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Rethinking mental illness

A look at the state of mental health and its inverse, mental illness, from prominent Yale School of Medicine faculty and researchers from the departments of psychiatry and neuroscience.

Rethinking mental illness
Illustrated by Otto Steininger
Rethinking mental illness

Albert Rivera has had a hard-luck life. As a child, he experienced physical and emotional abuse. Now 38 years old and living in New Haven, he suffers from post-traumatic stress disorder (PTSD) and is in recovery from alcohol and opioid abuse. To top things off, he’s in transitional housing—without a dependable roof over his head.

Yet Rivera has hope for his future. He holds a job and he stays on an even keel by participating in two programs run by Yale School of Medicine. One helps people with mental illnesses deal with the stresses of life, and the other enables them to play positive roles in the community. “They help me cope,” Rivera says. “They gave me a purpose and made me part of something bigger than myself.”

The programs are examples of an emerging trend in the treatment of mental illnesses called recovery-oriented care and citizenship. The idea is that helping people cope with their illnesses and live productive lives as valued members of their communities is an essential part of their care—alongside medications, talk therapy, and other treatments.

Recovery-oriented care and citizenship are part of a major rethinking of mental illness and care that is now underway nationwide. Until recently, the primary focus among mental health professionals has been on identifying therapies that suppress the symptoms of disease and administering those therapies in a clinical setting. Increasingly, though, researchers are focusing on understanding the core causes and mechanisms of mental illness, and clinicians are helping their patients grapple with the social determinants of health while developing a sense of belonging in their communities.

In a sense, mental health care is being redefined—becoming ever more precise and personalized in the biological research sphere and more holistic and patient-centric in the way treatment is provided. “We need to think differently about psychiatry than we have in the past,” says John Krystal, MD ’84, HS ’88, the Robert L. McNeil, Jr. Professor of Translational Research, professor of psychiatry and of neuroscience, chair of the Department of Psychiatry at Yale School of Medicine, and chief of psychiatry at Yale New Haven Hospital. He believes the department will play a significant role in advancing science, improving care, and training the next generation of leaders in the field.

Progress is sorely needed. That’s because the state of mental health in the United States is poor. Nearly 20 percent of the population, or about 60 million people, suffer from some type of mental illness each year. More than 24 million people struggle with substance abuse.

The treatment of mental illness has undergone waves of change over the past 100 years. The field was defined in the early- to mid-20th century by mass institutionalization, poorly informed use of lobotomies, and the dominance of psychoanalysis. Over time, those approaches gave way to deinstitutionalization, rapid proliferation of drug treatments, cognitive behavior therapies, and now psychosocial interventions, including recovery-oriented care.

Understanding of the causes of mental illness has evolved as well. Psychiatry pioneer Sigmund Freud posited that mental illness is caused by conflicts between different parts of the mind resulting from childhood trauma. Later, leaders in the field came to believe that mental illness is the result of disruptions in biological processes. Now psychiatrists increasingly recognize the powerful impacts poverty and other traumatic life experiences have on mental health. “Each view has enriched the picture. They complement each other in explaining mental illness and fostering new treatment directions,” says Michael Sernyak Jr., MD, HS ’91, professor of psychiatry and CEO of Connecticut Mental Health Center (CMHC).

Yale has long been recognized as a national leader in psychiatry. Today its psychiatry department is one of the largest in the country, with more than 350 faculty members. Yale’s partnership with the VA Connecticut Healthcare System has produced numerous advances in PTSD treatment. Its joint venture with the state in CMHC provides psychiatric care for more than 5,000 economically disadvantaged people each year. Yale Child Study Center is renowned for research and clinical care. And the Interventional Psychiatry Service at Yale New Haven Psychiatric Hospital is a leader in providing people with severe mental illness with access to the latest experimental treatments.

New directions in the biology of mental illness

Breakthroughs in understanding human biology in the mid-20th century led to the development of medications for mood disorders and psychosis—alleviating suffering for millions of people. Yet most of the “wonder drugs” introduced during that era addressed the symptoms rather than the causes of disorders.

A new wave of biological research spanning neuroscience and genetics is deepening our understanding of mental illness’s underlying biology. This research promises to deliver a new generation of medications and treatments that target causes. “This is opening up a whole host of new treatment options,” says Gerard Sanacora, MD, PhD, HS ’98, FW ’99, the George D. and Esther S. Gross Professor of Psychiatry and director of the Yale Depression Research Program.

One of the major breakthroughs in this area came in the 1990s when Krystal and colleagues discovered that the drug ketamine, an anesthetic, could provide a fast-acting treatment for depression. Previously, antidepressants had focused on suppressing unruly chemicals in the primitive parts of the brain. But ketamine targets the chemical glutamate in the neocortex, where memory and thought reside. The drug treats a cause rather than a symptom. The hospital now offers experimental ketamine infusion therapy for depression.

These days, research labs within the School of Medicine are using neuroimaging and genetics to probe deeper into the workings of the brain. One lab, run by Ronald Duman, PhD, FW ’88, the Elizabeth Mears and House Jameson Professor of Psychiatry, professor of neuroscience, and director of the Abraham Ribicoff Research Facilities at CMHC, has been studying ketamine to better understand the pathophysiology of depression. His team discovered that for some individuals, chronic stress and depression cause atrophy and loss of synapses, reducing connectivity in the brain. Ketamine promotes the growth and vitality of synapses. “We’re learning more about how the brain works,” says Duman.

One of the team’s primary goals is to discover alternative therapies to ketamine that don’t carry the drug’s negative side effects, such as hallucinations.

As researchers probe the brain, they’re making discoveries that may lead to a reclassification of mental illnesses. Today, psychiatrists refer to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) to make their diagnoses. Its classifications of disorders are based primarily on observations of behavior. Increasingly, researchers find that the phenomena they observe in the brain do not line up with DSM diagnoses. There’s too much overlap to separate these phenomena into strict categories. As research advances, it may turn out that many illnesses have the same causes, such as stress and inflammation—leading to new treatment strategies.

Because of the ever-increasing role of neuroscience in psychiatry, the Department of Psychiatry’s residency program has evolved to include training in applying neuroscience to clinical practice. “The goal is to help clinicians arrive at more accurate diagnoses and to communicate better with patients about what’s going on,” says David Ross, MD ’05, PhD ’04, associate professor of psychiatry, who led the initiative.

Rather than relying on traditional lectures, the curriculum includes videos, interactive exercises, and resources for self-directed study.

Ross, working with colleagues at Columbia University and the University of Pittsburgh, discovered that few residency programs around the country were incorporating neuroscience into how they taught psychiatry. To address that gap, Ross’ group created the National Neuroscience Curriculum Initiative (NNCI), which offers a comprehensive set of teaching and learning resources, many of which were first implemented at Yale. Today, more than 100 residency programs use the curriculum, and the website has 36,000 registered users from 153 countries.

Helping patients live in the world

In 1977, two women in Madison, Wis., Harriet Shetler and Beverly Young, met for lunch to discuss the challenges faced by their sons, who had been diagnosed with schizophrenia. That fateful meeting marked the beginning of the mental-health patients’ advocacy movement, which has pushed the psychiatric community to provide care that respects patients’ rights and wishes. Out of that shift in perspective came recovery-oriented care.

The core idea is that people with mental illness can recover even though they’re not “cured.” They can live satisfying lives—holding jobs, enjoying their families, and contributing to society. “These interventions are aimed at the recovery of daily function and life. The focus is on helping a person have the kind of life they want,” says Larry Davidson, PhD, FW ’92, professor of psychiatry and director of the Yale Program for Recovery and Community Health (PRCH).

His organization does research, training, and policy development aimed at equipping health care and social service agencies to support recovery-oriented care. It also runs experimental programs in New Haven that provide direct support for patients—including person-centered care planning and community-based recovery programs.

The ultimate goal of recovery-oriented care is achieving wellness—improving mental and physical health by expanding awareness and making better choices in all dimensions of life. Wellness is not the absence of illness or stress; it’s making the best of one’s situation.

Citizenship adds another dimension, recognizing the rights, responsibilities, roles, resources, and relationships necessary for contributing to community on one’s own terms, often through involvement in collective endeavors.

A lot of the work being done at PRCH is practical and utilitarian. The programs help people get jobs and diplomas. CMHC, for instance, provides bicycles for some of its low-income patients, enabling them to get to appointments and jobs on time, and improving their physical fitness and self-esteem.

There’s also a strong emphasis on heeding the wishes of the patient. For instance, a person may choose to forgo a medication that suppresses their symptoms because it also makes them groggy, interfering with their ability to work and socialize.

A key element in such programs is the role of peers—individuals who have experienced mental illness and/or substance abuse who advise and guide patients as they navigate their recovery. A peer-support staff member in New Haven, Richard Youins, helps run a weekly discussion group at CMHC and coordinates Magicians Without Borders, which teaches people magic tricks they can use as icebreakers when they tell their stories in public. “When I was in addiction, if somebody had told me I would someday have a job where I was doing good things for other people, I would have laughed. But it happened,” he says. “We’re all walking, breathing possibilities.”

Studies of the PRCH programs have shown that peer support reduced hospital readmissions by 42 percent, reduced hospital stays by 48 percent, and improved relationships with health care providers.

The School of Medicine is also helping people in recovery play roles in reforming the mental health care system. Lived Experience Transformational Leadership Academy, a nine-month training program, prepares people to develop and enhance their capacity for leadership. “We need leaders with lived experience at the table so that we can together transform health care organizations,” says Chyrell Bellamy, PhD, MSW, associate professor of psychiatry and director of Peer Services and Research at PRCH.

In order to equip future psychiatrists to provide recovery-oriented care, the Department of Psychiatry has developed a robust social justice and health equity program within the residency curriculum. “We can predict more about a person’s health from their ZIP code than their genetic code, so we need to train residents about implicit bias and the roles of communities in mental health,” says Robert Rohrbaugh, MD ’82, HS ’86, FW ’88, professor of psychiatry and deputy chair for Education and Career Development.

The social justice and health equity program takes residents out of the classroom and clinic into New Haven’s neighborhoods, where they learn how such factors as housing, employment, transportation, and neighborhood gardens can be barriers to health or help improve it.

For Hana Ali, MD, a second-year resident, the program was a revelation. A guided tour last year of the New Haven neighborhood where she lived took her under the surface to understand the experiences of her neighbors. “It told me there are lived experiences of the patient we take care of that we have no idea about. In order to care for a person, you need to get a full sense of them—what their lives are like,” she says.

Along both vectors where mental illness is being rethought, the biological and the behavioral, researchers and clinicians are gaining knowledge rapidly. “It is wonderfully stimulating to work in a community where the issues arising from basic science, the clinic, and the community converge,” says Krystal.

Huge challenges remain. The mechanisms of the brain are amazingly complex and difficult to interpret. The interactions of individuals with others and society are so varied. There are many stressors in modern life.

Yet School of Medicine faculty members are optimistic that new scientific discoveries and new approaches to treatment will improve the lives of those who suffer from mental illnesses. “We’ll have breakthroughs. It’s what we are as a species,” says William Sledge, MD, HS ’75, the George D. and Esther S. Gross Professor of Psychiatry Emeritus, who was for many years the medical director of psychiatry at the hospital. “We will find a way.”