Toward a new understanding of mental illness
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0:01 - 0:03So let's start with some good news,
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0:03 - 0:06and the good news has to do with what do we know
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0:06 - 0:08based on biomedical research
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0:08 - 0:12that actually has changed the outcomes
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0:12 - 0:15for many very serious diseases?
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0:15 - 0:17Let's start with leukemia,
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0:17 - 0:19acute lymphoblastic leukemia, ALL,
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0:19 - 0:22the most common cancer of children.
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0:22 - 0:24When I was a student,
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0:24 - 0:28the mortality rate was about 95 percent.
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0:28 - 0:31Today, some 25, 30 years later, we're talking about
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0:31 - 0:34a mortality rate that's reduced by 85 percent.
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0:34 - 0:37Six thousand children each year
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0:37 - 0:41who would have previously died of this disease are cured.
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0:41 - 0:43If you want the really big numbers,
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0:43 - 0:46look at these numbers for heart disease.
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0:46 - 0:48Heart disease used to be the biggest killer,
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0:48 - 0:49particularly for men in their 40s.
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0:49 - 0:53Today, we've seen a 63-percent reduction in mortality
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0:53 - 0:55from heart disease --
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0:55 - 1:00remarkably, 1.1 million deaths averted every year.
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1:00 - 1:02AIDS, incredibly, has just been named,
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1:02 - 1:05in the past month, a chronic disease,
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1:05 - 1:08meaning that a 20-year-old who becomes infected with HIV
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1:08 - 1:12is expected not to live weeks, months, or a couple of years,
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1:12 - 1:14as we said only a decade ago,
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1:14 - 1:16but is thought to live decades,
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1:16 - 1:21probably to die in his '60s or '70s from other causes altogether.
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1:21 - 1:24These are just remarkable, remarkable changes
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1:24 - 1:26in the outlook for some of the biggest killers.
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1:26 - 1:28And one in particular
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1:28 - 1:30that you probably wouldn't know about, stroke,
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1:30 - 1:32which has been, along with heart disease,
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1:32 - 1:34one of the biggest killers in this country,
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1:34 - 1:36is a disease in which now we know
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1:36 - 1:39that if you can get people into the emergency room
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1:39 - 1:41within three hours of the onset,
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1:41 - 1:44some 30 percent of them will be able to leave the hospital
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1:44 - 1:47without any disability whatsoever.
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1:47 - 1:49Remarkable stories,
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1:49 - 1:51good-news stories,
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1:51 - 1:54all of which boil down to understanding
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1:54 - 1:58something about the diseases that has allowed us
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1:58 - 2:01to detect early and intervene early.
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2:01 - 2:03Early detection, early intervention,
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2:03 - 2:06that's the story for these successes.
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2:06 - 2:09Unfortunately, the news is not all good.
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2:09 - 2:11Let's talk about one other story
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2:11 - 2:13which has to do with suicide.
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2:13 - 2:16Now this is, of course, not a disease, per se.
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2:16 - 2:19It's a condition, or it's a situation
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2:19 - 2:20that leads to mortality.
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2:20 - 2:23What you may not realize is just how prevalent it is.
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2:23 - 2:28There are 38,000 suicides each year in the United States.
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2:28 - 2:30That means one about every 15 minutes.
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2:30 - 2:33Third most common cause of death amongst people
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2:33 - 2:36between the ages of 15 and 25.
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2:36 - 2:38It's kind of an extraordinary story when you realize
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2:38 - 2:41that this is twice as common as homicide
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2:41 - 2:43and actually more common as a source of death
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2:43 - 2:47than traffic fatalities in this country.
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2:47 - 2:49Now, when we talk about suicide,
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2:49 - 2:53there is also a medical contribution here,
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2:53 - 2:55because 90 percent of suicides
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2:55 - 2:57are related to a mental illness:
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2:57 - 3:00depression, bipolar disorder, schizophrenia,
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3:00 - 3:03anorexia, borderline personality. There's a long list
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3:03 - 3:05of disorders that contribute,
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3:05 - 3:09and as I mentioned before, often early in life.
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3:09 - 3:12But it's not just the mortality from these disorders.
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3:12 - 3:14It's also morbidity.
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3:14 - 3:16If you look at disability,
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3:16 - 3:18as measured by the World Health Organization
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3:18 - 3:22with something they call the Disability Adjusted Life Years,
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3:22 - 3:24it's kind of a metric that nobody would think of
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3:24 - 3:25except an economist,
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3:25 - 3:29except it's one way of trying to capture what is lost
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3:29 - 3:32in terms of disability from medical causes,
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3:32 - 3:35and as you can see, virtually 30 percent
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3:35 - 3:37of all disability from all medical causes
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3:37 - 3:39can be attributed to mental disorders,
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3:39 - 3:42neuropsychiatric syndromes.
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3:42 - 3:44You're probably thinking that doesn't make any sense.
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3:44 - 3:47I mean, cancer seems far more serious.
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3:47 - 3:50Heart disease seems far more serious.
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3:50 - 3:53But you can see actually they are further down this list,
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3:53 - 3:55and that's because we're talking here about disability.
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3:55 - 3:58What drives the disability for these disorders
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3:58 - 4:02like schizophrenia and bipolar and depression?
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4:02 - 4:05Why are they number one here?
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4:05 - 4:06Well, there are probably three reasons.
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4:06 - 4:08One is that they're highly prevalent.
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4:08 - 4:11About one in five people will suffer from one of these disorders
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4:11 - 4:14in the course of their lifetime.
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4:14 - 4:16A second, of course, is that, for some people,
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4:16 - 4:18these become truly disabling,
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4:18 - 4:21and it's about four to five percent, perhaps one in 20.
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4:21 - 4:25But what really drives these numbers, this high morbidity,
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4:25 - 4:28and to some extent the high mortality,
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4:28 - 4:32is the fact that these start very early in life.
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4:32 - 4:35Fifty percent will have onset by age 14,
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4:35 - 4:3875 percent by age 24,
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4:38 - 4:41a picture that is very different than what one would see
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4:41 - 4:44if you're talking about cancer or heart disease,
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4:44 - 4:47diabetes, hypertension -- most of the major illnesses
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4:47 - 4:51that we think about as being sources of morbidity and mortality.
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4:51 - 4:57These are, indeed, the chronic disorders of young people.
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4:57 - 5:00Now, I started by telling you that there were some good-news stories.
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5:00 - 5:02This is obviously not one of them.
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5:02 - 5:05This is the part of it that is perhaps most difficult,
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5:05 - 5:07and in a sense this is a kind of confession for me.
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5:07 - 5:13My job is to actually make sure that we make progress
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5:13 - 5:15on all of these disorders.
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5:15 - 5:17I work for the federal government.
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5:17 - 5:19Actually, I work for you. You pay my salary.
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5:19 - 5:21And maybe at this point, when you know what I do,
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5:21 - 5:23or maybe what I've failed to do,
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5:23 - 5:25you'll think that I probably ought to be fired,
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5:25 - 5:28and I could certainly understand that.
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5:28 - 5:30But what I want to suggest, and the reason I'm here
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5:30 - 5:33is to tell you that I think we're about to be
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5:33 - 5:38in a very different world as we think about these illnesses.
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5:38 - 5:41What I've been talking to you about so far is mental disorders,
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5:41 - 5:43diseases of the mind.
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5:43 - 5:46That's actually becoming a rather unpopular term these days,
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5:46 - 5:48and people feel that, for whatever reason,
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5:48 - 5:52it's politically better to use the term behavioral disorders
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5:52 - 5:56and to talk about these as disorders of behavior.
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5:56 - 5:58Fair enough. They are disorders of behavior,
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5:58 - 6:00and they are disorders of the mind.
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6:00 - 6:02But what I want to suggest to you
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6:02 - 6:04is that both of those terms,
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6:04 - 6:07which have been in play for a century or more,
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6:07 - 6:10are actually now impediments to progress,
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6:10 - 6:14that what we need conceptually to make progress here
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6:14 - 6:19is to rethink these disorders as brain disorders.
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6:19 - 6:21Now, for some of you, you're going to say,
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6:21 - 6:23"Oh my goodness, here we go again.
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6:23 - 6:26We're going to hear about a biochemical imbalance
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6:26 - 6:28or we're going to hear about drugs
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6:28 - 6:33or we're going to hear about some very simplistic notion
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6:33 - 6:36that will take our subjective experience
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6:36 - 6:42and turn it into molecules, or maybe into some sort of
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6:42 - 6:45very flat, unidimensional understanding
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6:45 - 6:49of what it is to have depression or schizophrenia.
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6:49 - 6:53When we talk about the brain, it is anything but
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6:53 - 6:57unidimensional or simplistic or reductionistic.
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6:57 - 7:00It depends, of course, on what scale
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7:00 - 7:02or what scope you want to think about,
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7:02 - 7:08but this is an organ of surreal complexity,
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7:08 - 7:12and we are just beginning to understand
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7:12 - 7:14how to even study it, whether you're thinking about
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7:14 - 7:16the 100 billion neurons that are in the cortex
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7:16 - 7:19or the 100 trillion synapses
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7:19 - 7:21that make up all the connections.
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7:21 - 7:25We have just begun to try to figure out
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7:25 - 7:28how do we take this very complex machine
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7:28 - 7:31that does extraordinary kinds of information processing
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7:31 - 7:34and use our own minds to understand
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7:34 - 7:37this very complex brain that supports our own minds.
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7:37 - 7:40It's actually a kind of cruel trick of evolution
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7:40 - 7:43that we simply don't have a brain
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7:43 - 7:46that seems to be wired well enough to understand itself.
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7:46 - 7:49In a sense, it actually makes you feel that
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7:49 - 7:51when you're in the safe zone of studying behavior or cognition,
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7:51 - 7:53something you can observe,
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7:53 - 7:56that in a way feels more simplistic and reductionistic
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7:56 - 8:01than trying to engage this very complex, mysterious organ
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8:01 - 8:03that we're beginning to try to understand.
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8:03 - 8:07Now, already in the case of the brain disorders
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8:07 - 8:09that I've been talking to you about,
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8:09 - 8:11depression, obsessive compulsive disorder,
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8:11 - 8:13post-traumatic stress disorder,
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8:13 - 8:16while we don't have an in-depth understanding
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8:16 - 8:20of how they are abnormally processed
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8:20 - 8:22or what the brain is doing in these illnesses,
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8:22 - 8:25we have been able to already identify
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8:25 - 8:27some of the connectional differences, or some of the ways
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8:27 - 8:30in which the circuitry is different
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8:30 - 8:32for people who have these disorders.
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8:32 - 8:34We call this the human connectome,
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8:34 - 8:36and you can think about the connectome
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8:36 - 8:38sort of as the wiring diagram of the brain.
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8:38 - 8:40You'll hear more about this in a few minutes.
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8:40 - 8:43The important piece here is that as you begin to look
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8:43 - 8:47at people who have these disorders, the one in five of us
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8:47 - 8:49who struggle in some way,
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8:49 - 8:51you find that there's a lot of variation
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8:51 - 8:54in the way that the brain is wired,
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8:54 - 8:57but there are some predictable patterns, and those patterns
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8:57 - 9:01are risk factors for developing one of these disorders.
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9:01 - 9:04It's a little different than the way we think about brain disorders
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9:04 - 9:06like Huntington's or Parkinson's or Alzheimer's disease
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9:06 - 9:09where you have a bombed-out part of your cortex.
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9:09 - 9:12Here we're talking about traffic jams, or sometimes detours,
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9:12 - 9:15or sometimes problems with just the way that things are connected
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9:15 - 9:16and the way that the brain functions.
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9:16 - 9:19You could, if you want, compare this to,
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9:19 - 9:22on the one hand, a myocardial infarction, a heart attack,
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9:22 - 9:24where you have dead tissue in the heart,
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9:24 - 9:28versus an arrhythmia, where the organ simply isn't functioning
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9:28 - 9:30because of the communication problems within it.
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9:30 - 9:32Either one would kill you; in only one of them
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9:32 - 9:34will you find a major lesion.
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9:34 - 9:37As we think about this, probably it's better to actually go
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9:37 - 9:40a little deeper into one particular disorder, and that would be schizophrenia,
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9:40 - 9:43because I think that's a good case
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9:43 - 9:46for helping to understand why thinking of this as a brain disorder matters.
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9:46 - 9:50These are scans from Judy Rapoport and her colleagues
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9:50 - 9:52at the National Institute of Mental Health
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9:52 - 9:56in which they studied children with very early onset schizophrenia,
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9:56 - 9:57and you can see already in the top
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9:57 - 10:00there's areas that are red or orange, yellow,
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10:00 - 10:02are places where there's less gray matter,
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10:02 - 10:04and as they followed them over five years,
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10:04 - 10:06comparing them to age match controls,
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10:06 - 10:08you can see that, particularly in areas like
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10:08 - 10:10the dorsolateral prefrontal cortex
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10:10 - 10:14or the superior temporal gyrus, there's a profound loss of gray matter.
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10:14 - 10:16And it's important, if you try to model this,
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10:16 - 10:18you can think about normal development
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10:18 - 10:21as a loss of cortical mass, loss of cortical gray matter,
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10:21 - 10:25and what's happening in schizophrenia is that you overshoot that mark,
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10:25 - 10:26and at some point, when you overshoot,
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10:26 - 10:29you cross a threshold, and it's that threshold
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10:29 - 10:33where we say, this is a person who has this disease,
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10:33 - 10:35because they have the behavioral symptoms
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10:35 - 10:37of hallucinations and delusions.
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10:37 - 10:39That's something we can observe.
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10:39 - 10:44But look at this closely and you can see that actually they've crossed a different threshold.
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10:44 - 10:47They've crossed a brain threshold much earlier,
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10:47 - 10:50that perhaps not at age 22 or 20,
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10:50 - 10:53but even by age 15 or 16 you can begin to see
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10:53 - 10:56the trajectory for development is quite different
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10:56 - 10:59at the level of the brain, not at the level of behavior.
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10:59 - 11:01Why does this matter? Well first because,
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11:01 - 11:04for brain disorders, behavior is the last thing to change.
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11:04 - 11:07We know that for Alzheimer's, for Parkinson's, for Huntington's.
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11:07 - 11:10There are changes in the brain a decade or more
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11:10 - 11:15before you see the first signs of a behavioral change.
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11:15 - 11:18The tools that we have now allow us to detect
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11:18 - 11:22these brain changes much earlier, long before the symptoms emerge.
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11:22 - 11:25But most important, go back to where we started.
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11:25 - 11:29The good-news stories in medicine
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11:29 - 11:32are early detection, early intervention.
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11:32 - 11:35If we waited until the heart attack,
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11:35 - 11:39we would be sacrificing 1.1 million lives
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11:39 - 11:42every year in this country to heart disease.
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11:42 - 11:44That is precisely what we do today
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11:44 - 11:49when we decide that everybody with one of these brain disorders,
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11:49 - 11:52brain circuit disorders, has a behavioral disorder.
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11:52 - 11:55We wait until the behavior becomes manifest.
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11:55 - 12:00That's not early detection. That's not early intervention.
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12:00 - 12:01Now to be clear, we're not quite ready to do this.
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12:01 - 12:04We don't have all the facts. We don't actually even know
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12:04 - 12:07what the tools will be,
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12:07 - 12:11nor what to precisely look for in every case to be able
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12:11 - 12:15to get there before the behavior emerges as different.
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12:15 - 12:18But this tells us how we need to think about it,
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12:18 - 12:20and where we need to go.
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12:20 - 12:21Are we going to be there soon?
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12:21 - 12:24I think that this is something that will happen
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12:24 - 12:27over the course of the next few years, but I'd like to finish
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12:27 - 12:29with a quote about trying to predict how this will happen
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12:29 - 12:32by somebody who's thought a lot about changes
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12:32 - 12:34in concepts and changes in technology.
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12:34 - 12:36"We always overestimate the change that will occur
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12:36 - 12:38in the next two years and underestimate
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12:38 - 12:42the change that will occur in the next 10." -- Bill Gates.
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12:42 - 12:44Thanks very much.
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12:44 - 12:46(Applause)
- Title:
- Toward a new understanding of mental illness
- Speaker:
- Thomas Insel
- Description:
-
Today, thanks to better early detection, there are 63% fewer deaths from heart disease than there were just a few decades ago. Thomas Insel, Director of the National Institute of Mental Health, wonders: Could we do the same for depression and schizophrenia? The first step in this new avenue of research, he says, is a crucial reframing: for us to stop thinking about “mental disorders” and start understanding them as “brain disorders.” (Filmed at TEDxCaltech.)
- Video Language:
- English
- Team:
- closed TED
- Project:
- TEDTalks
- Duration:
- 13:03
Morton Bast edited English subtitles for Toward a new understanding of mental illness | ||
Morton Bast approved English subtitles for Toward a new understanding of mental illness | ||
Morton Bast edited English subtitles for Toward a new understanding of mental illness | ||
Thu-Huong Ha accepted English subtitles for Toward a new understanding of mental illness | ||
Thu-Huong Ha edited English subtitles for Toward a new understanding of mental illness | ||
Joseph Geni edited English subtitles for Toward a new understanding of mental illness | ||
Joseph Geni added a translation |