Five years later, I encountered Patrick again at a meeting on mental health care in Washington, DC, and I was struck by how much he had changed. He was composed, focused, and responsive. When I inquired about this apparent change, he explained that he had received effective treatment for his bipolar disorder and substance abuse and was living a healthy lifestyle and feeling great. A year later I attended his engagement party in New York. After the toasts and congratulatory comments, Patrick pulled me aside and informed me that he had decided to devote the next phase of his career to being an advocate for mental illness and addictions.
Inspired by his decision, I made up my mind to run for the APA presidency the very next day. If I was fortunate enough to win, I thought Patrick would be the perfect partner in my own mission to eliminate the stigma associated with mental illness and educate people about psychiatry. Since then, Patrick and I have worked together on many psychiatry-related legislative initiatives, including the Final Rule of the Mental Health Parity and Addiction Equity Act, the Patient Protection and Affordable Care Act, and the Helping Families in Mental Health Crisis Act. We have also joined efforts to communicate the true state of affairs about mental illness, addiction, and mental health care to the public. Patrick has become perhaps the most visible, articulate, and effective spokesperson for mental illness in America—and the first politician to confront his own serious mental illness in such a public and positive manner.
Former congressman Patrick Kennedy (right) with Vice President Joseph Biden and the author at the 50th Anniversary of the Community Mental Health Act at the JFK Presidential Library in Boston, October 25, 2013. (Ellen Dallager Photography, American Psychiatric Association, 2014)
Patrick Kennedy, along with Bradley Cooper, Glenn Close, and Jane Pauley, is joined by many other celebrities, including Alan Alda, Goldie Hawn, and Arianna Huffington, who are all beginning to use their visibility and influence to raise awareness about mental illness. This is a good start, but the truth is that we will only overcome the stigma of mental illness when the public is fully convinced that medical science understands mental illness and can provide effective treatment. Fortunately, even more impressive developments in psychiatry are just around the corner.
A Bright Future
Over the past two hundred years, the history of psychiatry has been characterized by long stretches of stagnation punctuated by abrupt and transformative changes—many of which, regrettably, were not for the better. But we have entered a period of scientific advances that will produce a stream of innovations more dazzling than any that have come before.
One of the most promising arenas of research is genetics. It is virtually certain that no single gene alone is responsible for any particular mental illness, but through increasingly powerful genetic techniques we are starting to understand how certain patterns or networks of genes confer levels of risk. These genetic signatures will lead to more precise diagnosis of patients. They will also permit earlier identification of persons vulnerable to severe mental illness, enabling preventive interventions.
Glenn Close’s family provided one of the first examples of the application of genetics in psychiatry. In 2011, her sister Jessie and nephew Calen volunteered for a research study at McLean Hospital in Massachusetts led by Dr. Deborah Levy, a psychologist at Harvard. A genetic analysis of Jessie and Calen’s DNA (using ROMA-like methods) revealed that they shared a rare genetic variant resulting in extra copies of the gene that produces an enzyme that metabolizes the amino acid glycine, which has been implicated in psychotic disorders (as it helps to modulate the activity of the excitatory neurotransmitter glutamate). Extra copies of this gene meant that Jessie and Calen were deficient in glycine, since their body overproduced the enzyme that metabolized glycine. When Dr. Levy gave them supplemental glycine, Jessie and Calen’s psychiatric symptoms markedly improved. It was like watching a patient’s fever decline after giving him aspirin. When they stopped taking the supplemental glycine, their symptoms worsened.
Using a genetic test on Glenn Close’s sister and nephew in order to identify a specific drug that could ameliorate their mental illness was one of the very first applications of personalized medicine in psychiatry. It holds the promise of revolutionizing the diagnosis and treatment of mental illness.
I believe we will soon have useful diagnostic tests for mental illness. In addition to the progress made toward genetic tests, there are several other promising technologies that could lead to tests that can aid in diagnosis and treatment selection, including electrophysiology (establishing an EKG-like test of brain activity), serology (which would produce a blood test similar to the tests for cholesterol or prostate-specific antigen), and brain imaging (using MRI and PET procedures to detect signature brain structures and activity). The FDA recently approved PET testing for Alzheimer’s disease, and we are getting very close to using brain imaging to aid in the diagnosis of autism. Then, instead of Daniel Amen’s spurious claims for SPECT-based diagnosis of mental illness, we will have scientifically proven methods of diagnosis using brain-imaging procedures.
Advances in psychiatric treatment are also occurring on other fronts. New drugs are being developed that are more precisely targeted in terms of where and how they act within the brain. Brain stimulation therapy (the treatment modality that began as ECT) is also undergoing remarkable progress. Researchers have devised two new forms of brain stimulation that are much less invasive than ECT: transcranial magnetic stimulation (TMS) and transcranial direct-current stimulation (TDCS). These therapies use magnetic fields or weak electrical current to stimulate or dampen brain activity in specific anatomic regions without inducing a seizure, and they are noninvasive and don’t require anesthesia. They can be used to target specific brain sites believed to be the source of symptoms of psychosis, depression, and anxiety.
For the most severe and intractable mental illnesses that don’t respond to medications or other forms of brain stimulation therapy, deep brain stimulation (DBS) offers new hope. DBS involves surgically implanting an electrode into a precisely defined neural structure. While this procedure is highly invasive and requires neurosurgery, as a treatment of last resort it has been used successfully to treat extreme cases of obsessive-compulsive disorder and depression, as well as neurological disorders like Parkinson’s disease and torsion dystonia.
One encouraging avenue of psychotherapy research is coming out of cognitive neuroscience, a field that studies the software of the brain. This work is beginning to elucidate the neural bases of mental functions that can be modified through talk therapy—and mental functions not amenable to talk therapy. We are starting to understand the specific neurobiological processes that are active during psychotherapy and can use this information to refine psychotherapy techniques, applying them only to conditions that they are most likely to help.
Other researchers are combining specific medications with talk therapy to enhance its efficacy. Antidepressants, antipsychotics, and anxiolytics are frequently used to reduce symptoms that interfere with a patient’s ability to benefit from talk therapy—it’s hard to meaningfully engage when you are having psychotic thoughts or hearing screaming voices, severely depressed, or paralyzed by anxiety. Drugs that enhance learning and neuroplasticity can increase the effectiveness of psychotherapy and reduce the number of sessions necessary to produce change.
One example of such synergistic effects is combining cognitive-behavioral therapy with D-cycloserine, a drug initially approved for the treatment of tuberculosis. Scientists have learned that D-cycloserine enhanced learning by acting on glutamate receptors in the brain. When D-cycloserine is used with cognitive-behavioral therapy, it appears to enhance its effects. Similar joint drug-psychotherapy treatments have also been successfully applied to patients with obsessive-compulsive disorder, anxiety disorders, and PTSD.
Another recent example came from the lab of my colleague Scott Small, a neurologist at Columbia University. Small found that a concentrated extract of flavanols from
cocoa beans dramatically enhanced the memory of people with age-associated memory impairment by stimulating neural activity in the hippocampus. Such neutraceutical compounds may provide a new approach to cognitive rehabilitation.
We are also seeing the start of a flood of Internet-based applications for mobile devices that assist patients with treatment adherence, provide auxiliary therapeutic support, and enable patients to remain in virtual contact with their mental health providers. David Kimhy, the director of the Experimental Psychopathology Laboratory at Columbia University, developed a mobile app that schizophrenic patients can use when they are in distress. If their auditory hallucinations intensify, they can launch a cognitive-behavioral script on their smart phone that instructs them how to cope with their symptoms:
Screen 1: Do you hear voices right now? [Yes / No]
Screen 2: How strong is the voice? [1–100 scale]
Screen 3: What would you like to do?
Relaxation Exercise
Pleasurable Activities
Explore Causes
Nothing
Screen 4.1: Relaxation Exercise: [Run on-screen guided breathing exercise for 45 seconds]
Richard Sloan, director of Behavioral Medicine of Columbia Psychiatry, monitors bio-signals (including heart rate, blood pressure, respiration, temperature, muscle tension) of patients by having them wear accouterments ranging from wrist bands to vests tricked out with sensors that transmit data in real time, thereby providing a virtual display of a person’s emotional state.
Psychiatry has come a long way since the days of chaining lunatics in cold stone cells and parading them as freakish marvels in front of a gaping public. After a difficult and often disreputable journey, my profession now practices an enlightened and effective medicine of mental health, giving rise to the most gratifying moments in a psychiatrist’s career: bearing witness to clinical triumphs. Often, these are not merely the relief of a patient’s symptoms but the utter transformation of a person’s life.
A few years back I had a patient like Abigail Abercrombie who suffered from panic attacks and had been homebound for two decades. At first, I had to make house calls just to see her, since she refused to leave the dismal safety of her cramped Manhattan apartment. When she was finally able to visit me at my office, she sat near the open door with her bicycle perched just outside so she could flee at any moment. Today, she goes hiking with her husband, socializes with friends, and takes her children to school, telling me, “I feel like my world has become a hundred times larger.”
I treated a fifty-year-old man who suffered from a nearly lifelong depression and twice tried to kill himself. He quit several jobs and was unable to maintain a romantic relationship. After two months of treatment with antidepressant medication and psychotherapy, he felt that a veil of gloom had been lifted and asked, “Is this how most people feel? Is this how most people live?”
My friend Andrew Solomon also suffered from suicidal depression for years before receiving effective treatment. He wrote eloquently about his illness in The Noonday Demon: An Atlas of Depression, a Pulitzer Prize finalist and winner of the National Book Award. Today, he is happily married and enjoys a very successful career as a writer, activist, and highly prized speaker. “Without modern psychiatry,” Solomon assures me, “I truly believe I might have been dead by now.”
Not so very long ago, those suffering from bipolar disorder, such as Patrick Kennedy, had every reason to believe that their lives would inexorably lead to financial ruin, public humiliation, and wrecked relationships. Kay Jamison, another dear friend, was whipsawed between careening flights of mania and crushing bouts of depression when she was a graduate student and junior faculty member in psychology at UCLA. Her prospects looked bleak. Today she is a tenured professor of psychiatry at Johns Hopkins and was named a “Hero of Medicine” and one of the “Best Doctors in the United States” by Time magazine. Her writing, including five books, is highly acclaimed and earned her an honorary doctor of letters from the University of St. Andrews. She says psychiatry “restored her life.”
What about the most severe and frightening of psychiatry’s flagship illnesses, the supreme scourge of the mind: schizophrenia? Today, if a person with schizophrenia, the most virulent form of psychosis, comes to the psychiatry department of a major medical center and fully avails herself of quality treatment—and sticks with it after she is discharged—the most likely outcome is recovery and the ability to have an independent life and continue her education or career. Consider my friend Elyn Saks.
She grew up in an upper-middle-class family in Miami, where she enjoyed the love of her parents and the sunny comforts of a Norman Rockwell–like childhood. Though in retrospect there may have been a few clues about her mental illness to come—when Elyn was eight, she would not go to bed until all her shoes and books had been carefully arranged in unvarying and precise order, and she often hauled the covers over her head because some menacing figure was lurking outside her bedroom window—any casual visitor to the Saks home would have found a happy, intelligent, and perfectly normal little girl. It was not till she went to college, at Vanderbilt University in Nashville, that her behavior began to change.
At first, Elyn’s hygiene deteriorated. She stopped showering regularly and often wore the same clothes day after day till her friends told her to change them. After that, her activities grew downright disturbing. On one occasion she bolted from her dorm room for no discernible reason, abandoning a friend who was visiting her from Miami, and dashed around the quad in the freezing cold waving a blanket over her head and declaring for all to hear that she could fly. However, these foreboding signs failed to elicit treatment for her, nor did they prevent her from graduating as class valedictorian and winning a Marshall scholarship to study in England at Oxford University.
In England she experienced her first psychotic breakdown. She describes this episode in her award-winning book The Center Cannot Hold: My Journey Through Madness: “I was unable to sleep, a mantra running through my head: I am a piece of shit and I deserve to die. I am a piece of shit and I deserve to die. I am a piece of shit and I deserve to die. Time stopped. By the middle of the night, I was convinced day would never come again. The thoughts of death were all around me.”
She was hospitalized with the diagnosis of schizophrenia, yet—this being 1983—she was treated mainly with talk therapy. No medication was prescribed for her.
After she was released, she somehow completed her studies at Oxford and was even admitted to Yale Law School, but her illness worsened. In New Haven, Elyn started to believe that people were reading her mind and attempting to control her movements and behavior. Moreover, her thoughts were disjointed and bizarre, and when she spoke she was barely coherent. One afternoon she visited the office of her contracts professor, a smart, funny woman whom Elyn liked and idealized because “she’s God and I will bask in her God-like glow.” When Elyn arrived, looking and acting strange, the professor informed her that she was concerned about her and suggested that Elyn come home with her as soon as she finished up some work in her office. Delighted, Elyn promptly jumped to her feet and climbed out the window onto the ledge. Rocking and kicking her feet, she began belting out Beethoven’s “Ode to Joy.” Elyn was hospitalized again, this time against her will, and was placed in physical restraints and forcibly medicated.
Elyn told me that this was the worst experience of her life, the moment when it really sank in that she was mentally ill—suffering from incurable, perpetual, mind-warping schizophrenia. She felt sure she would never have a normal life. “I thought I would need to reduce the scope of my dreams,” she said. “Sometimes I just wanted to be dead.” But in New Haven, she encountered a pluralistic psychiatrist (“Dr. White,” in her memoirs)—a Freudian psychoanalyst who embraced the therapeutic power of psychopharmaceuticals—who provided her with both structure and hope by talking with her each and every day while waiting for her medication to take hold and continuing thereafter. She eventually was place
d on clozapine, a new antipsychotic drug with superior therapeutic powers, approved for use in the U.S. in 1989.
Encouraged by Dr. White, Elyn decided that she would not let her illness dictate her fate. She began learning everything she could about schizophrenia and diligently participated in all of her treatments. Before long, she was functioning well and living a clear-headed life once again. She believes her family’s, and subsequently her husband’s, unwavering love and support were essential to her success, and having met them, I wholeheartedly concur.
Supported by her loved ones and by a pluralistic psychiatry, Elyn has gone on to enjoy an extraordinary career as a legal scholar, mental health advocate, and author. Today she is an associate dean and professor of law, psychology, psychiatry, and the behavioral sciences at the University of Southern California. She won a MacArthur “Genius” award and recently gave a TED talk urging compassion for those with mental illness, recognizing the importance of human empathy in her own recovery, and wrote her bestselling book.
Elyn Saks, Kay Jamison, and Andrew Solomon didn’t just have their symptoms alleviated. With the aid of effective, scientifically based, compassionate, and caring treatment, they were able to discover entirely new identities within themselves. This was an impossible dream a century ago and was not the norm even thirty years ago, at the start of my medical career. Today, recovery is not just possible, but expected. A self-determined, fulfilling life is the goal for all people with mental illness.
However, despite this progress and the proliferation of auspicious developments in our society’s understanding of mental illness and psychiatry, I am under no illusion that the specters of psychiatry’s past have vanished, or that my profession has freed itself from suspicion and scorn. Rather, I believe that after a long and tumultuous journey, psychiatry has arrived at a pivotal and propitious moment in its evolution—a moment well worth celebrating, but also an opportunity to reflect on the work that still lies ahead. In doing so I am reminded of Winston Churchill’s famous declaration after Britain’s long-awaited triumph at the 1942 Battle of El Alamein. It was the Allies’ very first victory in World War II after an extended series of demoralizing defeats. Seizing the moment, Churchill announced to the world, “This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”
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