I attended a meeting last week at one of the foremost departments of psychiatry in the country, if not the world: the Columbia Physicians and Surgeons/Psychiatric Institute's department, led by the eminent Dr. Jeffrey Lieberman, a colleague and good friend (disclosure: Psychiatric Institute is a research facility of the New York State Office of Mental Health, where I am Medical Director). A series of workshops offered faculty members an opportunity to learn about innovative and emerging science in what causes psychiatric illnesses and how to diagnosis and treat them.
I went to one session on personalized medicine in psychiatry. In short, personalized medicine is about what treatments are more likely to work with which patients. In psychiatry, for example, reliably identifying clinical features or imaging (brain MRI) or EEG or other markers would tell doctors whether a particular medicine for depression will be more or less likely to work. We really need biomarkers to improve response rates and reduce time to response by selecting a medicine that is more likely to work. My field needs more to offer than it does today. Some of the best scientists in the world, from Columbia/PI as well as Harvard and other academic centers, are searching for answers.
Other sessions included work underway on genetic testing, novel treatments for schizophrenia, perinatal mental health, eating disorders and cultural and social issues in mental health.
I was struck by the amazing creativity of the researchers and clinicians and the promise that they hold for a future where psychiatrists and other medical and mental health professionals will be ever more able to understand the underlying genetic and nervous system mechanisms of psychiatric illness; to provide novel and effective treatments with fewer side effects (whether these be from medications, therapy and safe brain stimulation); and to improve our capabilities to match patient to treatment. But while knowledge is exploding, true advances are still to come. I thought, once again, that the greatest advances in the mental health of people with serious mental illnesses (like depression bipolar illness, PTSD, OCD, eating disorders and schizophrenia) in the next five years, maybe longer, will be from more effectively delivering proven mental health treatments to more people who can benefit from them. Sometimes called the "science to practice gap," I like to think of it as closing the gap between what we know and what we do.
Mental illnesses, even without their major role in physical illnesses, are highly prevalent: more than one in five people in this country annually will experience a mental disorder. That is tens of millions of people. Yet a disturbingly low 20 percent of the millions of people who need mental health care in this country are receiving it. That means four out of five people who might benefit are not! When mental disorders are not treated, they cause great individual and family suffering, because the pain of mental disorders is no less than that of physical illnesses -- though it can be less visible. The greatest tragedy is suicide, which can appear to a person to be a solution and an escape from unbearable mental pain and hopelessness, when in fact it is a permanent "solution" to a temporary problem. Suicide among our veterans bears testimony to this tragedy, with the death toll from suicide among Iraq and Afghanistan soldiers exceeding combat deaths.
The costs do not stop with human suffering: the economic cost of undetected and untreated mental disorders impacts our workplaces (through absenteeism, reduced productivity and disability) and adds extraordinary burden to our medical system, because people with chronic physical illnesses like heart disease, diabetes, high blood pressure, asthma and cancer commonly co-occur with depression and other treatable mental conditions -- which, unless properly treated, impair a person's ability to recover and manage their physical illness.
What do I mean when I say that health and mental health care are not doing enough of what we know works? For example, only half of people with depression who come to their primary care doctor have that condition detected, and of those, less than half receive treatment that follows recognized "care paths," or guidelines about how to best treat a condition. For example, in New York State, most people who turn to a mental health clinic for a serious mental condition do not stay for more than four visits, far too few visits to effectively improve their condition. For example, only a small fraction of people with an illness like bipolar disorder or schizophrenia receive comprehensive care, in an ongoing manner, where they are on medications, engaged in therapy, have family counseling and receive support to stay in or return to school or work.
Psychiatry has many treatments that work. In fact, its treatments rival those for chronic physical conditions in their effectiveness. But psychiatry's therapeutics only work if disorders are screened for and properly identified and then when patients come, stay in treatment and get proven (evidence-based) treatments. Efforts are underway -- but are too limited to date -- to reduce the barriers to effective care, which include stigma, insufficient knowledge dissemination (to doctors, patients and families), ambiguous standards for screening and treatment, too little attention to recognizing when care is not good enough and assisting programs with the quality improvement techniques that will change their provision of care for the better, and financing mechanisms that encourage doing the right thing, not just doing something, to name a few.
So, when I left my workshop, I thought that while there is great promise for the future, what we owe our patients and their families right now is improving the everyday practice of psychiatry. I promise to do my part to make that happen.
The opinions expressed herein are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
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