- [Dr. Borenstein] Welcome to Healthy Minds.

I'm Dr. Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

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Today on Healthy Minds.

- The COVID-19 pandemic has created all sorts of challenges for everyone throughout the United States.

And that has had a profound impact on mental health and actually mental health care.

About 50% of Americans have experienced at one point in time an increase in depression or anxiety symptoms.

That the rates of visits to emergency rooms for adolescent boys and especially adolescent girls has increased dramatically through the pandemic.

And we know that there are some communities in the United States that were affected more severely from a mental health perspective than others.

- That's today on Healthy Minds.

This program is brought to you in part by the American Psychiatric Association Foundation, The Bank of America Charitable Gift Fund, and the John & Polly Sparks Foundation.

(gentle music) Welcome to Healthy Minds.

I'm Dr. Jeff Borenstein.

Today I speak with Dr. Josh Gordon, the director of the National Institute of Mental Health.

Josh, thank you for joining us today.

- Thanks for having me, Jeff.

- I'd like you to share with us what exactly does the National Institute of Mental health do?

Tell us about the institute.

- The National Institute of Mental health is the principle federal agency in the United States that funds research into mental illness.

Our mission is to conduct basic and clinical research to improve the understanding and treatment of mental illnesses.

And we do that with the aim of discovering cures and preventative efforts, to be able to reduce the burden of mental illness for everybody - During the period of COVID, I'd like to speak a little bit about what you found in your position as director of NIMH, how it relates to COVID.

- The COVID-19 pandemic has created all sorts of challenges for everyone throughout the United States.

And that has had a profound impact on mental health and actually, mental health care.

We know, for example, that about 50% of Americans have experienced at one point in time an increase in depression or anxiety symptoms.

We know that the rates of visits to emergency rooms for adolescent boys and especially adolescent girls has increased dramatically through the pandemic.

We know that the burden of healthcare for mental healthcare providers has shifted from in person into telehealth, creating a whole new way of providing that care.

And we know that there are some communities in the United States that were affected more severely from a mental health perspective than others.

Communities of first responders, communities of minoritized individuals, communities of low socioeconomic status, Native American communities.

These communities were hit hardest by the pandemic directly, but also suffered the greatest mental health effects.

- You mentioned a number of important aspects, one of which is the use of telemedicine, telepsychiatry.

I'd like you to speak a little bit about that and how it's really helped in terms of dealing with some of the challenges that the pandemic has brought about.

- The good news with regard to telehealth and telepsychiatry in particular is that we've been laying the groundwork that enabled that shift that had to occur during COVID.

Through really years, decades of research.

NIMH funded research, research funded by other organizations has shown that you can effectively deliver mental healthcare interventions remotely.

Over the telephone, through video connections if you do it right.

And fortunately, when the pandemic occurred and many if not most physicians and mental health providers had to switch to virtual visits, we had shown that that could work.

And they were able to pivot quickly, thanks to advanced technology.

And in fact, if you look at certain indices of mental healthcare delivery, the shift to telehealth resulted in increased delivery of evidence-based mental healthcare.

Just one quick example.

In federally funded healthcare centers in the state of California, the number of behavioral healthcare visits actually rose as the pandemic shut down in-person services, because more people were able to make their appointments, more people were able to come and see a mental healthcare provider.

So tele-mental health has really helped, not just weather the storm of the pandemic, but if anything, to increase access for those who need it.

- In many ways, it's shown how the use of technology really can help people.

And we're not in the same room, but we're using similar kind of technology to have this conversation.

And it makes it much easier for a person who otherwise may not be able to travel to their psychiatrist or other mental health professional to just be able to do it from their own home.

- This is what I was hearing from all of my colleagues who were seeing patients in New York in March and April and really throughout the country.

The number of people who missed appointments dropped dramatically.

And when they began to reopen their practices as the pandemic eased slightly into the summer of 2020 and beyond, many patients preferred the ease and the efficacy of the remote visits.

It's not a replacement for everything.

And we know that the video screen can't convey all the nuances of human communication, most importantly, of course, touch.

But it can be really helpful and it can be an incredibly important tool.

A tool that can be used long past the pandemic in terms of increasing access in areas where there aren't enough mental healthcare providers.

- I wanna shift gears a little bit and speak about how the pandemic affected research.

Tell us about that.

- Yeah, Jeff, the pandemic had a profound effect on research in a number of different ways.

First and foremost, many, if not most laboratory and clinical based research programs were shut down completely for anywhere from six weeks to months on end.

Of course, COVID related research, that was prioritized for preservation, but just like workplaces everywhere the laboratory and academic workplaces where mental health research gets done had to look out for the safety of the scientists that go to work every day.

Like other industries that can only be done in person, those laboratories, those clinics, they started opening back up again six weeks, three months later, but at lower densities.

And in particular, clinical research, which relies on volunteers coming into the clinical research environment was faced with a real problem.

People didn't want to journey to the academic medical centers.

They didn't want to get on a subway or in a cab.

They didn't want to come in for in-person evaluation.

So much of that clinical research actually had to pivot, just like clinical care, to remote opportunities, remote assessments, et cetera.

So that slowed everything down.

And of course, didn't slow everything down equally.

Early career investigators who didn't have the resources to pivot to telehealth right away or who had critical infrastructure disrupted and didn't necessarily have the resources to get it jump started again, they were affected more than others.

Researchers with young children, women, and men, but especially women, 'cause we know they continue to bear more of the burden for caring for kids at home, were dramatically affected.

Because when they were home, trying get their papers out, apply for grants and do analyses and things that they could do at home, they had a harder time doing it because they also had to care for their kids who were home from school learning remotely.

Tremendous, tremendous disruption of the research enterprise.

- You point out the younger investigators who were beginning, and that's really the future of research.

It's the next generation.

What's being done to help them so that we don't lose that next generation.

- Yeah, we all have to work together.

The entire research enterprise has to work together to make sure that we're not losing this generation.

NIH is doing its part with automatic extensions to training grants and to eligibility for early career awards.

We're trying to put some money where our mouth is in this regard and help these folks weather that delay, weather the storm.

Researchers everywhere can do their part by understanding when they're reviewing grants, when they're reviewing promotion for these young investigators as they go up for academic appointments, as they go up for academic advancement, that there's gonna be a period of reduced productivity because of what happened with COVID.

But I think what we're seeing now as the scientific enterprise has come back is that there's no lack of enthusiasm amongst these investigators to keep things going.

They're working hard and they're doing their best so it's up to the rest of us to help support them as they try to restart their career.

- I wanna ask you, you have a broad vision of research going on throughout the United States and really, around the world.

What are some of the most exciting advancements that you are seeing at this point in time?

- Well, I'm a basic neuroscientist, Jeff.

You know that, you've known me for a long time.

So I'm really excited about some of the things that we can do in terms of enhancing or understanding of the way the brain guides behavior.

So I'm gonna start there.

We have, at the NIH been supporting a grant initiative.

You know the NIH Brain Initiative, which seeks to develop the tools and technologies necessary to really interrogate how the human brain works.

And we just this fall saw an explosion of knowledge about the different kinds of cells in the brain, where they're located, what they're made of, how they connect and how those connections drive behavior.

Publishing a huge numbers of papers, but papers aren't what it's about.

It's about the knowledge and the capacity to increase that knowledge.

I'm really excited about the ability of these new technologies to be used by these fantastic young scientists we're just talking about to interrogate the brain.

And that's one thing that drives me.

On the other end of the spectrum we're seeing a lot of progress in certain specific areas around clinical care.

One of them, for example, is postpartum depression.

Investigators have shown that postpartum depression can be prevented with psychotherapy delivered during pregnancy to at risk women.

And that just received approval from the US Preventative Services Task Force.

So it's now women everywhere can have access to this if they're at risk for depression.

And if they do get depression, there's a brand new medication on the market due to years and years of basic science research that is effective.

The first ever specific treatment for postpartum depression is now available to women suffering from postpartum depression.

So there's a lot to be excited about in the research space.

One of the things... Another thing that I'll mention that I'm also really excited about is the power of data and computation to bring to bear.

And one area where that's already beginning to have an effect is the ability to predict amongst a population of people you have under care in a healthcare system, for example, who might be at greatest risk of dying by suicide so that you can direct resources to help reduce that risk.

So a lot of things to be excited about in the research world right now.

- We were speaking about younger investigators before, I want to ask you about younger people and the issue of the development of mental illnesses in youth and early adulthood.

Tell us about what you're seeing with regards to potential areas of prevention.

- One piece of astounding research that was published earlier this year was the result of a study that's been a couple of decades in the making.

Scientists some time ago, about 15 years ago, decided that they wanted to test the ability of a rather simple intervention to help middle school kids at risk for substance abuse and mental illnesses.

The intervention was they helped the kids, these middle schoolers, identify adults that they trusted in their community.

And they took those adults and they gave them a few simple short courses on mentoring.

How do you mentor a middle school kid?

That's it.

Very, very simple intervention.

Now, sometime thereafter, five or six years ago they showed that that was really beneficial in terms of helping those kids in high school and reducing their rate of substance use and some other things.

But the astounding data that they published just earlier this year is that those children who went through this intervention, who were connected with mentors that received some training, 10 years later they were dying of any cause at lower rates.

So this simple and intervention in middle school prevents a whole host of medical and psychiatric problems from emerging later, and it literally saves lives.

So there's a lot of potential to build resilience in children.

We talk a lot about risk factors, about youth being vulnerable, about youth contracting mental illnesses in the these critical periods of adolescence.

But there's a lot of potential to be able to use research to find ways to build resilience and prevent the onset of those illnesses.

- It's amazing that research could run the full gamut of studying specific cells in the brain and their interactions, all the way to something that would seem so straightforward as mentoring people who are gonna help young kids.

- It is amazing.

And one of the things that I like about my job is that I get to think about all those kinds of research.

I get to think about how studying receptors on the cells of neurons that respond to GABA, gamma-aminobutyric acid, a little chemical, how that might be useful in terms of developing a medicine for postpartum depression.

But I also get to think about what we need to do now to help people who are suffering and how we can improve the delivery of evidence-based practices.

And I think it's very, very important that we in the mental health research community recognize that we need to fund all these different kinds of research.

Because yes, we need to do something for the people who are suffering now, but we also need to think how can we truly transform our ability to prevent and cure mental illnesses in the future by investing in basic science now.

So we need it all.

- What types of things do you see coming down the road in five or 10 years?

What do you envision as things for people to really be hopeful about with future treatments?

- Well, if I'm thinking the five-year timeframe, let me start there.

We have a number of research programs that are aimed... That are in this roughly described area of personalized medicine.

In mental health, by personalized medicine, what we're really trying to do is figure out if someone walks into a doctor's office with depression, what is that person gonna best respond to?

We've got some wonderful treatments for depression.

We've got antidepressant medication, we've got cognitive behavioral therapy, we have deep brain stimulation, we have electroconvulsive therapy.

Lots of wonderful, wonderful treatments for depression.

But someone comes into my office and I diagnose depression, I don't know which one of those is gonna work best for that individual.

The reason why I think that's a five-year timeframe, that's a near term timeframe, is we can use the power of data and the power of computation.

Without necessarily understanding why, we can use information that we can get about these individuals.

From brain scans, from genetics, from electrophysiological studies, like EEGs, and from behavioral tests, and from talking to the patient.

If we can put all that information into one database and get that information on lots of individuals, then we can make predictions about which individuals are more likely to respond to say, medication as opposed to psychotherapy, or psychotherapy as opposed to medication.

And I think we're pretty close.

We've got some studies that have come out in the last couple of years showing that if you have this type of pattern of brain activity on a brain scan, you're more likely to get better with magnetic resonance.

You're more likely to get better with transcranial magnetic stimulation, if you have a particular pattern of brain activity on a brain scan.

So we need to really get that up and running a little bit better, but it's promising for the next five years - Just as if somebody has an infection, we could know which antibiotic to use for that infection.

We can get closer to the point where if somebody has depression, we can know which treatment matches this person and their depression.

- Exactly right, exactly right.

We just need to know what tests we have to run.

And there are some promising tests out there, more and more.

So we need to prove they work.

And I think that's a shorter timeframe than some other questions that we're asking.

- And how about some of the other things that may take a little bit more time but also can have a tremendous impact?

- There are a number of studies that we're trying to do to improve treatments for schizophrenia.

We just started a new collaborative project called the Accelerating Medicine's Partnership for Schizophrenia, or AMP Schizophrenia Initiative.

This is a public private partnership run by the foundations for the National Institute of Health, with a number of different nonprofit and for-profit partners.

We've all invested in this collectively.

And what we're trying to do is study individuals in what's so called the clinical high risk state for schizophrenia.

These are adolescents who have symptoms that are disturbing them and who are suffering from things like social withdrawal and difficulty in schools that indicate they are at risk for developing psychosis.

This partnership is aimed at characterizing those individuals well enough to be able to test treatment interventions that will reduce that risk and that will help them with the symptoms that they're enduring.

And what I like most about this partnership and what gives it the potential to pay off in the nearer term, maybe 10 years instead of five, is that we're partnering with drug companies who have innovative hypotheses and compounds that target those hypotheses for how schizophrenia evolves during these early time periods in youth.

So it's a very promising endeavor and I hope that it will pay off in the near term.

- It is exciting to think about prevention.

In other fields of medicine, we'll talk about cardiology, if somebody has signs of potential heart attacks such as high blood pressure, cholesterol, et cetera, we treat that before there's a heart attack so that there isn't one.

The idea of doing intervention so that somebody doesn't develop schizophrenia is extremely exciting.

- It is exciting, and there's some early clues that it might be possible.

So for example, there are some psychotherapeutic interventions when put together in a care management package that and shown to reduce the impact of psychosis development in these kids.

So there's a lot of possibility there.

There's also possibility in preventing the recurrence of episodes of bipolar disorder.

If we can detect them earlier with say, cell phone technologies and other things that assess moment to moment how someone is feeling as opposed to only when the doctor sees them every few weeks.

So there's a lot of possibility for reducing the impact and burden and mental illness through prevention.

- One of your roles is to do everything that you can to make sure that there is enough financial support for research on the brain and psychiatric conditions.

I'm wondering, how do you do that?

How do you explain to the public, to the Congress, to other constituencies?

How do you explain the importance of this research and that more needs to be done?

- I think to convince people of the importance of mental health research requires you to convey two kind of simple facts.

The first fact is that mental illnesses are tremendously burdensome, right?

I don't have to tell you that, you know that more than anyone perhaps in your position.

You've seen it, you've talked with people, you're a provider, and you know that.

But people need to know that depression is number one cause of disability worldwide.

People need to know that mental illnesses are in the top 10 in terms of disability in the United States, that suicide is a number one or number two cause of death amongst youth depending upon the age group you're talking about.

People need to know those facts, needs to know that mental illness is tremendously burdensome.

That's number one.

But you can't stop there.

You can't just say it's a problem and it's a big problem.

You need to say that research can provide the solutions to the problem, right?

So emphasizing the successes that mental health research has had over the years is also important.

So I talk about, well, cognitive behavioral therapy, which is an incredibly efficacious treatment for depression, for anxiety, and a number of other mental health conditions.

I talk about the drugs that have been developed with the help of NIMH funds and with the help of the researchers who've been working on these things for, sometimes, decades.

I talk about the promise of what we're doing now to reduce the burden of schizophrenia, to reduce suicide rates in the United States.

One has to talk about the successes, because for people to invest in mental health research, they don't...

It's important that yes, they understand that it's that it's a tremendous problem, that it creates burden, that it harms people.

But they also have to know that investing in mental health research will alleviate that burden and will help people.

- Well, we know that a lot more new needs to be done.

During the course of our careers we've seen tremendous advances.

And to get the more that needs to be done accomplished, we need to continue to support research.

- Yeah, and especially the young brightest ones who are the most innovative.

That's really important.

- Josh, I want thank you for joining us today and thank you for your leadership at NIMH, which is certainly having a tremendous impact.

Thank you.

- Thank you, Jeff.

Thanks for having me.

Thanks for the opportunity to talk with you and to tell your viewers about what we're doing at NIMH.

- [Dr. Borenstein] Until next I'm Dr. Jeff Borenstein.

(gentle music) Do not suffer in silence.

With help there is hope.

This program is brought to you in part by the American Psychiatric Association Foundation, The Bank of America Charitable Gift Fund, and the John & Polly Sparks Foundation.

Remember, with help there is hope.

(gentle music continues)