Moving Towards a Less Wrong Medical Model

And I must say, there was bothfreedom and challenge for me in recognizing that our perception of the externalworld, and our relationship to it, is a product of our neurologicalcircuitry.  For all those years ofmy life, I really had been a figment of my own imagination! - Dr. JillBolte Taylor, author of My Stroke of Insight

Everyday, we all experience something that we call"reality."  This reality is made upof our beliefs, understandings, emotions, and experiences.  Underlying these experiences is aframework of nerve cells that we call our brain.  Many studies have shown that strategically destroying certainareas of the brain can alter or erase an individual's experience of reality insome way.  Many illnesses, such asAlzheimer's disease, also illustrate the point that without this chemical andelectrical circuitry, reality as we know it begins to melt away.[i]

For most of us, we live our lives without giving muchthought to the underlying framework that makes our experiences possible.  We are happy to conduct our business onthe level of this experiential reality. This line of thinking characterizes thecurrent medical model of mental health, and it leaves room forimprovement.  Here are some of thecriteria that the DSM IV outlines for major depression.[ii]

1.                    Depressed mood most of the day, nearly every day asindicated by either subjective report or observation of others. 

2.                    Markedly diminished pleasure in all or almost allactivities most of the day, nearly every day. 

3.                    Significant weight loss when not dieting. 

4.                    Insomnia or hypersomnia nearly every day.

5.                    Fatigue or loss of energy nearly every day. 

6.                    Recurrent thoughts of death, recurrent suicidalideation without a specific plan, or a suicide attempt or a specific plan forcommitting suicide. 

All of these criteria are within the realm of our behavioral andemotional experiential reality. None of the criteria listed refer specifically to the structure offunction of brain tissue.  Althoughcurrent treatment for depression is sometimes aimed at manipulation of braincells, as discussed later, it is often imprecise and ineffective.

            Theconsequences of the current medical model of mental health are obvious, but oftenoverlooked.  Health care providershave no choice but to use the tools that are available to them at thetime.  These tools have often beenprovided by a health care industry concerned more about the bottom line thaninnovation and development of effective patient care.  What creates profits in today's society are changes that wecan see and experience in the real world.  Thus, as a society, we have become efficient and effective atproducing change on the level of reality that we experience day in and day out.  As a result, we have treatments withmechanisms of action that are often blunt, imprecise, and not wellunderstood.  Patients are "cured"of a certain condition only to be riddled with numerous side effects andunforeseen long-term penalties.

In the mental health world, this is exceedinglyrelevant.  The current medicalmodel provides an unsatisfactory means for addressing mental health.  Strategies and assumptions fordiagnosing and treating patients need to be reconsidered and recontextualized.  If reality is a product of our neuralframeworks, then the focus of research and development needs to shift away fromour experiential reality towards an exploration of the ways in which we canunderstand the nature of our brain circuitry, our ability to manipulate it, andthe effects of manipulating it. Future discoveries and care in the mental health sector should becharacterized by an increased elegance that reflects a growing understanding ofthe nature of the framework.  As aresult, not only will error and side effects be decreased and accuracy indiagnosis and treatment increased, but an overall less wrong understanding ofmental health and what it entails will be achieved.

As one might imagine, there are several challengesfacing the medical model of mental health that prevent it from moving forward.  First, our ability to advance mental healthtreatments is inhibited by current technology.  In such a delicate environment, we must continually developour ability to manipulate neural pathways in a precise way without interferingwith surrounding tissue. 

Next, a major challenge to the evolution of the medicalmodel of mental health is our lack of ability to see the relationship betweenmanipulation of our experienced reality and the framework of our neurons.  In proposing a critique of the medicalmodel, it is not my intention to suggest that health care researchers andproviders neglect experiential reality. On the contrary, this is the fabric of life and if there is anythingthat can be said to make us "uniquely human" this is certainly a part ofit.  A less wrong model of mentalhealth will have the ability to distinguish the subtle interaction between thecircuitry and the outward experience. 

Finally, and most importantly, a fundamental challengefacing the medical model of mental health treatment today is the dynamicstructure of the brain and how it relates to our definition of what it means tobe mentally healthy or unhealthy. This single feature provides a crucial distinction between mental healthand physical health and provides direction towards development of a less wrongmodel of mental health.

Considering the boggling complexity of the physicalstructure of the brain, it might not be surprising to realize how little weactually know about how to effectively and reliably change the brain to achieveour treatment goals.  A discussionof the brain is frequently characterized by vagaries and ambiguities.  Phrases like the "love area," or the"God spot" are not uncommon to hear. In general, we don't know much beyond what the brain looks like and thatactivity in certain areas of the brain is correlated with certain behaviors andexperiences of the world.  Thethree previously mentioned challenges are often reflected in popular mentalhealth treatment methods where we work on the level of experiential reality. 

For example, a current mental health treatment is deepbrain stimulation.  Deep brainstimulation is a treatment that is used to treat disorders from Parkinson'sdisease to major depression.  Whileit is often effective at decreasing the amount of tremors that Parkinson'spatients experience, or helping lift the cloud of a major depressive episode,the mechanism of action is largely a mystery.  Doctor's aren't sure of how the stimulations work, they justknow that sending electricity through the brain can relieve some of thesymptoms involved with certain disorders.[iii]  As one might imagine, sending shockssemi-blindly into the brain can have undesired neuropsychological symptoms suchas apathy, compulsive gambling, hypersexuality, and cognitive dysfunction.[iv]  Deep brain stimulation is a perfectexample of the need for a greater specificity and elegance in the medical modelof mental health treatment.  It isakin to solving a problem with your television by violently shaking it insteadof trying to understand the real issue, which probably lies in the underlyingcircuitry or wiring.  

Another area that shows potential for improvement istalk therapy.  Talk therapy is oneof the most popular treatments in mental health care today.  Traditionally, the realm of talktherapy has been our experiences, beliefs and emotions.  Everything from treatment, to symptoms,to diagnosis was on this level.  However,this outside reality is only a product of our underlying neural networks. Thus,the role of talk therapy needs to be reconsidered and recontextualized.  Although talk therapy is effective atcreating change on the level of reality, it is salient to inquire into themechanism of how changes in our thoughts and behaviors create changes in ourneurons. 

Finally, psychotropic medications are a perfect exampleof the inadequacy of the medical model of mental health.  Pharmaceuticals have become a majortool in the treatment of mental disorders throughout the last few decades.  In spite of this, there is relativelyvery little that is known about the mechanism of actions for many drugs.  The idea that pharmaceuticals areprescribed and used based on biological understanding and effectiveness is aninaccuracy that industry marketing representatives have cultivated.  Selective serotonin reuptake inhibitors(SSRIs) are one of the most popular anti-depressant medications beingprescribed today.  Although theyare effective for many, the level of refinement that might be expected from a"cutting-edge" treatment is not what some might believe.  In general, SSRIs work by flooding thebrain with the neurotransmitter serotonin.  Although they are sometimes successful at treating the emotionaland physiological symptoms associated with depression and anxiety, there are manyundesirable side effects such as suicidality and sexual dysfunction.[v]  However, there is a problem with SSRIs thatillustrates a more fundamental problem with mental health treatments ingeneral.  They are used based onthe assumption that if you increase a certain pathway or neurotransmitter inthe brain, then you may be able to produce a constant state of happiness, focusetc.  This assumption iscontraindicated by what we know about the dynamic nature of the brain.

When one considers the state of current mental healthtreatments, a trend begins to emerge. As a society, we have become effective at achieving a desired change onthe level of our experiential reality. However, this change is often brought about by a manipulation of ourunderlying neural framework that is imprecise at best and blind brute force atworst. 

However, this deficiency in understanding outlines thetremendous potential to innovate and improve in the mental health care field.  New treatments are already beginning toaddress the challenges that face the medical model of mental health.  The next generation of mental healthtreatments will be characterized by two trends.  First, an increased understanding of how the neurologicalframework of our brains affects our experiences and how we are able toaccurately and efficiently manipulate this framework to achieve our health caregoals.  Second, an increasedunderstanding of the dynamic nature of the brain which will give us no choicebut to reconsider how we define "healthy" and "unhealthy" and force us to askourselves whether manipulation is even a plausible answer.  

New technology is also helping us move around andreorganize the brain better.  Onefield of study that shows extreme promise for increasing the elegancy oftreatment of mental health conditions is nanotechnology.  Nanotechnology is the discipline ofcontrolling and engineering objects on a microscopic scale, often a few millionthsof an inch.  For a structure as dynamicand subtle as the brain, nanotechnology may provide a graceful way ofaccurately influencing our neural circuits without disturbing surroundingframework.  Exciting discoveriesare being produced at top research institutions throughout the country.

At Northwestern University in Chicago, two physicianshave developed a method to help damaged nerves regenerate.[vi]  Damaged nerves normally do not showmuch regrowth.  However, SamuelStupp and John Kesslar have devised a way to deliver healing amino acids todamaged nerve tissue.  Upon arrivalat their destination, microscopic molecules arrange themselves into filamentsupon which the amino acids are distributed.  The amino acids help prevent the formation of scar tissueand spur regrowth of healthy normal nerve tissue. [vii]  

At MIT neuroscientists have discovered a way to engineerself-assembling peptides that form into a biological scaffold that will allowdamaged nerve tissue can regrow. The nano-scaffold resembles the normal cellular matrix upon which cellsusually grow.  The biologicalscaffold is also inert to the immune system, so surrounding body tissues do notattempt to reject the scaffold via an immunological response.  While not 100% of the tissueregenerates, enough tissue returns to regain function over the disabledfunction. So far, the research has only been conducted in hamsters.  However, scientists predict that thetechnique will eventually be able to help humans who have suffered strokes andother brain damage.[viii]

Not all innovations are coming from neurologicalresearch labs.  NASA has producedminiature tubes called nanotubes which are tens of thousands of times narrowerthan a human hair but several centimeters long.  The nanotubes can be used to deliver medication, such aschemotherapy, or other molecular agents to brain tissue non-invasively.  Researchers hope that the techniquewill be useable on humans within the next five years to treat stroke, trauma,and neurodegenerative disorders.[ix]

Certain conditions may not ask how we can manipulate thecurrent structure of the brain but instead how we can build new structure alltogether.  An answer to thisquestion is coming in the form of stem cells.  Stem cells are the undifferentiated starter cells from whichall other cells are created. Scientists in Japan have recently discovered a method for coaxing stemcells to turn into tissue resembling the cortical tissue in our brains.[x]  This technique provides extreme promisefor diseases that involve degeneration or damage of nerve tissue.

In another promising study, performed on mice, at theSalk Institute of Biology, researchers were able to get neurons in the brainsof adult mice to differentiate into different types of nerve cells.[xi]  For example, they were able totransform cells that were part of the neuronal framework into glial supportcells.  The results of this studyshow potential because the changes were made in intact, dynamic brains, whichis a considerably different environment than petri dish neurons.  Researchers predict that the treatmentmay be useful for diseases such as multiple sclerosis, a condition where themyelin sheath surrounding neuronal axons degrades.  This technique could potentially help to rebuild thosemyelin sheaths. 

One of the main challenges to the medical model of mentalhealth is to understand the connection between our experiential world and theneural framework in our brains. One technique, called real-time fMRI (rtfMRI)is helping to make the connection between our experience of the world and ourneural connections.  In studies atStanford, individuals are hooked up to an MRI machine and allowed to observetheir brain activity in real-time. When therapy sessions are conducted under these conditions, the patientand therapist can actually observe the effects of therapy techniques on brainactivity. 

This technique can also be used to condition and createnew neural pathways.  Researchersat the California Institute of Technology employed real-time fMRI to conditionnew neural pathways in participants by rewarding desired brain activity.[xii]  Subjects were placed in an fMRI machineand viewed pictures of different stimuli. If the subject was able to successfully create brain activity thatcorrelates with hand or foot movement without actually moving their hands andfeet, they received a monetary reward. The results of the study showed that once the participants had learnedto induce the appropriate brain activity, they were able to recreate it andincrease it over time.  This studyis a perfect example of our developing ability to understand how ourexperiential world and our neurological framework interact and relate. 

Perhaps the most perplexing challenge facing theevolution of mental health is how to deal with the dynamic structure of thebrain.  Challenges arising frominsufficient technology and lack of understanding of the relationship betweenour outside world and our brains call for a change in methodology and tactics.  While these changes are certainlyrelevant in certain situations where a biophysiological cause is apparent, for alarge part of mental health they may prove to be inadequate.  The reason is the nature of thebrain.  In other organ systemsthroughout the body, it is a reasonable approximation to assign certainfunctions and structures.  However,the nature of the brain is such that it is designed to change, explore, anddevelop new connections.[xiii]  In other words, the scaffolding in ourbrains is not static.  This forcesus to reconsider many of our assumptions. Whereas we can be relatively certain that if we align two ends of abroken bone in a certain way, they will regrow and regain function, we cannotmake analogous assumptions in the brain. If we were able to identify the neural organization that leads tohappiness, for example, and we were able to organize the neurons into thoseexact specifications it would prove to be irrelevant.  Once we had all the puzzle pieces in place they willimmediately begin a never-ending process of change.  Thus is the nature of the brain.  We are unable to say that a certain organization orstructure is the ideal because there can never be one stable organization orstructure.  What does it mean tohave mental health, then?  Perhaps,mental health is the ability of the brain to carry out the process of ongoingexploration and development of new connections.  In this light, nanotechnology and rtfMRI may assumecompletely new roles in helping to facilitate the brain's ability tocontinually grow. 

The current medical model has not yielded failures.  It has yielded results.  However, I suggest that we take a lookat these results and ask ourselves whether we can do better.  It is my belief that the answer is yes,we can come to a less wrong model for mental health and treatment.  The neural framework of our brains isbeing slowly but surely uncovered. Soon, we will become much more adept at moving and manipulating thetissue in ways that we know to be beneficial.  However, the random nature of the brain and the implicationsthat follow are factors that we will always have to consider in mentalhealth.  If we can never definemental health as an ideal physiological state, as we might in the physicalhealth realm, then we must define a new goal.  If the natural state of the brain is to explore, change, andform new connections, then perhaps our goal in mental health should be tofacilitate the brain's ability to do just that.

[i] http://www.ninds.nih.gov/disorders/alzheimersdisease/alzheimersdisease.htm

[ii] http://www.mental-health-today.com/dep/dsm.htm

[iii] http://www.time.com/time/magazine/article/0,9171,1214939,00.html

[iv] http://en.wikipedia.org/wiki/Deep_brain_stimulation#Potential_complications_and_side_effects

[v] http://en.wikipedia.org/wiki/Ssri

[vi] http://www.washingtonpost.com/wp-dyn/articles/A49758-2005Jan30.html

[vii] http://www.northwestern.edu/newscenter/stories/2008/03/selfassembledsacs.html

[viii] http://web.mit.edu/newsoffice/2006/brainfix.html

[ix] http://www.nasa.gov/topics/technology/features/nanotube-20080116.html

[x] http://www.cdb.riken.go.jp/en/04_news/articles/pdf/08/081106_csc.pdf

[xi] http://www.nature.com/neuro/journal/v11/n8/abs/nn.2148.html

[xii] http://www.dana.org/grants/imaging/detail.aspx?id=4480

[xiii] Dr. PaulGrobstein in conversation