Richard K' Nakamura, Ph'D'

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Science and Service Opening Pathways to Better
Mental Health
Complexities of Co-occurring Conditions Meeting
Richard K. Nakamura, Ph.D. Deputy
Director National Institute of Mental Health
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NIMH Mission

• Reduce the burden of mental and behavioral
  disorders through research on mind, brain and
  behavior

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How do we do this?

• NIMH budget is over 1.3 billion
• 7th Largest Institute of the NIH
• Most goes into 2000 research grants around the
  country based on expert review that funds less
  than 1/3 of applications.

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The Burden of Mental Illness is Enormous
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World Bank and the World Health Organization

• Global Burden of Disease
• To measure both premature death and disability, a
  single measure was developed
• Disability Adjusted Life Year
• DALY
• One DALY is one lost year of healthy life.

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Disease Burden by Illness - DALY World,
2000All Ages
Lower respiratory infections Perinatal
conditions HIV/AIDS Unipolar depressive disorders
Diarrhoeal diseases Ischaemic heart
disease Cerebrovascular disease Road traffic
accidents Malaria Tuberculosis
0 1 2 3 4 5 6 7
Percent of Total
Source World Health Organization World Health
Report, 2001
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Disease Burden by Illness - DALY World,
200015-44 year olds
HIV/AIDS Unipolar depressive disorders Road
traffic accidents Tuberculosis Alcohol use
disorders Self inflicted injuries Iron-deficiency
anemia Schizophrenia Bipolar affective
disorder Violence
0 2 4 6 8 10 12
Percent of Total
Source World Health Organization World Health
Report, 2001
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Disease Burden by Illness - DALY United States,
Canada and Western Europe, 200015 - 44 year olds
Unipolar depressive disorders Alcohol use
disorders Road traffic accidents Drug use
disorders Self inflicted injuries Bipolar
disorder Migraine Schizophrenia Hearing Loss,
adult onset HIV/AIDS
0 2 4 6 8 10 12 14 16
18
Percent of Total
Source WHO Burden of Disease Statistics, 2001
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Disease Burden by Illness - DALY United States,
Canada and Western Europe, 2000 All Ages
Percent of
Source World Health Organization Burden of
Disease Statistics, 2001
total DALYs


Includes self-inflicted injuries
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Causes of Disability United States, Canada and
Western Europe, 2000 All Ages
Percent of
Source World Health Organization Burden of
Disease Statistics, 2001
total YLDs


Includes self-inflicted injuries
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Suicide in America

• 11th Leading cause of death (1.3 of all deaths)
• 30,662 in 2001 (undercounting likely)
• 8th leading cause of death in men
• 3rd leading cause of death in 15-24 year olds
• Suicide outnumbered homicide by 3 to 2
• There are now twice as many deaths due to suicide
  than due to HIV/AIDS
• 90 had a mental illness

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Comorbidity of Mental Disorders with Any
Substance Abuse
Rank Order of Mental Disorders by Odds Ratio
with Substance Odds Axis
/ Disorders Abuse or Dependence Ratio
Bipolar I 61 7.9 Bipolar II 48 4.7 Schiz
ophrenia 47 4.6 Panic Disorder 36 2.9 Obse
ssive Compulsive Disorder 33 2.5 Dysthymia 3
1 2.4 Unipolar Depression 27 1.9 Phobia 2
3 1.6
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The Brain Changes

• We now understand that our genes specify a
  general plan with many options. Our brain
  changes its physical structure through behavior
  and interactions with the environment

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A Revolution

• Our new understanding of the brain integrates
• nature and nurture
• mind and brain
• genes and the environment

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Neurogenesis in the Adult Human
I
II
Source Eriksson et al., 1999
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Stress Impairs Neurogenesis
Dentate Gyrus, Marmoset Monkey
400
300
plt.05
BrdU Labeled Cells/mm3

200
100
Gould 1998
0
Control
Stress
Dentate Gyrus, Adult Rat
4000
3000
plt.05

2000
BrdU Labeled Cells
1000
Gould 2000
0
Dominant
Subordinate
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Physical Activity Neurogenesis
Source van Praag et al., 1999
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Science 301 805-809, 2003
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Source Trachtenberg et al Nature, December 2002
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Anxiety PTSD
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Evidence in Humans PTSD Patients Fail to Show
mPFC Activation When Exposed to Traumatic
Reminders
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Non-PTSD
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PTSD
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Science, 302 386-388, 2003
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Modulation of Cortical-Limbic Pathways in Major
Depression Treatment-Specific Effects of
Cognitive Behavior Therapy Kimberly Goldapple,
MSc Zindel Segal, PhD Carol Garson,MA Mark
Lau, PhD Peter Bieling, PhD Sidney Kennedy, MD
Helen Mayberg, MD Arch Gen Psychiatry. 200461
34-41.
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Summary Modulation of Common System Treatment-S
pecific Effects
attention-cognition
pCg
PF9
P40
-
CBT
hippocampus
mF9/10
mood state
Emotion-cognition integration
thal
bg
aCg24
oF11
Cg25
a-ins
-
drug
bs
hth
am
vegetative-circadian
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Anxiety PTSD
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BEST BUYS IN MENTAL HEALTH
Gavin Andrews, Cathy Issakidis, Kristy
Sanderson, Justine Corry, Helen Lapsley Policy
Epidemiology Group, School of Psychiatry, UNSW
WHO Collaborating Centre, St Vincents Hospital
Sydney
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Best Buys study disorders covered

• Affective depression, dysthymia, bipolar
  disorder
• Anxiety panic/agoraphobia, social phobia,
  generalized anxiety disorder, post-traumatic
  stress disorder
• Alcohol abuse and dependence
• Schizophrenia

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Results Current Treatment
Coverage Effective Burden Efficiency coverage
averted /YLD Depressive
Disorders 60 34 15 20 000 Anxiety
Disorders 35 20 13 15 000 Alcohol
Disorders 11 6 2 98 000 Schizophrenia 100 13 196
000 Total 40 23 13 30 000
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Results Optimal Treatment
Coverage Effective Burden Efficiency coverage
averted /YLD Depressive
Disorders 60 60 23 11 000 Anxiety
Disorders 35 35 20 9 000 Alcohol
Disorders 11 11 5 53 000 Schizophrenia 100 100 22
107 000 Total 40 40 20 18 000
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