s why our research focus is directed towards developing a better understanding of the underlying biology that would help us to develop even more targeted approaches to treatment. Researchers are making significant progress in developing innovative treatments that address the range of symptoms patients experience, but the absence of biomarkers makes it more difficult to develop preventive measures and target treatments to individual patients as we can in oncology and cardiovascular disease.
Companies such as Lundbeck have seen the growing burden of mental illness on patients, families and society at large. As the biopharmaceutical industry, in collaboration with scientists in academia and government, continues to translate research insights into innovative treatments, it is equally critical to raise awareness about the need for improvements in the delivery of mental health care. It is going to take the combined voice of scientists, the medical community, patient advocates and the general public to prioritize mental health the way we do physical health in this country. Millions of Americans are depending on us to do so.
Torsten Madsen has recently been appointed Chief Medical Officer and VP of US Drug Development at Lundbeck. Torsten brings extensive experience to the mental health space after his most recent role as Divisional Director of International Clinical Research Mood & Anxiety Disorders at Lundbeck’s headquarters in Copenhagen. He holds an M.D. and a Ph.D. from Copenhagen University and has worked as a postdoctoral associate in the Department of Molecular Psychiatry at Yale University and was a resident physician in psychiatry at Arhus University Hospital before joining Lundbeck in 2006. Torsten recently relocated to the United States with his wife and three children.
It’s about time that Americans have a conversation about the consequences of untreated mental illness and the need for better treatments and more access to care. Two events this week have raised this important issue and both need to be paid attention to.
In a powerful article in the USA Today on Tuesday, May 13, Liz Szabo chronicled the implications of our current mental health treatment system – the fact that early 40% of adults with "severe" mental illness — such as schizophrenia or bipolar disorder — received no treatment in the previous year, according to the 2012 National Survey on Drug Use and Health. Among adults with any mental illness, 60% were untreated. State and local governments continue to decrease investments in mental health services, reducing spending over $5 billion dollars in the last 5 years.
The consequences of this lack of treatment are overwhelming to families and communities. Jails and prisons have become the de-facto mental health treatment system. Families have no-where to turn for support or treatment, and suicide is a too common outcome for many living with these illnesses. The implications for our economy are also staggering as serious mental illnesses cost the U.S. more than $317 billion annually in lost wages, health care expenditures and disability benefits.
We all know that understanding the problem is but the first step to solving the problem. Broad recognition that our nation’s mental health system is woefully underfunded and fragmented is important, but not sufficient. Similarly, broad recognition that mental health illnesses are real, common, and treatable is important, but will not lead to more treatment capacity on its own. We need to ensure that ‘treatment’ is front and center in America’s ongoing conversation on mental health.
Luckily there is some good news to report on this front. On April 1 of this year, President Obama signed the Protecting Access to Medicare Act (H.R. 4302) into law. This legislation includes provisions of the Excellence in Mental Health Act, which will increase access to community mental health and substance use treatment services while improving Medicaid reimbursement for these services. As passed, this will take the form of an 8 state, 2-year Medicaid demonstration project. This is an important first step, but now the real work is to make sure that this program becomes the national standard.
Similarly, NIMH and America’s biopharmaceutical industry are investing in understanding the brain and developing new treatments. These efforts must also be expanded and supported so that available treatments provide meaningful improvements for individuals, families, and communities.
I am glad that awareness and investment in mental health treatments are improving. Let’s work together to keep the momentum going.
Mr. Ingoglia is Senior Vice President of Public Policy and Practice Improvement for the National Council for Behavioral Health where he leads the national charge to ensure people have access to their potential to live full and complete lives. During the last eight years at the National Council, he has made valuable contributions to the organization in establishing direction and achieving specific goals for the over 2100 member organizations nationwide.
As leader of the Policy and Practice Improvement Team, Mr. Ingoglia transforms the conversation about mental health and delivery of services. He effects change at both the national and state policy level by, among other things, playing a major role in Federal and State policy advocacy and analyses on myriad issues relevant to behavioral health financing and health reform. His influence and advice on policy is informed by insight gained as a result of providing site-of-service technical assistance to members.
Mr. Ingoglia has a deep knowledge of the field from both personal and professional experience. At the age of 25, when he realized that his mother had an undiagnosed anxiety disorder, he began to appreciate the impact that effective treatment can have. This very personal experience lead to a career in mental health, which started by volunteering at an emergency clinic, which then lead to a Masters of Social Work, and then to providing direct care.
Mr. Ingoglia is also an adjunct faculty member of The George Washington University Graduate School of Political Management, where he teaches Mental Health Policy and Congress and The Politics of Non-Profits.
Before joining the National Council, Mr. Ingoglia provided policy and program design guidance to the Center for Mental Health Services at the Substance Abuse and Mental Health Services Administration under the U.S. Department of Health and Human Services. Earlier in his career, he directed state government relations and service system improvement projects for the National Mental Health Association, performed policy analysis for the National Association of Social Workers, and designed educational programs for mental health and addictions professionals for the Association of Ambulatory Behavioral Healthcare.
He holds a Master of Social Work and a Bachelor of Arts in Social Work, both from The Catholic University of America.
From both Republicans and Democrats in the House, we have bills proposing mental healthcare reform. Each has strong points that resonate with the Depression and Bipolar Support Alliance (DBSA). We are eager to continue to talk and collaborate with Murphy, Barber, and their colleagues so we can represent the needs and concerns of DBSA’s two million constituents across the country who, like me, have personal experience with mental healthcare. DBSA hopes the voices of people with mental health conditions will not be lost within the conversation, and we need the dialogue not to devolve into a partisan fight in which only people with mental health conditions—and the general public—lose.
Two things are essential to DBSA in realistic, practical considerations for treatment of mental health conditions:
Ability for doctors, caregivers, and patients to work together to choose and adjust treatments based on individual response, circumstance, and preference is crucial. Mental healthcare is highly individual and almost always involves multiple modalities; there is not yet, and is unlikely to be, a “magic bullet” that by itself can relieve symptoms and create wellness. Most of us with mood disorders, for example, benefit from a treatment combination that may include medication, talk therapy, devices (such as TMS or ECT), lifestyle modifications (including increased exercise and sleep regulation), and/or peer support. While it can be tempting to focus on one form of treatment as most important, the evidence base (a central tenet of both bills) suggests that a multi-pronged approach is most effective. As can be expected in a population that benefits from such a diverse mix of options, course corrections allowing for the right combinations must be readily achievable in a system that truly works.
Peer support and peer support services are low-cost aids to managing and sticking with complicated, multifaceted treatment regimens. Their inclusion in any bill, and any budget, that deals with mental healthcare will be a win on all fronts. Treatment programs including peer providers show better gains in participants’ quality of life, self-image, outlook, and social support—and users experience fewer major setbacks. When provided with peer role models, people with mental health conditions show significant reductions in isolation; this increases physical activity and other wellness-enhancing behaviors that are vital to symptom reduction and maintenance of stability. Those who have access to peer support also show greater gains in symptom knowledge and management—and, crucially, medication adherence—when compared to individuals receiving traditional services only. And peers, who are often more proficient with the technical aspects of benefit acquisition than anyone else, provide information and rapport that keep individuals engaged with their treatment process. (Indeed, even the best treatment is not useful if people do not engage and then adhere to it!) Plus, peer support service roles on treatment teams often provide a re-entry to the work force for people with mental health conditions who had previously been unable to work. So from a wellness perspective, treatment adherence perspective, and employment perspective, peer support and peer support services will be immensely beneficial to all concerned with mental health.
No matter its origins, a dialogue on mental healthcare is an excellent development. DBSA urges consideration of the diversity of treatment combinations and the inclusion of peer support and peer providers as the conversation continues.
Allen Doederlein is President of the Depression and Bipolar Support Alliance (DBSA), the nation’s premier peer-led mental health organization focusing on mood disorders. DBSA reaches 2,000,000 people each year with current, readily understandable information about depression and bipolar disorder and empowering tools focused on an integrated approach to wellness. DBSA’s reach is further expanded by its national network of 15 state organizations, 300 chapters, and 900 support groups, which provide life-saving, free peer support to tens of thousands of individuals who seek information and support on their paths to the healthy lives they want to lead.
Allen works with the Board of Directors and Scientific Advisory Board to develop, articulate, and steward DBSA’s vision, mission, and core values. As the staff leader, Allen facilitates DBSA’s strategic initiatives, organizational alliances, and partnerships; serves as organizational spokesperson; and oversees generation of both contributed and earned revenues.
Mental health conditions pose a heavy human and economic burden in the United States. According to the National Institute of Mental Health, 1 in 4 American adults have been diagnosed with a mental health disorder – and serious mental illnesses cost the U.S. more than $317 billion annually in lost wages, health care expenditures and disability benefits.
Biopharmaceutical research companies, working in collaboration with academia, government researchers, patient organizations and others, are applying new scientific approaches and evolving knowledge of disease to bring new solutions to individuals who face mental disorders such as anxiety, depression, schizophrenia or substance use disorders, as shown in our latest Medicines in Development Report on Mental Health. The 119 mental health treatments in the pipeline offer hope for individuals affected by a mental health condition and their loved ones.
Although advances in our understanding of mental health disorders and how to treat them have allowed America’s biopharmaceutical companies and other partners in the collaborative ecosystem to continue to make progress in researching new treatments, additional scientific research is needed to reduce the destructive toll of these disorders and allow more people to lead healthier, more productive lives.
Researchers face a number of challenges when it comes to mental illnesses including a limited understanding of how current treatments work in the brain; a lack of biomarkers that help clinicians’ diagnose accurately, measure disease progression and assess treatment response; and the complexity of mental disorders themselves.
Another challenge in the fight against mental illness includes barriers to seeking as well as adhering to treatment. These barriers can include patient and family attitudes, treatment-related issues (side effects), health system factors, cultural influences, and the perceived stigma associated with mental disorders. Recognition of the important of treatment adherence is particularly critical to advancing dialogue on mental health conditions. Adherence to medication dosing and scheduling is essential for treating mental health conditions effectively and helping to control costs by decreasing the number of relapses, hospitalizations and limiting indirect costs like lost productivity.
In the face of these challenges, it is more important than ever to raise awareness about mental health and reduce the barriers preventing those who are struggling from seeking help. We must continue to make the conversation of mental health an open dialogue, within and outside of the lab.
Dr. Bill Chin leads PhRMA’s Scientific & Regulatory Affairs department. A physican, an endocrinologist and an academic at heart, Dr. Chin envisions establishing PhRMA as the premiere convener in advancing drug discovery and development, regulatory sciences and collaborative partnerships.