I was born in 1955, as the Dark Ages of mental health treatment in the 20th Century was coming to an end. There were 600,000 mentally ill people – 356 per 100,000 – more or less permanently hospitalized in public or private asylums. Those ravaged by severe and persistent mental illness couldn’t walk the streets without being victimized, being arrested for crimes big and small, or worse. With our limited understanding of mental illness – even though the standard of care varied widely -hospitalization was actually the most humane form of treatment available.
Over the next few years, medications that would manage depression and psychosis came into popular use, and these folks were deinstitutionalized, and treated in community mental health centers. (President Kennedy, who had a sister with mental illness, enacted the nationwide system.) Not much progress was made in the next two decades with regard to medication. The side effects of antidepressants were often worse than the cure, so many continued to suffer, or self-medicated with alcohol and other drugs.
As Viet Nam ended, a whole new population of hurting souls were searching for solace. Depression, Posttraumatic Stress Disorder and addictive illness plagued these walking wounded, and the existing system and treatments provided, in most cases, cold comfort.
Psychotherapy was making advances, though, and cognitive behavioral therapy now offered relief to many whom depressive thoughts and beliefs had incapacitated. Albert Ellis’s Rational Emotive Behavioral Therapy (REBT) also changed lives.
What makes mental illness – and treatment of depression in particular – so challenging is the wide disparity in presentation. There is a high degree of variation in symptoms, course of illness, and response to treatment, indicating that depression may have a number of complex and interacting causes. This intricate constellation posed a major challenge to researchers attempting to understand and treat the disorder. But in the 80’s, scientists began to better understand the role of the brain in mental illness. This, with the advent of Selective Serotonin Reuptake Inhibitors (SSRIs) like Prozac presaged the second wave of treatment advances. Relief for mild to moderate depression as now available to millions.
Recent advances in research technology are now bringing scientists at the National Institutes of Mental Health closer than ever before to characterizing the biology and physiology of depression in its different forms, and to the possibility of identifying effective treatments.
One of the most challenging problems in depression research and clinical practice is refractory (hard to treat) depression. While approximately 80 percent of people with depression respond very positively to treatment, a significant number of individuals remain “treatment refractory.” Even among treatment responders, many do not have complete or lasting improvement, and adverse side effects are common. Thus, an important goal of NIMH research is to advance the development of more effective treatments for depression — especially treatment-refractory depression — that also have fewer side effects than currently available treatments.
NIMH is far from the only place advances are being made. Evidence from neuroscience, genetics, and clinical investigation now demonstrate conclusively that depression is a disorder of the brain. There are new conceptualizations of the pathogenesis and pathophysiology of major depression. With this, new medications are being developed. The neuropharmacology of affective disorders is a rapidly advancing field of scientific interest.
Genetics research indicates that vulnerability to depression results from the influence of multiple genes acting together with environmental factors. Studies of brain chemistry and of mechanisms of action of antidepressant medications continue to inform the development of new and better medical and psychotherapy treatments.
Modern brain imaging technologies are revealing that in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly, and that critical neurotransmitters — chemicals used by nerve cells to communicate — are out of balance. Soon, and certainly during my lifetime, a clinical psychotherapist will not begin a course of treatment without first looking at the patient’s brain scans. More people will find relief, and more lives will be saved. I look forward to that day.