Making sense of mental health problems
Making sense of mental health problems

This free course is available to start right now. Review the full course description and key learning outcomes and create an account and enrol if you want a free statement of participation.

Free course

Making sense of mental health problems

2.2 Scientific advances in understanding mental health problems

In the next activity you will hear about how biomedical research can help us to understand and therefore treat mental health problems.

Activity 3 A medical perspective

Allow about 30 minutes

Now watch the video of Dr Thomas Insel talking about biomedical research. Below is a text box for you to record any notes you might wish to make while watching or after watching the talk. One thing you might like to think about is the ethical dilemmas posed by identifying individuals as having a possible psychotic disorder before they display any signs of having a problem.

Once you have watched the video, answer the questions that follow.

Download this video clip.Video player: Video 2 Thomas Insel
Skip transcript: Video 2 Thomas Insel

Transcript: Video 2 Thomas Insel

[APPLAUSE]

THOMAS INSEL:
So, let’s start with some good news. And the good news has to do with what do we know based on biomedical research that actually has changed the outcomes for many very serious diseases. Start with leukaemia – acute lymphoblastic leukaemia, ALL, the most common cancer of children.
When I was a student, the mortality rate was about 95%. Today, some 25, 30 years later, we’re talking about a mortality rate that’s reduced by 85%. Six thousand children each year who would have previously died of this disease are cured.
But if you want the really big numbers, look at the numbers for heart disease. Heart disease used to be the biggest killer, particularly for men in their 40s. Today, we’ve seen a 63% reduction in mortality from heart disease – remarkably, 1.1 million deaths averted every year.
AIDS, incredibly, has just been named, in the past month, a chronic disease, meaning that a 20-year-old who becomes infected with HIV is expected not to live weeks, months or a couple of years, as we said only a decade ago, but is thought to live decades, probably to die in his 60s or 70s from other causes altogether. These are just remarkable, remarkable changes in the outlook for some of the biggest killers. And one in particular that you probably wouldn’t know about, stroke, which has been, along with heart disease, one of the biggest killers in this country, is a disease in which now we know that, if you can get people into the emergency room within three hours of the onset, some 30% of them will be able to leave the hospital without any disability whatsoever.
Remarkable stories, good-news stories, all of which boil down to understanding something about the diseases that has allowed us to detect early and intervene early. Early detection, early intervention, that’s the story for these successes. Unfortunately, the news is not all good. Let’s talk about one other story, which has to do with suicide.
Now this is, of course, not a disease per se. It’s a condition, or it’s a situation that leads to mortality. What you may not realise is just how prevalent it is. There are 38,000 suicides each year in the United States. That means one about every 15 minutes. Third most common cause of death amongst people between the ages of 15 and 25. It’s kind of an extraordinary story, when you realise that this is twice as common as homicide and actually more common, as a source of death, than traffic fatalities in this country.
Now, when we talk about suicide, there is also a medical contribution, here. Because 90% of suicides are related to a mental illness – depression, bipolar disorder, schizophrenia, anorexia, borderline personality – there’s a long list of disorders that contribute and, as I mentioned before, often early in life. But it’s not just the mortality from these disorders. It’s also morbidity.
If you look at disability, as measured by the World Health Organisation, with something they call the Disability Adjusted Life Years – it’s kind of a metric that nobody would think of except in an economist, except it’s one way of trying to capture what is lost, in terms of disability, from medical causes. And, as you can see, virtually 30% of all disability from all medical causes can be attributed to mental disorders, neuropsychiatric syndromes.
You’re probably thinking that doesn’t make any sense. I mean, cancer seems far more serious. Heart disease seems far more serious. But you can see actually they’re further down this list. And that’s because we’re talking here about disability.
What drives the disability for these disorders like schizophrenia and bipolar and depression? Why are they number one, here? Well, there are probably three reasons.
One is that they’re highly prevalent. About one in five people will suffer from one of these disorders in the course of their lifetime. A second, of course, is that, for some people, these become truly disabling, and it’s about 4% to 5%, perhaps 1 in 20.
But what really drives these numbers, this high morbidity – and, to some extent, the high mortality – is the fact that these start very early in life. Fifty percent will have onset by age 14, 75% by age 24 – a picture that is very different than what one would see if you’re talking about cancer or heart disease, diabetes, hypertension – most of the major illnesses that we think about as being sources of morbidity and mortality. These are indeed the chronic disorders of young people.
Now, I started by telling you that there were some good-news stories. This is obviously not one of them. This is the part of it that is perhaps most difficult. And, in a sense, this is a kind of confession for me. My job is to actually make sure that we make progress on all of these disorders.
I work for the federal government. Actually, I work for you. You pay my salary. And maybe, at this point, when you know what I do – or maybe what I’ve failed to do – you’ll think that I probably ought to be fired. And I can certainly understand that.
But what I want to suggest, and the reason I’m here, is to tell you that I think we’re about to be in a very different world, as we think about these illnesses. What I’ve been talking to you about so far is mental disorders, diseases of the mind. That’s actually becoming a rather unpopular term, these days. And people feel that, for whatever reason, it’s politically better to use the term ‘behavioural disorders’ and to talk about these as disorders of behaviour. Fair enough. They are disorders of behaviour, and they are disorders of the mind.
But what I want to suggest to you is that both of those terms, which have been in play for a century or more, are actually now impediments to progress. That what we need, conceptually, to make progress, here, is to rethink these disorders as brain disorders. Now, for some of you, you’re going to say, oh my goodness, here we go again. We’re going to hear about a biochemical imbalance, or we’re going to hear about drugs, or we’re going to hear about some very simplistic notion that will take our subjective experience and turn it into molecules or maybe into some sort of very flat, unidimensional understanding of what it is to have depression or schizophrenia.
When we talk about the brain, it is anything but unidimensional or simplistic or reductionistic. It depends, of course, on what scale or what scope you want to think about, but this is an organ of surreal complexity. And we are just beginning to understand how to even study it, whether you’re thinking about the 100 billion neurons that are in the cortex or the 100 trillion synapses that make up all the connections.
We have just begun to try to figure out, how do we take this very complex machine that does extraordinary kinds of information processing and use our own minds to understand this very complex brain that supports our own minds? It’s actually a kind of cruel trick of evolution, that we simply don’t have a brain that seems to be wired well enough to understand itself. In a sense, it actually makes you feel that, when you’re in the safe zone of studying behaviour or cognition, something you can observe, that in a way feels more simplistic and reductionistic than trying to engage this very complex, mysterious organ that we’re beginning to try to understand.
Now, already in the case of the brain disorders that I’ve been talking to you about – depression, obsessive compulsive disorder, posttraumatic stress disorder, while we don’t have an in-depth understanding of how they are abnormally processed, or what the brain is doing in these illnesses, we have been able to already identify some of the connectional differences, or some of the ways in which the circuitry is different for people who have these disorders.
We call this ‘the human connectome’. And you can think about the connectome sort of as the wiring diagram of the brain. You’ll hear more about this in a few minutes. The important piece here is that, as you begin to look at people who have these disorders, the one in five of us who struggle in some way, you find that there’s a lot of variation in the way that the brain is wired, but there are some predictable patterns. And those patterns are risk factors for developing one of these disorders.
It’s a little different than the way we think about brain disorders like Huntington’s or Parkinson’s or Alzheimer’s disease, where you have a bombed-out part of your cortex. Here, we’re talking about traffic jams, or sometimes detours, or sometimes problems with just the way that things are connected and the way that the brain functions. You could, if you want, compare this to, on the one hand, a myocardial infarction, a heart attack, where you have dead tissue in the heart, versus arrhythmia, where the organ simply isn’t functioning because of the communication problems within it. Either one would kill you. In only one of them will you find a major lesion.
As we think about this, probably it’s better to actually go a little deeper into one particular disorder, and that would be schizophrenia. Because I think that’s a good case for helping to understand why thinking of this as a brain disorder matters.
These are scans from Judy Rapoport and her colleagues at the National Institute of Mental Health, in which they studied children with very-early-onset schizophrenia. And you can see already, in the top, there are areas that are red, or orange, yellow, are places where there’s less grey matter. And, as they follow them over five years, comparing them to age-matched controls, you can see that, particularly in areas like the dorsolateral prefrontal cortex or the superior temporal gyrus, there’s a profound loss of grey matter. And it’s, important if you try to model this, you can think about normal development as a loss of cortical mass, loss of cortical grey matter.
And what’s happening in schizophrenia is that you overshoot that mark. And at some point, when you overshoot, you cross a threshold. And it’s that threshold where we say, this is a person who has this disease, because they have the behavioural symptoms of hallucinations and delusions. That’s something we can observe.
But look at this closely, and you can see that, actually, they’ve crossed a different threshold. They’ve crossed a brain threshold, much earlier, that, perhaps not at age 22 or 20, but even by age 15 or 16, you can begin to see the trajectory for development is quite different – at the level of the brain, not at the level of behaviour. Why does this matter?
Well, first, because, for brain disorders, behaviour is the last thing to change. We know that for Alzheimer’s, for Parkinson’s, for Huntington’s. There are changes in the brain a decade or more before you see the first signs of a behavioural change.
The tools that we have now allow us to detect these brain changes much earlier, long before the symptoms emerge. But, most important, go back to where we started. The good-news stories in medicine are early detection, early intervention.
If we waited until the heart attack, we would be sacrificing 1.1 million lives every year in this country to heart disease. That is precisely what we do today, when we decide that everybody with one of these brain disorders, brain-circuit disorders, has a behavioural disorder. We wait until the behaviour becomes manifest. That’s not early detection. That’s not early intervention.
Now, to be clear, we’re not quite ready to do this. We don’t have all the facts. We don’t actually even know what the tools will be, nor what to precisely look for, in every case, to be able to get there before the behaviour emerges as different.
But this tells us how we need to think about it and where we need to go. Are we going to be there soon? I think that this is something that will happen over the course of the next few years. But I’d like to finish with a quote about trying to predict how this will happen, by somebody who’s thought a lot about changes in concepts and changes in technology.
‘We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next 10.’ – Bill Gates. Thanks very much.

[APPLAUSE]

End transcript: Video 2 Thomas Insel
Copy this transcript to the clipboard
Print this transcript
Video 2 Thomas Insel
Interactive feature not available in single page view (see it in standard view).
You can type text here, but this facility requires a free OU account. Sign in or register.
Interactive feature not available in single page view (see it in standard view).

Question 1

What percentage of mental health conditions have become established by the age of 24?

a. 

75%


b. 

65%


c. 

55%


d. 

45%


The correct answer is a.

Answer

According to Insel’s figures, 75% of mental disorders have become established by the age of 24.

Question 2

What is the main reason for Thomas Insel drawing attention to psychiatric disorders?

a. 

Because he has a personal interest


b. 

Because they are easy to treat


c. 

Because their treatment lags behind physical disorders


d. 

Because their existence is contested


The correct answer is c.

Answer

Insel points to the successes that medical science has had in tackling conditions such as leukaemia, heart disease, stroke and AIDS. By contrast it has, so far, had little impact on preventing the development of mental health disorders.

Question 3

What is Insel’s preferred term for the mental health problems he is talking about?

a. 

Mental disorders


b. 

Brain disorders


c. 

Behavioural disorders


d. 

Psychiatric disorders


The correct answer is b.

Answer

Insel sees these problems as disorders of the brain.

Question 4

What does Insel see as being the root cause of mental health problems such as depression, obsessive compulsive disorder and post-traumatic stress disorder in the brain?

a. 

Disruption to synaptic pathways


b. 

Areas of dead tissue


c. 

Chemical imbalances


d. 

Impact of external factors


The correct answer is a.

Answer

Insel believes that it is possible to find differences in the brains of people with disorders that indicate disruption to the synapses, which allow communication between different parts of the brain.

Question 5

What does Insel see as being the root cause of schizophrenia in the brain?

a. 

Disruption to synaptic pathways


b. 

Loss of cortical grey matter


c. 

Chemical imbalances


d. 

Impact of external factors


The correct answer is b.

Answer

Insel says that ‘... you can think about normal development as a loss of cortical mass, loss of cortical grey matter, and what’s happening in schizophrenia is that you overshoot that mark, and at some point, when you overshoot, you cross a threshold’.

Comment

Scientific advances such as those outlined by Dr Thomas Insel offer the possibility of a better understanding of the workings of the brain and of what can go wrong in certain circumstances. However, these advances also raise questions about how to best use the information obtained. For instance, if brain imaging did reveal the likelihood of someone having a psychotic disorder, how sure could the clinician be that the person would go on to develop the disorder and what would be the effect on the person’s life of being told that they were at risk? Medical approaches, in common with other approaches to mental health problems, have to take ethical and practical factors into account when introducing innovations into practice.

K314_1

Take your learning further

Making the decision to study can be a big step, which is why you'll want a trusted University. The Open University has over 40 years’ experience delivering flexible learning and 170,000 students are studying with us right now. Take a look at all Open University courses.

If you are new to university level study, find out more about the types of qualifications we offer, including our entry level Access courses and Certificates.

Not ready for University study then browse over 900 free courses on OpenLearn and sign up to our newsletter to hear about new free courses as they are released.

Every year, thousands of students decide to study with The Open University. With over 120 qualifications, we’ve got the right course for you.

Request an Open University prospectus