The Biology of Mental Disorders - OTA Archive

189 Pages·1995·2.07 MB·English

The Biology of Mental Disorders
September 1992
OTA-BA-538
NTIS order #PB92-228477
GPO stock #052-003-01299-5
Recommended Citation:
U.S. Congress, Office of Technology Assessment, The Biology of Mental Disorders,
OTA-BA-538 (Washington, DC: U.S. Government Printing Office, September 1992).
For sale by the U.S. Government Printing Office
Superintendent of Documents, MaiI Stop, SSOP, Washington, DC 20402-932X”
ISBN 0-16 -038047-2
ii
In Appreciation
SILVIO O. CONTE
The Office of Technology Assessment dedicates this report to the memory of the late Congressman
Silvio O. Conte, in recognition of his enthusiastic support for research into the brain and mental
disorders. Congressman Conte demonstrated that support in many ways, including his request for
this study. His leadership in this area significantly contributed to the gains, already made and yet
to come, in understanding and treating mental disorders.
. . .
Ill
Foreword
The 1990s bear witness to two opposing realities of mental illness. One is the pressing
and even tragic nature of mental disorders: serious mental disorders, including schizophrenia
and major mood and anxiety disorders, afflict millions of Americans, producing long-lasting
and disabling symptoms. The other reality is improved technologies and advances in brain
research that provide hope for alleviating the substantial burden of mental disorders—to
individuals with these conditions, their families, and society at large-and the continuing
research and development that promises future gains.
Recognizing both the public health problem posed by mental disorders and the recent
gains and future promise of brain research, several congressional committees requested or
endorsed this report, which is the fourth in a series of OTA studies on ‘‘New Developments
in Neuroscience. ’ The House Committees on Appropriations; Energy and Commerce;
Science, Space, and Technology; Veteran Affairs; and the Senate Subcommittee on Science,
Technology, and Space of the Committee on Commerce, Science, and Transportation
requested this study. The study was endorsed by Senator Edward M. Kennedy, Chairman of
the Senate Committee on Labor and Human Resources.
The Biology of Mental Disorders presents a summary of research into the biological
factors associated with schizophrenia, bipolar disorder, major depression, obsessive-
compulsive disorder, and panic disorder. The report also discusses support for this research
and the social context in which it moves forward. OTA concludes that, indeed, there have been
important advances in understanding the biology of these disorders, and that rich opportunities
for further research exist. While we know that these mental disorders cannot be understood
in biological terms alone-psychological and social factors are important for a complete
picture of mental disorders and their treatment-we conclude that further biological research
will significantly improve our understanding and treatment of these conditions. Mindful of the
advances and continued opportunities in research, the report provides policy options for action
by the U.S. Congress in three areas: support for research, implications of research findings,
and the dissemination of new information.
OTA prepared this report with the assistance of a panel of advisers and reviewers selected
for their expertise and diverse points of view. Additionally, dozens of individuals from
academia, professional and advocacy groups, and Federal agencies cooperated with OTA staff
through interviews or by providing written material. OTA gratefully acknowledges the
contribution of each of these individuals. As with all OTA reports, however, the responsibility
for the contents of this report is OTA’s alone.
8(?
&# L’&A--
JOHN H. GIBBONS
~ Director
1 US. Congress, Office of Technology Assessment, Neurotoxicity: Identifying and Controlling Poisons of the Nervous
System, OTA-BA-436 (Washington DC: U.S. Government Printing OffIce, April 1990); U.S. Congress, Office of ‘Ikchnology
Assessment, Neural Grafling: Repairing the Brain and Spinal Cord, OTA-BA462 (Washingto~ DC: U.S. Government Printing
Office, September 1990); U.S. Congress, Office of Technology Assessment, Biological Rhythms.’ Implications for the Worker,
OTA-BA-463 (Washington DC: U.S. Government Printing Office, September 1991).
New Developments in Neuroscience Advisory Panel
Peter S. Spencer, Chair
Center for Research on Occupational and Environmental Toxicology
Oregon Health Sciences University
Portland, OR
Robert H. Blank Ronald Kartzinel Herbert Paroles
University of Canterbury Elan Pharmaceutical Research Corp. College of Physicians and
Christchurch, New Zealand Gainesville, GA Surgeons
Columbia University
James F. Childress Alan Kraut
New York, NY
Department of Religious Studies American Psychological Society
University of Virginia Washington, DC Richard M. Restak
Charlottesville, VA Neurological Associates
Franklin E. Mirer
Washington, DC
Fred H. Gage Health and Safety Department
Department of Neuroscience United Auto Workers
University of California, San Diego Detroit, MI
La Jolla, CA
Albert S. Moraczewski
Bernice Grafstein Pope John XXIII Medical, Moral
Department of Physiology Research, and Education Center
Cornell University, School of Houston, TX
Medicine
New York, NY
The Biology of Mental Disorders Study Panel
Michael S. Gazzaniga Ellen McGrath Alan A. Stone
Dartmouth Medical School The Psychology Center Harvard Law School
Hanover, NH Laguna Beach, CA Cambridge, MA
James T. Havel Neil J. Risch David B. Wexler
Mental Health Policy Resource Yale University University of Arizona
Center, Inc. School of Medicine Tuscon, AZ
Washington, DC New Haven, CT
David Taiwai Wong
David J. Kupfer Sara-Ann Steber Eli Lilly and Co.
Western Psychiatric Institute University of Pennsylvania Indianapolis, IN
and Clinic Philadelphia, PA
Pittsburgh, PA
NOTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the advisory panel members.
The panel does not, however, necessarily approve, disapprove, or endorse this report. OTA assumes fi.dl responsibility for the
report and the accuracy of its contents.
vi
OTA Project Staff—The Biology of Mental Disorders
Roger C. Herdman, Assistant Director, OTA
Health and L&e Sciences Division
Michael Gough, Biological Applications Program Manager
David R. Liskowsky, Project Director, New Developments in Neuroscience
Laura Lee Hall, Study Director
Sema K. Aydede, Contractor
Jacqueline T. Keller, Research Assistant
Alan P. Lozier, Intern
Michelle C. Munson, Intern
Claire L. Pouncey, Research Analyst
M. Catherine Sargent, Research Assistant
Support Staff
Cecile Parker, Office Administrator
Linda Journette-Rayford, Administrative Secretary
Jene Lewis, Secretary
Contractors
Blair Burns Potter (editor), Bethesda, MD
John P. Ambrose and J. David Gallagher, National Mental
Health Association, Alexandria, VA
William T. Carpenter, Maryland Psychiatric Research Center, Baltimore, MD
Roland D, Ciaranello, Stanford University School of Medicine, Stanford, CA
John M. Kane, Long Island Jewish Medical Center, Glen Oaks, NY
Jaques M. Quen, New York Hospital-Cornell Medical Center, New York, NY
Greg Scandlen, Health Benefits Letter, Alexandria, VA
Contents
Page
Chapter 1. Summary, Policy Issues, and Options for Congressional Action . . . . . . . . . . . . . . . . 3
Chapter 2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Chapter 3. What Are Mental Disorders? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Chapter 4. Mental Disorders and the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Chapter 5. The Genetics of Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Chapter 6. Research Effort and Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.23
Chapter 7. Public Attitudes and Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Appendix A. Decade of the Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Appendix B. Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Appendix C. List of Contractor Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Appendix D. Acronyms and Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Chapter 1
Summary, Policy Issues, and
Options for Congressional Action
CONTENTS
Page
DECADE OF THE BRAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
SCHIZOPHRENIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. .. .. .. .. .. ... ... ......+ . . . . . 6
MOOD DISORDERS: MAJOR DEPRESSION AND BIPOLAR DISORDER . . . . . . . . . 8
ANXIETY DISORDERS: OBSESSIVE-COMPULSIVE DISORDER AND
PANIC DISORDER . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
A SYNTHESIS: UNDERSTANDING THE ROLE OF BIOLOGY . . . . . . . . . . . . . . . . . . . . 13
THE RESEARCH ENTERPRISE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
What Level of Public Concern Motivates Research Into Mental Disorders? . . . . . . . . . 14
What Is the Level of Research Support? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
What Factors Create Barriers to Research? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
IMPLICATIONS OF BIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
POLICY ISSUES AND OPTIONS FOR CONGRESSIONAL ACTION . . . . . . . . . . . . . . . 21
ISSUE 1: Federal Support for Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ISSUE 2: Implications of Scientific Advances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
ISSUE 3: Dissemination of New Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Boxes
Box Page
l-A. The Cost of Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
l-B. The Final Symptom: Mental Disorder and Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
l-C. Darkness Visible-A Personal Account of Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
l-D. Media Portrayals of Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
l-E. Eugenics and Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
l-F. Educating the Public About Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Figures
Figure Page
l-l. The Cost of Mental Disorders, 1985 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
l-2. Membership in the Society for Neuroscience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
l-3. Distribution of Federal Support of Neuroscience Research, Fiscal Year 1990 . . . . . . 5
l-4. PET Scan of an Individual With Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
l-5. Mood Disorders Among Twins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
l-6. PET Scan of an Individual With Obsessive-Compulsive Disorder . . . . . . . . . . . . . . . . 13
l-7. NIMH Budget, Fiscal Years 1980-92 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
l-8. Funding of the Division of Basic Brain and Behavioral Sciences,
Fiscal Years 1988-92 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 17
l-9. Funding of the Division of Clinical Research, Fiscal Years 1980-92 . . . . . . . . . . . . . . 17
Tables
Table Page
l-1. Prevalence of Severe Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
l-2. Obsessions and Compulsions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
l-3. Comparison of Costs and Research Funding, Fiscal Year 1985 . . . . . . . . . . . . . . . . . . . 16
l-4. Drugs in Development for Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
l-5. DEPRESSION Awareness, Recognition, and Treatment Program,
Fiscal Years 1986-91 . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Chapter 1
Summary, Policy Issues, and Options for Congressional Action
Mental disorders can strike with savage cruelty, age of hospital beds in Department of Veterans
producing nightmarish hallucinations, crippling par- Affairs (VA) hospitals: Fully 40 percent of all VA
anoia, unrelenting depression, a choking sense of inpatient care is for persons with mental disorders.
panic, or inescapable obsessions. The sheer number Perhaps most tragically, approximately one-third of
of Americans with mental disorders transforms this homeless single adults and 10 to 15 percent of
personal tragedy into a widespread public health individuals who are incarcerated in jails and prisons
problem. Nearly one in three American adults will have a severe mental disorder such as schizophrenia
experience a mental disorder during his or her or bipolar disorder.
lifetime, whether one of the disorders considered in
this report [schizophrenia, bipolar disorder (com- One of the most powerful factors affecting people
monly known as manic depression), major depres- with mental disorders and their families is the stigma
sion, obsessive-compulsive disorder, and panic dis- often attached to these conditions. While the pub-
order; table 1-1], or one of a variety of other lic’s attitudes and knowledge about mental disorders
conditions, including cognitive impairment (as in have improved during the last 30 years, negative
Alzheimer’s disease), substance abuse or depend-
attitudes toward and ignorance of these disorders
ence, phobias, and antisocial personality disorder.
still abound. A sizable number of people continue to
Moreover, approximately 1.7 to 2.4 million Ameri- be frightened by the notion of mental illness. The
cans currently suffer from a persistent and severely
public fears that people with mental disorders are
disabling mental disorder, such as schizophrenia or
violent and dangerous and perceives them to be dirty
bipolar disorder.
and unattractive, therefore often treating them with
What are the costs of this public health problem? disrespect, if not rejecting them outright. Further-
The most recent and comprehensive estimate of the more, despite gains in knowledge about specific
total costs of mental disorders—for fiscal year
Figure l-l—The Cost of Mental Disorders, 1985
1985—added up to $103.7 billion (figure l-l) (box (in billions of dollars)
l-A). When adjusted for inflation, this figure reaches Other costs
$136.1 billion in 1991. However, dollar figures $4.5
alone, no matter how large, do not convey the toll
Mor
mental disorders take. These disorders can be
extremely disabling, significantly compromising
productivity and the ability to work. It has been
estimated that individuals with mental disorders fill
25 percent of all hospital beds and, further, that
one-third of these persons suffer from schizophrenia.
Mental disorders account for an even larger percent-
Table l-l—Prevalence of Severe Mental Disorders
Adults diagnosed with
disorder during their Direct health-related costs
lifetimes $42.5
Disorder (%)
In 1985, mental disorders cost the United States more than$103
Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.0 billion. Approximately 41 percent of that cost-$42.5 billion—
Bipolar disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.8 stemmed from hospital care, medication costs, and other treat-
ment costs. Nearly half of the costs of mental disorders-$47.4
Major depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.9 billion-derives from lost productivity.
Obsessive-compulsive disorder . . . . . . . . . . . . . . . . 2.6 SOURCE: Rice, S. Miller, et al., The Economic Costs
Alcohol and Drug Abuse and Mental Illness, report submitted to
Panic disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6
the Office of Financing and Coverage Policy, Alcohol, Drug
SOURCE: Robins and D.A. Psychiatric Disorders America, Abuse, and Mental Health Administration, U.S. Department of
The Epidemiologic Area Study (New York, NY: Free Health and Human Services (San Francisco, CA: Institute for
Press, 1991). Health and Aging, University of California, 1990).
–3–