Abstract Mental disorders are common, complex, highly morbid conditions for which basic underlying mechanisms are poorly understood. Despite the utility of many existing treatments, there remains vast unmet need for more effective and safer therapeutics. Most current medicines for mental disorders are based on chemical modifications of serendipitously discovered mid-twentieth-century prototypes, and widely used diagnostic manuals remain phenomenological and conceptually confused. After decades of stasis, research on mental disorders has reached an inflection point. Unbiased large-scale genetics provides information that, if interpreted circumspectly and integrated with neurobiology, provides “finding tools” for causal biological mechanisms that can advance discovery of biomarkers, preventive interventions, and better treatments. However, uncritically applied predictive genomic technologies can produce fatalism and exacerbate stigma. Moreover, polygenic risk scores for cognitive ability and risk of mental illness are already being offered commercially for embryo selection with in vitro fertilization, a worrisome resurgence of eugenics hiding in liberal (noncoercive) guise.
{"title":"The Biology of Mental Disorders: Progress at Last","authors":"Steven E. Hyman","doi":"10.1162/daed_a_02038","DOIUrl":"https://doi.org/10.1162/daed_a_02038","url":null,"abstract":"Abstract Mental disorders are common, complex, highly morbid conditions for which basic underlying mechanisms are poorly understood. Despite the utility of many existing treatments, there remains vast unmet need for more effective and safer therapeutics. Most current medicines for mental disorders are based on chemical modifications of serendipitously discovered mid-twentieth-century prototypes, and widely used diagnostic manuals remain phenomenological and conceptually confused. After decades of stasis, research on mental disorders has reached an inflection point. Unbiased large-scale genetics provides information that, if interpreted circumspectly and integrated with neurobiology, provides “finding tools” for causal biological mechanisms that can advance discovery of biomarkers, preventive interventions, and better treatments. However, uncritically applied predictive genomic technologies can produce fatalism and exacerbate stigma. Moreover, polygenic risk scores for cognitive ability and risk of mental illness are already being offered commercially for embryo selection with in vitro fertilization, a worrisome resurgence of eugenics hiding in liberal (noncoercive) guise.","PeriodicalId":47980,"journal":{"name":"Daedalus","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139299088","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"社会学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract The underpinnings of today's mental health crisis include both social structural inequities and neurobiological vulnerabilities. The COVID-19 pandemic has compounded and escalated a long-standing problem, rendering the mental health crisis and its dangerous consequences visible and exigent. We now possess a clearer and more nuanced understanding of the broken mental health care system and its serious inadequacies, as well as its potential for effective caregiving. The professional forms of knowledge and practice are paralleled by an even more substantial system of care involving families, networks, communities, and, of course, those living with mental health conditions themselves. Even when delivered by community care workers, psychotherapy can be as effective as somatic treatments for some mental health conditions. Harm reduction and other public health approaches offer means of preventing or mitigating the disastrous human toll of the substance use disorder epidemic. Social technology offers new opportunities for enhancing mental health and well-being. With these informal systems alongside standardized health care systems, the future could realize a mental health care system with much greater potential to avert the worst harms and offer effective care to many more.
{"title":"Introduction: How Mental Health Matters","authors":"Anne E. Becker, Giuseppe Raviola, Arthur Kleinman","doi":"10.1162/daed_e_02029","DOIUrl":"https://doi.org/10.1162/daed_e_02029","url":null,"abstract":"Abstract The underpinnings of today's mental health crisis include both social structural inequities and neurobiological vulnerabilities. The COVID-19 pandemic has compounded and escalated a long-standing problem, rendering the mental health crisis and its dangerous consequences visible and exigent. We now possess a clearer and more nuanced understanding of the broken mental health care system and its serious inadequacies, as well as its potential for effective caregiving. The professional forms of knowledge and practice are paralleled by an even more substantial system of care involving families, networks, communities, and, of course, those living with mental health conditions themselves. Even when delivered by community care workers, psychotherapy can be as effective as somatic treatments for some mental health conditions. Harm reduction and other public health approaches offer means of preventing or mitigating the disastrous human toll of the substance use disorder epidemic. Social technology offers new opportunities for enhancing mental health and well-being. With these informal systems alongside standardized health care systems, the future could realize a mental health care system with much greater potential to avert the worst harms and offer effective care to many more.","PeriodicalId":47980,"journal":{"name":"Daedalus","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139303426","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"社会学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract This essay chronicles the history of medical associations between schizophrenia and Blackness that emerged during the tumultuous decades of the 1960s and 1970s, when American psychiatrists overdiagnosed schizophrenia in Black men in ways that undermined brain science of the era. I provide data to show how racially disparate diagnostic outcomes resulted not solely from the attitudes or biases of clinicians, but from a series of larger political and social determinants, most notably changing frameworks surrounding mental illness and political protest. I conclude by highlighting how training clinicians to examine their own cultural biases also needs to include training in how structures and institutions produce symptoms and diseases, and how we can only build better structures to support health if we can individually and then communally imagine them.
{"title":"The Protest Psychosis & the Future of Equity & Diversity Efforts in American Psychiatry","authors":"J. Metzl","doi":"10.1162/daed_a_02033","DOIUrl":"https://doi.org/10.1162/daed_a_02033","url":null,"abstract":"Abstract This essay chronicles the history of medical associations between schizophrenia and Blackness that emerged during the tumultuous decades of the 1960s and 1970s, when American psychiatrists overdiagnosed schizophrenia in Black men in ways that undermined brain science of the era. I provide data to show how racially disparate diagnostic outcomes resulted not solely from the attitudes or biases of clinicians, but from a series of larger political and social determinants, most notably changing frameworks surrounding mental illness and political protest. I conclude by highlighting how training clinicians to examine their own cultural biases also needs to include training in how structures and institutions produce symptoms and diseases, and how we can only build better structures to support health if we can individually and then communally imagine them.","PeriodicalId":47980,"journal":{"name":"Daedalus","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139300799","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"社会学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Isaac R. Galatzer-Levy, Gabriel J. Aranovich, Thomas R. Insel
Abstract Over the past two decades, advances in digital technologies have begun to transform three aspects of mental health care. The use of sensors and artificial intelligence (AI) have provided new, objective measures of how we think, feel, and behave. The ease of connecting and communicating remotely has transformed the brick-and-mortar practice of mental health care into a telehealth service, increasing access and convenience for both patients and providers. And the advent of digital therapeutics, from virtual reality for treating phobias to conversational agents for delivering structured therapies, promises to alter how treatments will be delivered in the future. These digital transformations can help to solve many of the key challenges facing mental health care, including access, quality, and accountability. But digital technology introduces a new set of challenges around trust, privacy, and equity. Despite high levels of investment and promotion, there remain profound questions about efficacy and safety of digital mental health technologies. We share our experiences from the front lines creating digital innovations for mental health, with a focus on what a digital transformation of care could deliver for millions with a serious mental illness.
{"title":"Can Mental Health Care Become More Human by Becoming More Digital?","authors":"Isaac R. Galatzer-Levy, Gabriel J. Aranovich, Thomas R. Insel","doi":"10.1162/daed_a_02040","DOIUrl":"https://doi.org/10.1162/daed_a_02040","url":null,"abstract":"Abstract Over the past two decades, advances in digital technologies have begun to transform three aspects of mental health care. The use of sensors and artificial intelligence (AI) have provided new, objective measures of how we think, feel, and behave. The ease of connecting and communicating remotely has transformed the brick-and-mortar practice of mental health care into a telehealth service, increasing access and convenience for both patients and providers. And the advent of digital therapeutics, from virtual reality for treating phobias to conversational agents for delivering structured therapies, promises to alter how treatments will be delivered in the future. These digital transformations can help to solve many of the key challenges facing mental health care, including access, quality, and accountability. But digital technology introduces a new set of challenges around trust, privacy, and equity. Despite high levels of investment and promotion, there remain profound questions about efficacy and safety of digital mental health technologies. We share our experiences from the front lines creating digital innovations for mental health, with a focus on what a digital transformation of care could deliver for millions with a serious mental illness.","PeriodicalId":47980,"journal":{"name":"Daedalus","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139305804","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"社会学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Psychological treatments are among the most effective interventions for a wide range of mental health conditions but remain inaccessible to most people who could benefit from them, including in many high-income countries. We describe two case studies from South Asia that demonstrate innovatively designed psychological treatments addressing many of the barriers that limit their scalability. The treatments are brief, less complex, and delivered by frontline providers, such as peer counselors in community settings. These case studies, alongside a large and growing literature from around the world, provide the foundation for a paradigm shift in mental health care by rejecting the nihilistic notion that communities do not have enough resources to address mental health problems or that these problems are too complex to address. Central to this notion is the recognition that mental health problems can be addressed effectively with resources that every community possesses: people who care for others in their communities.
{"title":"Empowering the (Extra)Ordinary","authors":"Vikram Patel, Atif Rahman","doi":"10.1162/daed_a_02041","DOIUrl":"https://doi.org/10.1162/daed_a_02041","url":null,"abstract":"Abstract Psychological treatments are among the most effective interventions for a wide range of mental health conditions but remain inaccessible to most people who could benefit from them, including in many high-income countries. We describe two case studies from South Asia that demonstrate innovatively designed psychological treatments addressing many of the barriers that limit their scalability. The treatments are brief, less complex, and delivered by frontline providers, such as peer counselors in community settings. These case studies, alongside a large and growing literature from around the world, provide the foundation for a paradigm shift in mental health care by rejecting the nihilistic notion that communities do not have enough resources to address mental health problems or that these problems are too complex to address. Central to this notion is the recognition that mental health problems can be addressed effectively with resources that every community possesses: people who care for others in their communities.","PeriodicalId":47980,"journal":{"name":"Daedalus","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139299145","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"社会学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract What makes for good mental health care? What are the barriers to good care and, when they can be overcome, what accounts for successful treatment? What does successful treatment and care, in fact, mean? Can they mean different things to different people? If so, how can we think about them in a practical way that is useful to patients, families, and clinicians? On the one hand, from work infields as various as neuroscience, clinical psychology, and anthropology, we are learning (and rediscovering) more and more about how the human mind works and the many ways that psychological suffering can be preempted and treated. On the other hand, in many ways, the mental health care system is either dysfunctional or working against what we know to be best for psychological and social flourishing-the disappearance, for example, of true “care” from medical and mental health care systems. In this essay, set against the background of diverse perspectives provided by the foregoing essays in this volume, we attempt to frame and address some of these basic questions, giving priority to practical, down-to-earth, lay, and professional considerations.
{"title":"Good Mental Health Care: What It Is, What It Is Not & What It Could Be","authors":"Arthur Kleinman, C.M.Angela Gardner","doi":"10.1162/daed_a_02042","DOIUrl":"https://doi.org/10.1162/daed_a_02042","url":null,"abstract":"Abstract What makes for good mental health care? What are the barriers to good care and, when they can be overcome, what accounts for successful treatment? What does successful treatment and care, in fact, mean? Can they mean different things to different people? If so, how can we think about them in a practical way that is useful to patients, families, and clinicians? On the one hand, from work infields as various as neuroscience, clinical psychology, and anthropology, we are learning (and rediscovering) more and more about how the human mind works and the many ways that psychological suffering can be preempted and treated. On the other hand, in many ways, the mental health care system is either dysfunctional or working against what we know to be best for psychological and social flourishing-the disappearance, for example, of true “care” from medical and mental health care systems. In this essay, set against the background of diverse perspectives provided by the foregoing essays in this volume, we attempt to frame and address some of these basic questions, giving priority to practical, down-to-earth, lay, and professional considerations.","PeriodicalId":47980,"journal":{"name":"Daedalus","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139305466","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"社会学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Mood disorders are common, painful, and closely tied to suicide and alcohol and substance use. They are also treatable. Mania and depression, a part of the human record for as long as it has been kept, were well-recognized and described by physicians of antiquity. Our knowledge of mood disorders has broadened and deepened in the many centuries since those early times, and crosses many scientific and clinical fields, including genetics, neuropharmacology, neuroimaging, psychopathology, and neuropsychology. We have as well a rich history of personal narratives of depression and bipolar disorder that gives a different but essential perspective; I present several of these accounts here.
{"title":"Disorders of Mood: The Experience of Those Who Have Them","authors":"Kay Redfield Jamison","doi":"10.1162/daed_a_02036","DOIUrl":"https://doi.org/10.1162/daed_a_02036","url":null,"abstract":"Abstract Mood disorders are common, painful, and closely tied to suicide and alcohol and substance use. They are also treatable. Mania and depression, a part of the human record for as long as it has been kept, were well-recognized and described by physicians of antiquity. Our knowledge of mood disorders has broadened and deepened in the many centuries since those early times, and crosses many scientific and clinical fields, including genetics, neuropharmacology, neuroimaging, psychopathology, and neuropsychology. We have as well a rich history of personal narratives of depression and bipolar disorder that gives a different but essential perspective; I present several of these accounts here.","PeriodicalId":47980,"journal":{"name":"Daedalus","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139291797","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"社会学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract Despite massive unmet needs, U.S. mental health care systems and policy continue to aim too low. Laments about brittle foundations-including inadequate funding, fragmentation, stigma, lack of parity, ineffectiveness, unavailability, overmedicalization, and coercion-all share the same source. The mental health system is not working because it has been chasing the wrong goal: to treat illness, rather than to enable people to do nurturing things together. A focus on community nurturing and caring changes everything. It yields better treatment approaches while also engaging with the mutually reinforcing and desperately needed work of social cohesion, emotional well-being, participatory action, and communal learning and connection. In fact, the nurtured emotional health of individuals is fundamental to humane and resilient societies and to democracy itself. And in the face of environmental collapse and the related unraveling of core institutions, the stakes have never been higher. This essay makes the case for a paradigm shift in care and explores a recent effort to implement it at scale: ThriveNYC. The successes and especially the failures of ThriveNYC point to the possibilities and challenges of this essential mission.
{"title":"Democracy Therapy: Lessons from ThriveNYC","authors":"Gary Belkin","doi":"10.1162/daed_a_02034","DOIUrl":"https://doi.org/10.1162/daed_a_02034","url":null,"abstract":"Abstract Despite massive unmet needs, U.S. mental health care systems and policy continue to aim too low. Laments about brittle foundations-including inadequate funding, fragmentation, stigma, lack of parity, ineffectiveness, unavailability, overmedicalization, and coercion-all share the same source. The mental health system is not working because it has been chasing the wrong goal: to treat illness, rather than to enable people to do nurturing things together. A focus on community nurturing and caring changes everything. It yields better treatment approaches while also engaging with the mutually reinforcing and desperately needed work of social cohesion, emotional well-being, participatory action, and communal learning and connection. In fact, the nurtured emotional health of individuals is fundamental to humane and resilient societies and to democracy itself. And in the face of environmental collapse and the related unraveling of core institutions, the stakes have never been higher. This essay makes the case for a paradigm shift in care and explores a recent effort to implement it at scale: ThriveNYC. The successes and especially the failures of ThriveNYC point to the possibilities and challenges of this essential mission.","PeriodicalId":47980,"journal":{"name":"Daedalus","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139305978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"社会学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract The 1980s, by common consensus, saw a big and remarkably rapid pivot away from previously dominant psychoanalytic and social science perspectives in American psychiatry and toward a so-called medical model foregrounding biology and the brain. The standard understanding is that this happened because, after years of wandering lost in a Freudian desert, the field had finally gained some fundamental new biological understandings of mental illness. The standard understanding is wrong. Nothing of sudden significance had happened on the biological front. There had been no major scientific or therapeutic breakthroughs. Why, then, did the field really pivot? This essay aims to explain. The answer is important, not least because choices made back then have directly shaped the fraught world of psychiatry with which we live today.
{"title":"Mental Health's Stalled (Biological) Revolution: Its Origins, Aftermath & Future Opportunities","authors":"Anne Harrington","doi":"10.1162/daed_a_02037","DOIUrl":"https://doi.org/10.1162/daed_a_02037","url":null,"abstract":"Abstract The 1980s, by common consensus, saw a big and remarkably rapid pivot away from previously dominant psychoanalytic and social science perspectives in American psychiatry and toward a so-called medical model foregrounding biology and the brain. The standard understanding is that this happened because, after years of wandering lost in a Freudian desert, the field had finally gained some fundamental new biological understandings of mental illness. The standard understanding is wrong. Nothing of sudden significance had happened on the biological front. There had been no major scientific or therapeutic breakthroughs. Why, then, did the field really pivot? This essay aims to explain. The answer is important, not least because choices made back then have directly shaped the fraught world of psychiatry with which we live today.","PeriodicalId":47980,"journal":{"name":"Daedalus","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139302700","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"社会学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abstract This essay draws on Frantz Fanon's insights about the sociogenesis of psychiatric disorders, and on the insights of feminist standpoint theory, to sketch a map toward sociogenic mental health. We argue that psychiatry should move away from iatrogenesis (the harms of our current individual-level and pathologizing approach) toward sociogenesis of mental health through robust collaboration with social movements of oppressed people, and their collective healing approaches, ranging from harm reduction centers to community gardens. The essay ends with the outlines of a reinvented, community collaborative psychiatry that supports sociogenesis.
{"title":"Rethinking Psychiatry: Solutions for a Sociogenic Crisis","authors":"Helena Hansen, Kevin J. Gutierrez, Saudi Garcia","doi":"10.1162/daed_a_02032","DOIUrl":"https://doi.org/10.1162/daed_a_02032","url":null,"abstract":"Abstract This essay draws on Frantz Fanon's insights about the sociogenesis of psychiatric disorders, and on the insights of feminist standpoint theory, to sketch a map toward sociogenic mental health. We argue that psychiatry should move away from iatrogenesis (the harms of our current individual-level and pathologizing approach) toward sociogenesis of mental health through robust collaboration with social movements of oppressed people, and their collective healing approaches, ranging from harm reduction centers to community gardens. The essay ends with the outlines of a reinvented, community collaborative psychiatry that supports sociogenesis.","PeriodicalId":47980,"journal":{"name":"Daedalus","volume":null,"pages":null},"PeriodicalIF":1.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139292459","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"社会学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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