Science plays the long game, but people have mental health issues now
When I joined The New York Times Science staff in 2004, reporters in the department had a saying, a reassuring mantra of sorts: “People will always come to the science section, if only to read about progress.”
I think about that a lot as I say goodbye to my job, covering psychiatry, psychology, brain biology and big-data social science, as if they were all somehow related. The behavior beat, as it’s known, allowed tremendous freedom: I wrote about the mental upsides of binge drinking, playing the lotto and sports fandom. I covered basic lab research, the science of learning and memory, the experience of recurrent anguish, through the people who had to live with it. And much, much more.
Like most science reporters, I had wanted to report on something big, to have a present-atthe-creation run that would shake up our understanding of mental health problems. At minimum, I expected research that would help people in distress improve their lives.
But during my tenure, the science informing mental health care did not proceed smoothly along any trajectory. On the one hand, the field attracted enormous scientific talent, and there were significant discoveries, particularly in elucidating levels of consciousness in brain injury patients who appear unresponsive; and in formulating the first persuasive hypothesis of a cause for schizophrenia, based in brain biology.
On the other hand, the science did little to improve the lives of the millions of people living with persistent mental distress. Almost every measure of our collective mental health — rates of suicide, anxiety, depression, addiction deaths, psychiatric prescription use — went the wrong direction, even as access to services expanded greatly.
What happened? After 20 years covering the field, here and at the Los Angeles Times, I have a few theories, and some ideas on what might be required to turn things around.
Early on in my job, I started to field a steady stream of calls and emails, usually from parents asking for advice.
“My son is suicidal. We’ve tried everything. What do we do?”
“Our daughter is cutting herself, she’s out of control. Can you recommend a therapist, or someone to talk to?”
More than a few of these queries came from colleagues at The Times. Others came from friends and family.
I always provided suggestions and referrals (with a disclaimer), and helped decode the psychiatric jargon, if needed. I also followed up later, to see how their issues were going. This second conversation was a reminder, every time, that the mental health system, for all its caring professionals, is chaotic and extremely difficult to navigate. There are few systemwide standards, and vast and hidden differences in quality of care. Good luck finding an authoritative guide to navigating the full range of appropriate options.
In time, those seeking help became the lens through which I saw my job, and their questions became my own. What does a diagnosis of bipolar really mean, in a young child? Is this drug necessary? How trustworthy is the evidence?
One answer to that last question came in the mid-2000s, when the Food and Drug Administration had a series of hearings on whether antidepressant drugs, like Paxil, Prozac and Zoloft, backfired in a small number of users, causing suicidal thinking and behavior.
The hearings were hair-raising. Hundreds of family members who had lost a loved one crowded the rooms, their anger and expectation sucking up most of the oxygen; and some of the parents, it was clear, knew at least as much about the drugs as the doctors.
By 2006, the FDA had concluded that a so-called black-box warning on antidepressant drug labels was warranted, citing the suicide risk for children, adolescents and young adults. Many psychiatrists were dismayed by the decision, insisting it would discourage the use of valuable medications.
The antidepressant wars, as this debate came to be known (it rages on today), also helped uncover the influence of industry money on academic psychiatry. The pharmaceutical industry paid researchers at brand-name institutions to talk up drugs at seminars and conferences; it paid for “expert panels” to promote their use; and it often had outside firms write up the studies themselves, massaging the data.
This state of affairs made it virtually impossible to interpret psychiatric drug studies. Some experiments were undoubtedly honest, rigorous efforts to document the diffuse effects of a medication. Others were no more than “infomercials,” in the phrase of the late Dr. Bernard Carroll, one of the most stubborn critics of his own profession — drug ads, in effect, dressed up as research. The infomercials were usually easy to spot, but not always; and without knowing the back story, the money trail, you couldn’t be sure what to believe.
When it came to judging government-funded research projects — a cleaner enterprise, presumably — I again asked the questions that people in crisis continually asked me. Is this study finding useful for my son, or my sister, in any way? Or, more generously, given the pace of research: Could this work potentially be useful to someone, at some point in their lifetime?
The answer, almost always, was no. Again, this is not to say that the tools and technical understanding of brain biology didn’t advance. It’s just that those advances didn’t have an impact on mental health care, one way or the other.
Don’t take my word for it. In his forthcoming book, “Recovery: Healing the Crisis of Care in American Mental Health,” Dr. Thomas Insel, former director of the National Institute of Mental Health, writes: “The scientific progress in our field was stunning, but while we studied the risk factors for suicide, the death rate had climbed 33%. While we identified the neuroanatomy of addiction, overdose deaths had increased by threefold. While we mapped the genes for schizophrenia, people with this disease were still chronically unemployed and dying 20 years early.”
And on it goes, to this day. Government agencies, like the National Institute on Drug Abuse and the National Institute of Mental Health, continue to double down, sinking enormous sums of taxpayer money into biological research aimed at someday finding a neural signature or “blood test” for psychiatric diagnoses that could be, maybe, one day in the future, useful — all while people are in crisis now.
I have written about some of these studies. For example, the National Institutes of Health is running a $300 million brain-imaging study of more than 10,000 young children with so many interacting variables of experience and development that it’s hard to discern what the study’s primary goals are. The agency also has a $50 million project underway to try to understand the myriad, cascading and partly random processes that occur during neural development, which could underlie some mental problems.
These kinds of big-science efforts are well-intended, but the payoffs are uncertain indeed. The late Scott Lilienfeld, a psychologist and skeptic of big-money brain research, had his own terminology for these kinds of projects. “They’re either fishing expeditions or Hail Marys,” he’d say. “Take your pick.” When people are drowning, they’re less interested in the genetics of respiration than in a life preserver.
In 1973, the prominent microbiologist Norton Zinder took over a committee reviewing grants by the National Cancer Institute to investigate viruses. He concluded the program had become a “gravy train” for a small group of favored scientists, and advised slashing their support in half. A hard, Zinder-like review of current behavioral science spending would, I suspect, result in equally heavy cuts.
How can the fields of behavior and brain science begin to turn the corner, and become relevant in people’s lives? For one, prominent scientists who recognize the urgency will have to speak more candidly about how money, both public and private, can warp research priorities. And funders, for their part, will have to listen, perhaps supporting more small teams working to build the psychological equivalent of a life preserver: treatments and supports and innovations that could be implemented in the near future.
There’s a reason that so many people use binge drinking, playing the lotto and runaway eating to support their mental health: because the effects are reliable. Because they don’t require a prescription. And because they’re available, right