let 's start with some good news and the good news has to do with what do we know based on biomedical research that actually has changed the outcomes for many very serious diseases
today some twenty five thirty years later we 're talking about a mortality rate that 's reduced by eighty five percent six thousand children each year who would have previously died of this disease are cured if you want the really big numbers look at these numbers for heart disease
heart disease used to be the biggest killer particularly for men in their forty s today we 've seen a sixty three percent reduction in mortality from heart disease
remarkably one point one million deaths averted every year
aids incredibly has just been named in the past month a chronic disease
meaning that a twenty year old who becomes infected with hiv is expected not to live weeks months or a couple of years as we said only a decade ago but is thought to live decades probably to die in his sixty s or seventy s from other causes altogether
these are just remarkable remarkable changes in the outlook for some of the biggest killers
and one in particular that you probably wouldn 't know about stroke which has been along with heart disease one of the biggest killers in this country is a disease in which now we know that if you can get people into the emergency room within three hours of the onset some thirty percent of them will be able to leave the hospital without any disability whatsoever
remarkable stories
good news stories all of which boil down to understanding something about the diseases that has allowed us to detect early and intervene early early detection early intervention that 's the story for these successes unfortunately the news is not all good
let 's talk about one other story which has to do with suicide now this is of course not a disease per se it 's a condition or it 's a situation that leads to mortality
what you may not realize is just how prevalent it is there are thirty eight thousand suicides each year in the united states that means one about every fifteen minutes third most common cause of death amongst people between the ages of fifteen and twenty five
it 's kind of an extraordinary story when you realize that this is twice as common as homicide and actually more common as a source of death than traffic fatalities in this country
now when we talk about suicide there is also a medicalcontribution here because ninety percent of suicides are related to a mentalillnessdepression bipolar disorder schizophrenia anorexia borderline personality there 's a long list of disorders that contribute
and as i mentioned before often early in life but it 's not just the mortality from these disorders
it 's also morbidity if you look at disability as measured by the world health organization with something they call the disability adjusted life years
of all disability from all medical causes can be attributed to mental disorders neuropsychiatric syndromes
you 're probably thinking that doesn 't make any sense i mean cancer seems far more serious heart disease seems far more serious
but you can see actually they are further down this list and that 's because we 're talking here about disability what drives the disability for these disorders like
schizophrenia and bipolar and depression why are they number one here
well there are probably three reasons one is that they 're highly prevalent about one in five people will suffer from one of these disorders in the course of their lifetime
is the fact that these start very early in life
fifty percent will have onset by age fourteen seventy five percent by age twenty four a picture that is very different than what one would see
if you 're talking about cancer or heart disease diabetes hypertension most of the major illnesses that we think about as being sources of morbidity and mortality
these are indeed the chronic disorders of young people
now i started by telling you that there were some good news stories this is obviously not one of them this is the part of it that is perhaps most difficult and in a sense this is a kind of confession for me my job is to actually make sure that we make progress
on all of these disorders i work for the federal government actually i work for you you pay my salary and
and to talk about these as disorders of behavior fair enough they are disorders of behavior and they are disorders of the mind but what i want to suggest to you
is that both of those terms which have been in play for a century or more are actually now impediments to progress that what we need
conceptually to make progress here is to rethink these disorders as brain disorders
now for some of you you 're going to say oh my goodness here we go again we 're going to hear about a biochemical imbalance or we 're going to hear about drugs or we 're going to hear about
some very simplistic notion
that will take our subjective experience and turn it into molecules or maybe into
some sort of very flat unidimensional understanding of what it is to have depression or schizophrenia
when we talk about the brain
it is anything but unidimensional or simplistic or reductionistic it depends of course
but this is
an organ of surreal complexity and we are just beginning to understand
how to even study it whether you 're thinking about the one hundred billion neurons that are in the cortex or the one hundred trillion synapses that make up all the connections
we have just begun to try to figure out how do we take this very complex machine that does extraordinary kinds of information processing and use our own minds to understand this very complex brain that supports our own minds it 's actually a kind of cruel trick of evolution that
we simply don 't have a brain that seems to be wired well enough to understand itself in a sense it actually makes you feel that when you 're in the safe zone of studying behavior or cognition something you can observe that in a way feels more simplistic and reductionistic than trying to engage this
very complexmysterious organ that we 're beginning to try to understand now already in the case of the brain disorders that i 've been talking to you about depression obsessive compulsive disorder post traumatic stressdisorder while we don 't have an in depth understanding
of how they are abnormally processed or what the brain is doing in these illnesses we have been able to already identify some of the connectional differences or some of the ways in which the circuitry is different for people who have these disorders we call this the human connectome and you can think about the connectome
sort of as the wiring diagram of the brain you 'll hear more about this in a few minutes the important piece here is that as you begin to look
but there are some predictable patterns and those patterns are risk factors for developing one of these disorders
it 's a little different than the way we think about brain disorders like huntington 's or parkinson 's or alzheimer 's disease where you have a bombed out part of your cortex here we 're talking about traffic jams or sometimes detours or sometimes problems with just the way that things are connected and the way that the brain functions you could if you want compare this to
on the one hand a myocardial infarction a heart attack where you have dead tissue in the heart versus an arrhythmia where the organ simply isn 't functioning because of the communication problems within it either one would kill you in only one of them will you find a major lesion
as we think about this probably it 's better to actually go a little deeper into one particular disorder and that would be schizophrenia because i think that 's a good case for helping to understand why thinking of this as a brain disorder matters
these are scans from judy rapoport and her colleagues at the national institute of mental health
you can see that particularly in areas like the dorsolateral prefrontal cortex or the superior temporal gyrus there 's a profound loss of gray matter and it 's important if you try to model this you can think about normal development as a loss of cortical mass loss of cortical gray matter
and what 's happening in schizophrenia is that you overshoot that mark and at some point when you overshoot you cross a threshold and it 's that threshold where we say this is a person who has this disease because they have the behavioral symptoms of hallucinations and delusions that 's something we can observe but look at this closely and you can see that actually
they 've crossed a different threshold they 've crossed a brain threshold much earlier
that perhaps not at age twenty two or twenty but even by age fifteen or sixteen you can begin to see the trajectory for development is quite different at the level of the brain not at the level of behavior
why does this matter well first because for brain disorders behavior is the last
thing to change we know that for alzheimer 's for parkinson 's for huntington 's there are changes in the brain a decade or more before you see the first signs of a behavioral change the tools that we have now allow us to detect these brain changes much earlier
long before the symptoms emerge but most important go back to where we started the good news stories in medicine are early detection early intervention
if we waited until the heart attack
we would be sacrificing one point one million lives every year in this country to heart disease that is precisely what we do today
when we decide that everybody with one of these brain disorders brain circuit disorders has a behavioral disorder we wait until the behavior becomes manifest
that 's not early detection that 's not early intervention
now to be clear we 're not quite ready to do this we don 't have all the facts we don 't actually even know what the tools will be
nor what to precisely look for in every case to be able to get there before the behavior
emerges as different
but this tells us how we need to think about it and where we need to go
are we going to be there soon i think that this is something that will happen over the course of the next few years but i 'd like to finish with a quote about trying to predict how this will happen by somebody who 's thought a lot about changes in concepts and changes in technology we always overestimate the change that will occur in the next two years and underestimate
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