The Future of Psychiatry

00:00:11 are you ready I'm an associate director of the center before I introduce the participants of today's roundtable I have two brief announcements one is that the next program on the beauty and unity of mathematics is on December 1 and then on December 15 it's a program on animal consciousness and then other programs

00:00:43 you will see if you go to the website I will make a very brief introduction of the participants today if want more information on them you go to our website there's a detailed bio - Michael first who is sitting right there this professor professor of clinical psychiatry at Columbia University Laura Hirsch mine is professor of psychiatry

00:01:14 at University of Michigan Frances Lee is the chair of the department of psychiatry of Cornell Medical Cornell Medicine Robert Michaels is the watchman McDermott University professor of medicine and psychiatry at Weill Cornell and my close thought is the Walsh vector is the neuroscientist professor of pharmacology at Weill Cornell so as you know the format is a spontaneous conversation amongst the participants thank you

00:02:12 well we were just talking a minute ago before everybody started about the fact that I'm a historian and I'm uh you know the only woman and the only non New Yorker so I guess a perspective but we were talking about wondering whether the history should start first apart looking to the future but the problem with starting in the past is if you're imagining a narrative do we want that you the way people tend to use history is to tell the story about the president are we are we talking about the past as the the battle days that are leading to

00:02:43 the future with new discoveries new new advances new neuroscience new whatever are we going to use the past to tell a story of decline that we've lost track of the things that we used to do that we used to do well and now we're back we're in soulless territory of just symptom counting with due appreciation to DSM so you know you can use the use the history to to to tell the story of decline the story of progress or as I tend to see it the story of things that continue the

00:03:15 themes that come up over and over and over and over and over again the the the things that we keep that we discover and rediscover we discover brains we discover sometimes we discover statistics I'm reading a great book on the history of statistics now that points out that we were doing the we psychiatrists were doing statistical counting in the 17th century and so the idea of counting and looking at numbers is not new we humans like to do that

00:03:46 first step is trying to understand things put some put some order and things hopefully patterns will emerge it'll have understandings and that's been going on for a very long time and that continues to be used to be the main everybody wonders and it PSM diagnostic Statistical Manual was the statistical part and that was because it originally was used for collecting statistics in mental hospitals and nowadays I guess the Kerr argue the coding allows people to

00:04:16 collect statistics that's it's really a they only reason they keep the assets for historical reasons it's a well-known document that's really not statistical anymore but you raise the idea of starting out by I mean the DSM unfortunately remains a descriptive observational system with almost no depth to it at all and people have criticized it for that reason which is certainly a valid criticism but it remains useful because there's no alternate always the thing when somebody it trashes the DSM less whoa okay so what do you want to replace it with it usually you don't get much response so

00:04:48 it's incredibly limited but it continues despite all of the advances in neuroscience and and everything else a good thing used to have value it's that organizing principle it's looking everything from the basic science point you will have to it just a disclaimer

00:05:19 but I remember that one of the attraction was this field is that if new genes came out and everybody believed that after a while I will be able to explain some of the symptoms and maybe actually we can define a certain disease based on diseases disease genes and historically now we know that it's actually absurd another case if anything is even more complicated so have been struggling with this in my lab and in

00:05:51 the university that how actually to solve that problem and we can discuss it later but but obviously we have to move out from the single gene and even multiple gene because we have to understand how the environment is really thinking on this whole gene that for if you have time maybe discuss about this I say still the genome is a puppet and the genome can or epigenome rather can explain a lot of things so historically I think they really moved a lot from our genes and now we have the

00:06:23 epigenome and hopefully we will have some chance to be a little bit deeper into this how because that still yes we are a very simple equation we have an epi genome now but like in the seven 1890s that we have a lot of things but we don't understand how they work together how interact but I think it's a little bit more verification now we have all players so it's almost that you need another level of understanding and it's

00:07:05 muffled here - this is better is it or you're not actually much closer to understanding the pathophysiology like yeah disorder response the hundreds of genes that have now been found the best example like that was at this meeting was to study the success story now the best success story in psychiatry is autism 99 genes will now have met Craig

00:07:38 genome-wide significant early very penetrant high in exercises they account with 1% or less than 1% of all autism in in this population and but is it is each of these papers is a major paper this is considered the best advance of that we can do weight and it's absolutely not there how to move forward and I think this is something that I struggled also this is it's just that that the hope as my closest friend worse than 20 years

00:08:11 ago just like in pulmonology ornithology you just get a bunch of genes and then be able to pull cancer and then be able to move forward and what's clear is this is not a link young cow that they're the the brain is probably more complicated there's some number like 550,000 or 150 trillion synapses yeah this is us for us to people who think that single chain or

00:08:42 100 genes could help explaining it was a very sobering meeting event but if I may just to the fact that so basically I think it's the finish is like 50 years ago in the Facebook force or Amazon started so basically the idea if you think about it is that you get all of this information they collect information personal information and 15 years ago they just started now they have a tremendous amount of information

00:09:14 and naturally form each of us now they have average but they can actually figure out what next your next move is and maybe send you an advertisement and we've all said that sell you some pet food or something because you know that you have a pet at home so there and more complex so I was thinking maybe that kind of strategy because we have now genes epigenomes and a lot of that long sides right we have thousands of this so how to put together all of individual players as they would pull out the

00:09:45 society to a comprehensive understanding and how the society works and how the brain works but I was just thinking that other day about this but it's still probably is not the right template because it's a very to dimension of what they do they just collect that they can interpret what our problem is that we have multi-dimensional we have genes and their synapses connectivity then we have circuitry functions and then behaviour behavior which is very elusive right but most people work with that level so I think

00:10:18 it has to be something where you could integrate data sets like the you had the face looking down face but yeah sense but you would be able to actually in a 3d almost fashion to integrate all of this information to a comprehensive understanding of the brain I have no idea what basic I'm talking about you but I'm just basically saying that it's just something which you'll be the next most of time this research you don't really know what is the next big step but if something has to be way beyond of

00:10:50 this to dementia understanding what we have now and probably nobody knows this is just somebody will come up so that's why I think it's a good idea to to invest NIH and I am each puts a lot of money in these things they have competition people now artificial intelligence intelligence comes in so maybe something is coming out and but we don't know what it is and unfortunately they're not able to to answer the future of Psychiatry I'm afraid but we just have to put money and then waiting 14

00:11:21 Internet as in the concept to coming out from this and I don't see yet for the major conditions let's say is the or the studies focused on finding out what causes the condition or are the studies also focused on dissecting it into the

00:11:52 symptoms and trying to figure out what causes it's simpler at this point the main the least from what I can get the main thrust where the money is going he's collecting as many samples to get hundreds of thousands of samples of biologics in person meaning DNA and other and to try to do large statistical analysis essentially genome-wide Association and and they've succeeded in finding now

00:12:24 over 200 schizophrenia genes accounting again for low percentage the risk a 25% of the risks with the finish they just completed in England of study where they took 100,000 people with depression and they were able to point 50 genes that look what they might be affected 15 5-0 but we can't wallow effect sizes for each of these but essentially this is worth the effort our took again it's

00:12:56 sort of this is sort of like counting it's sort of like they just want to accumulate as many potential genes that might be a risks gene at this point and these are still early days that's it but 20 years ago there was there were none so if you divide by zero this is infinitely better well if you say 50 genes are responsible for the depression then what but they account for so little of the risk so it's sort of like it's a small effect size that there is a the

00:13:29 best there's an example is they one of the genes is a glutamate receptor which makes some what sense do to make receptors are everywhere not so but the problem this one you made yourself do they found is is that it's everywhere so how you're going to actually target and drawing them into or something like that it's going to be very difficult drug companies have been targeting this class of receptors already so in many ways this then we're sort of stuck then with

00:14:00 then again the complexity of the nervous system and the brain and then even though we have a one hit that makes some sense it's still very hard to report you know it's interesting thinking about all of this data because again this brings me back to this book I'm reading on the history of statistics and statistics in psychiatry in particular where they were drowning in data in the nineteenth century you know one of the one of Helens from arguments was that he was spending all of his time with data he had so much data and he didn't know what to do with

00:14:30 it and obviously we have a better capacity for managing data but the thing that came after all of his data in the in the early 20th century was Freud and psychoanalysis to said okay we're not going to talk about these big groups we're gonna talk about one person and we're going to talk about how what makes up this one person and how this one person's inner conflicts manifested in these symptoms or these experiences and so I'm wondering if the future may be if somebody gets to the point where we have all this data and it and it's

00:15:00 it's little pixels and it's everywhere and it doesn't cohere to a particular picture that we're gonna have another wave of people saying no actually what we need are individuals individual relationships you know where we are we're all we're spending all of our time bumping into people as we're looking on our on our phones not engaging with people are we gonna have a backlash where maybe psychiatrists will lead maybe we'll follow to say no actually what we need to do is work on interpersonal interactions and that one patient again and and go back in a different way I don't know if we stop

00:15:32 doing that now according to some of our patients we have but I think it's really not exclusive and and they absolutely did you have to do both we do certainly not they are but in a clinic so you do certainly the individual but they our goal is really to understand the basic framework of a disease rather than an individual and maybe how an individual can end up with a disease phenotype from

00:16:04 this overall concept and you are more interested in obviously why this person got there but it I think it's just the two sides of the the same story and we just have to do both there's an interesting sort of like similar backlash going right now in this other field of systems neuroscience where people thought that you just need your image more people and as they're going through various tasks or even whether they're sitting just to look at their connect their brain connectome just as a bring everyone up to speed 20 years ago

00:16:35 it was found that that the brain actually organized itself into sort of like hubs within there in the brain and you can actually just get a what they call a resting state without any task you can actually get a scan and actually see these hubs in the brain and this is work of Mark Oracle at Washington University and people were fascinated by this and no one has really been able to sort of understand how is it that you can measure blood flow in the brain and actually see these self-organized networks and and so then

00:17:09 everyone got excited and just kept on collecting thousands and thousands of scans so now we have hundreds of thousands of scans within the studies now at Wash U where Marcus was is there they now decided that everyone's network is individualized everyone's brain is that when you average it you get some average of Brandon looks like no brain on the planet Earth so now what they're doing is that they're they're actually taking individuals and actually just scanning

00:17:40 them over and over again for example during the course of depression or during something so they can scan them at the height of symptom pathology and then at some other point whether or not so I think this is the goal now that you might want to basically go back to India and then learn something from these individuals in a way that had not been thought of before I think there's been some drug studies on that that this n of one studies where you you take a single person as the study it's a and and how

00:18:12 the how they interact with medication and that's sort of this new thing that's being because there's so many individual differences it's essentially this is that you can't that the principles that even have tried to put together a brain connectome is very difficult even though NIH is spending lots of money on these connectome projects that ultimately you it might actually just sort of like you sort of like if you want to understand fruit don't you don't blend it together I believe that responses a little bit simpler because then you ask the

00:18:42 question why this drug is actually working in one individual actually understand the the pharmacology of that based on an enzyme which is either stronger or weaker in certain individuals record sick enzymes but basically they just metabolize the drug many times this is crucial so and we can even now a patient can be screened because it's genetically based one can take a sample from blood then it's every cell is the same and we can basically figure out that is a fast metabolizer a

00:19:15 slow metabolizer and maybe that's the reason somebody is actually side effects or another person does not respond that it's just a dose relationship so that that may be somewhat easier to understand then what the underlying cause which could be thousands of different ways but i still believe that itself still has something common feature or features that it is a circuitry I kind of start to believe in circuitry no-nobody's but maybe it's

00:19:46 just appeals it's fashionable but but circuitry in anymore models at least you can understand how the secretary can be linked to a set of behavior we can model in a circuits it can activate we can deactivate certain variable even become we can we can tailor because celerity mission in certain areas of pain had become began to response but of course after below and underneath there's a lot of genes and synapse and other things

00:20:17 you just don't understand I'm gonna go back to where we started and be a little provocative to me psychiatry is defined like all medical specialties as everything that's relevant to helping people with a certain kind of problem and the neuroscience research base that we've been talking about is fascinating

00:20:47 exciting intriguing and essentially totally irrelevant to helping any living patient it may have some hope for the future although a possible outcome of the work is that this strategy will lead to anything helpful for patients or maybe to some modest modest twists some of our current drugs almost all of our current biologic treatments were

00:21:20 discovered by happenstance not by scientific research they're serendipitous if we never spent the penny on any neuroscience basic research over the last hundred years it would make trivial difference to current psychiatric patients but we didn't know that I mean obviously clearly that's a problem I mean the thought was that we were going to crack the problem by going there a science but as our historian warned us we have to study the past we

00:21:54 won't repeat there was a money wait it was wasted in the sense that didn't give us what we wanted but I'm a second - nothing yes it was a a very intelligent gamble that lost so short-term of us we don't know about the funeral I just want that for background because when we talk about the excitement of contemporary neuroscience research we're talking about possible hopes for a fairly distant future we're

00:22:25 not talking about anyone who's mentally ill today or anything that might help that person but what one of the side effects of the neuroscience thing is I believe it's been partly responsible for lowering the stigma of mental disorders it's unfortunate because somehow if it's in the brain therefore people shouldn't be sick but if it's it the fact that it has helped stigma in a way it's sad that it took something like this but I think it has people having a brain disease the calling schizophrenia brain disease I mean all over and calling

00:22:56 substance-abuse a brain if you believe it's a brain disease but people call it a brain disease partly to try to reduce the stigma so this angle to split this besides the fact we're trying to look for answers is actually I think kind of an improvement with respect to the place of psychiatry in medicine and also the place of patients with mental disorders within the myths of medical that's the rhetoric of neuroscience yes that findings no but that's that's a part of the ban all this money was well if it if it achieves nothing but that then it

00:23:26 would have been well spent as - one thing the profit outside of that though is that there are patients expectations of do for them or - I you know that they they sit there and wait for us to fix their brain disease well they don't want to put any have too much serotonin I read about that we can't give me a drug to reduce that and then I'll feel better right right and so the expectations are very high our drug sir okay we are therapies are good but people have to put effort into it really outside the neuroses for example

00:23:58 if infectious diseases going back hundreds of years and then figure people figured out that if it's a cleaner environment probably can avoid something we didn't know my troop our microbiota or Martin microorganisms but I think eventually when this boxer discovered cloned the gene structure and understood then we know the target we can design antibiotics more precisely not just by by luck like not unassuming was certain a lot but now everything is designed or

00:24:28 age would have not been treated in the vein unless you know maybe had the virus near the structure we have the genome and actually the trucks it should have eloped at targeting a particular gene so I think we are just a few hundred years maybe behind psychiatry but basically he story tells me that yes this is the typical curve there accidental and then fortress findings and we use it because that's the only way we have maybe they

00:24:58 are not even useful to develop further drugs like in a serotonin blocker so that we couldn't go further beyond that so we need some other information to build another way and we are just not there yet but I think we have a just patient and I don't know it will be see that deterrent but but it just have to be this is the normal course I think there is to than medicine first of all I always say I agree with you Bob and I think

00:25:31 it's sort of sort of reflective effective but that the quenelle residents are Carrington residents really have to know nothing about the brain in order to be an outstanding resting that that the training itself does not require us to eat you know the mechanism of action of paying the drugs that they're giving because we actually don't know for example even how they feel maybe it's all I could teach them you don't medical school and she's not taken very seriously but well you say the way forward is if if instead of putting our X percent GDP into

00:26:04 neuroscience research how do you how do you construct moving the field of psychology which as I said is to help these people that are better leaving very difficult lives and of Laura's proportionately for example in prison anyway and how can we help these this that psychiatrists are an impossibly difficult and very important question and I'll translate it pragmatically how should the nation devote its resources

00:26:35 for toward the issues of mental illness and we're doing it wrong we're spending too much money in tertiary care for people with serious mental illnesses not enough money in preventive medicine even where we know certain things that would make a difference in would work we certainly would do much more for the next X years fifty hundred of the

00:27:06 populations psychiatric problems if we put more money into early child development mentoring experiences and a facility then [Music] Church that in tertiary care strategies for the persistent and chronic mentally ill that are biological agents we know

00:27:37 that the pattern of drug use in this country has more to do with physicians needing to placate dissatisfied and angry patients rather than with knowledge about the impact of the drugs of their behavior or their brain but we know that the skilful physicians know they can reduce the patient's dissatisfaction with the treatment by writing in description and the more

00:28:08 expensive the medicine but it's very hard to revise the system so the goal is total public health rather than satisfying individual consumers and a current health delivery system as as it's a comfortable satisfying and source

00:28:40 rather than the health of the nation that's a public health disaster to support it politically that's not really psychiatry but it has a lot more to do with mental health in the next hundred years the neurosciences the only thing I would say that is we've already put an X number of billions or a million hundreds of millions of dollars in these sort of early intervention studies

00:29:11 public health government such as head start and if I'm not yet seen any data that is it's just that we have not put enough is it it's it's not clear to me that we make removing the needles even with the programs we have now or is it that that the needle is just so hard to move well I'm not sure it starts the answer Francis but for example you know that this lady I'm sure better than I do that the children of depressed mothers who are depressed during pregnancy

00:29:46 little helpers we know how to treat depression better than most things we wanted including depressed pregnant women and depressed women postpartum but we don't deliver that treatment effectively to lots of populations we would have warm public health mental health benefit by organizing the warm intervention to assure the mental health of pregnant and postpartum women then

00:30:22 they're almost anything else we get for our inventory I'm just I think the neuroscience is fascinating I believe we should invest in it but I think that there's a there's a an image problem I think we sell it with the implication that is going to make a difference of soon and I don't think that's true on the other hand if we tell the truth

00:30:52 we're gonna lose resources so people act irrationally the way you get a largest grant and the greatest congressional appropriation is to suggest not that the connectomes are fascinating but they may lead to a cure for Alzheimer's disease possibly Thursday you can't imagine anyone not using that strategy because we do have data that

00:31:24 that strategy works well the trade-off there is is that there's a fixed amount of money available for research and we've seen in NIH the amount of research that's gone into treatment development if all got shunted over into this neuroscience thing so if we had unlimited money when we go I can just sum neuroscience and we can do this but it doesn't work that way so part of the we are we are somebody's getting the money with certain portions of psychiatry and neuroscience or getting the money but the patients I think the

00:31:54 treatment research is really dried up on me it's a lot of is that going to form a suit depending on pharmaceutical companies and they have unfortunately their motives are always aligned with ours so it's a real problem but you're ready that this is the way you sell money from the government but by diluting the government into these promises we get don't get good results for the research and we're really depriving use of the money elsewhere again I don't know what the solution is but I think that's a problem with the success of

00:32:26 getting money for Neuroscience but isn't the hope that the research is going to give you the tools oh no that's right but I think it's proper supply that's not happening that's that's not happening I mean Bob said it's not happening soon but what does that mean it's not happening tomorrow it's not happening in 20 years we don't as what the one thing that's been very clear is everybody said the more we study it the more difficult it gets and that's the you know years ago this neuroscience

00:32:56 thing Co all we had to do is see a sequence of genome all we have to do is this all we have to do is that and every time we do that we're just waiting for that one there's not a single biological tested psychiatry for diagnosis and we you know one thing I remember when I was working without on Francis of the dsm-4 we wrote this guidebook and we put a set to the guidebook it was in the Alzheimer's section and we were saying that we're very confident in the next five years by the time this book is out there's going to be a biological test for Alzheimer's and boy was that all right still off heroin 30 25 years later

00:33:27 and we're still you you speak to the outside people there's over another five year over years to get that right but there's this elusiveness they're actually turning these into now it's not clear what you do about that you don't want to say well let's just give up and stop doing it but there is this problem with putting money in a direction that has proven to be very very complicated at what point again if we have a minimum money item well keep pursuing that but it's coming at the cost of resources being spent on research for better delivery of treatment you just eventually the thing about the delivery

00:33:57 of the treatment you know how to treat depression in pregnant women but there's a delivery properly putting or money it's a fee on how to solve those problems would probably get better short-term results but those are much harder to sell this let's spend money on delivery of care when I was in medical school in a pathology lab one of the professors would walk around the lab while we were looking at microscopes of cancer cells cancer tissue while you were smoking so we medical students told him you know

00:34:32 you are preferred pathology we were looking at cancer there's a connection between lung cancer and smoking why are you smoking he said cancer is cured in ten years I'm talking about the 60s so but that doesn't mean that the research in cancer has not borne a lot of fruit so that today with immune therapy targeted therapy and so on we are so much further than when I was a medical student so why wouldn't the same thing happen in your

00:35:03 and the parallels there for us right but it's gonna be cured ten years the hubs all over medicine they've actually made a lot more progress like the precision medicine is a good example that entire field and all of you know when you apply that to psychiatry we are so far away whatever precision minutes that's discussed it's always cancer I mean that is has been the area of medicine with my district you argue infectious diseases always be precision medicine but cancer is a great example and they have made I mean you could argue that all that amount money spent on cancer which has been by way historically much much more

00:35:34 orders of magnitude more than was spent in mental health but you're right that's finally beginning to pay off a part of it I think however complicated the cancer story is it is more tractable and then I think the psychiatry story because the of all the insistence is it's as so much more complex to the brain then I think it knew always assuming cancer thing would be that hard because it looks like it should be simple and that's turned out to be extremely complex oh yeah there's a parallel there it looks doable than we see it's not and you put a lot of money in it and finally we're getting some result so that would be the argument

00:36:05 let's just do it in our field and the same thing will happen and it's possible but I think the only downside of that is there's a limited pie of money and what's not being smelling by pursuing this goal and what you're saying probably means that we will probably have to spend as much money as we do in cancer which is probably ten times as much as is being spent on all brain disorders so it's not surprising we've not met a needle at this point this is in fact and that it took cancer

00:36:37 may be a better analogy to think that we're about 30 years behind cancer that might be the best way think about it at this point you know and that but that in order to get to where cancer is we're gonna have to put more money in and I would not to be as provocative as Bob but I would actually say that the money that was spent on sort of fundamental neuroscience or fundamental biology is probably the best money spent because we really don't know

00:37:07 the brain that well we think we do if you think about how why we move so quickly in terms of of tackling HIV to a sort of a chronic disease is because of the fundamental biology of understanding how viruses replication is not necessarily just linked to side carry but yeah talk about neurology basically this money first of all is not a big

00:37:37 amount from the basic science perspective to be honest compared to the cancer it's like general peanuts but but basically so this money is really not only understanding disease but also understanding how the brain functions which has different implications in the computer science or societal problems or behavioral things which is nothing to do with an exact disease necessarily but still how we interact with each other social behavior Wars and peace and a lot of implications so I think in fact a

00:38:12 roughly small portion of the somewhat basic Mercer much they spent on differently disease related and it's not a lot of money unfortunately and then it allows competition for this money that's I totally understand that not enough I do feel that I think is not whether you put left or I demolish just has to be conceptually different thinking in the governmental are all orders or the city level so it's just a thinking but what if there's not enough money going there I totally agree but

00:38:43 it's not a problem that social are the basic sense budget because it has to fight for it no question I pretty much agree with what's been said I would hear something and and suggest a possible inference what is it I'm a strong advocate of basic research neuroscience is basic research like molecular biology or genetics the the yield of that is greater than any other research we do but it has willfully little to do with

00:39:15 psychiatry that's all I'm not arguing it's not interesting that relevant not helpful not practical it just isn't particularly related to psychiatry its major relationship to psychiatry is the rhetoric of social funding you can't get somebody who's in control of a foundation to give you a hundred million dollars for connectome study but you can for L Center study and therefore it requires someone who knows

00:39:46 how to write the paragraph that starts with the statistics about Alzheimer's and ends with something and ends with something about connectomes the other thing is that there is a sort of public image which makes perfect sense that we have these huge problems we have heart

00:40:17 disease we have cancer we have mental illness and neurologic diseases but it doesn't work that way from a biology point of view the brain is more complicated than the rest of the body put together the brain diseases are most challenging in terms of their understanding and treatment than all the other diseases we ever think of or treat doesn't help me we have basic scientists

00:40:47 in the nose I want help about 40% of all the genes go to the brain how much does it best probably 60 60 percent now that's a measure of something or other but how they how they express that's the question of course but is the magnitude is relevant in that we're dealing with what the mayor thought was half of his problem and we know that anyone who ever went to medical school knows that you

00:41:19 can slice all the other organs of the most biomedical research when I was a involved in laboratory work started by slicing an organ and putting it in a Waring blender but you can't do that with the brain work that way so the fact that the brain is more than everything else in terms of the complexity of its problem is an important proviso so certainly we need more basic research

00:41:51 psychiatry deals with very difficult problems and I think Francis is optimistic what he says 30 years that we're about 30 years behind you said that did you Francis and I meant 30 years maybe where you got the number I think we have to recognize that there's a order of magnitude difference in the problems we face when we talk about the future of

00:42:24 cardiology or oncology or orthopedic server ophthalmology on the one hand and the future of psychiatry on the other but one of the startling things we're going to face in the future Gayatri is that most of the people we'll be treating 50 years from now we don't think of as being patients now because we haven't conceptualized how we can make a difference in their lives but the history of the last 50 years in psychiatry as we move from its two major

00:42:56 diseases schizophrenia and bipolar disease to recognize the huge pools of people out there who have personality disorders who have addictions with problems and living that were never thought of as medical or psychiatric but can be helped by interventions even at the food level were it now I don't think we're gonna see that growth of patients with cancer or heart disease or any other disease category but we are with mental health diseases but if I if I can

00:43:29 just go back to this cancer example I remember because Memorial can sloan-kettering is just next door and we have a lot of collaborations so they they were stuck with cancer like 2025 years ago they have been developing new drugs which are little bit different than the previous one they certainly got a little increase but it's not tremendous movement and then suddenly there was a paradigm shift with this Indian therapy which was mentioned and nobody knew that is coming nobody it just came out from the dark and then

00:44:01 obviously people have been working on it but suddenly there was a critical mass of clinical finding the best of critical findings which were translatable to humans in the mouse one could do that where before but it had to be developed the technology where you could actually use it in humans and humans will tolerate this and I think in cancer research will tell you that they are that was a paradigm shift because now the only person but the the cure rate is incredible it's very expensive but I think it's just you never know when it happens it can happen in in

00:44:33 and the gamin in 50 years so but I'm just waiting for such a paradigm shift which we don't really know as they didn't know that it's super now because they are trying different things from bone marrow transplantation to different things but this for some reason became practical feasible in humans and actually this is but was it because of I don't know it so well but is it because there was some basic we made in immunology that means this happened I am not

00:45:03 familiar I'm just hearing from them that it was just suddenly change lamps would switch to this kind of strategy they're far better and now that these people who have been not is not not responder still suddenly a different route basic mutated or not no chance they just come back I'm it is a miracle yeah so this is what people need in psychiatry then somebody would be treatment treatment to destroy schizophrenic switches are really serious or or suicidal and then suddenly

00:45:33 you have a treatment which it we just cannot even comprehend that today we should also don't believe that sorry we should all study constraints for example what the reason why they made the part of the reason why they made the progress in knowledge and so on is the ability to study cancer cells now it's not that easy to study schizophrenia cells so cancer allowed you to study

00:46:04 things in a completely different way from different angles and you now the treatment comes in from different well the lack of an animal model for schizophrenia I mean animal models for cancer if always been around exactly I mean there wasn't a that could be a breakthrough of some really amazing animal model for some of these illnesses came up that could be open the door for for a lot I would say though that I think it might have been basic understanding of immunology because that actually also

00:46:35 now we have drugs for MS met multiple sclerosis that we didn't have and they're also in the immuno therapy realm also where they target the t-cells so it turns out even if even neurologists got lucky that it turns out that these advances that the drugs that they were making to basically make t-cells quiescent or actually very effective for MS which would and even and they didn't so I think this will in is still a chronic disorder which was there but they had nothing decade ago the fact

00:47:05 that they have four to three to four new drugs in the pipeline it's still quite impressive so I think we're waiting for that moment also so in terms of research where is the research in slightly in terms of those major illnesses I mentioned here where is that research Pakistan I think the genetics so I would say most of the money right now is in in genetics connectome these are the big like the brain initiative is essentially

00:47:37 neural imaging and then there's let's continue lot of money go sort o epigenetic which is my epigenetic model but epigenetics I think just to mentor mentioned four of them is that basically but most people realize that genes do not solve the problem and we know that environment cannot work through geez so the concept came in that environment will actually produce some change in the DNA structure or the DNA function without changing a base pair so the

00:48:07 sequence is the same but our secondary modifications but if you view it from a functional perspective it doesn't really matter whether you have a mutation and it alters a gene function or you have a be called chromatin which is the larger assemble of DNA and in surrounding forests you can have a same functional change as a result of so what we many people I know because it's pretty competitive know what is to write around but basically the quarantine is

00:48:38 that you propose that environment whether this is early childhood adversity that or maybe is a during pregnancy maybe the mother is deeply depressed but there is something memory built-in to the child or a fetal DNA which is again now the change of the sequence but it's a permanent so the child will work with born with us it's a regulatory problem like a mutation would be and it ended up with a little bit different function at the gene level

00:49:09 which is translated to a circuit level and then function level want they the chart is adolescence typically when their body's connection is made so I think that's what a lot of money comes into this which is a fundamental secure good concept and very new because we don't really know this we call this areas and bounded sensitive areas may be organ you know we can call the marks or whatever you want to call but we don't really understand those but even outside of neuroscience epigenetics is also

00:49:39 cancer cancer it's actually cancer is a more developed face again so we learn a lot from cancers but some of the cancer finds cannot be translated because the genius which are regulated are totally different in cancer you would have that how fast these are proliferate or divide grow and in a sense more important how maybe a synaptic function is retailored so it's a little bit different and it's just a several order of many to do more complex that's the problem a complexity but you point it out which means that it

00:50:12 takes more time but just to sort of simplify your work may close but what you've found in your own lab is that that that this the level of stress of the mother the grandmother or the great-grandfather or whatever all have impact on the young infant so we can trace down on the granddaughters talk about animals here but there are some human studies but the granddaughters will carry the memory of a grandparent either you can

00:50:45 have like stress infection or even early childhood adversity which it was very narrow band of Psychiatry so so we can actually tell from the granddaughter DNA that the grandmother had some in fact so that was very useful to let's say you have a child and you are not sure whether the child will be more you see some sign maybe I'm I'm not clinician but I can imagine that you're a child and you are not really sure

00:51:16 better the risk a very high or no but you see some signs you could come back and then test letter that's chart actually had some kind of impact through some ancestors life and you would say yes I see some impacts I would be more careful and maybe tree that particular individual and you can actually sample the epigenome not by having to get a brain biopsy papaya yeah we are doing from the blood that shows zombie no we don't have this is a cue the fungus so

00:51:46 we just take a little blood and we can because the blood also responds to this and there is a correlation between the blood disperse the brain responds these are not so it's my topic memory the memory in this case you cannot say this is a precise like an episode would be in our life or like or or ass room or remembering this environment it's really just the adversity component it's a negative balance of this whole situation which is really somehow waters certain

00:52:17 genes which will be so secure genetic fingerprint so so it's not a memory we like to use memory because everybody understands memory but shall lose memory so you will not just a good example you will not remember that the adversity occurred in a or b or c environment but you know that was some really bad experience it's not not post-traumatic stress disorder where somebody can recall the exact location and going back to the same restaurant or same battlefield it will have a reaction it is more of a general anxiety that in

00:52:49 general the anxiety level is really high almost sometimes you don't even know why because the person doesn't have to have an input it's already built in the DNA the chromatin or epigenome because somehow predated maybe not even in the individuals life but in the ancestors life so your mechanism is is beautiful and articulate and very sophisticated but that that that basic understanding that a person is affected by the their

00:53:19 ancestry psychiatrist have been saying 450 years that's not new right so it works well the thing that worries me of course is that exact thinking is what got us to eugenics this idea that the best thing to do would be just eliminate those genes eliminate those people eliminate those races you know and with the obvious know it's sure conclusions and what happened in Germany and and so and the thing is that that the the scary

00:53:51 part of those kinds of interventions as they they start off well intended and in the United States so it wasn't just you know these crazy folks in another country so again that the question is so alright so you find this then what but yeah but but just expanding so what you would say that it's known it was totally anecdotal there was no scientific evidence for that and in science we never believe so at least in basic science you never take it really true until you actually prove mechanistically

00:54:23 so our standards are really in that kind of secure well for the standards of the time yeah but they looked at pedigrees together Dana they interviewed families I mean for the standard yeah that's what I think oh so that was the same thing no but yes so that was certainly a such an association record association and now for a scientific point of view you want to have the association to a causative relationship because if this is an association you cannot do anything about it because if you do things can be associated and you influence one thing

00:54:54 it doesn't feel things my point is though for the standards of this so that for the scientific standards of the time 150 years ago that was truth that was the nervous entry it wasn't it I mean they believed that was the Kasbah now you're saying this is truth and so I'm I wouldn't doubt that your science is more sophisticated question is 150 years from now is somebody gonna look back and say well you know your science was all very nice but so and that's that that's the kind of but what a big difference is when you have that causative

00:55:25 relationship then you have a chance to actually manipulate the system if an association then basically the two things are independent from each other it's just coincidental so you don't have the tool you don't have the opportunity your chance to actually influence your outcome it's something which is correlated with so that's a very difference because they did I mean they thought they did but it's wrong wrong things I mean science we don't know that we don't know that are there are crude

00:55:55 treatments because there could you know would match the sensitivity of that kind of precise treatment even you know SSRIs or that's not really causative we don't want a causative because it's Association so costly when you have an absolute non-player molecule path a which is linked to and then you may later pass a and then then you face the outcome so that's what we need for them forever develop new drugs are there any

00:56:26 conditions where it is been shown specific epigenetic change is responsible for it so this is good this is another problem so there's not one single gene single nose but and then we don't have a manipulation very multiple so that's very difficult to make there but I think that that's actually one way to think about it to figure out the bay to work with multiple chains but I remember when

00:56:59 I was at school manipulating one gene was a tall order nobody is that student will start in a lab and in my mind the person can change their gene the poor single gene we can manipulate me three genes and if you asked these people east you should be just a single cell and a lot of same cell they can manipulate thousands at the same time what we would need is that so they put it hundreds of genes or thousands of genes you know complex

00:57:31 mammalian neuron and you just don't have the technology but people have been working but in cancer aren't they using various HVAC inhibitors right now yes is try to affect I got a Jimmy yes but yeah because selectivity that's also not enough if they don't have it yeah select selectivities is really important that you basically target only those nothing else it doesn't they the classical manipulation but we had 20 years ago develop we don't have to have they don't

00:58:02 have any multiple genes lot of genes they said all marketing so but not only the psychotic conditions were cardiovascular diabetes hypertension these are all the same problem and they cannot really improve because they have tears of hundred genes one person has this combination other person that combination but we do know that this problem a lot of genes each has a very small contribution but you still need they have different constellations so these are all systems biology so I think system by legit another field which

00:58:32 might need a lot of money but again much higher level than artificial intelligence who do nobody's which is one dimension of set sail I wanna use this to segue into something that I think is often not seen this way but the availability of our finer tools for assessing genetic risk at the level even of an ovum means that we're really into you a form of euthanasia except very early so when we

00:59:06 decide to not implant a fertilized egg that's carrying the Huntington's gene that's just early euthanasia early early eugenics biologically it's the same thing we're clearing the population of an ox's gene by selecting who will support an oval destroy the Nazis waited a few decades afterwards before doing

00:59:37 the same thing and we don't really have a dialogue socially about the meaning of that in our attitude toward it we're doing something you know way even more intriguing because the methods for doing this are available to some social classes and not to others so we've set up a system where if you're in a certain social class you get eugenics to get rid of bad genes and if you're in a

01:00:08 different class you don't and we're going to distribute the bad genes class wise in the culture that's a very interesting psychiatric I don't know if it's a psychiatric issue maybe I think much of what our effective interventions might be in the next few decades maybe at the pre-implantation level of eugenics we can possibly get rid of some

01:00:40 major psychiatric disorders if we have enough community acceptance of screening and selective implantation of fertilized ovum that don't carry those disorders the thing that is I mean apart from the larger ethical issues of which there are many the other thing that strikes me is if we're trying to help say this kids schizophrenia for focusing on schizophrenia we're if we're trying to convince our patients who have

01:01:11 schizophrenia that they have lives worth living that that disease is not going to define them that they can live full lives that they have worth as a human and then at the same time we say that we're gonna try to eliminate the genetic risk for that you know what does that say you know we we care about you but actually we wish you hadn't been born I mean that and that you know we're not at a stage where we really have to wrestle with that other than as a thought experiment but that's we're close to it well depending on you yeah it's pending

01:01:42 who you talk to you know so just yeah totally agree and and yesterday I just for accidentally opened NIH National Center for Health that there's a whole branch trying to really address this question system very relevant but I recall another effort from NIH which is more about repairing the D gene or genius so there are a lot of money goes into our field which is basically say desiccation and it's a child is born but can be really really Stan or more rate

01:02:16 regulation or whatever situation and now just a couple of years to probably you know the new technology where you can actually get in the cell again it's just a sellable we don't have the brain level but some yeah now some can do it and a single gene and you can actually repair it you can eliminate the physical or or or molecular problem and basically you it's very similar to to repairing an enzyme effect for example with a virus where you would have a child with an

01:02:47 enzyme defect and it's pretty technically speaking is relatively simple because it's just an enzyme which is everywhere so you make make a white blood cell then this white blood cell be produced now and you exchange the deficiency they're new at the gene therapy so that's a similar concept except that you go to the brain cell or a brain region and then you basically re-establish the normal situation it's it's sound fiction and it's just laborat of things but it's certainly in the land it sits in a

01:03:19 one-gene it can be done and it's just five years ago that was the first of four years ago so there are new things happening yeah and we just need Rogers not only new things but we need a scale up from one it's always with one gene and then you have to have 900 genes simultaneously so it's going a little slow obviously some degree of the repair of genes the technology's there now it's not only a mutation prepared you can rate this so-called epigenetic what i

01:03:51 referred which is know which is more complex you can repair that as well but the issue is in terms of mental illnesses to first determine what genes we're talking about you have a hundred dreams a small effect you can't be fixing those genes I gotta make any difference but the whole idea is science that you have these hundreds of tracks of research and some people working at it and suddenly everything is just converge and that's the hope so they scale up the technology the brain and we

01:04:21 don't have access to the range so we need a new technology to get to the brain so when everything converges maybe 100 years from now then then this is this is where you say maybe our servers to invest this money but otherwise it wouldn't be there and that's the hope but I think that was a hope in cancer the thing is that that are we do need to help our patients now and you know because it isn't sexy but there is a lot in systems of care that we in psychiatry used to do a lot with the whole Asylum

01:04:52 movement the whole beginning of the the profession of psychiatry in the United States was based on systems of care this idea that we build asylums to take care of people to restore them to sanity and and so we have similar problems to what Dorothea Dix was complaining about 170 years ago we have people in the jail's people on the streets people who are suffering who don't have family looking after them and in Michigan we are reinventing the idea that we need to take a look at state hospitals our Republican governors over succeeding decades closed most of our state

01:05:23 hospitals and now all of a sudden we have to have a conversation about maybe reopening some reopening new new kinds of new systems of care and working on ways of taking care of people because gene therapy isn't available in our lifetime it's hard to talk about that it's hard to say that were we needs bricks and mortar we don't just need I think it's two different things so we have to talk about both yeah I mean I'm not saying that you know the money should come from there I mean this is more a political issue actually what you're saying

01:05:55 but for the patient to the next 20 years neuroscience is probably not going to know it's probably not the social charity it's like you know probably the smart all the or the astrophysics is not necessarily in a lifetime but we still pay or fund astrophysics or going to Mordor probably we won't be there in the next few years but still in some respect how humanity and technologies develop

01:06:28 but just to segue into something that might be a little bit more positive even though I think that neuroscience is gonna take 20 years there are certain things that and it just happens by sher coincidence it's happening in my department but I Cornell we have bigger one of the investigators at Ueno who's a psychiatrist has figured out a way to use neural imaging to subtype depression into four categories by the connectome

01:07:00 and he is able to do it in granted his only one study of 1200 patients but he's able to basically get to do it with 90% specificity and sensitivity so he has the shock of actually possibly getting a bot the first biomarker for a psychiatric disorder what subtypes where did the subtypes come from so what he did was he got 600 patients with major depression and then and Oporto of control mates matched

01:07:35 controls got their resting state scans which I described there's and basically through machine learning / artificial intelligence asked the computer to tell them is there do these people fall into different subtypes who do the brain connectomes look different than the controls and then the computer gave what they call a classifier sort of like yes here's a template where you this this is the template for depression number 1 2 3 4 then he took another set of samples of

01:08:06 300 new people with depression or not depression or schizophrenia and this classifier could separate out people with schizophrenia versus depression with 99% precision and so so these are these are different subtypes that I'm didn't have no they're not phenomenological subside no these were the computer was not taught DSM so the computer was agnostic to Nick it was just here and essentially and each

01:08:38 subtype has a slightly different abnormality in connectivity with the prefrontal cortex so first of all he can be confirmed that the prefrontal cortex is probably very important for the major depression and they all have slightly different well they don't look different clinically as support right I guess that was they really don't look that different clinically miraculously subtypes actually fall into anhedonic anxious they actually do really amazingly do and it was not taught the computer was not taught this and so that

01:09:09 is health that's life yeah so that essentially they natural which makes sense that if you're an hedonic than the hub that's involved in the reward circuitry is probably going to be the one that's broken while the one that that where you're sort of more anxious it's going to be probably more mmm prefrontal cortical because of the anxiety circuits related there so it fell out naturally and now we're gonna but but what is so remarkable is that so there's a another form of treatment called trance magnetic stimulation which

01:09:40 is was which we had wild enthusiasm ten years ago but has shown to be only effective for forty percent and mild for mild to moderate depression what he found was was that only one subtype responded off the way to TMS so now the new clinical trial he's running is to do it that was a retrospective study that he did now he's doing a prospective study to see whether or not he can subtype them ahead of time then give them TMS and basically see whether or

01:10:11 not that this is actually gonna hold up but you can sort of now see how you can use this not obviously we as psychiatrists and psychologists and social workers we can diagnose pretty well but what this can tell you is is that what he noticed was was that after the people who responded to TMS their connect tone changed to normal so basically you now have not only a diagnostic tool but something that could probably tell you whether or not the treatments you had was possibly effective or not effective

01:10:42 in changing at least one sort of no at least some objective measure that the future would be at least only at Cornell but maybe other persons and you would get your brain scanned in the outpatient clinic if you come in for depression and then basically then then different treatments would be tailored to that it sounds very but human one brain scan will tell you this yes so basically because he got the computer to come up with what they call it a computational

01:11:13 classifier so then the classifier will then sort of sort it out and just say this you fit into bio type one two three or four and and so then and and if you put in someone who has schizophrenia they go you don't fit into any of these biotech you know you do you do not you know the trust so he's now trying to develop the schizophrenia bio type in the bipolar disorder biotech but for now he started with oppression to but you but the reason why this was possible was because so many people you know we're

01:11:48 doing resting-state scans so he didn't have to scan 1,200 people he got people's data from 1200 people from 1200 subjects from and then just use the computer to basically do the analysis but I think this is possibly what's gonna happen in that's why it's still important to do all these studies because who you that this 10-minute resting state scanner is gonna be so important for this type of work I think the ideas that we could be basically

01:12:18 able to tailor things but it is really quite remarkable even to me it's hard to wrap my mind around the fact that the brains has an intrinsic connectivity that can be picked up in ten minutes by a I miss you in a century that's been around for 50 years essentially technology was always there no one he only what he did is used just like he just put the pieces together you know he was able to do

01:12:50 so if it replicates the psychiatry is full of 50 years if they started the DST of tests that look like if they're going to be great so at fall fewer applications are now being but not for the replications for the bio typing so people from other universities not us Lillian it's a for depression not for any other some of the president that'd be pretty damn good yeah we're very we'll see what happens but what's really nice is is that and I the thing that I got from it was then

01:13:22 we've all we've we've also begun or he and begun doing this because that's the and with anxiety disorders fall to them some the brain did not read DSM Julie and it'd be good

01:13:52 and not the sort of you those are probably going to be very different for each I can assure you that I hope it replicates to but that's an optimistic note so they can stop if you have a question you walk

01:14:24 have facts various fields of science over the years how many years it took for half the things before the truth somewhere how many years will take me care what you think is true now yeah I'm not gonna predict the future but I will tell you a funny story about yeah I found a book that was written from the American Cup

01:14:55 ecology and in I think in 1965 they wrote this book called psychopharmacology in the year 2000 where they were predicting and they were drugs that people have helping them happy and help them that weren't happy

01:15:26 because we weren't going to solve the food problems but I'll stay with the answer to everything that's gonna cure up it was gonna cure then two years after this book was in the United take long say we're back to hallucinogens I went

01:15:58 back to where they not have they not been that maybe over the 30 years because that was a big mistake that's got to be true and not true yeah that's the way paper that you could laugh at when it's

01:16:29 be funny in the other yeah you had sure he was ready a paper by the RDoc project people to our dock project was an attempt to toss out the dsm of proton ology the tree base the ideas we're going to discover the the circuits of the brain and then we're going to build up and you know this huge-ass all these studies were going to explore the treatments went on the lemon said in 15 years it was so off and the knee is the fool

01:17:03 of predicting something in 15 years because there's a wrong and ever so you're right I mean assume a lot of what we know is going to be thank you dr. Lee the end you mentioned no models to do a rest frame from a typical friends oh these are cute these are in patients patients and it's made me wonder what what is a healthy brain

01:17:41 [Music] someone that doesn't meet any criteria for any just DSM disorder but you're absolutely right now it's sort of a circular argument but so what I think we don't have a really good idea of what rain is just will become brave so a brain these things

01:18:14 we have an idea what the healthy mind is the analyst to figure that out thank you for the and my question is with some question which way funding should go what will be the what patience and patience rules and what values should guide institution would value

01:18:46 medicine station what's the future of pictograms no questions - in court grants are supposed to be so there's been a but whatever various news then

01:19:19 to the community that seemed to look work senator but they're too complicated or something to be implemented and so something where you take a treatment grant is too actually or I think the taps agree great

01:19:50 earlier into people therapy that has been validated institution can you two queens the queens clinic and have trained the people there golly around lots of money is being poor sorry treatments

01:20:24 would have to say that the bigger question is is that we actually don't just to sort of segue we actually don't have the work force liver meant to the treatment percent of 20% of our population that work for so I'm not actually sure I would say that no I think what do rationale for the

01:20:56 grants has been mainly due to educated behavioral treatments have been able to be implemented and but it's probably because they don't have enough providers that can deliver it somewhat I think you the two threads of dr. Mike one of them about about prevention and the allocation

01:21:28 without him I'm going to echo that also given how we started off with the progress with the genetic research given that we spent most of the time talking about that at this meat so what what does that mean so I will offer a rotational we're where we are today and that and that and that

01:22:00 there's a enormous cultural almost delusional denial of of the source of most ecology which which dr. Michaels mentioned which has something to do with the early development early development early attachment addict a traumatic abandonment early childhood even even no data from moving to another country they may be the and mental illness and yet there's no

01:22:32 money provided for that kind of research so I suggest we take all of the money the end then we make as far as so now I'm was a big rock the

01:23:02 science research I think you met expectation we've had amongst pay you together that's ramp and in psychotic

01:23:34 thank and so part of the getting rid of stigma I think we're getting rid of stigma okay broken brains we've just added another time you a person

01:24:08 then he did a case conferences okay yells about actress sir if there's a strong patient who's the I'm gonna

01:24:38 pharmacogenetic testing and getting history you several comments are fall for I'll start with the last one I think the psychological psychodynamic all in favor of talking to patients

01:25:10 listening to them and getting to know them in fine texture in detail which you feel a member of I suspect from what you said I think that community has failed to demonstrate value added from the information it collects for the majority of psychiatric patients so although we may not like it the fact is that if you want to be cost effective the first thing you do is make a DSS then use the

01:25:40 standard treatment for that diagnosis and wait eight weeks a third of your patients will be better and there's no point in finding out how they felt about their mother it's irrelevant to the outcome of the intervention if your focus is on the outcome of the intervention you'd focus your subtle nuanced history-taking and ship development I'm the group of patients who need it and white profit

01:26:11 from it but the community doesn't like doing that and it has an almost ethical quality it's a it's not humanistic no orthopedic surgeon worries about being humanistic before setting a colles fracture but psychiatrists do sometimes or conversely they don't because they're tired of those that do and they're arguing with them so your DSM diagnosis begin to in many psychiatrists hands

01:26:43 substance of the person is sitting next to you on the bus it's an unsolved problem it's a major problem in psychiatric education so that if you travel around the country and you make rounds and things like that you find a fair number of young psychiatrists very happy if they can document the dsm-5 diagnostic conclusion even if they're not the vaguest idea who it is they're talking about on the other hand the the

01:27:16 research problem not resolved is when does it make a difference and very importantly when does it not make a difference sometimes sometimes I think too often I think you can't do it no I you know I I

01:27:47 created a structured interview for research and I see people to horrible jobs because they don't ask the right court you'll get below the surface I mean it's not a checklist so nobody who's ever worked on the DSM has ever claimed otherwise however because it look so simple people there's a human nature here to do the simple quick and the D in sentiment you could argue is one of the worst things that happens it's a lab psychiatrist to do what our colleagues and the rest of Medicine to try to do the quick and things like getting a bunch of blood tests and not talking to the patient so it's

01:28:17 facilitated that it's kind of plus I think it's treatment and people have responded better but there's a huge cost and I agree about the psychiatric education it's up to psychiatric education to to go against that tendency for people to want a cookbook approach and tell them over and over again that isn't you're not gonna get good results now unfortunately it'd be nice if there were studies that could actually show for sure check actually in it's hard for me to believe too right

01:28:51 people who that's my game with the Audi buddy who's gotta fund that you're right be great thing to do but there's also an idiot in the profession patient in-depth that it's almost rather than

01:29:22 efficiency or efficacy and that's a weak argument in a competitive world no you're right you see how we've gotten where we are and I thought it'd be great if we can undo that with data if you were like like the head of some federal Finance had with health finance teeth and said what we need to do this then they would ask well just show me why we should invest billions in this direction rather than in this direction we need that study a series of it but we may be

01:29:53 going backwards and and having to do that retrospectively with the current generation of kids were raising now so raising an entire generation of consumers of mental health care who think that all they have to do is sit there and somebody will do it they will do a checklist look at a diagnosis they've got a pill then something that worth that they again or it's our failure to treat rather than their failure to engage so I just had a patient in the hospital a 19 year old

01:30:24 student and we get a lot of university students at U of M on the inpatient unit and she she had depression I don't know what that means for this teenager but she'd been on every drug I could name she'd gotten ect she had never engaged with therapy because as far as she was concerned that was effort that she didn't want to put into and and we were done she was still depressed she was not bothering to go to her and you know she needed to actually put some work in and she didn't want to hear that she wanted the magic the magic pill we're you know

01:30:57 racing its generation of consumers have been all health care to not take a role in their own recovery and I worry about that I'm pleased that we've position you still have send it for getting the sociologic

01:31:43 my question I that statement have any of you been studying up abilities now there's xiety anxiety may be identified as good stay if it's no guided correctly person is facing something in society that is not right

01:32:15 did again is a symptom not necessarily it's a state it's not bad I mean we all know you know if you have a test to and you don't have enough anxiety to study for you're going to fail it's anxiety or adaptive parts of the human being who can't live exactly you

01:32:49 perhaps even her death you deal with illness Z in that context but when you have these thumbs coupled with some disability that's causing

01:33:20 it's somehow impact Billy what you need work well you know that it'd be symptoms severe enough always been in normal greeting for one year after the loss of

01:33:51 loved one every day and agree right with that prick tip so there's always a point where you figure out when these symptoms are heat when you know it's when they become educated my case basis it can be very do simple

01:34:22 apps from theory you my name is I am interest I have a suggest and I would like to have a boss to it David

01:34:56 but the man who can stop obsessive-compulsive disorder my quest statement here is that in the review of the book that I have Adam argues

01:35:26 is in favor of a more calm you suggests from a categorical approach mental illness which the category

01:35:57 approach driven by the DSM thank that was the dry windy in the you approach the hope what are the just to move it anyone in the knows that the categorical approach is of fiction there's no hard boundary but any mild depression

01:36:36 you so medicine if the rest of medicine is categorical abdomen as your people category so this tension between measuring and recognizing that there has to be a point where you go from a measurement to the smbus but people reify they think these boundaries in the book handed down from or something not the hot somehow

01:37:10 they have some meaning to really shouldn't have said it I've always here as a lifelong yeah thing with its we're struggling with what happens to the cats and how they become real clinicians to practice because you wouldn't know time to give medicine right now if you have five out of nine symptoms of depression and you've all

01:37:42 the clinical trials would use that definition you could say well if my patient version impression the one that was in the trial all know there are probability responding this treatment is because that's what the studies is he it you not enough for an illness howdy sir yes that you have to that's why it says at the front of the book

01:38:12 going to training and see like patients to be able to get to feel what they are but you it's they put in the door up to continuous revisions they realized that it was or this year's we're gonna redo the whole book now they said you know one of the reason they did that is very difficult to roll it within the

01:38:43 electronic world the belief is you giman now there's actually a committee set up that anyone outside can make proposals now if you make a proposal you have to have the data to back it up but the other thing it's great in theory and and you know very critical of dia have had issues some and this this

01:39:16 mentions incredibly you sort of a lot of little you hold on you don't but students that were created by second professor stay you know so complicated that I imagine anybody

01:39:48 actually right now is with you know 20 different domains and if you're high in this law it's like it's only on yeah yeah yeah credibly Complexo it is anymore yo lat it's one set of problem thank you

01:40:20 you issue zees sim serves in general dimensional approaches serve information categorical approaches discard inference when you reduce multiple dimensions into

01:40:54 willing to spend a lot of time clinician of data they have so that my kid you wanting diagnosis cell certainly not much and there's an argument DSM is a repurpose

01:41:25 it says that the first sentence of the introduction but the authors of DSM or where's Lila they're largely invested primary loyal you allottee disorders lots but the most complex so the committee that was

01:41:58 supposed to solve the problem came up with a dimensional system then the parent can be worried about it and extra committees were brought in to review it and decide about it and we ended up with both of you loser if some the treatment that was correlated the dimensions pensions would suddenly become very very popular yeah I agree with that thank you thank you very much for

01:42:31 participating in this been very good to hear everybody I just when you guys were referring the issue that the separation that occurred at the turn of the century with Freud diversa Jasper you know don't really I in the proper way I think that there was

01:43:03 a group of people that were mainly psychiatrists dealing with the population which was you know history individual whereas Jasper's and the German philosophical psychiatrist we're looking at people who were much more profoundly dysfunctional they were had different depths of illness Jasper's and

01:43:37 his treaties had the meat the biological psychiatrists have seen some type of biological basis first whereas the outpatient psychiatrist predominantly were what is that

01:44:08 or that beaut continued for a century and um it's pretty clear that the first predominated psychiatrists the it was

01:44:44 you Oh biological markers we were fast you asylum right a patient biggest

01:45:18 as if they are you know discipline these are visas event and that's one of the leading miss misunderstandings because what's happened is that you know 100 genes about rain is a

01:45:56 psychiatry from a lot of the ooh disciplines that deal with the brain which is much more linear and I mean of course they've expanded because at one point they were hang out because could find the lesion and they thought they were all gonna be part of which was initially

01:46:28 for community that's gone leave represents whole level organization that has its own code so answers that becomes misleading it's too linear for the majority of second

01:46:59 we're just that are based on genetics usually it's on the why there hasn't been more literature that has been able to prove is because of course linear mechanisms are much much easier to so now we start to understand that those people the world is what is making them feel

01:47:30 when they take can you come to a closure cuz that people wait we have to stop about line that's why does you keep water

01:48:01 those are the most important things that make life worth living those are the things that are over the mind and even laud the information theorist when he said you know was the father of information it's not really about information that he proved it was just statistic data okay think you made your point

01:48:35 hi as a data person myself I wanted to offer up the results from a literature review out of the University of Colorado Denver School of Medicine they look at analysis of all the published studies up until 2012 on antidepressant use versus the use of psychodynamic psychotherapy and what they found was that the effect size and the stud there were 74 Studies on the use of antidepressants alone was

01:49:05 0.3 which means about 3 standard deviations between the control group and the intervention group that received antidepressants and when they looked at studies and paid were patient where they had control groups versus patients that have received psychodynamics I'd be the average effect we're standing it seems that there's something about establishing a lion so a relation focus on expressing feelings when those things are established in the treatment patient

01:49:42 you and yeah you

01:50:18 cancer is myocardial infarction or tuberculosis or dentistry four or five that's important there are different treatments there are several types of psychotherapy cognitive behavior therapy is very popular dynamic therapy is the beloved of dynamically oriented psychiatrist pharmacotherapy realists seem to have

01:50:50 order of magnitude similar effect to mild to moderate depression my own reading is that with severe depression the pharmacotherapy shows an advantage but even more striking you don't even mention it the most effective treatment for severe depression is electro convulsive therapy there's a huge amount of data that it's not even in your in your survey but again yeah

01:51:25 Lynch of depression is your well pressed cover or you may need treatment and then you get better and then you're well again that's not the natural history of depression the majority of depressed patients have a long term usually lifelong predisposition or vulnerability to depression and they have more than one episode and therefore an important goal of the treatment is to modify that vulnerability and the likelihood of subsequent episodes we've been manically

01:51:57 effective in that with bipolar disease but that's a small amount of total depression it's not quite clear how effective we are what oh is that if you continue the treatment indefinitely it continues to work but no patient continues treatment indefinitely pathologic transit we have a problem you want me to end no no going we are finished

01:52:31 well I though is you that the drugs are effective take the drugs first in fact the best drugs we have helped about 1/3 of the patients who take them that's not widely

01:53:03 recognized partly because the pharmaceutical industry doesn't advertise it that way they'll tell you two-thirds of the patients who think the drugs get better which is true but with a placebo one-thirty collage effect efficacy our best pharmacologic treatments effects one-third of the people who take the treatment the same might be true over sang terribly in terms of reading depression look on your face you like that I think

01:53:59 thank no it's the other gentleman I think personal I'll be quick I'm interested to know what the panelists think about the future hope for psychiatric treatment by hallucinogenics specifically psilocybin and chem means interested to know what the state of the situation is now and what the prognosis is for future research and application it's still pretty early I think that

01:54:30 studies are in that so certainly the Kevin's story says Kennedy's legal to give and easier to study as with most things it's got a little life in the beginning but as more studies are being done there's clearly solid evidence that people respond to ketamine and people who don't who ever resisted depression I don't respond anything else sometimes respond to ketamine the problem of ketamine of course is requires continuous treatment and we don't know how yeah there's a lot we don't know there's a signal there that is announced at one week you know as far

01:55:04 as the rest of the psychedelics go again there's a signal there as well I mean this is a sad thing is because of what happened in the 60s and the overreaction to the misuse of psychedelics these things have been added in hands of researchers for 4050 years now luckily and it's coming back in in the studies now coming in more and more that the clinical trials for all kinds of you know originally the cancer patients who were terminal because you know the only people who could depend the Mets they were allowed and they got a very good results and and it's now the trying for

01:55:35 more and more application than the future of psychedelic treatment is very promising so but the problem is we don't want to start telling people they should go buy mushrooms on the streets are taking it because there's so much that's unknown dosing and these things that they had affects even the you know the studies are you psilocybin there sir you it's complicated like what is the placebo that's a problem because you're right

01:56:07 [Music] thing that has fat seriously I think we will stop up thank you so they were dress that were brought up once between medicine and psychiatry you know somatic medicine doctors and psychiatrist and the other contrast was between

01:56:39 you but you the way patients is better patience but it seems to be that is kind of been an irony that in in in the course of my career as a psychiatrist where I've watched medicine people very interested in narrative so now with Columbia you get a master's degree in their medicine and the medical of course that's like my entry

01:57:14 we we Cayden great skills in the sense and it's funny to me that we're not the ones teaching narrative medicine to the nation of medical students what almost universal width that's untrue and is in force was not a psychiatrist Freud was a neurologist who treated patients who ended up we know the rest of us but

01:57:45 the psychiatry grows out of general medicine neurology wasn't the specialty or he was seeing his patient outpatient with physical symptoms the history - it's moving away medicine and away from psychiatry but in fact my view analytic interview skills and patient

01:58:17 recognition are most with collided the leash you we're supposed to learn they are used to be supposed to learn these days although the impatient seriously members and lizard-skin

01:58:49 we're diseased with our probably least people they're much more important physically ill or like mentally ill but this see

01:59:25 stuff on an impatience can you yes you know you haha

01:59:56 he's not taking his meds anymore after him so there's the story and it's funny at University reinvented a Medical Humanities program quarters of because we say stuff we need it okay

02:00:28 you I'm a fourth-year medical student applying for psychiatry I'm so very interested in this talk I really thank you all for being here today so my question when I visit the future and understand all that neuroscience we're talking about immunology and more targeted therapies nanobots hallucinogens all the neuro stimulation before well I'm hearing problem this is

02:00:59 the future of Psychiatry it sounds more like reallocating resources delivering care if my future psychiatrists the property gonna see more the acceleration of patents new therapies and modalities or should we leave you advocating for spend the money where it's coffee most impactful things like housing or the early challenge benches so in five years after you finish your residency you should will only see the most ill patients and then at some point so that

02:01:33 most of the other mild-to-moderate will hopefully be taken care of by the primary care or some other do you well at some point realized that the treatments that your armamentarium you have is limited then you will go I heard this talk about psilocybin I gotta do something for my patient this is why I think there's such great interest because we have a limited repertoire of what we can offer our very very ill patients and we [Applause]

02:02:06 you