If Kennedy and Insel are right, this last frontier may be like President Kennedy's visionary race to the moon, but in this case repairing the brain is not a race or a dream, but combined effort of many disciplines and perhaps much harder work than any moonshot. —Dee Higley, psychology professor
Patrick Kennedy received several wake-up calls before he finally heard the bell.
Perhaps the most dramatic was at 2:45 a.m. on a May morning in 2006, when the five-term congressman from Rhode Island drove into a barricade at the U.S. Capitol, appearing incoherent as he told police he was late for a vote.
The next day at a press conference, Kennedy acknowledged that he suffered from long-standing drug and alcohol addiction combined with a bipolar disorder that often pairs with addiction.
It's tough for a Kennedy to walk away from politics, and for four more years he soldiered on. But in January 2011 he left Congress, realizing that he needed time and space to get well.
Feb. 22 marks two years of complete sobriety for Kennedy, and the bipolar disorder is controlled. In the interval he married Amy Petitgout, a middle school teacher. He now has a stepdaughter from his wife's previous marriage and a son, Owen, born last April. Grounding himself in a strong nuclear family has been both a source of strength and a payoff for his progress.
Mental illness is very much a family matter. More than 4 million American children and adolescents suffer from serious mental challenges that cause significant disruption at home or school, according to the National Alliance on Mental Illness. Half of all mental disorders begin by age 14, and 21 percent of children aged 9 to 17 have some degree of mental or addictive impairment.
Since leaving Congress, Kennedy has not only gotten well, he has also made the leap from mental health poster boy to mental health policy advocate. Shortly after leaving Congress, he helped launch One Mind for Research, an intensive 10-year project designed to unify and advance treatment research on mental health and substance addiction.
One Mind's CEO is Gen. Peter Chiarelli, former vice chief of staff of the U.S. Army, who has worked extensively on post-traumatic stress among returning soldiers.
Kennedy calls the project a "moon shot to the mind."
The shot will need to be quick, because policy changes are already afoot. In 2008, Congress passed and President George W. Bush signed a statute requiring insurance companies to treat mental illness and substance addiction the same as other maladies. Kennedy was a leading co-sponsor of the bill.
But the "parity" law is not yet fully implemented, and advocates are anxiously awaiting final rules from the Obama administration. Late last month two former U.S. senators, Pete Domenici, R-N.M., and Gordon Smith,R-Ore., wrote a Wall Street Journal op-ed challenging the administration to speed up the new rules. Both senators arrived there the hard way. Domenici has a daughter who suffers from schizophrenia, and Smith lost a son to depression-bred suicide.
And yet, when the new insurance rules do come online, health professionals will be torn between expectations that they treat mental illnesses as routine medical procedures and the persistent reality that diagnosis and treatment for most mental maladies remain opaque.
The task before Kennedy and his allies is to see through policy changes while shifting public attitudes and accelerating research. The complex influences of genetics and environment on the mind remain a daunting jungle.
"Addiction is almost inevitable," Kennedy said, "if you experiment and use as a teenager, when your brain is not fully developed, before the prefrontal cortex has made its connections to the rest of the brain."
"That doesn't happen until your early 20s," he said. "We know now that nine out of 10 alcoholics and addicts started when they were teenagers." He knows. He was there.
"I had a genetic predisposition for manic depression," he said, "and at home my mother suffered from alcoholism and my father from severe post-traumatic stress," a reference to the trauma of seeing his older brothers assassinated.
Kennedy's parents divorced when he was 13, and he soon began getting counseling and experimenting with drugs. The drugs took. The counseling didn't.
"I would be alright for awhile, but then need help," he said, explaining why he ultimately had to leave public office. "I could stop self-medicating for periods of time, but could never stay stopped. I could get this delusion that I was OK because I was appearing at press conferences with important people. It makes you think you don't have a problem. Denial was enormous for me.
"The common ground from autism, to addiction, to Alzheimer's," according to Kennedy, "is that these are brain illnesses. They are physiological."
Most mental health experts would agree, but they would insist on caveats.
"Sadly, we don't know that much about what causes these syndromes that we call illnesses," said Bob Drake, a professor of psychiatry at Dartmouth Medical School. "They are not really illnesses in the same sense that congestive heart failure, or asthma or hypertension are illnesses, where we actually know something about what is going on in the cells of the body."
Drake's concerns are shared by Tom Insel, the neuroscientist who heads the National Institute of Mental Health.
"I would say the fundamental science about the brain has really undergone a revolution over the last decade or two, and we are far ahead of where we were," Insel told NPR last summer. "But taking that information and turning that into something that's clinically useful has still been a struggle."
Not just drugs
Drake worries that uncertain diagnoses and sketchy treatments combine in an overreliance on poorly understood and poorly managed drugs.
"It is not unusual at all for us to see young people coming in on 13 medicines," Drake said. "Obviously, when someone is on 13 meds, you don't have any idea what is going on." Patients are often deadened by the side effects, Drake said. "So we gradually get them off, one and then another, and then another in order to see who's there. The symptoms are controlled because they are almost catatonic."
Drake sees old-school Freudian psychoanalysis as a failed approach, and now argues that an excessively medication-oriented paradigm has also failed. The alternative is a "biopsychosocial" approach that avoids reducing psychiatry to a search for pathogens and antidotes.
Drake points to controlled studies in Australia and the Netherlands that use a minimal treatment strategy for young people with early psychosis. "They find that after six years those on the low dose strategy are functioning much better," Drake said.
For any kind of mental illness, Drake argues, much hinges on a healthy home environment, pro-social friends, and support for functioning in school or work. "Even if it's only part-time work," he added.
"We know how to do those things," Drake said. "We don't usually pay for those things, though. We pay for hospitalizations and pharmaceuticals."
"If you talk to people in the real world about what they want, they want housing, jobs, friends. They want a therapist who will help them manage their symptoms without being overwhelmed by too much medicine and side effects."
Increasingly, best practices try to balance medications and therapy, said Dee Higley, a psychology professor at Brigham Young University who specializes in addiction.
"You can modify the brain through therapy," Higley said. "You are not fixed in a particular brain structure, even as adults." Higley is referring to an approach know as "cognitive behavioral therapy," which is producing dramatic results in treating addiction and other mental challenges.
"What most psychotherapists are doing now is to get people started on medication so the brain is calmed down," Higley said, "and then over time people can wean themselves off the medication, and the therapy becomes the principle treatment." Higley stresses, however, medications will often remain needed indefinitely.
Many at the highest level of psychiatry share concerns about casual overuse of medication. While the new policy push is to get early diagnosis and prevent psychosis, the methods to get there are intensely controversial.
The new diagnostic manual by the American Psychiatric Association, due out in May, has stirred a firefight in the profession. Allen Francis and Robert Spitzer, two luminaries in the field, warned in an open letter that new, looser diagnostic standards "could add tens of millions of newly diagnosed 'patients' — the majority of whom would likely be false positives subjected to the needless side effects and expense of treatment."
Saving the world
Medication is attractive, partly because it can sometimes work wonders, but also because reducing illness to a pathogen and hitting it with an antidote might allow everyone to go home. In contrast, the holistic approach Drake favors is very difficult to scale and requires deep reaches into private lives.
"We are a small agency, but we are a bold agency. We are trying to save the world," said Anne Mathews-Younes, a division director at the Substance Abuse and Mental Health Services Administration.
Much like Drake, Mathews sees mental health as wrapped up in all the deprivations or shocks that would jar an otherwise healthy life, tipping someone who is predisposed to depression or other dysfunction over the edge.
Mathews calls these environmental dangers "risks" and the positive alternative "protective factors." The idea is that many people are predisposed to tip into a mental disorder or addiction if certain environmental "triggers" occur. Avoiding or controlling these triggers is often all that is needed to avoid or control long-term problems.
"Poverty is a risk," Mathews said. "Family dysfunction is a risk. A lack of education is risk. We have a column where we say, if you have this many risk factors, it is very hard to be resilient and make it through life."
Mathews speaks of "targeting" such families, "getting in early" before problems develop. SAMSHA literature speaks of parenting classes and early childhood education, all under the rubric of encouraging mental health and controlling addiction.
"I'm not suggesting that drugs have no role at all," Mathews said, "but in many instances, a person with support can be in a very good position to judge what he or she needs. I have a lot of confidence in people's ability to make decisions for themselves."
And yet, to ensure the needed support, SAMSHA reaches to the most intimate household details of those at risk — a paradox with troubling economic implications for doing the job right.
Holding his own
Back in Rhode Island, Patrick Kennedy will soon be celebrating his two-year sobriety anniversary.
In the heady whirlwind of public life, first elected to office at 21, Kennedy never had a chance to get his feet on the ground. Power and pressure fed addiction and mental illness in feedback loops. Leaving Congress gave him the space he needed.
Kennedy and his future wife dated for over a year before tying the knot in the July 2011. "The good thing is that she got to see me when I wasn't well," he said.
But for two years now, she's seen the good side. Kennedy exercises every day, goes to bed early, eats well and is in much better physical condition. He also attends an hour-long 12-step addiction meeting every day. "Even on the road, I find one," he said. He engages in breathing exercises and has learned to anticipate when an episode is coming on and counter it.
The changes in lifestyle and strong family and social support have allowed him to live without medication for now. None of this was possible when he was in Congress.
Dee Higley is initially skeptical when he hears that Kennedy is managing without medication. "We really don't have good data for bipolars doing very well with just therapy, but we have a lot of data showing that medications work quite well," Higley said.
But he takes a step back when he learns of Kennedy's rigorous regimen. Therapy often works for some patients and not for others, Higley said, because some go home and internalize what they learn, hard wiring it into the brain, while others set it aside until the next session.
"Attending a group daily is like practicing the same things he was learning in therapy," Higley said. "If you go to someplace where you are reminded every day of what you have learned, its like therapy every day and you are much more successful." In short, Kennedy may be defying the odds through strong social support and his own hard work and determination.
If so, we have come full circle. "It's chemistry, not character," Kennedy had said in our conversation.
But it's not just chemistry. There is no pharmaceutical silver bullet. And experts are clear that environment will always play a potent role — harmful triggers for failure and social support for recovery. And Kennedy's own experience suggests that personal factors also carry weight.
With so many crosscutting variables, it's no surprise that this "last frontier" of medicine and policy remains maddeningly elusive.
"If Kennedy and Insel are right," Higley said, "this last frontier may be like President Kennedy's visionary race to the moon, but in this case repairing the brain is not a race or a dream, but combined effort of many disciplines and perhaps much harder work than any moonshot."