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Thomas R. Insel, M.D. Director, NIMH

Recovery : How Research Will Change Practice. June 13, 2008. Thomas R. Insel, M.D. Director, NIMH. Noah – 36 months in a life. Number of outpatient providers: 80. Number of outpatient visits: 326. Number of ER visits 84. Number of inpatient admissions: 19.

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Thomas R. Insel, M.D. Director, NIMH

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  1. Recovery : How Research Will Change Practice June 13, 2008 Thomas R. Insel, M.D. Director, NIMH

  2. Noah – 36 months in a life Number of outpatient providers: 80 Number of outpatient visits: 326 Number of ER visits 84 Number of inpatient admissions: 19 Number of inpatient diagnoses: 22 Methadone and cocaine overdose: 7/28/06

  3. Noah – 36 months in a life Number of psychotropic meds 20 Number of outpatient prescriptions: 245 Insurance bill for inpt + outpt care $235K Cost of outpatient medications: $19K Methadone and cocaine overdose: 7/28/06

  4. “Coordination” of Mental Health Services in the U.S. Medicare Medicaid CMHS HUD Education SSA SMHA State Medicaid Agency V.R. CMHC PHA Case Mgt. M.H. Care Housing Job Support Consumer M.D. Meds Income Support Hogan, 2002

  5. Resources Matched with Public Health Need Direct and indirect components of the economic burden of serious mental disorders, excluding incarceration, homelessness, comorbid conditions and early mortality. ($ in billions) 1992 2002 Health Care Expenditures $62.91 $100.12 Loss of earning $76.71 $193.23 Disability (SSI + SSDI) $16.41 $24.34 Totals $156.0 B $317.6 B Insel, Am J Psychiatry, 2008

  6. Disparities in Mental Health Care Adjusted for age, sex, income level, education, urbanicity, region of the country, employment status, and marital status. Wang et al. Am J Public Health 2002

  7. Mental Disorders: Mortality • Over 30,000 suicides per year (in the U.S.) - 90% related to mental illness • For context: • 18,000 homicides • 20,000 AIDS deaths • only 3 forms of cancer > 30,000

  8. Public Health Impact:Early Mortality in Individuals with Major Mental Illness (MMI) • Data from outpatient • and inpatient clients • diagnosed with MMI • Average age at time • of death : 56 years • Increased likelihood • of dying from suicide • Medical co-morbidities Adapted from Colton and Manderscheid, 2006, Prev Chronic Dis

  9. Where is the problem??? Family??? The Patient??? The system??? The doctors??? The Illness Pharmaceutical companies??? Stigma??? Insurance companies???

  10. Disruptive Innovations For Preemption and Recovery Mental disorders are brain disorders. Mental disorders are developmental disorders. Mental disorders result from complex genetic risk plus experiential factors. Current treatments may be necessary but not sufficient for recovery.

  11. Mental disorders as brain disorders PNAS, 2007

  12. Brain differences associated with depression Area 25 – altered metabolism and 39% (bipolar) and 48% (unipolar) reduced grey matter volume Cg25 Drevets et al., Nature, 1997

  13. DepressionRecovery Cg25 Prefrontal 9 Cg25 Affect in Subgenual Cingulate (BA25) Depressed Affect increased CBF/Met’b Cg25 decreased CBF/Met’b Prefrontal 9 Cg25 R Mayberg et al. Am J Psych 156:675-82 1999

  14. Disruptive Innovations In Mental Health Mental disorders are brain disorders. Mental disorders are developmental disorders. Mental disorders result from complex genetic risk plus experiential factors. Current treatments may be necessary but not sufficient for recovery.

  15. Alzheimer’s: A Developmental Disorder? Lancet Neurol 2007

  16. Schizophrenia: A Developmental Brain Disorder Genetic risk Unusual thought content Suspicion/paranoia Social impairment History of substance abuse 68-80% prediction Arch Gen Psych, 2008

  17. Progressive Brain Structural Changes Mapped as Psychosis Develops in “At Risk” Individuals Sun et al, Schiz Res., 2008

  18. 2018 2008 1988 Schizophrenia Trajectory Stage 1: Presymptomatic, Risk factors, Cognitive deficit with challenge [< Age 15] Stage 2: Prodrome, cognitive deficits emerging, minor disability [Age 15 – 18] Stage 3: Psychosis, acute disability, family costs [Age 18 – 24] Stage 4: Chronic illness, medical complications, social costs [> Age 24]

  19. Disruptive Innovations In Mental Health Mental disorders are brain disorders. Mental disorders are developmental disorders. Mental disorders result from complex genetic risk plus experiential factors. Current treatments may be necessary but not sufficient for recovery.

  20. 2007 second quarter February 2008 2007 third quarter 2007 first quarter 2007 fourth quarter 2006 2005 Manolio, Brooks, Collins, in press.

  21. Why does genomics matter? • Genes are not going to yield a diagnostic test • Genes are not going to identify a cause But • Genetic variation can identify risk • Genes can reveal mechanisms of disease Thus, genes can point to new targets for prevention and treatment

  22. Pathways to Pathophysiology Meyer-Lindenberg & Weinberger, Nature Rev Neurosci, 2007

  23. Disruptive Innovations In Mental Health Mental disorders are brain disorders. Mental disorders are developmental disorders. Mental disorders result from complex genetic risk plus experiential factors. Current treatments may be necessary but not sufficient for recovery.

  24. Current Treatments: How Good? 10,000 patients, 200 sites, 3 diseases, practical trials CATIE (chronic schiz) Real world setting Recovery of function Practical questions STAR*D (MDD) STEP-BD (Bipolar)

  25. Current Treatments: How Good? • Schizophrenia: 74% discontinuation of anti-psychotics, limited access to psychosocial Rxs • Depression: 31% remitted at 14 weeks, 67% at 1 year, limited access to CBT • Bipolar: 21% stable for 8 weeks in first 6 months, high rates of medical co-morbidity • Childhood disorders: dx prevalence increase 10-fold for autism, 40-fold for bipolar, no selective meds and few proven behavioral approaches

  26. Practical Trials – What Did We Learn? • We can optimize care in real world settings • With optimized care, outcomes are not optimal • Current treatments help too few people get better and very few get well

  27. Research For Recovery • Pathophysiology (genes to cells to circuits to behavior/cognition and back) • Trajectory of mental disorders (predictive biomarkers, individual risk) • New interventions (rational, preemptive, personalized therapeutics) • Participatory efforts (reducing disparities, focus on recovery)

  28. Then (1998) Diagnosis: Unitary RESEARCH Mechanism: Chemical imbalance Treatment: First generation Imagine (2018) Diagnosis: Dimensional Mechanism: Genes to behavior Treatment: Personal & pre-emptive Now (2008) Diagnosis: Categorical but co-morbid Mechanism: Brain circuit dysfunction Treatment: Second generation

  29. Research for Prevention, Recovery, and Cure www.nimh.nih.gov

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