Behavioral Health Forum:Integrating the Science and the Practice for the FutureUniversity of Texas MD Anderson Cancer CenterHouston, TX – June 8, 2012

John M. Oldham, MD, MSSenior Vice President and Chief of StaffThe Menninger ClinicProfessor and Executive Vice ChairMenninger Department of Psychiatry and Behavioral SciencesBaylor College of Medicine;Immediate Past President, American Psychiatric Association

Changing Stages in the Field of Psychiatry

Era Predominant Influence

1940s – 1970s Psychoanalytic (psychogenic)

1960s – present Psychopharmacological (chemical imbalance)

1980s – present Biopsychosocial

1990 – 2000 Decade of the Brain (NIMH)(Bidirectional Gene-Environment Interaction)

2000 - 2010 Decade of Discovery (NIMH)(Genomics, proteomics, molecular neurobiology, “neuropsychotherapy”)

Rethinking Mental Disorders

• Mental disorders are brain disorders• Mental disorders are developmental

disorders• Mental disorders result from complex

genetic risk plus experiential factors

- T Insel, 2012

Mental Disorders are Chronic and Disabling

WHO 2008

Annual U.S. Cost of Brain Disease

• 2012 estimated medical and long-term costs related to brain disease = $515B (19% of total national health expenditures)

• 2012 estimated medical, non-medical, and long-term costs = $934B

- Michael Thompson, Price Waterhouse Cooper, 2012

Mental Disorders: Mortality

• Over 36,000 suicides per year in the U.S. (CDC, 2008)

• For context: 18,000 homicides 33,000 traffic fatalities

- T Insel 2012

Mental disorders are the chronic diseases of the young

The Most Costly Conditions

Insel, JCI, 2009

High Heritability of Mental Disorders

Insel, Sci Am, 2010

Hopelessness, helplessness, suicidal thoughts, anorexia, loss of libido, sleep disturbance

Depression as a Brain Disorder

Frasure-Smith N et al. JAMA. 1993;270:1819-1825.

0

5

10

15

20

25

30

0 1 2 3 4 5 6Months After Heart Attack

Mort

alit

y (

%)

Depressed (n = 35)Nondepressed (n = 187)

Cumulative Mortality for Depressed and Non-depressed Patients Following Heart Attack

Modified from Duman, Heninger, Nestler, AGP

54(7):597-606, 1997

Other neuronal insults:• Hypoxia-Ischemia• Hypoglycemia• Neurotoxins• Viruses

Genetic Factors

Increased Survival and Growth

Atrophy/Death of Neurons

Normal Survival and Growth

Glucocorticoids Serotonin and NE

BDNF

GlucocorticoidsBDNF

NormalStress + Heritable Risk Depression

Antidepressants and/or

Psychotherapy

500

400

300

200

100

50 55 60 65 70 75 80 85 90 95 00

Death

s p

er

10

0,0

00

Year

~ 514,000 ActualDeaths in 2000

~ 1,329,000 ProjectedDeaths in 2000

Impact of Research on Heart Disease

•63% decrease in mortality

•~ 1 million early deaths averted per year

•$2.6 trillion in economic return

•New, effective treatments and prevention strategies

Mill

ions

of

People

1971 1986 1990 2003

9

6

3

Number of Survivors

Impact of Research on Cancer• For the first time in

recorded history, annual cancer deaths in the United States have fallen

• 10 million survivors

Impact of Research on Mental Illness• Diagnosis is by observation, detection is late,

prediction is poor.• Etiology is unknown; prevention is not well-

developed for most disorders.• Treatment is trial and error – no cures, no

vaccines.

Bottom line:• Prevalence has not decreased for any illness.• Mortality has not decreased for any illness.

- T Insel, 2012

Molecule Cell System Individual SocialGWASSequencingTransgenicsEpigeneticsDatabases

Stem CellsRNAseqProteomicsOpticalimagingDatabases

Electrode arraysConnectomicsImagingDatabases

SensorsEye gazeCognitivetoolsEpidemiologyDatabases

Web 2.0Knowledgemanagement

NIMH Research Domain Criteria (RDoC):Transforming Diagnosis

Cost of Genomic Sequencing

- T Insel, 2012

YEAR COST TIME

1 Million Bases: 2001 $6,000 Several weeks

2012 19 cents Several hours

Entire Genome: First $3 Billion 12 years

Today $1000 2 days sequence, 9 days analysis

The Menninger Mental Health Epicenter

Goal: “The MD Anderson of Mental Health”

New Directions at The Menninger Clinic

• Vice President and Medical Director• Susan Hardesty, M.D.

• Comprehensive Psychiatric Assessment Service• Benjamin Weinstein, M.D.

• Professional Assessment Service• Christopher Flynn, M.D.

• Research• Outcomes (Allen)• Suicide (Greene, Ellis, Jobes)• Addiction (Kosten, Flack)• Mentalization (Fonagy, Bleiberg, Allen)• Personality Disorders (Skodol, Oldham, Bender, Morey)• Translational – e.g. “neuropsychotherapy” (future

Menninger/Baylor studies)• Admissions Service

• James Flack, M.D.• Future research, educational, and clinical partnerships with

Baylor

Proposed Menninger / Baylor Neuroscience Project• Standardized clinical diagnosis on all adult

patients (SCID I & II)• Specialized brain imaging • Gene sequencing to identify heritable risk

factors

(Provisionally approved, Baylor IRB)

Thank you for your interest