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As the COVID-19 pandemic eases, a mental-health crisis still has us in its grip. My fellow-psychiatrists and I continue to be flooded with referrals, desperate calls, emergencies, and relapses—likely the consequences of years of isolation and grinding anxiety, loss, school disruption, and who knows what kinds of viral assaults on the brain. Preliminary studies report elevated rates of suicide, anxiety and depression, addiction, developmental delay, and psychiatric E.R. visits. Socially marginal people, health-care workers, and the young all seem especially at risk.
COVID has left us destabilized, in the midst of what might be thought of as a psychiatric pandemic. How bad will this be? Who will escape harm, and who will suffer the most? With the virus, we eventually understood the answers to these questions and focussed our public-health efforts accordingly. But the psychiatric consequences of the pandemic will be intrinsically more complex, varied, and obscure. First, there are millions of mourners whose loved ones succumbed to COVID, often in terrible, sudden ways. Then there are some who may be suffering from subtle neuropsychiatric effects of the infection. In addition, there are those stuck in chronic states of fight or flight, or helplessness—mental modes that affect our sense of time. Such people may be jumpy, irritable, violent, trigger-happy, drugged out, avoidant, defeated, morose, or self-harming, for reasons that no one can recall. Doug won’t acknowledge that he’s getting high so often because of the stress of the pandemic. Jen will be incensed if you imply that she’s cutting herself because of the difficulties of the past three years. As with traumas suffered by soldiers in war, the COVID past will slip into the present, darkening the future.
How should our psychiatric-health-care system respond? “We don’t have a psychiatric-health-care system,” the public-health expert Rosemary Stevens reminded me. She’s right. Americans suffering from mental illness routinely tumble through gaping cracks in our “system.” Homeless encampments, with many people in need of psychiatric help, sprawl along beaches near Los Angeles. Vast stretches of our heartland remain mental-health-care deserts. Chicago’s Cook County Jail has in recent years been our proud nation’s largest provider of psychiatric services. As for our struggling children, good luck finding help. The other day, I ran into a pediatrician who told me that she had just sent another suicidal teen to the emergency room; the kid was eleventh in line for a bed.
If by mental-health system we mean integrated parts working together, then it’s true that America doesn’t have one. Still, we do have an array of governmental agencies, nonprofits, biotech and pharmaceutical companies, hospitals, clinics, and medical colleges—in addition to an army of researchers, epidemiologists, psychiatrists, psychologists, social workers, and therapists—that could be called upon to meet whatever post-COVID challenges we face. The National Institute of Mental Health sits at the center of this constellation. Founded in 1949, the N.I.M.H. was originally charged with leading America’s mental-health research, prevention, and treatment efforts after the Second World War, when startling numbers of veterans had “become mentally unbalanced in fighting for their country,” as the Post put it at the time. Since then, as the self-proclaimed largest funder of psychiatric research in the world, the N.I.M.H. has dominated the mental-health-and-illness ecosystem; its priorities nourish growth or extinguish it. One might imagine that comprehending and responding to the mental-health effects of the pandemic would skip to the front of that line.
Few of my clinical colleagues believe that will happen. Their pessimism reflects not just the current state of mental-health care in our country but decades-old trends that have reshaped how we think about mental illness—shifts that have blinded us to cataclysms like the one we have just endured. What should we do to correct our course?
Psychiatry has always been a “Rashomon”-like affair, with triumphalists and vilifiers, sincere testimonials from the saved and tragic ones from the lost. It is held by some to be humane and a force for progress, yet it has offended, at varying times, religious believers, libertarians, Marxists, Foucauldians, and “hard” scientists. Critics have never been in short supply.
So I should have been prepared to have my head spin when I interviewed clinicians, historians, and prominent leaders in the field about our capacity to respond to a post-COVID mental-health crisis. One day, I spoke to Allen Frances, the editor of the fourth Diagnostic and Statistical Manual of Mental Disorders, who was not optimistic and looked back in regret. “For me, the tragedy is that, on my watch—the last sixty years I’ve been involved in psychiatry—we have seen the care of patients deteriorate, not improve,” he said. The next day, Herbert Pardes, a former N.I.M.H. director, was more upbeat. Surveying the same time period, he noted that the stigma long attached to mental illness had diminished, and that new knowledge and treatments had blossomed.
Both, it turns out, are right. Psychiatry is composed of three intertwined enterprises: community care for sufferers; a medical specialty devoted to diagnosing and treating patients; and research programs focussed on mind/brain science. At their best, all three efforts aid and constructively challenge one another. But, in this country, during the past few decades, each has gone its own way. This fragmentation has been dramatic, tragic, and certain to compromise our capacity to respond to the post-COVID crisis.
The availability of community care—essentially, food, shelter, and support for people with mental illness—is shaped by social values regarding those in need. Those ethical commitments have fluctuated over time. In the early nineteenth century, enlightened Western nations built asylums that were mostly justified in humanitarian terms, but those places of respite eventually became too-big-to-care institutions that warehoused and brutalized their occupants. In postwar America, as the welfare state came under increasing attack, and criticism of these so-called snake pits grew louder, state asylums closed. The sickest and poorest never made it to underfunded—or often unfunded—community mental-health centers. With the emergence of managed-care insurance, in the nineteen-eighties, shockingly short in-patient hospital stays led to still symptomatic patients’ being routinely discharged to the street or swept up into prison. There wasn’t funding for anything better. That is still the case. Should a mental-health epidemic strike us, there is no one to provide care at that scale.
This grim picture is made more painful by contrast with what the medical field of psychiatry, along with its allied disciplines, now can do. Médecine mentale, as it was once called, has long sought to stabilize itself with clear diagnoses and treatments; owing to the mysteries of the mind and brain, it didn’t get too far. Forty years ago, however, American psychiatry found its footing: the third edition of the Diagnostic and Statistical Manual cut free speculative claims about causation, sticking to diagnostic categories based on reliable and coherent clusters of symptoms and signs. Clinicians of all stripes now shared a common language. In reaction to orthodox Freudians and eager lobotomists, a “biopsychosocial” perspective took root, which encouraged practitioners to shun ideology and pragmatically address the biological, psychological, and social aspects of mental illness. Psychoanalysis grudgingly made room for an array of empirically validated psychotherapies. Medications such as Prozac, Effexor, and Risperdal emerged; they were mostly safe and, if not curative, often very helpful.
All these changes were accompanied by publicity campaigns attacking stigma. Mental disorders, we were reminded on billboards and in commercials, were no different from diabetes or any other illness. This work paid off. Today, princes, athletes, senators, and celebrities no longer hide their psychic struggles. And so, paradoxically, around three decades ago, as our commitment to care for the poor and uninsured evaporated, clinical psychiatry could boast of increased social acceptance and tools that were more effective than ever.
Many disorders remained far from cured; some were fully treatment resistant. But, for those patients, there was still hope. Psychiatry’s researchers were tasked with discovering the causes of these disorders. It was a gargantuan job, and a lot depended on its success. In the eighties, Senator Pete Domenici, a loyal supporter of mental-health efforts, told the Stanford neuroscientist Jack Barchas—a point person in the effort to stop cuts to mental-health spending by the Reagan Administration—that, although the country could not afford to care for all of its mentally ill, it could support finding cures for their diseases. During the nineties, which President George H. W. Bush declared the Decade of the Brain, hundreds of millions of dollars were directed to the N.I.M.H. in that effort.
Meanwhile, the institute shed some of its original congressional mandate for treatment and prevention, by giving the job of funding mental-health services to a new federal entity, the Substance Abuse and Mental Health Services Administration. From then on, as one former N.I.M.H. director told me, undertreatment and homelessness were SAMHSA’s responsibilities. As the Human Genome Project launched, and brain-scanning technology leapt forward thanks to functional MRI, pressure to find genetic and brain signatures for psychiatric illnesses grew. Yet, as the new millennium commenced, a specific scan for disorders such as schizophrenia remained elusive. Dreams of single genetic causes were dissipating. A crisis was brewing.
History holds a large, unmarked graveyard filled with the ideas of those who tried to pin down the ultimate causes of mind/brain illnesses. Critics and scholars have portrayed some of the memorable failures—a procession of phrenologists, degeneration theorists, germ enthusiasts, wild psychoanalysts, political revolutionaries, and sexual liberationists. All of them pushed for their cherished notion, only for it ultimately to be found misguided, wanting, or worse.
There’s an underlying reason for all this zigzagging. Picture an archer’s target; at the bull’s-eye, place the most basic of possible causes for mental illness—say, genes. Huntington’s chorea, a fatal disease that affects cognition and movement, is solely genetic: it sits wholly at the center of the target. But other, more common conditions, such as schizophrenia and bipolar disorder, can only partly be predicted in terms of genetic risk, and, in most other forms of mental illness, genetic determinism further diminishes. To fully understand those diseases, we have to start looking to the next ring in the target. What else might be at work? We may now take aim at neurons, then jump out to neural circuits and networks, then to the entire brain with its hundred billion neurons and trillions of synapses. At any of these different levels of biology, a pathogenic event might disrupt us.
As if that were not enough to overwhelm us, there is much more to consider. Next, our psychiatric archers must move their focus from the brain to the mind, bump up against the mind-brain problem, hurry past dozens of philosophers, and simply grant that minds, in part, can cause things to happen. After that, they must turn their attention to the other outer rings, such as the self, individual behavior, the social world, and the nonhuman environment. Each of those holds the possibility of specific kinds of trouble: negative thought patterns; chronic affects like fear or shame; relationships filled with abuse; deprivation, poverty, and our catchall term for many horrors, trauma; and then, in that very last circle, poisons, bacteria, and viruses.
By taking up all of the rings on that target as potentially interacting causes of illness, psychiatry captures a rich set of human possibilities, from errors in our molecules to forces like racism. Clinicians can take a shot at any of them, unleashing as many arrows as they need. Prozac, psychotherapy, leaving a brutal spouse? Yes, yes, and yes. But experimental science requires studies that reduce a vast field of variables to an independent one whose effect can be tested. Unlike a psychiatrist working with a patient, a scientist in search of a soluble problem must limit herself to only one spot. And so psychiatry has long been a scientifically unstable discipline; it has veered back and forth between different explanatory models because its object of study, the mind/brain, presents the most overwhelming array of epistemological problems in all of medicine. In our quest for valid and reliable answers, it’s easy to get lost.
In 2002, at a moment when the clinical promise of the Decade of the Brain remained unfulfilled, it came time to choose a new N.I.M.H. director. Thomas Insel, a leader in the quest to find biological explanations for complex behaviors, got the job. Insel was brilliantly successful, famous for illuminating the role of the hormone oxytocin in eliciting bonding behavior in voles—an important finding in the emerging field of social neuroscience. Frustrated by the weaknesses in the nation’s mental-health-research program, he concluded that they stemmed from one of the foundations of clinical work: DSM-III was serving practitioners and patients well enough, but its categories were sometimes too muddy for researchers in search of well-defined scientific targets. How many specific kinds of depression lurked in “D.S.M. 296.31, Major Depressive Disorder, Recurrent, Mild”? Most experts would guess that there were many. And, if one did not tease apart those variants, how could anyone figure out what caused Jim’s depression but not Jane’s, why Zoloft worked on Amelie but not Eli?
In 2010, Insel and his team unveiled the Research Domain Criteria, or RDoC, a new framework for the study of mental disorders that introduced its own nomenclature and benchmarks. The move seemed to separate scientific research from the language and culture of patient treatment—a divorce made more bitter when Insel suggested that DSM categories were mere constructs “based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.”
RDoC’s influence was felt across the institute’s research portfolio. It aspired to be objective. It also prompted scientists to ask questions about disorders in a very specific way. You could study problems like hyperactivity in kids, post-traumatic stress disorder in rape victims, or self-harm in adolescents—but, to maximize your chances of being funded, your study had to incorporate a measurable characteristic, such as a gene or neural circuit, that reflected an underlying biological process. In a 2013 TED talk, Insel, standing before mesmerizing brain scans and images of neurons, assured his audience that new knowledge based on this approach—he had previously called it “clinical neuroscience”—would soon sweep away two centuries of psychiatry.
Since then, this new paradigm has powerfully altered what psychiatric scientists look for—and what they look past. For example, researchers have discovered hundreds of genetic loci associated with schizophrenia and with major depression, and more than fifty for bipolar disorder and autism. Each time a new correlation is found, geneticists celebrate. But, as E. Fuller Torrey, an advocate for the severely mentally ill, told me, so much success has added up to failure. “They have identified a lot of risk genes, not any that cause a disease,” he said. “That’s very embarrassing to them.”
Insel left the N.I.M.H. in 2015, and later confessed that one of the reasons he did so was this same dispiriting realization. In a 2017 interview, he elaborated on his departure. “I spent thirteen years at N.I.M.H. really pushing on the neuroscience and genetics of mental disorders,” he said. “And when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness. I hold myself accountable for that.” When I spoke to Insel recently, he said, of RDoC, “I think it became an academic exercise. . . . You want to pick up measures that actually are of value to patients, families, and providers. And RDoC got way too complicated. It wasn’t really tied to clinical outcomes in a way that would matter.”
Meanwhile, a decade spent in search of so-called biomarkers crushed clinical investigators who had been trained to use descriptive DSM categories and who aimed their studies at symptom relief and therapeutic impact. By 2015, only around ten per cent of the N.I.M.H. budget was directed toward clinical research. Psychotherapy researchers, who had made much progress before RDoC, saw their funding dry up. Barbara Milrod, of Albert Einstein College of Medicine, told me, “I am angry, as a psychiatrist and as a clinical researcher, because we are doing nothing for our patients and losing generations of researchers and methods.”
Imagine a lighthouse keeper whose beam and horn guide ships in storms. Imagine that this operator, in an epiphany, realizes that all the difficulties he encounters come from water and air. He determines to study the chemistry of H2O and O2. This steward is no eccentric but rather a prestigious and powerful voice in his field; thanks to his financial largesse, many others follow his lead. They all stop worrying about their beacons and foghorns, and no longer bother with weather reports, tides, or distress signals from vessels. When called to task, they assure those whose loved ones have drowned that, though it might take fifty or a hundred years, the riddle of water and air will eventually be solved.
Sound ludicrous? But where were our psychiatric sentinels as opioids, alcoholism, and suicide ripped through the struggling towns of middle America? It took two economists, Anne Case and Angus Deaton, vacationing in Montana, to notice the early mortality of white males around them, and, in 2015, alert us to the shocking numbers of what they called “deaths of despair.” Why did the mental-health-research community fail to notice this? One reason, perhaps, is that there is no gene for social collapse.
The COVID pandemic, with its complex biopsychosocial effects, was a cataclysm that emerged from our environment, and its psychiatric consequences have only begun to be understood. Much of its impact, I fear, might simply be ignored, because many of our lookouts remain intently focussed on threats from the opposite end of the causal spectrum. While we concentrated on things like neural circuits, a viral menace attacked. The fear, helplessness, and isolation that it created roiled our communities and families, put great pressure on our emotional and psychic lives, and deeply affected our children. We need to pivot so as to better comprehend those realms, for the pandemic has thrown overly reductive assumptions about neuroscience into contradiction. Yes, malfunctioning brains can make us ill, but three years of death, uncertainty, and angst have demonstrated a homespun truth: the world can really mess you up.
The United States has the most funding for psychiatric research in the world, arguably the greatest array of professional talent, and significant private and public capacities. And yet the rising tide of mental illness after COVID will only highlight how our social contract with those patients has long been broken. The idea that shelter and humane care are human rights has dedicated advocates but little political power. In addition, although clinicians are armed with medications and therapies, they have long been pleading for new and better tools. Guidance about what this once-in-a-century pandemic might bring their way should come from our scientific and public-health leaders in Washington, but they are divided, with separate fiefdoms for psychiatric research, alcohol abuse, drug abuse, epidemiology, and the delivery of services. We suffer from systemic failures that seem to be no one’s responsibility.
A notable exception, Vivek Murthy, the Surgeon General, has called attention to the post-pandemic psychiatric crisis, citing burnout among frontline health workers, a spike in teen suicide, and an “epidemic of loneliness and isolation.” But who will take up his call? The National Institutes of Health has created the RECOVER initiative, which will support studies of the medical aftereffects of COVID, and Congress has allocated a small amount of money directly to the N.I.M.H. for COVID-targeted research. It’s not obvious what will happen when those funds run out.
To be clear, no one I spoke with advocated for calling off the Mars mission to understand the brain; exciting work is being done in optogenetics, in circuit dynamics, and in mapping the brain’s structural network (the “connectome”), to name just a few domains. It is critical that the U.S. invest in such basic research. Similarly, it would be unconscionable not to pursue solid, clinically relevant neuroscience. But there needs to be an adjustment. When I spoke to the present N.I.M.H. director, Joshua Gordon, he admitted that the introduction of RDoC had come at a cost. “It wasn’t communicated to the scientific community in a way that they understood. They took it as a kind of severing of the N.I.M.H. from diagnostic frameworks,” he said. “In my opinion, what should have been said was that it’s clear that there’s heterogeneity within our disorders, and there’s overlap across our disorders. The diagnostic labels are useful. But they have not proven tremendously useful in terms of uncovering biology.” Since Gordon’s appointment, in 2016, the N.I.M.H. has somewhat relaxed its focus on RDoC methodology. When I queried him about its value, he said, “Certainly I emphasize it less than my predecessor did.” Yet RDoC’s adoption reflected decades of at times quite strident belief that the causes of all “real” psychiatric illness could be captured by clinical neuroscience. These may not be commitments that can be easily undone.
Surrounded by this jarring disjunction between high-minded science, clinical urgency, and human suffering, I was reminded of my year as a medical intern, when a different terrifying infection was sweeping the country. On New Year’s Eve, 1987, I held a young man’s feverish hand as he fought to breathe. By then, scientists had isolated H.I.V., and the National Institute of Allergy and Infectious Diseases, led by Anthony Fauci, had begun research on a vaccine. Access to possible drugs was stalled, while gay men perished. A community rose up in protest. Fauci now recalls meetings that he had with ACT UP and one of its leaders, Larry Kramer, as critical to the realignment of his priorities. Thankfully so. If the government had bet the house on an H.I.V. vaccine, we would still be waiting. Instead, accelerated and liberalized clinical protocols, “short-term” fixes, and deeper collaboration saved countless lives.
Today, the COVID pandemic may be over, but our psychiatric crisis continues. It should serve as an alarm that shakes us out of our slumber and reframes our thinking. We need to balance our mental-health efforts to include funding more clinical trials, actively researching sociological and psychological determinants of mental health and illness, revitalizing and refining public-health efforts for early treatment and prevention, and looking for innovative ways both to care for the underserved and to provide humane asylum. Will we? Indifference, bureaucratic rigidity, and ideological opposition will likely resist such changes. Back in 1987, months before I sat up with my dying patient, ACT UP formed. What will it take this time, I wonder, to remake our future? ♦
Sourse: newyorker.com
