Giving the Devil His Due: Thoughts on Ramping Up the Fight against Brain Disease (Mental Illness)
In the span of two decades we went from the V-2 rocket to an orbiting satellite the size of a grapefruit to manned spaceflight. Our quest to cure mental illness has not moved nearly so quickly. My question is: Do we throw the same volume of resources at curing mental illness that we hurl at exploring our solar system? The cost/benefit analysis would tell us, “No.” And the speed of advance certainly has not been as swift. In fact, depression is the costliest disease on the planet in terms of treatment costs, lost productivity, and reduced lifespan. The battle against mental illness needs a bigger budget. According to the Information Technology and Innovation Foundation, the total economic burden of mental illness in the United States was $1 trillion in 2015. Meanwhile, $200 billion of that cost may be attributed to treatment. The Depression Center at the University of Michigan reports lost productivity costs employers nearly $50 billion annually as workers miss 27 work days on average. Two-thirds of these days are chalked up to employees being present at work but not fully engaged and productive. Globally, the World Health Organization calls depression the leading cause of disability and reports that only half of people suffering from depression worldwide get the treatment they need.
Studies have demonstrated that depression is a brain disease that affects parts of the brain that govern reasoning and emotions. (Kramer, 2005.) Sufferers are also more likely to experience depression and have less resilient brains with each episode. Small wonder so many of us have difficulty at work, seem emotionally blunted, and make poor decisions. But before we can wage war against this insidious affliction, we must call it what it is — a disease. Merriam-Webster defines disease as a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms. In most cases, mental illness is more than a disorder, or even a syndrome — a collection of symptoms. Autism and Alzheimer’s have attained disease status, but depression and bipolar disorder haven’t seemed to earn the same status.
Nevertheless, mental illness is as destructive as it is difficult to treat. Besides damaging brain tissue at a cellular level, depression simply makes it hard to live. Everything becomes foggy. Even little decisions become monumental obstacles. Simple tasks turn into enormous undertakings. Depression robs you of enjoyment of things that routinely give you pleasure — work, hobbies, and perhaps most painful of all, time spent with family and friends. And if you’re bipolar like I am, you also have manic episodes — periods of euphoria, sleeplessness, and compulsive behavior — that are accompanied by irritability, recklessness, and, sometimes, delusions or grandiosity. It’s a recipe for disaster; it seems fun at the time, but a guy can leave a lot of damage in his wake. So, it’s bad news and more bad news. It’s tough to explain things to your kids and your employer, the enjoyment is only fleeting, and the aftermath gives you plenty of self-defeating material to beat yourself up with when you eventually hit rock bottom.
Part of the reason it’s so hard to get people to think of mental illness as a disease is that society romanticizes it, pointing out the correlation between depression, bipolar disorder, and the artistic temperament, for example. I learned in college and graduate school that a good researcher, statistician, or economist never equates correlation with causation. It’s probably just as easy to find a correlation between mental illness and healthcare workers, coal miners, or bus drivers. Not exactly as romantic as being a painter or composer. This halo effect also fails to account for the devastating impact of an illness which knows no occupational boundaries. Most of the people who think it would have been a tragedy to have given van Gogh medication for mental illness have never suffered seemingly endless despondency, suicidal ideation, or paralyzing anxiety, let alone delusions or hallucinations. There is no empirical evidence that mental illness enhances creativity. There are only anecdotes to support the notion that suffering begets art. (Check out the article The Real Link Between Creativity and Mental Illness.) It is much more likely that the privations suffered by artists actually inhibit creativity and productivity. A writer who is manic might be prolific, but at the expense of producing much more than gibberish. In my experience as a manic or depressed writer, I have found that both creativity and productivity suffered in direct proportion to the severity of my symptoms. My best work has always been done in rare periods of lucidity and calm reflection, unrestricted by the weight of depression and free from the unruly terrors of full-blown mania. My mind is like a diesel engine, belching smoke and other pollutants — even with a pharmacological catalytic converter in place, environmental damage is being done. When my mood is properly regulated, it’s like converting the engine to a cleaner-burning fuel source, like compressed natural gas — all the performance without the unnatural effect on my surroundings.
I can’t help but wonder what the world would be like if van Gogh could have been properly treated or if Hemingway and Kurt Cobain hadn’t felt the need to resort to the gun. My soul cries out in selfish pity: “Another album! One more series of French countryside paintings! More Nick Adams stories and elegiac tales of war!” Like many authors, psychiatrist Peter D. Kramer went on a book tour after releasing Listening to Prozac in 1993. In a later book, Against Depression, Kramer reveals that the question audience members ask most often is: “What if drugs like Prozac® had been available to (insert name of genius here)? To his credit, Kramer, who advocates for the eradication of depression and its attendant symptoms, despises this question because the inquiring party is trying to bait the speaker into an argument about whether medication inhibits creativity and productivity. The support for this argument is sketchy, at best. Even Nancy Andreasen, one of the early proponents of the illness-begets-creativity rationale, has backed off.
Even if I were to cede the argument — which is delicately supported by anecdotes and pseudo-science that have evolved to conventional wisdom — I accept neither the posthumous fame of van Gogh or the contemporary deification of Hemingway in exchange for the wrecked relationships, flirtations with death, hidden demons, squandered fortunes, and unrealized potential that come with severe and persistent mental illness. If we accept the disease status of mental illness — and I believe the evidence, at minimum, points in that direction — then we must treat it like a disease with terrible primary and secondary consequences. Anything less is, as one author described misguided faith, like flying over a tornado-ravaged town and expecting the wreckage to spell out a cure for cancer. Sometimes, there is no upside. So why let mental illness off the hook? Does anyone really believe that autistic savants become piano virtuosos or mathematical prodigies because they are autistic? Did near-terminal cancer make Lance Armstrong a seven-time Tour de France winner? No and no.
Sometimes, in the case of talented people with autism, the best explanation is that they are extraordinary people who happen to have a disease that, in some cases, makes it difficult or impossible to carry out the simplest of tasks. In Armstrong’s case, (he was beating older, more experienced athletes in road races and triathlons when he was a teenager) the almost inhuman performance seems to have been a product of amazing ability, willpower, perseverance, and performance-enhancing drugs. Whatever the case, whatever the disease, it is ludicrous and irresponsible to assign it virtues. You don’t cure disease like cancer with happy thoughts. Neither can thinking, alone, stop the advance (yes, it is a progressive disease) of depression. Deadly diseases like cancer and depression require multi-faceted interventions: pharmaceutical, lifestyle, cognitive, spiritual, and even surgical or mechanical.
If we’re going to wipe out the pestilence of mental illness, we must come at it firing from all barrels. Still, I believe pharmacology should remain the primary weapon. And we can, and should, do better in this area of the arsenal. It seems to me that corporate researchers churn out passable medications with little regard for side effects. Meanwhile, drug kingpins consistently develop new products that deliver the desired result every time. Maybe the Big Pharma guys should take a page from the drug dealer handbook on marketing and customer service: Give the people what they want and they will buy it. Sell a junkie poor quality meth and world will spread quickly and profits will dry up just as fast. So why do mental health consumers have to accept medication interventions that are just o.k.? One reason might be that healthcare providers, advocacy groups, and consumers themselves are not doing enough of the right things well to accelerate forward momentum.
We are all complicit in this atrocity, and no one seems to be rattling sabers at the root causes. We kind of keep doing the same things, hoping they’ll work. Much of the treatment regimen is based on clients self-reporting, rather than objective exploratory scans of the affected region, i.e. the brain. We need earlier identification, at the genetic level, of propensity toward these lethal maladies. We need novel pharmaceutical and surgical interventions that focus on eliminating symptoms, rather than merely lowering their acuteness. This, I believe, is a matter of life and death for millions. Drug companies should be required, by law, to fund mental health research that focuses not only on medications but also on companion therapies. This would include mainstreaming — when appropriate — treatments that are in the experimental phase more quickly. Things like stem cell therapy, genomic and gene therapy, neuronal intervention, and grafting of brain tissue. Also, we can’t rely purely on benevolent scholars and practitioners to develop the next cognitive therapy or dialectical behavior therapy. We should also mandate that drug companies allocate research and development dollars to creating effective drugs for mental illness in direct proportion to the prevalence of those disorders.
We must also fully leverage the power of information sharing, employing big data and greater connectivity across learning, teaching, research, and experiential platforms. We also need more larger and more complex longitudinal studies of suffers and control groups to better inform the discovery of potential solutions. And while we’re at it, let’s drop the whole mental health parity farce and go to an insurance model that provides subscribers the care they need for the illnesses from which they suffer. This requires total buy-in from the medical community, including general practitioners, who need to refer patients to psychiatrists and stop dabbling in the specialty themselves. They refer patients to eye doctors and orthopedists all the time. Let’s get mental illness back in that category of care.
All of this, and more, could reside under a mental illness recovery initiative, or MIRI, which could also serve as the clearinghouse for all the historic and contemporary data and findings, and put forth a punch list of to-dos to divide and conquer the complex problem with a coordinated effort. A governing board would split the workload among universities, government, associations, corporations, and individuals, based on priority of need and strengths.
Government could play a much stronger positive role. So far, they have really let sufferers down by neglecting mental health. Nowadays, inpatient treatment seems to be a race to see how fast the patient can be discharged at the expense of beneficial medication adjustments and therapy under close supervision. The trend over two decades and eight hospitalizations in my case has been shorter stays and more abbreviated outpatient programming. The government must step in and force insurance companies to do the right the right thing and follow the recommendation of the treatment team, even it means longer hospital stays. Otherwise, treatment becomes a disruptive revolving door. Mental illness is a disease of the bran and when disease symptoms are sever, extended hospital stays may be appropriate. Anything else amounts to denial of treatment that could save a life and they wouldn’t do that to a cancer patient. Would they?
While I do believe incentives exist for insurance companies to keep the true nature of mental illness nebulous and for Big Pharma to defer a cure in the interest of profits from incremental solutions, I don’t think there is a problem with the public’s level of compassion. In fact, there is a rich mix of empathy and admiration not unlike the one that exists for other diseases. Nor is the root problem stigma. It is the confusion and foot-dragging about calling mental illness a disease. I’ve said it before, but it bears repeating: We can’t eliminate it until we properly define it.
And before we can truly broadcast the disease message to the world we must gain agreement within our own community of mental health consumers and providers. We must elevate the conversation from sound bites and slogans to a powerful blend of science and emotion. I think this is what makes breast cancer such an endearing and enduring cause, for three reasons: 1.) It’s a disease and is accepted as such; 2.) Real progress (read: curing people) has been made in a relatively short time, and 3.) People identify with the disease and its victims through stories and their own personal experiences. It’s clearly a recipe for success. The Susan G. Komen Foundation raised just $200 million last year, yet breast cancer victims can now expect an 83-percent 10-year survival rate. Adding contributions from the National Institutes of Health and the National Cancer Institute, the total input comes to $1.5 billion.
The National Institutes for Mental Health has an annual budget of $1.5 billion, yet 41,000 people who suffer mental illness commit suicide every year, and brain diseases are the cause of 350,000 annual premature deaths from companion illnesses, knocking 10 years off their life expectancy. Same expenditures, different outcomes. This doesn’t even address the issue of quality of life, which can be horrible for people suffering from mental illness. Despite our best defenses and even with near-100-percent compliance, these brain diseases still manifest themselves in life-altering and dangerous symptoms.
I believe we can do better than the status quo. The efficacy of cognitive therapy has fallen steadily since its introduction in 1977. (Johnsen and Fribort, 2015.) Too many resources are at risk. And many of us who fully utilize available resources continue to suffer. The fact is, we need new tools and methods to defeat these insidious diseases once and for all. We now know that those “wonder drugs” that help increase the presence of serotonin in the brain aren’t the answer. But there is an answer. To win the battle requires a concerted effort and placing brain disease on an equal footing with other morbid conditions. Then we can get about the business of replacing stopgaps with cures.