Mental Illness Across the Ages

Good evening everyone My name is Mark Frankel, I am director of the AAAS Scientific Responsibility, Human Rights and Law program under the [inaudible] this series is held at AAAS This is the third in our neuroscience and society series in 2015, and tonight’s topic is mental illness through the ages from children, to adolescence, to middle age and the elderly We have an excellent series of speakers who have accepted our invitation to address us on the topic Before I go any further, I’d like to introduce a relatively new staff addition to AAAS, but by no means someone who’s new to the community of people who are concerned about the role of science and technology in society He’s been with us less than a year and I believe this is his first opportunity to attend one of our series events So please welcome to AAAS our new chief executive officer and former member of congress, Dr Rush Holt who is in the back Rush, we’re delighted to have you here and look forward to your joining us for other events in this series as your schedule permits This series, as some of you will know is a partnership with the Dana Foundation I want to acknowledge not only their financial support but also their collaboration in planning these events Every year at the end of the series for that year we get together and brainstorm about topics, and we end up with a list of, I don’t know, maybe nine or ten without repeating of course topics from previous years This is by the way is the end of our fourth year We brainstorm about what will be topics, what’s coming up, what’s emerging or what’s just plain interesting, at least would be interesting to a public audience I want to thank them for all of the contributions that they make intellectually to the programs as well as financially In planning for tonight’s topic I did a bit of background research and was struck by some of the numbers associated with mental illness in the United States I have no doubt that our speakers will likely introduce others, but here are some that stood out for me Nearly 5 million children in the United States have some type of serious mental illness with an estimated $247 billion spent each year just on childhood mental disorders Mental illness is linked to suicide which is the second leading cause of death among adolescents between the ages of 12 and 17 years, and over 8% of adolescents suffer from depression that lasts a year or more, and that depression is the leading cause of disability in the United States in people over five years of age As someone who does not work in this particular field, I found those numbers quite striking, and I think it goes without saying and just looking at the numbers, forgetting of course for a moment the personal price that people pay Just looking at the numbers suggest that we have a topic of great social importance for all of us in the United States, and I suspect you can get similar numbers from other parts of the world as well Now to our program, after which we’ll end around seven and there will be a reception just outside the auditorium, and you’re all invited to join us and the speakers and informally converse about the topic of the day or whatever else interests you You have speaker bios in your program, this is the program which I hope you picked up So I’m not going to use a lot of time to go through all of these biographical materials, they’re there for you to look at as you see fit, but I will highlight a few things in my introducing each individual speaker There will be no questions after each talk, we’ll save those for a period that will follow the third speaker when all of them will come up here, we’ll have a moderated discussion or a conversation, and then we’ll open it up to the people in the audience You’ll see mics on the aisles, microphones, this is being videoed and recorded, it will be posted on the Dana Foundation website Typically it’s a week to 10 days afterwards, but we will also have a link to it from the AAAS website One final announcement that I forgot that I want to alert you to, and that’s our final event in the series for 2015, it’s going to be on October 27th here, and has a working

title of creativity and genius Creativity and genius and we’re still fleshing things out a bit at this moment, but put that on your calendar and you’ll hear from us when we’re ready to go Without further ado, let me introduce our first speaker, Dr. Nelson Freimer Dr. Freimer is the Maggie G. Gilbert Professor in the department of psychiatry and human genetics in the David Geffen School of Medicine Director of the Center for Neurobehavioral Genetics, director of the Depression Grand Challenge, and Associate Director of the Semel Institute for Neuroscience and Human Behavior all at UCLA His research tends to focus on using the tools of large scale genomic science to elucidate the genetic basis of common human disorders, but he’s particularly interested in the number of those that fall under the rubric of mental illness He is going to focus on mental illness in the midlife and elderly timeframe Please join me in welcoming Dr. Freimer Thank you for asking me to join this session and it’s really a privilege to be involved in really such a valuable series, this is really an incredible thing that AAAS and Dana do As Mark said, I’m going to talk about mental illness in mid and late life, and this is a pretty heavy charge for 20 minutes of talk What I’m going to try to do is very briefly, sort of give a summary of what the illnesses that we’re talking about are, a little bit about their prevalence and impact, he’s already said a little bit about that Then I’ll say something about treatment and the issues of treatment for these disorders in mid and late life, and then finally I’ll take a prerogative of just spending a couple of minutes talking about genetics and the role of research in really hopefully developing better treatments which as you’ll hear is something that we really need for these diseases What we’re talking about when we talk about the main mental disorders of midlife and late life, the adult mental disorders can really be broken down into these categories Disorders of thought by which we mainly mean schizophrenia which consists of mainly psychotic symptoms like delusions, hallucinations, disorganization of speech and behavior, and the so-called negative symptoms, loss of volution, loss of affect and so forth Disorders of mood by which we mean major depression and bipolar disorder, where both major depression bipolar disorder are characterized by episodes of depression which people are mostly familiar with which involve depressed mood, loss of pleasure, alterations in sleep and weight, either up and down, slowed speech, loss of energy and concentration, feelings of worthlessness and its most extreme form, suicidality which Mark also mentioned Bipolar disorder also involves episodes of mania which, simplistic terms are essentially the opposite of depression, elevated mood, pursuit of pleasurable activities usually ones that are risky and could have catastrophic consequences with a decreased need for sleep, pressured speech, flight of ideas and grandiosity Both depression and bipolar disorder may have psychotic symptoms Anxiety disorders which may be the most common of all of these disorders for example, panic disorder, social phobia, some people would include post-traumatic stress in this category I’m not going to talk about it anymore in the interest of time The neurocognitive disorders which, again, some people may not consider a mental disorders, but I think that they do go with the other disorders that we’re talking about What really differentiates these disorders from the other ones we’re talking about is that whereas the other ones are diagnosed and really recognized entirely on the basis of symptoms and subjective manifestations The neurocognitive disorders such as Alzheimer’s disease, frontotemporal dementia, vascular dementia are diseases for which we actually understand something about the underlying biology, we understand the pathology which is different in all of these types of disorders In many cases, we actually have identified the genetic contributions of these diseases which has really led to the sort of the start of gaining traction on more specific treatments One thing I want to mention though is that all of these disorders are very prevalent, schizophrenia the least at 1%, but as you can see with depression in about 7-10%, bipolar disorder is 3-4%, anxiety disorder is as high as 20%, and these neurocognitive disorders as high as 5-6% These are among the most common disorders that face our society

As Mark mentioned, these disorders have an incredible impact on society So, if one looks at the burden of disease by which we usually mean the premature loss of life or mortality and disability, mental disorders throughout the adult age ranges are the leading contributors to the burden of disease until the very, very last years of life when cancer and heart disease overtake it For most of these period of mid and late life, it’s really the mental disorders that are the biggest impact diseases in the society Depression as he also mentioned is the leading one of all Depression is the disease that is the leading contributor of global disease burden and even more so in North America This is really a very significant health problem However, the funding for these diseases is really not commensurate with the burdens that they represent Now, I think that one should not just equate the amount of funding that the disease, the research in the disease gets with its burden of disease I mean clearly, AIDS research has been enormously important not only for the United States but for the world, but I do just want to really emphasize the fact that considering the burden that it represents, depression in particular has been enormously underfunded at the federal level and also in terms of philanthropy It’s one of the reasons why we still understand so little about this disorder, and again, this is something that characterizes really all of these adult psychiatric disorders While we talk about all of these disorders as being adult mental disorders, they all have different periods of the life span in which they’re particularly important This is actually a slide which shows the impact of disease that is the impact on the burden of disease of different disorders at different points in a lifetime I won’t talk about the childhood, adolescent disorders that you’ll hear about in the next talk, but to talk about the adult disorders at the beginning of adulthood disorders such as schizophrenia, drug and alcohol abuse play a particularly large role As you can see, in large part because of the excess mortality that affects people that have these disorders, for example, people with schizophrenia, it’s estimated something like a 10 to 15-year lower life expectancy than the rest of the population, and so by end of life, these disorders play a much smaller role In contrast, depression which is shown here in this light purple horizontal bar represents the largest prevalence and impact disorder really throughout the adult range Bipolar and anxiety disorders again are fairly constant throughout the adult lifespan It’s important though to interpret these kinds of statistics cautiously and I’m just going to give an example of this with respect to depression This is from what’s called the National Comorbidity study, a very large epidemiology study in the US If you look at this you would think that prevalence follows this very neat process where it remains about the same prevalence, and then it’s much less prevalent among the elderly However, if one dissects this further, what you can actually see is that what really is determining this apparent decrease in prevalence among the elderly is really that depression is characterized by a cohort effect whereby each cohort, as in each younger cohort has a higher prevalence of depression at an earlier onset so that those who are now in early adulthood will, by the time they are in late life, having much higher prevalence of depression than the individuals who are now over 60 This is something that’s actually, again, a very important point because it speaks to what will be and it really an epidemic of depression in mid and late life over the next several decades To talk about treatment, the first point I want to make is that in some ways treatment has come in enormously long way over the past couple of hundred years This is a painting by Goya called the Madhouse from about 200 years ago, and it sort of conforms to what you might imagine was the treatment of severe mental illness in the middle ages where people who were suffering from these disorders were essentially thrown in to what essentially amounted to prisons and not offered any treatment

While we’ve gotten a lot better, it’s also really important to recognize the incredible deficit of treatment that we have for these disorders and our society, and this is something that particularly I think affects the United States One very important point is that psychiatric inpatient treatment is almost completely disappearing In fact, we have about the same number of psychiatric inpatient beds now that we had in 1850 when what you might consider the humane treatment was just starting That’s really had the effects that mental illness is now seen primarily in places like the criminal justice system where rating from about 40% of the population of federal prisons, to about 60% of the population of local jails are affected with major mental illness to the point where … not as facetious comment, it’s stated that the Los Angeles Jail is the largest psychiatric hospital in the world I’ve heard similar things about the Cooke County Jail and I think it just speaks to the overall problem The other place where mental illness is found to be an incredibly high degree is on the streets where among the homeless, at least 30% of the population also suffers from major mental illness However, it’s not just in these settings where treatment is really insufficient If you look at the population as a whole, less than 40% of all adults who have mental illness received any kind of treatment in the past year There’s a major problem with ethnic disparities here where, as you might expect that certainly not a great percentage of the white population receives care for mental illness, but you can see that it’s much greater than among Hispanic, black and asian populations Really, the major point about the treatment of adult mental illness is that it’s just not being done I mean we can talk about the inadequacies of our treatments which I will in a moment, but really the major point that I want to get at of this entire talk is that we really are doing very little to treat what is an enormous problem We know that the failure to treat has really devastating effects both for the society and for the individuals affected, and this is particularly true in the mid and late life For example, taking depression, the failure to treat depression is associated with functional decline and increased disability throughout the mid and late life period It’s associated with increased use of regular health services that is non-mental health services, and this has become an enormous economic issue It’s also associated with increased mortality among individuals over the 50 months after being diagnosed with depression, there’s a four times higher rate of mortality I’m just going to mention briefly suicide and cardiac deaths While teen suicide is something that obviously gets a lot of attention and it’s been an obvious tragedy, the highest both in rate and in number of suicides are among individuals in mid life What I think people maybe really surprised by is that the rate remains incredibly high even among the elderly, so that again, next to the group that’s in the age range of 45 to 54, those over the age of 75 have the second highest rate of suicide of any age range For cardiac disease similarly, mortality is an incredible consequence of depression This slide just shows over the months after myocardial infarction, the mortality rate among individuals who were not depressed compared to individuals who are depressed You don’t really need any kind of statistics to see that this is really an incredibly powerful effect that depression has on death after myocardial infarction Just to talk very briefly about the treatments that we have for these major disorders of adult life, and again, this is something that could be an hour long discussion in its own right The major categories of treatments include psychotherapy which includes both a whole range of what might be called traditional psychotherapies, more recently has been particularly were called evidence-based therapies such as cognitive and behavioral therapy, drug therapy including anti-psychotic treatments, mood stabilizing treatments which are primarily used in bipolar disorder, and anti-depressants which are used in really all of the different categories of adult mental illness Neuromodulation treatment is a category that’s gotten a lot of attention in the last few years In particular, for depression the sort of initiation of methods such as transcranial

magnetic stimulation or even deep brain stimulation which involves implantation of electrodes to stimulate particular areas of the brain I also want to really emphasize that sort of the oldest of all of these forms of treatment in some ways is electroconvulsive therapy or ECT which of all the treatments for depression is actually the most effective, and actually because of that fact is increasingly being used Really, all of our current treatments are unsatisfactory and that’s what’s going to drive my talk about research in the last few minutes For example, anti-psychotic drugs have really serious side effects For schizophrenia they mostly target the so-called positive symptoms like hallucinations and delusions, they really don’t at all target the negative symptoms which are really the ones that maybe the most disabling, which really are the ones that prevent people from say, going to school or going to work We really have no treatments for bipolar depression that are very effective, and this is really the major source of disability for bipolar disorder is the inability to treat the depressive phase We’re actually pretty good at treating and preventing the manic phase with stabilizing drugs Depression treatments are really incredibly unsatisfactory, they take too long to work, they usually take months to begin to show an effect, they’re very, very modestly effective Perhaps 50% of the people who were treated with either psychotherapy or drugs get only at best a very partial effect They are completely non-specific, although depression is probably a very heterogeneous disorder, when we go to treat depression it’s like throwing a dart while we’re blindfolded, we really have absolutely no targeting at this point I just want to mention that are special issues in the treatment of mental illness in late life Neurocognitive disorders, we essentially have no treatments which really do anything to slow, much less to stop the decline in cognition from these disorders The treatments that we use for other disorders may in fact worsen cognition, so drugs that we use to treat say psychosis or depression Because of the fact that people in the elderly having a lot of other medical problem, there’s an increased problem with side effects and drug-drug interactions Again, throughout the entire range of these disorders, we have really no good treatments at this point that we should feel very satisfied with The last point that I want to make is that to improve treatments we must understand causation Our current diagnostic system in psychiatry, in particular that that describe these adult disorders is based on observation and self-report As I mentioned, the neurocognitive disorders are based on pathology, or at this point even based on molecular understanding For disorders like depression, schizophrenia, bipolar disorder, they really all are still diagnosed according to the system developed by Emil Kraepelin who is a German psychiatrist At the turn of the last century, based on his observations, because people stayed in mental hospitals at that time for years, he was able to make observations over years in most of his patients On the basis of course of illnesses he separated the mood disorders, depression, bipolar disorder from thought disorders like schizophrenia He really made these categorizations based on the observation that people with schizophrenia had a, what he considered a chronic and unrelenting course, whereas these disorders had an episodic course Of course, this doesn’t really conform to the complete clinical reality, and so, if one actually looks at these disorders which he treated as completely separate, one can see that at the level of the clinical manifestations, if not, the disease course, that it’s the clinical manifestations that are the targets for treatment Things like hallucinations, like suicidality, like delusions, that there’s an incredible overlap between these disorders One can see this when one looks at the results of genetics studies Recent studies have really emphasized this overlap has a genetic basis For example, if we look at the whole range of studies that had been undertaken comparing bipolar disorders with schizophrenia, depression with schizophrenia, depression with bipolar disorder, one can see that these disorders at the genetic level are really quite correlated with each other That is to really get to the causation involves trying to study them together, and it’s really the only way that we’re going to get to new treatments in my opinion Now in the last couple of slides, this slide actually summarizes the history of genetic

research for these disorders Without go through it in detail, this takes the whole range of the psychiatric disorders, and we’ve already talked about how highly prevalent they are, they all have a very strong genetic basis, they all have a very high degree of heritability in families We are now just beginning to get success from doing genetic studies, so studies looking at common genetic variation, we now have for example for schizophrenia, over 110 different genes that are now conclusively associated with schizophrenia which is in my mind a truly remarkable accomplishment However, the results have been much less good for some of the other disorders, and I’ll particularly mention depression which as I have been emphasizing is the most prevalent and the one that has the largest impact where we’ve really at this point had almost no success for genetic studies That’s really because in order to elucidate the genetic contribution to disease like depression which is so heterogeneous and complex, is going to take very, very large studies This is a quote from Steve Hyman who’s a former director of the National Institute of Mental Health which is saying that to understand the molecular and mechanisms of depression, we’re going to need to collect data from more than 100,000 people The last thing I want to talk about is the endeavor that I’m most involved with which is called the depression grand challenge and has the goal of ultimately eliminating the burden of depression Sort of taking Steve Hyman’s challenge and its word were now embarked on the study of 100,000 with depression to try to identify the genetic contributions to depression risk which will lead to new molecular targets for treatment, to identify markers for depression course of treatment response So that unlike throwing a dark at the dart board blindfolded, we’ll have more specific treatment, and this really is what people nowadays are calling precision medicine and it’s gotten a lot of publicity recently Ultimately from the results of these studies, we will hopefully be able to implement new treatments and preventive interventions This is something that I’ve been mentioning here for depression, but really it’s the same process that we hope will occur for all of these disorders Thank you I told you they’d be on the numbers, they were all very discouraging unfortunately So our next speaker, thank you Dr. Freimer, our next speaker is Dr. Ann Marie Albano She is a professor of clinical psychology and psychiatry at the Columbia University Medical Center, and founder and director of the Columbia University Clinic for Anxiety and related disorders She’s board certified in clinical child and adolescent psychology, and is the inaugural editor of evidence-based practice in child and adolescent mental health Evidence-based practice is a phrase that really resonates here at AAAS I’m delighted she’s able to join us, and you might imagine, she’s going to be discussing mental illness among children and adolescents Please join me in welcoming her Thank you My turn to mess up here In this talk, what I want to go over today is a bit of discussion of the rates of mental illnesses in kids, children and adolescent, you saw a little bit of it in the previous talk but we’ll talk more in-depth What we know about treatment, what we know about treatment based on the science but what we know also about what’s going on in the community I want to focus on two neglected age groups, the very young children and those who are emerging into adulthood, and then what we’re going to be looking at going forward First, let’s just take a quick look at the scope of the problem This is a slide from the study of the National Comorbidity Survey of adolescents conducted by Kathleen Merikangas in addition to Ron Kessler and others What I want you to focus on here is bearing in mind when do these disorders start and what are these disorders that wreak havoc in the lives of children So here’s the age in years, and this is cumulative percent in terms of prevalence Starting at age four you see the onset of anxiety disorders, this continue a steep and steady rise throughout adolescents through age 18, and as we saw previously, throughout the lifespan Anxiety disorders in childhood predict every mental illness you can name in adulthood In the old days, parents would be told about their child’s fear of the dark, fear of separating, don’t worry they’ll grow out of it, it’s a phase

What this data and others have shown is they are not phases, in fact, anxiety disorders are the gateway disorders for every mental health condition that comes next We have to keep that in mind, these are not being conditions Next, the age of onset around six to seven years of age, eight, are the disruptive behavior disorders We’re talking here about ADHD and oppositional defiant disorder, and then when we hit the adolescent years you’re looking at conduct disorder What might be precursors to then antisocial personality These are the next disorders of onset You see here then, adolescent depression Depression sometimes will occur earlier in childhood but mostly girls 13 to 14 years or age are at higher risk, and then for boys it’s a little later, 15 to 16 years of age But depression is typically preceded by anxiety, so remember that Finally, the last disorders of onset per say are the substance used conditions, so 16, 17 years of age A lot of times use of substances is in response to self-medication of anxiety or depression, or in reaction to acting out that you get from the externalizing disorders These disorders add to one another, and it’s very rare in any of our studies that we have conducted to find only one or two conditions in a youth of any given age, they are usually multiply comorbid with three, four, five or more conditions in one child Just so we also look at this, these are rates for now autism spectrum diagnosis You could see from 2000 going to 2010, what we look at is an increased prevalence but actually this may be more of a better characterization and classification of youth who have the spectrum, or on the spectrum in one way If I talk to colleagues like Cathy Lord who’s an expert in this If I talk to colleagues like Cathy Lord, who’s an expert in this area, she will say that we are really categorizing kids more Whether there are kids who are false positives here? It depends There’s a wide range of variation on who gets diagnosed with these disorders But the bottom line is that children are suffering They’re suffering early and they’re suffering from all the conditions that you heard talked about in adults, they’re just coming on earlier time So what do we do about this? Because one of the things we know is for any given mental health problem, it interferes with the child’s functioning It interferes with their ability to progress in school It interferes with their ability to make and keep friends and become socially adept It interferes with family functioning, and then the vegetative aspects of it They don’t know how to sooth themselves They get into great distress There’s a lot of somatization and such, so kid’s are really suffering in a big way Now the good news is that we do have effective treatments And just to give some of the examples of some of the key studies in child and adolescent mental health funded by the national institutes of mental heath One is the child anxiety mulitmodal study, where we had 488 children between the ages of seven to 17 randomly assigned to combination treatment of cognitive-behavioral therapy, or SSRI of sertraline, cognitive-behavioral therapy alone, sertraline, or pill placebo The good news from the acute outcomes are that three different treatments are affective for the anxiety disorders This is separation, social, and generalized anxiety disorder What you find is the combination treatment is the most effective, significantly better than all others But the two monotherapies are just as effective as one another, and they too are significantly better than pill placebo Effective treatments Let’s keep that in mind The outcomes for this holdout over six months in terms of keeping the children after we broke the blind, we kept the kids who were responders on maintenance therapy, and they continued to hold their outcomes over six more months If you look at the other large trials that were conducted, the multimodal treatment of ADHD study, this was the largest study ever funded for the treatment of youth Again, I think they were closer to seven to 14 years of age with ADHD Here what we find is methylphenidate or the stimulant medication is equally effective by itself to combination of methylphenidate with behavioral interventions The behavioral interventions involve classroom training, parent training, and some self controlled training for the youth By itself, behavioral interventions were not significantly different from just whatever you can get in the community that wasn’t an evidence-based treatment However, over the longer, longer terms, the behavioral interventions caught up with the

kids who were treated with combination or methylphenidate It just might be that for these behavioral treatments, they take a little longer In the treatments for adolescents with depression study, of which I was a principal investigator there too, combination therapy for adolescents between the ages of 12 and 17 is the most effective treatment There what we saw is cognitive- behavioral therapy with Prozac In fact, also, when you have the combination you have fewer incidents of suicidality or self-halm Okay? But then fluoxetine, or Prozac, by itself was effective and better than CBT, which did not separate from placebo after 12 weeks Again, if you go out to 16 weeks CBT is doing well We likewise know that interpersonal therapy also, again, doesn’t come on as quickly in terms of the effects of the medication, but then also is an effective therapy evidence based for adolescent depression Finally the pediatric OCD treatment study, combination treatment, was superior to all the others but CBT was superior to the medication only The medication actually was just beating placebo here The bottom line, what we know, is we do have effective treatments in pharmacotherapy and also in evidence based cognitive-behavioral, behavioral interventions, and interpersonal therapy This is just a follow up of the TAD study, the Treatments for Adolescent Depression study Again, you find this where the psychosocial intervention by itself tends to pick up over time in comparison to the medication conditions With that in mind, what’s happening in the community? What actually are kids getting when they seek care in the community from providers? Well, one thing to know, again, this is from the National Comorbidity Survey, the community prevalence of any disorder that you see here is not at all being touched by the prevalence of treatment for that disorder in the community So where we have an 11.7% prevalence of mood disorder, you’re only seeing about 4.6% of those kids receiving treatment If you look at disorders with high levels of prevalence, specific phobia, which are not, as I said, benign conditions 1.4% are receiving treatment Social phobia, which is one of the most prevalent anxiety disorders in adulthood, that is just gonna stick with these kids, again 1.4% So we’re pretty bad at getting kids into treatment at a time when they most need it I want you to also bear in mind something When children develop a mental illness, as you saw in the first slide, it starts early As soon as they develop a mental illness, they become very different from their peers They are taken off the developmental trajectory of just normal development They are not socializing the way the other kids are They are not accessing and learning from their teachers and in the environment of school the way others are They are more disrupted in terms of their mood and regulating their emotions than others They’re not learning social problem solving skills They’re not becoming independent For whatever reason, maybe because they’re suffering, maybe because the parents are anxious about how behind they are, this is where what the laypeople call “helicopter parenting,” we call parental overprotection occurs Parents swoop in to help What happens is kids fall behind developmentally and they don’t learn to struggle and deal with things and the skills that the other kids have, so they chronically fall behind others So, what we need to do is deliver effective interventions, but here’s something for us to think about Where is the gap between having developed effective interventions in studies and transporting them and delivering them into the community? Well, one of the things that we know is that what we call a research to practice gap, for any kind of intervention, is whether the intervention is provided or not provided based on evidence There’s different types of evidence We could have evidence of a positive effect, like you see for some of the slides I show for depression, anxiety, and so forth If that treatment from the TAD study, the MTA, any of them, if they’re delivered in the community, there’s no practice gap, things are fine But if a child, let’s say, is referred for an anxiety disorder and they are not given

one of the evidence based interventions, they’re maybe sent to playing solitaire therapy or something, that is a failure to translate the evidence That child then doesn’t get help with getting back on track of managing the emotions, and then also developmentally on track We also know about treatments in the community that actually have evidence of a harmful effect When that intervention is provided, that causes harm Okay? So that’s a gap that can be harmful There may be evidence of no effect, that is, there’s no evidence that this treatment works It’s kinda like giving out placebos This is opportunity costs When kids and parents spend time and resources in a therapy that’s going nowhere and the child is not referred to an evidence based treatment Then, finally, we just have some treatments that do not have studies behind them yet, but they’re out there We could talk about traditional psychotherapies where we need to study these interventions and understand what’s happening Just to understand what is delivered in the community, many kids get sent for disruptive behavior disorders to bootcamp type settings There is, in fact, evidence that these programs do harm So kids should not be sent there They actually should be sent to more of the fast track or multisystemic therapy, or dialectical behavioral therapy approaches, which have evidence behind them We also know dolphin and equine therapy It’s equine therapy in the north It’s dolphin therapy in Florida Lot’s of kids with disruptive behavior disorders, anxiety, depression, you name it, there absolutely, there’s not evidence thus far that these treatments work So what happens, and these are costly treatments for families, opportunity is lost Because again, the child is in a program that’s not changing their mental illness issue, not putting them back developmentally where they need to be The families are sinking money They’re losing hope, and the child is losing time Let’s remember, you only have 18 years, roughly, until you are supposedly out in the world Some of the more severe problems that we’ve seen, these rage reduction holding therapies, where you wrap a child in a blanket or various ways, children have actually died from this Again, it does harm We’ve heard a lot in the news recently about conversion or reparative therapies for sexual orientation Again, these do harm, thank goodness This is where we see kids committing suicide These are prominent in the news A number of cases because of families trying to get them converted to being straight Thank goodness, these therapies are being outlawed in certain states So again, there’s different problems with the translation of the evidence based to the community and that is also being served by the fact that, in training programs for mental health practitioners, psychiatry, psychology, PsyD’s, and masters of social work, for example We really don’t train and compel the programs to offer evidence based treatments Psychiatry has come online They’re doing a better job But even in my beloved psychology, we are not compelling training programs We’re not making accreditation based on whether they train in evidence based treatments They offer some courses, but they don’t require them They don’t require competency The other thing to bear in mind, is like I said, besides the fact that all kids suffer, what we also know is that in the community, if you are between the ages of three and seven and you have a mental health disorder, you are now more likely to be prescribed an antipsychotic than not This data comes from a wonderful researcher by the name of Mark Olfson, who I happen to be married to, and his colleagues The sad thing that’s illustrated here, first of all, especially if you’re a boy between the ages of two or three, but also girls, you are not, in these data these kids did not have a mental health visit in the year prior to getting prescribed this medication There’s no evidence, randomized controlled trials, for anxiety, ADHD, and other diagnoses, except in the area of autism spectrum So, we have to do something, because, in fact, there are evidence based parenting programs, parent-child interaction therapy and others that are highly effective for turning around kids in this age group We also need to look at our emerging adults, what Jeffrey Arnett, the developmentalist, calls the age of in between The problem with our emerging adults, 18 to 29, is there are no services specializing

in the transition Child and adolescent psychiatrists say goodbye Adult psychiatrists say, “Eh, come around when you’re 30, 35.” These kids, though, are struggling There’s no coordination between services for them and a very low rate of referrals amongst this age group So again, with this cohort, and this is from the national comorbidity survey, you see high rates of disorder in terms of prevalence in lifetime for the various conditions of anxiety I’m just picking at anxiety, but mood disorders and others too Then when you look at who’s getting care, this is a slide that shows in children 13 to 18, and then after age 18, use of services drop significantly when you hit the young adulthood, or emerging adulthood, years So, conditional service use means that they used any services in the three months prior to the occasion of a mental condition When they’re under their parents’ roof, they’re getting it But as soon as they can say no, this doesn’t mean they get out from under the parents, they stay home They’re refusing services because they can From a public health perspective, and I’m gonna hand this over in a second here on that, but just bear in mind, in the state of working with children and adolescents there are concerns that we have because we have high prevalence of these diagnoses that take kids off their developmental trajectory, which double whammy’s them These conditions build upon one another Anxiety leads to depression, to substance abuse, and so forth What happens is, although we have effective treatments, many children do not receive them And when they are receiving treatments in the community, they may not be evidence based treatments In fact, they may be treatments that can do much harm So, we need to find ways of beefing up and really disseminating effective treatments, but engaging kids and their families One of the things that we have to do, too, is given that we have effective treatments, we still have to answer the main question that parents come into centers like mine with “What do we start with for my kid? How long do they have to be in that therapy? What’s gonna happen when it stops?” Now, I’m of the opinion, having worked for many years with children and adolescents, that kids should be kids They shouldn’t be on somebody’s couch or in my empty chair for the time of their development They should be in when they need it, but they need skills and evidence based treatments so they can get back into their world What we need to do then is to continue to develop our treatments and make use of what we’re learning in neuroscience, in genetics, and in other areas of medicine and psychiatry, where we can target various risk factors and various mechanisms There’s a lot that needs to go on to look at what happens within families, what kind of risk factors, such as behavioral inhibition and others, that put kids at risk for certain disorders, and see how to tailor treatments to meet these needs We need to disseminate our effective treatments for youth who are early in development, such as parent management training, and address something that is not often studied when we study child treatments, and that is what about the parents? Just late breaking news in the last week, Golda Ginsburg, from the University of Connecticut, formerly from Hopkins, just published the results of her study that looked at group of families that were randomly assigned to just getting psychoeducation, information, and being monitored These are families who had children with anxiety disorders Versus families who were randomly assigned to receive for the parents a program that addressed their anxiety and the way that they parented their anxious child What was found in this study, then, is that the kids who go the coping program, the families with the coping program, were delayed and had much less occurrence of a new anxiety disorder Whereas those kids whose parents had problems themselves and were assigned to the education program, they did develop anxiety disorders What we have to do is focus on the parents in a way that we haven’t before In addition, we have to increase access to care I think a big thing is changing the standards by which programs operate for training clinicians and states operate for licensing clinicians That’s something that has to happen Also, require our clinicians to deliver evidence based treatments

I think the Affordable Care Act is helping with that in many ways because it is much more outcomes based Just so we take a look here, in terms of young adults who now have health insurance, they are now seeking treatment for mental health care, and are making use of being on their insurance policies of their parents much longer, which will hopefully keep them engaged in treatments so that they can get access to care over the longer term and not just tune out once they turn 18 So, I’ll just summarize These disorders start early in childhood They run a chronic course They build upon one another We have effective treatments but they’re not readily as accessible Even though they are there in a lot of places, kids don’t often receive care It’s critical for us to understand how to address what kids need for how long, and then also how to deal with taking them off treatments when the time comes Okay? I will leave it at that Thank you Doctor [inaudible] Well, we’ve sort of looked at the spectrum, if you will, along age categories Now our final speaker is gonna sort of look at a bigger picture Sort of the social and policy perspective She is Doctor Colleen Barry, who is associate professor and associate chair for research and practice in the department of health policy and management at Johns Hopkins Bloomberg School of Public Health Her research is focused on the impact of policies on such things as to broaden access to mental health and substance use disorder treatment through insurance expansions Other issues: equalizing insurance coverage for those services comparable to other medical benefits, and alter financing to improve integration of behavioral and medical care I think to a certain extent, we’re going to hear about the access issue in this presentation that we heard about from our previous speakers That even if there is treatment out there, a lot of the people who need it are not getting it There are probably a lot of reasons, from the personal to the societal for that I expect that we’re going to hear about some of those from Dr. Barry So please join me in welcoming her to make her presentation Thank you to the AAAS and to the Dana Foundation for inviting me to be here to speak today I’m gonna orient my talk in the following way: I’m gonna first build on my colleagues’ presentations by thinking about the population with mental illness, in particular in the context of how healthcare services are delivered, and importantly, how they’re financed I’m gonna briefly talk about some major federal policy changes over the last few years that have aimed to address the treatment gap and the evidence based care and quality gap that we’ve heard about I’m gonna end by putting these issues in the context of what we know, since part of the focus of this session is on society, what we know about society’s attitude towards mental illness and the issue of stigma To begin, I’m gonna skip over this slide, because I think we’ve made the case so far that these conditions are highly prevalent and they can be extremely debilitating for individuals with more severe disorders Here in the U.S., we spend about $172 billion, or about 7.4% of total healthcare spending, on mental illness and substance abuse Most of this is related to mental illness About 6.3% of total healthcare spending dollars It’s important to note that the share of total healthcare spending that’s going to mental health has actually been decreasing over time This is, in large part, because of the rapid increase in the denominator, the total healthcare spending dollar, over the last few years You saw this in a somewhat different form in the prior presentations, but if you look more closely at how the money is spent, you see that about 14.5% of all adults 18 and older here, I’m focused on adults, receive some mental health treatment during the year But not all of those with a diagnosable mental illness receive services In fact, only about 41% receive some type of treatment The likelihood of receiving treatment is associated with the severity of your condition

About 63% of those with a serious mental illness receive treatment in a year, about half with a moderate mental illness, and about 30% with a mild mental illness Here I’ll also note, interestingly, that about 8.5% of those with no diagnosable illness receive treatment as well This could represent a variety of things, including people with no need for treatment getting treatment, but also individuals who have been well maintained on treatment and are thus asymptomatic Here, and I think that Venn diagrams are popular in the panel today, but this version of the Venn diagram is trying to illustrate this issue, where you can see the larger circle shows the number of people with a diagnosis of mental illness The second circle depicts those who receive treatment Clearly, some with a diagnosis don’t receive treatment and some receive treatment but don’t have a formal diagnosis The third circle depicts individuals with serious impairment And, again, some of this group falls outside the treatment system And some may have an impairment maybe because of loss of a family member, but don’t meet diagnostic criteria The largest portion of mental health spending is clearly devoted to the intersection of these three circles Those with a diagnosis receiving treatment and with high levels of impairment It’s important to note that the U.S. healthcare system doesn’t always do a good job of matching mental health services to those with the greatest need Here, and this point was already made so I’m not going to dwell on it, we’ve seen a huge decline in the number of beds available in the U.S. for psychiatric treatment paralleling this shift away from inpatient care We’ve heard a lot in the news and elsewhere about overcrowding in emergency rooms due to psychiatric patients and what hospitals report as emergency department boarding of patients with psychiatric illness This is supported by recent survey of state mental health authorities that found that the majority of states, a great majority of states, reported substantial shortages in psychiatric beds If you break down the spending on mental health services, financed by government versus by private sector, for mental health compared to the overall healthcare system, you can see they look somewhat different We spend more public dollars on the mental health sector, about 60% of total mental health spending compared to only about 50% when you look at the overall health sector This difference reflects a long history here of government involvement in financing of care for individuals with mental illness Here, this shows the distribution of spending on mental health treatment by payer You can see that Medicaid, this is the program for low income individuals in the country, and the private health insurance system are shouldering the bulk of this distribution of spending, each about a quarter I wanna draw your attention to the 11% out of pocket This is individuals paying out of their own pockets for services for themselves or for their families I wanna emphasize the point here that this represents a major shift Financial protection from the costs of mental health treatments has improved dramatically over the last 50 years This, I’m gonna just take a quick departure to tell a story about senator Paul Wellstone, who many of you may remember who, prior to his death, had been very involved in advocacy issues and legislation in mental health He described his motivation for being involved in this issue as due to his experience, the experience of his brother who, during his college years, had a breakdown, we called it a breakdown, left college, and was hospitalized for a period Paul Wellstone’s brother returned to college He did well He graduated, but it took his working class parents over 20 years to pay off the accumulated medical expenses So I don’t wanna, I would be remissed by not noting what a difference has occurred over this time period in the out of pocket burden Not to say that it has gone away Here I show how mental health spending is divided across different types of treatments This also illustrates a shift over the past several decades The share of spending dedicated to inpatient care has dropped dramatically We’ve seen a substitution toward outpatient treatment and psychotropic medication use as evidenced in the prior talks The sheer mental health spending devoted to prescription drugs has tripled over this time

period, you can see, from 8% to 28% You can also see that that share is flattening Since the beginning of 2002, and continuing into the present, many of the commonly used medications to treat depression, to treat psychosis, have lost patent protection The cost of these drugs have really decreased as a result The share of spending dedicated to drugs has flattened and lowered, as a result, and will continue over the next few years Here I wanna sort of make an even stronger point related to the reliance on psychotropic medications On this slide, you can really see this By looking at the combination of the light blue piece of the pie, the red pie, and the green pie, you can see that together 81% of all individuals receiving mental health treatment receive psychiatric medication So this is a large share of the treatment we are currently providing It’s worth emphasizing that blue slice that shows that almost half of all individuals who receive any treatment are receiving only a medication The second generation medications are generally somewhat easier to dose and prescribe, making it easier for primary care physicians to get involved in the treatment of mental health conditions We see, from this graph, that the vast majority of spending on mental health treatment, almost three quarters, is still being spent in the mental health specialty sector However, access to specialty providers is a real problem In particular, within certain specialties, child psychiatry for example, and within certain areas, in particular rural areas where it’s really hard, often, to get access In a recent study, about two thirds of primary care physicians reported that they couldn’t get an outpatient mental health specialty referral for their patients This is a much higher rate than for other specialties Another issue that’s linked to this, and that creates barriers to access, is that many psychiatrists don’t participate in either private or public insurance Psychiatrists are much less likely than other types of specialty position groups to participate with only 55% accepting private insurance, 55% accepting Medicaid, and even less, about 45% I’m sorry 55% accepting Medicare and only about 45% accepting Medicaid With that I wanna, just in my limited time, switch quickly to overview two of the major policy changes that have occurred in the last few years that have aimed at both the access issue and some of the delivery system challenges and financing challenges that I’ve talk about Those policies are the Federal Mental Health and Addiction Parity Law that was passed by congress in 2008, and the Affordable Care Act First I’m gonna just begin with parity Historically, private health insurance has been much more limited for mental health, and for substance abuse, than for general medical care Here I show you a benefit comparison for what I would call a typical private employer sponsored plan circa 2007 or 2008 You can see that mental health benefits include certain annual limits on the number of inpatient days and outpatient visits that aren’t paralleled on the medical side as well paralleled on the medical side, as well as higher levels of coinsurance, often we saw higher copays as well And mental health advocates viewed these limits, the differential insurance coverage, as evidence of discrimination and worked for years to achieve so called purity, meaning equity in insurance coverage And we’re able, after about 15 years, to pass the Paul Wellstone and Pete Deomenici Mental Health Parity and Addiction Act in 2008 It was implemented in 2010 It was extended in some pretty important ways in 2014 The law applies to both employer sponsored plans with 50 or more employees, under the Affordable Care Act it’s extended to the individual and small group market as well As well as some government programs It prohibits these special types of treatment limits, it requires equity in financial requirements

and it also requires equity in what’s called in this sort of techy, nerdy way, non-financial treatment limits Which basically means prior authorization, utilization review, the adequacy of provider networks All of these on the mental health and addiction side need to, by law, be equivalent to what’s provided on the general medical, surgical side Quickly, there are a lot of pieces of this large law, the Affordable Care Act, that have potential implications for individuals with mental illness First, it enacted a series of insurance market reforms for example, prohibiting health plans from using pre-existing condition exclusions or charging much higher premiums based on an individual’s health status Clearly relevant to the population of individuals with health insurance Second, and perhaps most importantly, in the states that have now counting 31, including the District, expanded Medicaid, which is again the program for low income Americans there is much broader access to insurance coverage for low income populations We describe in health policy that the sort of Medicaid expansion is carrying the lion’s share of the impact for individuals with mental illness when you think about the Affordable Care Act as a whole, in the states that have expanded Also, the establishment of the new individual and small group marketplaces within all 50 states, provides subsidies to lower income individuals, many of which have diagnosable mental health conditions and aren’t part of traditional employer based insurance So this creates another route to accessing care It, as we heard from the prior slide, expands coverage for young adults up to age 25, so they can get coverage through their parent’s policy This is particularly important given what we know about age of onset of many of these conditions And the ACA includes a whole set of different delivery system and payment reforms that hold promise for changing the financing model in a way that incentivizes both better integration, treating people sort of in a whole body sense, mind and body in a more comprehensive integrated way As well as strong financial incentives for pushing evidence based care And a lot of work force incentives as well Why are efforts to broaden access to insurance coverage under the ACA important for individuals with mental illness? Let me just sort of illustrate this very quickly with this pre-ACA slide where you can see a much larger proportion of those with serious mental illness and other mental health disorders were uninsured prior to the ACA compared to the population without mental health disorders And you see in particular those with severe mental illness were much less likely than those without mental health disorders to have had access to private insurance To end, clearly there’s a lot more I could say about those topics, but I wanna end my presentation by just saying a word or two about societal attitudes And these data that I’m going to present here are from a study that we published in the New England Journal of Medicine in 2013 As you can see, nearly half of the American public view people with mental illness as more dangerous than the general public Only 29% of the public would be willing to work closely on a job with a person with a severe mental illness And only 33% expressed a willingness to have a person with a serious mental illness as a neighbor So you can see these high levels of perceived dangerousness and desire for social distance have persisted over the years And these attitudes are actually quite striking when put alongside what’s been a really significant shift in public attitudes toward less severe disorders A higher level of comfort, there’s a, certainly a cohort effect to it, but a higher level of comfort among the public with sharing that someone’s on an anti-depressant or sharing that they’ve seen a counselor to deal with some life issues Yet we see these persistently high, negative attitudes increasing even in some cases toward the more severely ill So what explains the persistence of these negative attitudes toward people with severe

mental illness? It’s hard to know exactly, but changes in media portrayals, and the sort of nature of media coverage and the changing sort of demographics of how we as a society interact and view people with mental illness, I think probably have something to do with it We saw the slide related to rates of homelessness among the mentally ill, rates of incarceration among the mentally ill And these media portrayals can in turn influence the design of public policy, including the passage of laws like the one in New York focused on gun control measures Specifically with regard to individuals with mental illness even in the context of data showing that mental illness explains very little of societal violence And we conducted an experiment that we published in the American Journal of Psychiatry, in which we randomized a nationally representative group of adults to read a story of a mass shooting, or to be randomized to a control arm Those viewing the mass shooting story were, unsurprisingly, much more likely to rate people with severe mental illness as dangerous, and much more likely, about 14 percentage points And I wanna end I think with a quote from Steve [Sharfstein] whose run Sheppard Pratt Health System, which is right down the road from my office at Hopkins And he’s run this health system for almost 30 years now He says, “Will we ever see an end to the stigma that’s associated with mental illness? No, not as long as there are untreated, delusional, disheveled, threatening, homeless individuals on our streets and in high profile media examples of violence.” Thank you Okay so thank you very much We are now obviously inviting the three to join me on stage, and this is the way we’re gonna work for the rest of the evening before the reception, I’m going to ask one question of all three and then we’re gonna open it up to the audience So while they’re answering my question perhaps some of you with questions can move to the microphones on either side of the room to be prepared to ask your questions We would like to know who you are and your affiliation if you’re willing to share that with us And we would like you to ask a succinct question We don’t need another speaker to add to our time frame What we need is short, succinct questions that they will be able to respond to hopefully in the same manner and be able to answer many of those questions that arise So, my first question, do you have the mics? You all ready to go? They’re on, excellent So I have a hypothetical for you, at least my question’s hypothetical, your answer I hope will be real Let’s assume that the Dana Foundation called you up and said, money is no object Again it’s hypothetical Money is no object, what would you propose? What would be the most important thing related to the kinds of comments each of you made here today, tonight, as a research project? What would you want funded more than anything else, money is not an object, in terms of a research project? Dr. [Freimer], can we start with you and then just move down the row? Well, you know I think that answer is everything, and particularly if money is no object One of the things that I’ve increasingly come to believe is that no piece of this in isolation can really make sufficient progress I mentioned that I’m now involved in this thing called the grand challenge in depression, and the reason I became involved in that is because it became clear to me that I could, my colleagues could, find the causes of mental illness ultimately, hopefully through genetic studies and other approaches But that really wouldn’t do very much for all the people that are suffering if that at the same time there weren’t efforts in the areas that the other speakers talked about To improve the access to treatment, to decrease stigma, to get people to have a different view of mental illness All of these things I think really have to be done together So really, I really believe that in comparison with other areas of medicine and biomedical science, mental has suffered from a fracturing and a disconnection of all these different components And one of the things we could do with resources is really bring all the strands together in

a way that they never have been before Thank you, Dr. [Alvanno]? Well, what he said And I think what would do is examine the impact of bringing services to the places where we find children That is in the schools And having mental health check ups and clinics available in school systems across the board Is your system on? Am I on? Can you hear me now? Okay But that’s what I would do In a way the Affordable Care Act I think is trying to have practice teams that are multi-disciplinary in primary care settings, but I would want to move those teams into the school setting Okay Again, money is no object, Dr. [Barry] what would you propose? And while she’s answering, again, if you’d like to go to the mics and be prepared to ask your questions, please do so Please, go ahead So I think it’s critical to have a robust research agenda related to understanding whether these policies that we’re designing are achieving the ultimate goal, which is to close the treatment gap All of our presentations have touched on this enormous treatment gap and quality of care gap And so, for example, it’s not enough to just give somebody an insurance card, it doesn’t make a difference in the receipt of care and their receipt of high quality care It’s not enough to create financial incentives for different types of providers to work together better Is it making a difference in the kinds of care that people with mental illness get? We know that individuals with mental illness die much earlier from preventable, chronic medical conditions And so it’s critical to see whether these policy interventions, and we’re in this incredibly interesting innovative moment in our country’s history with regard to policy change related to health care and mental health and addiction in particular Is it making a difference? Well thank you all, I think Dr. [Gill] from the Dana Foundation, we have a good portfolio for Dana to consider next year Okay, so as promised let’s start here and then we’ll go back and forth Name, affiliation, and your question please sir Sure Hi, my name is Dan [McHale] from George Mason University My question’s for Dr.Freimer and the other panelists You mentioned the global disease burden for mental illness and the relative lack of funding for mental illness research, some of us are part of a student group dedicated to trying to close that gap Wondered if you had any advice for us and the general public on increasing support for researchers? Well, it’s very gratifying to hear that students are actually advocating for improvements in this area You know, I think that it is largely going to be the vocal involvement of young people in particular, saying how important this is that’s gonna change this It’s gonna change when congress and the other bodies that are responsible for appropriating funds for research are consistently told how important this is I also think that we need to do a better job of educating the public about the benefits of science based practice And you know, words like evidence based treatment, science, these are buzz words now that draw a lot of hot emotions on one side or the other of pro or against these things But the bottom line is that the evidence based interventions save lives and somehow we have to get the broader population to understand that, while working on the issue of stigma, and to lobby to put more funding, and allocate more funds that we have in the public trust towards mental health and mental illness Okay Over here, please Yes, hi Jonathan [Drake] from triple AS In the last presentation there was a very fascinating time series graph showing the changes in treatment modalities; decline of inpatient, dramatic rise of prescription drugs

And what I notice was that the take off in prescription drug use occurred right around 1998, which seems to me to be about the time I first saw television advertising for prescription drugs all over the place, saturating the air waves And so that led me to another question, which is, to what extent, and is it even known to what extent, these changes in treatment modalities are driven by changes in public policy versus changes in individual’s preferences, or how they choose to be treated, versus the imperatives of the health care industry? Dr. Barry do you wanna- I might turn to my colleagues to talk about this too but certainly there has been a big increase in direct consumer advertising There has been a large reliance in the mental health field on detailing and free samples And I think it’s sort of this part of the marketplace And so I think one key issue that we worry about is conflict of interest and in part motivated by our students, the push in recent years has been for medical schools, for residency programs, to put very strict conflict of interest policies in place to make sure that that influence is not impairing prescribers and student’s sense of sort of where the evidence is in prescribing and making treatment decisions based on evidence And making sure that we have an environment that’s free of conflict of interest to the greatest extent possible Any of the other panelists wanna quickly respond? Yeah, I mean I think there are couple of things I’d just say in addition to that I mean, in relationship to the point about advertising, I think in part it relates to the fact, if you look at the first generation of drugs that were used against mental illness, they were almost all discovered by accident, and not by pharmaceutical companies For example, lithium, which was the drug that made, in some ways, the biggest difference for mood disorders, was discovered entirely by accident by a practitioner in Australia Similarly, first anti-psychotics were discovered by accident as anesthetic agents and so forth So in part I think it reflects the fact that the pharmaceutical industry in the 70’s and 80’s was actually for the first time really engaged in developing drugs for psychiatry So I think in the 90’s is when you saw the effect of that And then the other point, which was also made in one of the talks is that one of the trends in these medications was from agents that really needed to be used by specialists, to agents, which were much safer and could be used by primary care doctors with the SSRI anti-depressants being the best example of that They essentially became ubiquitous throughout the healthcare system in the US and around the world Thank you Can I just add more one point, that might not be a popular point, but especially what I see in families Families who are burdened in many ways, both parents are working, there’s a lot of stress, medications are often easier, because whether you’re with your child taking them to therapy, or you yourself are struggling, therapy is work It’s a lot of hard work and so sometimes I think that’s there And I think, you know, the primary providers of medication are typically primary care docs and such these days And they’re not doing mental health assessments, they don’t have the time to spend to learn about the patient and then refer to a therapist They’re responding to what they’re hearing in terms of sematic complaints and stress and stuff, sleep issues It’s a lot easier for the patients, so they’re going for it So again, I think education of the public is so important Good, okay Please, over there Yes, I’m Deborah [Arucnle] triple AS What is the current status of the arguments, of the controversy over prescribing Prozac to teenagers? Do you wanna take this? You’re the psychiatrist on the panel Yeah so the question relates to the controversy of prescribing, I think it’s not just Prozac, but really the entire class of anti-depressant drugs to teenagers

This relates to some evidence that suggests that in contrast to adults who get these medications, that teenagers may be more likely to be sort of, become prone to violence to themselves or others as a result of this treatment I think it’s, to be honest, totally unclear whether that’s so or not These are so complicated, these relationships Whether it’s that they really are doing something specific that has this negative effect, or whether it’s a result of actually people beginning to show a response, and whereas before they were apathetic and unable to leave their room, and now suddenly they’re able to get out and do something I think that remains unclear What I’d like to do now, since we’re at seven o’clock, what I’d like to … Honor those who were up to ask questions, if you would go ahead starting here then back to there, then back to there, to please ask your questions serially and then we’ll ask the panelists to respond to them Good evening my name is Samantha [Dawson] I recently graduated from Georgetown University My question relates to the decrease in inpatient treatment Not only are there enough beds currently, but there’s also been a decrease in CBT offered to inpatients Evidence based treatments have proven that combination treatment is the most effective in most cases and I wonder whether you have any, anyone in the panel has any suggestions on how we can address this issue, either policy wise, to ensure that people gain access to the care they need Especially when in crisis in inpatient treatment Okay, so please remember that question, think about your response Over there? Hi, my name is Lang [Wong] I’m a triple AS science to technology policy fellow at the National Institute of Neurological Disorders and Stroke My question is for Dr. Alvanno, I was surprised to see how low the treatment prevalence numbers you showed were in contrast, some would argue that the diagnosis rates for some mental health disorders can be too high So, for example, some people say that all these kids nowadays don’t have ADHD, it’s that our idea of what is normal is what’s shifting So how do we reconcile those differences and perspectives? Thank you Thank you And our final question Yes, Jessica [Windham] from triple AS I have two quick questions My first for Dr. Barry, and that relates to what you mentioned at the end about stigma I was thinking in particular about the Lufthansa tragedy in Europe What do you consider to be the role and/or the responsibility of the scientific community with regard to educating the media about how they portray mental illness and people with mental illness in the context of such tragedies? And for our other two presenters, we know about research that’s occurring as far as genetic heredity of depression, but I was wondering the extent to which there’s research going on about the environmental heredity for children growing up in families in which one or more family members have depression? Okay I thought, very good series of questions Dr. Barry do you wanna start? No one person has to answer all three Okay I’m gonna just quickly respond to the two that I think pertain to my presentation and then I’ll turn it over to the experts here First on inpatient treatment decline and inpatient treatment You know, our standard under [inaudible] is that we provide treatment in the least restrictive environment and so I think part of the decrease in inpatient treatment has been connected to the civil rights movement that has touched the mental health field And that is to provide individuals with the most appropriate treatment in the least restrictive environment, and that led to the community mental health movement, which of course was terrible underfunded But I think that most folks will agree that the answer is not to drive up inpatient treatment rates, but rather to make sure that we have the right services for people at the right stage they are in their treatment needs And in particular, we have a huge problem with crisis intervention And there are some really innovative programs out there, New York has a great one to try to get people out of this waiting pattern in emergency rooms and get them into real crisis intervention services And for some individuals, some period of inpatient care is gonna be appropriate, and for longer than is currently available But I think there’s value in this idea of least restrictive treatment environment that we need to build an effective community based treatment system around

With regard to the point about the media and the obligation of the media The Carter Center has a wonderful program that I want everybody to know about that’s related to journalism and mental illness And they’ve had many cohorts of journalists that have come and been part of this effort to try to provide journalists with information both related to the nature of these diagnoses, but the impact of stigma on public support for policy, individual’s willingness to seek treatment and to do their jobs as journalists in a way that doesn’t further drive up stigmas So this is, I think, a really important program And one last thing I’ll say about news media and messaging I think it’s clear that we need stigma reducing messages And there’s a science here, and we do experiments in the lab to try to understand how to communicate with the public better about mental illness And one thing, we’ve learned a lot of important information related to changing the way we communicate, and one is that if you can show individuals, through the media or through other types of communication, stories of recovery, stories of successful treatment, people that are successful in treatment, those stories can change public attitudes And I think the disservice that we do is only showing through the news media these stories of people in distress, stories of people who are homeless, stories of people that have done terrible things and we haven’t been aggressive about showing the stories of treatment that works Thank you Dr. Alvanno, which questions? I’ll take the question on why is there such a low rate of treatment in the community whereas the rates of the prevalence of these disorders are so high Some more recent analyses actually are showing among kids who are being treated, part of the good news is that there’s been an increase recently in children with more serious mental illnesses, or serious impairment in functioning, are getting care Not enough, but that has risen some The question about, on the other hand, is there are children who are being treated that aren’t necessarily … They’re more mildly impaired And why do they then have and make use of treatment that they probably, or they might not need, we’re not sure And this may be that some categorization for those kids around learning disabilities or milder ADHD and such But at least there’s been a shift that we know of the more impaired kids, getting better access to care, so that’s good news So we may be seeing a little bit of shift in terms of treatment, but again, what we need to do is equip the work force to deliver effective treatments and it is through effective treatments that we may engage more people, more kids to stay in care where they need it Thank you, Dr. Freimer? Okay So I’m just gonna take one minute to … The three of us have agreed on about 99% of everything that we’ve discussed, but I just wanted to take issue with one comment Which is, I actually disagree on the point about hospitalization, I think as a result of trying to make less restrictive we’ve ended up making more restrictive care because of the fact that treatment has gone from the hospital to the criminal justice system And so, anyway I just wanna make that point But I’ll answer also the point about genetics and the environment And really what I believe is that the main end result of genetics is not going to actually be the identification of the molecules, that it’s really going to allow us to study the environment in a much more rigorous way than we’ve ever been able to before We’ve seen this throughout all other areas of medicine as we’ve begun to understand genetics, we can really focus in on what are the, really the relevant environmental exposures for disease, in a way that we were never able to before And the environment is a huge space that encompasses everything in our lives, and we’re never gonna be able to understand it, if we try to understand our entire environment So my view is that what genetics is gonna do, is it’s gonna allow us to focus on what are the most specifically important aspects of the environment that contribute to these diseases Well thank you all and please join me in thanking our speakers